Quiz 55 Flashcards
A 7-year-old Hispanic female has a 3-day history of a fever of 40.0°C (104.0°F), muscle aches, vomiting, anorexia, and headache. Over the past 12 hours she has developed a painless maculopapular rash that includes her palms and soles but spares her face, lips, and mouth. She has recently returned from a week at summer camp in Texas. Her pulse rate is 140 beats/min, and her blood pressure is 80/50 mm Hg in the right arm while lying down.
Which one of the following is the most likely diagnosis? (check one) A. Mucocutaneous lymph node syndrome B. Leptospirosis C. Rocky Mountain spotted fever D. Scarlet fever E. Toxic shock syndrome
Rocky Mountain spotted fever
While all of the diagnoses listed are in the differential, the most likely is Rocky Mountain spotted fever (RMSF) (SOR C). It occurs throughout the United States, but is primarily found in the South Atlantic and south central states. It is most common in the summer and with exposure to tall vegetation (e.g., while camping, hiking, or gardening), and is transmitted by ticks. The diagnosis is based on clinical criteria that include fever, hypotension, rash, myalgia, vomiting, and headache (sometimes severe). The rash associated with RMSF usually appears 2–4 days after the onset of fever and begins as small, pink, blanching macules on the ankles, wrists, or forearms that evolve into maculopapules. It can occur anywhere on the body, including the palms and soles, but the face is usually spared.
Mucocutaneous lymph node syndrome is a similar condition in children (usually <2 years old), but symptoms include changes in the lips and oral cavity, such as strawberry tongue, redness and cracking of the lips, and erythema of the oropharyngeal mucosa.
Leptospirosis is usually accompanied by severe cutaneous hyperesthesia.
The patient with scarlet fever usually has prominent pharyngitis and a fine, papular, erythematous rash.
Toxic shock syndrome may present in a similar fashion, but usually in postmenarchal females.
A 48-year-old male who weighs 159 kg (351 lb) is admitted to the hospital with a left leg deep vein thrombosis and pulmonary embolism. Treatment is begun with enoxaparin (Lovenox).
Which one of the following would be most appropriate for monitoring the adequacy of anticoagulation in this patient?
(check one)
A. Anti-factor Xa levels
B. Activated partial thromboplastin time (aPTT)
C. Daily INRs
D. Daily factor VIII levels
In severely obese patients (>330 lb) and those with renal failure, low molecular weight heparin therapy should be monitored with anti-factor Xa levels obtained 4 hours after injection. Most other patients do not need monitoring. The INR is used to monitor warfarin therapy, and the activated partial thromboplastin time (aPTT) is used to monitor therapy with unfractionated heparin.
Under current guidelines, hospice programs are most likely to serve patients dying from: (check one) A. heart failure B. COPD C. severe dementia D. multiple strokes E. cancer
The general requirement for enrolling an individual in hospice is that they have a terminal illness and an estimated life expectancy of 6 months or less. Given these criteria, it is not surprising that over 40% of hospice patients have a cancer diagnosis.
A healthy 48-year-old bookkeeper who works in a medical office has a positive PPD on routine yearly screening. Which one of the following would be most appropriate at this point? (check one)
A. A chest radiograph
B. A repeat PPD
C. Treatment with isoniazid and one other antituberculous drug for 12 months
D. Anergy testing
A chest radiograph
Clinical evaluation and a chest radiograph are recommended in asymptomatic patients with a positive PPD (SOR C). A two-step PPD is performed on those at high risk whose initial test is negative. Asymptomatic patients with a positive PPD and an abnormal chest film should have a sputum culture for TB, but a culture is not required if the chest film is negative. Persons with a PPD conversion should be encouraged to take INH for 9 months with proper medical supervision. Patients with a negative PPD who are still at high risk for TB, especially HIV-positive patients, could be evaluated for anergy, but it is not recommended at this time.
Which one of the following decreases the absorption of orally administered calcium supplements? (check one) A. Taking calcium carbonate with meals B. Taking calcium citrate with meals C. Vitamin D supplementation D. Proton pump inhibitors
Long-term histamine H2 -blocker or proton pump inhibitor use is associated with decreased absorption of calcium carbonate. Patients taking these medications who require calcium supplementation should use calcium citrate to improve absorption. Calcium carbonate preparations should be given with a meal to improve absorption. Vitamin D is important in calcium absorption.
A 16-year-old high-school football player plants his left foot to make a cut and feels his left leg give way. He feels a pop in the knee, followed by acute pain. He is evaluated on the field, and examination with the knee flexed 20° reveals that the tibia can be displaced farther anteriorly than with the uninvolved knee. Which one of the following conditions is most likely? (check one) A. Patellar tendon rupture B. Posterior cruciate ligament tear C. Anterior cruciate ligament tear D. Tibial plateau fracture E. Patellar dislocation
Anterior cruciate ligament tear
Approximately 50% of patients with this injury develop osteoarthritis in 10–20 years. Findings that help make the diagnosis of ACL tear include a noncontact mechanism of injury, an audible popping sound, early swelling of the joint, and the inability to participate in the game after the injury. Many patients can walk normally and can perform such straight-plane activities as climbing stairs, biking, or jogging.
Patients with patellar tendon rupture are unable to fully extend their knee and examination shows a palpable defect in the patellar ligament and a high-riding patella.
The mechanism of injury of tibial plateau fractures in a healthy young male generally involves a highenergy collision causing a valgus force with axial loading.
Patients with patellar dislocations have symptoms similar to those of an ACL injury, including an audible crack or pop and the feeling of the knee giving way after a twisting motion. Immediately following the injury, however, examination would show an obvious deformity, but the patella may spontaneously relocate prior to the on-field exam. There would be no instability on the Lachman maneuver.
The best available evidence supports which one of the following guidelines for discussing serious illnesses?
Physicians should delay having a detailed discussion with the patient about the expected prognosis of cancer until staging is completed
acute pericarditis.
Although the EKG findings appear specific for the early stages of pericarditis, myocardial infarction would also be included in the differential diagnosis. However, unlike with acute pericarditis, the EKG in myocardial infarction typically demonstrates ST elevation that is localized and convex, often has Q waves, and rarely shows PR-segment depression. A friction rub can be heard in up to 85% of patients with acute pericarditis. An echocardiogram is often performed to determine the type and amount of effusion. Conventional therapy for acute pericarditis includes NSAIDs, such as aspirin and ibuprofen. Recent studies demonstrate that adding colchicine to aspirin may be beneficial in reducing the persistence and recurrence of symptoms.
An otherwise healthy 37-year-old male presents to your office with a 2-week history of redness and slight irritation in his groin. On examination a tender erythematous plaque with mild scaling is seen in his right crural fold. The area fluoresces coral-red under a Wood’s light.
Which one of the following would be the most appropriate treatment at this time?
The characteristics of this lesion, including coral-red fluorescence under a Wood’s light, suggests Corynebacterium infection, which is associated with erythrasma. Tinea cruris caused by Microsporum infection fluoresces green, while intertrigo and tinea cruris caused by Epidermophyton or Trichophyton infections do not fluoresce. Erythromycin, either systemic or topical, is the treatment of choice.
An otherwise healthy 40-year-old male comes to your office for follow-up of elevated liver enzymes on an insurance examination. He is 173 cm (68 in) tall and weighs 113 kg (250 lb) (BMI 37.7 kg/m2). He says he drinks about two beers per week. Findings are normal on a physical examination, except for a slightly enlarged liver. AST and ALT levels are twice the upper limits of normal.
Which one of the following would be the most appropriate next step?
(check one)
A. A liver biopsy
B. Ultrasonography of the liver
C. Colonoscopy
D. Testing for viral hepatitis
E. Repeat AST and ALT levels in 3 months
Nonalcoholic fatty liver disease is the most likely diagnosis in this patient, but hepatitis B and C should be ruled out. The patient’s alcohol consumption of less than two drinks per week makes alcoholic fatty liver disease unlikely. A liver biopsy would not be appropriate at this time. Liver ultrasonography should be considered after hepatitis B and C are ruled out. The patient is younger than the recommended screening age for colonoscopy.
