Quiz13 Flashcards
A U.S. Preventive Services Task Force “D” recommendation indicates
A “D” recommendation means the U.S. Preventive Services Task Force (USPSTF) recommends against
the service. There is moderate or high certainty that the service has no net benefit or that the harms
outweigh the benefits. An “I” recommendation means the USPSTF concludes that the evidence is lacking,
of poor quality, or conflicting, and the balance of benefits and harms cannot be determined. A “C”
recommendation means the USPSTF recommends selectively offering or providing this service to
individual patients based on professional judgment and patient preferences. There is at least moderate
certainty that the net benefit is small. A “B” recommendation means the USPSTF recommends the service.
There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit
is moderate to substantial. An “A” recommendation means the USPSTF recommends the service and there
is high certainty that the net benefit is substantial. The highest levels of evidence and most recent evidence
available are used by the USPSTF in making all of its recommendations.
A 24-year-old gravida 2 para 1 at 9 weeks gestation sees you for a routine prenatal check. She
complains of significant nausea, and recommended dietary modifications have not helped. She
drives a school bus so she would like to avoid sedating medications.
Nearly 75% of pregnant women are affected by nausea and vomiting of pregnancy. Though dietary
modifications are often recommended, there is little evidence to support their use. Vitamin B6 is
recommended as first-line therapy. It is safe to use in the first trimester and is associated with less
drowsiness compared with other medications.
Scopolamine is effective for nausea and vomiting of pregnancy but should be avoided in the first trimester
due to the possibility of causing trunk and limb deformities. Likewise, methylprednisolone is also effective
but should be avoided in the first trimester as it is associated with an increased risk of cleft palate if used
before 10 weeks of gestation. Auricular acupressure has been found to be ineffective.
Dental procedure. Ppx for endocarditis
According to the American Heart Association’s 2007 guidelines, prophylaxis to prevent bacterial endocarditis associated with dental, gastrointestinal, or genitourinary procedures is now indicated only for high-risk patients with prosthetic valves, a previous history of endocarditis, unrepaired cyanotic congenital heart disease (CHD), or CHD repaired with prosthetic material, and for cardiac transplant recipients who develop valvular disease.
Based on a risk-benefit analysis in light of available evidence for and against antibiotic prophylaxis, these
recommendations specifically exclude mitral valve prolapse and acquired valvular disease, even if they are
associated with mitral regurgitation. The American Dental Association has endorsed this guideline.
overweight
She has a total cholesterol level of 251 mg/dL, an
HDL-cholesterol level of 31 mg/dL, and a triglyceride level of 1250 mg/dL. The
LDL-cholesterol level could not be calculated and measured 145 mg/dL.
Treatment of hypertriglyceridemia depends on its severity. Contributing factors include a sedentary
lifestyle, being overweight, excessive alcohol intake, type 2 diabetes mellitus, and genetic disorders.
Triglyceride levels of 150–199 mg/dL are considered mild hypertriglyceridemia, levels of 200–999 mg/dL
are moderate, 1000–1999 mg/dL are severe, and levels >2000 mg/dL are considered very severe. Patients
with hypertriglyceridemia in the mild to moderate range may be at risk for cardiovascular disease, but
those who have severe or very severe hypertriglyceridemia have a significant risk of pancreatitis.
In addition to having the patient exercise, reduce intake of fat and carbohydrates, and lose weight, she
should also be counseled to avoid alcohol. For patients at risk for pancreatitis, fibrates are recommended
as the initial treatment for pancreatitis. It should be noted that statins may have a modest
triglyceride-lowering effect and may be helpful in decreasing cardiovascular risk in those who have
moderately elevated triglycerides. However, they should not be used alone in patients who have severe
hypertriglyceridemia. Studies have also shown that while omega-3 fatty acids decrease triglycerides and
very low density lipoprotein cholesterol levels, they may increase LDL-cholesterol levels. Treatment with
omega-3 fatty acids does not decrease total mortality or cardiovascular events, and therefore is not
recommended.
Niacin does seem to have the advantage of raising HDL cholesterol and lowering LDL cholesterol, but it
has never been proven in clinical trials to have benefit with regard to the primary outcome of
cardiovascular disease, and some trials have shown significant increases in adverse events.
A 30-year-old female stepped off a curb earlier today and twisted her left ankle. She was able
to bear weight immediately following the injury and tried to continue her normal routine, but the
pain in her ankle and foot increased over the next few hours.
She comes to your office and your examination reveals swelling of the ankle and bruising of the
lateral foot. Tenderness to palpation is present over the distal aspect of the fibula and lateral
malleolus and to a lesser degree over the proximal fifth metatarsal. No bony tenderness is
present along the medial aspect of the ankle or foot.
According to the Ottawa Ankle Rules, which one of the following would be most appropriate
at this point?
Radiographs of the ankle and foot
The Ottawa Ankle Rules are widely accepted guidelines for appropriate evaluation of ankle and midfoot
injuries occurring in adults age 19 or older presenting for the first time in a clinical setting. The guidelines
utilize the historical and physical findings to determine which radiographic studies, if any, are indicated.
Patients who were able to bear weight immediately following their injury and who can take 4 steps
independently in a clinical setting require radiographic study only when the following criteria are met: pain
is present in the malleolar zone and bony tenderness of the posterior edge or tip of either malleolus is
elicited (ankle radiograph), or pain is present in the midfoot zone and bony tenderness of either the base
of the fifth metatarsal or the navicular region is present.
severity of anorexia nervosa
According to the DSM-5, the level of severity of anorexia nervosa is based on the patient’s body mass
index (BMI). Mild is a BMI >17.0 kg/m2, moderate is a BMI of 16.0–16.99 kg/m2, severe is a BMI of
15.0–15.9 kg/m2, and extreme is a BMI <15.0 kg/m2. Recurrent episodes of binge eating or purging
behavior help differentiate restricting type from binge-eating/purging type, but do not indicate severity.
Orthostatic changes in pulse or blood pressure and refusal to eat are criteria for inpatient hospitalization,
but are not part of the classification of severity according to the DSM-5. Amenorrhea can be a clinical sign
of anorexia nervosa but is not part of the classification of severity.
A 45-year-old male with diabetes mellitus returns to your office for follow-up. He is on
metformin (Glucophage), 1000 mg/day, as well as atorvastatin (Lipitor), 40 mg daily for
hyperlipidemia. There is no diagnosis of hypertension, and his blood pressure at today’s visit
is 120/70 mm Hg. Laboratory results include a hemoglobin A1c of 6.4% and an LDL-cholesterol
level of 105 mg/dL. His urine albumin/creatinine ratio is in the microalbuminuric range for the
first time.
A repeat urine albumin/creatinine ratio
This normotensive diabetic patient, appropriately screened for microalbuminuria, should have this finding
confirmed on at least one of two additional spot tests, since temporary factors other than nephropathy can
also result in microalbuminuria. Once a diagnosis of chronic kidney disease is confirmed, renal
ultrasonography should be ordered to detect potentially reversible causes.
A 24-hour urine is not necessary since the urine microalbumin/creatinine ratio correlates well with a
24-hour urine for albumin. Metformin is not contraindicated in the presence of microalbuminuria alone
without a decline in the glomerular filtration rate. The patient is already on high-intensity statin therapy
and there is no specific indication to increase the statin dosage based on his current LDL-cholesterol level
since treatment to the target LDL-cholesterol goal has fallen out of favor.
Which one of the following comorbid conditions increases the risk that latent tuberculosis
infection will progress to active disease
Risk factors for progression from latent to active tuberculosis include lung cancer, diabetes mellitus,
alcoholism, recent contact with a person who has an active tuberculosis infection, any condition treated
with immunosuppressive therapy, and lung parenchymal diseases such as COPD, silicosis, or lung cancer.
The medically underserved and those in low-income groups are also more at risk of progression, as well
as children under age 5 and individuals weighing less than 90% of their ideal minimum body weight.
Which one of the following immunizations is indicated for all pregnant women at any stage of
pregnancy?
Influenza vaccine is indicated for all pregnant women, and there are no known deleterious effects on the
course of pregnancy or the fetus. Women are advised to avoid pregnancy for 28 days after receiving MMR
or varicella vaccines. HPV vaccine is not recommended during pregnancy.
methimazole
Approximately 0.3% of patients taking methimazole develop agranulocytosis, usually within the first 60
days of starting therapy. Other rare complications of methimazole include serum sickness, cholestatic
jaundice, alopecia, nephrotic syndrome, hypoglycemia, and loss of taste. It is associated with an increased
risk of fetal anomalies, so propylthiouracil (PTU) is preferred in pregnancy. The other medications listed
are not known to cause the combination of agranulocytosis and cholestatic jaundice that this patient has.
