Quiz 34 Flashcards
The strategy that will identify the highest percentage of previously unrecognized cases of
chronic hepatitis C is to screen which one of the following?
(check one)
A. All sexually active men and women between the ages of 18 and 29
B. Everyone born between 1945 and 1965
C. Everyone who had a blood transfusion or organ transplant before 1992
D. Everyone who has ever used intravenous drugs
E. All men who have sex with men
The hepatitis C virus is spread through contact with infected blood (usually unscreened
blood transfusions, which were the norm before 1992), intravenous drug use, or high-risk
sexual activity. However, studies have shown that screening only patients with high-risk
medical or clinical histories will identify just 20%–33% of infected patients. As a different
strategy, both the CDC and the U.S. Preventive Services Task Force have recommended
one-time screening of patients born between 1945 and 1965. It is estimated that this
cohort includes 75% of all patients who have chronic hepatitis C.
Which one of the following is the best radiographic test for confirming the diagnosis of renal colic?
CT is the gold standard for the diagnosis of renal colic. Its sensitivity and specificity are superior to those of ultrasonography and intravenous pyelography. Noncalcium stones may be missed by plain radiography but visualized by CT
A 50-year-old male has a pre-employment chest radiograph showing a pulmonary nodule. There are no previous studies available.
Which one of the following would raise the most suspicion that this is a malignant lesion if found on the radiograph? . (check one)
A. The absence of calcification
B. Location above the midline of the lung
C. A diameter of 4 mm
D. A solid appearance
Pulmonary nodules are a common finding on routine studies, including plain chest radiographs, and require evaluation. Radiographic features of benign nodules include a diameter <5 mm, a smooth border, a solid appearance, concentric calcification, and a doubling time of less than 1 month or more than 1 year.
Features of malignant nodules include a size >10 mm, an irregular border, a “ground glass” appearance, either no calcification or an eccentric calcification, and a doubling time of 1 month to 1 year
A previously healthy 67-year-old male sees you for a routine health maintenance visit. During the physical examination you discover a harsh systolic murmur that is loudest over the second right intercostal space and radiates to the carotid arteries. The patient denies any symptoms of dyspnea, angina, syncope, or decreased exertional tolerance. An echocardiogram shows severe aortic stenosis, with an aortic valve area of <1 cm 2, a mean gradiant >40 mm Hg, and an ejection fraction of 60%.
Which one of the following would be most appropriate at this point?
Watchful waiting is recommended for most patients with asymptomatic aortic stenosis, including those with severe disease (SOR B).
This is because the surgical risk of aortic valve replacement outweighs the approximately 1% annual risk of sudden death in asymptomatic patients with aortic stenosis. Peripheral α-blockers, such as prazosin, should be avoided because of the risk of hypotension or syncope. Coronary angiography should be reserved for symptomatic patients who do not have evidence of severe aortic stenosis on echocardiography performed to evaluate their symptoms, or for preoperative evaluation prior to aortic valve replacement. Exercise stress testing is not safe with severe aortic stenosis because of the risk of death during the test.
A 43-year-old female presents to your office for evaluation of a chronic cough that has been present for the past 6 months. She is not a smoker, and is not aware of any exposure to environmental irritants. She does not have any systemic complaints such as fever or weight loss, and does not have any symptoms of heartburn or regurgitation. She is not on any regular medications.
Auscultation of the lungs and a chest radiograph show no evidence of acute disease. A trial of an inhaled bronchodilator and antihistamine therapy does not improve the patient’s symptoms.
Which one of the following would be the most appropriate next step?
A trial of a proton pump inhibitor
Gastroesophageal reflux disease (GERD) is one of the most common causes of chronic cough. Patients with chronic cough have a high likelihood of having GERD, even in the absence of gastrointestinal symptoms (level of evidence 3).
In fact, up to 75% of patients with a cough caused by GERD may have no gastrointestinal symptoms. The cough is thought to be triggered by microaspiration of acidic gastric contents into the larynx and upper bronchial tree.
A 27-year-old white male construction worker suffers from severe plaque-type psoriasis that has required systemic therapy. Which one of the following is associated with this condition? (check one)
A. A reduced overall risk of cardiovascular mortality
B. A decreased risk of skin cancer with successful treatment
C. A low likelihood of recurrence with successful treatment
D. An increased risk for the condition in the children of affected individuals
E. Low body mass index and difficulty maintaining weight
Psoriasis is a genetic inflammatory condition that has been associated with a significant risk of cardiovascular morbidity and mortality.
Cigarette smoking may increase the risk of developing psoriasis. Psoriasis is also associated with an increased likelihood of obesity, diabetes mellitus, and metabolic syndrome.
hypothyroidism becomes pregnancy
increase dose of levothyro.
A 69-year-old female presents with postmenopausal bleeding. You consider whether to begin your evaluation with vaginal probe ultrasonography to assess the thickness of her endometrium.
In evaluating the usefulness of this test to either support or exclude a diagnosis of endometrial cancer, which one of the following statistics is most useful? (check one)
A. Likelihood ratio
Likelihood ratios indicate how a positive or negative test correlates with the likelihood of disease. Ratios greater than 5–10 greatly increase the likelihood of disease, and those less than 0.1–0.2 greatly decrease it. In the example given, if the patient’s endometrial stripe is >25 mm, the likelihood ratio is 15.2 and her post-test probability of endometrial cancer is 63%. However, if it is ≤ 4 mm, the likelihood ratio is 0.02 and her post-test probability of endometrial cancer is 0.2%.
Heart Failure meds
ACE is best, but everyone gets salt restriction, water restriction, ace and bb.
Direct-acting vasodilators such as isosorbide dinitrate also could be used in this patient, but ACE inhibitors have been shown to be superior in randomized, controlled trials (SOR B). β-Blockers are also recommended in heart failure patients with systolic dysfunction (SOR A), except those who have dyspnea at rest or who are hemodynamically unstable. These agents have been shown to reduce mortality from heart failure.
A diuretic such as furosemide may be indicated to relieve congestion in symptomatic patients. Aldosterone antagonists such as spironolactone are also indicated in patients with symptomatic heart failure. In addition, they can be used in patients with a recent myocardial infarction who develop symptomatic systolic dysfunction and in those with diabetes mellitus (SOR B). Digoxin currently is recommended for patients with heart failure and atrial fibrillation, and can be considered in patients who continue to have symptoms despite maximal therapy with other agents.
