Quiz 60 Flashcards
A 25-year-old male who came to your office for a pre-employment physical examination is found to have 2+ protein on a dipstick urine test. You repeat the examination three times within the next month and results are still positive. Results of a 24-hour urine collection show protein excretion of <2 g/day and normal creatinine clearance. As part of his further evaluation you obtain split urine collections with a 16-hour daytime specimen containing an increased concentration of protein, and an 8-hour overnight specimen that is normal.
Additional appropriate evaluation for this man’s problem at this time includes which one of the following?
No specific additional testing
Persons younger than 30 years of age who excrete less than 2 g of protein per day and who have a normal creatinine clearance should be tested for orthostatic proteinuria. This benign condition occurs in about 3%–5% of adolescents and young adults. It is characterized by increased protein excretion in the upright position, but normal protein excretion when the patient is supine. It is diagnosed using split urine collections as described in the question. The daytime specimen has an increased concentration of protein, while the nighttime specimen contains a normal concentration. Since this is a benign condition with normal renal function, no further evaluation is necessary
A 50-year-old male is brought to the emergency department because of a syncopal episode.Prior to the episode, he felt bad for 30 minutes, then developed nausea followed by vomiting. During a second bout of vomiting he blacked out and fell to the floor. His wife did not observe any seizure activity, and he was unconscious only for a few seconds. His history is otherwise negative, his past medical history is unremarkable, and he currently takes no medications. A physical examination is normal.
Which one of the following would be the most helpful next step?
(check one)
A. CT of the head
B. Carotid ultrasonography
C. A CBC and complete metabolic profile
D. Echocardiography
E. An EKG
An EKG
The workup of patients with syncope begins with a history and a physical examination to identify those at risk for a poor outcome. Patients who have a prodrome of 5 seconds or less may have a cardiac arrhythmia. Patients with longer prodromes, nausea, or vomiting are likely to have vasovagal syncope, which is a benign process. Patients who pass out after standing for 2 minutes are likely to have orthostatic hypotension. In most cases, the recommended test is an EKG. If the EKG is normal, dysrhythmias are not a likely cause of the syncopal episode. Laboratory testing and advanced studies such as CT or echocardiography are not necessary unless there are specific findings in either the history or the physical examination.
In a patient presenting with unstable angina, which one of the following findings would denote
the highest risk for death or myocardial infarction?
(check one)
A. New-onset angina beginning 2 weeks to 2 months before presentation
B. Angina with hypotension
C. Angina provoked at a lower threshold than in the past
D. Increased anginal frequency
Unstable angina patients at high risk include those with at least one of the following:
• Angina at rest with dynamic ST-segment changes ³1 mm
• Angina with hypotension
• Angina with a new or worsening mitral regurgitation murmur
• Angina with an S3 or new or worsening crackles
• Prolonged (>20 min) anginal pain at rest
• Pulmonary edema most likely related to ischemia
When a screening test identifies a cancer earlier, thereby increasing the time between diagnosis and death without prolonging life, this is called
lead-time bias
Lead-time bias is when a screening test identifies a cancer earlier, thereby increasing the time between diagnosis and death without actually prolonging life. Length-time bias is when a screening test finds a disproportionate number of cases of slowly progressive disease and misses the aggressive cases, thereby leading to an overestimate of the effectiveness of the screening.
Attributable risk is the amount of difference in risk for a disease that can be accounted for by a specific risk factor.
A 42-year-old white female presents to your office as a new patient. She states that she has an 8-year history of abdominal cramps and diarrhea. Her symptoms have not responded to the usual treatments for irritable bowel syndrome. She has no rectal bleeding, anemia, weight loss, or fever, and no family history of colon cancer. Her medical history and a review of symptoms is otherwise negative, and a physical examination is normal. Which one of the following would be the most appropriate next step in evaluating this patient? (check one) A. A CBC B. A TSH level C. A complete metabolic panel D. Serologic testing for celiac sprue E. Stool testing for ova and parasites
In patients who have symptoms of irritable bowel syndrome (IBS), the differential diagnosis includes celiac sprue, microscopic and collagenous colitis, atypical Crohn’s disease for patients with diarrhea-predominant IBS, and chronic constipation (without pain) for those with constipation-predominant IBS. If there are no warning signs, laboratory testing is warranted only if indicated by the history.
During a comprehensive health evaluation a 65-year-old African-American male reports mild, very tolerable symptoms of benign prostatic hyperplasia, rated as a score of 7 on the American Urological Association Symptom Index. He has never smoked, and his medical history is otherwise unremarkable. Objective findings include an enlarged prostate that is firm and nontender, with no nodules. A urinalysis is normal and his prostate-specific antigen level is 1.8ng/mL.
Based on current evidence, which one of the following treatment options is most appropriate at this time?
(check one)
A. Observation, with repeat evaluation in 1 year
B. Saw palmetto
C. An α-receptor antagonist
D. A 5-α-reductase inhibitor
Watchful waiting with annual follow-up is appropriate for men with mild benign prostatic hyperplasia (BPH). Prostate-specific antigen (PSA) levels correlate with prostate volume, which may affect the treatment of choice, if indicated (SOR C). PSA levels >2.0 ng/mL for men in their 60s correlate with a prostatic volume >40 mL. This patient’s PSA falls below this level. In men with a prostatic volume >40 mL, 5 -reductase inhibitors should be considered for treatment (SOR A). -Blockers provide symptomatic relief in men whose disease has progressed to the point that they have moderate to severe BPH symptoms (SOR A). A recent high-quality, randomized, controlled trial found no benefit from saw palmetto with regard to symptom relief or urinary flow after 1 year of therapy. The American Urological Association does not recommend the use of phytotherapy for BPH. Surgical consultation is appropriate when medical therapy fails or the patient develops refractory urinary retention, persistent hematuria, or bladder stones.
A 47-year-old female presents with progressive difficulty hearing. She is employed as an office worker, has no significant past medical history, and takes no medications. Physical examination shows no gross abnormalities of her outer ears. The external ear canals are free of cerumen, and the tympanic membranes move well to insufflation. Weber’s test and the Rinne test have results that are compatible with a conductive hearing loss.
Which one of the following is the most likely cause of this patient’s hearing loss?
Otosclerosis typically presents between the third and fifth decades, and is more common in women. The chief feature of otosclerosis is a progressive conductive hearing loss. Occasionally, when lesions impinge on the stapes footplate, a sensorineural loss may occur. All of the other choices are exclusively sensorineural in character. Meniere’s disease also causes fluctuating hearing loss. Noise-induced hearing loss frequently and characteristically is accompanied by tinnitus. Perilymphatic fistula is associated with sudden unilateral hearing loss with tinnitus and vertigo. Acoustic neuroma is associated with tinnitus and gradual hearing impairment.
