Quiz 57 Flashcards
A 68-year-old African-American male with a history of hypertension and heart failure continues to have shortness of breath and fatigue after walking only one block. He has normal breath sounds, no murmur, and no edema on examination. His current medications include furosemide (Lasix), 20 mg/day, and metoprolol extended-release (Toprol-XL), 50 mg/day. He previously took lisinopril (Prinivil, Zestril), but it was discontinued because of angioedema. A recent echocardiogram showed an ejection fraction of 35%. Which one of the following would be most likely to improve both symptoms and survival in this patient? (check one) A. Valsartan (Diovan) B. Metolazone (Zaroxolyn) C. Digoxin D. Verapamil (Calan, Isoptin) E. Isosorbide/hydralazine (BiDil)
In patients with systolic heart failure, the usual management includes an ACE inhibitor and a ß-blocker. Since this patient had angioedema with an ACE inhibitor, an angiotensin receptor blocker may cause this side effect as well. Adding metolazone is generally not necessary unless the patient has volume overload that does not respond to increased doses of furosemide. Digoxin may improve symptoms, but has not been shown to increase survival. For patients who cannot tolerate an ACE inhibitor, especially African-Americans, a combination of direct-acting vasodilators such as isorbide and hydralazine is preferred.Verapamil has a negative inotropic effect and should not be used.
A 70-year-old white female comes to your office for an initial visit. She has taken levothyroxine (Synthroid), 0.3 mg/day, for the last 20 years. Although a recent screening TSH was fully suppressed at <0.1 μU/mL, she claims that she has felt “awful” when previous physicians have attempted to lower her levothyroxine dosage. You explain that a serious potential complication of her current thyroid medication is: (check one) A. adrenal insufficiency B. carcinoma of the ovary C. carcinoma of the thyroid D. hip fracture E. renal failure
Women older than 65 years of age who have low serum TSH levels, indicating physiologic hyperthyroidism, are at increased risk for new hip and vertebral fractures. Use of thyroid hormone itself does not increase the risk of fracture if TSH levels are normal.
A 34-year-old white male letter carrier has developed progressively worsening dysphagia for liquids and solids over the past 3 months. He says that he has lost about 30 lb during that time. On examination, you note that he is emaciated and appears ill. His pulse rate is 98 beats/min, temperature 37.8°C (100.2°F), respiratory rate 24/min, and blood pressure 95/60 mm Hg. His weight is 45 kg (99 lb) and his height is 170 cm (67 in). His dentition is poor, and there is evidence of oral thrush. His mucous membranes are dry.
You palpate small posterior cervical and axillary nodes. The heart, lung, and abdominal examinations are normal. You promptly consult a gastroenterologist, who performs upper endoscopy, which reveals numerous small ulcers scattered throughout the esophagus with otherwise normal mucosa.
As you continue to investigate, you take a more detailed history. Which one of the following is most likely to be related to the patient’s problem?
Intravenous drug use
A young man with weight loss, oral thrush, lymphadenopathy, and ulcerative esophagitis is likely to have HIV infection. Intravenous drug use is responsible for over a quarter of HIV infections in the United States. Esophageal disease develops in more than half of all patients with advanced infection during the course of their illness. The most common pathogens causing esophageal ulceration in HIV-positive patients include Candida, herpes simplex virus, and cytomegalovirus. Identifying the causative agent through culture or tissue sampling is important for providing prompt and specific therapy.
A 4-year-old male presents with a 3-day history of sores on his right leg. The sores began as small red papules but have progressed in size and now are crusting and weeping. Otherwise he is in good health and is up to date with immunizations.
On examination he has three lesions on the right anterior lower leg that are 0.5–1.5 cm in diameter, with red bases and honey-colored crusts. There is no regional lymphangitis or lymphadenitis.
Which one of the following is the preferred first-line therapy?
The lesions described are nonbullous impetigo, due to either Staphylococcus aureus or Streptococcus pyogenes. Topical antibiotics, such as mupirocin, but not compounds containing neomycin, are the preferred first-line therapy for impetigo involving a limited area
A 29-year-old female presents with redness of her left eye. She has just returned from a summer
beach vacation with her children and woke up with a red eye. Your examination reveals a watery
discharge, a hyperemic conjunctiva, and a palpable preauricular lymph node. Her cornea is clear
on fluorescein staining.
Which one of the following is most appropriate for this patient? (check one) A. Reassurance only B. Culture-guided antibiotic therapy C. Quinolone eyedrops D. Corticosteroid/antibiotic eyedrops E. Urgent ophthalmologic referral
Viruses cause 80% of infectious conjunctivitis cases and viral conjunctivitis usually requires no treatment.
Bacterial conjunctivitis is associated with mattering and adherence of the eyelids. Topical antibiotics reduce
the duration of bacterial conjunctivitis but have no effect on viral conjunctivitis. Allergic conjunctivitis
would be more likely if the patient reported itching. Antibiotics or corticosteroids would not be helpful in
this patient, and would not prevent complications.
The majority of cases of viral conjunctivitis are caused by adenoviruses, which cause pharyngeal
conjunctival fever and epidemic keratoconjunctivitis. Pharyngeal conjunctival fever is characterized by high
fever, pharyngitis, and bilateral eye inflammation. Keratoconjunctivitis occurs in epidemics, and is
associated with a watery discharge, hyperemia, and ipsilateral lymphadenopathy in >50% of cases.
Fibromyalgia is characterized by tender trigger points (check one)
A. along the medial border of each scapula
B. bilaterally at the anatomic snuffbox
C. at the insertion of the Achilles tendon into the posterior heel
D. at the second and third web spaces on the plantar surface of the foot
The typical fibromyalgia trigger points lie along the medial scapula borders, as well as the posterior neck, upper outer quadrants of the gluteal muscles, and medial fat pads of the knees. Tenderness of the anatomic snuffbox, Achilles tendons, or web spaces of the toes would most likely be related to another diagnosis.
A 47-year-old female presents to your office with a complaint of hair loss. On examination she has a localized 2-cm round area of complete hair loss on the top of her scalp. Further studies do not reveal an underlying metabolic or infectious disorder.
Which one of the following is the most appropriate initial treatment?
(check one)
A. Topical minoxidil (Rogaine)
B. Topical immunotherapy
C. Intralesional triamcinolone (Kenalog)
D. Oral finasteride (Proscar)
E. Oral spironolactone (Aldactone)
Intralesional triamcinolone
These findings are consistent with alopecia areata, which is thought to be caused by a localized autoimmune reaction to hair follicles. It occasionally spreads to involve the entire scalp (alopecia totalis) or the entire body (alopecia universalis). Spontaneous recovery usually occurs within 6–12 months, although areas of regrowth may be pigmented differently. Recovery is less likely if the condition persists for longer than a year, worsens, or begins before puberty. The initial treatment of choice for patients older than 10 years of age, in cases where alopecia areata affects less than 50% of the scalp, is intralesional corticosteroid injections. Minoxidil is an alternative for children younger than 10 years of age or for patients in whom alopecia areata affects more than 50% of the scalp.
Which one of the following is a risk factor for intermittent claudication? (check one)
A. Hyperthyroidism
B. Hypercalcemia
C. Diabetes mellitus
D. Hypogonadism
E. Elevated angiotensin-converting enzyme
Diabetes mellitus and cigarette smoking are significant risk factors for intermittent claudication, as are hypertension and dyslipidemia.
