Quiz 41 Flashcards
hematocrit of 55.0% (N 36.0–46.0) and a hemoglobin level of 18.5 g/dL (N 12.0–16.0).
Which one of the following additional findings would help establish the diagnosis of polycythemia vera?
Polycythemia vera should be suspected in African-Americans or white females whose hemoglobin level is >16 g/dL or whose hematocrit is >47%. For white males, the thresholds are 18 g/dL and 52%. It should also be suspected in patients with portal vein thrombosis and splenomegaly, with or without thrombocytosis and leukocytosis. Major criteria include an increased red cell mass, a normal O2 saturation,and the presence ofsplenomegaly. Minor criteria includeelevated vitamin B 12 levels, elevated leukocyte alkaline phosphatase, a platelet count >400,000/mm3 and a WBC count >12,000/mm3 . Patients with polycythemia vera may present with gout and an elevated uric acid level, but neither is considered a criterion for the diagnosis.
Over the last 6 months a developmentally normal 12-year-old white female has experienced intermittent abdominal pain, which has made her quite irritable. She also complains of joint pain and general malaise. She has lost 5 kg (11 lb) and has developed an anal fissure.
Which one of the following is the most likely cause of these symptoms?
The most common age of onset for inflammatory bowel disease is during adolescence and young adulthood, with a second peak at 50–80 years of age. The manifestations of Crohn’s disease are somewhat dependent on the site of involvement, but systemic signs and symptoms are more common than with ulcerative colitis. Perianal disease is also common in Crohn’s disease. Irritable colon and other functional bowel disorders may mimic symptoms of Crohn’s disease, but objective findings of weight loss and anal lesions are extremely uncommon. This is also true for viral hepatitis and giardiasis
Celiac disease and giardiasis can produce Crohn’s-like symptoms of diarrhea and weight loss, but are not associated with anal fissures.
A 67-year-old female has started receiving home hospice care. Her attending physician can bill through which one of the following? (check one)
A. Medicare Part A
B. Medicare Part B
C. Medicare Part C
D. Medicare Part D
E. The attending physician cannot bill Medicare
Submit Answers
As long as the attending physician is not employed by hospice, Medicare Part B can be billed. Medicare Part A (hospital insurance) covers inpatient care in hospitals and skilled nursing facilities, hospice, and home health services, but not custodial or long-term care. Medicare Part B (medical insurance) covers outpatient physician services, including office visits and home health services.
Medicare Part C (Medicare Advantage Plans) is offered by private companies, and combines Part A and Part B coverage. These plans always cover emergency and urgent care, and may offer extra coverage such as vision, hearing, dental, and/or health and wellness programs. Most plans also include Medicare Part D, which provides prescription drug coverage. Medicare Part D plans vary with regard to cost and drugs covered.
tetnus
The Advisory Committee on Immunization Practices (ACIP) periodically makes recommendations for
routine or postexposure immunization for a number of preventable diseases, including tetanus. Since 2005,
the recommendation for tetanus prophylaxis has included coverage not only for diphtheria (Td) but also
pertussis, due to waning immunity in the general population. The current recommendation for adults who
require a tetanus booster (either as a routine vaccination or as part of treatment for a wound) is to use the
pertussis-containing Tdap unless it has been less than 5 years since the last booster in someone who has
completed the primary vaccination series.
In this scenario, no additional vaccination is needed at this time, since the patient is certain of completing
the primary vaccinations and received a tetanus booster within the previous 5 years. Had the interval been
longer than 5 years, then a single dose of Tdap would be appropriate unless his previous booster was Tdap.
Tetanus immune globulin is recommended in addition to tetanus vaccine for wounds that are tetanus-prone
due to contamination and tissue damage in persons with an uncertain primary vaccine history. Plain tetanus
toxoid (TT) is usually indicated only when the diphtheria component is contraindicated, which is
uncommon.
A 45-year-old female presents to your office because she has had a lump on her neck for the past 2 weeks. She has no recent or current respiratory symptoms, fever, weight loss, or other constitutional symptoms. She has a history of well-controlled hypertension, but is otherwise healthy. On examination you note a nontender, 2-cm, soft node in the anterior cervical chain. The remainder of the examination is unremarkable.
Which one of the following would be most appropriate at this point?
Monitoring clinically for 4–6 weeks, then a biopsy if the node persists or enlarges
There is limited evidence to guide clinicians in the management of an isolated, enlarged cervical lymph node, even though this is a common occurrence. Evaluation and management is guided by the presence or absence of inflammation, the duration and size of the node, and associated patient symptoms. In addition, the presence of risk factors for malignancy should be taken into account.
Immediate biopsy is warranted if the patient does not have inflammatory symptoms and the lymph node is >3 cm, if the node is in the supraclavicular area, or if the patient has coexistent constitutional symptoms such as night sweats or weight loss. Immediate evaluation is also indicated if the patient has risk factors for malignancy. Treatment with antibiotics is warranted in patients who have inflammatory symptoms such as pain, erythema, fever, or a recent infection.
In a patient with no risk factors for malignancy and no concerning symptoms, monitoring the node for 4–6 weeks is recommended. If the node continues to enlarge or persists after this time, then further evaluation is indicated. This may include a biopsy or imaging with CT or ultrasonography. The utility of serial ultrasound examinations to monitor lymph nodes has not been demonstrated.
A 45-year-old male is seen in the emergency department with a 2-hour history of substernal chest pain. An EKG shows an ST-segment elevation of 0.3 mV in leads V4–V6.
In addition to evaluation for reperfusion therapy, which one of the following would be appropriate?
Oral clopidogrel (Plavix)
This patient has an ST-segment elevation myocardial infarction (STEMI). STEMI is defined as an ST-segment elevation of greater than 0.1 mV in at least two contiguous precordial or adjacent limb leads. The most important goal is to begin fibrinolysis less than 30 minutes after the first contact with the health system. The patient should be given oral clopidogrel, and should also chew 162–325 mg of aspirin.
Enteric aspirin has a delayed effect. Intravenous β-blockers such as metoprolol should not be routinely given, and warfarin is not indicated. Delaying treatment until cardiac enzyme results are available in a patient with a definite myocardial infarction is not appropriate.
A 36-year-old female sees you for a 6-week postpartum visit. Her pregnancy was complicated by gestational diabetes mellitus. Her BMI at this visit is 33.0 kg/m2 and she has a family history of diabetes mellitus.
This patient’s greatest risk factor for developing type 2 diabetes mellitus is her:
A history of gestational diabetes mellitus (GDM) is the greatest risk factor for future development of diabetes mellitus. It is thought that GDM unmasks an underlying propensity to diabetes. While a healthy pregnancy is a diabetogenic state, it is not thought to lead to future diabetes. This patient’s age is not a risk factor. Obesity and family history are risk factors for the development of diabetes, but having GDM leads to a fourfold greater risk of developing diabetes, independent of other risk factors (SOR C)
A 67-year-old male is admitted to your inpatient service with a week-long acute exacerbation of
COPD. He also has hypertension and type 2 diabetes mellitus. After 24 hours of intravenous
fluids and intravenous methylprednisolone, he is now tolerating oral intake.
Which one of the following corticosteroid regimens is best for this patient at this time?
Systemic corticosteroid therapy reduces the hospital length of stay in patients with acute COPD
exacerbations (SOR A). Oral therapy has been shown to be as effective as the intravenous route in patients
who can tolerate oral intake (SOR B). A randomized, controlled trial has demonstrated that 5-day courses
of systemic corticosteroid therapy are at least as effective as 14-day courses (SOR A). Inhaled
corticosteroids are beneficial in some COPD patients but nebulizers generally do not offer significant
advantages over metered-dose inhalers in most patients.
Actinic keratoses of the skin may progress to:
Actinic keratoses are scaly lesions that develop on sun-exposed skin, and are believed to be carcinoma in situ. While most actinic keratoses spontaneously regress, others progress to squamous cell cancers.
A 52-year-old male presents with a small nodule in his palm just proximal to the fourth metacarpophalangeal joint. It has grown larger since it first appeared, and he now has mild flexion of the finger, which he is unable to straighten. He reports that his father had similar problems with his fingers. On examination you note pitting of the skin over the nodule. The most likely diagnosis is: (check one) A. degenerative joint disease B. trigger finger C. Dupuytren’s contracture D. a ganglion E. flexor tenosynovitis
Dupuytren’s contracture is characterized by changes in the palmar fascia, with progressive thickening and nodule formation that can progress to a contracture of the associated finger. The fourth finger is most commonly affected. Pitting or dimpling can occur over the nodule because of the connection with the skin.
Degenerative joint disease is not associated with a palmar nodule. Trigger finger is related to the tendon, not the palmar fascia, and causes the finger to lock and release. Ganglions also affect the tendons or joints, are not located in the fascia, and are not associated with contractures. Flexor tenosynovitis, an inflammation, is associated with pain, which is not usually seen with Dupuytren’s contracture.
