Quiz 22 Flashcards
A 3-year-old male is brought to your office for a well child visit. The history indicates that
the child has a vocabulary of about 100 single words and has not begun to speak in 2-word
phrases. An ear examination is normal and the parents have no concerns regarding the
child’s hearing. They report that the child is interacting with others normally.
Which one of the following would you propose?
In a 3-year-old, red flags that would suggest the need for immediate speech-language
evaluation include the inability to understand prepositions or action words or the child
having a vocabulary that consists of less than 200 words (SOR C). A child should use
2-word phrases by 2½ years of age.
The evaluation should be performed through a local early developmental intervention
program or a speech-language pathologist.
A previously healthy 29-year-old pediatric nurse has a 3-day history of malaise, arthralgias,
and a nonpruritic rash. The rash is a faint, maculopapular, irregular, reticulate exanthem
that covers her thighs and the inner aspects of her upper arms. Symmetric synovitis is
present in several distal and proximal interphalangeal joints and in her
metacarpophalangeal joints. Small effusions, warmth, and tenderness are noted in her left
wrist and right elbow. No other joints are affected.
The most likely cause of this problem is
Also known as erythema infectiosum or fifth disease, parvovirus B19 infection is a fairly
common cause of an exanthematous rash and arthritis in younger women. This infection
should be particularly suspected in health care workers who have frequent contact with
children.
A 65-year-old Hispanic male with known metastatic lung cancer is hospitalized because of
a 2-week history of decreased appetite, lethargy, and confusion. Laboratory evaluation
reveals the following:
Serum calcium……………………….. 15.8 mg/dL (N 8.4–10.0)
Serum phosphorus…………………. 3.9 mg/dL (N 2.6–4.2)
The initial management of hypercalcemia of malignancy includes fluid replacement with
normal saline to correct the volume depletion that is invariably present and to enhance
renal calcium excretion.
Although intravenous
pamidronate has become the mainstay of treatment for the hypercalcemia of malignancy,
it should be considered only after the patient has been made euvolemic by saline repletion.
The test-and-treat strategy is appropriate for patients with dyspepsia who are younger than
55 years of age and have no alarm symptoms for gastric cancer. Testing for Helicobacter
pylori in patients with GERD is not recommended.
A 53-year-old female with a 6-week history of burning in the chest after eating
In patients with an acute ST-elevation myocardial infarction, fibrinolysis may be preferred
as a reperfusion strategy over percutaneous coronary intervention (PCI), depending on
factors such as when the symptoms began and the transport time to the nearest
PCI-capable hospital. In which one of the following situations would fibrinolysis be most
appropriate?
Once an ST-elevation myocardial infarction is identified, a reperfusion strategy should be
chosen as quickly as possible. In general, percutaneous coronary intervention (PCI) is
preferred because it leads to improved outcomes compared to fibrinolysis when performed
in high-volume medical facilities without treatment delays. If a patient’s first medical
contact is at a PCI-capable hospital or the time from first medical contact to device time
is less than 120 minutes, PCI is the preferred intervention for patients presenting with
symptoms for less than 12 hours. If the transfer time to a PCI-capable hospital is not short,
such as the example of a patient with an onset of symptoms 6 hours ago and a transport
time to the nearest PCI-capable hospital of more than 2 hours, then fibrinolysis is the
preferred management strategy.
If there are absolute contraindications to fibrinolysis (such as a history of an ischemic
stroke within the past 3 months), then PCI is preferred even if the transport time will not
be short. In cases where the onset of symptoms was more than 12 hours ago but less than
24 hours ago and evidence of ongoing ischemia exists, it is still reasonable to pursue
reperfusion therapy, and PCI would be the preferred strategy if it is available.
DM meds
Metformin has been shown to reduce mortality rates in patients with type 2 diabetes
mellitus (SOR A). Acarbose, an α-glucosidase inhibitor, reduces the risk of cardiovascular
events, including myocardial infarction, in patients with impaired glucose tolerance or type
2 diabetes mellitus (SOR B). Rosiglitazone has been shown to be associated with an
increased risk of myocardial infarction and death from cardiovascular causes
sulfonylurea
insulin secretagogues such as glipizide
Laboratory results
that show an elevated procalcitonin level would help differentiate systolic heart failure from
Procalcitonin is a biomarker that is elevated with bacterial infections but not with viral
infections. The laboratory test for procalcitonin has a high sensitivity and can help exclude
bacterial pneumonia in patients with acute heart failure, which can help expedite
appropriate therapy with antibiotics. If the procalcitonin level is low a bacterial infection is
less likely and antibiotics should not be given.
A fourth-generation HIV antibody/antigen test is negative
and her serum creatinine level is 0.6 mg/dL (N 0.5–1.1).
Which one of the following additional test results must be documented before offering
preexposure prophylaxis for HIV with emtricitabine/tenofovir (Truvada)?
Emtricitabine/tenofovir is the only currently approved regimen shown to be effective for
HIV preexposure prophylaxis (PrEP) (SOR A). This patient has multiple sexual partners,
including one at high risk for HIV infection due to intravenous drug use, and thus should
be offered PrEP (SOR C).
In patients without signs of acute HIV, PrEP may be initiated after
documentation of negative fourth-generation HIV antibody/antigen testing, normal renal
function, and hepatitis B infection and immunization status. Tenofovir can be toxic to the
kidneys and is not recommended in patients with an estimated glomerular filtration rate
<60 mL/min/1.73 m2.
Emtricitabine and tenofovir are both also active against hepatitis B virus (HBV) infection,
so the use of PrEP in patients with active HBV must be carefully considered. If a patient
with active HBV stops taking PrEP, reactivated HBV can cause liver damage. Patients
susceptible to HBV infection should be immunized.
Scaphoid fracture
This injury tends to occur when
the wrist is hyperextended and the hand is pronated and radially deviated/
A thumb
spica cast (a short arm cast with the thumb immobilized) for 6–10 weeks is appropriate for
nondisplaced distal fractures. Surgical treatment should be considered for displaced or
proximal fractures.
