Questions 51-100 Flashcards
- A 68-year-old male with end-stage lung cancer is being treated for pain secondary to multiple visceral and skeletal metastases. He has been on oral ibuprofen and parenteral morphine. However, over the past few weeks he reports progressive worsening of his pain. In order to achieve better pain control his morphine dosage has been continuously titrated up. In spite of this increase he continues to report severe pain that is now diffuse and occurs even when his caregivers touch him.
Which one of the following would be most appropriate at this time?
A) Increase the morphine dosage until continuous sedation is obtained
B) Attempt a reduction in the morphine dosage
C) Add an anxiolytic to help relieve anxiety
D) Advise the family that nothing more can be done for his pain
ANSWER: B
Opioid-induced hyperalgesia is characterized by a paradoxical increase in sensitivity to pain despite an increase in the opioid dosage. It is seen in patients who are receiving high doses of parenteral opioids such as morphine. Patients report the development of diffuse pain away from the site of the original pain. Allodynia, a perception of pain in the absence of a painful stimulus, is also typical in opioid-induced hyperalgesia. Strategies to manage this condition include reducing the current opioid dosage, and occasionally eliminating the current opioid and starting another opioid. The addition of non-opioid pain medications should also be considered. The addition of an anxiolytic is not likely to improve this patient’s pain (SOR C).
- A 42-year-old male with a 4-year history of multiple sclerosis (MS) presents with an acute attack manifested by ataxia, incoordination, and dysarthria. Which one of the following is indicated for managing this flare-up of his MS?
A) Fingolimod (Gilenya)
B) Glatiramer (Copaxone)
C) Interferon-B (Avonex, Betaseron)
D) Methylprednisolone (Medrol)
E) Pramipexole (Mirapex)
ANSWER: D
Corticosteroids, either orally or parenterally, are the first-line treatment for acute exacerbations of multiple sclerosis (MS) (SOR A). A Cochrane review found no significant differences in outcomes based on the route of administration. Disease-modifying agents such as interferon beta, glatiramer, and immunosuppressants such as fingolimod may decrease the frequency of exacerbations and slow the progression of MS but are not the agents of first choice for treatment of acute flareups. Pramipexole does not have a primary role in the treatment of MS, although it might be used to treat certain specific symptoms as an adjunct therapy.
- A 24-year-old female presents to the emergency department because she thinks she is having an allergic reaction to her medication for depression. About 3 hours after taking her first dose of citalopram (Celexa) she noted extreme anxiety, agitation, palpitations, and a dry mouth. On examination she has a blood pressure of 180/110 mm Hg, a pulse rate of 120 beats/min, a respiratory rate of 24/min, and a temperature of 37.2°C (99.0°F). Her pupils are dilated and she has slow, continuous horizontal eye movements. Marked hyperreflexia is noted in the lower extremities.
In addition to supportive care, the patient should be given intravenous
A) propranolol
B) diphenhydramine
C) haloperidol lactate (Haldol Lactate)
D) flumazenil (Romazicon)
E) diazepam
ANSWER: E
Serotonin syndrome is a result of increased serotonergic activity in the central nervous system and may be life-threatening. It is usually a combination of autonomic hyperactivity, neuromuscular abnormality, and mental status changes. The most common group of medications that may cause this is the SSRIs. Serotonin syndrome most commonly occurs in the first 24 hours of treatment. Patients often present with agitation and confusion, tachycardia, and elevated blood pressure, as well as a dry mouth. While there are usually no focal neurologic findings, hyperreflexia and even spontaneous clonus may be seen. The finding of slow, horizontal movement of the eyes is also helpful in making the diagnosis.
The initial management is to discontinue the offending agent, begin supportive care, and attempt to calm the patient verbally. Many times medication is needed, and the drug of choice is an intravenous benzodiazepine such as lorazepam or diazepam. If treatment for tachycardia or hypertension is needed, propranolol should not be used due to its longer activity. Haloperidol should be avoided, as it may actually increase anticholinergic activity. Flumazenil is rarely used, although it has been used for tricyclic antidepressant overdosage, and it carries a significant risk of inducing seizures. If the patient does not respond to calming with benzodiazepines, the antidote would be cyproheptadine.
- In a patient with sepsis, which one of the following would confirm a diagnosis of septic shock?
A) A 1.0 mg/dL increase in the creatinine level
B) A platelet count of 20,000/mm3 (N 150,000–350,000)
C) A WBC count of 25,000/mm3 (N 4300–10,800)
D) A serum bilirubin level of 7.0 mg/dL (N less than 1.0)
E) A serum lactate level of 2.0 mmol/L (N 0.5–1.0)
ANSWER: E
Diagnostic criteria for sepsis include leukocytosis. Diagnostic criteria for severe sepsis (sepsis plus organ dysfunction) include an increase in the serum creatinine level greater than 0.5 mg/dL, thrombocytopenia, and hyperbilirubinemia. A diagnosis of septic shock requires either hyperlactatemia or hypotension refractory to intravenous fluids.
- A study finds that the positive predictive value of a new test for breast cancer is 75%, which means that
A) among patients with known breast cancer who had the test, 75% had a positive test
B) among patients with no breast cancer who had the test, 75% had a negative test
C) 75% of patients who tested positive actually had breast cancer
D) 75% of patients who tested negative did not have breast cancer
ANSWER: C
Positive predictive value refers to the percentage of patients with a positive test for a disease who actually have the disease. The negative predictive value of a test is the proportion of patients with negative test results who do not have the disorder.
The percentage of patients with a disorder who have a positive test for that disorder is a test’s sensitivity. The percentage of patients without a disorder who have a negative test for that disorder is a test’s specificity.
- A 49-year-old male brings you a copy of his laboratory results obtained during an insurance examination. The patient says he feels fine, but his bilirubin level was 2.5 mg/dL (N less than 1.0). He says he averages 5 alcoholic beverages per week and takes no medications other than occasional ibuprofen. On examination he is not jaundiced and has no scleral icterus, and the remainder of the examination is within normal limits, including palpation of the liver and spleen. Laboratory testing reveals a normal CBC, normal liver enzyme levels, and normal serum haptoglobin. Bilirubin fractionation reveals an indirect level of 2.0 mg/dL and a direct level of 0.5 mg/dL (N less than 0.4).
The most likely diagnosis is
A) asymptomatic cholecystitis
B) alcoholic liver disease
C) Gilbert’s syndrome
D) hemolytic anemia
ANSWER: C
Gilbert’s syndrome is a hereditary condition associated with unconjugated hyperbilirubinemia (usually with a bilirubin level less than 5.0 mg/dL). The bilirubin level increases with infection, exertion, and fasting. Patients are asymptomatic and have otherwise normal liver function studies. The differential diagnosis includes hemolytic anemias, which cause a decrease in serum haptoglobin, an increase in lactate dehydrogenase, and/or CBC abnormalities, particularly on the peripheral smear.
- A healthy 18-year-old female sees you for a preparticipation evaluation and well care visit prior to soccer season. She has no significant previous medical history and no current problems. She says she is not sexually active. She has completed the HPV vaccine series.
Which one of the following would be most appropriate for cervical cancer screening for this patient?
A) No screening at this visit
B) Annual Papanicolaou tests
C) Papanicolaou testing alone every 3 years
D) Papanicolaou testing and HPV testing every 3 years
ANSWER: A
The U.S. Preventive Services Task Force recommends against screening for cervical cancer for women younger than 21, for women over the age of 65 who have had adequate screening in the recent past and are not at high risk, and for women who have had a hysterectomy with removal of the cervix and no history of CIN 2 or 3 or cervical cancer (USPSTF D recommendation). Women between the ages of 21 and 65 can be screened every 3 years with cytology alone, or the interval can be increased to 5 years after age 30 by using a combination of cytology and HPV testing (USPSTF A recommendation). The history of HPV vaccination is not a factor in screening decisions. Other organizations such as the American Cancer Society and the American College of Obstetricians and Gynecologists have similar guidelines.
- Which one of the following can help to minimize the pain of lidocaine (Xylocaine) injection?
A) Slowly inserting the needle through the skin
B) Avoiding injection into the subcutaneous tissue
C) Injection of the solution only after fully inserting the needle at the target site
D) Cooling the solution to refrigerator temperature prior to injecting it
E) Buffering the solution with sodium bicarbonate
ANSWER: E
Lidocaine buffered with sodium bicarbonate decreases the pain associated with the injection. This effect is enhanced when the solution is warmed to room temperature (SOR B). Rapidly inserting the needle through the skin, injecting the solution slowly and steadily while withdrawing the needle, and injecting into the subcutaneous tissue also minimize the pain of injection.
- Which one of the following is most appropriate for patients with asplenia?
A) Lifelong daily antibiotic prophylaxis
B) Antibiotics for any episode of fever
C) An additional dose of Hib vaccine
D) Avoiding live attenuated influenza vaccine
E) Withholding pneumococcal vaccine
ANSWER: B
Asplenic patients who develop a fever should be given antibiotics immediately. Due to the increased risk of pneumococcal sepsis in asplenic patients, vaccinations against these particular bacteria are specifically recommended. Since pneumococcal conjugate vaccine (PCV13) and pneumococcal polysaccharide vaccine (PPSV23) can interact with each other they should be given at least 8 weeks apart. Prophylactic penicillin given orally twice a day is particularly important in children under 5 years of age who are asplenic, and may be considered for 1–2 years post splenectomy in older patients. Lifelong daily antibiotics may be considered following post-splenectomy sepsis. The risk for Haemophilus influenzae type b infection is not increased in asplenic patients, so additional vaccine is not needed for those who have already been vaccinated. Live attenuated influenza vaccine may be used in asplenic patients, unless they have sickle cell disease.
- A 37-year-old graphic designer presents to your office with a history of several months of radial wrist pain. She does not recall any specific trauma but notes that it hurts to hold a coffee cup. Finkelstein’s test is positive and a grind test is negative, and there is tenderness to palpation over the radial tubercle.
Which one of the following would be most appropriate at this point?
A) Plain radiography focusing on the scaphoid
B) Rest and a thumb spica wrist splint
C) MRI of the wrist
D) A short arm cast
ANSWER: B
This patient has de Quervain’s tenosynovitis. Finkelstein’s test has good sensitivity and specificity (SOR C) in patients with a negative grind test. A positive grind test would be more consistent with scaphoid fracture. A hand radiograph with secondary thumb spica splinting would be appropriate for a suspected scaphoid fracture, but the insidious onset as opposed to overt trauma makes this diagnosis unlikely in this case. A short arm cast is not indicated in de Quervain’s tenosynovitis but may be appropriate for forearm/wrist fractures.
- A 19-year-old college wrestler presents with cellulitis of his left arm extending from a small pustule on his hand to the axilla. He appears acutely ill and has a temperature of 38.9°C (102.0°F). His WBC count is 22,000/mm3 (N 4300–10,800). He is admitted to the hospital.
The initial drug of choice for this patient would be
A) ciprofloxacin (Cipro)
B) clindamycin (Cleocin)
C) doxycycline
D) trimethoprim/sulfamethoxazole
E) vancomycin
ANSWER: E
Methicillin-resistant Staphylococcus aureus (MRSA) is the predominant cause of suppurative skin and soft-tissue infection. While community-acquired strains have been susceptible to many antibiotics, clindamycin is associated with Clostridium difficile enterocolitis, trimethoprim/sulfamethoxazole is usually used orally only for outpatient treatment, and doxycycline and minocycline are often effective clinically but seldom used for serious infections. Resistance to quinolones is increasing and may emerge during treatment. Vancomycin given parenterally is generally still the drug of choice for hospitalized patients.
- Which one of the following is an indication for a second dose of pneumococcal polysaccharide vaccine in children?
A) A cerebrospinal fluid leak
B) Cyanotic congenital heart disease
C) Type 1 diabetes mellitus
D) Sickle cell disease
E) Chronic bronchopulmonary dysplasia
ANSWER: D
Patients with chronic illness, diabetes mellitus, cerebrospinal fluid leaks, chronic bronchopulmonary dysplasia, cyanotic congenital heart disease, or cochlear implants should receive one dose of pneumococcal polysaccharide vaccine after 2 years of age, and at least 2 months after the last dose of pneumococcal conjugate vaccine. Revaccination with polysaccharide vaccine is not recommended for these patients. Individuals with sickle cell disease, those with anatomic or functional asplenia, immunocompromised persons with renal failure or leukemia, and HIV-infected persons should receive polysaccharide vaccine on this same schedule and should also be revaccinated at least 3 years after the first dose.
- A 66-year-old male who was hospitalized 2 months ago for an episode of heart failure sees you for follow-up. He complains of pain in his chest and on examination you note tenderness and a slight fullness deep to his nipple bilaterally.
Which one of the following drugs on his medication reconciliation list is most likely to cause this type of discomfort?
A) Digoxin (Lanoxin)
B) Enalapril (Vasotec)
C) Eplerenone (Inspra)
D) Hydralazine
E) Spironolactone (Aldactone)
ANSWER: E
Spironolactone, an aldosterone antagonist, can bind to androgen and progesterone receptors, in addition to the mineralocorticoid receptors, resulting in breast tenderness and gynecomastia. Eplerenone, another aldosterone antagonist, has greater specificity for the mineralocorticoid receptors and is therefore less likely to cause breast tenderness and gynecomastia than spironolactone. While there have been case reports of gynecomastia with ACE inhibitors and digoxin, it is noted to be rare. The side effect profile of hydralazine does not include gynecomastia.
- A 30-year-old female reports that she and her husband have not been able to conceive after trying for 15 months. She takes no medications, has regular menses, and has no history of headaches, pelvic infections, or heat/cold intolerance. Her physical examination is unremarkable. Her husband recently had a normal semen analysis.
Which one of the following would be the most appropriate next step?
A) Observation for 1 year
B) TSH, free T4, and prolactin levels
C) Hysterosalpingography
D) An estradiol level
E) A luteal-phase progesterone level
ANSWER: E
Although infertility issues may be very complex, the primary care physician can initiate an appropriate workup. For women who are having regular menstrual cycles, ovulation is very likely. Ovulation can be confirmed by a progesterone level greater than or equal to 5 ng/mL on day 21 of the cycle. If this is the case, tubal patency should be confirmed with hysterosalpingography or laparoscopy. Obstruction or adhesions would require surgical correction, but if there are none, referral for assisted reproductive technology would be appropriate.
Should the progesterone level be less than 5 ng/mL, anovulation should be investigated with TSH, estradiol, FSH, and prolactin levels. Treatment can be initiated if findings reveal the cause of the problem, but if they are unremarkable it is reasonable to try clomiphene to induce ovulation. If this is unsuccessful, referral would be the next step.
- A 48-year-old male sees you for a routine health maintenance examination. His blood pressure is 142/90 mm Hg and you recommend that he return for a repeat blood pressure measurement. Eight weeks later his blood pressure is 138/88 mm Hg. He denies any symptoms on a review of systems. He tells you that on his 40th birthday he abruptly stopped smoking after smoking a pack of cigarettes a day since his early twenties. He is adopted and cannot provide a family history.
According to U.S. Preventive Services Task Force guidelines, which one of the following conditions should this patient be screened for now?
A) Abdominal aortic aneurysm
B) Peripheral arterial disease
C) Colon cancer
D) Type 2 diabetes mellitus
E) Hemochromatosis
ANSWER: D
U.S. Preventive Services Task Force (USPSTF) guidelines recommend that asymptomatic adults with sustained blood pressure greater than 135/80 mm Hg be screened for type 2 diabetes mellitus using fasting plasma glucose, a 2-hour glucose tolerance test, or hemoglobin A1c measurements (USPSTF B recommendation). Screening for colon cancer with either annual high-sensitivity fecal occult blood testing, sigmoidoscopy every 5 years, or colonoscopy every 10 years is also recommended for adults between the ages of 50 and 75 years (USPSTF A recommendation). Men who have ever smoked (defined as 100 or more cigarettes) should be screened once for abdominal aortic aneurysm (USPSTF B recommendation) between the ages of 65 and 75. Similar screening is recommended in men who have never smoked, but this is a USPSTF grade C recommendation. No recommendation has been made with regard to screening for peripheral vascular disease, and the recommendation on screening for hemochromatosis is listed as inactive on the USPSTF website.
- Which one of the following conditions is the leading cause of death for patients with rheumatoid arthritis?
A) Infections
B) Coronary artery disease
C) Thromboembolic disease
D) Lymphoma
E) Lung cancer
ANSWER: B
As is true for the general population in the United States, coronary artery disease is the leading cause of death in patients with rheumatoid arthritis (RA). RA patients have accelerated atherosclerosis related to a chronic inflammatory state. It is thus particularly important to address modifiable risk factors for coronary disease in these patients, including tobacco use, hypertension, and dyslipidemia. Patients with RA also have an increased risk of lymphoma, lung cancer, and thromboembolic disease, but these are not as common as coronary disease. Infections are a concern for patients on disease-modifying agents but are not the leading cause of death.
- A 67-year-old male presents with a persistent, intermittent cough. He says that his exercise tolerance has decreased, noting that he becomes short of breath more easily while playing tennis. He smoked briefly while in college but has not smoked for over 45 years, and reports no history of known pulmonary disease.
You obtain pulmonary function testing in the office to help you diagnose and manage his respiratory symptoms. His FVC and FEV1/FVC are both less than the lower limit of normal as defined by the Third National Health and Nutrition Examination Survey. Repeat testing following administration of a bronchodilator does not correct these values.
Which one of the following would be most appropriate at this time?
A) A methacholine challenge test
B) A mannitol inhalation challenge test
C) Exercise pulmonary function testing
D) Testing for diffusing capacity of the lung for carbon monoxide (DLCO)
ANSWER: D
An FVC that falls below the lower limit of normal (LLN), defined as the fifth percentile of spirometry data obtained from the Third National Health and Nutrition Examination Survey, is consistent with a restrictive pattern of pulmonary function. An FEV1/FVC less than the LLN is consistent with an obstructive defect. A mixed pattern exists when both values are below the LLN, as in this case. The patient should now be referred for full pulmonary function testing, including diffusing capacity of the lungs for carbon monoxide (DLCO).
DLCO is a quantitative measure of gas transfer in the lungs. Diseases that decrease blood flow to the lungs or that damage alveoli will lead to less efficient gas exchange and result in a lower DLCO value. Bronchoprovocation (a methacholine challenge, a mannitol inhalation challenge, or exercise testing) should be performed if pulmonary function test results are normal but exercise- or allergen-induced asthma is suspected.
- You see a 5-year-old white female with in-toeing due to excessive femoral anteversion. She is otherwise normal and healthy, and her mobility is unimpaired. Her parents are greatly concerned with her appearance and possible future disability, and request that she be treated.
You recommend which one of the following?
A) Observation
B) Medial shoe wedges
C) Torque heels
D) Sleeping in a Denis Browne splint for 6 months
E) Derotational osteotomy of the femur
ANSWER: A
There is little evidence that femoral anteversion causes long-term functional problems. Studies have shown that shoe wedges, torque heels, and twister cable splints are not effective. Surgery should be reserved for children 8–10 years of age who still have cosmetically unacceptable, dysfunctional gaits. Major complications of surgery occur in approximately 15% of cases, and can include residual in-toeing, out-toeing, avascular necrosis of the femoral head, osteomyelitis, fracture, valgus deformity, and loss of position. Thus, observation alone is appropriate for a 5-year-old with uncomplicated anteversion.
- Effective treatments for obsessive-compulsive disorder include
A) Freudian analysis
B) benzodiazepines
C) amphetamine salts
D) atypical antipsychotics
E) repetitive exposure to fearful stimuli
ANSWER: E
In obsessive-compulsive disorder (OCD), intrusive thoughts cause anxiety, which patients suppress with recurring behaviors. Various types of psychotherapy have been tried, but repeated exposure to fearful stimuli has been the best. Repeated and prolonged exposure to stimuli that elicit fear, combined with strict avoidance of any compulsive behaviors, seems to be the most effective method for controlling the obsessive-compulsive behaviors. Tricyclic antidepressants and SSRIs are also effective for treating OCD.
Freudian analysis is ineffective for relieving the anxiety associated with OCD. Benzodiazepines can help with anxiety but do little for long-term control, while amphetamines aggravate anxiety and are not helpful. Atypical antipsychotics may help with other mental disorders associated with obsessive-compulsive behavior but do not treat the disorder itself.
- A 77-year-old male presents with significant postherpetic neuralgia in a chest wall distribution. Which one of the following is most likely to be effective in diminishing his discomfort?
A) Oral valacyclovir (Valtrex)
B) Topical lidocaine (Xylocaine) patches
C) Thoracic epidural corticosteroid injections
D) Herpes zoster vaccine
E) Acupuncture
ANSWER: B
Antiviral drugs are useful for treatment of acute herpes zoster but not for treatment of postherpetic neuralgia. Herpes zoster vaccine can prevent postherpetic neuralgia by reducing the incidence of herpes zoster but it has no role in the treatment of neuralgia. Neither acupuncture nor epidural corticosteroid injections are helpful in treating postherpetic neuralgia. Topical agents such as lidocaine patches and capsaicin cream or patches have been shown to reduce symptoms of postherpetic neuralgia, as have the oral agents gabapentin, pregabalin, and amitriptyline.
- While performing a digital rectal examination of the prostate on a 67-year-old patient with diabetes mellitus, you note the findings shown below. The patient confirms that the area has been itchy for some time but he has been reluctant to seek care. He has tried a variety of over-the-counter moisturizing lotions with limited success.
Of the following topical treatments, which one is most likely to provide significant improvement?
A) Antibacterial ointment
B) Antifungal cream
C) Antiviral ointment
D) Corticosteroid cream
E) Rubbing alcohol
ANSWER: D
Plaque psoriasis is characterized by silvery-white scales adhered to well demarcated erythematous papules and/or plaques, typically on the scalp, extensor surfaces of the elbows and knees, or buttocks, and often extending to other exposed areas of the body. When limited to skin folds or the genital region, psoriasis can easily be confused with other conditions such as bacterial or fungal intertrigo. The lesions in this variant, known as flexural or inverse psoriasis, usually appear smooth and moist to the point of maceration, often with minimal to no scaling. Affected patients may report significant pruritus and an unpleasant odor in the involved area. Evidence-based data for treatment options is limited but supports topical application of mild corticosteroid creams, vitamin D preparations, or coal tar products. Medium- or higher-potency corticosteroid creams are best avoided, as the affected areas are either delicate, occlusive, or both, and susceptible to corticosteroid-induced atrophy.
