Questions 151-200 Flashcards
- A 52-year-old female presents with vulvovaginal dryness and pain with intercourse. She has not menstruated for 6 months and denies hot flashes, insomnia, or other vasomotor symptoms. She has no past history of cancer or surgery. Her examination is consistent with vaginal atrophy.
Which one of the following is the recommended first-line treatment for this patient?
A) Oral estrogen
B) Oral estrogen and progestogen
C) Vaginal estrogen
D) Vaginal estrogen and oral progestogen
ANSWER: C
Vaginal atrophy is a common symptom accompanying menopause. Local application of estrogen is the most effective treatment (SOR A) and is FDA approved for this indication. Efficacy ranges from 80% to 100%. All formulations are equally effective, so patient preference should drive the choice. Potential adverse effects of vaginal estrogen include candidal infections, bleeding, burning with application, and breast pain.
It is not necessary to add an oral progestogen to the local estrogen treatment. Vaginal estrogen does not lead to endometrial proliferation, so endometrial protection in a patient who still has her uterus is not necessary.
- A 1-year-old female has head lice. She has three siblings who have been treated unsuccessfully for this problem with permethrin (Nix).
Which one of the following would be the best alternative treatment for this child?
A) Benzyl alcohol lotion (Ulesfia) B) Malathion 0.5% lotion (Ovide) C) Permethrin cream rinse D) Pyrethrin shampoo (Pronto) E) Spinosad (Natroba)
ANSWER: A
The frequency of head lice infestations has increased in recent years, and resistance to permethrin is now common. Permethrin is unlikely to be effective in this child since her siblings’ infestations have failed to respond to it. Of the other choices, only benzyl alcohol lotion is approved for use in children under 2 years of age.
- A 32-year-old female presents with complaints of moderate irritability and anxiety during the week before nearly all of her menstrual periods. During this time she also has problems with weight gain and breast tenderness. She says she is her “usual happy self” at other times during the month. You diagnose premenstrual syndrome (PMS).
Which one of the following complementary and alternative therapies has been shown to be helpful in reducing the symptoms of this problem?
A) Saffron B) St. John’s wort C) Soy D) Pyridoxine (vitamin B6) E) Vitamin E
ANSWER: D
Premenstrual syndrome (PMS) may be diagnosed when recurrent psychological and physical symptoms occur only during the week prior to menses. The presence of more severe affective and somatic symptoms that cause significant dysfunction in a patient’s social and work life is more consistent with premenstrual dysphoric disorder. Both pyridoxine (vitamin B6), 50–100 mg/day, and chasteberry, 20 mg/day, have been shown in randomized, controlled trials to reduce the symptoms of PMS compared with placebo. No good evidence supports the use of vitamin E, saffron, St. John’s wort, or soy.
- During a routine office visit, a 65-year-old female asks if she should be screened for carotid artery stenosis. The patient has a history of controlled hypertension and hypercholesterolemia, and a family history of stroke. Physical examination of the carotid artery is normal and the patient is asymptomatic.
Which one of the following is consistent with U.S. Preventive Services Task Force and American Heart Association recommendations regarding carotid artery ultrasonography for this patient?
A) She does not need screening ultrasonography at this time
B) She should have one-time screening ultrasonography now
C) She should have routine screening ultrasonography now and every 5 years
D) She should have routine screening ultrasonography now and every 10 years
ANSWER: A
The U.S. Preventive Services Task Force and the American Heart Association/American Stroke Association recommend not performing carotid artery screening with ultrasonography or other screening tests in patients without neurologic symptoms because the harms outweigh the benefits. In the general population, screening tests for carotid artery stenosis would result in more false-positive results than true-positive results. This would lead to surgical procedures that are not indicated or to confirmatory angiography. As a result of these procedures, some patients would suffer serious harms such as death, stroke, or myocardial infarction, which outweigh the potential benefit surgical treatment may have in preventing stroke.
- A 35-year-old white female comes to your office with a 3-month history of the gradual onset of pain and tenderness in her wrists and hands. She also complains of 1 hour of morning stiffness. She denies rash, fever, or skin changes. On physical examination she has symmetric swelling of the proximal interphalangeal joints and metacarpophalangeal joints. Motion of these joints is painful. She has no rash or mouth ulcers. Radiographs of the hands and wrists are negative, and a chest film is unremarkable. A CBC is normal, but the erythrocyte sedimentation rate is elevated at 40 mm/hr. Latex fixation for rheumatoid factor is negative, and an antinuclear antibody (ANA) test is negative.
The most likely diagnosis in this patient is
A) rheumatoid arthritis B) systemic lupus erythematosus C) sarcoidosis D) Lyme disease E) calcium pyrophosphate deposition disease
ANSWER: A
This patient has rheumatoid arthritis (RA) by symptoms and physical findings. A positive latex fixation test for rheumatoid factor is not necessary for the diagnosis. A negative rheumatoid factor does not exclude RA, and a positive rheumatoid factor is not specific. Rheumatoid factor is found in the serum of approximately 85% of adult patients with RA; in subjects without RA, the incidence of positive rheumatoid factor is 1%–5% and increases with age.
The ANA test is positive in at least 95% of patients with systemic lupus erythematosus, but in only about 35% of patients with RA. Elevation of the erythrocyte sedimentation rate is seen in many patients with RA, and the degree of elevation roughly parallels disease activity. At a mean of 6 months after the onset of Lyme disease, 60% of patients in the United States have brief attacks of asymmetric, oligoarticular arthritis, primarily in the large joints and especially in the knee.
- A 68-year-old female with a previous history of multiple medical problems presents to your office with dizziness. She describes this dizziness as an “off-balance” or “wobbly” feeling. She has not had a sensation of spinning or motion, or loss of consciousness. She is not anxious or depressed. She takes the following medications:
Lovastatin (Mevacor), 20 mg daily for hypercholesterolemia
Metoprolol succinate (Toprol-XL), 25 mg daily
Chlorthalidone, 12.5 mg daily
Lisinopril (Prinivil, Zestril), 20 mg daily for hypertension
Sertraline (Zoloft), 25 mg daily for menopausal symptoms
Alendronate (Fosamax), 70 mg weekly
Calcium, 600 mg 2 times daily
Vitamin D, 1000 units daily for osteoporosis
Oxybutynin (Ditropan XL), 10 mg daily for overactive bladder
Acetaminophen, 1000 mg 2 times daily for osteoarthritis
Meclizine (Antivert, Bonine), 25 mg 3 times daily as needed for dizziness
Cyclobenzaprine (Flexeril), 5 mg 3 times daily as needed for muscle spasm
Zolpidem (Ambien), 5 mg at bedtime as needed
A physical examination is normal, including a neurologic examination, and the patient has a normal gait. There is no evidence of peripheral neuropathy, and Romberg testing is normal. There is no orthostatic decrease in blood pressure. The Dix-Hallpike maneuver is negative. A CBC, chemistry profile (CMP), TSH level, and vitamin B12 level are normal.
Which one of the following would be most appropriate at this point?
A) A 24-hour heart monitor B) A tilt table test C) Carotid ultrasonography D) Medication reduction E) Increasing the dosage of sertraline to 50 mg daily
ANSWER: D
This patient has a disequilibrium type of dizziness. Causes of this include medication side effects, Parkinson’s disease, and peripheral neuropathy. In this patient the history and examination do not indicate a specific cause. She is on several medications, and one or more could be contributing to her symptoms. A trial of medication reduction should be considered before ordering additional studies.
- A 54-year-old male presents to your office with a chief complaint of vomiting and diarrhea, along with stomach cramps. He has not noticed blood in his stool or vomit.
His symptoms began in the middle of the night, approximately 4 hours after he ate at a local delicatessen. He has not been out of the country and has not eaten any exotic foods or foods that are not part of his normal diet. His vital signs include a temperature of 37.0°C (98.6°F), a pulse rate of 90 beats/min, and a blood pressure of 130/80 mm Hg.
Which one of the following organisms is implicated in this patient’s presumed case of food poisoning?
A) Staphylococcus aureus
B) Clostridium botulinum
C) Campylobacter jejuni
D) Enterohemorrhagic Escherichia coli
ANSWER: A
Among the causes of food poisoning, Staphylococcus aureus is associated with the shortest incubation period (1–6 hours). Most cases are related to contamination of food by infected human carriers. Leaving food to cool slowly at room temperature allows organisms that produce enterotoxins to multiply. Common food sources include ham, poultry, potato or egg salad, cream, and pastries.
Campylobacter jejuni infections can be subclinical or symptomatic. Symptoms usually occur within 2–4 days of exposure to the organism in food or water. A prodrome of fever, headache, and myalgias occurs 24–48 hours before the diarrheal symptoms begin. Vomiting is usually not a symptom of the infection. Clostridium botulinum is usually associated with canned foods. Enterohemorrhagic Escherichia coli produces a Shiga-like toxin, which kills intestinal epithelial cells. While the symptoms are like those of food poisoning, they are much more severe and are usually associated with bloody diarrhea (SOR C).
- A 45-year-old male with type 1 diabetes mellitus receives a corticosteroid injection for osteoarthritis of the left knee. Which one of the following is true regarding monitoring of his blood glucose levels?
A) Glucose levels should be closely monitored for 48 hours
B) Glucose levels should be closely monitored for 7 days
C) Glucose levels should be closely monitored for 14 days
D) No additional monitoring is necessary
ANSWER: D
A single intra-articular injection has little or no effect on glycemic control (SOR A). Soft-tissue or peritendinous injections can affect blood glucose levels for 5–21 days, however, and diabetic patients should closely monitor blood glucose levels for 2 weeks following these injections.
- A 14-year-old male with Tanner stage 1 pubic hair has prepubertal-size testes. His height is at the 3rd percentile. The physical examination is otherwise unremarkable.
Which one of the following additional findings would be most consistent with constitutional delay of growth and puberty?
A) Impairment of the sense of smell B) Delayed bone age C) Elevated LH and FSH D) Elevated thyrotropin E) Elevated prolactin
ANSWER: B
Constitutional delay of growth and puberty (CDGP) tends to be inherited. Bone age is delayed, but growth potential is often normal. LH and FSH are elevated in hypergonadotropic hypogonadism, but this is not characteristic of CDGP. Thyrotropin is most often elevated in hypothyroidism, which can cause a secondary delay in growth and puberty. Anosmia is characteristic of Kallmann syndrome, but not CDGP. Puberty is also delayed in this form of hypogonadotropic hypogonadism. Prolactin is elevated in some pituitary tumors and by dopamine-blocking agents (SOR C).
- A 52-year-old African-American male sees you for a routine visit. His only medical problem is hypercholesterolemia. Because you wish to initiate a statin, you order a liver profile with the following results:
Totalbilirubin. . . . . . . . . . . . . 2.0mg/dL(N0.0–1.0)
Directbilirubin. . . . . . . . . . . . 0.2mg/dL(N0.0–0.4)
Albumin. . . . . . . . . . . . . . . . . 4.0g/dL(N3.5–5.0)
LDH. . . . . . . . . . . . . . . . . . . . .250U/L(N45–90)
AST(SGOT). . . . . . . . . . . . . . .25U/L(N7–27)
ALT(SGPT). . . . . . . . . . . . . . . .15U/L(N1–21)
Alkalinephosphatase. . . . . . 25U/L(N13–39)
Which one of the following would best explain these results?
A) Alcoholic hepatitis B) Steatohepatitis C) Chronic hepatitis C D) Hemolysis E) Gilbert’s syndrome
ANSWER: D
The combination of elevated LDH and elevated unconjugated bilirubin with otherwise normal liver enzyme levels suggests hemolysis. Gilbert’s syndrome would not explain the LDH elevation. Hepatitis is unlikely with normal transaminase levels.
- A 44-year-old female has recently lost her best friend to ovarian cancer. She has no family history of cancer in her siblings, parents, or grandparents. She requests screening for ovarian cancer. Her physical examination, including a pelvic examination, is normal.
According to current guidelines, which one of the following would be best for this patient?
A) CA-125 testing B) CA-125 testing and ovarian ultrasonography C) Ovarian ultrasonography alone D) CT of the pelvis E) No screening
ANSWER: E
Routine screening of the general population for ovarian cancer is not recommended by any professional society.
- A pregnant 32-year-old gravida 2 para 1 develops an acute deep-vein thrombosis in the left lower extremity during the third trimester. The patient had a cesarean delivery with her first pregnancy and wants to breastfeed.
Which one of the following is the treatment of choice?
A) Low molecular weight heparin
B) Unfractionated heparin
C) Warfarin (Coumadin)
D) A vena cava filter
ANSWER: A
The preferred anticoagulant for venous thrombosis during pregnancy is low molecular weight heparin. Unfractionated heparin requires more monitoring and may increase the risk of heparin-induced thrombocytopenia. Warfarin should not be used during pregnancy but may be used in women who are breastfeeding (SOR B).
- A 40-year-old male presents with a new rash. On examination you note multiple erythematous-to-yellow dome-shaped papules on the extensor surfaces of his extremities, on his buttocks, and on his hands. The papules are tender and pruritic. A biopsy reveals foamy macrophages and dermal extracellular lipids.
This patient’s rash is associated with
A) endocarditis B) systemic vasculitis C) a viral infection of the skin D) hypertriglyceridemia E) urticaria
ANSWER: D
Eruptive xanthomas like these are associated with elevated triglycerides, obesity, alcohol abuse, diabetes mellitus, and estrogen or retinoid therapies. The lesions of molluscum contagiosum can be distinguished from these xanthomas by the characteristic central umbilication of molluscum.
- For most patients, which one of the following is the most effective treatment for anemia of chronic disease?
A) Elemental iron
B) Erythropoietin
C) Prednisone
D) Optimal management of the underlying disorder
E) Combined therapy with oral iron, vitamin B12, folic acid, and erythropoietin
ANSWER: D
There is no specific therapy for anemia of chronic disease except to manage or treat the underlying disorder. Iron therapy is of no benefit, but erythropoietin may be helpful in some patients. There is no available data to suggest that combination therapy or prednisone is beneficial for this disorder.
- Which one of the following interventions for bed-wetting in children should be recommended as initial therapy?
A) Waking a child during the night and carrying him or her to the toilet
B) Restriction of fluids during the day
C) An enuresis alarm
D) Imipramine (Tofranil)
E) Oxybutynin (Ditropan)
ANSWER: C
Enuresis alarms should be offered as initial treatment for bed-wetting, based on randomized, controlled trials and cost-effectiveness evidence. Desmopressin can also be considered if the child or parents do not want to try an alarm. Restriction of fluids during the day should not be recommended, as it is important that children have enough to drink. Waking a child and carrying him or her to the toilet has not been shown to have a long-term effect on bed-wetting. Oxybutynin and imipramine should only be considered in cases where bed-wetting does not respond to initial treatment.
- Which one of the following is a contraindication to the use of combined hormonal contraceptives?
A) A family history of breast cancer in a first degree relative
B) Rheumatoid arthritis treated with immunosuppression
C) Morbid obesity
D) Migraine headaches with aura
E) Ovarian cancer
ANSWER: D
The U.S. Medical Eligibility Criteria for Contraceptive Use were created to guide health care providers in assessing the safety of contraceptive use for patients with specific conditions. Category 1 includes conditions for which no restrictions exist for use of the contraceptive method. Category 2 indicates that the method generally can be used, but careful follow-up may be required. Category 3 is used to classify conditions for which the method usually is not recommended unless more-preferred methods are not available or acceptable. Category 4 comprises conditions that represent an unacceptable health risk if the method is used. For combined hormonal contraceptives, migraine headaches with aura at any age are classified as category 4 because of the increased risk of ischemic stroke. A family history of breast cancer is category 1, rheumatoid arthritis treated by immunosuppression is category 2, a BMI greater than or equal to 30 kg/m2 is category 2, and ovarian cancer is category 1.
- A 5-month-old child begins to cough and wheeze. He has no previous history of respiratory problems, although he has had upper respiratory symptoms for the past 2 days. On physical examination you note tachypnea and mild intercostal retractions and wheezes.
The most likely diagnosis is
A) asthma B) bronchiolitis C) croup D) pertussis E) pneumonia
ANSWER: B
Acute bronchiolitis is a viral illness most frequently caused by the respiratory syncytial virus. Its peak incidence occurs at approximately 6 months of age. The illness frequently causes a few days of mild upper respiratory symptoms, followed by increased coughing and wheezing. Examination often reveals tachypnea and use of the accessory muscles of respiration, such as intercostal retractions. Acute asthma is uncommon in the first year of life, and is difficult to diagnose without recurrent episodes or prior respiratory problems. Croup usually presents with stridor, and pertussis and pneumonia do not usually present with wheezing.
- Which one of the following cardiac arrhythmias is associated with antipsychotic use?
A) Third degree heart block B) Paroxysmal atrial tachycardia C) Atrial fibrillation D) Ventricular fibrillation (torsades de pointes) E) Wolff-Parkinson-White syndrome
ANSWER: D
All antipsychotic agents can prolong ventricular repolarization, leading to a prolonged QT interval, which can in turn lead to torsades de pointes and sudden cardiac death. Although all antipsychotics can affect EKG intervals, the agents with the greatest propensity to prolong QTc are thioridazine, pimozide, droperidol, and ziprasidone. The incidence of sudden cardiac death among patients taking antipsychotics is about twice that of the general population.
- A 16-year-old female has had foot pain for the past 3 weeks. She has no known history of trauma, but is participating in cross-country running events for her high school and has significantly increased her training schedule over the past 2 months. An examination reveals tenderness at the base of the fifth metatarsal, but no swelling. Radiographs are negative, but a radionuclide bone scan shows increased uptake in the proximal portion of the fifth metatarsal.
Which one of the following would be most appropriate?
A) A reduced training schedule for 1 month
B) A DXA scan to evaluate bone mineral density
C) A wooden cast shoe
D) Ice and NSAID therapy only
E) Referral to an orthopedist
ANSWER: E
Stress fractures are caused by repetitive loading that exceeds the bone’s ability to heal. They occur more commonly in female athletes. Patients should be evaluated for risk factors such as eating disorders, menstrual irregularities, and chronic medical conditions. Lower-extremity alignment, gait, and strength should also be evaluated. High-risk fractures such as those of the femoral neck, anterior cortex of the tibia, or proximal fifth metatarsal should be referred to an orthopedist, as there is a high likelihood of fracture-related complications.
- You are treating a 68-year-old male for COPD, hypertension, systolic heart failure, and coronary artery disease. You are considering adding a B-blocker but you are concerned that it could affect his COPD.
Which one of the following options would be most appropriate for this patient?
A) Metoprolol tartrate (Lopressor), 12.5 mg twice daily B) Nadolol (Corgard), 20 mg daily C) Sotalol (Betapace), 40 mg twice daily D) Timolol, 5 mg daily E) Avoiding B-blocker use
ANSWER: A
Cardioselective B-blockers, such as metoprolol, should not be withheld from patients with COPD. Metoprolol could be started at a low dosage in this patient. Nadolol, timolol, and sotalol are not cardioselective.
