BOARD STUDY APRIL 2022 Flashcards
a common complication from a sleeve gastrectomy
gerd
t/f - HTN urgency - no symptoms - doesn’t need medications
true
if symtoms = htn emergency -
what is the only medicine that helps PREVENT seasonal affective disorder. This is not the same as treat
wellbutrin.
Treat = ssri/light therapy
BMI 41, 39 y/o with tons of comorbidities - what is going to cause the most effective weight loss long term:
meds, therapy, exercise, bariatric surgery
bariatric surgery - long term
Tennis elbow -
just modify activities!
Physical therapy can improve pain and function in the short term, but has not been shown to improve long-term outcomes at 1 year in randomized trials (SOR A). The evidence is weaker for bracing, with some studies showing improved pain and function at 3–6 weeks (SOR B). Recent randomized, controlled trials have made it clear that while corticosteroid injections reduce acute pain for up to 6 weeks, their use increases rates of poor long-term outcomes (SOR A).
.
A 56-year-old African-American male with long-standing hypertension and a 30-pack-year smoking history has a 2-day history of dyspnea on exertion. A physical examination is unremarkable except for rare crackles at the bases of the lungs. Which one of the following serologic tests would be most helpful for detecting left ventricular dysfunction? (check one) B-type natriuretic peptide Troponin T C-reactive protein (CRP D-dime Cardiac interleukin-2
BNP
A 35-year-old male presents with acute low back pain with no neurologic symptoms, and the pain does not radiate into either leg.
Which one of the following has been shown to be a useful treatment in this situation? (check one) Bed rest Acupuncture Lumbar traction Cyclobenzaprine (Flexeril) Methylprednisolone (Medrol)
D
for the first 7–14 days after the onset of symptoms.
If the answer would have been exercise/yoga etc… PICK THAT FOR SURE!
A mother meets you in the emergency department with her 3-week-old infant. The infant was delivered at term, with an uneventful prenatal and postnatal course to this point. The mother reports that the infant stopped breathing for 20–25 seconds, and that his lips and tongue appeared bluish. There was no coughing, choking, or congestion, but the child seemed “limp.” The episode ended when the mother vigorously stimulated her child and he started crying. On examination, the child appears normal.
Which one of the following would be most appropriate at this point?
(check one)
Reassurance and no further evaluation
Discharge with a home apnea monitor
Hospital admission for observation
Mandatory referral to child protective services
Direct laryngoscopy to rule out a foreign body
Admit - 20-25 seconds is a long time, with cyanotitc symptoms and not associated with feeeding etc…
A 30-year-old female at 36 weeks gestation has a positive culture for group B Streptococcus. Her past medical history is significant for the development of a nonurticarial rash in response to penicillin.
Which one of the following is most appropriate for intrapartum antibiotic prophylaxis in this patient? (check one) Azithromycin (Zithromax) Clindamycin (Cleocin) Vancomycin (Vancocin) Ampicillin Cefazolin
E
if anaphylaxis - clinda
A 68-year-old female presents with a 2-month history of watery diarrhea. She has not had any
blood or pus in her stools, and the stools are not oily. She has not had any history of fever,
chills, or weight loss, and has not traveled recently. She smokes one pack of cigarettes per day.
Her medications include ibuprofen, sertraline (Zoloft), and pantoprazole (Protonix). A CBC,
metabolic panel, C-reactive protein level, IgA anti-tissue transglutaminase level, total IgA level,
and stool guaiac test are all normal.
Which one of the following tests would be most likely to yield a diagnosis?
A) Clostridioides (Clostridium) difficile toxin
B) Colonoscopy
C) Fecal calprotectin
D) A stool culture
E) Stool examination for ova and parasites
B
- microscopic colitis likely
A would be if recent abx
C would be if concerned for UC/crohns
D shigella or salmonella - bloody diarrhea
E - recent travel with potential water contamination
A 68-year-old female presents with a 2-month history of watery diarrhea. She has not had any
blood or pus in her stools, and the stools are not oily. She has not had any history of fever,
chills, or weight loss, and has not traveled recently. She smokes one pack of cigarettes per day.
Her medications include ibuprofen, sertraline (Zoloft), and pantoprazole (Protonix). A CBC,
metabolic panel, C-reactive protein level, IgA anti-tissue transglutaminase level, total IgA level,
and stool guaiac test are all normal.
Which one of the following tests would be most likely to yield a diagnosis?
A) Clostridioides (Clostridium) difficile toxin
B) Colonoscopy
C) Fecal calprotectin
D) A stool culture
E) Stool examination for ova and parasites
B
- microscopic colitis likely
A would be if recent abx in the last 3 months
C would be if concerned for UC/crohns
D shigella or salmonella - bloody diarrhea
E - recent travel with potential water contamination
The etiology of this is unknown but there are several risk factors to consider,
including older age, female sex, and smoking status. Drugs with a high level of evidence for causing
microscopic colitis include NSAIDs, proton pump inhibitors, sertraline, acarbose, aspirin, and ticlopidine.
In order to reduce the risk of precipitated withdrawal,
buprenorphine induction should begin once the patient is exhibiting signs of mild to moderate withdrawal,
usually_____ hours after the last opioid use. Waiting until a patient goes through full withdrawal increases
the chances that the patient will revert back to using opioids.
8-12
uncomplicated wrist ganglion cyst - no symptoms
Which one of the following management options would you recommend?
A) Re-examination if she develops numbness, weakness, or increased pain
B) Immobilization of the wrist for 6 weeks and then re-examination
C) Aspiration of the lesion
D) Aspiration and injection of the lesion with a corticosteroid
E) Referral for excision of the lesion
A
This patient has a ganglion cyst, which is common and resolves spontaneously in 50% of cases, and
watchful waiting would be most appropriate at this time. Treatment is indicated if the cyst is causing
significant symptoms such as pain, numbness, or weakness, or for cosmetic reasons. Aspiration of the
lesion is the initial treatment, although recurrence may occur in 85% of cases. Immobilizing the wrist with
a splint or brace is sometimes helpful in the short term if the patient is bothered by the symptoms, but
immobilization does not provide lasting relief and could cause muscle atrophy. Corticosteroid injections
have not shown any benefit. Referral for excision is appropriate if there has been no improvement. Patients
should be advised that there is a 10%–15% recurrence rate even after excision.
A 57-year-old female with diabetes mellitus comes to your office for a routine follow-up. Her
current medications include metformin (Glucophage), 1000 mg twice daily. She tells you that
she does not exercise regularly and finds it difficult to follow a healthy diet. A hemoglobin A1c
today is 7.5%. She does not want to add medications at this time, but she does want to get her
hemoglobin A1c below 7%, which is the goal that was previously discussed.
Which one of the following would be the most effective way to improve glucose control for this
patient?
A) Discuss the components of a healthy diabetic diet and encourage her to follow it more
closely
B) Discuss the importance of regular exercise and encourage her to exercise 30–45 minutes
daily
C) Recommend that she check her glucose level 1–3 times daily to help determine what
adjustments need to be made
D) Start her on an additional medication
E) Refer her to a diabetes educator for medical nutrition therapy
E
Counseling by a diabetic educator or team of educators for medical nutrition therapy lowers hemoglobin
A1c by 0.2–0.8 percentage points in patients with type 2 diabetes. While a healthy diabetic diet and regular
exercise are important, simply reminding the patient of that fact is not likely to be as successful as
comprehensive diabetic education.
she shouldn’t be checking her sugars
t/f - breastfeeding may decrease the risk of atopic disease
true.
8. Which one of the following antihypertensive medications is LEAST likely to exacerbate erectile dysfunction? A) Clonidine (Catapres) B) Doxazosin (Cardura) C) Hydrochlorothiazide D) Losartan (Cozaar) E) Metoprolol
D
Angiotensin receptor blockers (ARBs) such as losartan are least likely to cause or exacerbate erectile
dysfunction. ARBs may have a favorable effect on erectile dysfunction by inhibiting vasoconstriction
activity of angiotensin. Clonidine, -blockers, hydrochlorothiazide, and -blockers are more likely to
negatively affect erectile function.
- You are providing end-of-life care for a 53-year-old female with end-stage colon cancer. Her
family reports that she is having significant abdominal pain, nausea, and vomiting, and she is
not able to tolerate oral intake. You suspect a malignant bowel obstruction.
Which one of the following interventions would be most likely to significantly improve her
symptoms?
A) Medical cannabis
B) Dexamethasone
C) Morphine
D) Octreotide (Sandostatin)
E) Polyethylene glycol (MiraLAX)
B
Malignant bowel obstruction is a common issue with gastrointestinal cancers. Corticosteroids can help
alleviate these symptoms, which is the focus in end-of-life care. Corticosteroids have numerous beneficial
effects in these situations, such as central antiemetic, anti-inflammatory, antisecretory, and analgesic
effects. Intravenous dexamethasone is generally recommended at a dosage of 4 mg 3–4 times daily for
malignant bowel obstruction because it has much greater anti-inflammatory effect than methylprednisolone.
Although octreotide is commonly used for this purpose, there is little evidence to support its use. Medical
cannabis can be used to treat nausea and vomiting in end-of-life care but is not effective for bowel
obstruction. Morphine can be used to treat pain and end-of-life dyspnea, but not nausea and vomiting.
- A 3-year-old male has developed multiple large areas of bullous impetigo on the legs, buttocks,
and trunk after being bitten numerous times by ants. Which one of the following would be the
most appropriate treatment?
A) Topical mupirocin ointment
B) Oral azithromycin (Zithromax)
C) Oral tetracycline
D) Oral trimethoprim/sulfamethoxazole (Bactrim)
E) Intramuscular penicillin G benzathine (Bicillin L-A)
D
Think about treating impetigo -
Impetigo may be caused by Streptococcus pyogenes or Staphylococcus aureus, but bullous impetigo is
caused exclusively by S. aureus. Oral trimethoprim/sulfamethoxazole is an appropriate treatment for skin
infections caused by S. aureus, including susceptible cases of methicillin-resistant S. aureus (MRSA).
Topical mupirocin ointment is not practical in very widespread cases or in cases with large bullae. Neither
azithromycin nor penicillin is a preferred treatment for impetigo, due to a high rate of treatment failure
UTD
In the trial, three- or five-day courses of oral trimethoprim-sulfamethoxazole and a single injection of benzathine benzylpenicillin were similarly effective for improving or healing impetigo within seven days
What makes the injection wrong is that oral therapy is preferred and keflex is usually the oral therapy to cover MSSA and strep A - but if it is MRSA, need bactrim
+1 RBC on a UA… in a guy who has smoked for 40 years.
Which one of the following would be the most appropriate follow-up?
A) Repeat dipstick urinalysis in 3 months
B) Microscopic urinalysis
C) Renal ultrasonography
D) CT urography
E) Referral for cystoscopy
B
Need to confirm if it is actual blood given UAs being very high risk for false positives.
Then if positive- he is high risk - C, D or E would all be ok.
- A 33-year-old gravida 2 para 1 presents to the hospital at 35 weeks estimated gestation with
premature rupture of membranes. A decision is made to manage the pregnancy expectantly and
delay delivery unless signs of infection or fetal distress are noted.
Based on current evidence, expectant management rather than immediate delivery increases the
risk of which one of the following complications?
A) Cesarean delivery
B) Antepartum or postpartum maternal hemorrhage
C) Time spent in the neonatal intensive-care unit
D) Neonatal sepsis
E) Perinatal or infant mortality
ANSWER: B
While historically the optimal management of premature rupture of membranes between 34 and 36 weeks
has been unclear, based on the PPROMT (Preterm Pre-labour Rupture of the Membranes close to Term)
trial published in 2015, expectant management appears to be associated with better neonatal outcomes.
Expectant management decreases the risk of cesarean delivery, neonatal respiratory distress, mechanical
ventilation, time spent in the neonatal intensive-care unit, and time spent in the hospital. Expectant
management did increase the risk of maternal antepartum or postpartum hemorrhage and intrapartum fever.
No differences were found between immediate delivery and expectant management in the risk of neonatal
sepsis, pneumonia, or perinatal or infant mortality.
t/f - statins can be usedi n breastfeeding
nope, not recommended - false
13-year-old baseball player who is right-hand dominant is brought to your office because of
a 3-week history of pain in the right shoulder. He recalls no specific injury but has been pitching
at least weekly for the past 3 months. He has moderate tenderness about the anterior and lateral
deltoid.
In addition to radiographic studies, the best initial management would include
A) complete rest from throwing activities
B) a sling and swathe
C) sugar-tong splints both proximal and distal to the elbow
D) physical therapy
A
The insidious onset of this patient’s pain without known injury and the lack of spontaneous resolution
strongly suggest an overuse injury. The differential diagnosis in this case would include Little League
shoulder, which is a stress injury to the proximal humeral physis in athletes with open growth plates. Other
considerations would include biceps or rotator cuff tendinitis, impingement syndrome, glenohumeral
instability, a labral tear, an acromioclavicular sprain, or a bone tumor. Pending radiograph results, the best
management strategy is complete rest from throwing activities. Patients with Little League shoulder should
rest from all throwing for an average of 3 months. In the absence of an acute injury there is no indication
for immobilization, and there is no indication for physical therapy for initial management of this condition.
review other flash cards
review USPSTF
24 y/o appendicitis - u/s or CT if suspected
CT for adults
u/s for kids
This patient has suspected appendicitis, and CT of the abdomen and pelvis with intravenous contrast is the
preferred initial imaging study. Ultrasonography is preferred in children, but not adults, as the initial study
for suspected appendicitis.
Which one of the following electrolyte disturbances would be consistent with tumor lysis syndrome? A) Hypocalcemia B) Hypokalemia C) Hyponatremia D) Hypophosphatemia E) Hypouricemia
A
Hyperphosphatemia, hyperkalemia, and hyperuricemia are indicative of tumor lysis syndrome.
Calcium levels are decreased due to binding with free phosphorus and a depletion of calcium in the bloodstream.
Sodium electrolyte levels are not as likely to be affected.
Which one of the following electrolyte disturbances would be consistent with tumor lysis syndrome? A) Hypocalcemia B) Hypokalemia C) Hyponatremia D) Hypophosphatemia E) Hypouricemia
A
Hyperphosphatemia, hyperkalemia, and hyperuricemia are indicative of tumor lysis syndrome.
Calcium levels are decreased due to binding with free phosphorus and a depletion of calcium in the bloodstream.
Sodium electrolyte levels are not as likely to be affected.
A 30-year-old male comes to your office for evaluation of hand weakness. On examination you
detect weakness when he tries to bring his thumb and index finger together. For confirmation
you ask him to try to hold on to a piece of paper between his thumb and index finger while you
try to pull it away. He is unable to resist when you pull on the paper.
The most likely explanation for these findings is an injury to the
A) brachial plexus
B) median nerve
C) musculocutaneous nerve
D) radial nerve
E) ulnar nerve
E
Initial general neurovascular assessment of an upper extremity injury includes evaluating for radial pulse
and digit movement and sensation. Weakness of the thumb and index finger pincer mechanism is indicative
of an ulnar nerve injury. Weakness in the shoulder or upper arm would indicate a potential brachial plexus
injury. Symptoms related to the median nerve generally include paresthesia of the thumb, index finger,
and long finger. Weakness of supination of the forearm would indicate a potential musculocutaneous nerve
injury. Weakness of active wrist extension would indicate a potential radial nerve injury.
how do you differentiate antisocial personality disorder, ODD, and conduct disorder
There are multiple criteria for conduct disorder - including aggression toward people and animals, theft, starting fires, and truancy. It may be associated
with other disorders.
Antisocial personality disorder, which is usually diagnosed after age 18, involves a
disregard for the rights of others.
ODD - is getting in trouble, but no actually harming others etc…
what cardiac pt’s should have prophylactic abx prior to a dental procedure
Antibiotic prophylaxis is not indicated unless the
patient has undergone aortic valve replacement or has a history of endocarditis.
After a thorough history and examination you determine that a 30-year-old male has an upper
respiratory infection with a persistent cough. He is afebrile and is otherwise healthy.
The best treatment for symptomatic relief of his persistent cough would be intranasal
A) antibiotics
B) antihistamines
C) corticosteroids
D) ipratropium (Atrovent)
E) saline
D
According to a Cochrane review of 10 trials without a meta-analysis, antitussives and
expectorants are no more effective than placebo for cough. Intranasal ipratropium is the only medication
that improves persistent cough related to upper respiratory infection in adults. Intranasal antibiotics,
antihistamines, corticosteroids, and saline would not improve this patient’s cough.
what meds should they be on for HFpEF
Studies of other medication classes with proven benefit for heart failure with reduced ejection fraction,
including ACE inhibitors, -blockers, spironolactone, and the angiotensin receptor–neprilysin inhibitor
sacubitril/valsartan,
have not shown the same effects in the setting of heart failure with preserved ejection
fraction.
For patients with heart failure with preserved ejection fraction, the use of these other medication
classes should be limited to the treatment of other comorbid conditions, such as hypertension, coronary
artery disease, atrial fibrillation, or chronic kidney disease.
t/f - ssri’s can increase your risk of a GI bleed
true
t/f - sleeve gastrectomy has the complication of cholelithiasis
false - this happens in bariatric surgery that causes malabsorption - roux en y, duodenal switch.
t/f - menstruation can affect a both albumin/creatinine and protein/creatinine ratio
true
A hypertensive urgency is defined as a confirmed blood pressure ________ Hg without
symptoms or signs of end-organ damage.
> 180/110–120 mm
how to manage hypertensive urgency in clinic
Patients without symptoms in the setting of severe hypertension rarely have end-organ damage.
Patients who are asymptomatic with persistently elevated blood pressures can be safely treated with oral
antihypertensives with close follow-up (SOR C). There is no standard workup for patients with
hypertensive urgencies, but common practice includes obtaining a basic metabolic panel, CBC, urinalysis,
EKG, and troponin to rule out end-organ damage.
Oral medications to lower blood pressure in a patient with a hypertensive urgency are not indicated unless
the patient is symptomatic. Symptoms such as headache or epistaxis warrant acute lowering of blood
pressure. Preferred medications include clonidine, labetalol, and captopril, among others. Oral nifedipine
is not recommended due to unpredictable blood pressure responses.
Patients with physical or laboratory evidence of end-organ damage should be admitted to the intensive-care
unit for intravenous treatment of blood pressure. Without symptoms of end-organ damage there is no need to transport patients to the emergency department, as hypertensive urgencies can be managed with outpatient care.
how to manage hypertensive urgency in clinic
Patients without symptoms in the setting of severe hypertension rarely have end-organ damage.
Patients who are asymptomatic with persistently elevated blood pressures can be safely treated with oral
antihypertensives with close follow-up (SOR C). There is no standard workup for patients with
hypertensive urgencies, but common practice includes obtaining a basic metabolic panel, CBC, urinalysis,
EKG, and troponin to rule out end-organ damage.
Oral medications to lower blood pressure in a patient with a hypertensive urgency are not indicated unless
the patient is symptomatic. Symptoms such as headache or epistaxis warrant acute lowering of blood
pressure. Preferred medications include clonidine, labetalol, and captopril, among others. Oral nifedipine
is not recommended due to unpredictable blood pressure responses.
Patients with physical or laboratory evidence of end-organ damage should be admitted to the intensive-care
unit for intravenous treatment of blood pressure. Without symptoms of end-organ damage there is no need to transport patients to the emergency department, as hypertensive urgencies can be managed with outpatient care.
More than 90% of children can speak three words at what age?
18 months
50%–90% can speak six words.
t/f - Topical, not oral, preparations of probiotics have good evidence for
reducing the risk of recurrent bacterial vaginosis.
true
is there evidence for probiotics in those with IBS-D
YES - lots of it. Think of GI.
is there evidence in the use of probiotics to prevent antibiotic induced diarrhea
yes
t/f- albuterol can help a child that has rsv bronchiolitis
false - Albuterol is ineffective for the wheezing associated with RSV since the mechanism of wheezing is not due
to bronchospasm
t/f- albuterol can help a child that has rsv bronchiolitis
false - Albuterol is ineffective for the wheezing associated with RSV since the mechanism of wheezing is not due
to bronchospasm
mild acne - would you choose
topical clinda
or
topical differin and why
differin -
you shouldn’t use monotherapy topical abx due to resistance.
early dementia or signs of self-neglect
screen for depression
CVID
Common variable immunodeficiency (CVID) is the only immunodeficiency condition listed that can present
later in life, while severe combined immunodeficiency, DiGeorge syndrome, and Wiskott-Aldrich
syndrome typically present prior to 6 months of age. CVID is a condition of impaired humoral immunity
and thus should be considered in a patient this age in the setting of recurrent bacterial infections such as
sinusitis or pneumonia. The blunted response to a vaccination challenge implies impaired IgG antibody
response, which differentiates CVID from a selective IgA deficiency.
A 62-year-old female sees you for a routine health maintenance visit and asks for your advice
regarding vitamin D supplementation. She is healthy and active, and jogs 1–2 hours three times
weekly.
Which one of the following would be the most appropriate advice regarding vitamin D
supplementation in this patient?
A) It is not recommended because she is asymptomatic
B) It will reduce the risk of certain cancers
C) It will reduce the risk of depression
D) It will reduce the risk of diabetes mellitus
E) It will reduce the risk of fractures
A
think about the USPSTF for the exam.
t/f = duloxetine especially associated with an increased risk of falls
true
s/e of paxil
Paroxetine should generally
be avoided in older patients due to a higher likelihood of adverse effects that include sedation and
orthostatic hypotension.
A 27-year-old soccer player presents with anterior hip pain along with a clicking sensation in the
hip when he runs or attempts lateral movements.
what should you be suspecting?
labral tear
labral tears usually present with anterior hip pain and may have catching, popping, or clicking
sounds associated with activities such as gymnastics, soccer, dancing, basketball, or hockey
CKD stage 3a and 3b
60-90 = grade 2 45-60 = 3a 30-45 = 3b = Ben is in his 30's, Ben has 3 letters 15-30 = 4 0-15= 5
He would like to start a clinic-wide program to focus on lead screening in asymptomatic children
5 years of age and younger. After reviewing U.S. Preventive Services Task Force guidelines, which one of the following should you tell the practice administrator?
A) There is insufficient evidence to recommend for or against lead screening in children 5
years of age and younger
B) All children 5 years of age and younger should undergo lead screening
C) All children who live in housing built before 1978 should undergo lead screening
D) There are accurate and reliable screening questionnaires to guide lead screening
A
The USPSTF went on to conclude that the current evidence is insufficient to assess the balance
of benefits and harms of screening for elevated blood lead levels in asymptomatic children 5 years of age
and younger. Although children living in older housing with lead-based paint are at higher risk of elevated
blood lead levels than those living in housing built after 1978, the USPSTF does not recommend routine
screening in asymptomatic children based on this risk factor.
`A 70-year-old male presents with a 2-year history of gradually progressive exertional dyspnea
associated with a dry cough and fatigue. A physical examination reveals bilateral basilar fine
inspiratory crackles on lung auscultation and acrocyanosis. A chest radiograph demonstrates
hazy opacities and reticular infiltrates of both lower lung fields. You suspect interstitial lung
disease.
Assuming that no underlying connective tissue disease is identified on serologic testing, which
one of the following additional studies could confirm a diagnosis of idiopathic pulmonary fibrosis
for this patient, potentially preventing the need for a subsequent lung biopsy?
A) Spirometry
B) High-resolution chest CT
C) Polysomnography
D) Echocardiography
E) Right heart catheterization
B
don’t for IPF as a diagnosis for my patients.
it is in the family of ILD
Spirometry usually shows a restrictive pattern, although it may be normal in early disease or
with comorbid emphysema.
t/f - hypothyroidism has been associated with adhesive capsulitis
true
A 55-year-old male sees you because of a second flare of gout. He has also had an elevated
blood pressure at the last few visits to your clinic and is hypertensive again today.
In addition to treating his gout flare, which one of the following would be the most appropriate
agent to treat his hypertension in light of his presenting problem?
A) Atenolol (Tenormin)
B) Hydralazine
C) Hydrochlorothiazide
D) Lisinopril (Prinivil, Zestril)
E) Losartan (Cozaar)
E
Losartan is the DOC in someone who has gout.
Both hydrochlorothiazide and losartan are known to have effects on the serum urate concentrations,
with hydrochlorothiazide causing an increase and losartan causing a decrease. The American College of
Rheumatology guideline does not recommend for or against the use of atenolol, hydralazine, and lisinopril
as antihypertensive treatment in patients with gout.
A 55-year-old male sees you because of a second flare of gout. He has also had an elevated
blood pressure at the last few visits to your clinic and is hypertensive again today.
In addition to treating his gout flare, which one of the following would be the most appropriate
agent to treat his hypertension in light of his presenting problem?
A) Atenolol (Tenormin)
B) Hydralazine
C) Hydrochlorothiazide
D) Lisinopril (Prinivil, Zestril)
E) Losartan (Cozaar)
E
Losartan is the DOC in someone who has gout.
Both hydrochlorothiazide and losartan are known to have effects on the serum urate concentrations,
with hydrochlorothiazide causing an increase and losartan causing a decrease. The American College of
Rheumatology guideline does not recommend for or against the use of atenolol, hydralazine, and lisinopril
as antihypertensive treatment in patients with gout.
72. Which one of the following types of complementary/integrative therapy is a form of mental training that requires calming of thoughts with the goal of achieving a state of detached observation? A) Aerobic exercise B) Cognitive-behavioral therapy C) Mindfulness-based meditation D) Tai chi and qi gong E) Yoga
C
Which one of the following is most likely to result
in a false-negative result and require confirmatory testing for detection?
A) Cannabis
B) Cocaine
C) Codeine
D) Morphine
E) Oxycodone (OxyContin)
E
However, these immunoassays do not
reliably detect synthetic or semisynthetic opioids such as oxycodone, oxymorphone, methadone,
buprenorphine, and fentanyl, as well as many benzodiazepines. Confirmatory testing is needed in situations
with an unexpected negative result in order to distinguish a false negative from a true negative.
A 3-year-old male undergoes surgery for intestinal malrotation (volvulus). A preoperative
comprehensive metabolic panel was normal. The patient’s postoperative potassium level is 4.6
mEq/L (N 3.4–4.7).
In addition to maintenance potassium, which one of the following fluids should be administered
in the postoperative period?
A) 0.2% NaCl with 5% dextrose
B) 0.45% NaCl with 5% dextrose
C) 0.9% NaCl with 5% dextrose
D) 3% saline
E) 5% dextrose in water
C
regular NS w/ dextrose
OA of the knee in a 64 y/o treatment options
Treatments with evidence of effectiveness for knee osteoarthritis include exercise, physical therapy, knee
taping, and tai chi.
Medical treatments should begin with full-strength acetaminophen and topical therapy,
then NSAIDs and, selectively, tramadol or other opioids.
Lateral wedge insoles, vitamin D supplements,
glucosamine and chondroitin supplements, and hyaluronic acid injections are all ineffective.
suspect parkinson's.... what is needed for the diagnosis A) No diagnostic testing B) CT of the brain C) MRI of the brain D) EEG E) A lumbar puncture
A
Parkinson’s disease is a clinical diagnosis and seldom requires testing. Imaging such as CT,
MRI, or EEG can be useful in ruling out other diagnoses but will not reveal findings suggestive of
Parkinson’s disease.
how does curettage and E&D look cosmetically
not great. Excisions are better
The U.S. Preventive Services Task Force (USPSTF) recommends prescribing low-dose aspirin after __
weeks gestation for asymptomatic women at high risk for preeclampsia.
12
In pregnant patients with
chronic hypertension, treatment with antihypertensive medications is recommended only when the blood
pressure is ________mm Hg, because aggressive blood pressure lowering may result in placental
hypoperfusion.
> 150/100
what is the starting dose of lantus
10 U nightly
A 78-year-old male with terminal lung cancer and long-standing COPD is admitted to a regular
medical-surgical care unit pending transfer to the hospice unit within the next day. You are
called about worsening anxiety and dyspnea. The patient is alert and anxious. He has a blood
pressure of 150/94 mm Hg, a pulse rate of 96 beats/min, a respiratory rate of 24/min, and an
oxygen saturation of 93% on 2 L/min of oxygen via nasal cannula.
Which one of the following would be most effective in this situation?
A) 40% oxygen by venti-mask
B) Dexamethasone
C) Hyoscyamine (Anaspaz)
D) Lorazepam (Ativan)
E) Morphine sulfate
E
Opiates are the most effective agents for treating dyspnea and the resultant anxiety in patients with terminal
cancer.
Not D
Dexamethasone, hyoscyamine, and
lorazepam have a frequent role in patients such as this one, but morphine sulfate or a similar fast-acting
opiate is the drug of choice (SOR B).
The American Academy of Pediatrics (AAP) recommends formal screening for maternal depression with
the Edinburgh Postnatal Depression Scale or the Patient Health Questionnaire–2 (PHQ-2) at which visits?
1-, 2-, 4-,
and 6-month well child visits.
The AAP recommends screening for autism at 18 months, but the U.S.
Preventive Services Task Force (USPSTF) finds insufficient evidence to recommend screening unless there
are parental concerns.
The AAP recommends screening for iron deficiency at 12 months, but the USPSTF
finds insufficient evidence for screening at this time.
just beware of the AAP vs the USPSTF…. I doubt there will be questions on this as a result…. but I would probably go with the USPSTF
We do hearing testing “otoacoustic emissions” for children at their newborn screen, do we do it any other time?
no
Fibroid treatmnet:
can you use an IUD?
only limited data = so nope
GnRH agonists are effective for providing symptom relief and reducing
fibroid size, but their use results in a hypoestrogenized state and should not be continued long term for a
sustained effect in premenopausal women.
embolization, surgery
t/f - tramadol can cause serotonin syndrome
yes! true
how long can a kid have back pain before you should get imaging
4 weeks
menieres triad
can vestibular migraines lok like it
what would make you conncerned for a vestibular schwannoma
triad: hearing loss, tinnitus, vertigo.
vestibular migraines usually dont have tinnitus - but can have eveything else.
Patients with vestibular
schwannoma typically present with gradual asymmetric hearing loss, but they can have tinnitus and vertigo
as well.
menieres triad
can vestibular migraines lok like it
what would make you conncerned for a vestibular schwannoma
triad: hearing loss, tinnitus, vertigo.
vestibular migraines usually dont have tinnitus - but can have eveything else.
Patients with vestibular
schwannoma typically present with gradual asymmetric hearing loss, but they can have tinnitus and vertigo
as well.
Children can
generally be safely restrained without a booster seat when their height reaches around 145 cm (57 in),
though this lower limit can vary based on the specific vehicle. All children who ride in motorized vehicles
should be restrained in the back seat until at least age 13 (SOR C).
So almost 5 ft
chronic indewelling uretheral cath… what should be done to prevent infection in someone who doesn’t have regular infections?
A) Routine daily hygiene of the meatal surface with soap and water
B) Daily periurethral cleaning with iodine
C) Daily oral antibiotics based on prior urine culture sensitivities
D) Routine instillation of an antimicrobial solution into the drainage bag
E) Regularly scheduled catheter exchanges at fixed intervals
A
No periurethral antiseptics reduce rates of CAUTI.
Catheters and drainage bags should only be changed when clinically indicated, such
as when there is an infection or obstruction.
CURB65
inpatient, icu, outpatient recs?
confusion, uremia, RR, BP >65
0-1 outpatient
2 - inpatient
>3 = icu
according to ITE for CAP tx in someone with NO comorbidities, without previous abx use in the last 3 months… what is the abx DOC?
Macrolides such as azithromycin are the treatment of choice for previously
healthy outpatients with no history of antibiotic use within the past 3 months.
according to ITE for CAP tx in someone with NO comorbidities, without previous abx use in the last 3 months… what is the abx DOC?
Macrolides such as azithromycin are the treatment of choice for previously
healthy outpatients with no history of antibiotic use within the past 3 months.
egophany is what
the E to A sound when listening
fremitus is what?
the hands on the back… you feel more dull vibrations or lack of movement on the infected side.
what is unique about buccal fractures
Treatment consists of short arm
immobilization, which is most easily performed with a removable splint or wrist brace. The Choosing
Wisely campaign states that these fractures do not require repeat imaging if there is no longer any
tenderness or pain with palpation after 4 weeks of splinting, and the patient can return to full activity as
tolerated.
panceratitis from hyperTAG… what is the trematn
fibrate
if they have an ASCVD - treat that with statins, but fibrate is first.
preventing PPD… do you do counselling, or do you treat with medication?
counselling
The USPSTF could not find evidence that exercise, amitriptyline, or
sertraline were beneficial.
A 34-year-old male sees you because he was recently informed that a partner he had unprotected
sex with last month has been diagnosed with HIV. You would advise this patient to initiate
ongoing antiretroviral therapy
A) immediately, because HIV testing is not necessary prior to initiation
B) at the time of diagnosis of HIV infection
C) when his CD4 cell count drops to <200 cells/ L
D) when his CD4 cell count drops to <500 cells/ L
E) when he develops an AIDS-defining illness
B
Not sure on this one because of …
“Oral PrEP is the use of antiretroviral (ARV) drugs before HIV exposure by people who are not infected with HIV in order to block the acquisition of HIV.”
I think A is wrong, because you do need an HIV test before starting PrEP
what is PEP
PEP is the use of antiretroviral drugs after a single high-risk event to stop HIV seroconversion. PEP must be started as soon as possible to be effective—and always within 72 hours of a possible exposure.
sx of dig toxicity
n/v, weight loss, abd px, yellow vision changes (but they probs won’t give this info as it is too easy)
Ankle sprain… what should you give as the best evidence for providing pain relief while also minimzing s/e?
A) Topical diclofenac gel (Pennsaid)
B) Topical menthol gel
C) Oral hydrocodone/acetaminophen (Lortab)
D) Oral ibuprofen
E) Oral tramadol
F) TENS unit
A
In 2020 the American College of Physicians and the American Academy of Family Physicians published
a guideline regarding the treatment of acute pain from musculoskeletal injuries (non–low back related).
This systematic review found good evidence to support the recommendation that topical NSAIDs be used
as first-line therapy to reduce pain and improve physical function. Topical NSAIDs were the only
intervention that improved multiple outcomes and were not associated with a statistically significant
increase in the risk for adverse events. Oral NSAIDs and acetaminophen were recommended as second-line
therapies, as they were found to be effective for pain relief but were associated with an increased risk for
adverse events. Topical menthol gel was not found to be effective as monotherapy but may be considered
when combined with a topical NSAID.
Nonpharmacologic approaches with evidence of benefit include specific acupressure and use
of a transcutaneous electrical nerve stimulation (TENS) unit.
RF
Which one of the following would be the most appropriate therapy?
A) Hydroxychloroquine (Plaquenil)
B) Methylprednisolone acetate (Depo-Medrol)
C) Naproxen
D) Intravenous immunoglobulins
E) Plasmapheresis
C
Using the Jones criteria for diagnosis, this patient has acute rheumatic fever, with two major criteria
(carditis and polyarthritis) and two minor criteria (fever and positive erythrocyte sedimentation rate).
NSAIDs such as naproxen can provide significant relief and should be administered as soon as acute
rheumatic fever is diagnosed (SOR B). Hydroxychloroquine is not FDA approved for the treatment of
acute rheumatic fever and would not be appropriate. Treatment with corticosteroids, intravenous
immunoglobulins, and plasmapheresis is not considered appropriate for acute rheumatic fever but may be
indicated for management of pediatric autoimmune neuropsychiatric disorders associated with streptococcal
infections (PANDAS).
RF
Which one of the following would be the most appropriate therapy?
A) Hydroxychloroquine (Plaquenil)
B) Methylprednisolone acetate (Depo-Medrol)
C) Naproxen
D) Intravenous immunoglobulins
E) Plasmapheresis
C
Using the Jones criteria for diagnosis, this patient has acute rheumatic fever, with two major criteria
(carditis and polyarthritis) and two minor criteria (fever and positive erythrocyte sedimentation rate).
NSAIDs such as naproxen can provide significant relief and should be administered as soon as acute
rheumatic fever is diagnosed (SOR B). Hydroxychloroquine is not FDA approved for the treatment of
acute rheumatic fever and would not be appropriate. Treatment with corticosteroids, intravenous
immunoglobulins, and plasmapheresis is not considered appropriate for acute rheumatic fever but may be
indicated for management of pediatric autoimmune neuropsychiatric disorders associated with streptococcal
infections (PANDAS).
A 51-year-old female presents with concerns about a change in her cognition. She says she has
difficulty retrieving words, loses her train of thought, and goes into a room and forgets why she
came there. She also has had more frequent hot flashes and sleep disturbances. She still
menstruates but has noticed a change from her previous pattern. A physical examination is
unremarkable, and recent laboratory tests were all normal, including vitamin B12 and thyroid
studies. Cognitive testing is normal.
Which one of the following would be the most appropriate next step?
A) Reassurance only
B) CT of the head
C) MRI of the brain
D) Hormone therapy
E) Referral to a neurologist
A
Cognitive changes are normal with menopause in like ~60% of women. But you only need HRT if you are going to help hot flashes and GU symptoms
Which one of the following would you recommend at this time for subclinical hyperthyroidism?
A) Observation only
B) A thyroglobulin level
C) Thyroid antibody studies
D) Thyroid ultrasonography
E) A thyroid uptake scan with radioactive iodine
A
The American Thyroid Association recommends observation for asymptomatic patients
with mildly low TSH (0.1–0.4 U/mL), so further evaluation is not indicated in this patient.
Further evaluation including thyroid antibody studies and a thyroid
uptake scan with radioactive iodine should be considered in older patients (>65 years), those with very
low TSH (<0.1 U/mL), and those with comorbidities.
undiagnosed RA flare x2 months in a 73 y/o Elevation of which one of the following would provide the most support for a specific diagnosis of her new arthritis symptoms? A) Anti-citrullinated protein antibody B) C-reactive protein C) Erythrocyte sedimentation rate D) Leukocyte count and differential E) Rheumatoid factor
A
Anti-citrullinated protein antibody is >95% specific for RA when significantly elevated.
Rheumatoid factor is also nonspecific for RA and may be positive due to cancer, infection, and other
autoimmune conditions.
A 68-year-old male with a history of COPD, hypertension, and hyperlipidemia presents with a
worsening cough and dyspnea with exertion over the past 3 months. His symptoms were
previously well controlled with tiotropium (Spiriva) daily and albuterol (Proventil, Ventolin) as
needed, and he has not had any COPD exacerbations in the past year until these symptoms
began. He has not had any change in sputum production. Recently he has been using his
albuterol inhaler several times a day to help relieve his shortness of breath with exertion.
A physical examination reveals a temperature of 37.0°C (98.6°F), a heart rate of 78 beats/min,
a respiratory rate of 16/min, a blood pressure of 144/82 mm Hg, and an oxygen saturation of
95% on room air. A cardiac evaluation reveals a regular rate and rhythm and he has no
peripheral edema or cyanosis. His lungs are clear with no wheezes or crackles, and there is a
mild prolonged expiratory phase.
According to current GOLD guidelines, which one of the following would be the most
appropriate next step in the management of this patient’s symptoms?
A) Add azithromycin (Zithromax)
B) Add inhaled fluticasone (Flovent)
C) Add inhaled salmeterol (Serevent)
D) Add inhaled fluticasone/salmeterol (Advair)
E) Discontinue tiotropium and start inhaled fluticasone
C
In patients on monotherapy with a long-acting bronchodilator such as a long-acting
muscarinic agonist (LAMA) or long-acting -agonist (LABA) who have continued dyspnea, the Global
Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend escalating therapy to two
bronchodilators. This patient has persistent dyspnea and is being treated with a single agent, a LAMA, so
his regimen needs to be escalated to include a LABA such as salmeterol. Once the symptoms are stabilized,
treatment can be de-escalated to a single agent. For patients with frequent COPD exacerbations or with
a diagnosis of asthma and COPD, the guidelines recommend adding an inhaled corticosteroid (ICS) such
as fluticasone to a LABA, LAMA, or both. Triple therapy with a LABA, a LAMA, and an ICS is not
indicated at this time as the patient has not yet been treated with a combination of a LAMA and LABA and
has not had any recent exacerbations. The addition of azithromycin may be considered in patients who are
already on triple therapy with a LABA, a LAMA, and an ICS and still having exacerbations. Monotherapy
with an ICS is not indicated in COPD and has been shown to increase the risk of developing pneumonia.
A 68-year-old male with a history of COPD, hypertension, and hyperlipidemia presents with a
worsening cough and dyspnea with exertion over the past 3 months. His symptoms were
previously well controlled with tiotropium (Spiriva) daily and albuterol (Proventil, Ventolin) as
needed, and he has not had any COPD exacerbations in the past year until these symptoms
began. He has not had any change in sputum production. Recently he has been using his
albuterol inhaler several times a day to help relieve his shortness of breath with exertion.
A physical examination reveals a temperature of 37.0°C (98.6°F), a heart rate of 78 beats/min,
a respiratory rate of 16/min, a blood pressure of 144/82 mm Hg, and an oxygen saturation of
95% on room air. A cardiac evaluation reveals a regular rate and rhythm and he has no
peripheral edema or cyanosis. His lungs are clear with no wheezes or crackles, and there is a
mild prolonged expiratory phase.
According to current GOLD guidelines, which one of the following would be the most
appropriate next step in the management of this patient’s symptoms?
A) Add azithromycin (Zithromax)
B) Add inhaled fluticasone (Flovent)
C) Add inhaled salmeterol (Serevent)
D) Add inhaled fluticasone/salmeterol (Advair)
E) Discontinue tiotropium and start inhaled fluticasone
C
In patients on monotherapy with a long-acting bronchodilator such as a long-acting
muscarinic agonist (LAMA) or long-acting -agonist (LABA) who have continued dyspnea, the Global
Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend escalating therapy to two
bronchodilators. This patient has persistent dyspnea and is being treated with a single agent, a LAMA, so
his regimen needs to be escalated to include a LABA such as salmeterol. Once the symptoms are stabilized,
treatment can be de-escalated to a single agent. For patients with frequent COPD exacerbations or with
a diagnosis of asthma and COPD, the guidelines recommend adding an inhaled corticosteroid (ICS) such
as fluticasone to a LABA, LAMA, or both. Triple therapy with a LABA, a LAMA, and an ICS is not
indicated at this time as the patient has not yet been treated with a combination of a LAMA and LABA and
has not had any recent exacerbations. The addition of azithromycin may be considered in patients who are
already on triple therapy with a LABA, a LAMA, and an ICS and still having exacerbations. Monotherapy
with an ICS is not indicated in COPD and has been shown to increase the risk of developing pneumonia.
which is better naltrexone or disulfram
naltrexone
Evidence does not support the use of disulfiram for AUD but it may be
offered in selected circumstances, particularly when patients do not tolerate other options and their goal
is abstinence.
when do you order a barium esophagram?
EGD can often miss a narrowing or esohpageal webs etc… this is when the barium esophagram is great.
can you give levofloxacin to kids
yes,
what is the most improtant lifestyle measure to prevent recurrent kidney stones
Increasing fluid intake to 2.5–3 L/day
diet rich in fiber and vegetables with normal calcium
content (1–1.2 g/day), limited sodium intake (4–5 g/day), and limited animal protein intake (0.8–1
g/kg/day) is strongly encouraged.
- limit protein, limit sodium .
-reduction in BMI is also helpful.
do diuretics help prevent kidney stones
Thiazide diuretics in higher dosages, such as 50 mg daily
of hydrochlorothiazide, have also been shown to be effective in preventing calcium stone formation.
Furosemide increases urinary calcium excretion and would increase the likelihood of
calcium stone formation.
An asymptomatic 53-year-old female recently underwent a right breast lumpectomy and radiation
therapy with curative intent. Over the next 5 years routine surveillance should include
A) annual unilateral left breast mammography
B) annual bilateral mammography
C) annual bilateral mammography and radionuclide bone scans
D) biannual bilateral mammography
E) biannual bilateral mammography and annual radionuclide bone scans
B
Primary care physicians should ensure that their patients who have undergone treatment for breast cancer
follow the recommendations of their oncologist, as well as receive a history evaluation and health
maintenance examination every 3–6 months for 3 years, every 6–12 months for 2 more years, and then
on an annual basis. For ongoing surveillance only annual mammography is recommended (SOR A), which
is bilateral in breast-conserving therapy and unilateral following a mastectomy.
does testosterone cause VTE
No
estrogen only.
t/f - bipolar has a strong FHx
yes
A 72-year-old female presents with pain, swelling, and decreased range of motion in her right
great toe for several months. There is no history of injury or overuse. On examination the
metatarsophalangeal joint is swollen and mildly tender, but not red. Dorsiflexion and plantar
flexion are approximately 30°. A radiograph shows joint space narrowing and a small bone spur.
Recommended management at this time would be
A) stretching and strengthening exercises
B) a rigid shoe insert
C) ibuprofen
D) a corticosteroid injection
E) surgical referral
ANSWER: B
Hallux rigidus affects as many as 50% of women and 40% of men by the age of 70. It is usually due to
osteoarthritis of the metatarsophalangeal (MTP) joint and presents as decreased range of motion, swelling,
and pain. With progression of the condition, flare-ups become more frequent and more severe, and it can
be mistaken for gout. Initial treatment is restriction of motion across the MTP joint. A stiffening shoe
insert does relieve pain and most patients see improvement without surgery. Custom orthotics, rigid
inserts, or hard-soled shoes are options that are more effective than NSAIDs. Corticosteroid injections,
preferably administered with ultrasound guidance, and surgery are reserved for those who fail to respond
to more conservative measures. Stretching and strengthening exercises are recommended for plantar
fasciitis more so than for hallux rigidus.
A 12-year-old male with type 1 diabetes is brought to your office for routine follow-up.
Laboratory work performed prior to the appointment shows an LDL-cholesterol level of 120
mg/dL.
In addition to counseling the patient on a heart-healthy diet and daily physical activity, which one
of the following would you recommend?
A) No additional measures
B) Fish oil supplements
C) Atorvastatin (Lipitor)
D) Ezetimibe (Zetia)
E) Gemfibrozil (Lopid)
I disagree with this question. The answer should be A
C
Current guidelines recommend initiating a statin, in addition to education regarding a healthy diet
and physical activity, for pediatric patients in this high-risk category with an LDL-cholesterol level >100
mg/dL. Statins such as atorvastatin are recommended for first-line treatment according to multiple studies
that demonstrate their efficacy and benefits in reduction of cardiovascular morbidity and mortality, along
with long-term studies demonstrating their safety.
———
UTD
We agree with the following ADA guidelines for screening for hyperlipidemia in children with T1DM [11,104]:
●Obtain a lipid profile at diagnosis, after glycemic control is well established and ideally in the fasting state. Perform the initial screen at age ≥2 years.
●If the profile is within the accepted risk levels (LDL <100 mg/dL), initiate serial testing at 9 to 11 years of age and repeat every three years. Borderline or abnormal values should be repeated for confirmation in the fasting state. If lipids are abnormal, annual monitoring is recommended. If the initial screen is normal but the child’s diabetes is in poor control (eg, A1C >9 percent), we suggest screening annually.
Pharmacologic treatment with lipid-lowering agents is recommended for children with diabetes over 10 years of age if LDL exceeds the following levels despite dietary and other lifestyle changes [11,104]:
- LDL ≥160 mg/dL (4.1 mmol/L)
- LDL between 130 and 159 (3.4 to 4.1 mmol/L) if one or more other cardiovascular risk factors are present (including obesity, tobacco use, or a family history of early cardiovascular disease)
Which one of the following is the leading cause of mortality among people 45–64 years of age? A) Accidents B) Diabetes mellitus C) Heart disease D) Malignancy E) Suicide
D
malignancy
heart
accident
suicide
Accidents are
the third most common cause of mortality in people 45–64 years of age, but they are the leading cause of
mortality among people 15–44 years of age
Heart disease is the second most
common cause of mortality in people 45–64 years of age, but it is the leading cause of mortality in people
65 years of age and older. Suicide is the fourth most common cause of mortality in adults 45–54 years of
age, and the eighth most common cause in adults 55–64 years of age.
t/f - does ARDS respond to supplemental oxygen therapy to help with the hypoxemia
no.
A previously healthy 38-year-old female with a normal BMI has a few warts at the base of her
great toe on the plantar surface. She noticed them a few years after she started to run regularly
for exercise but has not tried any at-home treatments. They are minimally raised and rarely
painful but occasionally cause irritation and she would like to get rid of them.
Which one of the following would be the most appropriate treatment?
A) Over-the-counter salicylic acid
B) Candida injections
C) Application of duct tape
D) Manual paring and extraction
E) Laser treatment
A
The application of duct tape has not been shown to be more effective than placebo.
Manual paring and extraction of plantar warts carries a greater risk for complications and is not necessary
for these flat, minimally bothersome warts.
*** the key to this question was minimally symptomatic.
A 44-year-old male with diabetes mellitus, hypertension, obesity, and chronic pain is on chronic
opiate therapy. He comes to your office because of a lack of sex drive, decreasing strength, low
overall energy levels, and hot flashes. After ruling out other causes you confirm that he has a
low total testosterone level on two separate early morning laboratory tests. He would like to start
testosterone therapy.
Which one of the following would be the most appropriate next step?
A) Order a PSA level and perform a digital rectal examination
B) Order LH and FSH levels
C) Order chromosomal studies
D) Discuss risks and benefits of testosterone replacement therapy and start low-dose
replacement
E) Inform him that testosterone replacement therapy would not be beneficial for him
because of its high risk
B - Checking LH and FSH levels is recommended to evaluate for
primary hypogonadism.
need to find a cause of the hypogonadism
Before initiating testosterone therapy, checking the patient’s PSA level and performing a digital rectal
examination are recommended, but in this case the initial workup is not yet complete.
what is CRPS
Complex regional pain syndrome (CRPS) is defined as a disorder of the extremities characterized by regional pain that is disproportionate in time or degree to the usual course of any known trauma or other lesion. The pain is not restricted to a specific nerve territory or dermatome and usually has a distal predominance of abnormal sensory, motor, sudomotor, vasomotor, and/or trophic findings.
The main clinical symptoms of CRPS are pain, sensory changes, motor impairments, autonomic symptoms, and trophic changes in the affected limb. Of these, pain is typically the most prominent and debilitating symptom
bronchiectasis - obstructive or restrictive
obstructive
medication induced lung diseases… obsturctive or restrictive
restrictive
The mother of a 6-month-old infant is concerned that her child’s feet are “deformed.” On
examination the heel bisector line is between the third and fourth digits on the right foot and on
the third digit on the left foot. You attempt to flex the feet, and both appear to be rigid.
Which one of the following would you recommend as a corrective intervention?
A) Night splints
B) Adjustable orthotic shoes
C) Braces
D) Physical therapy
E) Surgical correction
B
Adjustable orthotic shoes in infants who are not yet walking can be effective for the treatment of metatarsus
adductus (SOR B). These orthotics can be adjusted to apply an abduction force on the forefoot while
maintaining the heel in a neutral position.
UTD disagrees- they recommend stretching.
***the key to this question is that it is RIGID!
acute ischemic CVA BP limit
220/120 for the first 24 hours
thyroid nodule what are your first step(s)
second step if bloodwork is off
u/s
tsh
if tsh is low - then you need a scan (to see if it is a hot nodule) - radioactive iodine ablation.
if normal TSH/low TSH - the nodule needs biopsy depending on the u/s findings (it may say just monitor).
Anorexia nervosa with some binge-eating purging subtype. When considering the psychotherapy aspect of care for this patient, which one of the following
is preferred for treatment of her condition?
A) Cognitive-behavioral therapy
B) Dialectical behavioral therapy
C) Family therapy
D) Interpersonal therapy
E) Psychodynamic therapy
C
meh - I think this is a bad question. CBT is also appropriate for “her condition”.
ottawa knee rules?
- age >55
- isolated tenderness to the patella
- ttp fib head
- inability to flex to90 degrees
- inability to bear wear for 4 steps
***pain over the joint line does NOT count.
pes anserine bursitis - where is the pain located
anterior medial aspect of the tibia
A 4-year-old male is brought to your office by his mother because of a 2-day history of watery
diarrhea and vomiting and you diagnose acute gastroenteritis. On examination his mucous
membranes are sticky and he has decreased tear production, but his overall appearance is normal
and his eyes are not sunken. Using the Clinical Dehydration Scale, you estimate that he has mild
(3%–6%) dehydration.
Which one of the following should you recommend?
A) Water as tolerated
B) Half-strength apple juice followed by preferred fluids
C) The bananas, rice, applesauce, and toast (BRAT) diet
D) Intravenous fluids
E) Metoclopramide (Reglan)
B
oral rehydration is obviously best.
A randomized,
controlled trial has shown that initial rehydration with diluted apple juice followed by preferred fluids
resulted in fewer treatment failures than use of a formal electrolyte solution. This is likely due to the
increased likelihood that children will drink preferred fluids due to better taste, tolerability, and ease of
administration. Therefore, in high-income countries, this should be the recommended initial treatment for
mild dehydration due to gastroenteritis.
when should pericardiits be referred to a cardiologist?
if you don’t know the cuase (after virus etc…) and iti s refractory to NSAIDs/Colchicine
Due to the increased risk of endometrial cancer, current guidelines recommend that all women
>___years of age presenting with abnormal uterine bleeding undergo endometrial sampling.
45
when do you decide to get a EMB in a perimenopausal female
Irregular
menses can occur during the perimenopausal period but this patient’s increased frequency and volume of
vaginal bleeding combined with her age warrant further evaluation.
Transvaginal ultrasonography is recommended if a bimanual examination is abnormal or if symptoms
persist despite treatment…..
(I disagree)
A 55-year-old female presents with swelling and some redness in the area of her right ankle that
had a gradual onset over the past week. She has not had any injury, fever, or other signs of
systemic illness and has no pain. Her past medical history is significant for type 2 diabetes with
polyneuropathy that is moderately well controlled, hypertension, hyperlipidemia, and a BMI of
35 kg/m2.
On examination her right ankle and foot are slightly larger than the left, exhibit faint erythema,
and feel slightly warmer than the left. No pain is noted with palpation, and her ankle ligaments
appear to be intact. Pedal pulses are 2+ bilaterally and she has no calf pain or swelling.
Which one of the following would be the most appropriate next step?
A) Reassure her that the lack of pain indicates the absence of a serious disease process
B) Prescribe antibiotics for presumed cellulitis
C) Recommend compression stockings, leg elevation, and monitoring
D) Provide an ankle stabilizing brace
E) Obtain bilateral weight-bearing foot radiographs
no pain
no fever
no sign of systemic illness
= not cellulitis.
DM, BMI, neuropathy = think charcot
E - xrays could show you fractures of the midfoot.
It is usually PAINLESS.
when do you choose warfarin over a DOAC for afib
Valvular = Warfarin
If a patient has moderate to severe mitral stenosis or a mechanical valve,
then vitamin K antagonists are the preferred agent.
Non-valvular- DOAC
t/f - Breastfed infants born before 37 weeks gestation should receive iron supplementation
at 2 mg/kg/day after 1 month of life.
TRUE
A 34-year-old male began a sexual relationship with a woman 3 months ago and the relationship
ended on friendly terms last week. He received a call yesterday from the woman, who said she
had developed a rash that resulted in a diagnosis of syphilis and that he should be evaluated and
treated if appropriate. He has no symptoms and a serologic test for syphilis is negative. He has
no known drug allergies.
Which one of the following would be most appropriate at this time?
A) Daily self-inspection of the penis to identify a chancre
B) Observation with a repeat serologic test for syphilis in 6 weeks
C) Azithromycin (Zithromax), 2 g orally as a single dose
D) Penicillin G benzathine (Bicillin L-A), 2.4 million units intramuscularly as a single dose
E) Penicillin G benzathine, 2.4 million units intramuscularly once weekly for 3 weeks
D
***the key is 90 days!
When
the contact occurred more than 90 days before confirmation of a negative serologic test result, no treatment
is necessary.
For patients with a penicillin allergy,
oral treatment with doxycycline, 100 mg twice daily; tetracycline, 500 mg four times daily; or
azithromycin, 2 g as a single dose, has been effective as an alternate treatment option but should only be
used when penicillin is contraindicated and should be followed by close monitoring of serologic tests.
frail elderly person -
tx = exercise or nutritional supplments
exercise
Ulcers of _______ origin are due to tissue ischemia and are most typically deep but on the anterior leg,
distal dorsal foot, and toes, and have a dry, fibrous base with poor granulation tissue.
arterial
what locations do we see pressure ulcers
heels, hips, sacrum
episode of diverticulitis… what should be on done
While treatment of the initial episode with broad-spectrum antibiotics, early CT imaging to
detect complications, and colonoscopy 4–6 weeks after the resolution
169. Which one of the following is the most common cause of koilonychia (spoon-shaped nails)? A) Chronic pulmonary disease B) Hyperthyroidism C) Iron deficiency anemia D) Onychomycosis E) Psoriasis
C
If iron deficiency anemia is the cause of koilonychia, the nail will
return to a normal appearance when the anemia is corrected. Chronic pulmonary disease is associated with
clubbing of the nails. Hyperthyroidism can result in onycholysis (nail separation) and brown discoloration of the nail plate. Psoriasis typically causes pitted
nails, although patients can also have some hyperkeratosis and onycholysis.
At what fasting blood sugar level do you start insulin in an GDM mother?
Pharmacologic treatment should be initiated in patients with gestational diabetes mellitus (GDM) when
nutrition and exercise therapy are not adequate to meet goals. Accepted goals are fasting blood glucose
levels <95 mg/dL, 1-hour postprandial glucose levels <140 mg/dL, and 2-hour glucose levels <120
mg/dL.
An otherwise healthy 72-year-old male presents with a 4-week history of catching and triggering
of his right middle finger. When he awakens in the morning the finger is locked in flexion at the
proximal interphalangeal joint and he has to manually extend the finger. He enjoys playing golf
and painting, both of which are compromised by the triggering of his finger. He has not had any
pain or numbness.
Which one of the following would you tell him regarding his treatment options for this
condition?
A) Less than 15% of cases spontaneously resolve by 1 year
B) Splinting of the affected finger can result in complete resolution
C) NSAID injections have been found to be more effective than corticosteroid injections
D) Surgical release is the most cost-effective treatment
B
An otherwise healthy 72-year-old male presents with a 4-week history of catching and triggering
of his right middle finger. When he awakens in the morning the finger is locked in flexion at the
proximal interphalangeal joint and he has to manually extend the finger. He enjoys playing golf
and painting, both of which are compromised by the triggering of his finger. He has not had any
pain or numbness.
Which one of the following would you tell him regarding his treatment options for this
condition?
A) Less than 15% of cases spontaneously resolve by 1 year
B) Splinting of the affected finger can result in complete resolution
C) NSAID injections have been found to be more effective than corticosteroid injections
D) Surgical release is the most cost-effective treatment
B
remember DM is a RF.
Splinting, which is
a first-line treatment, has been shown to be effective. Single-joint orthoses at either the
metacarpophalangeal or the proximal interphalangeal joint can be effective (SOR B). The duration of
splinting can range from 6 weeks to 3 months.
A retrospective case series analysis of trigger finger managed by observation only found that trigger finger
resolved spontaneously in 52% of patients, with the majority resolving within 1 year.
all B-blockers can cause hyperTAG except one…
what other class of meds cause elevated TAG
coreg
estrogens
streoids
cholestyramine
thiazides
What to give to pt’s with croup after dex and still worsening
Heliox is a helium and oxygen
mixture that theoretically decreases airflow resistance but there is no clear evidence to support its use at
this time.
Humidified air inhalation has not been shown to have a clinical benefit in terms of croup scores
or hospital admissions.
- **Nebulized epinephrine should be reserved for patients with moderate to severe
croup.
**Oxygen should be administered if there are signs of hypoxemia or severe respiratory distress
PTSD first line? A) Alprazolam (Xanax) B) Clonazepam (Klonopin) C) Escitalopram (Lexapro) D) Dialectical behavioral therapy E) Individual trauma-focused psychotherapy
E
SSRI is after if therapy is not available or effective. prozac, paxil, zoloft
Benzodiazepines and escitalopram are not recommended
in the treatment of PTSD. Dialectical behavioral therapy is used in the treatment of borderline personality
disorder.
anti-dsDNA
anti-SmDNA
for what disease
SLE
DNA - Dana had Sam Earl
Adolescent
idiopathic scoliosis is generally defined as a lateral curvature of the spine or Cobb angle >__°. Cases with
a Cobb angle ___° can be just observed, but > ___ needs surgical correction
10
20
40
pregnant and influenza A) Baloxavir marboxil (Xofluza) B) Oseltamivir (Tamiflu) C) Peramivir (Rapivab) D) Zanamivir (Relenza)
B
Antiviral medications are recommended for the treatment of influenza only within 48 hours of symptom
onset (SOR A). However, in high-risk patient populations and in severe cases of disease, antivirals should
be provided regardless of the duration of symptoms (SOR B). According to the CDC, oseltamivir remains
the drug of choice for the treatment of influenza during pregnancy because it has good safety data.
t/f - verapamil has been shown to be a good migraine prophylaxis
false
Verapamil has previously been considered effective, but on reevaluation of previous studies, the
supporting data for verapamil is insufficient to prove efficacy.
Divalproex, topiramate, metoprolol, propranolol, and timolol have been shown to be effective for migraine
t/f - verapamil has been shown to be a good migraine prophylaxis
false
Verapamil has previously been considered effective, but on reevaluation of previous studies, the
supporting data for verapamil is insufficient to prove efficacy.
Divalproex, topiramate, metoprolol, propranolol, and timolol have been shown to be effective for migraine
Which one of the following
conditions is the most common cause of pulmonary hypertension?
A) Chronic thromboembolism
B) COPD
C) Idiopathic pulmonary arterial hypertension
D) Left heart disease
E) Sleep-disordered breathing
D
Left heart disease, including both preserved and reduced systolic function, is the most common cause of
pulmonary hypertension, while chronic thromboembolism, COPD, and sleep-disordered breathing are
other possible but less common causes. Idiopathic pulmonary arterial hypertension is a rare cause.
dry eye meds
Many systemic drugs have been reported to trigger dry eye, including diuretic agents, beta-blockers, other antihypertensive agents such as candesartan, antihistamines, decongestants, medications for Parkinson’s disease, antidepressant agents such as amitriptyline, anxiolytic agents, antispasmodic agents, anticonvulsant agents, gastric protection agents, oral contraceptives, and some herbal supplements.
The threshold for transfusing platelets to prevent spontaneous bleeding in the setting of hypoproliferative
thrombocytopenia in most adults is <10,000/ L (SOR A). A platelet count <20,000/ L is the threshold
for use of elective central venous catheter placement. For elective diagnostic lumbar puncture, major
elective non-neuraxial surgery, and interventional procedures, the threshold is a platelet count
<50,000/ L. For neuraxial surgery a threshold <100,000/ L is recommended.
10,000 - think of barbara richins
a line - 20
procedure 50
neuroaxial surg 100
If menarche has not occurred by age ____, or no
menses have occurred ___ years after the development of breast buds, an evaluation is recommended to evaluate primary ovarian failure.
15
3
A 56-year-old female with a history of stage III non–small cell lung cancer who is currently
receiving radiation treatment and chemotherapy sees you because of a poor appetite and a 4.5-kg
(10-lb) weight loss in the past month. She requests medication to improve her appetite and you
consider prescribing megestrol (Megace).
Which one of the following is a possible side effect associated with the use of megestrol in this
patient?
A) Hirsutism
B) Hypoglycemia
C) Improved libido
D) Thrombocytopenia
E) A venous thromboembolic event
E
Megestrol is a synthetic progestin with antiestrogenic properties which disrupt the estrogen receptor cycle.
Most progestins I feel like end in -enone (drospirenone)
(norethindrone)
norgestimate
… progester RONE
YES - progesterone by itslef increases the risk of clots.
This is a chemo treatment… so think hair loss, decreased libido, thrombocytopenia… and oddly hyperglycemia (maybe like a steroid response)
patellofemoral pain… where is the pain felt
under the patella.
- A healthy 36-year-old female who is a nonsmoker sees you for a routine well woman
examination. She has been sexually active with five partners in the last 2 years. She has never
had an abnormal Papanicolaou (Pap) smear. Last year’s Pap test with high-risk HPV co-testing
was negative. You review her immunization status and note that she received the influenza
vaccine last fall.
Which one of the following vaccines that this patient has never previously received would you
recommend for her?
A) Hepatitis A vaccine
B) HPV vaccine (Gardasil 9)
C) Meningococcal polysaccharide conjugate vaccine (Menactra)
D) Pneumococcal polysaccharide vaccine (PPSV23, Pneumovax 23)
E) Recombinant zoster vaccine (Shingrix)
B
\The only vaccine indicated for this patient would be the HPV vaccine, which the CDC recommends as a
routine vaccination for all patients starting at 11 or 12 years of age through 26 years of age but can also
be considered in adults 27–45 years of age who have not previously received the vaccine and are most
likely to benefit.
Routine vaccination for hepatitis A is recommended only for patients who are at high risk
of hepatitis A infection, but that is not the case with this patient.
meningococcal is not given after the age of 24.
shingrix… who can get it?
how many doses?
There is only 1 vaccine now - they no longer do the zostavax.
The RZV requires two doses administered intramuscularly for protection. The second dose should be administered two to six months after the first
This schedule should be used for all patients, including those with a history of prior herpes zoster and those who previously received zoster vaccine live (ZVL).
Although data are limited, the United States Centers for Disease Control and Prevention (CDC) advises that recombinant vaccines, such as RZV, can be administered at the same time as other adult vaccines but at different anatomic sites
if recent infection - wait 1 year
A 36-year-old female sees you for a routine health maintenance visit. She reports worsening hair
growth on her chin and abdomen over the last few years. The excessive hair growth first
appeared in her late teens and she has been dissatisfied with the cosmetic results of various hair
removal methods. She is generally healthy aside from a BMI of 31 kg/m2. She does not take any
medications, is a nonsmoker, and has had a bilateral tubal ligation. Her menses are regular.
A complete physical examination is consistent with some terminal hairs in the distribution she
described and is otherwise unremarkable. Laboratory results are normal, including fasting lipids,
a comprehensive metabolic panel, a hemoglobin A1c, and a TSH level.
Which one of the following would be the recommended first-line treatment for this patient’s
condition?
A) Drospirenone/ethinyl estradiol (Yasmin)
B) Flutamide
C) Leuprolide (Eligard)
D) Metformin (Glucophage)
E) Spironolactone (Aldactone)
a
First-line therapy for hirsutism in women who do not desire pregnancy and for whom cosmetic
treatments are not effective is combined oral contraceptives (SOR B), which decrease androgen production
in the ovaries by decreasing LH levels.
Metformin is not effective for the treatment of hirsutism (SOR B). While
this patient likely has PCOS, the anti-insulin medications will not affect excess hair growth. Antiandrogen
treatments such as spironolactone and finasteride are second-line therapies that can be added to the
combined oral contraceptives if there is no improvement after the first 6 months (SOR A).
A 36-year-old female sees you for a routine health maintenance visit. She reports worsening hair
growth on her chin and abdomen over the last few years. The excessive hair growth first
appeared in her late teens and she has been dissatisfied with the cosmetic results of various hair
removal methods. She is generally healthy aside from a BMI of 31 kg/m2. She does not take any
medications, is a nonsmoker, and has had a bilateral tubal ligation. Her menses are regular.
A complete physical examination is consistent with some terminal hairs in the distribution she
described and is otherwise unremarkable. Laboratory results are normal, including fasting lipids,
a comprehensive metabolic panel, a hemoglobin A1c, and a TSH level.
Which one of the following would be the recommended first-line treatment for this patient’s
condition?
A) Drospirenone/ethinyl estradiol (Yasmin)
B) Flutamide
C) Leuprolide (Eligard)
D) Metformin (Glucophage)
E) Spironolactone (Aldactone)
a
First-line therapy for hirsutism in women who do not desire pregnancy and for whom cosmetic
treatments are not effective is combined oral contraceptives (SOR B), which decrease androgen production
in the ovaries by decreasing LH levels.
Metformin is not effective for the treatment of hirsutism (SOR B). While
this patient likely has PCOS, the anti-insulin medications will not affect excess hair growth. Antiandrogen
treatments such as spironolactone and finasteride are second-line therapies that can be added to the
combined oral contraceptives if there is no improvement after the first 6 months (SOR A).
A 52-year-old male presents with moderate symptoms of prostatism. A prostate examination is normal. His post-void residual volume is 90 mL. His PSA level is 0.75 ng/mL (N 0.0–4.0). He says his nocturia has become troublesome and you decide to initiate therapy.
This patient does NOT meet the criteria for use of which one of the following? (check one)
Doxazosin (Cardura)
Finasteride (Proscar)
Tadalafil (Cialis)
Tamsulosin (Flomax)
Silodosin (Rapaflo)
Finasteride
Pharmacologic options for benign prostatic hyperplasia and lower urinary tract symptoms include an
α-adrenergic blocker,
a 5-α-reductase inhibitor (if there is evidence of prostatic enlargement or a PSA level >1.5 ng/mL),
a phosphodiesterase-5 inhibitor,
or antimuscarinic therapy.
So ED and BPH - could try tadalafil
A 4-year-old female is brought to your office because of a history of constipation over the past several months. Her mother reports that the child has 1–2 bowel movements per week composed of small lumps of hard stool. She strains to have the bowel movements, and they are painful. The child eats normally like her two siblings.
Which one of the following would be most effective at this time? (check one) Daily fiber supplements Lactulose Magnesium hydroxide (Milk of Magnesia) Polyethylene glycol (MiraLAX) Senna
miralax baby
Evidence does not support the use of fiber supplements in the treatment of
functional constipation.
do you need imaging studies on a kid with a radial head subluxation
nope, as long as you are not worried about a fracture
Which one of the following is the most appropriate first-line therapy for primary dysmenorrhea?
(check one)
Combined monophasic oral contraceptives
Combined multiphasic oral contraceptives
Subdermal etonogestrel (Nexplanon)
Intramuscular medroxyprogesterone (Depo-Provera)
NSAIDs
E
Which one of the following is the most appropriate first-line therapy for primary dysmenorrhea?
(check one)
Combined monophasic oral contraceptives
Combined multiphasic oral contraceptives
Subdermal etonogestrel (Nexplanon)
Intramuscular medroxyprogesterone (Depo-Provera)
NSAIDs
E
They should be started
at the onset of menses and continued for the first 1–2 days of the menstrual cycle.
Combined oral
contraceptives may be effective for primary dysmenorrhea, but there is a lack of high-quality randomized,
controlled trials demonstrating pain improvement (SOR B).
what is the difference between an essential tremor and a physiological tremor
Patients who have essential tremor have symmetric, fine tremors that may involve the hands, wrists, head,
voice, or lower extremities. This may improve with ingestion of small amounts of alcohol. There is no
specific diagnostic test but the tremor is treated with propranolol or primidone.
Enhanced physiologic
tremor is a postural tremor of low amplitude exacerbated by medication. There is usually a history of caffeine use or anxiety. - caused by something (caffeine, anxiety, medication)
Cerebellar tremor is an intention tremor with ipsilateral involvement on
the side of the lesion.
A 10-year-old male has an 8-mm induration 2 days after a tuberculin skin test. He shares a bedroom with his 18-year-old brother who was recently diagnosed with tuberculosis. There are no other historical or physical examination findings to suggest active tuberculosis infection and a chest radiograph is normal.
Which one of the following would be most appropriate at this point? (check one)
toring with annual tuberculin skin testing
Observation and repeat tuberculin skin testing in 3 weeks
Rifampin (Rifadin) daily for 4 months
Isoniazid daily for 9 months
Once-weekly isoniazid and rifampin for 3 months
Does this kid have latent or active TB?
D
Based on CDC guidelines an induration 5 mm at 48–72 hours following an intradermal injection of tuberculin is a positive test in individuals who have been in recent contact with a person with infectious TB, those with radiographic evidence of prior TB, HIV-infected persons, and immunosuppressed patients. For other individuals at increased risk for TB, the threshold for a positive test is an induration 10 mm at 48–72 hours. For those with no known risks for TB infection, the induration must exceed 15 mm in size to be considered positive. Once positive, there is no indication for additional skin tests.
A positive screening test along with a review of systems, a physical examination, and a chest radiograph that do not show evidence of active infection confirms the diagnosis of latent TB.
A 62-year-old female with diabetes mellitus presents to your office with left lower quadrant pain and guarding. She has a previous history of a shellfish allergy that caused hives and swelling.
Further evaluation of this patient should include which one of the following? (check one)
Ultrasonography of the abdomen
CT of the abdomen and pelvis with oral and intravenous (IV) contrast
Oral corticosteroids and antihistamines, then CT of the abdomen and pelvis with oral and IV contrast
Intravenous corticosteroids and antihistamines, then CT of the abdomen and pelvis with oral and IV contrast
Laparotomy
B
There is no correlation between shellfish allergies and allergic reactions to contrast. Patients with moderately severe to severe reactions to IV contrast in the past would need pretreatment with corticosteroids.
You see a patient with a serum sodium level of 122 mEq/L (N 135–145) and a serum osmolality of 255 mOsm/kg H2O (N 280–295). Which one of the following would best correlate with a diagnosis of syndrome of inappropriate antidiuresis? (check one)
A fractional excretion of sodium below 1%
Elevated urine osmolality
Elevated serum glucose
Elevated BUN
Low plasma arginine vasopressin
B
urine osmolality must be high in conjunction with both low serum sodium and low osmolality. The BUN should be normal or low and the fractional excretion of sodium >1%.
A 45-year-old African-American male returns to your clinic to evaluate his progress after 6 months of dedicated adherence to a diet and exercise plan you prescribed to manage his blood pressure. His blood pressure today is 148/96 mm Hg. He is not overweight and he does not have other known medical conditions or drug allergies.
Which one of the following would be the most appropriate initial antihypertensive treatment option for this patient? (check one) Chlorthalidone Hydralazine Lisinopril (Prinivil, Zestril) Losartan (Cozaar) Metoprolol
A For African-Americans, thiazide diuretics and calcium channel blockers, both as monotherapy and as a component in multidrug regimens, have been shown to be more effective in lowering blood pressure than ACE inhibitors, angiotensin II receptor blockers, or β-blockers, and should be considered as first-line options over the other classes of antihypertensive drugs unless a comorbid condition is present that would be better addressed with a different class of drugs
AA and Hispanics think thiazides or CCB
AA is not the same as ArB or ACei
Medicare Part A provides hospice care but Medicare Part B does not.
Think of A as hospice and hospital
B as clinic
D as meds
A 69-year-old male with type 2 diabetes mellitus, obesity, and a history of coronary artery disease sees you for follow-up of his diabetes. His hemoglobin A1c has increased to 8.7% despite therapy with metformin (Glucophage), 1000 mg twice daily, and insulin glargine (Lantus).
Which one of the following additional medications would be most effective for reducing his blood glucose level and lowering his risk of cardiovascular events? (check one) Exenatide (Byetta) Glipizide (Glucotrol) Liraglutide (Victoza) Rosiglitazone (Avandia) Sitagliptin (Januvia)
C
Liraglutide, exenatide, and dulaglutide are all GLP-1 receptor agonists. Of these, only liraglutide has been shown to lower the risk of recurrent cardiovascular events and has received FDA approval for this indication.
Empagliflozin, an SGLT2 inhibitor, has also been associated with secondary prevention of cardiovascular disease.
Em and Liz are the best at protecting my heart!
A 2-year-old African-American male with a history of sickle cell disease is brought to your office for a well child check. Which one of the following would be most appropriate for screening at this time? (check one) A chest radiograph A DXA scan Abdominal ultrasonography Renal Doppler ultrasonography Transcranial Doppler ultrasonography
5th times the charm
E
Individuals with sickle cell disease are at increased risk for vascular disease, especially stroke. All sickle cell patients 2–16 years of age should be screened with transcranial Doppler ultrasonography (SOR A). A chest radiograph, abdominal ultrasonography, a DXA scan, and renal Doppler ultrasonography are not recommended for screening patients with sickle cell disease.
UTD: In children ≤16 years of age with hemoglobin SS or hemoglobin S-beta thalassemia that produces no hemoglobin A, referred to as S beta thalassemia zero, cerebral blood flow should be evaluated by transcranial Doppler (TCD) annually, because children at risk for strokes can be identified with this technique and the incidence of stroke can be reduced by the use of regular blood transfusion therapy aimed at maintaining the maximum hemoglobin S level at less than 30 percent
You note that the infant’s upper lip is thin and the philtrum is somewhat flat.
Which additional finding would increase your concern for fetal alcohol syndrome? (check one)
Curvature of the fifth digit of the hand (clinodactyly)
A supernumerary digit of the hand
Flattening of the head (plagiocephaly)
Metatarsus adductus in one foot
Syndactyly of the toes (webbed feet)
also 5th times the charm
A
In addition to clinodactyly, fetal alcohol syndrome is associated with camptodactyly (flexion deformity of the fingers), other flexion contractures, radioulnar synostosis, scoliosis, and spinal malformations. It is also associated with many neurologic, behavioral, and cardiovascular abnormalities, as well as other types of abnormalities.
hypothyroid, hyperthryoid or both are associated with a polyneuropathy
hypothyroidism
hypothyroid, hyperthryoid or both are associated with a polyneuropathy
hypothyroidism
A 60-year-old male presents with a several-month history of a dry cough and progressive shortness of breath with exertion. On examination he has tachypnea and bibasilar end-inspiratory dry crackles, and a chest radiograph reveals interstitial opacities.
Which one of the following patient occupations would most likely support a diagnosis of silicosis? (check one) Baker Firefighter Stone cutter Goat dairy farmer High-tech electronics fabricator
C
Stone cutting, sand blasting, mining, and quarrying expose patients to silica, which is an inorganic dust that causes pulmonary fibrosis (silicosis).
Occupational exposure to beryllium, which is also an inorganic dust, occurs in the high-tech electronics manufacturing industry and results in chronic beryllium lung disease.
Exposure to organic agricultural dusts (fungal spores, vegetable products, insect fragments, animal dander, animal feces, microorganisms, and pollens) can result in “farmer’s lung,” a hypersensitivity pneumonitis.
Other organic dust exposures, such as exposures to grain dust in bakers, can lead to asthma, chronic bronchitis, and COPD.
Firefighters are at risk of smoke inhalation and are exposed to toxic chemicals that can cause many acute and chronic respiratory symptoms.
You see a 3-year-old female with a 2-day history of intermittent abdominal cramps, two episodes of emesis yesterday, and about five watery, nonbloody stools each day. She does not have a fever, her other vital signs are normal, and she has not traveled recently. Today she has tolerated sips of fluid but still has mild fatigue and thirst. An examination is normal except for mildly dry lips. A friend at preschool had a similar illness recently.
Which one of the following would be the most appropriate initial management of this patient? (check one)
A sports drink and food on demand
Half-strength apple juice and food on demand
Ginger ale and no food yet
Water and no food yet
A bolus of intravenous normal saline and no food yet
B
The World Health Organization recommends oral rehydration with low osmolarity drinks (oral rehydration solution) and early refeeding. Half-strength apple juice has been shown to be effective, and it approximates an oral rehydration solution. Its use prevents patient measurement errors and the purchase of beverages with an inappropriate osmolarity. Low osmolarity solutions contain glucose and water, which decrease stool frequency, emesis, and the need for intravenous fluids compared to higher osmolarity solutions like soda and most sports drinks
Early refeeding has been shown to decrease the duration of illness.
heart murmur that worsens with valsalva… think what?
you are increasing afterload, HCOM
An 85-year-old female with advanced Alzheimer’s disease is brought to your office for treatment of agitation, aggressive behavior, and delusions. Behavioral and psychological interventions have had little success and the family is willing to try medications because they prefer to keep the patient at home.
Which one of the following would most likely help control this patient’s symptoms? (check one) Alprazolam (Xanax) Aripiprazole (Abilify) Donepezil (Aricept) Haloperidol
abilify
if geri- think abilify
Aripiprazole produces small reductions in behavioral and psychological symptoms of dementia, and it has the least adverse effects of the atypical antipsychotics.
Typical antipsychotics such as haloperidol have significant side effects and would not be a good choice
if someone is using the progesterone only pill, butonly in the luteal phase of their cycle are they getting benefit
nope - they will not have suppressed ovulation and the bleeding will be irratic
OA failing nsaids… what do you recommend
PT
A 66-year-old male recently underwent percutaneous angioplasty for persistent angina with exertion. He does not have any symptoms now. His LDL-cholesterol level is 90 mg/dL.
Which one of the following would be most appropriate for secondary prevention of this patient’s coronary artery disease? (check one)
No drug treatment
Evolocumab (Repatha), 140 mg subcutaneously every 2 weeks
Ezetimibe (Zetia), 10 mg daily
Rosuvastatin (Crestor), 20 mg daily
Simvastatin (Zocor), 40 mg daily
D
Patients <75 years of age with established coronary artery disease should be on high-intensity statin regimens if tolerated. These regimens include atorvastatin, 40–80 mg/day, and rosuvastatin, 20–40 mg/day. Moderate-intensity regimens include simvastatin, 40 mg/day.
hhigh intensity = think Rich Allen = Rosuva and Aotrva
20-40/40-80
A 62-year-old female who is a new patient requests a thyroid evaluation because she has a history of abnormal thyroid test results. You obtain a copy of her records, which include a TSH level of 0.2 μU/mL (N 0.4–4.2) and a free T4 level of 2.0 ng/dL (N 0.8–2.7) from 3 years ago. She reports feeling well and has no other health conditions. She does not take any medications.
A physical examination reveals normal vital signs, a BMI of 23 kg/m2, no neck masses, a normal thyroid size, and normal heart sounds. Laboratory studies reveal a TSH level of 0.1 μU/mL, a free T4 level of 2.5 ng/dL, and a free T3 level of 3.1 pg/mL (N 2.3–4.2).
Treatment for this condition would be indicated if the patient has an abnormal (check one) calcium level DXA scan glucose level lipid level thyroid ultrasonography study
B
Common causes of subclinical hyperthyroidism include Graves disease, autonomous functioning thyroid adenoma, and multinodular toxic goiter. Subclinical hyperthyroidism may progress to overt hyperthyroidism; this is more likely in patients with TSH levels <0.1 μU/mL. Even in the absence of overt hyperthyroidism these patients are at higher risk for several health conditions, including atrial fibrillation, heart failure, and osteoporosis. For this reason it is important to assess for these conditions and consider treating the underlying thyroid condition, as well as the complication. The American Thyroid Association recommends treating patients with complications who are either over age 65 or have a TSH level <0.1 μU/mL.
BPPV
Which one of the following findings during the examination would confirm the diagnosis? (check one)
Nystagmus when vertigo is elicited
Vertigo that occurs immediately following the test-related head movement
Persistence of vertigo for 5 minutes following the test-related head movement
A drop in systolic blood pressure of >10 mm Hg when supine
A
The Dix-Hallpike maneuver, which involves moving the patient from an upright to a supine position with the head turned 45° to one side and the neck extended 20° with the affected ear down, will elicit a specific series of responses in these patients. Following a latency period that typically lasts 5–20 seconds but sometimes as long as 60 seconds, the patient will experience the onset of rotational vertigo. The objective finding of a torsional, upbeating nystagmus will be associated with the vertigo. The vertigo and nystagmus typically increase in intensity and then resolve within 1 minute from onset.
YOU HAVE TO WAIT….
which ssri should be avoided in the elderly
Paroxetine should generally be avoided in older patients due to a higher likelihood of adverse effects
t/f - benzos in PTSD are not great
true - Benzodiazepines such as lorazepam can treat symptoms of hyperarousal but have been associated with adverse effects and should be avoided in the treatment of PTSD (SOR B).
worst supplement….
st johns wort
mental health diagnosis and hx of alcohol abuse… what do you think?
avoid benzos
sllipped capital femoral epiphysis… what age
8-15
On examination the most indicative sign is limited internal rotation of the involved hip. Bilateral radiographs of the hips, including frog-leg lateral views, should be obtained in any adolescent who presents with a new limp and pain in the groin, hip, thigh, or knee (SOR C).
A 70-year-old male comes to your office for preoperative clearance for a right total hip replacement. He is a nonsmoker and has a history of mild hypertension controlled with amlodipine (Norvasc). The history indicates that he is able to perform 7–8 METS of activity without any concerning symptoms. A physical examination, including vital signs, is normal.
Your evaluation should include which one of the following tests? (check one) A chest radiograph Coagulation testing An EKG Liver function studies Renal function studies
E
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.
A 50-year-old female presents with pain in her right forefoot. She recently ran her first full marathon after several years of inactivity and says the pain started gradually over the last few weeks of her training and has slowly gotten worse. You order radiographs of the foot, which show a stress fracture of the second metatarsal.
You would recommend (check one)
resumption of regular activity if the pain does not recur with activity after 1 week of rest
no weight bearing on the right foot for 6 weeks
no weight bearing for a few days, followed by a walking boot, then a rigid-soled shoe in 4–6 weeks
a walking boot for 12 weeks
referral to an orthopedic surgeon for further evaluation
C
think of bradley - no weight bearing, then a walking boot quickly
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.
An 11-year-old female is referred to you after a sports physical examination because 2+ protein was found on a random dipstick urinalysis. She feels well and does not have any health concerns. She plays soccer an average of 5 days a week.
The patient’s medical history is unremarkable and she takes no medications. Menarche has not occurred. She does not report any urinary or back symptoms, recent illness, edema, or weight change. A physical examination is normal. A dipstick urinalysis in your office shows 1+ protein but is otherwise normal.
Which one of the following would you recommend next? (check one)
Withdrawing from all physical activity for 24 hours and a 24-hour urine for protein
A spot protein/creatinine ratio performed on first morning urine
Serum BUN, creatinine, electrolyte, and albumin levels
Ultrasonography of the kidneys and bladder
B
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.
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.
. 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
this of this with the elderly that are on it for alzheimers delirium
TB exposure while travelling… how soon should you do a skin test or a quant gold
8-10 weeks, so about 2 months.
Patients with illness anxiety disorder are overly concerned with bodily functions, and can often provide accurate, extensive, and detailed medical histories.
think of Kara - vestibulodynia patient.
A 70-year-old male presents to your office for follow-up after he was hospitalized for acute coronary syndrome. He has not experienced any pain since discharge and is currently in a supervised cardiac rehabilitation exercise program. His medications include aspirin, lisinopril (Prinivil, Zestril), and metoprolol, but he was unable to tolerate atorvastatin (Lipitor), 40 mg daily, because he developed muscle aches.
Which one of the following would you recommend? (check one) Evolocumab (Repatha) Ezetimibe/simvastatin (Vytorin) Fenofibrate (Tricor) Niacin Omega-3 fatty acid supplements
B
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.
A 50-year-old male presents with difficulty straightening his left ring finger. Examination of the affected hand reveals a nodule of the palmar aponeurosis and associated fibrous band that limits full extension of the fourth finger. He is unable to fully extend both the metacarpophalangeal (MCP) joint and the proximal interphalangeal (PIP) joint, with MCP and PIP contractures estimated at 40° and 20°, respectively.
Which one of the following would be the most appropriate management strategy? (check one)
Observation until the PIP contracture is >90°
Serial intralesional injection with a corticosteroid
Cryosurgery of the fibrous nodule
Referral for physical therapy
Referral for surgical release of the contracture
E
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.
A 44-year-old female presents for a pretravel consultation and asks about medication options for traveler’s diarrhea. She will be on an organized tour traveling to a country with a very low risk for this problem. She plans to take all precautions to further reduce her risk but would also like you to recommend a medication she can take.
Which one of the following would be an appropriate recommendation? (check one)
A short course of azithromycin (Zithromax) if she develops diarrhea
Loperamide (Imodium) daily, starting 1 day prior to travel and continued until 1 day after returning home
Probiotics daily, starting 1 week prior to travel and continued until 1 week after returning home
Ciprofloxacin (Cipro) daily, starting 2 weeks prior to travel and continued until 4 weeks after returning home
Bismuth subsalicylate daily, starting 2 weeks prior to travel and continued until 4 weeks after returning home
a
Azithromycin is preferred to treat severe traveler’s diarrhea. Rifaximin or fluoroquinolones may be used
to treat severe nondysenteric traveler’s diarrhea.
PEPTO CAN HELP PREVENT
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.
CURB 65 … what are the parameters
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.
megestrol is used for what
an appetite stimulant
megestrol is used for what
an appetite stimulant
A 30-year-old female is planning a trip to Australia and is concerned about motion sickness.
Which one of the following medications is most effective for preventing this problem? (check one)
Dimenhydrinate (Dramamine)
Diphenhydramine (Benadryl)
Meclizine (Antivert)
Promethazine
Scopolamine
E
A 30-year-old female is planning a trip to Australia and is concerned about motion sickness.
Which one of the following medications is most effective for preventing this problem? (check one)
Dimenhydrinate (Dramamine)
Diphenhydramine (Benadryl)
Meclizine (Antivert)
Promethazine
Scopolamine
E
pityriasis rosea This condition is associated with (check one) no additional pregnancy risk a small-for-gestational-age newborn congenital cataracts multiple birth defects spontaneous abortion
E
This is generally a benign disease except in pregnancy. The
epidemiology and clinical course suggest an infectious etiology. Pregnant women are more susceptible to
pityriasis rosea because of decreased immunity. Pityriasis rosea is associated with an increased rate of
spontaneous abortion in the first 15 weeks of gestation.
A 30-year-old female reports that she and her husband have not been able to conceive after
trying for 15 months. She takes no medications, has regular menses, and has no history of
headaches, pelvic infections, or heat/cold intolerance. Her physical examination is
unremarkable. Her husband recently had a normal semen analysis.
Which one of the following would be the most appropriate next step? (check one) Observation for 1 year TSH, free T4, and prolactin levels Hysterosalpingography An estradiol level A luteal-phase progesterone level
E
Then if no ovulation check B
Treatment can be initiated if findings reveal the cause of the problem, but if they are
unremarkable it is reasonable to try clomiphene to induce ovulation. If this is unsuccessful, referral would
be the next step.
A 34-year-old female sees you because of cramping diarrhea for the past several months following resection of her terminal ileum as treatment for Crohn’s disease. She is not aware of any exposure to individuals with similar symptoms. She has not had any fever, chills, nausea, vomiting, or myalgias, and she has not noticed any blood in her stool. She is passing several loose stools daily, mostly after meals. She has not been able to identify any clear relationship to the type of food she eats.
Which one of the following would be the best initial treatment option for this patient? (check one)
A dairy-free diet
Cholestyramine (Questran) daily
A Lactobacillus probiotic supplement (Lactinex) 4 times daily
Loperamide (Imodium) as needed
Psyllium fiber (Metamucil) twice daily
5th times the charm
B
Diarrhea that develops in patients with ileal Crohn’s disease or following ileal resection is usually due to increased amounts of bile acid remaining in the stool. This affects colonic secretion and motility and various protein factors in the gut, resulting in the development of bile acid diarrhea (BAD). Although various tests can be performed to evaluate the stool, gut flora, and bowel function, a therapeutic trial with a bile acid sequestrant such as cholestyramine is most often used for both the diagnosis and treatment of BAD. Reducing fat intake may also be beneficial. Loperamide can lessen the diarrhea in some patients but should not be the primary treatment because chronic use can result in constipation. Fiber supplementation may help to produce a more formed stool and could be used as an adjunct treatment when appropriate.
Which one of the following treatments has been shown to improve the quality of life for a patient with tinnitus? (check one) Antidepressant therapy Ginkgo biloba Niacin Vitamin B12 Cognitive-behavioral therapy
E
