AAFP: Nonspecific Flashcards
A 63 y/o male with a hx of alcoholism and compensated hepatic cirrhosis asks if there are pain medications he can use to treat his chronic low back pain and knee and hand osteoarthritis. He also has occasional headaches. He has not used alcohol for several years. Which one of the following medications is CONTRAINDICATED in this patient?
A. Acetaminophen
B. Gabapentin
C. Naproxen
D. Pregabalin (Lyrica)
E. Tramadol
C. Naproxen
Although pts with chronic mild liver disease may take NSAIDs, they should be avoided in all pts with cirrhosis, due to risk of precipitating hepatorenal syndrome.
Pregabalin and gabapentine are not metabolized by the liver.
Acetaminophen, while toxic in high doses, can be used safely in dosages of 2-3 g/day.
Tramadol is also safe in pts with cirrhosis.
Many of the changes that occur as part of aging affect pharmacokinetics. Which one of the following is INCREASED in geriatric patients?
a. Drug absorption
b. GFR
c. Lean body mass
d. Volume of distribution of water-soluble compounds such as digoxin
e. % of body fat
e. % of body fat
In older persons, there is a relative increase in body fat and relative decrease in lean body mass, which causes increased distribution of fat-soluble drugs such as diazepam. This also increases the elimination half-life of such medications.
The Vd of water-soluble compounds such as digoxin is decreased in older pts, which means a smaller dose is required to reach a given target plasma concentration.
A 45 y/o obtunded male is brought to the ER by ambulance. Slow, shallow respirations are noted. His wife tells you that he is being treated by a local pain specialist for chronic back pain stemming from a severe workplace injury 2 years ago. A urine immunoassay drug screen is negative for opioids. Which one of the following opioid medications would NOT be detected by this drug screen?
a. Codeine
b. Fentanyl
c. Hydrocodone
d. Hydromorphone (Dilaudid)
e. Morphine
b. Fentanyl
Synthetic opioid medications are generally not discovered when screening urine for opioids using an immunoassay method. These synthetic opioids include fentanyl, methadone, and oxymorphone.
Opioid reversal should still be considered in this patient, and a search for a fentanyl patch is indicated.
You see a 16 y/o white F for a preparticipation evaluation for volleyball. She is 183 cm (72 in) tall, and her arm span is greater than her height. She wears contacts for myopia. Which one of the following should be performed at this time?
a. EKG
b. Echo
c. Stress test
d. CXR
e. Coronary MR angiography
b. Echo
Marfan syndrome is an AD disease manifested by skeletal, ophthalmologic, and CV abnormalities. Men taller than 72 inches and women taller than 70 inches who have two or more manifestations of Marfan syndrome should be screened by echo for associated cardiac abnormalities. These signs and sx include cardiac murmurs or clicks, kyphoscoliosis, anterior thoracic deformity, arm span greater than height, upper to lower body ratio more than 1 SD below the mean, myopia, and ectopic lens.
Patients with Marfan syndrome who have echo evidence of aortic abnormalities should be placed on beta-blockers and monitored with echo every 6 mo.
In the U.S., cow’s milk is NOT recommended for children until the age of:
a. 4 mo
b. 6 mo
c. 9 mo
d. 12 mo
e. 15 mo
d. 12 mo
Whole cow’s milk does not supply infants with enough vitamin E, iron, and essential fatty acids, and overburdens them with too much protein, sodium, and potassium. Skim and low-fat milk lead to the same problems as whole milk, and also fail to provide adequate calories for growth.
Human breast milk or iron-fortified formula, with introduction of certain solid foods and juices after 4-6 months of age if desired, is appropriate for the first year of life.
A 17 yo male presents to the urgent care clinic 15 minutes after being stung by a wasp. He feels weak, his voice is hoarse, and he is beginning to have trouble breathing. Which one of the following should be administered first?
a. IM epinephrine
b. IV diphenhydramine (Benadryl)
c. IV famotidine (Pepcid)
d. IV methylprednisolone sodium succinate (Solu-Medrol)
e. IV bolus of NS
a. IM epinephrine
H1 and H2 histamine blockers and corticosteroids may be useful, but they are not the first-line treatments for an anaphylactic rxn to a Hymenoptera sting.
In a woman with PCOS, the risk is increased the most for carcinoma of the:
a. breast
b. cervix
c. colon
d. endometrium
e. ovary
d. endometrium
Several disorders that are common in women with PCOS are associated with an increased risk for endometrial carcinoma.
Those disorders include: obesity, hyperinsulinemia, DM, anovulatory cycles, and high androgen levels
A 30 yo female is referred to you by a local optometrist after she was treated several times for anterior uveitis. You are concerned about an associated systemic disease. She feels well otherwise, and denies back or joint pain, rash, cough, or fever. A CXR reveals enlarged mediastinal lymph nodes. Which of the following is most likely to be associated with her recurrent uveitis?
a. Cat-scratch disease
b. Lyme disease
c. Sarcoidosis
d. Syphilis
e. Tuberculosis
c. Sarcoidosis
Many patients w/ uveitis have an associated systemic disease. Some medications may cause secondary uveitis, and conditions such as ocular lymphoma and bloodborne infection may masquerade as primary uveitis.
In North America, the most common conditions associated with uveitis are:
Seronegative spondyloarthropathies, sarcoidosis, syphilis, RA, reactive arthritis
All the conditions listed may be associated with uveitis, but given the CXR findings and clinical scenario in this case, sarcoidosis is the most likely.
A 12 yo white male who lives in a household with several cats presents with axillary lymphadenopathy. Which one of the following is the best initial test for establishing a diagnosis of cat-scratch disease?
a. Lymph node biopsy
b. Blood cultures
c. IgG testing for Bartonella henselae
d. IgG testing for nontuberculous Mycobacterium species
c. IgG testing for Bartonella henselae
* Bartonella henselae* is the organism that causes cat-scratch disease. IgG titers over 1:256 strongly suggest active or recent infection. IgM elevation suggests acute disease but production of IgM is brief. Lymph node biopsy is reserved for cases where node swelling fails to resolve or dx is uncertain. The organism is difficult to culture and cultures are not recommended.
A 74 yo female presents to the ER in respiratory distress with slightly altered mental status. Her urine drug screen is positive for opioids. The patient and her family deny opioid use. You know this patient well and also doubt she is taking opioids. She has been taking dextromethorphan, guaifenesin, azithromycin (Zithromax), and pseudoephedrine. Which one of these could be causing a false-positive test for opioids on her urine drug screen?
a. Dextromethorphan
b. Guaifenesin
c. Azithromycin
d. Pseudoephedrine
a. Dextromethorphan
Dextromethorphan, diphenhydramine, ibuprofen, and even fluoroquinolones are among the many agents that can cause a false-positive urine drug screen for opioids.
Pseudoephedrine can cause a false-positive test for amphetamines.
A 20 yo male college student comes to the ER in January acutely short of breath and looking very ill, with tachypnea, tachycardia, nausea, and a headache. Pulse oximetry shows an oxygen saturation of 100% on room air, and ABG measurement shows a PaO2 of 95 mm Hg. Of the following, which one is the most likely dx?
a. CO poisoning
b. ARDS
c. Methemoglobinemia
d. Lobar pneumonia
e. Viral pneumonia
a. CO poisoning
CO exposure most commonly results from fuel combustion in heaters, stoves, or automobiles, so it is most often seen during cold periods when people are in closed quarters. Symptoms include headache, nausea, vomiting, and weakness, and patients have a flushed complexion, so sx are commonly attributed to viral flu-like illnesses.
CO poisoning results in the formation of carboxyhemoglobin, which does not carry oxygen. All oxygen-carrying sites are occupied by CO, which has such a high affinity for hemoglobin, that oxygen cannot displace it. If a patient has a carboxyhemoglobin level of 25%, and their hemoglobin level is 12 mg/dL, their effective hemoglobin level is only 9 mg/dL since 25% of their hemoglobin is not carrying oxygen. Maximum oxygen saturation that can be attained is 75%. However, a pulse oximeter will show an oxygen saturation of 100% because the color of carboxyhemoglobin is bright red, which is what the pulse oximeter is detecting. Thus, pulse oximetry is not reliable in patients with CO poisoning.
Similarly, ABG measurements are based on oxygen gas tension (pO2) and not oxygen content or true oxygen saturation. The only ABG abnormality in CO poisoning may be metabolic acidosis, which is a consequence of inadequate oxygen delivery to peripheral tissues. This causes an anaerobic metabolism and lactic acid production, but is not seen early in CO poisoning.
Serious cases of pneumonia, ARDS, or methemoglobinemia would produce abnormalities on pulse oximetry or ABG measurements. To detect CO poisoning, it would be necessary to order either a CO level or a co-oximetry test.
Which one of the following has been shown to be effective for Lyme disease prophylaxis after removal of an engorged deer tick?
a. Amoxicillin
b. Ceftriaxone (Recephin)
c. Cefuroxime axetil (Ceftin)
d. Doxycycline
e. Clarithromycin (Biaxin)
d. Doxycycline
While all the abx listed have been used to treat Lyme disease, the only abx that has been shown to be effective for chemoprophylaxis is doxycycline.
A 72 yo male is brought to your office by a friend because of increasing confusion, irritability, and difficulty walking. This began shortly after the patient’s car broke down in a rural area and he had to walk a mile to get to a phone and call the friend. The temperature outdoors has been near 100 F. On exam, the patient has a rectal temperature of 103.1 F, pulse rate of 110 bpm, and a BP of 100/60 mm Hg. His shirt is still damp with sweat. Which one of this patient’s findings indicates that he has heatstroke rather than heat exhaustion?
a. Confusion
b. Sweating
c. His temperature
d. His HR
e. His BP
a. Confusion
Heat exhaustion and heatstroke are both on the continuum of heat-related illness. Heatsroke is a much more severe condition than heat exhaustion. Evidence of CNS dysfunction is evidence of heatstroke rather than heat exhaustion, even if other symptoms are not severe and point to heat exhaustion. Heatstroke is a medical E.
A 47 yo male is hospitalized for severe lower-extremity MRSA cellulitis. He is started on IV vancomycin and his home medications, which include metoprolol and escitalopram (Lexapro), are continued. On day 3, in preparation for discharge, he is transitioned to oral Bactrim. Two hours after taking his first dose he reports severe swelling of his lips, wheezing, hoarseness, and hives. His BP, which was previously normal, is now 84/62 mm Hg. You order emergent therapy with IM epinephrine, 0.3 mg; IV methylprednisolone sodium succinate, 125 mg; and IV diphenhydramine (Benadryl), 50 mg. However, no clinical improvement is noted after 15 min. Which one of the following should you recommend now?
a. Another dose of IM epi
b. Another dose of IV methylprednisolone
c. Another dose of IV diphenhydramine
d. IM glucagon
e. IM betamethasone sodium phosphate/betamethasone acetate
d. IM glucagon
A 45 yo male who is being treated for chronic alcohol dependence with monthly injections of naltrexone (Vivitrol) presents with significant pain due to a fractured ankle, and IV pain medication is required. Which one of the following medications would be most useful in this situation?
a. Fentanyl
b. Hydromorphone (Dilaudid)
c. Ketorolac
d. Meperidine (Demerol)
e. Morphine
c. Ketorolac
Naltrexone is given in 380-mg monthly injections for the chronic tx of alcohol and opioid dependence. It is an antagonist of mu-opioid receptors, and blocks the pain relief properties of opioid agonists. Regional anesthesia and/or non-opioid analgesics are indicated when urgent pain relief is needed in a patient on long-term naltrexone therapy.
Ketorolac is the only medication listed that is not an opioid agonist.
