Quiz 61

Question 1

A 35-year-old male consults you about a vague chest pain he developed while sitting at his desk earlier in the day. The pain is right-sided and was sharp for a brief time when it began, but it rapidly subsided. There was no hemoptysis and the pain does not seem pleuritic. His physical examination, EKG, and oxygen saturation are unremarkable. A chest film shows a 10% right pneumothorax. Which one of the following is true in this situation?

Answer 1

The majority of patients presenting with spontaneous pneumothorax are tall, thin individuals under 40 years of age. Most do not have clinically apparent lung disease, and the chest pain is sometimes minimal at onset and may resolve within 24 hours even if untreated. Patients with small pneumothoraces involving less than 15% of the hemithorax may have a normal physical examination, although tachycardia is occasionally noted. The diagnosis is confirmed by chest radiographs. Studies of recurrence have found that an average of 30% of patients will have a recurrence within 6 months to 2 years. The treatment of an initial pneumothorax of less than 20% may be monitored if a patient has few symptoms. Follow-up should include a chest radiograph to assess stability at 24–48 hours. Indications for treatment include progression, delayed expansion, or the development of symptoms. The majority of patients with spontaneous pneumothoraces, and perhaps almost all of them, will have subcutaneous bullae on a CT scan.

Question 2

A 45-year-old male is hospitalized for the management of alcohol withdrawal syndrome. His
symptoms include tachycardia, diaphoresis, tremors, and visual hallucinations. His CIWA-Ar
(Clinical Institute Withdrawal Assessment for Alcohol, Revised) score is 18, indicating moderate
alcohol withdrawal.

Which one of the following medications has been shown to reduce the risk of developing
seizures in this situation?

Answer 2

Lorazepam (Ativan)

Benzodiazepines play a key role in the management of alcohol withdrawal syndrome (AWS), especially
as they are highly effective in the prevention and treatment of seizures associated with this syndrome. In
general, nonbenzodiazepine anticonvulsants are not effective for preventing seizures in patients with AWS.
Therefore, their use is not recommended in those at risk for seizures or those who have a CIWA-Ar score
in the moderate or severe range. The potential for abuse with these agents is much lower than with
benzodiazepines, and they are preferred over benzodiazepines for outpatient management of AWS,
especially in those with a past history of substance abuse. Carbamazepine and valproic acid may be
effective for managing the symptoms associated with AWS. Gabapentin has been shown to be as effective
as lorazepam in treating AWS and reducing alcohol use during withdrawal. Phenytoin is not effective for
the treatment or prevention of seizures associated with AWS

Question 3

This patient appears to be experiencing sepsis syndrome due to urinary infection. The renal failure that has resulted is almost certainly due to low perfusion of the kidneys (prerenal azotemia).

What do you do?

Answer 3

High-rate intravenous normal saline

Metabolic acidosis will likely reverse with appropriate hydration, and sodium bicarbonate should be reserved for severe acidosis (<10–15 mmol/L) or for those with chronic kidney disease

Intravenous furosemide is contraindicated.

Question 4

1. First-line agents for the treatment of hirsutism in patients with PCOS
2. Firstline agents for ovulation induction and treatment of infertility in patients with PCOS

Answer 4

1. spironolactone, metformin, and eflornithine
2. metformin and clomiphene, alone or in combination with rosiglitazone

Oral contraceptives would improve the patient’s menstrual irregularities and hirsutism, but she wishes to become pregnant.

Question 5

Which one of the following drugs would be the most appropriate empiric therapy for nursing home–acquired pneumonia in a patient with no other underlying disease?

Answer 5

Levofloxacin (Levaquin)

The major concern with regard to pneumonia in the nursing-home setting is the increased frequency of oropharyngeal colonization by gram-negative organisms.

Question 6

He has been treated with SSRIs, SNRIs, and atypical antipsychotics in high doses and in various combinations without significant improvement.

Which one of the following would be most likely to improve this patient’s depression at this point?
  (check one)
 A. Cognitive-behavioral therapy 
 B. Psychoanalysis 
 C. Electroconvulsive therapy 
 D. Goal-directed psychotherapy 
 E. Limbic stimulation

Answer 6

Electroconvulsive therapy has been shown to be more effective than psychiatric therapy, pharmacologic therapy, and other interventions in depressed older patients.

Question 7

A 55-year-old obese male with hypertension and daytime somnolence is found to have severe obstructive sleep apnea, with an apnea-hypopnea index of 32 on an overnight polysomnogram.
Which one of the following is considered to be first-line therapy for this patient’s condition?

Answer 7

Patients with severe sleep apnea (apnea-hypopnea index >29) and concomitant cardiovascular disease benefit the most from treatment for obstructive sleep apnea. Because it is relatively easy to implement and has proven efficacy, continuous positive airway pressure (CPAP) is considered first-line therapy for severe apnea.