Questions 151-200 Flashcards
- You are caring for a 42-year-old female with symptoms and physical findings consistent with chronic fatigue syndrome. Her CBC, metabolic panel, TSH level, C-reactive protein level, rheumatoid factor test, antinuclear antibody test, and phosphorus level are all normal. You have assessed her for comorbid diagnoses of chronic pain, depression, and sleep disturbance, which are all negative.
The best evidence-based initial treatment would be
A) hydrocortisone B) methylphenidate (Ritalin) C) melatonin D) cognitive-behavioral therapy E) white fluorescent light therapy
Item 200
ANSWER: D
Persons being evaluated for chronic fatigue should be assessed for comorbid depression, sleep disturbance, and pain (SOR C). According to the Centers for Disease Control and Prevention, the initial evaluation should include a urinalysis, a CBC, a metabolic panel, and measurement of TSH, antinuclear antibody, C-reactive protein, rheumatoid factor, and phosphorus (SOR C). In addition, Britain’s National Institute for Health and Clinical Excellence (NICE) guidelines recommend immunoglobulin A endomysial antibodies to screen for celiac disease. The etiology of chronic fatigue syndrome is not clearly defined and is likely multifactorial.
The initial treatment should be cognitive-behavioral therapy (CBT) or graded exercise therapy, or both (SOR A). CBT has been shown to decrease anxiety, improve work and social adjustment, decrease postexertional malaise, and improve overall fatigue (SOR A). There is not good evidence to support the use of hydrocortisone, fludrocortisone, or antiviral medications in the treatment of chronic fatigue syndrome. Other treatments that do not appear effective include melatonin, citalopram, methylphenidate, and galantamine.
- A 60-year-old white female is admitted to the hospital with a submassive pulmonary embolism. Which one of the following is most effective for assessing right ventricular dysfunction in this situation?
A) Echocardiography
B) Physical examination
C) 12-Lead electrocardiography
D) Contrast-enhanced CT of the chest
Item 199
ANSWER: A
Echocardiography is the best study for detecting right ventricular (RV) dysfunction and also allows for estimation of pulmonary artery pressure. Abnormal findings on the physical examination or EKG may be the earliest indicators of RV dysfunction, but these may also appear normal. CT will show RV enlargement, which is predictive of 30- and 90-day mortality, although it is not as quantitative as the EKG (SOR A).
- A 56-year-old female with a history of poorly controlled type 2 diabetes mellitus presents with a complaint of progressive loss of sensation and weakness in both legs over the past 2 days and low back pain that is nonradiating. She also reports that she is unable to feel bowel movements or urination. She says she has not had any fever or chills.
On examination she has a low-grade fever with a blood pressure of 142/84 mm Hg. She has no sensation to pinprick or vibration from the T9 level down, bilaterally. She is unable to move her legs voluntarily or resist gravity, and no reflexes are elicited in the lower extremities. Her WBC count is 12,700/mm3 (N 4000–10,000) and her erythrocyte sedimentation rate is 127 mm/hr (N 1–25).
Which one of the following would be most appropriate at this point?
A) Antiplatelet therapy
B) Intravenous corticosteroids
C) Thoracic spine films
D) MRI of the thoracic spine
Item 198
ANSWER: D
This patient has symptoms and signs consistent with a spinal cord lesion. With rapidly progressing symptoms of paraparesis and sensory abnormalities in a diabetic patient, an epidural abscess is likely. This is considered a neurologic emergency, because a permanent deficit can result if the problem is not addressed promptly. MRI of the thoracic spine, which is the level of her deficits, is the best next step in the evaluation of this patient. Intravenous antibiotics are a necessary treatment, along with surgical debridement, if the MRI demonstrates the underlying problem. Thoracic spinal films are not helpful in this situation. Neither antiplatelet therapy nor corticosteroids are indicated for a spinal epidural abscess.
- A 45-year-old male who is being treated for chronic alcohol dependence with monthly injections of naltrexone (Vivitrol) presents with significant pain due to a fractured ankle, and intravenous pain medication is required. Which one of the following medications would be most useful in this situation?
A) Fentanyl B) Hydromorphone (Dilaudid) C) Ketorolac D) Meperidine (Demerol) E) Morphine
Item 197
ANSWER: C
Naltrexone is given in 380-mg monthly injections for the chronic treatment of alcohol and opioid dependence. It is an antagonist of u-opioid receptors, and blocks the pain relief properties of opioid agonists. Regional anesthesia and/or nonopioid analgesics are indicated when urgent pain relief is needed in a patient on long-term naltrexone therapy. Ketorolac is the only medication listed that is not an opioid agonist.
- A 69-year-old female with coronary artery disease, diabetes mellitus, and chronic asthma presents to your office for follow-up. During the visit she expresses concerns about recent reports of unsafe air quality in your region.
Which one of the following is reasonable counseling regarding the health risks of ambient air pollution for this patient?
A) Ambient air pollution has not been clearly shown to increase complications of her chronic diseases
B) She should take her normal vigorous daily walk outside despite air quality alerts because the health benefits of exercise outweigh the risks
C) She should avoid areas near busy roads, which are major sources of multiple outdoor air pollutants
D) Use of air conditioning will likely make her indoor air quality worse
E) Ozone pollution usually peaks in the winter months
Item 196
ANSWER: C
It is estimated that particulate air pollution caused 100,000 deaths in the United States in 2010. The United States Environmental Protection Agency (EPA) publishes air quality data in the form of the Air Quality Index (AQI), which is calculated based on measured levels of the five major regulated air pollutants (surface ozone, particulate matter, sulfur dioxide, carbon monoxide, and nitrogen dioxide). AQI is reported as a number from 1 to 300, with corresponding colors ranging from green (1–50 or “good”) to maroon (200–300 or “very unhealthy”). Levels of particulate air pollution are consistently associated with exacerbations of cardiovascular and pulmonary disease, as well as other illnesses. Physicians should counsel people with chronic heart and lung disease like this patient to avoid heavy or prolonged exertion when AQI levels are >100 (SOR C).
Ozone production is increased by heat, sunlight, and humidity and is generally worse in the warmer months. Motorized vehicles are known to produce carbon monoxide, nitrogen dioxide, and particulate matter, and these pollutants are known to be present at higher concentrations near busy roads. California has responded to this concern by banning construction of schools within 500 feet of major highways. Recirculating air conditioning is likely to reduce indoor exposure to ambient air pollution when levels are unsafe outside.
- The leading type of injury in adults age 65 and older is
A) automobile accidents B) falls C) gunshot wounds D) fire-related injuries E) hypothermia
Item 195
ANSWER: B
Falls are the leading cause of injury in adults age 65 and older. Between 30% and 40% of community- dwelling adults in this age group fall at least once per year.
- A 58-year-old female consults you about smoking cessation. She has been intolerant of varenicline (Chantix) but tells you her sister was able to stop smoking with the use of bupropion (Wellbutrin).
A history of which one of the following would be a relative contraindication to the use of bupropion?
A) Coronary artery disease B) Depression C) Eczema D) Hypothyroidism E) Seizures
Item 194
ANSWER: E
Bupropion should not be used with MAO inhibitors or in patients with seizure or eating disorders. The other medical conditions listed are not contraindications, and bupropion can be used for the treatment of depression.
- A 55-year-old male is brought to the emergency department because of confusion and seizures. He has a history of hypertension and obstructive sleep apnea due to obesity. He is unconscious on arrival and no other history is available. An examination shows no focal neurologic findings, but a general examination is limited because of his size. Breath sounds are diminished, and heart sounds are difficult to hear. He has venous insufficiency changes on his lower extremities, with brawny-type edema. Vital signs include a pulse rate of 90 beats/min, a blood pressure of 140/90 mm Hg, and an oxygen saturation of 96%.
Laboratory testing reveals a glucose level of 120 mg/dL and a sodium level of 110 mEq/L (N 135–145), with normal renal function tests and liver enzyme levels. A chest radiograph shows mild cardiomegaly.
Which one of the following is the treatment of choice for this patient?
A) Valsartan (Diovan) B) Furosemide C) Vasopressin (Pitressin) D) Hypertonic saline E) Conivaptan (Vaprisol)
Item 193
ANSWER: D
This patient has severe hyponatremia manifested by confusion and seizures, a life-threatening situation warranting urgent treatment with hypertonic (3%) saline. The serum sodium level should be raised by only 1–2 mEq/dL per hour, to prevent serious neurologic complications. Saline should be used only until the seizures stop. Some authorities recommend concomitant use of furosemide, especially in patients who are likely to be volume overloaded, as this patient is, but it should not be used alone. The arginine vasopressin antagonist conivaptan is approved for the treatment of euvolemic or hypervolemic hyponatremia, but not in patients who are obtunded or in a coma, or who are having seizures.
- A 69-year-old female is unable to obtain adequate calcium from dietary sources. She is on long-term therapy with pantoprazole (Protonix) for peptic ulcer disease.
Which one of the following would be the most appropriate calcium supplement for this patient?
A) Oyster shell calcium B) Calcium carbonate C) Calcium lactate D) Calcium gluconate E) Calcium citrate
Item 192
ANSWER: E
Women over the age of 50 require at least 1200 mg of calcium a day. Inadequate calcium intake is common, particularly in older women, and is associated with increased bone loss and an increased fracture risk. Supplements should be considered when dietary intake is inadequate. Calcium carbonate is the least expensive and most commonly used supplement, but it is constipating and stomach acid improves its absorption. Calcium gluconate and calcium lactate are rarely used for fracture prevention or calcium supplementation. Bone meal and oyster shell calcium are primarily composed of calcium carbonate but may contain lead or other contaminants since they are derived from natural sources. In addition, their absorption without stomach acid is erratic.
Calcium citrate is less dependent on stomach acidity for absorption and it may be used with long-term gastric acid suppression agents. It may be taken without regard to food or meals.
- Which one of the following does the American College of Obstetricians and Gynecologists recommend as first-line treatment for nausea and vomiting in pregnancy?
A) Doxylamine (Unisom) and pyridoxine (vitamin B6) B) Ondansetron (Zofran) C) Prochlorperazine D) Promethazine (Phenergan) E) Metoclopramide (Reglan)
Item 191
ANSWER: A
Nausea and vomiting are common in early pregnancy and can affect the health of both the pregnant woman and the fetus. Mild cases of nausea and vomiting can be controlled with lifestyle and dietary changes. It is recommended that patients eat frequent small meals consisting of dry and bland foods, avoid spicy and fatty foods, eat high-protein snacks, and eat crackers in the morning before rising. If the nausea and vomiting are not controlled with dietary modifications, the first-line treatment is vitamin B6, 10–25 mg, and doxylamine, 12.5 mg, 3–4 times per day. The other antiemetics can also be used in pregnancy, but vitamin B6 and doxylamine should be tried first because of the balance of safety and efficacy.
- A 44-year-old female presents with a 2-week history of postprandial right upper abdominal pain. Since yesterday her pain has worsened in intensity and she has been vomiting. The patient does not use tobacco or drink alcohol, and takes no medications. Laboratory findings include a serum lipase level of 105 IU/L (N 14–51), a serum amylase level of 155 U/L (N 36–128), a serum total bilirubin level of 1.5 mg/dL (N 0.0–1.0) and an alkaline phosphatase level of 200 IU/L (N 33–96).
The recommended initial imaging in this situation is
A) no routine imaging unless the clinical course becomes complicated
B) transabdominal ultrasonography
C) contrast-enhanced CT
D) magnetic resonance cholangiopancreatography (MRCP)
E) MRI
Item 190
ANSWER: B
The American College of Gastroenterology recommends transabdominal ultrasonography for all patients with acute pancreatitis (strong recommendation, low quality evidence). Contrast-enhanced CT and MRI should be reserved for patients who have an unclear diagnosis, are not clinically improving after 48–72 hours, or develop complications.
- Plan-Do-Check-Act (PDCA) describes which one of the following?
A) The accreditation process to become a patient-centered medical home
B) One of the National Quality Forum’s Safe Practices for Better Healthcare
C) The cycle of continuous quality improvement
D) Donabedian categories of quality measurement
E) The Chronic Care Model
Item 189
ANSWER: C
Improving quality and efficiency in medicine is best done using a systems approach. One of the tools for improving a system of care is to utilize the “Plan-Do-Check-Act” cycle of continuous quality improvement. This cycle includes a planning stage to identify an improvement strategy. An implementation stage is followed by a time of evaluation for effectiveness. Finally, a decision is made to adopt or abandon the initial strategy. The cycle is then repeated as many times as necessary to attain the desired results.
- A 3-year-old male is carried into the office by his mother. Yesterday evening he began complaining of pain around his right hip. Today he has a temperature of 37.6°C (99.7°F), cries when bearing weight on his right leg, and will not allow the leg to be moved in any direction. A radiograph of the hip is normal.
Which one of the following would be most appropriate at this time?
A) A CBC and an erythrocyte sedimentation rate B) A serum antinuclear antibody level C) Ultrasonography of the hip D) MRI of the hip E) In-office aspiration of the hip
Item 188
ANSWER: A
This presentation is typical of either transient synovitis or septic arthritis of the hip. Because the conditions have very different treatment regimens and outcomes, it is important to differentiate the two. It is recommended that after plain films, the first studies to be performed should be a CBC and an erythrocyte sedimentation rate (ESR). Studies have shown that septic arthritis should be considered highly likely in a child who has a fever >38.7°C (101.7°F), refuses to bear weight on the affected leg, has a WBC count >12,000 cells/mm3, and has an ESR >40 mm/hr. If several or all of these conditions exist, aspiration of the hip guided by ultrasonography or fluoroscopy should be performed by an experienced practitioner. MRI may be helpful when the diagnosis is unclear based on the initial evaluation, or if other etiologies need to be excluded.
- An otherwise healthy 55-year-old female is diagnosed with hypertension, based on multiple measurements of systolic blood pressures ranging from 142 to 148 mm Hg and diastolic blood pressures in the range of 90–96 mm Hg over the past 4 months. You are now discussing medication options. The patient exercises regularly and conscientiously adheres to a very healthy diet, and has a BMI of 20 kg/m2. She is concerned with the potential long-term adverse side effects of medication in general, and asks if any agents have potential advantages.
Which one of the following medications has been shown to reduce bone loss and may reduce her risk of future hip fractures?
A) Amlodipine (Norvasc) B) Hydrochlorothiazide C) Lisinopril (Prinivil, Zestril) D) Losartan (Cozaar) E) Metoprolol (Lopressor, Toprol-XL)
Item 187
ANSWER: B
Thiazide diuretics have proven efficacy in the treatment of hypertension in all age groups and sexes. When used as antihypertensive agents, the reduction in adverse cardiovascular outcomes equals that of B-blockers, calcium channel blockers, and ACE inhibitors. Successful thiazide treatment of hypertension is especially effective in preventing heart failure or strokes. Unlike the other options listed, thiazide diuretics have also been shown to slow cortical bone loss in postmenopausal females and to reduce the incidence of osteoporosis and hip fractures in those who take it continuously. This protective beneficial side effect disappears within 4 months following discontinuation of thiazide therapy. As with all medications there are potential disadvantages of thiazide use, including excessive urinary losses of potassium and sodium and possible increases in serum glucose levels.
- The preferred site for an emergency airway is
A) the thyrohyoid membrane
B) the cricothyroid membrane
C) immediately below the cricoid cartilage
D) through the first and second tracheal rings
E) at the level of the thyroid isthmus
Item 186
ANSWER: B
Fortunately, emergency tracheotomy is not often necessary, but should one be necessary the best site for the incision is directly above the cricoid cartilage, through the cricothyroid membrane. Strictly speaking, this is not a tracheotomy, because it is actually above the trachea. However, it is below the vocal cords and bypasses any laryngeal obstruction. The thyrohyoid membrane lies well above the vocal cords, making this an impractical site. The area directly below the cricoid cartilage—which includes the second, third, and fourth tracheal rings, as well as the thyroid isthmus—is the preferred tracheotomy site under controlled circumstances, but excessive bleeding and difficulty finding the trachea may significantly impede the procedure in an emergency.
- A 70-year-old male with a past medical history significant for long-standing diabetes mellitus and hypertension presents with a stroke. CT of the head shows mild atrophy, with no acute bleeding.
In the first 24 hours after his stroke, starting treatment to control his blood pressure is recommended if it reaches what threshold level?
A) 150/90 mm Hg B) 160/100 mm Hg C) 180/100 mm Hg D) 200/110 mm Hg E) 220/120 mm Hg
Item 185
ANSWER: E
Elevated blood pressure may have a protective effect in the initial period after an ischemic stroke, and studies have shown adverse outcomes when it is lowered in the acute period. Blood pressure usually will spontaneously decrease without treatment in the first several hours after presentation, and antihypertensive treatment should not be started in the first 24 hours after an acute stroke unless blood pressure exceeds 220/120 mm Hg, or treatment is warranted because of another medical condition such as acute myocardial infarction. Tighter blood pressure control becomes more important after the first 24 hours.
- Which one of the following is associated with the use of stimulant medications for attention-deficit disorder in adults?
A) Lower success rates compared to nonstimulant medications B) Weight gain C) A low risk of medication abuse D) Serious adverse cardiovascular events E) Increases in blood pressure
Item 184
ANSWER: E
Stimulants are preferred over nonstimulant medications for adults with attention-deficit disorder. Stimulant medications can aggravate psychosis, tics, or hypertension and are therefore contraindicated in patients with these problems. The main side effects of these drugs include insomnia, dry mouth, weight loss, headaches, and anxiety. They are classified as schedule II drugs due to their potential for abuse. The risk for serious adverse cardiovascular events is very low, although these drugs can increase resting heart rate and elevate both systolic and diastolic blood pressure.
- A 23-year-old female complains of lower abdominal and pelvic pain, increased vaginal discharge, and postcoital bleeding. Her pain worsens during intercourse, and is accompanied by occasional nausea and vomiting and a feverish feeling. She is sexually active with several male partners.
A physical examination is remarkable for an oral temperature of 38.6°C (101.5°F), cervical motion tenderness, adnexal tenderness without a mass, and a prominent cervical discharge. Office laboratory results include an elevated erythrocyte sedimentation rate and an elevated WBC count. Saline microscopy of vaginal secretions shows abundant numbers of WBCs but is negative for Trichomonas vaginalis and bacterial vaginosis. You order nucleic-acid amplification tests for Chlamydia trachomatis and Neisseria gonorrhoeae.
Which one of the following would be most appropriate at this point?
A) Treatment based on clinical findings B) Treatment when results of testing for Chlamydia trachomatis and Neisseria gonorrhoeae are available C) Transvaginal ultrasonography D) Pelvic CT E) Laparoscopy
Item 183
ANSWER: A
The diagnosis of pelvic inflammatory disease (PID) is based primarily on the clinical evaluation. Significant consequences can occur if treatment is delayed. Physicians should therefore treat on the basis of clinical judgment without waiting for confirmation from laboratory or imaging tests (SOR B). No single symptom, physical finding, or laboratory test is sensitive or specific enough to definitively diagnose PID (SOR C). Clinical diagnosis alone based on the history, physical examination, and office laboratory results is 87% sensitive, transvaginal ultrasonography is 30% sensitive, and laparoscopy is 81% sensitive but unnecessarily invasive and not cost-effective. A study examining the diagnostic performance of CT in acute PID concluded that the overall sensitivity of CT is poor.
- Which one of the following has been shown to be LEAST effective in the treatment of irritable bowel syndrome?
A) Fiber
B) Probiotics
C) Antispasmodics
D) Antidepressants
Item 182
ANSWER: A
Fiber is ineffective in the treatment of adult irritable bowel syndrome (IBS) (SOR A). Symptoms do improve, however, with several different medications and alternative therapies. Exercise, probiotics, antibiotics, antispasmodics, antidepressants, psychological treatments, and peppermint oil all have evidence that they may improve IBS symptoms (SOR B). A Cochrane review of 15 studies involving 922 patients found a beneficial effect from antidepressants with regard to improvement in pain and overall symptom scores compared to placebo. SSRIs used in these trials included citalopram, fluoxetine, and paroxetine, and tricyclic antidepressants included amitriptyline, desipramine, and imipramine. Buspirone, clonazepam, divalproex sodium, and risperidone have not been shown to be effective for symptom relief in IBS patients.
- A 69-year-old patient presents with a 2-day history of wrist pain after sustaining a fall at home. On examination there is diffuse swelling and tenderness across the dorsal aspect of the wrist. Radiographs are shown below.
Which one of the following would be the most appropriate treatment?
A) A long arm posterior splint B) A radial gutter splint C) A sugar-tong splint D) A thumb spica splint E) An ulnar gutter splint
Item 181
ANSWER: C
The radiograph shows a distal radial fracture (Colles fracture) with a minimal amount of displacement or impaction. Such fractures can be treated with immobilization for 4–8 weeks. According to a Cochrane review, there is insufficient evidence from randomized trials to determine which methods of conservative treatment are most appropriate for the more common types of distal radial fractures in adults.The use of a single sugar-tong splint or a short arm cast is recommended for these fractures. Volar or dorsal splints are generally not recommended, as they do not restrict pronation and supination. Orthopedic referral is recommended in the presence of intra-articular fractures (radiocarpal, distal radioulnar), carpal bone injuries, and dislocation of the distal radioulnar joint. The other splints listed are not recommended for immobilizing distal radial fractures (SOR B).
