Test 58

Question 1

Premenstrual syndrome

Answer 1

The lifetime risk of a psychiatric disorder in patients with premenstural syndrome approaches 80%. These include primarily mood and anxiety disorders.

Question 2

Carbon monoxide poisoning

Answer 2

Acute carbon monoxide poisoning often causes headache, malaise, nausea, and dizziness; more severe cases may present with seizure, syncope, coma, and/or myocardial ischemia. Diagnosis requires arterial blood gas analysis with carboxyhemoglobin level measured by co-oximetry. Pulse oxymetry cannot diagnose carbon monoxide poisoning (no differentiation between carboxyhemoglobin and oxyhemoglobin).

Question 3

Vulvovaginitis

Answer 3

Diagnostic criteria for bacterial vaginitis include a thin, homogenous vaginal discharge; an amine odor after application of potassium hydroxide; the presence of clue cells on wet mount microscopy; and a vaginal pH >4.5. Treatment is metronidazole or clindamycin.

Question 4

Vulvovaginitis

Answer 4

Bacterial vaginosis in pregnancy is associated with an increased risk for obstetric complications (spontaneous abortion, preterm labor). However, there is insufficient evidence that treatment (metronidazole) decreases the incidence of these complications; therefore, the primary purpose of treatment is symptom relief.

Question 5

Osteoporosis

Answer 5

Bisphosphates can cause hypocalcemia due to decreased bone resorption. A normal serum calcium level should be confirmed prior to initiation of therapy. In addition, vitamin D deficiency can increase the risk of hypocalcemia; total body vitamin D stores should be assessed with a serum 25-hydroxyvitamin D level.

Question 6

Lyme disease

Answer 6

Lyme disease is transmitted by the Ixodes tick after 36-48 hours of attachment. Patients with tick attachment <36 hours or with unengorged ticks are at low risk for Lyme disease. Tick saliva may cause cutaneous irritation several hours after tick removal; this should not be confused with erythema migrans, which takes >3 days to develop.

Question 7

Thyroid cancer

Answer 7

Thyroid lymphoma usually presents as rapid enlargement of the thyroid gland in patients with Hashimoto’s thyroiditis. Pemberton’s sign is the presence of facial plethora or neck vein distention when the arms are raised and confirms an enlarged thyroid gland as the cause of esophageal obstructive symptoms.

Question 8

Power and sample size

Answer 8

The power of a study is the ability to detect the difference between 2 groups (treated vs nontreated, exposed versus nonexposed). Increasing the sample size increases the power of a study. As a result, the confidence interval of the point estimate (odds ratio) becomes narrower.

Question 9

Myocardial infarction

Answer 9

Acute inferior wall MI often causes sinus bradycardia due to an increase in vagal tone triggered by SA and right ventricular wall ischemia. IV atropine is the initial treatment of choice in patients with hemodynamically significant bradycardia (PE, hypotension) due to inferior wall MI.

Question 10

Atopic dermatitis

Answer 10

Eczema herpeticum is a herpes simplex virus infection associated with atopic dermatitis. Lesions present as painful vesicles that evolve into “punched-out” erosions with hemorrhagic crusting. Disseminated disease (keratitis, hepatitis) is a complication, and systemic antiviral therapy (acyclovir) should be initiated immediately.

Question 11

Increased intracranial pressure

Answer 11

Pseudotumor cerebri most commonly occurs in obese women of childbearing age. It is also thought to occur secondary to endocrine disorders and the usage of some medications, including the acne treatments isotretinoin and minocycline.

Question 12

Anthracycline cardiotoxicity

Answer 12

Radionuclide ventriculography has high accuracy and reproducibility for measuring ejection fractions. Its most common use is in the initial evaluation and subsequent follow-up of patients receiving cardiotoxic chemotherapy agents such as doxorubicin.

Question 13

Hypothyroidism

Answer 13

Patients with coronary artery disease are at risk of myocardial ischemia when levothyroxine is first started and the medication should be started very slowly in these patients. Hypothyroidism (in the absence of myxedema coma or other severe symptoms) usually only mildly increases the perioperative risk.

Question 14

Dilated cardiomyopathy

Answer 14

Patients with a history of peripartum cardiomyopathy are at risk of recurrence, further left ventricular (LV) function decline, and death in subsequent pregnancies. The risk is stratified based on LV function at diagnosis and current LV function as assessed by transthoracic echocardiogram.

Question 15

Urethritis

Answer 15

Patients with nongonococcal urethritis frequently have continued symptoms after azithromycin therapy due to reinfection, resistance, or infection with an organism (Mycoplasma genitalium) not susceptible to azithromycin. Patients should receive repeat urethral gram stain and nucleic acid amplification testing of the urine for common urethritis organisms to identify the best next treatment.

Question 16

Health care policy and economics

Answer 16

Copays (fees paid by the patient to each service) can deter patients from seeking needed care. However, routine waiver of copays for patients with insurance constitutes a misrepresentation of the charges collected by the practice, violates the contract between the insurance plan and physician, and is a form of insurance fraud.

Question 17

Keratosis pilaris

Answer 17

Keratosis pilaris is characterized by retained keratin plugs in the hair follicles. It presents with small papules; a roughened skin texture; and mottled, perifollicular erythema, most commonly on the posterior surface of the upper arm. Treatment included emollients and topical keratolytics (salicylic acid, urea).