Quiz 47

Question 1

The mother of a 16-year-old male calls to report that her son has a severe sore throat and has been running a fever of 102°F. Which one of the following additional findings would be most specific for peritonsillar abscess?

Answer 1

Trismus is almost universally present with peritonsillar abscess, while voice changes, otalgia, and odynophagia may or may not be present. Pharyngotonsillitis and peritonsillar cellulitis may also be associated with these complaints. Otalgia is common with peritonsillar abscess, otitis media, temporomandibular joint disorders, and a variety of other conditions. Peritonsillar abscess is rarely found in patients who do not have at least a 3-day history of progressive sore throat.

Question 2

While playing basketball, a 29-year-old male falls on his outstretched hand with his wrist fully extended. He sees you the following day because of diffuse wrist pain and decreased range of motion. The point of maximal tenderness is on the dorsal aspect of the wrist between the extensor pollicis brevis and extensor pollicis longus tendons. There is no visible deformity. Radiographs show no fracture.

Answer 2

In order to reduce the potential for serious complications, including vascular necrosis and non-union, it is imperative that both the wrist and the thumb be immobilized. In the case described, a thumb spica splint is the best option initially. It should be worn continuously until a follow-up evaluation, including radiographs, in 1–2 weeks.

Question 3

A 42-year-old male seeks your advice regarding smoking cessation. You recommend a smoking cessation class, as well as varenicline (Chantix).
You caution him that the most common side effect is: (

Answer 3

The most common adverse event attributed to varenicline at a dosage of 1 mg twice a day is nausea, occurring in approximately 30%–50% of patients. Taking the drug with food lessens the nausea.

Question 4

Occlusion of the circumflex artery is most likely to cause EKG changes in:

Answer 4

Circumflex occlusion causes changes in I, AVL, and possibly V5 and V6 as well. Left anterior descending coronary artery occlusion causes changes in V1 to V6. Right coronary occlusion causes changes in II, III, and AVF.

Question 5

You test a patient’s muscle strength and find that his maximum performance consists of the
ability to move with gravity neutralized. This qualifies as which grade of muscle strength, on
a scale of 0 to 5?

Answer 5

Muscle strength is scored on a scale of 0 to 5. The inability to contract a muscle is scored as 0. Contraction
without movement constitutes grade 1 strength. Movement with the effect of gravity neutralized is grade
2 strength, while movement against gravity only is grade 3 strength. Movement against gravity plus some
additional resistance indicates grade 4 strength. Normal, or grade 5, strength is demonstrated by movement
against substantial resistance.

Question 6

The National Weight Control Registry includes individuals who have lost substantial weight
without surgery, and have maintained the weight loss for an average of 5 years.

Which one of the following behaviors is typical of these individuals?

Answer 6

Individuals on the National Weight Control Registry typically eat a low-fat diet rich in complex
carbohydrates, eat breakfast daily, weigh themselves at least once a week, and are physically active for
60–90 minutes a day.

Question 7

Patients with which rheumatologic condition have the highest relative risk of internal malignancy compared to the general population?   (check one)
 A. Systemic scleroderma 
 B. Systemic lupus erythematosus 
 C. Sjögren’s syndrome 
 D. Rheumatoid arthritis 
 E. Dermatomyositis

Answer 7

Dermatomyositis

All the others have higher risk of cancer than general population, but Dermatomyositis has more of a risk.

Sjogren’s think nonhodgkin’s lymphoma.

Question 8

A 36-year-old white male complains of episodic pain in the rectum over the past several years. The pain occurs every 3–6 weeks and is sharp, cramp-like, and severe. It lasts from 1 to 15 minutes. He has no other gastrointestinal complaints. A physical examination, including a digital rectal examination and anoscopy, is normal.

Answer 8

proctalgia fugax

Symptoms consistent with proctalgia fugax occur in 13%–19% of the general population. These consist of episodic, sudden, sharp pains in the anorectal area lasting several seconds to minutes. The diagnosis is based on a history that fits the classic picture in a patient with a normal examination. All the other diagnoses listed would be evident from the physical examination, except for sacral nerve neuralgia, which would not be intermittent for years and would be longer lasting

Question 9

The most common cause of acute interstitial nephritis is:   (check one)
 A. hypertension 
 B. pyelonephritis 
 C. collagen vascular disease 
 D. dehydration 
 E. hypersensitivity to medications

Answer 9

hypersensitivity to medications

Approximately 85% of cases of acute interstitial nephritis result from a drug-related hypersensitivity reaction; other cases are due to mechanisms such as an immunologic response to infection or an idiopathic immune syndrome. Hypertension and dehydration do not cause interstitial nephritis. Medications that most commonly cause acute interstitial nephritis through hypersensitivity reactions include penicillins, sulfa drugs, and NSAIDs.
Urinalysis typically reveals moderate to minimal proteinuria, except in NSAID-induced acute interstitial nephritis, in which proteinuria may reach the nephrotic range. Other typical findings include sterile pyuria, the absence of red blood cell casts, and frequently eosinophiluria, but none of these findings is pathognomonic. Withdrawal of the causative agent leads to resolution of the problem within 7–10 days in the majority of cases, and most patients have a good recovery.

Question 10

A 24-year-old female has noted excessive hair loss over the past 2 months, with a marked increase in hairs removed when she brushes her hair. She delivered a healthy baby 5 months ago. She is on no medications, and is otherwise healthy. Examination of her scalp reveals diffuse hair thinning without scarring. An evaluation for thyroid dysfunction and iron deficiency is negative.
Which one of the following is the most likely cause of her hair loss?

Answer 10

Telogen effluvium

The recycling of scalp hair is an ongoing process, with the hair follicles rotating through three phases. The actively growing anagen-phase hairs give way to the catagen phase, during which the follicle shuts down, followed by the resting telogen phase, during which the hair is shed. The normal ratio of anagen to telogen hairs is 90:10.
This patient most likely has a telogen effluvium, a nonscarring, shedding hair loss that occurs when a stressful event, such as a severe illness, surgery, or pregnancy, triggers the shift of large numbers of anagen-phase hairs to the telogen phase. Telogen-phase hairs are easily shed. Telogen effluvium occurs about 3 months after a triggering event. The hair loss with telogen effluvium lasts 6 months after the removal of the stressful trigger.

Anagen effluvium is the diffuse hair loss that occurs when chemotherapeutic medications cause rapid destruction of anagen-phase hair. Alopecia areata, which causes round patches of hair loss, is felt to have an autoimmune etiology. Female-pattern hair loss affects the central portion of the scalp, and is not associated with an inciting trigger or shedding. Discoid lupus erythematosus causes a scarring alopecia.