Quiz 21 Flashcards
You judge
her to be stable for surgery.
Which one of the following should you recommend that the patient start today? (check one) A. An ACE inhibitor B. A β-blocker C. A statin D. A diuretic
Statins are recommended
in the perioperative period for vascular surgery regardless of other cardiac risk factors; a statin would
ideally have been initiated previously in this case, but may still be started in the immediate preprocedural
period.
The most common source of chest pain in children is (check one) A. pulmonary B. cardiac C. musculoskeletal D. gastroesophageal E. psychogenic
musculoskeletal
Red flags that suggest a cardiac etiology include a patient history of palpitations with the chest pain, an
abnormal cardiac physical examination (rubs or gallops), exertional chest pain without another more likely
etiology such as asthma, and a positive family history. When any of the red flags is present, the patient
should be referred to a pediatric cardiologist.
An asymptomatic 60-year-old male sees you for a health maintenance visit. His past medical
history is significant for hypertension and hyperlipidemia. His medications include
chlorthalidone, 25 mg daily, and atorvastatin (Lipitor), 20 mg daily. He smoked 2 packs of
cigarettes a day for 20 years but quit 5 years ago. The physical examination is normal.
Laboratory findings include a normal basic metabolic panel, a cholesterol level of 210 mg/dL,
an HDL-cholesterol level of 34 mg/dL, an LDL-cholesterol level of 150 mg/dL, and a
triglyceride level of 200 mg/dL.
Which one of the following screening tests is recommended by the U.S. Preventive Services
Task Force for this patient? (check one)
Low-dose chest CT
The U.S. Preventive Services Task Force (USPSTF) recommends screening smokers for lung cancer with
low-dose CT. Patients should be age 55–80 and healthy. They should be current smokers or have quit
within the past 15 years, and have a 30-pack-year history of smoking. The screening test is low-dose CT
of the chest. Abdominal ultrasonography to screen for abdominal aneurysms is recommended for any male
age 65–75 who has ever smoked (USPSTF B recommendation). A bone density test screens for
osteoporosis and is recommended for women age 65 or older or in younger women at increased risk. The
USPSTF recommends against PSA testing (D recommendation) for prostate cancer, as well as screening
for carotid artery stenosis.
A 63-year-old female with community-acquired pneumonia is being treated with appropriate
antibiotics. The only abnormality on a basic metabolic panel is a serum sodium level of 121
mEq/L (N 135–145). She reports that her shortness of breath and cough are improving. She has
no other complaints on a review of systems.
On examination the patient is noted to have normal vital signs and mucous membranes are moist.
She has crackles in her right lower lobe. Skin turgor is normal. The remainder of the physical
examination is normal. Further testing reveals the following:
Urine sodium. . . . . . . . . . . . . . . . . . . . . . . . . . 50 mEq/L
Serum osmolality. . . . . . . . . . . . . . . . . . . . . . . 276 mOsm/kg (N 280–285)
Urine osmolality. . . . . . . . . . . . . . . . . . . . . . . ..300 mOsm/kg
Which one of the following would be most appropriate at this point?
Fluid restriction
This patient has hypotonic hyponatremia, manifested by low serum osmolality. She is asymptomatic and
has no signs of hypovolemia on her laboratory tests or physical examination. Her urine sodium is high and
her urine osmolality is low, which indicates the syndrome of inappropriate secretion of antidiuretic
hormone (SIADH). This is most likely related to her pneumonia, which is improving. The initial treatment
for mild euvolemic hyponatremia is fluid restriction. Intravenous isotonic saline would be indicated for
mild hypovolemic hyponatremia. Intravenous hypertonic saline would be indicated for severe hyponatremia
with symptoms. Intravenous diuretics would be indicated for hypervolemic hyponatremia, such as in heart
failure, along with fluid and sodium restriction.
colonoscopy. A high-quality examination reveals five 3- to 7-mm sessile polyps in the sigmoid
and rectal areas. Biopsy results show that they are hyperplastic polyps
When should this patient have her next colonoscopy?
Hyperplastic polyps <10 mm in size in the rectum and sigmoid colon carry a low risk for developing into
colon cancer. If they are the only finding, colonoscopy may be repeated in 10 years.
Screening for chronic hepatitis B infection is NOT recommended for which one of the following? (check one)
A. Patients on chronic immunosuppressive therapy
B. Patients with end-stage renal disease who are on hemodialysis
C. Household contacts of individuals with chronic hepatitis B
D. Pregnant women with no risk factors for hepatitis B
E. All newborns
All newborns
The CDC recommends screening for hepatitis B in patients on hemodialysis, household contacts of
individuals with chronic hepatitis B, patients on immunosuppressive therapy, and all pregnant women.
Other individuals who should be screened include anyone exposed to bodily fluids of infected individuals,
such as sexual partners or infants of infected mothers. Behavioral risks such as intravenous drug use are
also an indication for screening. Patients from areas where HBsAg prevalence is >2% should also be
screened.
A 67-year-old male with moderate macrocytosis complains of paresthesias of his feet. If the
patient has a borderline low vitamin B12 level, elevated levels of which one of the following
would suggest vitamin B12 deficiency?
Methylmalonic acid
Neurologic symptoms may develop with low-normal vitamin B12 levels in serum. In true vitamin B12
deficiency, methylmalonic acid and homocysteine levels are typically quite elevated, and these return to
normal with treatment. Gastrin levels may be abnormal in pernicious anemia, but are not diagnostic alone.
High ferritin levels are seen with increased iron stores in the liver, and ferritin levels are used to screen
for hemochromatosis.
In the United States the most common form of child abuse is
Neglect is the most common form of child abuse and is the most common type of abuse in children who
die as a result of abuse.
Potassium. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.3 mEq/L (N 3.5–5.0)
An EKG
Because hyperkalemia can have deleterious effects on the myocardium, an EKG is the first diagnostic test
in the workup of a patient with hyperkalemia. Although not all patients with hyperkalemia will have an
abnormal EKG, those who do need to be given intravenous calcium immediately to prevent arrhythmias
and cardiac arrest.
Which one of the following medications would be least likely to cause hypoglycemia in this patient? (check one) A. Canagliflozin (Invokana) B. Glimepiride (Amaryl) C. Glipizide (Glucotrol) D. Insulin glargine (Lantus) E. Metformin (Glucophage)
Metformin is an inexpensive first-line oral agent for type 2 diabetes mellitus. Its mechanism of action is
to increase the sensitivity of the liver and peripheral tissues to insulin. This assists the patient with weight
loss efforts and, unlike insulin secretagogues, has been proven to reduce mortality with long-term use.
When metformin is used as monotherapy it is not associated with episodes of hypoglycemia.
For many
years there has been a concern that metformin can increase the risk for lactic acidosis. This risk has been
assumed to be greater in conditions that can lead to tissue hypoperfusion, such as heart failure or
hypovolemia, or with renal impairment. The FDA has historically recommended against the use of
metformin for any patient with even mild renal impairment (creatinine >1.4 mg/dL for women and >1.5
mg/dL for men). However, a recent meta-analysis did not find supportive evidence for such restrictions.
Newer evidence suggests that the use of metformin is safe even with mild to moderate renal impairment
(eGFR >30 mL/min) (SOR A).
