AAFP free questions Flashcards
What to monitor on amiodarone therapy
TSH and free T4 every 6 months
Pediatric asthma is the most commonly encountered chronic illness, occurring in nearly one out of seven individuals. Short-acting β-agonists in the form of metered-dose inhalers are clearly favored for acute exacerbations, as well as for intermittent asthma. Treatment for persistent asthma requires the use of inhaled corticosteroids, with short-acting β-agonists used for exacerbations. For patients not well controlled with those options, either a long-acting β-agonist or a leukotriene receptor antagonist may be added. While both cromolyn and nedocromil are fairly devoid of adverse effects, their use is limited because of a lack of efficacy in the prevention of acute asthma exacerbations.
Palpitations are a common symptom in ambulatory care. Cardiac causes are the most worrisome so it is important to distinguish cardiac from noncardiac causes. Patients with a history of cardiovascular disease, palpitations that affect their sleep, or palpitations that occur at work have an increased risk of an underlying cardiac cause (positive likelihood ratio 2.0–2.3) (SOR C). Psychiatric illness, adverse effects of medications, and substance abuse are other common causes.
Palpitations that are worse in public places and those of very short duration (<5 minutes), especially if there is a history of anxiety, are often related to panic disorder. However, even a known behavioral issue should not be presumed to be the cause of palpitations, as nonpsychiatric causes are found in up to 13% of such cases. The use of illicit substances such as cocaine and methamphetamine can cause palpitations that are associated with dry mouth, pupillary dilation, sweating, and aberrant behavior. Excessive caffeine can also cause palpitations.
A Wood’s lamp may assist with the diagnosis of certain skin conditions. This patient’s presentation is consistent with erythrasma caused by a Corynebacterium minutissimum infection, and use of an ultraviolet light would reveal a coral pink color. Pale blue fluorescence occurs with Pseudomonas infections, yellow with tinea infections, and totally white with vitiligo. A lime green fluorescence is not characteristic of a particular skin condition.
Annual HPV screening in patients age 21–29 years has very little effect on cancer prevention and leads to an increase in procedures and treatments without significant benefit. In this age group there is a high prevalence of high-risk HPV infections but a low incidence of cervical cancer. If this patient were due for a Papanicolaou (Pap) test and results were ASC-US with a positive high-risk HPV or a higher grade abnormality, colposcopy would be recommended. Current recommendations are for a Pap test with cytology every 3 years for women age 21–29 years with normal results, and the frequency does not change with an increased number of normal screens. HPV is the most common sexually transmitted infection (STI) and up to 79% of sexually active women contract HPV infection in their lifetime, so the lack of other STIs does not preclude the possibility of an HPV infection.
The first step in the management of severe hypertension is determining whether a hypertensive emergency is present. A thorough history and physical examination are crucial (SOR C). Severe hypertension (blood pressure >180 mm Hg systolic or >110 mm Hg diastolic) with end-organ damage constitutes a hypertensive emergency. A physical examination should center on evaluating for papilledema, neurologic deficits, respiratory compromise, and chest pain. If end-organ damage is present the patient should be hospitalized for monitored blood pressure reduction and further diagnostic workup. If end-organ damage is not present and the physical examination is otherwise normal, a 30-minute rest with reevaluation is indicated. Approximately 30% of patients will improve to an acceptable blood pressure without treatment (SOR C). Home medications should then be adjusted with outpatient follow-up and home blood pressure monitoring (SOR A). Short-acting antihypertensives are indicated if mild symptoms are noted such as headache, lightheadedness, nausea, shortness of breath, palpitations, anxiety, or epistaxis. Diagnostic testing is not immediately indicated for asymptomatic patients (SOR C). A basic metabolic panel or other testing should be considered if mild symptoms are present. Aggressive lowering of blood pressure can be detrimental and a gradual reduction over days to weeks is preferred (SOR C).
The American Society of Anesthesiologists (ASA) has recently revised its physical status classification system. A healthy patient would be classified as ASA I, while a patient with mild systemic disease would be classified as ASA II. All patients who are having major surgery should be offered preoperative laboratory testing, including a CBC and renal function testing. For patients who are ASA III or IV and have chronic liver disease or take anticoagulants, coagulation testing should be considered. There is no compelling evidence to support either a chest radiograph or an EKG as part of a routine preoperative evaluation.
The recommended treatment for metatarsal stress fractures is no weight bearing for a few days, possibly using a posterior splint, transitioning to a walking boot or short leg cast, and then a rigid-soled shoe in 4–6 weeks. Callus formation on a radiograph and a lack of point tenderness signify adequate healing, and immobilization can be discontinued. Other recommended conservative therapy includes modified rest for 6–8 weeks with continuation of activities of daily living and limited walking. Normal activity can be resumed after 2–3 weeks with no pain. Additionally, the use of NSAIDs, ice, and stretching, as well as cross-training is recommended. Resuming regular activity after only 1 week of pain-free rest would not be recommended. Fractures of the fifth metatarsal should be carefully investigated to rule out a Jones fracture that may require orthopedic treatment. Treatment of the more common second and third metatarsal stress fractures is relatively straightforward.
It is important to distinguish serious illness from benign causes of proteinuria, which are the most common etiology in children. Confirming the presence of proteinuria is the next step in this case because functional (exercise/stress-induced) and orthostatic proteinuria are common types of proteinuria and are transient. A 24-hour urine for protein is a possible option, but would be impractical and burdensome for a healthy-acting 11-year-old. The pediatric nephrology panel of the National Kidney Foundation reported that a spot protein/creatinine ratio is a reliable test for ruling out proteinuria. A specialist referral, blood analysis, and ultrasonography are unnecessary unless persistent proteinuria is identified.
Behavioral and psychological symptoms of dementia include delusions, hallucinations, aggression, and
agitation. Antipsychotics are frequently used for treatment of these symptoms and are continued
indefinitely. For patients who have been taking antipsychotics for 3 months and whose symptoms have
stabilized, or for patients who have not responded to an adequate trial of an antipsychotic, it is
recommended that the drug be tapered slowly (SOR B).
Physicians should collaborate with the patient and caregivers when deciding whether to use an
antipsychotic. This is recommended because antipsychotic medications have adverse effects, including an
increased overall risk of death, cerebrovascular events, extrapyramidal symptoms, gait disturbances, falls,
somnolence, edema, urinary tract infections, weight gain, and diabetes mellitus. The risk of these harms
increases with prolonged use in the elderly.
One tapering method to consider is to reduce the daily dose to 75%, 50%, and 25% of the original dose
every 2 weeks until stopping the medication. This reduction pace can be slowed for some patients.
Diphenhydramine and lorazepam are on the Beers list of potentially inappropriate medications to use in
older patients and would not be recommended.
Individuals who travel internationally to areas with a high prevalence of tuberculosis (TB) are at risk for
contracting the disease if they have prolonged exposure to individuals with TB, such as working in a health
care setting. The CDC recommends either a TB skin test or an interferon-gamma release assay prior to
leaving the United States. If the test is negative, the individual should repeat the testing 8–10 weeks after
returning. A chest radiograph in asymptomatic individuals or prophylactic treatment at any point is not
recommended. Isoniazid and rifampin are options for treatment of latent TB.
This patient has thyroiditis with biochemical evidence for autoimmune (Hashimoto’s) thyroiditis. The most
appropriate plan of care is to begin thyroid hormone replacement and monitor with a repeat TSH level 6–8
weeks later. It is not necessary to include a T3 level when assessing the levothyroxine dose. There is no
need to routinely order thyroid ultrasonography when there are no palpable nodules on a thyroid
examination. Fine-needle aspiration may be necessary to rule out infectious thyroiditis when a patient
presents with severe thyroid pain and systemic symptoms
Easy access to a lethal means of suicide is a major risk factor for a successful suicide attempt. It is
important to eliminate access to firearms, drugs, or toxins for a patient with any suicidal ideation. Other
risk factors include, but are not limited to, a family history of suicide, previous suicide attempts, a history
of mental disorders, a history of alcohol or substance abuse, and physical illness. Another risk factor in
this patient is loss of a personal relationship. A history of borderline personality disorder (associated with
cutting) is not a risk for successful suicide. Any support from family or friends is helpful, even if it is
limited.
Somatic symptom disorder (formerly called somatization disorder) usually begins in the teens or twenties and is characterized by multiple unexplained physical symptoms, insistence on surgical procedures, and an imprecise or inaccurate medical history. These patients also commonly abuse alcohol, narcotics, or other drugs.
Patients with illness anxiety disorder are overly concerned with bodily functions, and can often provide accurate, extensive, and detailed medical histories. Malingering is an intentional pretense of illness to obtain personal gain. Patients with panic disorder have episodes of intense, short-lived attacks of cardiovascular, neurologic, or gastrointestinal symptoms. Generalized anxiety disorder is characterized by unrealistic worry about life circumstances accompanied by symptoms of motor tension, autonomic hyperactivity, or vigilance and scanning.
High-intensity statin therapy is recommended for patients younger than 75 years of age with known
coronary artery disease. For those who are intolerant of high-intensity statins, a trial of a
moderate-intensity statin is appropriate. There is evidence to support ezetimibe plus a statin in patients with
acute coronary syndrome or chronic kidney disease. Omega-3 fatty acids, fibrates, and niacin should not
be prescribed for primary or secondary prevention of atherosclerotic cardiovascular disease because they
do not affect patient-oriented outcomes. PCSK9 inhibitors such as evolocumab are injectable monoclonal
antibodies that lower LDL-cholesterol levels significantly and have produced some promising results, but
more studies are needed to determine when this would be cost effective.
This patient has Dupuytren’s disease with a contracture of the affected finger. Surgical release is indicated
when the metacarpophalangeal joint contracture reaches 30° or with any degree of contracture of the
proximal interphalangeal joint. Intralesional injection may reduce the need for later surgery in a patient
with grade 1 disease, but not if there is a contracture. There is no evidence to support the use of physical
therapy or cryosurgery.
The U.S. Preventive Services Task Force recommends against screening for cervical cancer for women
younger than 21, for women over the age of 65 who have had adequate screening in the recent past and
are not at high risk, and for women who have had a hysterectomy with removal of the cervix and no
history of CIN 2 or 3 or cervical cancer (USPSTF D recommendation). Women between the ages of 21
and 65 can be screened every 3 years with cytology alone, or the interval can be increased to 5 years after
age 30 by using a combination of cytology and HPV testing (USPSTF A recommendation). The history
of HPV vaccination is not a factor in screening decisions. Other organizations such as the American
Cancer Society and the American College of Obstetricians and Gynecologists have similar guidelines.
Traveler’s diarrhea is the most common infection in international travelers. A short course of antibiotics
can be taken after a traveler develops diarrhea and usually shortens the duration of symptoms (SOR A).
Azithromycin is preferred to treat severe traveler’s diarrhea. Rifaximin or fluoroquinolones may be used
to treat severe nondysenteric traveler’s diarrhea. Prophylactic antibiotics are not routinely recommended.
For patients at high risk, bismuth subsalicylate reduces the risk but does not need to be initiated prior to
travel. There is insufficient evidence for the use of probiotics to prevent traveler’s diarrhea. Loperamide
can be used with or without antibiotics after symptoms develop but is not recommended for prophylaxis.
There are several decision support tools to assist in predicting 30-day mortality for patients with
community-acquired pneumonia. Calculating the number of high-risk markers can aid in deciding whether
to admit the patient to the hospital. The risk of mortality increases with a respiratory rate 30/min,
hypotension, confusion or disorientation, a BUN level 20 mg/dL, age >65 years, male sex, or the
presence of heart failure or COPD.
This elderly patient is exhibiting classic signs of depression. The PHQ-2 has a similar sensitivity to the PHQ-9, but the PHQ-9 has a higher specificity in diagnosing depression (91%-94% compared to 78%-92%) and can assist in diagnosing depression. In addition to the PHQ-2 and PHQ-9 there are specific screening tools for use in the elderly population, including the Geriatric Depression Scale and the Cornell Scale for Depression in Dementia. Somatic issues and dementia can make it more difficult to screen for and diagnose depression in this population. The CAGE questionnaire screens for substance abuse. Megestrol is used to stimulate the appetite, but in this patient the appetite symptoms are likely secondary to depression so treating the depression would be a more appropriate starting point. The tricyclic nortriptyline is used to treat depression but is not first-line therapy, especially in the elderly. In general, a more extensive medical history and a physical examination are indicated before ordering MRI of the brain.
Methicillin-resistant Staphylococcus aureus (MRSA) is the predominant cause of suppurative skin and
soft-tissue infection. While community-acquired strains have been susceptible to many antibiotics,
clindamycin is associated with Clostridium difficile enterocolitis, trimethoprim/sulfamethoxazole is usually
used orally only for outpatient treatment, and doxycycline and minocycline are often effective clinically
but seldom used for serious infections. Resistance to quinolones is increasing and may emerge during
treatment. Vancomycin given parenterally is generally still the drug of choice for hospitalized patients.
This patient has a peripheral neuropathy. A review of the patient’s history and specific laboratory testing was performed to evaluate for the most common treatable causes of peripheral neuropathy, which include diabetes mellitus, hypothyroidism, and nutritional deficiencies. Additional causes of peripheral neuropathy include chronic liver disease and renal disease. It is important to consider medications as a possible cause, including amiodarone, digoxin, nitrofurantoin, and statins. Excessive alcohol use is another important consideration. In this patient, the mildly elevated total protein and erythrocyte sedimentation rate, which suggest a monoclonal gammopathy such as MGUS (monoclonal gammopathy of unknown significance) or multiple myeloma, should direct her workup. Serum protein electrophoresis is indicated to assess for this.
Other less common causes of peripheral neuropathy include carcinoma causing a paraneoplastic syndrome, lymphoma, sarcoidosis, AIDS, and genetic disorders such as Charcot-Marie-Tooth disease. Approximately 25% of patients with peripheral neuropathy have no clearly defined cause after a thorough evaluation and are diagnosed with idiopathic polyneuropathy.
MRI of the lumbar spine can identify central lesions causing spinal cord or nerve root compression but is not indicated in the evaluation of peripheral neuropathy. Serum angiotensin converting enzyme levels and a chest radiograph can assist in the diagnosis of sarcoidosis, which can cause peripheral neuropathy but is less likely in this patient. Cerebrospinal fluid analysis is important in assessing for chronic inflammatory demyelinating polyradiculoneuropathy, a more rare cause of peripheral neuropathy.
The annual failure rate of combined oral contraceptive pills with typical use is 9%. Typical failure rates for other contraceptive methods are 0.2% for the levonorgestrel IUD, 6% for injectable progestin, 18% for male condoms, and 22% for the withdrawal method.
Due to the disease prevalence and impact, effectiveness of screening instruments, and benefits of available treatment, the U.S. Preventive Services Task Force (USPSTF) recommends screening for major depressive disorder when adequate systems are in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. The USPSTF has made no recommendations regarding screening for bipolar disorder, generalized anxiety disorder, posttraumatic stress disorder, or schizophrenia.
This patient’s cat is well more than 10 days after the bite, so rabies vaccine is not necessary. Azithromycin is indicated for cat scratch disease, but the presentation does not suggest this. Severe infections may require incision, drainage, and intravenous antibiotics. A surgery consultation is recommended to evaluate for tendon sheath or joint infection.
In the treatment of active tuberculosis, direct observational therapy (DOT) involves providing the antituberculosis drugs directly to patients and watching them swallow the medication. It is the preferred care management strategy for all patients with tuberculosis. The use of DOT does not guarantee the ingestion of all doses of every medication, as patients may miss appointments, may not actually swallow the pills, or may regurgitate the medication, sometimes deliberately. Due to these limitations, the use of DOT does not remove the need to monitor patients for signs of treatment failure. DOT is effective in a wide variety of settings, including in the community with health nurses. It even shows benefit when the observation makes use of telehealth settings or mobile phones.
Among the important benefits of DOT are that it has been shown to decrease both the acquisition and transmission of drug-resistant tuberculosis and to increase treatment success in HIV-positive patients.
The patient is experiencing an acute cognitive change from baseline, indicating possible delirium. The Confusion Assessment Method (CAM) is a delirium diagnosis tool useful for evaluating acute cognitive changes. The other tests listed, including the Mini-Mental State Examination, Mini-Cog, Montreal Cognitive Assessment, and Saint Louis Mental Status exam, test chronic baseline cognitive function and are not designed to test for acute changes.
Reported cure rates for trigger finger after corticosteroid injection range from 54% to 86%. Corticosteroid injection for the other conditions listed results in temporary pain relief, but the underlying conditions are not improved by the injection.
Because of concerns about the growing epidemic of obesity in this population, the American Academy of Pediatrics now recommends screening for elevated serum cholesterol levels in children 9–11 years of age (SOR C). This patient should also be screened annually for depression beginning at 11 years of age and continuing through 21 years of age. Universal screening for iron deficiency anemia is recommended at 12 months of age and again at 15–30 months of age if the patient is determined to be high risk. HIV screening is recommended in adolescents 16–18 years of age, and age 21 is now the recommended starting age for screening for cervical dysplasia. Universal screening for diabetes mellitus is not recommended for children or adolescents.
Fibromyalgia is a chronic complex condition characterized by muscle pain, fatigue, muscle tenderness, and sleep disorders, often accompanied by mood disorders. SSRIs have been studied in the treatment of these symptoms, and while they have been shown to produce up to a 30% reduction in pain scores in patients with fibromyalgia, they have not been shown to affect fatigue or sleeping problems. They also have not been shown to be superior to tricyclics when treating pain. As with other patient populations, SSRIs have been shown to improve depression in those with fibromyalgia.
This patient has hyperactive delirium. The first step in management is to determine and treat the underlying cause if possible. There are multiple causes of delirium such as medications, infections, metabolic abnormalities, and underlying diseases. The first step in treatment is behavioral management with strategies to orient the patient. Haloperidol or antipsychotics may be used if the patient is at risk of harm. Lorazepam and anticholinergics should both be avoided, as they can worsen delirium. Restraints can also worsen the agitation and should not be used. Mirtazapine is an antidepressant and is not used in the treatment of delirium.
This patient would benefit from exercise to prevent or delay the onset of heart disease and hypertension, and to manage her weight. Exercise stress testing is not specifically indicated for this patient. Current recommendations are for healthy adults to engage in 30 minutes of accumulated moderate-intensity physical activity on 5 or more days per week.
Early systemic Lyme disease may manifest with facial nerve palsy, and treatment should include corticosteroids. The evidence for efficacy of antivirals for facial nerve palsy is lacking, especially beyond 3–4 days after onset. But in this case, specific treatment to eradicate the Lyme disease is also indicated, in order to prevent later, more severe systemic complications.
Patients with a history of cryptorchidism are at high risk for the development of testicular cancer, especially if orchiopexy is performed after puberty. If sonography shows a hypoechoic mass, a testicular biopsy is contraindicated, since it may contaminate the scrotum or alter the lymphatic drainage. Radical inguinal orchiectomy is both diagnostic and therapeutic. Watchful waiting would not be an option in this high-risk patient. CT of the chest, abdomen, and pelvis, and measurement of the tumor markers are useful for staging and as an indication of tumor burden, but they are not diagnostic.
Premature adrenarche without development of secondary sex characteristics is usually idiopathic and does
not lead to an abnormal pattern of development. Reassurance and surveillance over the next 3–6 months
would be most appropriate at this time. Laboratory studies and radiography warrant consideration if the
patient develops secondary sex characteristics before the age of 8, or if her height velocity increases
rapidly during the surveillance period.
Renal parenchymal diseases such as glomerulonephritis, congenital abnormalities, and reflux nephropathy
are the most common cause of hypertension in preadolescent children. Preadolescent children with
hypertension should be evaluated for possible secondary causes and renal ultrasonography should be the
first choice of imaging in this age group.
Renin and aldosterone levels are indicated if there is a reason to suspect primary hyperaldosteronism, such
as unexplained hypokalemia. Measurement of 24-hour urinary fractionated metanephrines and
normetanephrines is used to diagnose pheochromocytomas, which are rare and usually present with a triad
of symptoms including headache, palpitations, and sweating. Doppler ultrasonography of the renal arteries
is useful for diagnosing renal artery stenosis, which should be suspected in patients with coronary or
peripheral atherosclerosis or young adults, especially women 19–39 years of age, who are more at risk for
renal artery stenosis due to fibromuscular dysplasia. Sleep studies are indicated in patients who are obese
or have signs or symptoms of obstructive sleep apnea.
Topiramate increases the risk of kidney stones. It is a carbonic anhydrase inhibitor, which induces a
metabolic acidosis that leads to hypercalciuria and the formation of calcium phosphate stones. The risk of
kidney stones is not increased by escitalopram, levothyroxine, lisinopril, or metformin.
The fifth metatarsal has the least cortical thickness of all of the metatarsals. There are strong ligaments and
capsular attachments on the proximal fifth metatarsal that can put significant stress on this area of the bone,
leading to fractures. Nondisplaced tuberosity fractures can generally be treated with compressive dressings
such as an Aircast or Ace bandage, with weight bearing and range-of-motion exercises as tolerated.
Minimally displaced (<3 mm) avulsion fractures of the fifth metatarsal tuberosity can be treated with a
short leg walking boot. If the displacement is >3 mm, an orthopedic referral is warranted.
When psychogenic erectile dysfunction (ED) coexists with depression, treatment of the underlying mood
disorder is often an appropriate first step (SOR C). An antidepressant that is less likely to worsen the ED,
such as bupropion, mirtazapine, or fluvoxamine, should be chosen. Antidepressants that are more likely
to cause sexual side effects should be avoided, including SSRIs, SNRIs, and tricyclic and tetracyclic
antidepressants. Phosphodiesterase-5 inhibitors are the first line of treatment for ED (SOR A) and can be
used effectively in men with depression, in combination with treatments for mood disorders.
Ref: Yuan J, Zhang R, Yang Z, et al: Comparative effectiveness and safety of oral phosphodiesterase type 5 inhibitors for
erectile dysfunction: A systematic review and network meta-analysis.
HPV vaccine is currently recommended for males and females at age 11. Catch-up vaccination is
recommended until age 21 in males and 26 in females. Children who receive the first dose of the vaccine
before the age of 15 and receive two doses are considered adequately vaccinated. If the first dose is given
after age 15, a three-dose series is recommended.
Ref: Immunization schedules: Recommended immunization schedule for children and adolescents aged 18 years or younger,
The classic facial dysmorphologies associated with fetal alcohol syndrome are a smooth philtrum,
shortened palpebral fissures, and a thin vermilion border of the upper lip. Two out of these three
characteristics are required for the diagnosis of fetal alcohol syndrome. Low-set ears and a central chin
dimple are not associated findings.
Screening for developmental dysplasia of the hip (DDH) is somewhat controversial because the benefit of
treatment remains somewhat unclear. Despite the widespread practice of screening for DDH, ethical
newborn practices are difficult to determine. The American Academy of Family Physicians and the U.S.
Preventive Services Task Force have found insufficient evidence to recommend routine screening for
DDH. The American Academy of Pediatrics, however, recommends routine screening of all newborns
with physical examination maneuvers, and targeted screening ultrasonography for infants who were breech
in the third trimester, have a family history of DDH, or have a personal history of instability. Given this,
decisions should be individualized. Additional risk factors include female sex, firstborn status,
oligohydramnios, and a large-for-gestational-age infant.
Uncomplicated acute low back pain and/or radiculopathy is a benign, self-limited condition and early
imaging is associated with worse overall outcomes and is likely to identify minor abnormalities even in
asymptomatic patients. Imaging for acute low back pain should be reserved for cases that are suspicious
for cauda equina syndrome, malignancy, fracture, or infection. In the absence of red flags such as
progressive motor or sensory loss, new urinary retention or overflow incontinence, a history of cancer,
a recent invasive spinal procedure, or significant trauma relative to age, imaging is not warranted
regardless of whether radiculopathy is present, unless symptoms persist despite a trial of at least 6 weeks
of medical management and physical therapy.
Prophylactic antibiotics should be given for all closed-fist injuries unless the skin has not been penetrated,
and for puncture wounds caused by cat bites. The antibiotic should have both aerobic and anaerobic
activity and include Pasteurella coverage for animal bites and Eikenella coverage for human bites.
Suggested regimens include amoxicillin/clavulanate. If the patient is allergic to penicillin, clindamycin plus
levofloxacin or moxifloxacin, which has anaerobic coverage, can be used. Azithromycin, cephalexin, and
metronidazole are not first-line antibiotics following a cat bite.
This patient has blepharitis, a chronic inflammation of the eyelids. Seborrhea is a common cause in older
adults. In younger patients including children, colonization with Staphylococcus may be a contributing
factor. Meibomian gland dysfunction is often part of this condition, contributing to a reduced quality of
tear films, which leads to dry eyes and irritation. Other diagnoses to consider in this patient include
conjunctivitis, preseptal cellulitis, and Sjögren’s syndrome. Conjunctivitis typically involves the
conjunctiva and an eye discharge but less involvement of the eyelids is present. Cellulitis is an acute rather
than chronic condition and involves more pain and swelling. Sjögren’s syndrome causes dry eye but not
inflammatory changes of the lid.
The initial treatment of blepharitis consists of lid hygiene using warm compresses to remove dried
secretions and debris. Mild shampoo can help in this process and aid in keeping the bacterial colonization
load down. In severe or recalcitrant cases a topical antibiotic ointment may be applied to the lids. Oral
antibiotics can be considered for more severe cases.
The American Academy of Otolaryngology defines chronic rhinosinusitis as the presence of two of four
cardinal symptoms, which include nasal drainage, nasal obstruction, facial pain or pressure, and hyposmia
or anosmia, along with objective signs on examination or radiographic studies. This patient has three
cardinal symptoms of chronic rhinosinusitis and objective evidence on the physical examination. No nasal
polyps were seen on the examination. Granulomatosis with polyangiitis and sarcoidosis can both present
similarly but are uncommon causes of chronic rhinosinusitis. Allergic rhinitis can be associated with
chronic rhinosinusitis but would also present with allergic symptoms.
Malignant epidural spinal cord compression is an oncologic emergency that requires urgent MRI to confirm
the diagnosis. It is caused by a tumor compressing the dural sac and should be suspected with new-onset
progressive back pain that is worse when the patient is lying down. It is most commonly associated with
breast cancer and develops in approximately 5% of all patients with cancer. Once the diagnosis is
confirmed, an urgent management approach is needed. Corticosteroids and neurosurgical intervention can
preserve motor and sensory function. Attempting to alleviate the pain would not address this emergency.
According to national guidelines echocardiography is the preferred initial noninvasive testing modality
when pulmonary hypertension is suspected (SOR C). Pulmonary function tests provide helpful information
in regard to pulmonary capacity but are not necessarily diagnostic of pulmonary hypertension. CT of the
chest with contrast will not provide pulmonary pressures but may assist in the detection of pulmonary
emboli. A coronary calcium scan may be indicated to evaluate for coronary artery disease but it is not a
diagnostic test for pulmonary hypertension. Although right heart catheterization would provide pulmonary
pressure values it is considered more invasive than echocardiography and is not always necessary for
making the diagnosis.
This patient has medial knee pain related to repetitive use, most likely caused by pes anserine bursitis.
Iliotibial band syndrome is often related to overuse but causes pain in the lateral knee. The fibular head
is also lateral to the knee joint. Osgood-Schlatter disease is also often related to overuse but causes pain
at the insertion of the patellar ligament on the midline proximal tibia. A medial meniscal tear would
localize to the medial joint line rather than distal to the joint line and would more likely be associated with
positive findings from other examinations, such as a McMurray test.
Trichomoniasis classically presents as a greenish-yellow, frothy discharge with a foul odor. Erythema and
inflammation of the vagina and cervix are often present and can include punctate hemorrhages (strawberry
cervix). Atrophic vaginitis may cause a thin, clear discharge and is usually associated with a thin, friable
vaginal mucosa. Irritant/allergic vaginitis causes burning and soreness with vulvar erythema but usually
does not cause any significant discharge. Bacterial vaginosis more commonly presents as a thin,
homogenous discharge with a fishy odor and no cervical or vaginal inflammation. Vulvovaginal candidiasis
presents with white, thick, cheesy, or curdy discharge.
SGLT2 inhibitors are known to cause an increased risk of yeast vaginitis because their mechanism of action
involves blocking renal uptake of glucose, which results in an increase in glucosuria (SOR A). Common
side effects of metformin include gastrointestinal upset. DPP-4 inhibitors have very few side effects.
GLP-1 receptor agonists typically cause nausea and early satiety and weight loss. Sulfonylureas are
associated with weight gain and hypoglycemia.
Once the diagnosis of acute rheumatic fever is made, NSAIDs such as aspirin or naproxen should be
administered (SOR B). The therapeutic response to NSAIDs is often remarkable. Acetaminophen has not
been shown to be a superior analgesic for acute rheumatic fever. Gabapentin is not indicated, especially
considering that the pain does not have a neuropathic etiology. Opioids would not be considered first-line
treatment because of their adverse effects and the dramatic response of NSAIDs alone.
Diagnosing attention-deficit disorder in adults requires symptoms that interfere with social, academic, or occupational functioning and are present in more than one setting. DSM-5 states that a history of symptoms before age 12 is required for the diagnosis. DSM-IVspecified that symptoms must have been present before age 7.
Patients with a peanut allergy can have reactions to infinitesimal amounts of peanut protein, including residue on the lips of other people. This patient has successfully interrupted the course of anaphylaxis. Diphenhydramine can help reduce subsequent symptoms, and prednisone is generally given, although its value is unproven. However, the patient is at risk of a biphasic reaction and should go to an emergency department where additional epinephrine and resuscitation facilities are available. The American Academy of Pediatrics guideline recommends that all peanut-allergic patients who require a dose of adrenaline be observed in an emergency department.
Patients who have not already had a full allergy evaluation need to see an allergist, but this patient’s peanut allergy has been established. Peanut-allergic patients tend to have accidental exposure about once every 5 years in spite of efforts at avoidance.
In the first 3 to 4 days of illness, viral rhinosinusitis cannot be distinguished from early acute bacterial rhinosinusitis. If the patient seems to be improving and then symptoms start to worsen on days 5–10 of the illness (double sickening), acute bacterial rhinosinusitis should be suspected. The color of the nasal discharge should not be used as the sole indication for antibiotic therapy. One study showed that unilateral predominance with purulent rhinorrhea had an overall reliability of 85% for diagnosing sinusitis. After 10 days of upper respiratory symptoms, the probability of acute bacterial rhinosinusitis is 60%.
Antibiotic therapy should be considered if the patient does not improve after 7–10 days from the onset of symptoms or if the symptoms worsen at any time. According to most guidelines, the first-line antibiotic for treatment of adults with sinusitis is amoxicillin/clavulanate. Respiratory fluoroquinolones are not recommended as first-line medications, as they offer no additional benefits and have significant side effects. Second and third-generation cephalosporins, trimethoprim/sulfamethoxazole, and macrolide antibiotics are no longer recommended for initial therapy. This is due to high rates of resistance in Streptococcus pneumoniae and Haemophilus influenzae .
Gastroesophageal reflux accounts for a significant number of cases of failure to thrive, crib death, and recurrent pneumonia. Features of gastroesophageal reflux include a history of recurrent pneumonia, a low growth curve, a family history of sudden infant death syndrome, and normocytic anemia. A sweat chloride level of 20 mEq/L rules out cystic fibrosis. Normal serum calcium excludes DiGeorge’s syndrome. The battered child generally presents with more than just a single recurring medical problem. β-Thalassemia would be indicated by a microcytic anemia.
Childhood constipation is a very common problem encountered in outpatient practice. Most
childhood constipation is functional, which appears to be the case with this patient. She has
no evidence of organic disease, and she had a change in lifestyle that caused her to retain
stool, resulting in a cycle of constipation. Polyethylene glycol is easily tolerated, safe, and
easy to use. For this reason, it is the first-line therapy. A daily dose should resolve this
issue, although it is likely that the child will need another course of treatment, as functional
constipation is likely to recur. It is not reasonable in this case to provide no treatment, as
the child is uncomfortable. An enema would be unnecessary since oral therapies are very
likely to be effective. Behavioral therapies have not been shown to be as effective as
laxatives for functional constipation, and stringent therapy that is not related to food intake
is likely to increase the stress surrounding going to the toilet. There is no role for imaging
in a case where the suspicion of an organic cause is so low.
Key diagnostic features of autism spectrum disorder include deficits in social communication and interaction across multiple contexts and restricted, repetitive patterns of behavior, interests, or activities. The DSM-5 , which came out in 2013, created an umbrella diagnosis of autism spectrum disorder to consolidate four previously separate disorders: autistic disorder, Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified. Any individuals with a previous diagnosis of one of these disorders should now be given a diagnosis of autism spectrum disorder.
Cardiovascular disease, in particular ischemic heart disease, has now become the leading cause of human
deaths worldwide. It was once considered a disease of the wealthy, but now more than 80% of deaths from
noncommunicable diseases occur in low- to middle-income countries. The other conditions listed remain
among the top 10 causes of human deaths worldwide, along with stroke, lower respiratory infections,
COPD, diabetes mellitus, and road deaths.
This patient has symptoms consistent with hyperthyroidism, which could be caused by any of the options
listed. TSH is suppressed and free T4 and free T3 are elevated in all of these conditions. Only Graves
disease, however, will cause high radioactive iodine uptake on a thyroid scan. Uptake will be low in the
other conditions.
Postpartum thyroiditis
Silent thyroiditis
Subacute thyroiditis
Graves disease
Exogenous thyroid ingestion
Given this patient’s age, lack of symptoms, and possible family history, the presence of asymptomatic
bilateral hilar lymphadenopathy most likely represents stage 1 pulmonary sarcoidosis. Because the patient
does not have any symptoms and stage 1 sarcoidosis resolves in most cases, the most prudent course is to
reevaluate her in 6 months with a careful history, a physical examination, and a chest radiograph. Given
the normal spirometry results, pulmonary function tests are not needed at this time. Neither CT nor a lung
biopsy would change management at this time. Treatment is not indicated in stage 1 sarcoidosis but would
be merited if she developed increasing pulmonary symptoms or any extrapulmonary symptoms.
This patient presents with typical vasomotor symptoms that can begin in perimenopause and affect sleep
quality. Hormone therapy is the gold standard for treatment of vasomotor symptoms. Combination estrogen
and progesterone therapy is highly effective for vasomotor symptoms and provides protection against
uterine neoplasia. Although micronized progesterone decreases vasomotor symptoms there are no
long-term studies to assess the safety of progestin-only treatment for menopausal symptoms.
Compounded bioidentical hormone therapy creates safety concerns and is not a first-line therapy due to
limited government regulation and monitoring, the potential for overdosing and underdosing, impurities
or lack of sterility, and the lack of labeling describing risks. Testosterone alone is not FDA-approved for
use in women. Additionally, it has not been shown to be beneficial for treatment of vasomotor symptoms
in combination with hormone therapy and is associated with significant side effects. It may be useful for
hypoactive sexual desire in postmenopausal women. There is insufficient data to recommend the use of
herbal remedies such as black cohosh.
Catheter ablation is the most appropriate treatment for a patient with symptomatic Wolff-Parkinson-White
syndrome (WPW). Catheter ablation has a very high immediate success rate (96%–98%). The most
significant risk associated with the procedure is permanent atrioventricular block, which occurs in
approximately 0.4% of procedures. Adenosine and amiodarone are used for the acute management of
supraventricular tachycardia, but not for long-term management. Node-blocking medications such as
diltiazem and metoprolol should not be used for the long-term treatment of WPW, due to the increased risk
of ventricular fibrillation.
The CDC’s Advisory Committee on Immunization Practices recommends that patients with egg allergy
receive influenza vaccination. Previously unvaccinated patients ages 6 months to 8 years should receive
two doses of either trivalent or quadrivalent vaccine separated by 1 month.
The cause of hip pain is generally determined from the patient’s history and physical examination. A
positive flexion, abduction, external rotation (FABER) test that produces pain at the sacroiliac joint, lumbar
spine, and posterior hip is associated with sacroiliac joint dysfunction. The log roll test involves passive
supine internal and external rotation of the hip. When this test is positive for pain it is associated with
piriformis syndrome. While femoroacetabular impingement may be associated with a positive FABER test,
it would produce pain in the groin. Greater trochanteric pain syndrome results in lateral hip pain rather
than posterior pain. Osteoarthritis is usually associated with a limited range of motion and groin pain.
Patients who have a venous thromboembolism (VTE) require anticoagulation therapy for treatment and
prevention of recurrence. The risk of recurrence is greatest in the first year after the event and remains
elevated indefinitely. The risk for VTE recurrence is dependent on patient factors, such as active cancers
and thrombophilia. Current guidelines recommend treatment for at least 3 months. In patients who have
a reversible provoking factor such as surgery, anticoagulation beyond 3 months is not recommended.
The recommended first-line treatment for primary focal hyperhidrosis is topical 20% aluminum chloride.
It should be applied to affected areas nightly for 6–8 hours and works by obstructing the eccrine sweat
glands and destroying secretory cells. Iontophoresis and botulinum toxin are alternative first- or second-line
therapies for palmar and plantar hyperhidrosis and hyperhidrosis affecting the axillae, palms, soles, or
face.
Topical 2% glycopyrrolate must be compounded by a pharmacy and is indicated only for craniofacial
hyperhidrosis. Oral anticholinergics such as oxybutynin can be considered if other first-line treatments fail.
However, up to 10% of patients will stop taking these medications due to side effects such as dry mouth,
constipation, urinary retention, and blurred vision. Microwave technology is a newer treatment option that
has shown some promising results but should not be recommended as a first-line treatment. Sympathetic
denervation should be used only if other less invasive therapies have already been tried.
This patient presents with acute epididymitis. Typical symptoms develop gradually over 1–2 days with
posterior scrotal pain and swelling. Additional symptoms may include fever, hematuria, dysuria, and
urinary frequency. The pain may radiate to the lower abdomen. Physical examination findings may include
tenderness of the epididymis and testis along with swelling of the scrotum. Elevation of the scrotum may
decrease the pain (Prehn sign). Typical ultrasound findings include hyperemia, swelling, and increased
blood flow to the epididymis.
With testicular torsion the pain is often sudden in onset and severe, with associated nausea and vomiting
and no other urologic symptoms. A physical examination often demonstrates a high-riding testis that may
lie transversely in the scrotum. The cremasteric reflex may be absent. Ultrasound findings would
demonstrate decreased or absent blood flow with testicular torsion.
In sexually active adults <35 years of age, gonorrhea and Chlamydia are the most common causative
organisms of acute epididymitis. Ceftriaxone, 250 mg intramuscularly or intravenously once, with oral
doxycycline, 100 mg twice daily for 10 days, would be the appropriate treatment for acute epididymitis
(SOR C). In men over the age of 35 or those with a history of recent urinary tract surgery or
instrumentation, enteric organisms are the most likely cause and monotherapy with oral levofloxacin or
ofloxacin for 10 days would be the recommended treatment.
Written self-management plans have been shown to decrease respiratory-related hospitalizations in patients
with COPD. Although regular physical activity has clear health benefits, the methods are so varied in
studies of physical activity that there is currently no strong evidence to show it reduces hospitalizations in
COPD patients. Although FEV1 is important for predicting hospitalizations for a population, it is not
accurate enough to be useful in an individual patient. Daily oxygen therapy does not help to postpone the
first hospitalization. Nightly CPAP therapy reduces hospitalizations in patients with COPD and sleep
apnea, but not those with COPD alone.
Somatic symptom disorders account for approximately 5% of primary care visits. Effective pharmacologic
treatment includes sertraline and other SSRI-based therapy in addition to cognitive-behavioral therapy
(SOR B). Bupropion, monoamine oxidase inhibitors such as selegiline, anticonvulsants such as topiramate,
and antipsychotics such as clozapine are ineffective.
The TSH reference range is lower during pregnancy because of the cross-reactivity of the -subunit of
hCG. Levels of hCG peak during weeks 7–13 of pregnancy, and hCG has mild TSH-like activity, leading
to slightly high free T4 levels in early pregnancy. This leads to a feedback decrease in TSH.
This patient’s laboratory results and back pain suggest multiple myeloma (MM). He has a normocytic
anemia and evidence of renal insufficiency, which can indicate MM. The laboratory findings along with
worsening back pain indicate a need to order serum protein electrophoresis to look for MM. Flow
cytometry is generally used in patients with an elevated WBC count and suspected lymphoma. The
remainder of this patient’s CBC is normal, which makes a bone marrow issue less likely. His mean
corpuscular volume is also normal, making vitamin B12 deficiency less likely. A haptoglobin level could
be ordered, but protein electrophoresis is a better choice because the peripheral smear demonstrated no
evidence of a hemolytic problem.
Breast cancer survivors should undergo a history and physical examination every 3–6 months for the first
3 years after treatment, then every 6–12 months for the next 2 years, and then annually thereafter (SOR
C).
Papanicolaou testing guidelines do not change for patients with a history of breast cancer. Screening should
be repeated every 3–5 years according to American Society for Colposcopy and Cervical Pathology
(ASCCP) guidelines.
Mammograms of both breasts or the remaining breast are recommended no more often than yearly (SOR
A). Breast MRI is not recommended on a regular basis unless the patient has a high risk of recurrence,
a significant family history of breast or ovarian cancer, or a personal history of Hodgkin’s disease (SOR
C). While it is important to be alert for signs of cardiotoxicity due to prior chemotherapy,
echocardiography is indicated only if the patient has cardiac symptoms. Routine echocardiography is not
recommended (SOR C)
Several decision support tools can help guide the decision to order imaging of an injured knee, such as the
Ottawa Knee Rule, the Pittsburgh Knee Rule, and American College of Radiology (ACR) criteria. The
inability to take four or more steps immediately after an injury or in the emergency setting is an indication
for radiography in all three rules.
Age is an indication for radiography in acute knee pain in patients over 55 years of age according to the
Ottawa rule, or under 12 or over 50 years of age according to the Pittsburgh rule. The patient’s sex does
not factor into the criteria for imaging.
Bony tenderness is an indication for imaging according to the ACR and Ottawa rules, but only if isolated
over the proximal fibula or over the patella without other bony tenderness. The inability to flex the knee
to 90° is also an indication for imaging according to the ACR and Ottawa rules.
Injection of glucocorticoids (usually mixed with a local anesthetic) into the subacromial space may be
considered in patients with rotator cuff tendinitis if the pain is significant enough to interfere with sleep
and/or function despite adequate analgesia.
An intra-articular injection is appropriate for a patient with severe shoulder osteoarthritis. A corticosteroid
injection into the biceps or deltoid insertions is not appropriate. An acromioclavicular injection is
appropriate for acromioclavicular arthritis but not for rotator cuff tendinitis.
Tamsulosin promotes passage of ureter stones that are 5–10 mm in diameter. The number needed to treat
is five patients to cause the expulsion of one stone (SOR B). There was no difference in the percentage of
patients passing stones smaller than 5 mm when comparing tamsulosin to placebo, as these stones have a
high rate of spontaneous passage without any intervention. Naproxen and promethazine are sometimes used
for the management of pain and nausea associated with stones, but they have not been shown to facilitate
stone expulsion. Ciprofloxacin and nitrofurantoin are used to treat urinary tract infections but have not
been shown to facilitate stone expulsion.
This patient has severe community-acquired pneumonia based on clinical criteria, including an elevated
respiratory rate, confusion, and hypotension requiring aggressive fluid resuscitation. Corticosteroids such
as methylprednisolone have been shown to improve clinical outcomes such as length of stay, duration of
antibiotic treatment, and the risk of developing adult respiratory distress syndrome. The preferred choice
of antibiotic treatment for patients in the intensive-care unit is a -lactam antibiotic (ceftriaxone,
cefotaxime) or ampicillin/sulbactam, plus a macrolide alone or a macrolide and a respiratory
fluoroquinolone. The addition of levofloxacin is not necessarily preferred over just ceftriaxone and
azithromycin. Clindamycin is not indicated in the absence of risk factors for anaerobic infection such as
aspiration or alcoholism. Oseltamivir is not indicated in the absence of known or suspected influenza
infection.
Postpartum thyroiditis is defined as a transient or persistent thyroid dysfunction that occurs within 1 year
of childbirth, miscarriage, or medical abortion. Release of preformed thyroid hormone in the bloodstream
initially results in hyperthyroidism. During the hyperthyroid phase, radioactive iodine uptake will be low,
which can help to confirm the diagnosis. Pregnancy and breastfeeding are contraindications to radionuclide
imaging. Thyroid peroxidase antibody levels are elevated with chronic autoimmune thyroiditis
(Hashimoto’s thyroiditis), and patients present with symptoms of hypothyroidism. The Endocrine Society
and American Association of Clinical Endocrinologists do not recommend routine thyroid ultrasonography
in patients with abnormal thyroid function tests if there is no palpable abnormality of the thyroid gland.
Thyrotropin receptor antibody levels are positive in Graves disease.
This is a classic presentation for acute poststreptococcal glomerulonephritis (APSGN), with the onset of
gross hematuria associated with hypertension and systemic edema. This is most commonly seen in
school-age children, usually 1–2 weeks after an episode of pharyngitis or 3–4 weeks after an episode of
impetigo, caused by so-called nephritogenic strains of Group A -hemolytic Streptococcus. The hematuria
is caused by immune complex–mediated glomerular injury.
Bacteriuria may be seen in both upper and lower urinary tract infections, but may also be a spurious
finding, especially with the combined presence of epithelial cells. The classic finding on microscopic
urinalysis for acute glomerulonephritis is the presence of RBC casts. WBC casts are seen with acute
pyelonephritis. The presence of urinary eosinophils indicates acute interstitial nephritis. Calcium oxalate
makes up the most common type of kidney stones.
Antibiotics prescribed for antecedent pharyngitis do not prevent APSGN. Treatment is supportive,
controlling blood pressure and edema with a thiazide or a loop diuretic. The prognosis for resolution and
full recovery of the vast majority of patients with APSGN is excellent, especially in the pediatric age
group.
Multiple studies have determined that parenteral antiemetics have benefits for the treatment of acute
migraine beyond their effect on nausea. Most outpatient clinics do not have the ability to administer
intravenous metoclopramide, which is the preferred treatment. However, most clinics do have the ability
to administer intramuscular prochlorperazine or promethazine. Due to concerns about oversedation,
misuse, and rebound, treatment with parenteral opiates is discouraged but may be an option if other
treatments fail. Oral butalbital/acetaminophen/caffeine and oral ergotamine/caffeine have less evidence of
success in the treatment of acute migraine. Sumatriptan is contraindicated within 24 hours of the use of
rizatriptan.
Solar lentigines occur on sun-exposed skin and are known commonly as liver spots. A biopsy should be
performed if they grow rapidly, change rapidly, are painful, itch, bleed easily, heal poorly, or have an
atypical or suspicious appearance.
If no suspicious changes or symptoms are present there are various options for treatment, including topical
therapy with hydroquinone or retinoids, or ablative therapy with chemical peels, cryotherapy, intense
pulsed light, or laser therapies.
For women at high risk of developing preeclampsia, the U.S. Preventive Services Task Force (USPSTF)
recommends starting low-dose aspirin after 12 weeks gestation (B recommendation). While calcium
appears to be helpful in preventing preeclampsia for women with a diet deficient in calcium, the evidence
is not yet conclusive. The USPSTF recommendation does not address the use of fish oil, magnesium
gluconate, vitamin C, or vitamin D for the prevention of preeclampsia.
This patient has a calcaneal stress fracture as suggested by the history of increased running on a hard
surface, improvement with rest, and a positive calcaneal squeeze on examination. A delay in diagnosis
increases the risk of delayed union. MRI is the preferred imaging modality because radiographs often do
not detect a calcaneal stress fracture. A C-reactive protein level could be indicated if there were symptoms
or signs of infection or autoimmune illness. The clinical picture does not suggest a neurologic condition,
so nerve conduction velocity testing is not appropriate. While there are some case reports of the diagnosis
of stress fractures using ultrasonography, this is not the preferred imaging method.
Ref: Tu P: Heel pain: Diagnosis and management. Am Fam Physician 2018;97(2):86-
This patient presents with morbid obesity complicated by several obesity-related conditions. Bariatric
surgery has been shown to result in greater weight loss compared to nonsurgical interventions (SOR A).
It has also been shown to be highly effective in treating obesity-related comorbid conditions such as
diabetes mellitus (SOR A). Patients with a BMI 40 kg/m2 should be referred for consideration of bariatric
surgery (SOR B). While worksite intervention, exercise therapy, behavioral therapy, and pharmacotherapy
are appropriate treatments for obesity, these interventions are all less effective than bariatric surgery.
Dysmenorrhea affects 50%–90% of females and the great majority of cases are primary dysmenorrhea, or pain that occurs in the absence of pelvic pathology. After a complete history confirming cyclic cramping pelvic pain beginning around the start of menses and a negative urine pregnancy test, empiric treatment should be offered (SOR C). First-line treatment is an NSAID at moderate to maximum dosing, such as naproxen, 500 mg every 12 hours. Any NSAID can be used and should be started 1–2 days before the onset of menses and continued through the first several days of bleeding. A secondary benefit to NSAID use is a reduction in heavy menstrual bleeding. Combined estrogen/progestin oral contraceptives may also be used as first-line therapy or in conjunction with NSAIDs.
While screening for sexually transmitted infections is important for sexually active adolescents, it is not indicated in the evaluation of dysmenorrhea. Neither pelvic examination nor imaging is indicated when the history is consistent with primary dysmenorrhea. If there is evidence of secondary dysmenorrhea (due to pelvic pathology or a recognized medical condition), then an examination and imaging are indicated. Family physicians are able to manage the majority of cases of primary dysmenorrhea. If there is no improvement in treatment after 3 months, referral to a gynecologist may be indicated.
Symptoms of serotonin syndrome range from mild to life-threatening and typically appear minutes to hours after ingestion of serotonergic medications. SSRIs are the most commonly associated class of medication due to their widespread use. The Hunter Serotonin Toxicity Criteria are the most commonly used diagnostic tool. This patient has a history of serotonergic medication use, signs of inducible clonus, agitation, and diaphoresis, as well as hyperthermia. It is likely that the addition of dextromethorphan precipitated this episode. This patient’s history does not suggest an overdose of methylphenidate, and there is little evidence in this scenario for a serious infectious process. Malignant hyperthermia generally appears over a longer period of time and does not typically induce clonus. There are few, if any, choices for medication therapy of concomitant attention-deficit/hyperactivity disorder and depression that do not increase the risk of serotonin syndrome, so patients on these regimens should be educated about the symptoms of serotonin syndrome and common causative agents.
Although behavioral interventions are the mainstay of treatment for insomnia, they often need to be supplemented by pharmacologic therapy. When both doxepin and extended-release melatonin fail to provide benefit, a member of the Z-drug class should be tried next. Among the Z-drugs only eszopiclone provides an early peak onset and a long half-life, with a 1-hour approximate time to peak and a 6-hour half-life. While zaleplon has an equally short time to peak of 1 hour, it also has a 1 hour half-life. Antihistamines, including diphenhydramine and doxylamine, as well as atypical antipsychotics such as olanzapine, are not indicated unless used primarily to treat another condition.
The CDC’s Advisory Committee on Immunization Practices updated its recommendations in 2022 to include a two-dose series of recombinant zoster vaccine for all adults age 19 and older with HIV. Vaccination against meningococcal bacteria A, C, W, and Y (MenACWY) is also recommended, and meningococcal B (MenB) vaccination is only recommended based on the presence of other risk factors, including asplenia, complement deficiency, treatment with complement inhibitors, or risk due to outbreaks. Prophylactic emtricitabine/tenofovir is approved for pre- and postexposure prophylaxis of HIV, but would not be used alone in the care of patients with established HIV. Pneumocystis jirovecii prophylaxis, most commonly with sulfamethoxazole/trimethoprim, is recommended in patients with CD4 lymphocyte counts <200 cells/μL. Hepatitis B vaccine is recommended but would not be necessary for patients such as this one with natural immunity or confirmed immunity from vaccination.
Hypertriglyceridemia, defined as triglyceride levels 500 mg/dL, increases the risk of pancreatitis. It does not increase the risk of asthma, chronic kidney disease, gallstones, or hypothyroidism. Patients with hypertriglyceridemia should initiate therapeutic lifestyle modifications and should be treated with fibrates or niacin to help reduce the risk of pancreatitis.
For children up to 4 years of age who only have wheezing with respiratory infections, using an inhaled corticosteroid (IC) daily when a respiratory infection develops reduces exacerbations and the use of systemic corticosteroid therapy. It is uncertain if ICs affect growth, but they would be less likely to do so than systemic corticosteroids. Antibiotic therapy should be reserved for bacterial infections. Montelukast is indicated for the prevention of asthma and allergic rhinitis. The use of antihistamine decongestant preparations in children is not recommended due to potential side effects and minimal benefit.
This patient has a nondisplaced radial head fracture. Current evidence supports a brief period of immobilization followed by early range-of-motion exercises to avoid decreased range of motion. This results in good outcomes in 85%–95% of patients. Immobilization for 6 weeks using either a long arm posterior splint or a long arm cast is not necessary. More advanced or displaced fractures may require a referral to an orthopedist for cast placement or operative repair, but nondisplaced radial head fractures can be managed by primary care physicians.
This patient has an acute febrile illness and meets criteria for systemic inflammatory response syndrome (SIRS) and decompensated shock. Shock is a medical emergency requiring urgent treatment to prevent death or other complications. The four types of shock are differentiated based on clinical signs. Correct treatment hinges on accurate determination of the type of shock. This patient demonstrates high-output shock typical of septic shock. Initial treatment of septic shock begins with fluid resuscitation using isotonic crystalloid by an intravenous or intraosseous route. Recent guidelines recommend a minimum of 30 mL/kg of isotonic crystalloid, with a preference for lactated Ringer’s solution over normal saline. Hypotonic solutions, such as half-normal saline, should never be administered as a bolus. There is no indication for epinephrine or dobutamine in this patient. Norepinephrine can be indicated for septic shock that has not responded to fluid resuscitation.
Mastalgia is a common symptom requiring evaluation in the primary care setting. Cyclic mastalgia accounts for about two-thirds of all breast pain and is thought to be caused by increased sensitivity of the breast tissues to hormonal stimulation during the luteal phase of the menstrual cycle. Topical NSAIDs such as diclofenac are the first-line pharmacologic treatment for mastalgia (SOR B). Danazol is the only drug that is approved by the FDA for treatment of mastalgia, but it is poorly tolerated due to menorrhagia, muscle cramps, weight gain, and other androgenic effects. Goserelin is only indicated for severe, refractory mastalgia. Tamoxifen is more effective and better tolerated than danazol, but is associated with hot flashes, vaginal discharge, venous thromboembolism, endometrial cancer, and teratogenicity.
Complex regional pain syndrome (CRPS) usually develops after an injury, often a fracture, to a distal extremity, although it can present without prior injury. The diagnosis is made clinically using the history and physical examination. Its pathophysiology is poorly understood. Ultrasonography or MRI may be used to rule out other diagnoses but are not necessary for the diagnosis of CRPS. Nerve injury can be seen on nerve conduction testing with type 2 CRPS, also known as causalgia, but nerve injury is not always identified with type 1 CRPS, also known as reflex sympathetic dystrophy. Nerve conduction testing is not necessary for making the diagnosis, and both types of CRPS are treated with the same approach. A technetium 99m bone scan may reveal increased bone resorption at the site, but it is neither sensitive nor specific for CRPS.
Patients with end-stage renal disease and diabetes mellitus need careful monitoring of glucose because insulin requirements are difficult to predict and there is an increased risk of hypoglycemia in this setting. The optimal hemoglobin A1c has not been established but maintaining a value between 6% and 9% does decrease mortality. With close monitoring, insulin is preferred for most individuals. Sulfonylureas such as glimepiride and glyburide are associated with a high risk of hypoglycemia and should be avoided in these patients. Metformin should be avoided in those with a glomerular filtration rate <30 mL/min/1.73 m2. Pioglitazone should also be avoided in chronic kidney disease due to the risk of fluid retention and precipitating heart failure.
This patient has a stage 2 pressure ulcer. It is recommended that pressure ulcers not be cleaned with povidone/iodine, Dakin’s solution, hydrogen peroxide, wet-to-dry dressings, or any solutions that may impede granulation tissue formation. These sites should be cleaned with either saline or tap water and covered with hydrocolloid, foam, or another nonadherent dressing that promotes a moist environment.
Patients with rheumatoid arthritis being treated with anti-tumor necrosis factor therapy are at increased risk for septic arthritis. The most common cause of septic arthritis in adults is Staphylococcus aureus, followed by Streptococcus species. Escherichia coli causes about a fourth of the cases in the elderly. Fungal and mycobacterial causes such as Candida albicans or Mycobacterium tuberculosis are less common but must be considered in immunocompromised patients.
Family physicians are often asked to provide primary care for organ transplant recipients. Pregnancy should be avoided during the 12 months following transplantation because of the increased risk of preterm delivery and graft rejection. Female fertility typically increases post transplant. The use of an IUD avoids interactions with medications, does not increase the risk of infection, and is not affected by typical immunosuppressive therapies.
The remaining options are incorrect because of their higher failure and discontinuation rates. The CDC cites failure rates with typical use of 9% for combined oral contraceptives and the etonogestrel/ethinyl estradiol vaginal ring, 6% for injectable progesterone, 0.2% for levonorgestrel IUDs, and 0.08% for the copper IUD. Barrier method failure rates exceed 18%. Combined oral contraceptives and the vaginal ring also have potential estrogen-related side effects, and injectable progesterone use increases the risk for osteoporosis.
There are several types of chronic headaches, and they often respond to different treatments. Migraine is very prevalent and is characterized by headaches that are periodic, often unilateral, and frequently pulsatile. Migraine is familial and typically starts in childhood, adolescence, or young adulthood, and the headaches decrease in frequency over time. Some are associated with aura, which causes visual disturbances. In mild cases, over-the-counter medications may control symptoms. For most patients, however, treatment to control the attack can include triptans such as sumatriptan, and/or ergot alkaloids such as ergotamine. Treatment to prevent attacks may also be appropriate, and could include a β-blocker, antiepileptic drugs, or amitriptyline.
Tension headaches are usually bilateral and are typically described as dull or aching, but patients often describe tightness or pressure. They are not associated with symptoms such as throbbing, nausea, or photophobia. Tension headaches are more frequent than migraine but patients often treat them at home without seeking medical treatment. Frequent or persistent tension headaches can be treated with several drugs used for anxiety or depression, including amitriptyline. Stronger analgesics and ergotamine are not helpful.
Cluster headache is another type of chronic headache. This occurs most frequently in adult males, and often occurs over a period which may extend over many weeks, with repeated episodes or clusters. It most often occurs at night, and may recur several times during the night. The headache is unilateral and is associated with orbital pain and vasomotor phenomenon such as blocked nasal passages, rhinorrhea, conjunctival injection, and miosis. The headache can be treated with inhalation of 100% oxygen, and the headache cycle can be terminated with verapamil. Ergotamine or sumatriptan can be used at night to prevent attacks.
There are also variants of cluster headaches, including chronic paroxysmal hemicrania, which resembles cluster headache but has some important differences. Like cluster headaches, these headaches are unilateral and accompanied by conjunctival hyperemia and rhinorrhea. However, these headaches are more frequent in women, and the paroxysms occur many times each day. This type of headache falls into a group of headaches that have been labeled indomethacin-responsive headaches because they respond dramatically to indomethacin.
Cognitive-behavioral therapy for chronic insomnia is known to be superior to pharmacologic therapies (SOR A) and can be effectively administered by primary care physicians (SOR B). An important component of cognitive-behavioral therapy is sleep hygiene education to identify behaviors that can interfere with sleep, such as pets in the bedroom, caffeine consumption after 4 p.m., exercising within 2 hours of bedtime, and nicotine use. It is also important to identify factors that can facilitate sleep, such as maintaining an environment conducive to sleep, including a cool room and a comfortable bed. Addressing misunderstandings about normal sleep, reinforcing factual sleep-related information, and addressing stimulus control, such as limiting use of the bedroom to sleep and sex and delaying going to bed until sleepy, are among the other key components of a comprehensive cognitive-behavioral therapy program for chronic insomnia.
This patient has diarrhea-predominant irritable bowel syndrome (IBS). There are many treatments available, with varying degrees of evidence. SSRIs, along with tricyclic antidepressants, have been shown to decrease abdominal pain and improve global assessment scores in those with IBS. Polyethylene glycol is a treatment for constipation and would not help this patient. Acupuncture has not been shown to be superior to sham acupuncture in improving IBS symptoms. Neomycin has been shown to improve symptoms in constipation-predominant IBS but would not be helpful in diarrhea-predominant IBS. Soluble fiber such as psyllium improves symptoms and decreases abdominal pain scores in patients with IBS. Insoluble fiber has not been shown to improve any IBS outcomes.
Though symptoms of generalized anxiety disorder (GAD) overlap with other psychiatric and medical conditions, the case presented is most consistent with GAD. SSRIs are first-line therapy for GAD (SOR B). Benzodiazepines such as lorazepam can improve anxiety-related symptoms, but due to the side effects and addiction potential they are recommended for short-term use (SOR B). Bupropion is approved for the treatment of depression but is not used to treat GAD. Quetiapine may be considered as second-line therapy for GAD (SOR B). Methylphenidate is first-line therapy for attention-deficit/hyperactivity disorder but is not indicated to treat GAD. Psychotherapy, especially cognitive-behavioral therapy, is also first-line treatment for GAD (SOR A), and exercise can also improve symptoms (SOR B).
Low diffusing capacity of the lungs for carbon monoxide (DLCO) with normal spirometry indicates a disease process that disrupts gas transfer in the lungs without causing lung restriction or airflow obstruction. Common causes include chronic pulmonary emboli, heart failure, connective tissue disease with pulmonary involvement, and primary pulmonary hypertension. Asthma, bronchiectasis, COPD, and pulmonary fibrosis are associated with abnormalities on spirometry.
Patients with an artificial heart valve should be given antibiotic prophylaxis prior to dental procedures to prevent infectious endocarditis. The organisms that most frequently cause infectious endocarditis include Staphylococcus aureus (31%), Streptococcus viridans (17%), coagulase-negative staphylococci (11%), Enterococcus (11%), Streptococcus bovis (7%), and other streptococci (5%). Amoxicillin is the preferred medication for prophylaxis. Clindamycin or azithromycin can be used in patients with a penicillin allergy. If the penicillin allergy is not associated with anaphylaxis, angioedema, or urticaria, then cephalexin would be an appropriate antibiotic choice. Ciprofloxacin, doxycycline, rifampin, and trimethoprim/sulfamethoxazole are not used for bacterial endocarditis prophylaxis.
Prevention traditionally has been divided into three categories: primary, secondary, and tertiary. Primary prevention targets individuals who may be at risk to develop a medical condition and intervenes to prevent the onset of that condition. Examples include childhood vaccination programs, water fluoridation, antismoking programs, and education about safe sex. Secondary prevention targets individuals who have developed an asymptomatic disease and institutes treatment to prevent complications. Examples include routine Papanicolaou tests and screening for hypertension, diabetes mellitus, or hyperlipidemia. Tertiary prevention targets individuals with a known disease, with the goal of limiting or preventing future complications. Examples include screening patients with diabetes for microalbuminuria, rigorous treatment of diabetes mellitus, and post–myocardial infarction prophylaxis with β-blockers and aspirin.
The Centers for Disease Control and Prevention (CDC) provides specific recommendations for backup
contraception after IUD insertion. According to the CDC guidelines, this patient does not need to use
backup contraception if her IUD is inserted today because it was inserted within 7 days after menstrual
bleeding started. If the levonorgestrel IUD is inserted more than 7 days after menstrual bleeding starts,
the patient needs to abstain from sexual intercourse or use additional contraceptive protection for the next
7 days.
Elderly patients, especially those taking hydrochlorothiazide, are at risk for developing hyponatremia while taking carbamazepine. Carbamazepine is one of the medications that can cause the syndrome of inappropriate antidiuretic hormone secretion, as it interferes with the ability to dilute the urine. It does not lead to the other derangements listed (SOR A).
Prazosin is an α-adrenergic receptor antagonist and is recommended for the treatment of nightmares in posttraumatic stress disorder (SOR A). It is thought to reduce sympathetic outflow in the brain. Although clonidine may be tried, evidence of its effectiveness is sparse (SOR C). Clonazepam, propranolol, and divalproex have not been recommended.
Oral corticosteroids are not indicated in the treatment of plaque psoriasis. All of the other options are indicated only if topical treatments fail. Of the options listed, the combination of a topical corticosteroid and topical calcipotriene is considered the most appropriate for this patient. Another option would be to add topical tazarotene to the topical corticosteroid. However, when tazarotene is used as monotherapy it often fails to clear plaques and increases the incidence of skin irritation.
This patient presents with signs and symptoms that suggest age-related macular degeneration. Smoking is a modifiable risk factor and smokers should be counseled to quit (SOR C). The patient should be referred to an ophthalmologist for further evaluation and management. Watchful waiting would not be appropriate. Vitamin supplements with Age-Related Eye Disease (AREDS) and AREDS2 formulations have been shown to delay visual loss in patients with age-related macular degeneration (SOR A). Age-related macular degeneration is not reversible but treatment can delay progression or stabilize the changes (SOR A).
The American College of Gastroenterology recommends that patients with severe acute pancreatitis receive enteral nutrition. Enteral feedings help prevent infectious complications, such as infected necrosis, by maintaining the gut mucosal barrier and preventing translocation of bacteria that may seed pancreatic necrosis. Currently, continuous enteral feeding is preferred over bolus feeding. A meta-analysis has shown that continuous nasogastric enteral feeding started in the first 48 hours decreases mortality and the length of hospital stay.
Total parenteral nutrition is not recommended because of infectious and line-related complications. It should be avoided unless the enteral route cannot be used.
This child’s presentation appears most consistent with bites from an insect. Having multiple exposures on skin often not covered by clothing would be typical of household fleas or bedbugs. Tick bites are typically identified by the presence of an actively feeding insect or a single papular lesion. Similarly, brown recluse spider bites would not be expected to be multiple or recurrent. A chigger is the larval form of a mite, which is an eight-legged arthropod. The larval form has only six legs, and tends to crawl into spaces near constricted clothing and cause welts from their bites along the neckline, waistline, sock line, or more rarely on the genitals. A scabies infestation often presents as an eczematous rash in semi-protected folds of skin such as the web spaces of fingers, the umbilicus, the axillae, or the genital region.
Employing a presumptive approach rather than a participatory approach significantly increases the likelihood that a patient, parent, or guardian will accept a recommended vaccine. This strategy implies that accepting the immunization is the usual or normal choice. The correct option in this scenario presumes the patient will accept the immunization, while the remainder of the options ask if they will.
According to an international consensus statement, there are three criteria for diagnosing sarcoidosis: (1) a compatible clinical and radiologic presentation, (2) pathologic evidence of noncaseating granulomas, and (3) exclusion of other diseases with similar findings. The main exceptions to the need for histologic confirmation are the presence of bilateral hilar adenopathy in an asymptomatic patient (stage I) and the presentation of sarcoid-specific Lofgren syndrome—with fever, erythema nodosum, and bilateral hilar adenopathy that can be diagnosed based on clinical presentation alone. An asymptomatic patient with stage I sarcoidosis (bilateral hilar lymphadenopathy on chest radiography) without suspected infection or malignancy does not require an invasive tissue biopsy because the results would not affect the recommended management, which is monitoring only. Treatment is not indicated because spontaneous resolution of stage I sarcoidosis is common.
Reliable biomarkers for diagnosing sarcoidosis do not exist. Although the serum angiotensin converting enzyme level may be elevated in up to 75% of untreated patients, this lacks sufficient specificity, has large interindividual variability, and fails to consistently correlate with disease severity, all of which limit its clinical utility.
Pathologic evidence of noncaseating granulomas from the most accessible and safest biopsy site should be pursued only if there is an indication for treatment, such as significant symptomatic or progressive stage II or III pulmonary disease or serious extrapulmonary disease. If treatment is indicated, corticosteroids are the first-line treatment for sarcoidosis. Second- and third-line treatments include methotrexate, azathioprine, leflunomide, and biologic agents.
This patient has a peripheral neuropathy. A review of the patient’s history and specific laboratory testing was performed to evaluate for the most common treatable causes of peripheral neuropathy, which include diabetes mellitus, hypothyroidism, and nutritional deficiencies. Additional causes of peripheral neuropathy include chronic liver disease and renal disease. It is important to consider medications as a possible cause, including amiodarone, digoxin, nitrofurantoin, and statins. Excessive alcohol use is another important consideration. In this patient, the mildly elevated total protein and erythrocyte sedimentation rate, which suggest a monoclonal gammopathy such as MGUS (monoclonal gammopathy of unknown significance) or multiple myeloma, should direct her workup. Serum protein electrophoresis is indicated to assess for this.
Other less common causes of peripheral neuropathy include carcinoma causing a paraneoplastic syndrome, lymphoma, sarcoidosis, AIDS, and genetic disorders such as Charcot-Marie-Tooth disease. Approximately 25% of patients with peripheral neuropathy have no clearly defined cause after a thorough evaluation and are diagnosed with idiopathic polyneuropathy.
MRI of the lumbar spine can identify central lesions causing spinal cord or nerve root compression but is not indicated in the evaluation of peripheral neuropathy. Serum angiotensin converting enzyme levels and a chest radiograph can assist in the diagnosis of sarcoidosis, which can cause peripheral neuropathy but is less likely in this patient. Cerebrospinal fluid analysis is important in assessing for chronic inflammatory demyelinating polyradiculoneuropathy, a more rare cause of peripheral neuropathy.
The annual failure rate of combined oral contraceptive pills with typical use is 7%. Typical failure rates for other contraceptive methods are 0.2% for the levonorgestrel IUD, 4% for injectable progestin, 13% for male condoms, and 22% for the withdrawal method.
Due to the disease prevalence and impact, effectiveness of screening instruments, and benefits of available treatment, the U.S. Preventive Services Task Force (USPSTF) recommends screening for major depressive disorder when adequate systems are in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. The USPSTF has made no recommendations regarding screening for bipolar disorder, generalized anxiety disorder, posttraumatic stress disorder, or schizophrenia.
Fibromyalgia is a chronic complex condition characterized by muscle pain, fatigue, muscle tenderness, and sleep disorders, often accompanied by mood disorders. SSRIs have been studied in the treatment of these symptoms, and while they have been shown to produce up to a 30% reduction in pain scores in patients with fibromyalgia, they have not been shown to affect fatigue or sleeping problems. They also have not been shown to be superior to tricyclics when treating pain. As with other patient populations, SSRIs have been shown to improve depression in those with fibromyalgia.
Once the diagnosis of acute rheumatic fever is made, NSAIDs such as aspirin or naproxen should be
administered (SOR B). The therapeutic response to NSAIDs is often remarkable. Acetaminophen has not
been shown to be a superior analgesic for acute rheumatic fever. Gabapentin is not indicated, especially
considering that the pain does not have a neuropathic etiology. Opioids would not be considered first-line
treatment because of their adverse effects and the dramatic response of NSAIDs alone.
This patient has acute chest syndrome (ACS), a serious vaso-occlusive complication of sickle cell disease (SCD). Its cause may be multifactorial, but infections are common and antimicrobials are indicated. However, the clinical course of ACS is significantly different from infectious pneumonia in patients without SCD, due to the damaged microvasculature that occurs in ACS. Studies have shown that atypical pathogens predominate in ACS and it is therefore important to treat all patients with ACS with antibiotics that cover Mycoplasma and Chlamydophila. Viral infections are also common, especially in children with ACS. Other possible pathogens include Staphylococcusaureus, Streptococcus pneumoniae, and Haemophilus influenzae. Therefore, the use of a third-generation cephalosporin along with azithromycin is the recommended antibiotic coverage.
In addition to antimicrobials, treatment includes supportive care with supplemental oxygen, intravenous fluids, pain control, and incentive spirometry. Depending on the degree of anemia seen, a simple blood transfusion or exchange transfusion is often indicated as well. Consultation with a hematologist is recommended in the care of patients with ACS. Even with appropriate care, mortality rates in ACS are as high as 3%.
Recommendations to screen for vitamin D deficiency apply only to patients at risk and not to the general population. This patient’s obesity and her clothing style, which limits sun exposure to the skin, puts her at increased risk. Additionally, this patient’s muscle aches may be a symptom of vitamin D deficiency. The recommended test for this condition is a 25-hydroxyvitamin D level. A 1,25-dihydroxyvitamin D level is recommended to monitor, not diagnose, certain conditions. Parathyroid hormone, calcium, and alkaline phosphatase levels are poor indicators of vitamin D status.
Absorption of levothyroxine is impaired by several gastrointestinal conditions, including atrophic gastritis, chronic proton pump inhibitor use, and Helicobacter pylori infection. Treatment of H. pylori infection reverses this effect, and following eradication of the infection a reduction of the levothyroxine dosage by 30% or more will often be required.
Acute uncomplicated cystitis responds well to 3 days of trimethoprim/sulfamethoxazole, 160/800 mg twice daily. Increasing resistance to fluoroquinolones has been seen and they are therefore less likely to be successful. Because of the association with tendon rupture they are also not considered first-line treatment. β-Lactam agents have similar resistance issues. Azithromycin is not indicated for urinary tract infections.
Ibuprofen alone has produced good symptom relief, but antibiotics are frequently needed
for a definitive cure. The presence of diabetes or prediabetes should not change treatment (SOR A, SOR C).
The European Society of Cardiology 2016 Guidelines for Atrial Fibrillation state that the benefits of oral anticoagulation outweigh the risks in the majority of patients with atrial fibrillation who meet CHA2DS2-VASc criteria for oral anticoagulation. This includes the elderly and patients with cognitive impairment, frailty, or frequent falling. Oral anticoagulation is superior to aspirin for the prevention of stroke, while the bleeding risk with aspirin is not different than that of oral anticoagulation.
Use of the CHA2DS2-VASc criteria significantly increases the number of patients eligible for anticoagulation therapy compared with the CHADS2 scoring system. If there is concern about bleeding risk, particularly in patients older than 65 years of age, the HAS-BLED scoring system has been well validated, with a score of 3 or more indicating that a patient has a high likelihood of hemorrhage. This patient’s HAS-BLED score is 1 (age) and her estimated risk of major bleeding with 1 year of anticoagulation is 1.88%–3.3%. Her adjusted stroke risk is high (4.8% per year), as she has a CHA2DS2-VASc score of 4 (age ≥75, female, history of hypertension).
In addition to aspirin, a high-intensity statin, and sublingual nitroglycerin as needed, patients with chronic stable angina may be treated with β-blockers, calcium channel blockers, and/or long-acting nitrates. β-Blockers and heart rate–lowering calcium channel blockers should be avoided in this patient who already has bradycardia. Ranolazine, which affects myocardial metabolism, is not used as a first-line agent. Ivabradine is not a first-line agent and is used only in patients with heart failure. A long-acting nitrate or a dihydropyridine calcium channel blocker would be appropriate for this patient.
This patient has signs and symptoms of cubital tunnel syndrome, which is the second most common peripheral neuropathy. Symptoms develop because of ulnar nerve compression in the upper extremity, leading to sensory paresthesias in the ulnar digits and intrinsic muscular weakness. Vague motor problems, including poor coordination of the fingers and hand clumsiness, are frequent complaints. Provocative testing includes demonstration of Tinel’s sign over the cubital tunnel, and the elbow flexion test with paresthesias elicited over the ulnar nerve.
Carpal tunnel syndrome causes paresthesias in the distal median nerve distribution. Wartenberg’s syndrome reflects compression of the superficial radial nerve. Pronator syndrome is a proximal median nerve neuropathy, while anterior interosseous nerve syndrome, a rare clinical entity, causes paresis or paralysis of the flexor pollicis longus, and the flexor digitorum profundus of the index and long fingers.
If atrial fibrillation is converted back to sinus rhythm, the likelihood of the patient staying in sinus rhythm is best predicted from the diameter of the left atrium on the patient’s echocardiogram. Significant left atrium enlargement means the patient is unlikely to stay in sinus rhythm after successful conversion.
Other factors that predict a lack of success in maintaining sinus rhythm after cardioversion include a longer time in atrial fibrillation before cardioversion, or the presence of underlying heart disease, especially rheumatic heart disease.
Fractures of the clavicle are common in young individuals, usually from sports injuries or direct trauma. Eighty percent of these fractures occur in the midclavicle. Unless significantly displaced, these fractures do not require referral. They can be treated with just a sling for 2–6 weeks. A sling is more comfortable and less irritating than a figure-of-eight bandage. Passive range of motion of the shoulder is indicated as soon as the pain allows. Physical therapy may be started at 4 weeks after the injury.
In a patient with cancer, deep vein thrombosis of the leg or a pulmonary embolus is considered to be cancer-associated thrombosis. Low molecular weight heparin (LMWH), such as enoxaparin, should be chosen over the other anticoagulant options listed. (LMWH over warfarin is a Grade 2B recommendation; LMWH over dabigatran is a Grade 2C recommendation; LMWH over rivaroxaban is a Grade 2C recommendation; and LMWH over apixaban or edoxaban is a Grade 2C recommendation).
This child has gastroesophageal reflux. This is a normal physiologic process that occurs in infants. Most reflux events are caused by transient lower esophageal sphincter relaxation that is triggered by postprandial gastric distention. This relaxation can continue into childhood, but with growth and an upright eating position it generally improves. Reflux in infants can be treated by implementing body position changes while awake, lower volume feedings if they are overfed, thickening agents, and antiregurgitant formula. It is recommended to avoid the use of medication in infants that have regurgitation that is effortless, painless, and not affecting growth. When the infant is not growing well or appears to be in pain, it would be appropriate to initiate pharmacotherapy with an acid-suppressing medication. Abdominal ultrasonography would be indicated if there were forceful vomiting and concerns about possible pyloric stenosis.
Although the FDA has not approved the use of antipsychotics for aggressive behavior associated with dementia, they are often used to treat refractory behavioral and psychological symptoms of dementia. Their off-label use should be considered only when nonpharmacologic therapies are ineffective and the behaviors pose a risk of harm to the patient or others (SOR C), and the drug should be discontinued if there is no evidence of symptom improvement (SOR A). In a meta-analysis of three atypical antipsychotics, only aripiprazole showed small average reductions in behavioral and psychological symptoms of dementia. Olanzapine has demonstrated inconsistent results and ziprasidone is ineffective. Diphenhydramine is an anticholinergic agent and could exacerbate behaviors. Mirtazapine is indicated for depression. The American Geriatrics Society recommends against the use of benzodiazepines in older adults as a first choice for insomnia, agitation, or delirium.
There are three situations when a breach of confidentiality is justified: abuse of a vulnerable person (child or elderly), a public health risk (communicable disease), or substantial danger to the patient or others. While Chlamydia is not usually considered life-threatening or dangerous, it is communicable. Contacting sexual partners to notify and treat them to stem the spread of disease is recommended.
Sepsis is a severe life-threatening disorder that has a 25%–30% mortality rate. Early aggressive management has been shown to decrease the mortality rate. The initial step in the management of sepsis is respiratory stabilization. Fluid resuscitation should be started and followed by vasopressor therapy if there is an inadequate blood pressure response. Antibiotics should be initiated within 1 hour of presentation. Other interventions in early goal-directed therapy that have been shown to improve mortality rates include blood transfusions, low-dose corticosteroid therapy, and conventional (not intensive) glycemic control with a target glucose level of <180 mg/dL. Intensive management of glucose in critically ill adult patients (a target glucose level of 80–110 mg/dL) has been shown to increase mortality.
This child presents with oppositional defiant disorder (ODD). To meet the DSM-5 criteria for ODD, the child must demonstrate at least four symptoms from any of the following categories: angry/irritable mood (often loses temper, is often touchy or easily annoyed, is often angry and resentful), argumentative/defiant behavior (often argues with authority figures or with adults, often actively defies or refuses to comply with requests from authority figures, often deliberately annoys others, often blames others for his/her mistakes or misbehavior), and vindictiveness (has been spiteful or vindictive at least twice within the past 6 months). These behaviors must be directed toward at least one person other than a sibling.
Behavioral problems associated with conduct disorder are more severe, including aggression toward animals or other persons, destruction of property, and a pattern of theft or deceit. The person’s conduct frequently leads to conflict with authority figures.
Attention-deficit/hyperactivity disorder involves difficulty in following rules, struggles with authority figures, and possibly annoying others. In ODD, however, defiance of authority figures occurs in settings other than those where sustained attention or sitting quietly is required.
Bipolar disorder can include irritability and negative affect but the argumentative, defiant behavior or vindictiveness that occur in ODD do not routinely occur in mood disorders.
Intermittent explosive disorder involves repeated, sudden episodes of impulsive, aggressive, violent behavior or angry verbal outbursts in which the person reacts grossly out of proportion to the situation. Road rage, domestic abuse, throwing or breaking objects, or other temper tantrums may be signs of intermittent explosive disorder. Serious aggression toward others does not occur in ODD.
This patient’s history fits the diagnosis of functional dyspepsia. Two subtypes of this disorder have been described. The first, epigastric pain syndrome, is described as intermittent pain and burning in the epigastrium. The second, postprandial distress syndrome, is more typical of the symptoms this patient describes: postprandial fullness and early satiety. Although there is considerable benefit from reassurance and “naming” a patient’s condition, empiric treatment is also warranted. Patients with epigastric pain syndrome are more likely to respond to proton pump inhibitors or H2-blockers. Patients with predominantly postprandial distress symptoms are more likely to improve with a motility agent such as metoclopramide. Sucralfate, antacids, and selective antidepressants have not been shown to be more effective than placebo in functional dyspepsia, whereas tricyclic antidepressants and buspirone have shown some benefit and are reasonable next steps for this patient.
Community-acquired pneumonia in children is treated based on age. The most likely etiologic agents in a school-age child are Mycoplasma pneumoniae , Chlamydia pneumoniae , and Streptococcus pneumoniae . Group A Streptococcus and Haemophilus influenzae are less common causes. Staphylococcus aureus that is methicillin-resistant has become increasingly common. The preferred treatment for community-acquired pneumonia is a macrolide antibiotic such as azithromycin.
In children ages 5–16, Mycoplasma pneumonia tends to have a gradual onset of symptoms and seldom causes respiratory distress. Signs and symptoms may vary. The patient may develop a rash, musculoskeletal symptoms, or gastrointestinal symptoms. Radiographs may reveal bronchopneumonia, nodular infiltrates, hilar adenopathy, pleural effusions, or plate-like atelectasis. Ear pain may be due to bullous myringitis, although this may be viral as well. Laboratory findings may not be helpful, as the WBC count may be normal or slightly elevated. There may be thrombocytosis, an elevated erythrocyte sedimentation rate, an elevation of cold agglutinins, or an elevated reticulocyte count. A Coombs test is seldom needed, although it might be helpful at times. The diagnosis is generally made on a clinical basis.
In young patients with hypertension it is important to consider secondary causes in addition to the more common essential hypertension. This patient’s relatively young age and elevated home blood pressure readings despite drug therapy warrant further evaluation. The initial evaluation showed hypokalemia, which suggests an endocrine cause of hypertension, specifically hyperaldosteronism. Other potential causes of secondary hypertension include coarctation of the aorta, renal artery stenosis, thyroid disorders, obstructive sleep apnea, pheochromocytoma, and Cushing syndrome. Each of these presents with clinical findings that help to distinguish them from other potential causes, and the laboratory evaluation would depend on the suspected cause.
Based on her clinical presentation and classic ophthalmopathy, this patient has Graves disease. Unlike radioactive iodine, methimazole has been shown to decrease the risk of development or progression of ophthalmopathy in Graves disease (SOR B). Atenolol is used for symptomatic control in hyperthyroidism. Cholestyramine can help lower thyroid hormone acutely but is not a long-term treatment. Prednisone is used for severe hyperthyroidism and not long-term treatment. Atenolol, cholestyramine, and prednisone do not have any effect on the long-term complications of Graves disease.
Accepted mood stabilizers used for maintenance therapy in patients with bipolar disorder include lithium, valproate, lamotrigine, and some atypical antipsychotics such as olanzapine, quetiapine, and risperidone. The atypical antipsychotics are associated with weight gain and adverse metabolic changes. Annual testing for diabetes mellitus is recommended. Long-term maintenance therapy with a mood stabilizer is recommended in patients with bipolar I disorder due to the high risk of recurrent mania. Monotherapy with antidepressants is contraindicated. Although the typical antipsychotics may cause QT
prolongation, atypical antipsychotics such as quetiapine do so much less frequently, and most SSRIs do not cause this. Coadministration with sertraline is not contraindicated.
Conservative treatment is the recommended initial management for olecranon bursitis when there is no history of trauma or signs of septic bursitis. Aspiration of the bursal fluid is not recommended initially due to the risk of iatrogenic infection, but can be considered for symptomatic relief if there is significant enlargement or symptoms, or for diagnosis and culture if septic bursitis is suspected. Antibiotics are not recommended for aseptic bursitis and should be delayed in septic bursitis until after aspiration for culture. MRSA coverage may be indicated if the patient is at high risk for MRSA infection. An intrabursal corticosteroid injection is not routinely recommended for bursitis unless an underlying inflammatory condition is suspected, such as gout or rheumatoid arthritis. An intrabursal hyaluronic acid injection is not a recommended treatment for bursitis.
Generally, the goal for patients with vertebral compression fractures is early mobilization when tolerated. Bed rest is ordered only if movement is not tolerated. The evidence for back bracing is limited but it can be used after weighing the risks and benefits. Current evidence supports initial conservative treatment before considering vertebroplasty or kyphoplasty (SOR C). Neurosurgical consultation is not required in this case.
There has been a large increase in the number of diagnostic tests available over the past 20 years. Although tests may aid in supporting or excluding a diagnosis, they are associated with expense and the potential for harm. In addition, the characteristics of a particular test and how the results will affect management and outcomes must be considered. Clinically useful statistics for evaluating diagnostic tests include the positive predictive value, negative predictive value, and likelihood ratio.
The likelihood ratio indicates how a positive or negative test correlates with the likelihood of disease. Ratios greater than 5–10 greatly increase the likelihood of disease, and those less than 0.1–0.2 greatly decrease it. In the example given, if the patient’s endometrial stripe is >25 mm, the likelihood ratio is 15.2 and her post-test probability of endometrial cancer is 63%. However, if it is ≤4 mm, the likelihood ratio is 0.02 and her post-test probability of endometrial cancer is 0.2%.
The number needed to treat is useful for evaluating data regarding treatments, not diagnosis. Prevalence is the existence of a disease in the current population, and incidence describes the occurrence of new cases of disease in a population over a defined time period. The relative risk is the risk of an event in the experimental group versus the control group in a clinical trial.
The 2013 American College of Cardiology/American Heart Association cholesterol guideline suggests statin therapy for individuals with an estimated 10-year risk of atherosclerotic cardiovascular disease of 7.5% or greater. The U.S. Preventive Services Task Force and the National Institute for Health and Care Excellence recommend statin therapy when the patient’s 10-year risk of cardiovascular disease is 10% or greater. While international guidelines differ somewhat, other major guidelines would support similar recommendations.
Constitutional growth delay, defined as delayed but eventually normal growth in an adolescent, is usually genetic. If evaluation of the short adolescent male reveals no evidence of chronic disease, if his sexual maturity rating is 2 or 3, and if his height is appropriate for his skeletal age he can be told without endocrinologic testing that he will begin to grow taller within a year or so. His adult height may be below average but cannot be predicted reliably. Average sexual maturity ratings for a male of 14.3 years are 4 for genitalia and 3–4 for pubic hair. The history and physical examination would have given clues to any illnesses or nutritional problems.
Family physicians should know about health risks associated with adverse childhood experiences (ACEs). Many risk factors are associated with cumulative ACEs. As ACEs increase so do the risks for alcoholism, drug abuse, depression, suicide attempts, smoking, poor self-rated health, ≥50 sex partners, sexually transmitted disease, physical inactivity, severe obesity, and several chronic medical conditions that are leading causes of death in adults. Of the options listed, this child is at greatest risk for alcoholism.
α1-Blockers such as doxazosin, prazosin, and tamsulosin have been shown to hasten the passage of ureteral stones (level 2 evidence). They are probably more effective than calcium channel blockers (level 2 evidence). β-Blockers, phosphodiesterase inhibitors such as sildenafil, 5-α-reductase inhibitors such as finasteride, and thiazide diuretics have not been shown to hasten stone passage. However, thiazide diuretics have been shown to decrease stone formation in patients with hypercalciuria.
In 2013 nearly 180,000 bariatric surgery procedures were performed in the United States. Bariatric surgery does result in reduced all-cause mortality and more weight loss. National Institutes of Health Consensus Development Conference eligibility criteria include comprehension of risks, benefits, expected outcomes, alternatives, and required lifestyle
changes, including required postoperative lifelong supplements, diet changes, and follow-up appointments.
Posterior midline fissures cause pain during and after defecation. Most are caused by the passage of hard stool and when stretched cause bleeding. Conservative therapy consisting of bulk agents and stool softeners usually allows these to heal.
Internal hemorrhoids can cause bleeding with the passage of stool but are typically painless. External hemorrhoids can bleed with trauma but typically cause pain with thrombosis, independent of bowel movements. Anal fistulas and perirectal abscesses may intermittently drain purulent material. Abscesses can cause continuous pain, and a perianal mass may be noted on examination.
This patient’s MRSA bacteremia is considered uncomplicated due to the effectiveness of the antibiotic therapy and the lack of endocarditis or implanted prostheses such as heart valves. Therefore, the Infectious Diseases Society of America recommends that follow-up cultures of blood samples be obtained 2–4 days after the initial cultures and as needed thereafter to document clearance of bacteremia (SOR A; Quality of Evidence II).
GLP-1 agonists are contraindicated in patients with medullary thyroid cancer or multiple endocrine neoplasm syndrome, or with a family history of these conditions. They are not associated with heart failure, coronary artery disease, or hypothyroidism. They have been associated with pancreatitis in rare cases, but this is not a contraindication to prescribing them.
Coin rubbing is a traditional healing custom practiced primarily in east Asian countries such as Cambodia, Korea, China, and Vietnam. The belief is that one’s illness must be drawn out of the body, and the red marks produced by rubbing the skin with a coin are evidence of the body’s “release” of the illness. These marks may be confused with abuse, trauma from some other source, or an unusual manifestation of the illness itself.
Recent guidelines have suggested that hypotension (a systolic blood pressure <90 mm Hg or a diastolic blood pressure <60 mm Hg, for 15 minutes or longer) should be treated with thrombolysis in patients who are not at high risk for bleeding. Patients who have other indicators of cardiopulmonary impairment without signs of hypotension should be given anticoagulation therapy and aggressive supportive care, but should not be treated with thrombolytic therapy. If the patient’s condition continues to deteriorate as evidenced by the development of hypotension or other clinical indicators of cardiopulmonary compromise, thrombolysis may be considered.
This patient has osteomyelitis until proven otherwise. A radiograph of his right foot is the best initial test to look for evidence of this diagnosis. In most treatment settings, radiography is much easier to obtain than ultrasonography, CT, MRI, or technetium 99m bone scintigraphy. In addition, it is generally considerably less expensive than the other options listed. A radiograph also allows the physician to rule out other bony pathologies. MRI is useful if the radiograph is inconclusive, and is more helpful than radiography for determining bony versus soft-tissue infection. CT may be used in cases where MRI is contraindicated. Ultrasonography is not useful for evaluating bony lesions. Bone scintigraphy has low sensitivity, particularly in the setting of recent trauma or surgery.
According to the guidelines of the American Academy of Pediatrics, elemental iron supplementation (2 mg/kg per day) should begin at 1 month of age for exclusively breastfed infants born before 37 weeks gestation and should continue until 12 months of age, unless the infant had multiple blood transfusions.
All staff, visitors, and nursing home residents should observe strict handwashing practices when a resident has a MRSA infection. Barrier precautions for wounds and medical devices should also be initiated. Surveillance cultures are not warranted. Aggressive housekeeping practices play little, if any, role in preventing the spread of MRSA. Isolating the patient is not practical or cost effective.
Achilles tendinopathy is among the most common injuries in middle-aged distance runners. Oral NSAIDs may be helpful for temporary pain relief, but they contribute little to recovery from this injury. Corticosteroid injection is contraindicated due to the risk of tendon rupture. Surgical debridement and fixation in a walking boot may be considered as a last resort for difficult cases, but the most effective treatment overall is eccentric calf-strengthening exercises.
Screening for colorectal cancer (CRC) is recommended for average-risk individuals beginning at age 50 (SOR A). Individuals at higher risk include those with a personal history of adenomatous polyps, CRC, inflammatory bowel disease, genetic cancer syndromes, or a family history of either adenomatous polyps or CRC. Patients with a first degree relative with CRC or adenomatous polyps discovered before age 60, or two or more first degree relatives at any age with CRC or advanced adenoma, should undergo colonoscopy screening starting at age 40 or 10 years before the youngest age a family member was diagnosed, whichever comes first. The maximum surveillance interval for these patients is 5 years (SOR C). Patients with a single first degree relative diagnosed at age 60 or older, and patients with two affected second degree relatives, should undergo screening starting at age 40 by any recommended method, and at the same intervals for average-risk individuals (SOR C). Patients with small, distal hyperplastic polyps are considered to have a normal colonoscopy (SOR C). There is no need for referral to a gastroenterologist or interval fecal immunochemical testing (FIT) following an adequate colonoscopy.
Infantile hemangiomas usually appear by 4 weeks of age and stop growing by 5 months of age. As many as 70% leave residual skin changes, including telangiectasia, fibrofatty tissue, redundant skin, atrophy, dyspigmentation, and scarring. Systemic corticosteroids were the mainstay of treatment for hemangiomas during infancy until 2008, when the FDA approved oral propranolol for this indication. Intralesional corticosteroids can be effective for small, bulky, well localized lesions in infants. Laser therapy can also be used to treat early lesions or residual telangiectasia. Once involution is complete, however, as is the case with this child, elective surgical excision is the treatment of choice, producing better outcomes.
First-line agents for hypertension include ACE inhibitors, angiotensin receptor blockers, thiazide diuretics, and calcium channel blockers. Hydrochlorothiazide would be relatively contraindicated due to the patient’s gout. Losartan, an angiotensin receptor blocker, should not be added because the patient is taking an ACE inhibitor. Metoprolol succinate, a β-blocker, is not a first-line agent for blood pressure unless there is another indication such as systolic heart failure or migraine prophylaxis.
Penile enlargement in an 8-year-old male is a sign of precocious puberty. Isolated sparse pubic and axillary hair growth and axillary odor is referred to as premature adrenarche, and represents high levels of dehydroepiandrosterone rather than activation of the hypothalamic-pituitary-gonadal axis that leads to puberty. The isolated findings of premature adrenarche are generally considered benign. An 8-year-old with breast buds and a 10-year-old with menarche are within the normal range of expected pubertal development. Penile enlargement typically represents full activation of the hypothalamic-pituitary-gonadal axis and warrants endocrinologic evaluation in boys younger than 9 years of age.
According to the American College of Rheumatology criteria, this patient has systemic lupus erythematosus, with photosensitivity, arthritis, a positive antinuclear antibody test, and a positive anti–double-stranded DNA test. She has a mild form of the disease. Hydroxychloroquine reduces arthritis pain in lupus patients (SOR A) and is the preferred initial treatment for lupus arthritis. Cyclosporine and azathioprine are indicated for severe lupus or lupus nephritis. Mycophenolate is indicated for refractory lupus or lupus nephritis. Rituximab is indicated for severe refractory lupus.
In otherwise healthy stable patients with upper gastrointestinal bleeding, a transfusion of red cells is recommended when the hemoglobin level falls below 7.0 g/dL. In hypotensive patients with severe bleeding, a blood transfusion before the hemoglobin level reaches 7.0 g/dL is needed to prevent significant decreases below this level that would occur with just fluid resuscitation. In hemodynamically stable patients with known cardiovascular disease and significant upper gastrointestinal bleeding, 8.0 g/dL should be the threshold for a blood transfusion.
Elevated levels of NT-proBNP are known to indicate an increased likelihood of heart failure, and lower levels can rule out heart failure. However, certain patient characteristics can lead to higher levels of NT-proBNP even in healthy individuals. The use of one normal cutoff level for elevated NT-proBNP may not be appropriate. Even healthy female patients and those >65 years of age will have higher levels of NT-proBNP than younger male patients (SOR A).
NT-proBNP is negatively correlated with kidney function as measured by the estimated glomerular filtration rate (GFR) and albumin levels. Patients with a low GFR or a low level of albumin have higher NT-proBNP levels (SOR A). Interestingly, grip strength is negatively correlated with NT-proBNP as well.
A higher BMI is associated with a lower NT-proBNP. Thus, the utility of NT-proBNP to rule out heart failure in obese patients is decreased (SOR A).
NSAIDs such as ibuprofen should be used as first-line treatment for the control of pleuritic pain (SOR B).
NSAIDs do not have the analgesic potency of narcotics, but they do not cause respiratory suppression and
do not change the patient’s sensorium. Corticosteroids should be reserved for patients who cannot take
NSAIDs. Colchicine is used to treat pericarditis but not pleuritic pain.
Randomized, controlled studies yield stronger evidence than other types of studies, especially case-control or cohort studies, because randomization provides the greatest safeguard against unanticipated study bias. Evidence obtained from randomized, controlled studies is considered level 1 (strongest) by the U.S. Preventive Services Task Force. Evidence obtained from nonrandomized, controlled studies is considered level 2a, well-designed case-control and cohort studies are considered level 2b, and reports of expert committees or respected authorities are considered level 3 (weakest).
Legionella should be considered as a pathogen for community-acquired pneumonia when the patient has a history of a hotel stay or cruise ship travel within the past couple of weeks. Travel to or residence in Southeast Asia or East Asia is a risk factor for avian influenza, exposure to farm animals or parturient cats is a risk factor for Coxiella burnetii infection, exposure to bird or bat droppings is a risk factor for Histoplasma capsulatum infection, and travel to or residence in desert Southwest states with deer mouse exposure is a risk factor for Hantavirus infection.
In 2016 the CDC changed the recommendation for the number of HPV vaccine doses for children ages 11–14. Children in this age group need only two doses of HPV vaccine 6–12 months apart. However, if they received two doses of HPV vaccine less than 5 months apart, they still need to have the third dose. Children and young adults over the age of 14 and those with certain immunocompromising conditions still require three doses of HPV vaccine. There is no indication for a booster dose at a later date, nor is there clinical data to support using titers to gauge immunogenicity to HPV.
A fractured hip is possible and must be ruled out since there is difficulty bearing weight and the leg is externally rotated. Examination of a patient with severe dementia can be extremely difficult. Other findings with a fractured hip would include pain elicited on rotation and groin pain when applying an axial load. If the hip radiograph is negative, MRI of the knee may be considered.
Informed consent to treat is considered an important ethical and legal part of caring for children and adolescents. Some situations can become confusing when trying to balance the need for treatment, a child’s consent, and a parent or guardian’s permission. In most states, 18 is the age when legal decisions can be made; however, in some states 21 years old is the age of legal consent.
Children below the age of majority must have proof of permission to treat from a parent or guardian for non-emergent care. This does not apply to emergency situations in which a delay in care could result in serious harm. Another exception to parental consent is when a child is considered emancipated under state law. This can happen with a court order, or (in some states) if the child is married, is a parent, is in the military, or is living independently. Either biologic parent can consent to treatment unless one of them is explicitly denied guardianship. If a child presents with a non-emergent condition and does not have evidence of permission from a parent or guardian, permission should be sought before the physician interaction takes place.
By definition, a pulmonary nodule is a circumscribed, round lesion that may measure up to 3 cm in size and is surrounded by aerated lung. Management is based on the size of the nodule and the probability of malignancy. Risk factors for lung cancer include a previous malignancy, a positive smoking history, and age ≥65. Only 1% of nodules between 2 mm and 5 mm in size are malignant.
Nodules <8 mm are difficult to biopsy, and a PET scan is not reliable. The risk of surgery outweighs the benefits in nodules of this size. For a low-risk patient with a nodule 4 mm to <8 mm in size, a repeat noncontrast CT at 12 months is recommended. If it is unchanged, no further follow-up is needed.
Female pattern hair loss is categorized as diffuse and nonscarring. It presents with parietal hair thinning with preservation of the frontal hairline. Minoxidil 2% produces regrowth of hair in female pattern hair loss (SOR B). Oral finasteride is appropriate only for men with male pattern hair loss (SOR A). Hydroxychloroquine is used for inflammatory hair loss associated with discoid lupus erythematosus, which is focal and scarring. Topical corticosteroids are appropriate for alopecia areata (SOR B) but not for female pattern hair loss. Griseofulvin is used to treat tinea capitis, which presents as focal scale with erythema.
A recent review from the Agency for Healthcare Research and Quality (AHRQ) found the frequency of adverse events in older adults taking SSRIs such as sertraline and escitalopram was similar to placebo (SOR B). SSRIs also have lower discontinuation rates than tricyclic antidepressants such as amitriptyline or nortriptyline during treatment of up to 12 weeks (SOR B).
Evidence suggests that SNRIs including duloxetine and venlafaxine cause more adverse events and greater discontinuation of therapy during treatment of up to 12 weeks when compared to placebo (SOR B). A randomized, controlled trial involving duloxetine demonstrated an increased risk of treatment withdrawal due to adverse events and an increased risk of falls over 12–24 weeks.
Venlafaxine was compared to no antidepressant use in a large cohort study that had a median treatment period of 364 days and was associated with an increased risk of falls, fractures, and mortality.
The Joint Commission for Hospital Accreditation now requires a patient spiritual assessment upon hospital admission. Using the FICA Spiritual History Tool or HOPE questions for making the spiritual assessment is appropriate for the physician. HOPE is a mnemonic for sources of Hope, Organized religion, Personal spirituality and practices, and Effects on medical care and end-of-life issues. The FICA tool includes questions in the categories of Faith and beliefs, Importance, Community, and how to Address these issues when providing care. It is very appropriate for a physician to conduct a spiritual assessment in older, hospitalized patients with critical or terminal illnesses. Some patients may consider themselves spiritual but not necessarily religious.
This patient has confirmed peripheral artery disease (PAD) with an abnormal ankle-brachial index. Guideline-directed therapy for PAD includes low-dose aspirin, moderate- to high-intensity statin therapy, an ACE inhibitor or angiotensin receptor blocker, a structured exercise program, and smoking cessation. Apixaban is a novel oral anticoagulant that is used for stroke prevention in nonvalvular atrial fibrillation as well as treatment of deep vein thrombosis and pulmonary embolism. Apixaban is not used for the treatment of PAD.
This patient has physical findings and a history consistent with impetigo, a skin infection caused by Staphylococcus aureus and/or Streptococcus pyogenes . Since she has only one lesion, systemic antibiotics are not required as they would be for a patient with extensive disease or multiple lesions. Although bacitracin and neomycin are commonly used, they are much less effective for impetigo than mupirocin, despite some reports of resistance to mupirocin (level A-1 evidence).
Patellofemoral pain syndrome is one of the most common causes of knee pain in children, particularly adolescent girls. Pain beneath the patella is the most common symptom. Squatting, running, and other vigorous activities exacerbate the pain. Walking up and down stairs is a classic cause of the pain, and pain with sitting for an extended period is also common. The physical examination reveals isolated tenderness with palpation at the medial and lateral aspects of the knee, and the grind test is also positive.
Osgood-Schlatter disease is seen in skeletally immature patients. Rapid growth of the femur can cause tight musculature in the quadriceps across the knee joint. It typically appears between the ages of 10 and 15, during periods of rapid growth. Pain and tenderness over the tibial tubercle and the distal patellar tendon is the most common presentation. The pain is aggravated by sports participation, but also occurs with normal daily activities and even at rest.
Growing pains most often affect the thigh and quadriceps and occur during late afternoon or evening, or wake the patient at night. The joints are not affected. The pain typically goes away by morning, and may sometimes occur the day after vigorous or unusual activity.
Patellar tendinopathy is an overuse injury often seen in those who participate in jumping sports such as volleyball, and is also related to frequent stops and starts in football players. It typically causes infrapatellar pain, and findings include extensor mechanism malalignment, weakness of ankle flexors, and tightness of the hamstring, heel cord, and/or quadriceps.
Sever’s disease is an overuse syndrome most often seen between the ages of 9 and 14, and is related to osteochondrosis at the insertion of the Achilles tendon on the calcaneal tuberosity. It occurs during periods of rapid growth, causes heel pain during and after activity, and is relieved with rest. It is often related to beginning a new sport or the start of a season.
Current guidelines recommend that patients with an ST-elevation myocardial infarction (STEMI) who also have atrial fibrillation take dual antiplatelet therapy such as aspirin plus clopidogrel and a vitamin K antagonist, with a goal INR of 2.0–3.0. If a patient was already taking a direct-acting oral anticoagulant (DOAC) instead of warfarin for atrial fibrillation, the patient should continue with the DOAC in addition to dual antiplatelet therapy. The duration of triple therapy should be as short as possible, and aspirin can often be discontinued after 1–3 months. However, this patient’s STEMI occurred less than 2 weeks ago and he should continue triple therapy.
Urinary tract infection (UTI) is the most common bacterial infection in women. The annual incidence of UTI in women is 12%. Women who have had a UTI in the past are usually quite adept at diagnosing their own subsequent UTIs. Prospective studies have shown that women who suspect they have a UTI are more than 85% accurate based on culture results (SOR B). This is more accurate than dipstick testing, which has a sensitivity of 75% and a specificity of 82%. Nonpregnant female patients who have typical UTI symptoms without signs of pyelonephritis (i.e., fever and nausea) or vaginitis can be treated safely and effectively by phone.
Urine culture testing is not indicated for uncomplicated UTIs. It has been found that the traditional criterion for infection (100,000 colony-forming units/mL) is not sensitive for women with a UTI. Urine testing should be reserved for patients suspected of having pyelonephritis.
There are three first-line antibiotics for uncomplicated UTI. These include nitrofurantoin for 5 days, trimethoprim/sulfamethoxazole for 3 days, and fosfomycin as a single dose (SOR A). Fluoroquinolones are second-line agents and are best reserved for more serious infections such as pyelonephritis.
Urinary analgesics can be helpful with UTI symptoms but are not the preferred method of treatment, as antibiotics rapidly reduce the symptoms of infection.
Exercise-based therapy is the foundation for treating knee osteoarthritis. Foot orthoses can be helpful for anterior knee pain but this patient’s pain is located medially. The benefit of hyaluronic acid injections is controversial, and recommendations vary; recent systematic reviews do not support a clinically significant benefit. Weight loss is recommended for patients with a BMI >25.0 kg/m2. Wearing a knee brace has shown little or no benefit for reducing pain or improving knee function.
This patient is suffering from acute urinary retention, likely due to mild benign prostatic hyperplasia exacerbated by pain medication and a lack of activity. Acute urinary retention could also possibly be due to irritation of sympathetic and/or parasympathetic nerves near the spine. Placing an indwelling bladder catheter is appropriate. It would also be reasonable, although impractical in the short term, to teach the patient or his caretakers to intermittently catheterize him.
The likelihood of a successful return to voiding spontaneously will increase over time. However, the risk of catheter-associated urinary tract infection is estimated to be about 5% per day. Therefore, catheter removal and a trial of spontaneous voiding should be attempted after 48–72 hours. There is good evidence that starting an α-blocking medication such as tamsulosin during the time the catheter is in place will nearly double the success of the trial of spontaneous voiding. Finasteride in isolation is not recommended and oxybutynin would be contraindicated.
A wealth of evidence-based research has established the benefits of probiotics, especially in children. Probiotics, particularly Saccharomyces boulardii , have been shown to prevent the antibiotic-associated diarrhea that occurs in 5%–30% of children who receive antibiotics (SOR A). The number needed to treat to prevent one case of diarrhea is 10.
Probiotics reduce the pain associated with irritable bowel syndrome (IBS) but have not been shown to be helpful in reducing diarrhea or constipation in pediatric IBS patients (SOR A).
In breastfed infants, probiotics reduce daily crying time by up to an hour. Similar benefits have not been found in formula-fed infants or infants who are combining breastfeeding and formula. Probiotics have not been shown to prevent colic in any infants.
Other benefits of probiotics include the prevention of eczema and upper respiratory infections (SOR A). However, their use has not been shown to prevent allergies and asthma.
Acute mountain sickness (AMS) occurs in at least 25% of persons traveling to destinations over 8000 feet above sea level. Risk factors include rapid ascent, living at low altitudes (<2000 ft), a prior history of altitude illness, and strenuous physical exertion during the ascent. AMS is most often manifested by headache, fatigue, lightheadedness, and/or nausea. The best way to prevent AMS is gradual ascent, but medications may also be effective in prophylaxis, especially if a rapid ascent such as in motorcycling, driving, or flying to altitude is planned.
The drug of first choice in preventing AMS is acetazolamide, a carbonic anhydrase inhibitor, starting the day before ascent. It is, however, contraindicated in patients with sulfa allergy. The second-line drug for prevention is dexamethasone, which should be used for prophylaxis in sulfa-allergic patients. It is also used in the treatment of AMS and high-altitude cerebral or pulmonary edema, but immediate descent of at least 2000 feet is imperative if either of those more serious complications develop. While advocated as a prophylactic and treatment option for AMS, the results for ginkgo are mixed and it is therefore not recommended for use in this situation. Smoking cessation and physical conditioning are both good ideas for this patient, but neither will reduce his risk for developing AMS.
Family physicians should be familiar with age-appropriate cancer screening recommendations. Deaths from cervical cancer have been significantly reduced through screening. HPV testing is not recommended for screening in average-risk women younger than 30 years old. Cytology without HPV testing is recommended for screening every 3 years for an average-risk 21-year-old female.
Patients with systemic sclerosis (SS) in its final stages often develop a restrictive lung disease (SOR C). Interstitial lung disease and pulmonary artery hypertension are common. While the restrictive pattern is similar to idiopathic pulmonary fibrosis, this condition is characteristic of SS and is not idiopathic. Emphysema presents with an obstructive pattern on pulmonary function tests. Pulmonary edema can develop from cardiac malfunction and heart failure, but it is not present in this patient. Sarcoidosis is not related to SS. There is a 10-year mortality of 42% in patients with SS who have an FVC <50%. Cyclophosphamide may be helpful in some cases to improve lung function, decrease dyspnea, and improve the patient’s quality of life (SOR B).
This patient has type 2 diabetes mellitus and presents with new-onset edema in her lower
extremities, the most common presenting symptom of nephrotic syndrome (NS). Patients
with NS may also report foamy urine, exertional dyspnea or fatigue, and significant
fluid-associated weight gain. A 24-hour urine collection for protein (not creatinine) can be
used to diagnose proteinuria, but the collection process is cumbersome and the specimen
is often collected incorrectly. The protein-to-creatinine ratio from a single urine sample is
commonly used to diagnose nephrotic-range proteinuria. The role of a renal biopsy in
patients with NS is controversial and there are no evidence-based guidelines regarding
indications for a biopsy. Renal ultrasonography may be appropriate to assess for underlying
conditions and/or disease complications if the glomerular filtration rate is reduced. There
is no data to support using MRI in the diagnosis and management of nephrotic syndrome.
Vaccine delay and vaccine hesitancy are on the rise in the United States, so family physicians should be familiar with the nuances of vaccine catch-up schedules as well as contraindications. Rotavirus vaccine has age restrictions and should not be initiated after 14 weeks and 6 days of age. In addition, the rotavirus series must be complete by 8 months of age. These age restrictions are intended to ensure the vaccine is administered when it will be of maximal benefit to children given the slightly increased risk of intussusception after vaccine administration. Hepatitis B vaccine should be administered at routine intervals. Haemophilus influenzae type b, inactivated poliovirus, and pneumococcal conjugate can all be administered to this patient today. However, these vaccines have complex follow-up intervals based on the age at prior doses and age at catch-up. Therefore, the clinician should consult the CDC catch-up vaccine schedule to verify dosing intervals.
Colon cancer arises from adenomatous polyps, and generally requires at least 5 years of growth before malignant transformation. Villous adenomas carry a threefold increased risk for becoming malignant compared with other adenomatous types such as tubular or tubulovillous adenomas. The larger the polyp the greater the chance of malignancy, although malignant polyps <1.5 cm are rare. Hamartomas (juvenile polyps) and inflammatory polyps (often associated with inflammatory bowel disease) are benign. Hyperplastic polyps are the most common histologic type by far, but only rarely become cancerous.
The American Diabetes Association recommends screening for all asymptomatic adults with a BMI >25.0 kg/m2 who have one or more additional risk factors for diabetes mellitus, and screening for all adults with no risk factors every 3 years beginning at age 35. Current criteria for the diagnosis of diabetes mellitus include a hemoglobin A1c ≥6.5%, a fasting plasma glucose level ≥126 mg/dL, a 2-hour plasma glucose level ≥200 mg/dL, or, in a symptomatic patient, a random blood glucose level ≥200 mg/dL. In the absence of unequivocal hyperglycemia, results require confirmation by repeat testing.
Neonatal early-onset sepsis (EOS) has an incidence of 0.5 per 1000 live births according to the CDC, and group B Streptococcus (GBS) remains the most common cause. Risk factors for neonatal EOS include maternal GBS, prolonged rupture of membranes, intrauterine inflammation or infection, and the combination of inflammation and infection, commonly known as maternal chorioamnionitis, or triple I. Updated guidelines from the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists replaced traditional guidelines on prevention of neonatal EOS from the CDC.
Current guidelines recommend either categorical risk factor assessment, use of the neonatal EOS calculator, or enhanced observation. However, categorical risk factor assessment, similar to 2002 and 2010 CDC guidelines, would result in blood cultures and administration of antibiotics to any newborn where there was a maternal intrapartum fever.
The other two approaches, particularly use of the neonatal EOS calculator, have been demonstrated to decrease antibiotic administration. This calculator uses a multivariate approach to determining neonatal EOS risk, combining information from both the delivery and postpartum assessment of the newborn. Enhanced observation utilizes frequent clinical assessment and is thought to similarly reduce antibiotic administration. The AAP guidelines suggest C-reactive protein levels and CBCs have poor predictive value in identifying neonatal EOS and should not be used to guide management. Blood cultures are frequently obtained with co-administration of antibiotics and there is no data to suggest that blood cultures alone would reduce antibiotic administration.
This patient has signs and symptoms consistent with primary adrenal insufficiency (PAI). In Western countries autoimmunity is responsible for 90% of these cases. Because the corticotropin (ACTH) stimulation test has a higher degree of sensitivity and specificity than morning cortisol and ACTH concentrations, it is the preferred test in all patients with possible primary adrenal insufficiency. Serum aldosterone paired with plasma renin activity is used to screen for adrenal hyperplasia in hypertensive patients and also for establishing the existence of mineralocorticoid insufficiency in patients with PAI. Once the diagnosis is established, 21-hydroxylase antibodies and 17-hydroxylase progesterone levels are used to determine the etiology of PAI.
Validated clinical prediction rules can be used to estimate the pretest probability of deep vein thrombosis (DVT) and pulmonary embolism in a patient with dyspnea and chest pain, and to guide further evaluation (SOR C). Factors used for calculating the pretest probability include elevated heart rate without hemoptysis, a diagnosis of cancer, recent surgery/immobilization, previous thromboembolism, and signs and symptoms of DVT. Based on these rules the patient described in the scenario has a low score and therefore a low probability of pulmonary embolism.
A D-dimer level is the next most appropriate test for this low-probability scenario. Compression ultrasonography would be the next test for a patient with an intermediate or high pretest probability for DVT. CT angiography would be the next test for a clinically stable patient with an intermediate or high pretest probability of pulmonary embolism. A ventilation-perfusion scan would be the next test if a CT angiogram were indicated in a patient with a contraindication such as contrast allergy, renal disease, or pregnancy. Echocardiography would be the next test for a critically ill patient with a high pretest probability of pulmonary embolism.
NSAIDs, acetaminophen, and muscle relaxants are effective for the treatment of acute low back pain (SOR A). There is moderate-quality evidence that nonbenzodiazepine muscle relaxants are beneficial in the treatment of acute low back pain. There is also moderate-quality evidence that NSAIDs combined with nonbenzodiazepine muscle relaxants may have additive benefit for decreasing pain. Bed rest is not helpful in the treatment of acute back pain and is not recommended (SOR A). There is no evidence that lumbar support is helpful. Oral corticosteroids have not been found to be beneficial for isolated low back pain, but there is questionable benefit when there are associated radicular symptoms. There are several low-quality trials that show acupuncture has minimal or no benefit over sham treatment in acute back pain.
In patients ≥65 years of age treated with medication for type 2 diabetes mellitus, hemoglobin A1c values of 7%–8% have shown the greatest reduction in mortality in multiple studies. It is suggested that frequent hypoglycemia is associated with lower hemoglobin A1c values, and that presents a greater risk. Values over 9% are associated with greater mortality (SOR B). Thus, while the risk of complications increases linearly with hemoglobin A1c, mortality has a V-shaped curve.
Medication and/or a walking program have been shown to improve functional capacity in patients with symptomatic peripheral artery disease (PAD). However, this patient has critical limb ischemia and needs urgent revascularization. Endovascular therapy of isolated disease below the knee is not recommended. These patients should undergo femoral-tibial bypass. Warfarin is not recommended for the treatment of PAD.
When an otherwise healthy patient’s alkaline phosphatase level is elevated, it is helpful to determine whether the source of elevated isoenzymes is the liver or bone. One method is fractionation of the alkaline phosphatase by electrophoresis. A gamma-glutamyl transferase or 5 -nucleotidase level can also indicate whether the elevation of the alkaline phosphatase is from the liver. These enzymes are rarely elevated in conditions other than liver disease. Severe vitamin D deficiency can lead to osteomalacia with an elevated alkaline phosphatase.
The U.S. Preventive Services Task Force does not recommend routine physical examinations but recommends blood pressure screenings every 3–5 years for adults 18–39 years of age who are at low risk for hypertension. Mammograms are not recommended until age 40. Lead screening is recommended for at-risk individuals between 6 months and 6 years of age. Colorectal cancer screening for average-risk individuals is recommended at age 45. Counseling on tobacco use and other substance abuse is recommended as part of all routine preventive care.
In a patient with sepsis, vasopressors are indicated when fluid resuscitation does not restore organ perfusion and blood pressure. Norepinephrine and dopamine are the preferred pressor agents; however, norepinephrine appears to be more effective and has a lower mortality rate. Norepinephrine is the preferred drug for shock due to sepsis. Its relative safety suggests that it be used as an initial vasopressor. It is a potent vasoconstrictor and inotropic stimulant and is useful for shock. As a first-line therapy norepinephrine is associated with fewer adverse events, including arrhythmia, compared to dopamine. Phenylephrine, epinephrine, or vasopressin should not be used as first-line therapy. Vasopressin is employed after high-dose conventional vasopressors have failed. The use of low-dose dopamine is no longer recommended based on a clinical trial showing no benefit in critically ill patients at risk for renal failure. If an agent is needed to increase cardiac output, dobutamine is the agent of choice.
Long-acting reversible contraception (LARC) includes the copper IUD, levonorgestrel IUDs, and subdermal implants. LARCs can be placed at any point in the patient’s menstrual cycle (SOR A). There should be evidence that the patient is not pregnant prior to placement.
This patient has shoulder impingement syndrome (with a positive Hawkins impingement sign) and evidence of supraspinatus tendinopathy (with a positive empty-can rotator cuff test). However, the negative drop-arm rotator cuff test is evidence against a complete rotator cuff tear with a negative drop-arm rotator cuff test, and the absence of night pain supports this. Physical therapy, along with pain control using NSAIDs, acetaminophen, or short-term opiate medication, would be most appropriate as initial therapy. Complete shoulder rest is inappropriate since his daily activities are not aggravating the problem, and cessation of play is not necessary since other treatment options are available. A subacromial corticosteroid injection, while commonly done and likely to provide short-term pain relief, is unlikely to provide long-term improvement in pain and function. Surgery is a potential option if other treatments fail and a significant tear is proven, but is not preferable as an initial treatment.
The 2014 evidence-based guideline from the panel members appointed to the Eighth Joint National Committee (JNC 8) makes few suggestions regarding preferred initial agents for the treatment of hypertension. Of the options listed, only hydrochlorothiazide is a reasonable option for first-line treatment. Verapamil is rarely used for blood pressure control.
