Questions 101-150 Flashcards
- A 72-year-old female presents with a 2-month history of constipation. She says she has to strain to evacuate at least half the time and reports that her stools have become clay-like in consistency and narrower in caliber. At least half the time she has the sensation that evacuation is not complete, and she has occasionally used manual maneuvers to complete evacuation. She had a normal colonoscopy 8 years ago.
An abdominal examination is normal, and stool with a clay-like consistency is palpated during a rectal examination. No prolapse is seen with straining, and the anal wink is present. Screening laboratory tests indicate a mild microcytic, hypochromic anemia.
Which one of the following would be most appropriate at this time?
A) A trial of lactulose B) Lifestyle modifications C) Phosphosoda enemas D) Colonoscopy E) Pelvic floor muscle exercises
ANSWER: D
This patient has several red flags that require complete colon evaluation with endoscopy: age >50, a change in stool caliber, and obstructive symptoms. Other red flags include heme-positive stools, anemia consistent with iron deficiency, and rectal bleeding. Malignancy should be eliminated as a possible diagnosis prior to initiating any treatment. Biofeedback training is used to manage pelvic floor dysfunction caused by incoordination of pelvic floor muscles during attempted evacuation. Common symptoms include prolonged or excessive straining, soft stools that are difficult to pass, and rectal discomfort. The other options are appropriate management strategies once malignancy has been eliminated as a possibility.
- A 45-year-old male recently recovered from a second episode of left lower extremity cellulitis. He has onychomycosis on his left foot but is otherwise in good health.
Which one of the following treatments is best overall if eradication of the onychomycosis is necessary?
A) Ciclopirox topical (Penlac Nail Lacquer) B) Oral fluconazole (Diflucan) C) Oral griseofulvin (Grifulvin V) D) Oral itraconazole (Sporanox) E) Oral terbinafine (Lamisil)
ANSWER: E
Onychomycosis is a difficult condition to treat successfully. If symptoms are minimal, treatment is often deferred. Cellulitis of the involved extremity may be related to the onychomycosis and is an accepted reason to consider eradication treatment. Oral terbinafine is the best treatment in terms of cure rate and tolerability (SOR A). Significant liver disease is a contraindication.
Itraconazole is less effective and more toxic, and griseofulvin is significantly less effective. Topical ciclopirox lacquer is also less effective than terbinafine, although it eliminates the risk for systemic toxicity. Fluconazole is not indicated for onychomycosis.
- Effective communication with patients from other countries requires knowledge of communication styles within various cultures. Which one of the following is consistently appropriate for all patients from non–English-speaking countries?
A) Discouraging the use of family members as interpreters
B) Expecting patients to make their own decisions regarding care
C) Discussing test results with the patient only
D) Maintaining eye contact with the patient
ANSWER: A
Providing quality health care to individuals from diverse sociocultural backgrounds requires effective communication. Low health literacy in almost half of the U.S. population makes communication more difficult. When a language barrier exists it is better to have a professional interpreter than a family member, and children should be used as interpreters only in cases of emergency when no other source is available.
The typical approach to medical care in the United States assumes that patients want to make their own decisions based on guidance from their health care providers. However, there are cultures in which patient autonomy is not the norm. There may be a specific authority figure in the family that is regarded as the decision maker.
Effective communication also involves knowledge of communication styles within various cultures. Nonverbal communication can be through touch, eye contact, and personal space. For example, there are cultures in which direct eye contact is avoided, but in other cultures it is considered a sign of respect.
- A 55-year-old male with type 1 diabetes mellitus is being treated in the wound care clinic for a skin ulcer on his lower right leg. The ulcer is slow to improve. He comes to see you in the office because over the past 2 days his right knee has become swollen, red, warm, painful, and difficult to flex. When you examine him, his right knee is swollen, erythematous, indurated, and held in full extension. Active and passive ranges of motion are limited. Areas of erythema and induration continue to surround his leg ulcer. His WBC count is mildly elevated, but his erythrocyte sedimentation rate and C-reactive protein level are normal.
Which one of the following would be most appropriate at this point?
A) Plain radiographs B) Ultrasonography C) MRI D) Arthrocentesis E) Antinuclear antibody studies
ANSWER: D
Any patient with risk factors for infection who presents with acute joint swelling, pain, erythema, warmth, and joint immobility should be evaluated for septic arthritis. Risk factors for septic arthritis in this patient include a cutaneous ulcer and diabetes mellitus. Serum markers such as the WBC count, erythrocyte sedimentation rate, and C-reactive protein levels are often used to determine the presence of infection or inflammatory response. However, patients with confirmed septic arthritis may have normal erythrocyte sedimentation rates and C-reactive protein levels.
Because the clinical presentation of septic arthritis may overlap with that of other causes of acute arthritis, arthrocentesis is needed to differentiate between the various causes and, in the case of septic arthritis, to identify the causative agent and determine appropriate therapy. No findings on imaging studies are pathognomonic for septic arthritis. Antinuclear antibody studies may be indicated later in the course of management if synovial fluid analysis is not consistent with infection, and if synovial fluid cultures are negative.
- In addition to fluid resuscitation, which one of the following is the recommended first-line agent for the management of hypotension in a patient with sepsis?
A) Albumin B) Dopamine C) Epinephrine D) Norepinephrine (Levophed) E) Phenylephrine (Neo-Synephrine)
ANSWER: D
Norepinephrine is the recommended first-line vasopressor agent to correct hypotension in patients with sepsis (SOR A). Vasopressor therapy is required to sustain life and maintain perfusion in the face of life-threatening hypotension, even when hypovolemia has not yet been resolved. Maintaining a mean arterial pressure of at least 65 mm Hg is critical for tissue perfusion. Dopamine is recommended as an alternate first-line agent to elevate arterial pressure, but it is less potent compared to norepinephrine. Dobutamine is recommended as the first-line agent for managing hypotension in cardiogenic shock. Phenylephrine is recommended as the second-line agent for managing hypotension in patients with septic shock who also have tachycardia or dysrhythmias. Albumin and epinephrine are not recommended as first-line agents for managing hypotension in patients with sepsis.
- The husband of a 25-year-old white female consults you about his wife. Eighteen months ago, her last pregnancy was complicated by placental abruption, hemorrhagic shock, and the birth of a stillborn infant. She did not lactate and has not menstruated since the delivery. Since that time she has become increasingly fatigued and apathetic and has noticed a marked decrease in her libido.
Which one of the following is the most likely diagnosis?
A) Prolonged grief reaction
B) Postpartum pituitary necrosis
C) Postpartum depression
D) Iron deficiency anemia
ANSWER: B
A prolonged grief reaction, postpartum depression, and iron deficiency anemia could all cause fatigue, apathy, and decreased libido, but none of these conditions is characterized by failure to lactate and amenorrhea. This patient most likely has postpartum pituitary necrosis (Sheehan’s syndrome), a complication of childbirth in which hemorrhagic shock leads to pituitary necrosis. The syndrome is caused by the lack of hormonal influence from the anterior pituitary gland on other endocrine glands, resulting in failure to lactate, breast atrophy, mental apathy, low blood pressure, absence or deficiency of sweating, loss of secondary hair characteristics and libido, and loss of ovarian function, resulting in amenorrhea.
- A 58-year-old postmenopausal female sees you for an initial health maintenance visit. Her examination is normal and she has no complaints. You perform a Papanicolaou (Pap) test, which she has not had done in 15 years. The smear is read as “negative for intraepithelial lesion and malignancy, benign endometrial cells present.”
What would be the most appropriate follow-up for this finding?
A) A repeat Pap test in 4–6 months B) A repeat Pap test in 1 year C) HPV testing D) An endometrial biopsy E) Colposcopy and endocervical curettage
ANSWER: D
This patient should have an endometrial biopsy (SOR C). Approximately 7% of postmenopausal women with benign endometrial cells on a Papanicolaou smear will have significant endometrial pathology. None of the other options listed evaluate the endometrium for pathology. An asymptomatic premenopausal woman with benign endometrial cells would not need an endometrial evaluation because underlying endometrial pathology is rare in this group.
- Which one of the following is most likely to cause hypoglycemia when used as monotherapy?
A) Acarbose (Precose) B) Exenatide (Byetta) C) Pioglitazone (Actos) D) Repaglinide (Prandin) E) Sitagliptin (Januvia)
ANSWER: D
Repaglinide is a non-sulfonylurea agent that interacts with a different portion of the sulfonylurea receptor to stimulate insulin secretion. It has a relatively short duration of action, and while it may cause hypoglycemia this is less likely than with a sulfonylurea agent. Pioglitazone reduces insulin resistance and has no hypoglycemic effect. Acarbose delays absorption of carbohydrates such as starch, sucrose, and maltose, but does not affect the absorption of glucose and other monosaccharides. Sitagliptin inhibits the enzyme responsible for the breakdown of the naturally occurring incretins, and its major advantage is the absence of side effects. Exenatide stimulates insulin secretion in a glucose-dependent fashion, inhibits glucagon secretion, slows gastric emptying, and may have a central satiety effect. It does not cause hypoglycemia when used as monotherapy, but may increase the risk when used with an insulin secretagogue such as glyburide or glipizide.
- During hospital rounds you are called to attend the resuscitation of one of your patients, a chronic alcoholic with known esophageal varices secondary to hepatic cirrhosis, who just experienced sudden massive hematemesis that resulted in aspiration and respiratory arrest. Endotracheal intubation and suctioning appear to improve her respiratory crisis momentarily, but her pulse quickly becomes too weak to palpate. After 20 minutes of resuscitative effort, cardiac monitoring fails to detect any cardiac electrical activity, no spontaneous respiratory activity is noted, and the process is halted.
When completing the death certificate for this patient, the diagnosis most appropriately listed as the immediate cause of death is
A) cardiac arrest B) respiratory arrest C) upper gastrointestinal hemorrhage D) esophageal varices E) cirrhosis of the liver
ANSWER: C
Although the registration of death is a state function and the details may vary based on the laws and regulations of each state, recorded data is contractually shared with the National Vital Statistics System. To ensure consistency of reporting, the National Center for Health Certificates coordinates collection of the data points by providing a standard form which most state certificates are modeled from. The standard format includes a section titled “Cause of Death,” which is subdivided into two parts. In part 1, the immediate cause of death is to be recorded on the top line (labeled “a”). This is defined as the final disease, injury, or complication directly causing the death, and the directions clearly state that terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation are not to be entered without showing the etiology.
Additional lines are provided to list conditions leading to the cause of death, including a final line for entering the disease or injury that initiated the process leading to death. In this case, the proximate cause of death was the upper gastrointestinal hemorrhage. The source of the bleeding was most likely from esophageal varices resulting from hepatic cirrhosis, so those conditions should be entered respectively in the next two lines. The appropriate entry for the final line in part 1 would be chronic alcoholism.
Space is provided in part 2 to include significant conditions contributing to death, such as other chronic illness and tobacco use.
- Which one of the following patients is eligible for the Medicare hospice benefit?
A) A patient with end-stage COPD with a life expectancy of 6 months
B) A patient with amyotrophic lateral sclerosis with a life expectancy of 9 months
C) A patient on hemodialysis with a life expectancy of 12 months
D) A patient with stage IV breast cancer with a life expectancy of 18 months
ANSWER: A
Patients with a life expectancy of 6 months or less are eligible for the Medicare hospice benefit. This benefit allows patients to receive hospice care in either the home or hospital setting. In addition to patients with terminal cancer, patients with end-stage cardiac, pulmonary, and chronic debilitating diseases are eligible. Approximately two-thirds of patients enrolled in hospice die from non–cancer-related diagnoses, and approximately 60% of Medicare patients are not enrolled in hospice at the time of their death.
- A 16-year-old male asthmatic with no other medical problems presents with a severe attack of respiratory distress and a peak expiratory flow rate less than 40%. After 1 hour of acute treatment his respiratory distress has resolved, but he complains of blurred vision.
Which one of the following therapeutic agents would be the most likely cause?
A) Nebulized albuterol (Proventil, Ventolin) B) Nebulized ipratropium bromide C) Nebulized levalbuterol (Xopenex) D) Subcutaneous terbutaline E) Intravenous methylprednisolone
ANSWER: B
Ipratropium bromide is an anticholinergic agent. When nebulized it can sometimes cause inadvertent ocular effects. Blurred vision and pupil inequality may occur. Ipratropium has been shown to decrease the rate of hospital admissions in severe asthmatic attacks.
Corticosteroids may elevate glucose levels in diabetic patients. The onset would be more gradual, however. Adrenergic agents used for acute asthma do not commonly produce adverse ocular effects (level of evidence 3).
- A 77-year-old male presents for a periodic health evaluation. Your practice is organized as a patient-centered medical home, and this is the patient’s initial visit. His records indicate that he received all recommended screening tests and immunizations 4 years ago, and he asks what screening tests are necessary at his age.
The U.S. Preventive Services Task Force recommends that this patient be screened for which one of the following?
A) Prostate cancer B) Colorectal cancer C) Abdominal aneurysm D) Dementia E) Depression
ANSWER: E
While the U.S. Preventive Services Task Force (USPSTF) recommends against screening for prostate cancer using prostate-specific antigen testing, other screening methods have not been evaluated in controlled studies. For men who have smoked, one-time ultrasonography is recommended as a screen for aortic aneurysm between the ages of 65 and 75. The USPSTF has no recommendation for men who have never smoked.
The USPSTF states that no evidence supports routine colorectal cancer screening in patients age 76–85, but that there may be some individuals with specific considerations for whom colorectal cancer screening would be recommended.
At present, there is no evidence to support screening of older adults for dementia, but it is recommended that all adults be screened for depression when staff support is in place to ensure adequate diagnosis, treatment, and follow-up. In most instances, the elderly population will present to a primary care provider with somatic complaints (level of evidence 1b).
- An 82-year-old white male consults you following several syncopal episodes that are clearly orthostatic in nature. During the course of your evaluation you find that he has a large tongue, mild cardiomegaly, and findings suggestive of bilateral carpal tunnel syndrome.
The most likely diagnosis at this time is
A) pernicious anemia B) cervical spondylosis C) amyloidosis D) cardiomyopathy E) polymyalgia rheumatica
ANSWER: C
Amyloidosis is defined as the extracellular deposition of the fibrous protein amyloid at one or more sites. It may remain undiagnosed for years. Features that should alert the clinician to the diagnosis of primary amyloidosis include unexplained proteinuria, peripheral neuropathy, enlargement of the tongue, cardiomegaly, intestinal malabsorption, bilateral carpal tunnel syndrome, or orthostatic hypotension. Amyloidosis occurs both as a primary idiopathic disorder and in association with other diseases such as multiple myeloma.
- Which one of the following is true concerning people in the United States who do not have health insurance?
A) Most uninsured people are members of a family with at least one working adult
B) Most uninsured people who are employed full-time work for large companies
C) Most uninsured people who work part-time and have incomes below the poverty line are
eligible for Medicaid
D) On average, uninsured people have as much access to routine health care as those with
insurance
ANSWER: A
Most uninsured people in the United States are members of a family with at least one working adult. Most uninsured people who are employed work for small companies or work part-time. Most uninsured people who work part-time with incomes below the poverty line are not eligible for Medicaid. On average, uninsured people have less access to care and have poorer health outcomes.
- A 36-year-old male requests further testing for infertility. His female partner has undergone all testing, and her results are normal. He has recently undergone a semen analysis, which revealed azoospermia. Suspecting hypogonadism, you evaluate morning levels of FSH and total serum testosterone levels to help distinguish between primary and secondary causes.
Which one of the following would you expect with primary hypogonadism?
A) Normal levels of both FSH and testosterone
B) Low levels of both FSH and testosterone
C) Low FSH and increased testosterone
D) High FSH and low testosterone
E) High levels of both FSH and testosterone
ANSWER: D
If semen analysis suggests hypogonadism (e.g., severe oligospermia or azoospermia), it is important to distinguish between primary and secondary causes (SOR C). Evaluation of morning FSH and total serum testosterone levels can help make this determination. Low testosterone levels correlate with hypogonadism. High levels of FSH in the presence of low testosterone levels correlate with primary hypogonadism (SOR B). Low levels of both hormones suggest secondary hypogonadism (SOR B). High testosterone levels are unlikely to be associated with hypogonadism.
- A 32-year-old female presents with a history of recurring headaches. They are usually unilateral, last for 24–48 hours, have a pulsatile quality, and are associated with nausea. She sometimes experiences photophobia as well. The patient describes the headaches as intense, usually requiring her to limit her activities. She has tried several over-the-counter migraine medications that have been minimally effective in aborting these headaches, and requests a prescription for an abortive therapy.
Which one of the following would be the best choice for first-line therapy?
A) Acetaminophen B) Acetaminophen/oxycodone (Percocet) C) Butalbital/aspirin/caffeine (Fiorinal) D) Prednisone E) Sumatriptan (Imitrex)
ANSWER: E
Several medications from different classes are recommended as first-line abortive therapies to treat acute migraine. Because relatively few trials have directly compared the different medication classes, there are no definitive algorithms as to which class works best. NSAIDs and acetaminophen/aspirin/caffeine are recommended as first-line therapies and can be obtained over the counter (SOR A). Triptans are effective and safe for treatment of acute migraine and are recommended as first-line therapy (SOR A) but require a prescription. Opiates and barbiturates are not recommended because of their potential for abuse (SOR C). Acetaminophen alone is not effective, and the same is true of oral corticosteroids.
- A 24-year-old female presents to your office for a health maintenance evaluation. She mentions that she has had several episodes of indigestion after meals and started taking an over-the-counter proton pump inhibitor, which she feels has been helpful. She asks if it would be harmful to take this medicine on a long-term basis.
You tell her that evidence has shown that continuing to take this medication will increase her risk for which one of the following?
A) Hypomagnesemia
B) Vitamin B12 deficiency
C) Clostridium difficile colitis
D) Having a child with birth defects (if taken in the first trimester)
E) Colon cancer
ANSWER: C
Proton pump inhibitors (PPIs) have a powerful effect on inhibiting the production of acid in the stomach. This dramatically reduces symptoms of acid-mediated gastritis, peptic ulcer disease, and gastroesophageal reflux. However, a significant reduction in stomach acidity may cause unintended consequences involving processes that are physiologically dependent on low pH in the gastrointestinal tract. These theoretical risks include decreased levels of vitamin B12, iron, and/or magnesium; decreased bone density; an increase in gut infections or pneumonia; an increase in gastrointestinal neoplasms; and changes in absorption of other medications.
The evidence has been conflicting on some of these risks. Currently, consensus is emerging that chronic use of PPIs increases the risk for pneumonia and gut infections, primarily Clostridium difficile colitis (SOR B). PPIs may also decrease bone density in subsets of patients. These risks need to be weighed against the benefits that these medicines provide before prescribing them on a long-term basis.
- For adolescents with scoliosis, observation is always indicated for a curve below a threshold of
A) 20°
B) 30°
C) 40°
D) 50°
ANSWER: A
The diagnosis of idiopathic scoliosis is based on a coronal plane curvature >10°. It is a diagnosis of exclusion after congenital, neuromuscular, and myopathic diseases and conditions have been ruled out. Adolescent scoliosis is most common, and occurs in about 2%–3% of adolescents. More marked curvature (>30°) occurs in about 0.3% of adolescents, as measured on posterior-anterior and lateral radiographs using the Cobb method. For mild degrees of curvature there is an even distribution between girls and boys, but girls have a tenfold greater risk for more severe curvature.
Screening for scoliosis in the asymptomatic adolescent is controversial; the U.S. Preventive Services Task Force recommends against routine screening in its most recent update in 2004 (D recommendation). However, if idiopathic scoliosis is discovered incidentally or when the adolescent or parent expresses concern about scoliosis, options for further evaluation and treatment include observation for curvatures of less than 20° and consideration for bracing and/or surgery for more severe curvatures. The risk of progression depends on the amount of growth remaining, the magnitude of the curve, and the patient’s gender.
- A 40-year-old male presents with a 3-month history of persistent low back pain and stiffness. He cannot recall any specific episode associated with the onset of the pain, and intermittent ibuprofen has provided little benefit. The pain does not radiate into his legs. He has experienced similar back pain before, but it had always resolved within 2 weeks with rest, cutting back on his activities, and taking ibuprofen. During his third episode about a year ago MRI of his lumbosacral spine did not show any significant pathology.
When you examine the patient he describes mild, generalized discomfort with palpation throughout his lumbosacral region, but has full range of motion of his back, normal deep tendon reflexes, and good muscle strength in his legs. The straight leg–raising test produces mild low back discomfort but does not result in any leg pain.
Which one of the following treatment options has the best evidence for restoring function in this situation?
A) Acupuncture B) Back school C) Back exercises D) Spinal manipulation E) Epidural corticosteroid injection
ANSWER: C
This patient suffers from chronic low back pain, defined as pain, muscle tension, or stiffness localized below the costal margin and above the inferior gluteal folds, with or without sciatica, that has persisted for 12 weeks or more and is not attributed to a recognizable pathology. Among all the listed treatment options for chronic low back pain, only back exercises are given the “beneficial” recommendation in a systematic review. Acupuncture and spinal manipulation are in the “likely to be beneficial” category. Back school and epidural corticosteroid injections are of “unknown effectiveness.”
- A 63-year-old white male has been diagnosed with myasthenia gravis and is experiencing progressive muscle weakness despite maximum pharmacotherapy. Which one of the following surgical options would be most likely to improve his condition?
A) Thyroidectomy B) Radioactive thyroid ablation C) Adrenalectomy D) Removal of a pituitary microadenoma E) Thymectomy
ANSWER: E
Myasthenia gravis is a neuromuscular illness with an underlying immune-related cause. Corticosteroids and anticholinesterase medications such as oral pyridostigmine can be helpful, but thymectomy may be appropriate for patients with generalized disease not responding to medication. Thymectomy increases the remission rate and improves the clinical course.
