FCM Cases Flashcards
A 34-year-old woman who has no past medical problems nor is currently taking any medications comes into your office because she noticed a tender lump in her left breast starting approximately one month ago. She is worried because she has an aunt who had breast cancer that was BRCA positive, though her mother is BRCA negative. Her periods have been regular since they started at the age of 13 and occur every 32 days. She is currently menstruating. She has three children aged 12, 9, and 4. On exam, her BMI is 32, up from 28 three years ago and her other vital signs are stable. On breast exam, you note a mobile rubbery mass of approximately 1 x 1cm and with regular borders that is tender to palpation. You appreciate no axillary adenopathy. The rest of her physical exam is unremarkable. Of the information provided, which of the following places this patient at increased risk for breast cancer?
A. Age B. Weight C. Parity history D. Family history of cancer E. Age of menarche
The correct answer is B.
With a BMI of 32, obesity is the one risk factor for this patient based on the information given. Other risk factors for breast cancer include family history of breast cancer in a first degree relative (mother or sister - not aunt), prolonged estrogen exposure (menarche before age 12, menopause after 45, advanced age at first pregnancy), genetic predisposition (BRCA 1 or 2 mutation), advanced age (breast cancer risk increases with age, and this patient is relatively young), female sex, increased breast density and certain exposures (diethylstilbestrol, hormone or radiation therapy, heavy smoking).
A 64-year-old woman who is overweight with well-controlled hypertension comes to your office complaining of a lump in her breast that she noticed while showering. She denies any pain, tenderness, or skin changes. A pertinent review of systems is negative. Menarche began at the age of 10. Her first child was born when she was 31 and she had her second and last child at the age of 33. She experienced menopause at the age of 44. Her mother died of colon cancer when she was 65 and her father passed away from metastatic prostate cancer at the age of 70. She has no history of tobacco use ever and occasionally drinks a glass of wine with dinner. Her BMI is 34. Which of the information provided thus far puts the patient at decreased risk for breast cancer?
A. Age B. Weight C. Age at first birth D. Age at menarche E. Age at menopause
The correct answer is E.
The patient experienced menopause at the age of 44, which shortens her time of estrogen exposure, a known risk factor for the development of breast cancer. Factors associated with decreased breast cancer risk include pregnancy at an early age, late menarche, early menopause, high parity and medications such as selective estrogen receptor modulators along with NSAIDs and aspirin. Risk factors for breast cancer include family history of breast cancer in a first degree relative (mother or sister), prolonged estrogen exposure (menarche before age 12, menopause after 55, advanced age at pregnancy, obesity after menopause), female sex, genetic predisposition (BRCA 1 or 2 mutation), advanced age (breast cancer risk increases with age), increased breast density and exposures (diethylstilbestrol, hormone or radiation therapy, smoking).
A 63-year old woman comes into your office for her annual preventive exam. She has hypertension and type 2 diabetes. She is not sexually active. Her blood pressure is 125/80 and her physical exam otherwise is within normal limits. You recommend influenza and zoster vaccination. Her last colonoscopy was eight years ago and her last mammogram one year ago was normal. She has never had an abnormal Pap smear. At the age of 45 she had a total hysterectomy for fibroids. You tell her she does not require a Pap smear today because:
A. She has never had an abnormal Pap smear
B. She is not sexually active
C. She had a total hysterectomy for fibroids
D. She is 63 years old
E. She experienced menopause more than 10 years ago
The correct answer is C.
The patient described above underwent a total hysterectomy (total removal of the uterus and cervix with or without oophorectomy) for benign reasons (fibroids). USPSTF guidelines recommend against continued cervical cancer screening in patients whose uterus has been removed for benign disease and evidence showed cytologic screening to be very low yield and poor evidence that screening to detect vaginal cancers improves health outcomes in women after hysterectomy for benign disease. Cervical cancer screening should begin at the age of 21 and women between the ages of 65 and 70 who have had three or more normal Pap tests in the past ten years may choose to stop cervical cancer screening. Not being sexually active; age 63; only having had normal PAP smears and years since menopause are not reasons to stop screening for cervical cancer.
A 47-year-old woman comes into your office for a health care maintenance exam. She has hypertension and type 2 diabetes. She is not sexually active and has not yet experienced menopause. There is no family history of cancer. Her blood pressure is 118/78, her BMI is 34 and the remainder of her physical exam is within normal limits. Her vaccinations are up-to-date, she has a PAP smear today and will have labs drawn. According to USPSTF, which of the following is the best recommendation to give her concerning mammography?
A. Should have started at age 40 and every year thereafter
B. Should have started at age 40 and every 2 years thereafter
C. Start at age 50 and every year thereafter
D. Start at age 50 and every 2 years thereafter
E. Should have started at age 45 and every year thereafter
The correct answer is D.
Mammography has a sensitivity of 60% to 90% for detecting breast cancer and decreases breast cancer mortality. According to the most recent USPSTF guidelines, routine mammography is not indicated for women younger than 50 years old except as based on patient context (history) and beliefs about risks/benefits. The USPSTF recommends biennial testing for women between the ages of 50 and 74. There is insufficient evidence to assess the benefits versus risk of screenings in women after the age of 75. Other groups such as the American Cancer Society (ACS) and American College of Obstetricians and Gynecologists (ACOG) recommend yearly mammograms starting at age 40, continuing as long as the woman is in good health.
A 27-year-old woman comes into your office because she heard from her friend about a vaccination against cervical cancer and would like one. She has no medical problems and has had a Mirena IUD for three years. She has an allergy to latex and penicillin. She began having sex at the age of 18 and is currently sexually active with one partner. She occasionally uses condoms. She smokes half a pack of cigarettes per day. Her mother had endometrial cancer several years ago and had a total hysterectomy. Why is the patient not an ideal candidate for the Gardasil vaccination?
A. Age B. Sexual activity C. Mirena IUD D. Allergy to penicillin E. Tobacco use
The correct answer is A.
Gardasil9 is a vaccination against 9 HPV types and is approved for females ages 9 to 26. While the recommendation is to end at age 26, that does not mean it is dangerous; it just hasn’t been studied and will not likely be covered by insurance. Activity (B) is not a contraindication to Gardasil vaccination. The other choices are not contraindications to vaccinations.
A 55-year-old man with no significant past medical history presents for a routine physical exam. He last saw a doctor five years ago. Social history is remarkable for a 35-pack-year tobacco history since the age of 20. He indicates that his wife and children have urged him to quit smoking for the last few months. When you ask him if he has considered quitting, he replies, “I just don’t see what the big deal is!” Which stage of change best describes this patient at this time?
A. Precontemplation B. Contemplation C. Preparation D. Action E. Maintenance
The correct answer is A.
Based on this man’s response, it appears he has not actively considered quitting smoking despite his family’s concern. All options refer to different stages in the Transtheoretical stages of change model. Given that he has not actively contemplated quitting, the best stage to describe this patient at this time would be the Precontemplation stage and not any of the other responses.
A 48-year-old man with a past medical history that includes hypertension, Chronic Obstructive Pulmonary Disease (COPD), and hyperlipidemia presents to clinic as a new patient for a general physical exam. History reveals that he has been smoking a pack of cigarettes daily since age 20. He drinks two beers daily. He is intermittently noncompliant with his medications. Review of the state immunization database reveals that the only immunization he has received as an adult was a tetanus diphtheria shot administered 12 years ago. Which of the following vaccine combinations would be most appropriate for this patient?
A. Influenza, Meningococcal, and Zoster B. Influenza, Pneumococcal, and Tdap C. Influenza, Zoster, and Tdap D. Meningococcal, Pneumococcal, and Tdap E. Meningococcal, Pneumococcal, and Zoster
The correct answer is B.
Because this man has a diagnosis of COPD and smokes cigarettes, both annual Influenza and Pneumococcal vaccination are indicated. Because his last tetanus immunization was over 10 years ago and because he has not had a booster pertussis shot as an adult, a one-time Tdap is recommended. At this time meningococcal vaccine is recommended for adolescents and young adults and not indicated for this patient. Zoster vaccine is recommended to all adults at age 50 or older.
A 55-year-old man comes to the clinic for a visit. He has read about the dangers of being overweight and inquires about which category he fits into. He is 5’ 10’’ (1.78 m) and weighs 220 lbs (100 kg), BMI = 31.6. Which of the following categories most accurately describes the patient based on his BMI?
A. Underweight B. Ideal C. Overweight D. Obese E. Morbidly (very severely) obese
The correct answer is D.
Based on BMI measurements, Underweight is considered < 18.5; Ideal: 18.5 to 25; Overweight 25 to 30; Obese 30 to 40; Morbidly (very severely) obese > 40.
A 55-year-old man with a family history of melanoma presents to the clinic for evaluation of a skin lesion on his back which appeared three months ago. His wife first alerted him to it, hasn’t noticed it change and he has not noticed any symptoms associated with it. Physical examination reveals a 7 mm uniformly black macule that is symmetrically round with sharply demarcated borders on his upper back near the right shoulder. Which of the following characteristics would most justify it being biopsied today?
A. Symmetry B. Borders C. Color D. Diameter E. Location
The correct answer is D.
Using the ABCDE mnemonic, this nevus is not Asymmetrical, does not have irregular Borders, does not display Color variation and he does not describe any Evolution or change or symptoms. The only positive is that its Diameter is > 6 mm, which is considered a red flag supporting biopsy. Location is not considered a predictive factor for melanoma.
A 55-year-old man with no significant past medical history and generally healthy behaviors presents to clinic for a health care maintenance exam. He says, “I’d like to get tested for all types of cancer.” He does not have any family history of cancer. Review of systems is negative for any symptoms of prostate cancer, such as urinary frequency, urgency, retention, hematuria, weight loss, or back pain. He is a lifelong non-smoker, and he doesn’t drink alcohol or use recreational drugs. Which of the following screening tests is given either an A or B recommendation in favor of its routine use for patients such as this one?
A. Prostate Specific Antigen (PSA) testing
B. Lung cancer screening
C. Pancreatic cancer screening
D. ECG screening for coronary artery disease
E. Colon cancer screening
The correct answer is E.
The USPSTF gives colon cancer screening an A recommendation for people age 50 to 75 years due to clear evidence of benefit. Lung cancer screening is given a B recommendation for 55-year-old men with a 30 pack-year tobacco history and who have smoked in the past 15 years. This patient is a non-smoker. Pancreatic cancer screening and ECG screening are both given D recommendations (against their use). PSA screening is given a C recommendation, indicating that doctors and patients should make individualized decisions about the use of this test.
Ms. Marcos is a 65-year old woman with a past medical history of Type 2 diabetes, hypertension, and hypercholesterolemia who presents with six months of insomnia despite self-medication with acetaminophen, diphenhydramine, and herbal remedies. She is 5’ 2” and weighs 250 lbs.
When considering a differential diagnosis, which one of the following is a common cause of insomnia in the elderly?
A. Sleep Apnea B. Pneumonia C. Chronic sinusitis D. Asymptomatic coronary artery disease E. Hypoparathyroidism
The correct answer is A, sleep apnea.
Sleep apnea occurs in 20% to 70% of elderly patients. Obstruction of breathing results in frequent arousal that the patient is typically not aware of; however, a bed partner or family member may report loud snoring or cessation of breathing during sleep.
Some of the other most common causes of insomnia in the elderly are:
Environmental problems such as noise or uncomfortable bedding which are not conducive to sleep.
Drugs, Alcohol, and Caffeine such as over-the-counter, alternative, and certain recreational drugs.
Parasomnias such as restless leg syndrome/periodic leg movements/REM sleep behavior disorder. In restless leg syndrome, the patient experiences an irresistible urge to move the legs, often accompanied by uncomfortable sensations. In periodic leg movement and REM sleep behavior disorder, the patient experiences involuntary leg movements while falling asleep and during sleep respectively.
Disturbances in the sleep-wake cycle such as jet lag or shift work.
Psychiatric disorders such as primary depression and anxiety
Symptomatic cardiorespiratory disease (asthma, COPD, heart failure)
Pain or pruritus
Gastroesophageal reflux disease (GERD) due to heartburn, throat pain or breathing problems.
Hyperthyroidism The elderly frequently do not present with typical symptoms such tachycardia or weight loss, and therefore further laboratory studies may be required to detect this problem.
Ms. Anderson is a 60-year-old woman who comes in to clinic as a walk in appointment. She is tearful and is carrying a box of tissues in her hand. She says she doesn’t know why but she has been very sad of late. She reports trouble falling asleep and staying asleep. She used to be the head of her Bridge club, but quit two weeks ago and doesn’t feel like going out anymore. She also says she has lost interest in walking her dog, and now just allows him to use the doggie door to let himself out. She also says she feels weak and fatigued and no longer has the energy to do her gardening or shopping. She spends most of her day on the sofa crying while watching TV. She also reports a greatly diminished appetite. She denies suicidal or homicidal ideation, but she does have a history of a previous suicide attempt following her divorce seven years ago for which she was hospitalized. A recent CBC, CMP, CXR, TSH, U/A and CT of the head were all within normal limits. How long do the above symptoms need to be present in order to make the diagnosis of Major Depressive Disorder?
A. One week B. Two weeks C. Four weeks D. Five weeks E. Eight weeks
Correct Answer: B
Depressed mood or anhedonia and at least five of the following eight criteria must have been present for two weeks or longer. (Mneumonic = SIG E CAPS)
Sleep: Insomnia or hypersomnia nearly every day
Interest (loss of): Anhedonia (loss of interest or enjoyment) in usual activities
Guilt: Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
Energy (decreased): Fatigue or loss of energy nearly every day
Concentration (decreased): Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
Appetite (increased or decreased)
Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
Suicidal ideation: Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
Mr. Jones is an 82-year-old man who presents to the office for his six-month chronic disease visit. His diabetes and hypertension are controlled on his usual home medications. He reports that his wife died four weeks ago, and he is now experiencing insomnia most days of the week and fatigue and loss of energy nearly every day; reports decreased enjoyment of his activities, such as playing chess with his neighbor; and is also experiencing loss of appetite but no weight loss. He denies any suicidal ideation and has no previous suicide attempts. Mr. Jones says he often hears his wife’s voice while going to bed. He says he goes to church to pray. You are trying to determine if your patient’s symptoms are normal grief or if you should diagnose and treat him for Major Depressive Disorder (MDD). Which feature of Mr. Jones’ case would suggest MDD rather than a normal grief reaction?
A. Insomnia B. Change in appetite C. Inability to experience any joy D. Hearing wife's voice E. Fatigue
Correct Answer: C
The loss of a loved one can be a traumatic event and it is normal to experience a period of grief. DSM-5 states that MDD can be diagnosed during a period of grief as long as the criteria are met. Grief can be difficult to distinguish from major depression with symptoms of sadness, fatigue, changes in appetite, sleep disruption, and decreased concentration. Since your patient is also exhibiting diminished pleasure with normally enjoyable activities, this may indicate the patient has MDD, as pervasive unhappiness and misery are rarely a part of the normal grieving process. Other features that differentiate MDD from grief include:
Guilt about things other than actions taken or not taken at the time of death
Thoughts of death other than feeling that he or she would be better off dead or should have died with the deceased person
Morbid preoccupation with worthlessness
Marked psychomotor retardation
Prolonged and marked functional impairment
Hallucinatory experiences other than hearing the voice of, or transiently seeing the image of, the deceased person
Ms. Rogers is a 75-year-old woman who was found unresponsive in her house by her neighbor who had come over to help clean her house. An empty unlabeled pill container was found next to her on the bathroom floor. She was rushed to the ER, stabilized and is now in ICU on a mechanical ventilator. Which of the following are true regarding suicide in the elderly?
A. Elderly persons attempting suicide are more likely to be married and living with their spouse.
B. Elderly persons attempting suicide usually report good sleeping habits.
C. Suicidal behaviors increase with age, but rates of completed suicides dont.
D. Approximately 75% of the elderly who commit suicide had visited a primary care physician within the preceding month, but their symptoms went unrecognized.
E. Firearms are the most common means of suicide in the elderly.
Correct Answer: D
The USPSTF recommends screening all adults for depression, but especially patients with chronic diseases like diabetes, as they are at high risk for depression. The PHQ-2 inquires about the frequency of depressed mood and anhedonia over the past 2 weeks. The purpose of the PHQ -2 is not to establish a final diagnosis, but rather to screen for depression as a “first-step” approach. Patients who screen positive should be evaluated by the PHQ-9 to determine whether they meet the criteria for depression. Another screening tool which can be used is the Geriatric Depression Scale - Short Form (GDS-SF) which includes a series of 15 questions. Specifically related to suicide in the geriatric population: Elderly persons attempting suicide are more likely to be WIDOW(ER)S, AND LIVE ALONE; Elderly persons attempting suicide have REDUCED sleep quality; Suicidal behaviors DO NOT increase with age, but rates of completed suicides DO.
Drug overdose is the most common means of suicide in the elderly.
Ms. Burton is a 45-year-old woman who has never been to a primary care provider. She presents today to establish care and get her health in order. Her concerns today are: fatigue, weakness, numbness, insomnia, feeling sad at times, anhedonia, increased appetite, weight gain, dry skin, and increasing hair loss within the past month.
Her vital signs are:
- Heart rate: 78 beats/minute
- Respiratory rate: 18 breaths/minute
- Oxygen saturation: 95%
- Blood pressure: 152/84 mmHg
- Weight: 325 lbs
- Body Mass Index: 41 kg/m2
Today, her physical exam is significant for thinning hair, poor dentition, a systolic murmur heard at the left upper sternal border, an obese abdomen, and bilateral knee stiffness and pain on range of motion exam. Remainder of the physical exam is within normal limits. Which laboratory tests or studies can be done to rule out medical causes of insomnia, fatigue, and depression?
A. Chest-X Ray B. CBC, CMP, and TSH C. HgbA1c, lipid panel, urine microalbumin D. CT head without contrast E. MRI brain with contrast
Correct Answer: B
CMP can be used to detect electrolyte, renal and hepatic problems. TSH can be used to rule out hypo- or hyperthyroidism. CBC can be helpful to detect anemia and vitamin deficiencies. In addition, ESR can be used to test for rheumatologic disease. An ECG should be done if the patient is using drugs that might alter cardiac conductivity, such as TCAs.
A 60-year-old woman presents to the office complaining of increased frequency of urination and fatigue for the past several months. She denies fevers, dysuria, back pain, diarrhea and abdominal pain. She has noted some weight loss without working on diet or exercise. Her past medical history is significant for hyperlipidemia and hypertension, for which she takes simvastatin and lisinopril. She is a non-smoker and consumes one to two glasses of wine per week. Her vitals are:
Heart rate: 70 beats/minute
Blood pressure: 130/70 mmHg
Body Mass Index: 30 kg/m2
Physical examination reveals increased pigmentation in her axilla bilaterally. Her labs are as follows:
Random plasma blood glucose: 205 mg/dL
Creatinine: 0.8 mg/dL
TSH: 2.1 U/L.
What test is needed to diagnose diabetes mellitus?
A. The random blood glucose is sufficient B. Fasting blood glucose C. An oral glucose tolerance test D. HgbA1c E. Urine microalbumin
The correct answer is A.
The correct answer is (A). Diabetes can be diagnosed with either an HbA1c > 6.5%, a fasting plasma glucose ≥ 126 mg/dl (7.0 mmol/l), a plasma glucose ≥ 200 mg/dL (11/1 mmol/l) two hours after a 75 g glucose load, or symptoms (such as polyuria, polydipsia, unexplained weight loss) and a random plasma glucose ≥ 200 mg/dL (11.1 mmol/l).
Answers (B), (C), (D) and (E) are incorrect, as the diagnosis of diabetes can be made based on random blood glucose with symptoms.
A 42-year-old woman presents for a visit after recently being diagnosed with Type 2 diabetes. She has made a plan to work on diet and exercise. Her A1c is found to be 8.0%. What is the best medicine to start at this time?
A. A sulfonylurea B. Basal insulin C. Metformin D. GLP-1 receptor agonist E. An SGLT2 inhibitor
The correct answer is C.
The correct answer is (C). Sulfanylureas, GLP-1 receptor agonists, and SGLT2 inhibitors may be used as second-line agents. Insulin is generally not used until two other oral medications are insufficient to control the blood sugar, but most people with Type 2 diabetes become insulinopenic over time and require insulin treatment.
A 72-year-old woman with a 30-year history of Type 2 diabetes returns to your office for routine visit. She is taking 20 units of insulin glargine every morning and five units of insulin aspart with meals. The patient notes blurry vision for the past several months and a few days of dark spots in her vision. She denies headaches or nausea. What is true regarding diabetic retinopathy?
A. The majority of people with diabetes only develop retinopathy after 10 years with the diagnosis.
B. 40% of people with severe diabetes requiring insulin have retinopathy five years after diagnosis.
C. Vision changes are an early sign of retinopathy.
D. Primary care physicians should examine the retina on every visit for ongoing diabetes care.
The correct answer is B.
The correct answer is (B). The patient’s symptoms describe diabetic retinopathy. Proliferative retinopathy is prevalent in 25% of the diabetes population with ≥ 25 years of diabetes, but many patients have retinopathy much earlier. Early changes of retinopathy are asymptomatic. Patients need to see an ophthalmologist regularly for a dilated retina exam, not rely on a view of the retina from primary care physicians. Abnormalities seen include macular edema ( a common cause of blurry vision) and new blood vessel formation which can leak and cause dark spots in the vision. Diabetic eye disease often can be treated before vision loss occurs. Glaucoma (causing increased intraocular pressure) is 40% more likely in people with diabetes, but usually causes nausea, headaches, and narrowing of vision or halos around lights.
A 65-year-old male with known Type 2 diabetes mellitus presents to the Emergency Department with altered mental status. The patient experienced no known head trauma. His vitals are:
Temperature: 38.1 Celsius
Heart rate: 102 beats/minute
Respiratory rate: 16 breaths/minute
Blood pressure: 90/74 mmHg
His mucous membranes appear very dry and he is started on IV fluids. Neurological exam reveals no focal deficits. His plasma glucose is found to be 700 mg/dL. Urinalysis reveals no ketone bodies. What is the most likely diagnosis?
A. Thiamine deficiency B. Diabetic ketoacidosis (DKA) C. Cerebrovascular accident D. Hyperosmolar hyperglycemic state (HHS) E. Cardiac arrhythmia
The correct answer is D.
The correct answer is (D). HHS is seen typically in patients with Type 2 diabetes. It includes very high sugars > 600; ph > 6.4; dehydration; and lack of ketones in the urine and blood. Diabetic ketoacidosis is more common in Type 1 diabetes, and the patient will have ketone bodies in the urine. Thiamine deficiency can cause Korsakoff syndrome, and is typically seen in alcoholics with severe malnutrition, however, this patient is not a known alcoholic and doesn’t appear malnourished. Despite the confusion in this patient, stroke is an unlikely diagnosis in this case given the lack of focal deficits on exam. Cardiac arrhythmia can cause dizziness, but is less likely to cause prolonged altered mental status.
A 61-year-old female has recently been diagnosed with Type 2 diabetes. Her fasting glucose was 240 mg/dL and her A1c was 8.9%. Her BP has been 148/90 and 146/86 at two separate office visits. Her home BP measurements have been in a similar range. Her creatinine is 0.9 and she has no known heart disease. She currently takes losartan 100 mg daily for a diagnosis of hypertension. Which of the following would be the most appropriate step in managing this patient’s blood pressure?
A. Make no changes to her medications as her blood pressure is at goal. B. Start lisinopril daily. C. Start amlodipine daily. D. Start metoprolol daily. E. Start furosemide daily.
The correct answer is C.
The correct answer is (C). According to the 2017 AHA/ACC blood pressure guidelines, this patient’s blood pressure goal should be 130/80 mmHg. She is clearly above that, and she should have a blood pressure medication added (or in a highly motivated patient, dramatic behavioral changes with close follow up). There is no preference for a first line treatment for blood pressure in diabetic patients, although many providers start with and ACE inhibitor or ARB because diabetes is a risk factor for chronic kidney disease. Furosemide and metoprolol are not among the four major classes of medications for blood pressure management (ACEIs, ARBS, calcium channel blockers, and thiazides), so D and E are not acceptable choices. Lisinopril is an acceptable first-line choice, but it should not be combined with an ARB. Since this patient is taking losartan (an ARB), adding an ACEI is contraindicated. Amlodipine is a good choice for this patient.
A 65-year-old female presents to your office for a routine visit. She is found to have a blood pressure of 146/96 mmHg. You repeat the blood pressure in her other arm and get 148/92 mmHg. Her pulse is 70 and regular. Her last BP reading was one year ago and was 120/76 mmHg. She has no other medical problems. Her BMI is 28. She states that she likes to walk 30 minutes every other day with her husband and has been doing that for years now. At this time, the most appropriate diagnosis is…
A. White coat hypertension B. Elevated blood pressure reading C. Stage 1 hypertension D. Stage 2 hypertension E. Secondary hypertension
The correct answer is B.
To diagnose hypertension, two separate readings greater than 130/80 mmHg each time - taken a week or more apart - are needed. Furthermore, ideally home blood pressure readings in the hypertensive range would be needed to confirm that she does not have white coat hypertension. Because this patient has had elevated blood pressure documented on only one occasion (today), the most appropriate current diagnosis is elevated blood pressure.
If she has a second similarly elevated reading, Stage 2 hypertension may be diagnosed.
Stage 1 hypertension refers to blood pressures between 130-139/80-89 mmHg.
This patient has not yet been diagnosed with hypertension, so neither A, C nor D is appropriate.
A 68-year-old male was diagnosed with Stage 1 essential hypertension a few months ago and has been working on diet and lifestyle modifications. He has a BMI of 28, mild knee arthritis but no other medical diagnoses. He has been a patient of yours for several years, and returns today as planned. Today his blood pressure is 156/94 mmHg. The remainder of his cardiovascular exam is within normal limits. After counseling the patient, he agrees to start an antihypertensive medication. His creatinine is 0.9, urinalysis is normal, and electrolytes are within normal limits. which of the following is the most appropriate medication to begin in this patient?
A. Beta blocker B. Thiazide diuretic C. Nitrate D. Loop diuretic E. Clonidine
The correct answer is B.
This patient now meets criteria for Stage 2 hypertension as indicated by a systolic BP 140 to 159 mmHg and diastolic BP 90 to 99 mmHg.
The ACC/AHA guidelines recommend thiazide diuretics, ACE inhibitors, angiotensin II receptor blockers, or calcium channel blockers as first-line treatment for most patients with newly diagnosed hypertension, with a slight preference for chlorthalidone in the diuretic class.
The other options are not first-line treatments for hypertension.
A 54-year-old male with a history of chronic gout and GERD presents to your office for his health maintenance exam. Vitals today are blood pressure 138/88 mmHg, pulse 65 beats/min, respirations 10/min, afebrile, BMI 29 kg/m2. He smokes 10 cigarettes per day, does not regularly exercise, and drinks one to two beers daily, four or five times a week. He has no current concerns, review of systems is negative, and his physical exam is unremarkable. You recommend lifestyle changes. Which of the following changes is least likely to improve his blood pressure?
A. Smoking cessation B. DASH eating plan C. Weight loss D. Alcohol cessation E. Increased exercise
The correct answer is D.
While all of these options are reasonable lifestyle modifications to recommend for patients, this particular patient’s blood pressure is least likely to be reduced by alcohol cessation. Moderate alcohol consumption actually improves blood pressure by 2 to 4 mmHg; therefore, stopping his moderate alcohol consumption could increase his blood pressure. However, it is not recommended to encourage alcohol use in patients who do not drink, because of the risk of encouraging problem drinking.
Initiation of the NIH-sponsored Dietary Approaches to Stop Hypertension (DASH) eating plan has been shown to lower systolic pressure as have smoking cessation, weight loss, and increased exercise.
A 60-year-old male with a past medical history of chronic gout, depression, and Stage 1 hypertension presents to your office for a follow-up visit. He has been attempting to reduce his blood pressure with behavioral changes, but has had difficulty maintaining the changes. Today, his vitals are blood pressure 144/90 mmHg, pulse 78 beats/min, respirations 12/min, temperature 98.7 F. His recent basic metabolic panel was completely normal. Based on cholesterol levels he had done in the prior week, you calculate his 10-year ASCVD risk at 11%. As you consider starting a medication for his hypertension, which of the following medications is most likely to cause an adverse event in this patient?
A. Lisinopril B. Hydrochlorothiazide C. Amlodipine D. Losartan E. Metoprolol
The correct answer is B.
Hydrochlorothiazide (HCTZ) can cause hyperuricemia and therefore should be used with caution in patients with gout.
Metoprolol is not a first-line choice for the management of blood pressure, but there is no particular reason to expect this patient to experience an adverse drug event due to a beta-blocker.
While all of the other medications listed are appropriate first-line anti-hypertensives, many clinicians would select one of the other options over HCTZ for this patient given his history of gout.
A 62-year-old woman presents for follow-up of her hypertension and diabetes. In general, her chronic diseases are well controlled and she has suffered no target organ damage. She has worked hard to begin exercising, and is walking vigorously five times a week. She has also worked hard on dietary changes, and has been following the DASH eating plan very seriously. She quit smoking three months ago. Her blood pressure today is 148/88 mmHg, pulse is 72 and BMI is 32. She is taking metformin 500 mg twice daily, simvastatin 20 mg daily and hydrochlorothiazide (HCTZ) 25 mg daily, and she is compliant with her daily medications. Her labs today include an A1C of 6.6, an LDL of 88 and a basic metabolic panel within normal limits. Which of the following management steps today do you consider the most appropriate?
A. Increase HCTZ to 50 mg daily
B. Make no changes as she is at her treatment goals
C. Impress upon her the importance of making more lifestyle modifications
D. Add amlodipine 5 mg daily
E. Change her simvastatin to atorvastatin 20 mg
The correct answer is D.
The goal blood pressure for patients with hypertension is 130/80 mmHg, and this patient has not met this goal with HCTZ and major lifestyle changes.
Increasing the dose of HCTZ from 25 to 50 does not improve blood pressure further, so adding a second medication would be more beneficial. While commending her on her lifestyle changes is important, counseling about intensifying them is not likely to be realistic nor helpful given all that she has already done.
There is no need to change her statin, however calculating her ASCVD risk to determine whether she is on the appropriate dose would be helpful.
The current cholesterol guidelines recommend a moderate intensity statin for patients with diabetes. For simvastatin, a dose of 10 mg represents a low-intensity dose. Increasing this to 20 mg would put her management more in line with these guidelines, though it would not address her elevated blood pressure.
A 52-year-old woman with a history of diabetes and rheumatoid arthritis presents for her annual examination. She works in an office 10 hours a day, and rarely gets exercise. Her BMI is 23 and her blood pressure is 152/85. Her previous visit two months ago showed blood pressure of 148/82. Her father had a history of diabetes and her maternal grandmother died of rheumatic heart disease at the age of 42. She admits to marijuana drug use in the past and is a nonsmoker. Which of the following is a risk factor for coronary heart disease (CHD) that this patient has?
A. Age B. Family history C. Rheumatoid arthritis D. Obesity E. Lifestyle
The correct answer is E.
This patient’s lack of exercise and sedentary job are risk factors. Age becomes a risk factor over age 55 for women and 45 for men. The family history becomes a risk factor if a first degree relative has CHD male <55 and female <65. Rheumatoid arthritis is not a risk factor, and the patient is not obese.
Which of the following symptoms are most likely to be due to acute coronary syndrome?
A. 23-year-old male with acute onset of difficulty breathing and hyperresonance upon lung auscultation
B. 42-year-old woman with a pulsating pain in the center of her chest at night
C. 35-year-old man with chest pain radiating down his left arm after falling off a ladder at work one week ago
D. 59-year-old woman with palpitations that increase with exercise and are associated with nausea and vomiting
E. 55-year-old woman with diffuse central chest pain that is worse when lying down
The correct answer is D.
Palpitations, nausea, and vomiting are seen as prodromal symptoms of ACS in women more than men.
Young men with difficulty breathing and hyperresonance are likely to have a pneumothorax. Pulsating pain is one of the types of pain, along with pleuritic and positional pain, that is less likely to be related to heart disease. Chest pain in a young man associated with trauma is less likely to be ACS.
A 35 year old overweight woman in good health comes to the clinic for a routine physical. Which of the following screenings are recommended by the U.S. Preventative Services Task Force (USPSTF)?
A. Complete blood count B. Thyroid stimulating hormone levels C. Cholesterol panel D. Blood pressure screening E. HbA1C
The correct answer is D.
The only one of these that the USPSTF recommends in this age group is blood pressure screening. It is recommended to screen women with a cholesterol if there are risk factors for CHD.
Which of the following patients is an appropriate candidate for a exercise stress test?
A. A 58-year-old male who presents to the emergency room with constant substernal chest pressure, diaphoresis and shortness of breath
B. A 44-year-old female with a BMI of 40 kg/m2 and history of asthma
C. A 48-year-old female with a history of intermittent anginal episodes that have been controlled on medications.
D. A 52-year-old female with new atypical chest pain with a history of elevated cholesterol, smoking and family history of coronary artery disease
The correct answer is D.
An exercise stress test is useful if the pretest probability of the disease is high as in D with 3 significant risk factors. False positives increase if the pretest probability is low so the usefulness of a stress test is low in B. Likewise if the diagnosis is certain as in A then there is not as much use in getting a stress, especially in an unstable patient. Since the purpose of invasive treatment is symptom control, the patient in C has controlled symptoms and hence no need for stress testing.
A 62-year-old man with hypertension and diabetes is discharged home from the hospital, following a viral upper respiratory tract infection. He is prescribed several medications, including low dose aspirin. The patient asks you why he is taking aspirin along with the other medications. What is the reasoning behind your response?
A. Aspirin helps decrease the risk of ischemic stroke in men.
B. Aspirin helps decrease the risk of developing a hypercoagulable state.
C. Aspirin helps decrease the risk of myocardial infarction in men.
D. Aspirin decreases the risk of gastrointestinal hemorrhage.
The correct answer is C.
The USPSTF recommends initiating aspirin therapy in men age 45 to 79 years to reduce the risk of myocardial infarction. In women age 55 to 79, the USPSTF advises taking aspirin to reduce the risk of ischemic stroke. For both men and women, the benefit of decreased risk from those outcomes must be weighed against an increased threat of gastrointestinal hemorrhage. Other groups disagree that all men be treated, and only use aspirin for high risk patients, where the benefits outweigh the risk of GI hemorrhage, which is increased in patients taking aspirin.
Mr. Brown is a 42-year-old male accountant with a significant past medical history of obesity who presents to his primary care physician after one week of lower back pain. After moving into a new home three days ago, he woke up the next morning with bilateral lower back pain without any radiation. He denies any recent trauma, fever, chills, numbness, tingling, or incontinence. He has not had any urinary frequency or dysuria. He takes no medications and has no significant past medical history.
Which additional findings in his history or physical exam would make the diagnosis of lumbosacral sprain/strain more likely?
A. Increased pain with coughing B. Abnormal gait C. Point tenderness on spinous processes D. Loss of ankle jerk E. Spasm of paraspinous muscles
The correct answer is E.
Spasm of the paraspinous muscles suggests lumbosacral sprain/strain. Increased pain with coughing, abnormal gait and loss of ankle jerk point to conditions that compress a regional nerve root, while point tenderness on the spinous processes often indicates an origin in the vertebra (osteoporotic fracture, malignancy, etc.).
Mr. Giovanni is a 37-year-old male who drives a delivery truck. He presents to your clinic after acute onset of severe lower back pain, which began after lifting a large package while at work. When you enter the room, you find him standing, unable to sit comfortably.
On physical exam, he has limited lumbar flexion, reduced to 45 degrees, positive straight leg test at 45 degrees on the left, normal gait, but difficulty with heel walk. He has 4/5 strength on the left with ankle plantar flexion. Strength is preserved on the right.
Which of additional physical exam finding would be consistent with this man’s level of disc herniation?
A. Hypoactive ankle tendon reflex B. Decreased range of motion on lumbar extension C. 2/5 strength on hip flexion D. Decreased rectal tone E. Positive Stoop test
The correct answer is A.
The clinical signs presented by this patient-difficulty with heel walk and the abnormal strength of ankle plantar flexion-is consistent with nerve root impingement at the level of L5. Of the answers listed, a hypoactive ankle tendon reflex is also consistent with a nerve root impingement at this level. Pain with lumbar extension suggests degenerative disease or spinal stenosis, and spinal stenosis is similarly suggested by a positive stoop test. Diminished hip flexor strength suggests a lesion at the L2, L3, or L4 level and decreased rectal tone suggests a cauda equina lesion.
