Questions 101-150 Flashcards
- A 25-year-old male has developed a painless ulcer on the glans of his penis. After an appropriate examination and testing you diagnose primary syphilis and treat him with 2.4 million units of benzathine penicillin intramuscularly in a single dose. Eight hours later, while you are working the evening clinic, he returns because he has a fever of 100.6°F and a bad headache, which he rarely gets. He says he “aches all over.”
Which one of the following would be most appropriate at this time?
A) Three blood cultures from different sites at 30-minute intervals
B) CT of the head
C) A lumbar puncture
D) Doxycycline, 100 mg orally twice a day for 14 days
E) Reassurance and antipyretics
ANSWER: E
This patient is experiencing the Jarisch-Herxheimer reaction—an acute, transient, febrile reaction that occurs within the first few hours after treatment for syphilis. The condition peaks at 6–8 hours and disappears within 12–24 hours after therapy. The temperature elevation is usually low grade, and there is often associated myalgia, headache, and malaise. It is usually of no clinical significance and may be treated with salicylates in most cases. The pathogenesis of the reaction is unclear, but it may be due to liberation of antigens from the spirochetes.
- According to the American Diabetes Association, screening for diabetes mellitus in the asymptomatic patient with no risk factors should begin at which age?
A) 25 years B) 30 years C) 35 years D) 40 years E) 45 years
ANSWER: E
Testing for diabetes mellitus should be considered in all asymptomatic adults who have a BMI 325 kg/m2 and have one or more additional risk factors such as physical inactivity, a first degree relative with diabetes, a high-risk ethnicity, hypertension, hyperlipidemia, or polycystic ovary syndrome. In asymptomatic patients with no risk factors, screening should begin at age 45.
- A 44-year-old female with localized breast cancer is receiving counseling about adjuvant long-term therapy. Which one of the following is more likely to occur with an aromatase inhibitor such as letrozole (Femara) than with tamoxifen (Soltamox)?
A) Endometrial cancer
B) Venous thromboembolism
C) Inflammatory arthritis
D) Myalgias
ANSWER: D
Myalgias and noninflammatory arthralgias are more likely with aromatase inhibitors. Venous thromboembolism rarely occurs with these drugs. Endometrial cancer may occur with long-term use of tamoxifen.
- A 78-year-old asymptomatic male is found to have a platelet count of 90,000/mm3 (N 150,000–300,000) and a slightly decreased WBC count. Which one of the following would be most consistent with a diagnosis of myelodysplastic syndrome?
A) A normal RBC count and indices B) Normocytic anemia C) Microcytic anemia D) Macrocytic anemia E) Polycythemia
ANSWER: D
Myelodysplastic syndrome is a hematologic malignancy with a predisposition to leukemic transformation. It can present with findings of anemia, thrombocytopenia, neutropenia, or any combination of these. Anemia occurs in 80%–85% of patients and is typically macrocytic.
- A 12-year-old female with asthma sees you for a follow-up visit. The girl’s mother states that she is currently coughing several days per week and uses her albuterol (Proventil, Ventolin) inhaler 3–4 times weekly. She has awakened with a cough during the night 3 times in the last month. The patient thinks her asthma only mildly affects her day-to-day activity. In-office spirometry reveals that her FEV1 is 83% of predicted, with a normal FEV1/FVC ratio.
Which one of the following asthma classifications best fits this patient’s presentation?
A) Intermittent B) Mild persistent C) Moderate persistent D) Severe persistent E) Status asthmaticus
ANSWER: B
Education of asthmatic patients is critically important in their follow-up care. This includes informing patients about the severity of their asthma in addition to instruction about appropriate treatment modalities. The National Heart, Lung, and Blood Institute’s National Asthma Education and Prevention Program uses the following definitions for asthma severity:
Intermittent: Symptoms less than or equal to twice weekly, nighttime awakenings less than or equal to 2 times/month, short-acting B-agonist usage less than or equal to 2 days/week, no interference with daily activities, and normal FEV1 and FEV1/FVC ratio at baseline
Mild Persistent: Symptoms >2 days/week but not daily, nighttime awakenings 3–4 times/month, short-acting B-agonist usage >2 days/week but not more than once daily, minor limitation to daily activities, FEV1 greater than or equal to 80% predicted, and normal FEV1/FVC ratio
Moderate Persistent: Daily symptoms, nighttime awakenings greater than once weekly but not nightly, daily use of a short-acting B-agonist, some limitation to daily activity, FEV1 >60% but less than 80% of predicted, and FEV1/FVC ratio reduced by 5%
Severe Persistent: Symptoms throughout the day, nighttime awakenings nightly, short-acting B-agonist usage several times daily, extremely limited daily activities, FEV1 less than 60% of predicted, and FEV1/FVC ratio reduced by >5%
Status asthmaticus is a medical emergency and requires emergent treatment in a hospital setting.
- Which class of medication is first-line therapy for uncomplicated depression during pregnancy?
A) Monoamine oxidase inhibitors (MAOIs) B) SSRIs C) SNRIs D) Stimulants E) Tricyclic antidepressants
ANSWER: B
The treatment of depression in pregnancy is determined by the severity of the symptoms and any past history of treatment response. For women who have a new onset of mild or moderate depression, it may be best to start with nonpharmacologic treatments such as supportive psychotherapy or cognitive-behavioral therapy. These interventions may improve the depression enough that the patient will not need medications. However, in situations where pharmacologic treatment is clearly indicated, SSRIs are thought to have the best safety profile. Fluoxetine, sertraline, and citalopram have extensive data to support their safety in pregnancy and should be considered first line. Paroxetine is the one SSRI that is thought to carry an increased risk of congenital malformations with first-trimester exposure and should be avoided.
Tricyclic antidepressants are class D in pregnancy. SNRIs do not have as much safety data as SSRIs to support their use in pregnancy and would be considered a second-line choice. MAOIs are known teratogens and should be avoided in pregnancy. Stimulants are not first-line agents and should be avoided in pregnancy.
- In 2009, the Centers for Medicare & Medicaid Services introduced the concept of Accountable Care Organizations primarily to accomplish which one of the following objectives?
A) Prevent rates of reimbursement from growing faster than GDP
B) Increase reimbursement to medically disadvantaged regions of the United States
C) Require uninsured individuals to purchase health insurance at fair-market prices
D) Deliver more efficient, high-quality services by encouraging cooperation between health care providers
E) Reduce the power of integrated health systems to behave as monopolies
ANSWER: D
The concept of Accountable Care Organizations (ACOs) was introduced in 2009 by the Centers for Medicare and Medicaid Services (CMS) to encourage doctors, hospitals, and other health care providers to work together to deliver high-quality care and spend health care dollars more wisely. The ACO concept, together with a shared savings program, has had difficulty penetrating smaller practices and more rural regions of the country. There is also concern that ACOs may allow larger systems to work as a monopoly as an unintended consequence. For this reason the Department of Justice and the Federal Trade Commission are monitoring these organizations as they develop.
This new strategy of shared savings through coordinated health care is an alternative to the Sustainable Growth Rate (SGR) formula that CMS had previously hoped would contain health-care costs. The SGR was created to prevent Medicare rates from growing faster than the GDP. The high-profile topic of requiring individuals to carry health insurance has also been part of governmental reform initiatives but is not directly related to ACOs.
- A 57-year-old male comes to the emergency department after several episodes of vomiting preceded by moderately severe epigastric pain. He says the vomitus looked like coffee grounds. He tells you he has had “heartburn” in the past that was sometimes severe, and occasionally associated with vomiting, but these episodes were almost always relieved by oral antacids. This problem was exacerbated recently after he began taking ketorolac for moderate arthritic pain in his knees and hands. His past medical history and a review of systems reveal no major comorbid disorders.
The patient’s blood pressure is 125/82 mm Hg and his heart rate is 95 beats/min with no signs of shock. His hemoglobin level is 9.5 g/dL (N 13.0–18.0). He is admitted to the hospital and placed on a proton pump inhibitor (PPI) infusion. Upper gastrointestinal endoscopy performed within 3 hours of admission shows no blood in the upper gastrointestinal tract, but reveals a Mallory-Weiss tear and a stomach ulcer containing a dark spot in an otherwise clear base.
Management at this time should include which one of the following?
A) Transfusion with whole blood
B) Repeat endoscopy within 24 hours
C) Arteriography
D) Continued in-hospital observation for at least 72 hours
E) Discharge from the hospital on oral PPI therapy
ANSWER: E
Blood transfusions should be administered to patients with upper gastrointestinal bleeding who have a hemoglobin level less than or equal to 7.0 g/dL (SOR C). According to the Rockall risk scoring system, this patient’s mortality risk from gastrointestinal bleeding is low, based on the following: age less than 60, systolic blood pressure 3100 mm Hg, heart rate less than 100 beats/min, no shock, and no major comorbidities. The Mallory-Weiss tear adds no points to his total score, and the only stigmata of recent hemorrhage is a dark spot in an otherwise clean ulcer base, which also adds no points. His only scored finding is the presence of the ulcer, which adds a single point to his score.
Patients with low-risk peptic ulcer bleeding based on clinical and endoscopic criteria can be discharged from the hospital on the same day as endoscopy (SOR C). Routine second-look endoscopy is not recommended in patients with upper gastrointestinal bleeding who are not considered to be at high risk for rebleeding (SOR C). Arteriography with embolization is indicated only in patients with persistent bleeding.
- A 22-year-old male who is training for a marathon presents with a 2-week history of ankle pain. There is no history of trauma to the ankle. Your examination reveals tenderness over the distal tibia and you suspect a stress fracture.
The initial imaging study of choice for this patient’s ankle is
A) a plain radiograph B) ultrasonography C) CT D) MRI E) a radionuclide bone scan
ANSWER: A
Plain radiography should be the initial imaging modality to diagnose stress fractures (SOR C). One algorithm advocates radiography 2 weeks after the onset of symptoms (if symptoms persist), with repeat radiography the following week before performing more advanced imaging. An expert panel of the American College of Radiology recommends that MRI be considered next if plain radiography is negative.
- A 12-month-old male is brought to your office for a routine checkup and immunizations. He has not received medical care since his 4-month well child visit and has had no immunizations since that time.
Which one of the following vaccines is NOT indicated for this patient?
A) Varicella vaccine
B) Rotavirus vaccine
C) Hepatitis B vaccine
D) MMR vaccine
ANSWER: B
In general, when young children are found to be behind schedule in receiving recommended immunizations, catch-up immunization is important. However, the rotavirus series should not be started past 15 weeks of age, or continued past 8 months of age. This child should have received hepatitis B vaccine at 6 months of age, and should be given a catch-up dose. The MMR and varicella vaccines are recommended at the 12-month visit.
- A 69-year-old male with type 2 diabetes mellitus comes to your office for a routine follow-up visit. He takes insulin glargine (Lantus) as a basal insulin, with meal-time boluses of insulin lispro (Humalog). He reports repeated episodes of hypoglycemia with blood glucose levels in the 40–50 mg/dL range. He treats them appropriately by consuming about 15 g of carbohydrates. He has a history of severe episodes of hypoglycemia requiring emergency services. In addition to insulin, his current medications include simvastatin (Zocor), lisinopril (Prinivil, Zestril), and aspirin. He has both diabetic autonomic neuropathy and retinopathy.
Which one of the following factors in this patient’s case is the most significant predictor of severe hypoglycemia?
A) His age B) His sex C) His medications D) His previous episodes of severe hypoglycemia E) His diabetic autonomic neuropathy
ANSWER: D
In patients with type 2 diabetes mellitus, the single most important predictor of severe hypoglycemia is a previous history of severe hypoglycemia that required external assistance. It is thought that hypoglycemia reduces the body’s protective responses (glucagon and epinephrine) to subsequent episodes of hypoglycemia (SOR C). Increased blood glucose level goals and increased self-monitoring of blood glucose are the most important measures for avoiding further episodes.
Less significant risk factors for hypoglycemia include advanced age, use of five or more medications, African-American ethnicity, and recent hospital discharge (SOR B). Diabetic autonomic neuropathy may be a risk factor but this has not been definitively established.
- When compared with an occiput anterior fetal position, a persistent occiput posterior fetal position is less likely to result in
A) spontaneous vaginal delivery B) assisted vaginal delivery C) cesarean delivery D) a third or fourth degree perineal laceration E) excessive maternal blood loss
ANSWER: A
A persistent occiput posterior position is associated with a higher risk of cesarean delivery and assisted vaginal delivery, and a lower chance of spontaneous vaginal delivery. Assisted vaginal deliveries are associated with a higher rate of third- and fourth-degree perineal lacerations and postpartum hemorrhage.
- One year after being diagnosed with early Alzheimer’s disease, one of your long-time patients develops symptomatic carotid stenosis. A vascular surgeon has recommended surgical treatment, but the patient’s family is uncertain whether he should have the surgery and if he is capable of making the decision. The children are evenly split in their opinion regarding the surgery, and they ask for your input.
Which one of the following is true regarding this situation?
A) The patient is incapable of making this decision because of his dementia
B) The Mini-Mental State Examination score determines competence
C) The patient should be evaluated by a psychiatrist
D) A judicial determination of competence should be obtained
E) The patient’s decision-making capacity can be adequately assessed by clinical evaluation
ANSWER: E
The primary care physician can assess decision-making capacity based on the patient’s ability to reason, communicate, understand the proposed treatment, and grasp the consequences of accepting or declining the suggested treatment.
Formal mental status testing and determination of capacity are different functions. Accurate mental status testing is helpful for assessing the capacity to make decisions, but there is not a specific score that determines capacity. However, there is a certain level of cognitive impairment where a patient simply lacks any ability to receive and process health information. At somewhat higher levels of cognition a patient might lack specific mental abilities, but still be able to satisfy the requirements for making treatment decisions. A recent meta-analysis showed that Mini-Mental State Examination (MMSE) scores below 20 increase the likelihood of incapacity (LR 6.3), scores of 20–24 have no effect (LR 0.87), and scores greater than 24 significantly lower the likelihood of incapacity (LR 0.17).
Determination of capacity does not require legal intervention or psychiatric expertise. While there is no specific test for decision-making capacity, there are instruments available to assist physicians with making these assessments. The best validated of these is the Aid to Capacity Evaluation (ACE), which is free and available online (http://www.jointcentreforbioethics.ca/tools/documents/ace.pdf). It can be administered in 10–20 minutes.
Competence is a legal term in this situation. Decisions regarding competence are judicial determinations of the capacity to make nonmedical decisions such as financial decisions. Under the law, adults are presumed to be competent until a specific action of the appropriate court declares otherwise.
- A 70-year-old white female asks you to evaluate her right shoulder because of pain and limited range of motion. Further history reveals that 2 months ago she slipped in her kitchen and caught onto the refrigerator door handle to avoid falling to the floor. On examination she has pain and weakness at 45° of abduction and weakness on external rotation.
She should be treated for
A) bicipital tendinitis B) disruption of the glenoid fossa C) rotator cuff tear D) acromioclavicular separation E) incomplete fracture of the humeral head
ANSWER: C
This patient has a history and physical findings that are consistent with a rotator cuff tear. Most commonly the mechanism of injury in an acute rotator cuff tear is forced abduction of the arm with significant resistance. Often this will occur when a person attempts to break a fall with an outstretched hand. There is usually a sudden sensation of tearing pain in the shoulder. Pain and muscle spasm will limit shoulder motion. Patients with a large tear cannot initiate shoulder abduction and will have a discrepancy between active and passive motion. Patients with significant tears will also have a positive drop arm test. This test is performed by passively abducting the arm to 90° and asking the patient to hold the arm in that position while the examiner applies pressure on the distal forearm or wrist. The test is positive if the pressure causes the arm to drop suddenly.
Acute tears are generally managed with a splint and orthopedic referral for surgical repair. Chronic tears may be managed with shoulder rehabilitation but may ultimately require surgical repair as well.
Bicipital tendinitis is not generally caused by acute trauma, but by irritation and microtrauma due to repetitive elevation or abduction of the shoulder, causing an inflammatory reaction in the synovial sheath. Patients generally present with a complaint of pain in the anterior shoulder that radiates into the upper arm. It is more painful with activity and is worse at night. Abduction and external rotation of the arm exacerbates the pain. On examination there should be point tenderness in the bicipital groove. Active range of motion will be limited by pain but passive range of motion will be intact. There should not be any weakness.
Acromioclavicular separation is usually caused by a fall or a direct blow to the point of the shoulder with the shoulder abducted. The pain associated with this injury is over the acromioclavicular joint margin and there may be swelling. Depending on the severity of the injury there may be full range of motion but it may be restricted due to pain. There should not be any weakness associated with this injury.
A fracture of the humeral head generally occurs with a fall on an outstretched arm or direct blow to the lateral side of the arm. Generally there is pain or bruising over the fracture site. Movement will be restricted by pain, but there should not be any weakness.
A tear of the labrum can occur with acute trauma or from repetitive shoulder motion. Acute trauma may occur from a dislocation of the shoulder, falling on an outstretched arm, or direct blows to the shoulder. Generally, people with a tear of the labrum will have increased pain with overhead activity, popping or grinding, loss of strength, and trouble locating a specific point of pain.
- Which one of the following vesiculobullous diseases is associated with gluten sensitivity?
A) Bullous pemphigoid B) Herpes gestationis C) Erythema multiforme D) Porphyria cutanea tarda E) Dermatitis herpetiformis
ANSWER: E
Dermatitis herpetiformis is an immune-mediated vesicular disease that usually occurs in the young to middle-aged. The skin lesions are extremely pruritic grouped vesicles and erosions located on the scalp, posterior neck, and extensor surfaces of the elbows, knees, and buttocks. Most patients have a subclinical gluten-sensitive enteropathy that is reversible with a gluten-free diet, which can sometimes control the skin disease as well.
Erythema multiforme is an acute blistering eruption that occurs in all age groups. Porphyria cutanea tarda patients develop erosions and bullae on sun-exposed skin. Herpes gestationis is a rare autoimmune dermatosis of pregnancy, and bullous pemphigoid is an autoimmune blistering disorder seen in the elderly. Tense blisters and urticarial plaques occur on the flexor surfaces of the arms, legs, axillae, groin, and abdomen.
- A 32-year-old male comes to your office because of wrist pain following a fall on the ice 10 days ago. Examination of the wrist shows no deformity or swelling, but extension is decreased and he has diffuse tenderness over the dorsum of the wrist, particularly just distal and dorsal to the radial styloid. A radiograph is shown below.
Which one of the following does the radiograph show?
A) A hamate fracture
B) A scaphoid fracture
C) A lunate dislocation
D) A scapholunate dislocation
ANSWER: B
A dorsiflexion injury will typically cause a scaphoid fracture in a young adult, resulting in tenderness to palpation over the anatomic snuffbox. A plain posterior-anterior wrist radiograph is often normal. However, a special view with the wrist prone in ulnar deviation elongates the scaphoid, often demonstrating subtle fractures. Hook of the hamate fractures cause tenderness at the proximal hypothenar area 1 cm distal to the flexion crease of the wrist. When this fracture is suspected, carpal tunnel and supinated oblique view radiographs should be obtained. A scapholunate dislocation can be identified with a “clenched-fist” view and a supinated view with the wrist in ulnar deviation.
- An 18-year-old basketball player comes to your office for evaluation of finger pain. During a basketball game yesterday he was hit on the tip of his right second digit and now has finger pain and difficulty moving his finger. On examination he has bruising and tenderness over the distal interphalangeal (DIP) joint. His DIP joint is in the flexed position and he is unable to extend the joint. A radiograph shows a fracture at the dorsal surface of the proximal distal phalanx involving 10% of the joint space.
What is the most appropriate management of this injury?
A) Taping the finger to the adjacent finger B) Splinting in full extension C) Splinting in 45° of flexion D) Urgent surgical management E) Intermittent splinting for comfort
ANSWER: B
This patient has a mallet fracture. These fractures are caused by an axial load to the tip of an extended finger that causes forced flexion at the distal interphalangeal (DIP) joint. This leads to a fracture at the dorsal surface of the proximal distal phalanx where the terminal finger extensor mechanism inserts. The most appropriate treatment of a mallet fracture is to splint the DIP joint in extension for 8 weeks. The joint should remain in full extension for optimal healing. Any flexion of the finger may affect healing and extend the treatment time.
Surgical management has been recommended for fractures that involve more than 30% of the joint space, but a small study showed there was no difference in outcomes compared to treatment with extension splints. Buddy taping would not offer enough support to maintain the finger in extension at all times.
- A 31-year-old gravida 2 para 2 sees you for a routine annual visit. Her Papanicolaou (Pap) test is normal and high-risk HPV testing is negative. She has never had an abnormal Pap test.
According to the guidelines of the U.S. Preventive Services Task Force and the American College of Obstetricians and Gynecologists, this patient’s cervical cytology and HPV testing should be repeated in
A) 1 year B) 2 years C) 3 years D) 4 years E) 5 years
ANSWER: E
In women 30–65 years old, screening for cervical cancer with cervical cytology and HPV testing is recommended every 5 years. An alternative screening recommendation is to perform cervical cytology only, at 3-year intervals. A population study of 331,818 women demonstrated a 0.016% risk of cancer in the 5 years after having a negative result on both cervical cytology and an HPV test.
- A 59-year-old male college professor presents with a 2-month history of right medial knee pain. There is no history of injury or overuse. He has no other specific joint pain except for occasional myalgias and arthralgias of his legs and arms. On most days he has morning stiffness lasting 15–20 minutes after getting out of bed. A review of systems is otherwise negative.
On examination the right knee has full range of motion. There is tenderness at the medial joint line, but no clicking or ligamentous instability. There is crepitus with movement in both knees.
Which one of the following diagnostic tests would be most appropriate at this time?
A) Serologic testing B) Synovial fluid analysis C) Plain radiography D) MRI without contrast E) MRI with contrast
ANSWER: C
The most likely diagnosis for this patient’s knee pain is osteoarthritis. While he is likely to have disease in both knees, it is common for patients to have unilateral symptoms, especially early on. Although osteoarthritis is mainly a clinical diagnosis, plain radiography is the diagnostic study of choice if there is concern about other diagnostic possibilities. Narrowing of the medial compartment of the knee joint is typically the first radiographic finding; osteophytes are also commonly seen on plain films. In the scenario presented here, there is no need for laboratory testing at this time.
- An 87-year-old female is brought to the emergency department after losing consciousness at the dinner table. Her history indicates recent unintentional weight loss. Further evaluation ultimately reveals a large mass at the head of the pancreas and extensive metastasis to numerous organs, including the brain. Her life expectancy is estimated to be 2–3 weeks. The patient chooses to receive hospice care but becomes very depressed.
Which one of the following would be best for improving her depression?
A) Electroconvulsive therapy B) Methylphenidate (Ritalin) C) Mirtazapine (Remeron) D) Fluoxetine (Prozac) E) Nortriptyline (Pamelor)
ANSWER: B
There is good evidence that psychostimulants reduce symptoms of depression within days, making methylphenidate a good choice for this patient (SOR B). Electroconvulsive therapy is contraindicated due to her brain lesions. Mirtazapine, fluoxetine, and nortriptyline all take at least 3–4 weeks to have any antidepressant effects, and would not be appropriate given the patient’s life expectancy (SOR B).
