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Family Medicine > Pre-Test: Chronic Complaints > Flashcards

Pre-Test: Chronic Complaints Flashcards

1
Q

36 yo man is not having sexual fantasies and unmotivated to be sexually active… is not depressed. Physical exam is normal. What is the next step?

A

Measure free testosterone (accurate for bioavailable androgen)

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2
Q

30 yo woman dx w depression. She is concerned that medical tx may cause sexual dysfunction. In order to avoid sexual side-effects, which antidepressant would be best choice?

a. amitriptyline
b. paroxetine
c. citalopram
d. sertraline
e. bupropion

A

e. bupropion

TCAs/SSRIs –> sexual dysfxn

Bupropion actually dec. orgasm threshold

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3
Q

23 yo man comes to your office to discuss premature ejaculation. He has had this condition since beginning sexual activity at 17 years of age. He has tried behavioral methods, but these have not been successful.

Which of the following meds is most likely to help this condition?

a. Alprostadil
b. Fluoxetine
c. Bupropion
d. Sildenafil
e. Atenolol

A

a. Alprostadil –> treats erectile dysfxn

b. Fluoxetine –> inc. orgasm threshold

c. Bupropion –> dec. orgasm threshold
d. Sildenafil –> dec. orgasm threshold
e. Atenolol –> causes erectile dysfunction

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4
Q

most sensitive lab test to confirm alcohol abuse?

a. MCV
b. ALT
c. AST
d. GGT

A

d. GGT

Elevated GGT is shown to be more sensitive than an elevated MCV, ALT, or AST.

The specificity of GGT is low; it is elevated in nonalcoholic liver disease, diabetes, pancreatitis, hyperthyroidism, HF, and anticonvulsant use

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5
Q

Most specific laboratory test to confirm alcohol abuse?

A

MCV

An elevated MCV is 96% specific for alcohol abuse with a 63% predictive value

GGT is 76% specific with a predictive value of 61%

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6
Q

How does naltrexone work for alcoholism and opioid addiction?

A
  • Opioid: saturates opiate receptor sites and leaves them unavailable for opiate attachment
  • Alcohol: reduces reinforcing effect of alcohol (not allowing patients to become “drunk”)
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7
Q

How does disulfiram work in alcoholism?

A

Causes the body to have a negative rxn to ingested alcohol

Acts as a deterrent (flushing, nausea, vomiting)

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8
Q

Your pt asks you about pharmacotherapy to help him to prevent relapse of alcohol abuse. Which of the following medications is most effective for this purpose?

a. Disulfiram
b. Naltrexone
c. Acamprosate
d. TCAs

A

c. Acamprosate

Disulfiram, naltrexone, SSRIs, and acamprosate are currently used to prevent relapse of alcoholism.

Acamprosate seems to be the most effective –> affects both GABA and glutamine neurotransmission, both of which are imp in alcohol’s effect on the brain

The effects of this medication appear to be greater and longer-lasting than naltrexone… The addition of disulfiram can increase the effectiveness of acamprosate alone.

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9
Q

Varenicline (Chantix) to help with smoking cessation. Common side effects include:

A

Abnormal dreams

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10
Q

Withdrawal symptoms:

  • Cocaine?
  • Opiates?
  • Ecstasy?
  • Benzos?
A
  • Cocaine: Depression, serious cravings!
  • Opiates:
    • Early sx: lacrimation, rhinorrhea, yawning diaphoresis
    • Late sx: restlessness, irritability, bone pain, nausea, diarrhea, abdominal cramping
  • Ecstasy: Depression
  • Benzos: Mimic alcohol withdrawal: HTN, tachycardia, possibly seizures
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11
Q

You are evaluating a patient with a painful, swollen knee. Joint aspirate reveals clear fluid with a WBC count of 5000/mm3, 20% of which are PMN leukocytes. Which of the following is the most likely dx?

a. Gout
b. Pseudogout
c. Infectious arthritis
d. Osteoarthritis
e. RA

A

d. Osteoarthritis

Fluid aspirated from an osteoarthritic knee is characterized by generally clear joint fluid with a WBC count of 2000/mm3 to 10000/mm3. The distinguishing factor is the PMN leukocytes. In RA, more than 50% of WBCs are PMNs, while in OA, less than 50% of the WBCs are PMNs.

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12
Q

Dx vs confirmation of asthma

A

Dx: History (not all asthmatics wheeze and not all wheezing is asthma)

Confirmation: PFTs with and w/o bronchodilator therapy

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13
Q

If pt is intolerant of inhaled corticosteroid, what is the alternative?

A

Leukotriene receptor antagonist

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14
Q

A 22 yo man is seeing you to discuss his low back pain. He is athletic and exercises regularly. He denies any inciting event, does not have pain with movement, and denies radiation of the pain. Given this information, which of the following is the most likely dx?

a. Spondylolisthesis
b. Low back strain
c. Degenerative osteoarthritis
d. Lumbar disk herniation
e. Neoplasm

A

a. Spondylolisthesis

Spondylolisthesis = anterior displacement of vertebrae in relation to the one below. It is the most common cause of low back pain in pts younger than 26, especially athletes.

Back strain is also a common dx, but would generally follow an inciting event, and pain would be associated with movement.

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15
Q

Adjuvant therapy to NSAIDs for low back pain?

A

TCAs

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16
Q

Chronic bronchitis dx?

A

Lasting more than 3 mo for at least 2 consecutive yrs

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17
Q

A 62 yo smoker comes to your office for tx. After a thorough hx and physical exam, you believe he has COPD. He quit smoking 8 mo ago, but has not had any other treatment. Which of the following is the best first-line therapy for his condition?

a. SABA (albuterol)
b. Inhaled anticholinergic (ipratropium)
c. Inhaled corticosteroid
d. Oral theophylline
e. Oxygen

A

b. Inhaled anticholinergic (ipratropium)

due to longer duration of effects and no sympathomimetic activity

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18
Q

Abx coverage for COPD exacerbation

A

Azithromycin

but if severe, make sure to use antipseudomonals i.e. Zosyn (Piperacillin-Tazobactam)

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19
Q

Pt is developing chronic renal failure. Which lab abnormality would you most likely see first?

a. Hyperkalemia
b. Hyponatremia
c. Hyperphosphatemia
d. Fall in plasma bicarb
e. Anemia

A

e. Anemia

The kidney’s role in concentrating and diluting urine is usually retained until the GFR falls below 30% of normal. Therefore, hyponatremia, hyperkalemia, hyperphosphatemia, and metabolic acidosis (b/c of fall in plasma bicarb) generally occur in later stages of kidney disease.

The kidney is the source of erythropoietin, and anemia generally appears when the GFR falls below 60 mL/min.

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20
Q

What do patients with CKD most commonly die from?

A

CVD

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21
Q

You have been treating a pt for chronic pain since she finished her chemo for breast cancer. She describes the pain as “pins and needles” in her lower legs. Based on her comments, what is the best description for this pain?

a. Hypoesthesia
b. Hyperesthesia
c. Paresthesia
d. Allodynia
e. Nociceptive pain

A

a. Hypoesthesia –> numbness
b. Hyperesthesia –> increased sensitivity

c. Paresthesia –> pins and needles

d. Allodynia –> severe pain from innocuous stimuli
e. Nociceptive pain –> stems from tissue damage (such as arthritis and/or tumor)

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22
Q

Evaluating man with liver disease. All the following are elevated: AST, ALT, AP, GGT, Bilirubin, Prothrombin Time.

The following is decreased: Albumin.

Which lab result suggests that his liver disease is chronic?

A

Albumin

The rest represent acute hepatocellular injury.

Lab values that represent hepatic function (more chronic) include albumin, bilirubin, and prothrombin time.

23
Q

Most likely cause of death for pt who contracted Hep C?

a. Liver failure
b. HCC
c. Bleeding varices
d. Encephalopathy

A

c. Bleeding varices

2/2 chronic high pressure in portal veins

24
Q

You are taking care of 47 yo woman w cirrhosis. She asks you about transplantation as definitive tx option. Which of the following is an absolute contraindication to transplantation?

a. Active alcoholism
b. Portal vein thrombosis
c. HBsAg
d. HIV positivity
e. Extensive previous abdominal surg

A

b. Portal vein thrombosis

OR severe medical illness, malignancy, hepatobiliary sepsis, lack of pt understanding

The rest are relative contraindications

25
Q

A 62 yo woman comes to your office complaining of dyspnea. She has a hx of COPD, HTN, and diabetes. She also smokes and drinks heavily. Her evaluation reveals that she is in HF. Which of the following interventions will lead to functional improvement in this pt?

a. Optimizing tx of COPD
b. Optimizing tx of HTN
c. Optimizing glycemic control
d. d/c smoking
e. d/c alcohol

A

e. d/c alcohol

All are helpful but only d/c alcohol has been shown to IMPROVE

Those with alcoholic CM actually see improvement of the LV fxn with abstinence.

26
Q

pt with CHF due to LV systolic dysfunction… in addition to diuresis, what is the best first-line agent to use for tx?

A

ACEI

27
Q

68 yo man suffering from chronic CHF on Lasix, BB, and ACEi –> despite therapy, continues with refractory edema.

In his baseline state, he is comfortable at rest, but experiences some sx of HF with ordinary activity. What is the best diuretic to add?

A

Metolazone

Some pts have difficulty maintaining optimal fluid balance, and a second diuretic is needed. In this case, adding metolazone can significantly increase diuresis in the outpatient tx of HF with volume overload

28
Q

You are treating a pt for HF because of systolic dysfunction with daily diuretics and an ACEi. He is continuing to have symptoms with activity, but they do not seem to be related to volume overload. Adding which of the following medications has been shown to reduce symptoms and improve mortality?

a. Metolazone (Zaroxolyn)

b. Spironolactone (Aldactone)
c. Metoprolol

d. Nifedipine
e. Digoxin

A

c. Metoprolol

BBs (bisoprolol, metoprolol, carvedilol) inhibit the effects of SNS activation in HF patients.

Reduce symptoms, improve quality of life, and reduce mortality

Adding diuretics does not change mortality

Nifedipine can worsen sx

Digoxin improves sx, but does not decrease mortality

29
Q

Which of the following would be most helpful in the dx of Alzheimers?

a. MMSE
b. CT of brain
c. MRI of brain
d. Lumbar puncture
e. Blood work including serum chemistries, thyroid function testing, vitamin B12 levels, RPR, and liver function tests

A

a. MMSE

or clock drawing…. basic screening tests

30
Q

Which of the following medications has been shown to result in statistically significant benefit in advanced cases of dementia?

a. Donepezil
b. Galantamine
c. Rivastigmine
d. Memantine

A

d. Memantine

31
Q

How is the dx of diabetes made?

A
  • 2 separate random glucose measurements more than 200 mg/dL with classic signs of diabetes (polydipsia, polyuria, polyphagia, weight loss)
  • fasting glucose > 126 mg/dL
  • glucose reading > 200 mg/dL 2 hours after a 75 g glucose load
32
Q

A 39 yo diabetic man asks you questions about his diet. What type of diet improves glycemic control?

A

High-fiber diet

33
Q

Pt with type 2 diabetes –> on max dose of sulfonylurea, but her HbA1c is 9.2% (H). Review of her baseline laboratory tests reveals normal liver enzymes and a creatinine of 2.3 mg/dL. Which of the following mgmt options would be most beneficial?

a. Change to another sulfonylurea
b. Add a biguanide
c. Add a meglitinide
d. Add a thiazolidinedione
e. Add an alpha-glucosidase inhibitor

A

d. Add a thiazolidinedione

Meglitinides increase insulin secretion and should be taken before meals. They are excreted in the liver, therefore are safe in renal failure. Thiazolidinediones decrease insulin resistance and are an excellent choice for those with insulin insensitivity / NOT EXCRETED BY KIDNEY

WTF?

34
Q

48 yo man with type 2 DM returns for a follow up appointment. He currently takes metformin but is not as well-controlled as he’d like to be. He’d like to know more about sitagliptin (Januvia).

Which of the following best explains its MOA?

a. Inhibits glucagon release
b. Increases sensitivity of body to insulin
c. Inhibits hepatic gluconeogenesis
d. Enhances gastric emptying
e. Prolongs action of endogenously released GLP-1

A

c. Inhibits hepatic gluconeogenesis

GLP-1 is a gut-derived incretin hormone that stimulates insulin and suppresses glucagon secretion, delays gastric emptying, and reduces appetite and food intake.

Sitagliptin is a DPP-4 inhibitor which prolongs the activity of endogenously released GLP-1.

35
Q

Which insulin preparations provide the most stable insulin coverage without a peak time of maximum activity?

A

Detemir and Glargine (Lantus) do not have a predictable peak and last for around 24 hrs

36
Q

Treatment goals for persons with dyslipidemias

A
  • Pt with known CAD or diabetes, treatment goal for LDL cholesterol < 70 mg/dL
  • Pt with 10-year risk greater than 20%, the LDL goal < 100 mg/dL
  • Pt with risk between 10-20%, LDL treatment goal < 130 mg/dL
  • If risk is less than 10%, treatment goal < 160 mg/dL
37
Q

How does quiting smoking change lipid profile?

A

HDL will increase by 5-10 mg/dL

does not change other values

38
Q

You have prescribed niacin for a pt with elevated LDL and TGs. How to avoid flushing side effect?

A

Take aspirin before taking the niacin

Aspirin blocks much of the flushing that is associated with sustaine-release niacin preparations

39
Q

MoA of fish oil

A

Fish oil is high in omega-3 fatty acids and have been shown to be beneficial in lowering cholesterol.

Decrease secretion of triglycerides by the liver

40
Q

Which of the following increase HDL

a. Lovastatin
b. Colestipol
c. Ezetimibe
d. Fenofibrate
e. Cholestyramine

A

Fenofibrate

although Niacin > Fenofibrate

41
Q

Which drugs targets lowering TG

A

Fenofibrate

42
Q

Best course of action for postexposure prophylaxis against HIV

A

Immediately test for HIV antibodies and begin at least two-drug therapy

43
Q

You are caring for an HIV-infected woman. She had a normal Pap test 2 weeks ago. Which of the following is true?

a. She needs a repeat Pap test in 6 mo
b. She needs a repeat Pap test in 12 mo
c. She needs a colposcopy
d. She needs to have a colposcopy instead of her next Pap test
e. She should have prophylactice cone biopsy of the cervix

A

a. She needs a repeat Pap test in 6 mo

The incidence of cervical dysplasia in HIV positive women is 40%

More HIV infected women die of cervical cancer than do from AIDS, therefore Pap testing should be done every 6 mo

44
Q

Best lifestyle modification that will result in largest systolic BP reduction

A

If overweight –> lose weight

If normal weight –> DASH

45
Q

You are examining a 36 yo man with elevated BP. On occasion, his BP was 163/90, and on second occasion, his BP was 158/102.

Despite some modest weight loss, his BP is 166/92. What is the best treatment startegy at this point?

a. Use a thiazide diuretic
b. Use an ACEI
c. Use an ARB
d. Use a BB
e. Use a two-drug combination of medications

A

e. Use a 2-drug combination of meds

Stage 1 hypertension. Stage 1 hypertension is a systolic pressure ranging from 130 to 139 mm Hg or a diastolic pressure ranging from 80 to 89 mm Hg.

Stage 2 hypertension. More severe hypertension, stage 2 hypertension is a systolic pressure of 140 mm Hg or higher or a diastolic pressure of 90 mm Hg or higher.

46
Q

You have just diagnosed a 35 yo man with HTN. He is otherwise healthy and has no complaints. Which of the following is indicated in the initial evaluation?

a. TSH level assessment
b. Resting electrocardiogram
c. Stress test
d. Echo
e. Renal U/S

A

b. Resting electrocardiogram

47
Q

A 48 yo male pt suffered from a stroke. After full recovery, he follows up at your office. Which of the following medication options has been proven to lower his BP and prevent recurrent stroke?

a. ACEi
b. HCTZ
c. ACEi and HCTZ
d. BB
e. BB and HCTZ

A

c. ACEi and HCTZ

ACEi + diuretic

48
Q

You are evaluating a 39 yo otherwise healthy man with a family hx of ischemic heart disease. He describes chest pressure that radiates to his jaw when he walks up steps at work. Which of the following is the test of choice to determine if his chest pain is because of cardiac ischemia?

a. Exercise treadmill test (ETT)
b. Thallium exercise treadmill test
c. Stress echo
d. Dobutamine test

A

typically ETT but if LVH or LBBB, thallium exercise treadmill test

49
Q

You are medically treating an 85 yo woman with stable angina, and choose to use nitrates. Which of the following is the most imp consideration when using this medication?

A

Tolerance

50
Q

You decide to treat a severely depressed pt with fluoxetine. The response is dramatic and on follow up, he reports that he feels great. He has got a lot of energy–in fact, he hasn’t slept in 2 days. He just bought a new car despite losing his job. You suspect acute mania. Which of the following is the best choice of medications to control the acute symptoms?

a. Neuroleptics
b. Lithium
c. Valproic acid
d. Carbamazepine
e. Lamotrigine

A

a. Neuroleptics

In some bipolar pts, the diagnosis is made after the initiation of an antidepressant allows pts to cycle into a manic phase.

ALl the meds listed in this answer can be used to help bipolar disorder but only the neuroleptics will be of benefit in the acute phase.

The rest are all excellent options for maintenance once the acute mania is under control.

51
Q

Of the following, which is the most classic, distinguishing feature of ADHD?

a. Easy boredom
b. Daydreams
c. Inattention
d. Impulsivity
e. Hyperactivity

A

e. Hyperactivity

52
Q

A 45 yo woman presents to your office for evaluation. She reports that over the last few weeks, she has noted an enlarging mass in the front of her neck. She feels well, has had no changes in her health, and denies symptoms of hyper- or hypothyroidism. She also denies recent viral illness. On exam, you note a diffusely enlarged thyroid that is tender to touch. Which of the following is her most likely dx?

a. Hashimoto thyroiditis
b. Subacute lymphocytic thyroiditis
c. Subacute granulomatous thyroiditis
d. Suppurative thyroiditis
e. Invasive fibrous thyroiditis

A

a. Hashimoto thyroiditis (chronic lymphocytic thyroiditis) –> most common cause of goiter in the U.S. –> sometimes associated tenderness

b. Subacute lymphocytic thyroiditis –> generally non-tender
c. Subacute granulomatous thyroiditis –> usually follows viral illness + painful
d. Suppurative thyroiditis –> rare + fever, swollen thyroid, clinical manifestations = bacterial
e. Invasive fibrous thyroiditis –> gradually increasing gland that is firm, nontender

53
Q

When examining a 35 yo, you notice a firm 3-cm thyroid nodule. His thyroid studies are normal, and he is clinically euthyroid. Radionucleotide imaging demonstrates uptake in the thyroid nodule. Which of the following is the most likely dx?

a. Colloid cyst
b. Thyroid adenoma
c. Thyroid carcinoma
d. Metastatic disease
e. Neurofibroma

A

b. Thyroid adenoma

Once a thyroid nodule is found, the next step in the workup is radionucleotide imaging. If a nodule takes up radiotracer, it is termed a “hot” nodule.

Colloidal cysts and tumors do not take up tracer and are “cold” nodules. Therefore, “hot” nodules are more likely benign.

Neurofibromas would also be “cold.” Definitive dx can be made through needle aspiration.

Family Medicine (9 decks)

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