Test 63

Question 1

Immunizations

Answer 1

Anaphylaxis or encephalopathy following diphtheria-tetanus-acellular pertussis vaccine is an absolute contraindication to receiving additional doses. Minor illnesses (fever 105 F), local site reactions, and immunosuppression are not contraindications.

Question 2

Dermatoses of pregnancy

Answer 2

The initial presentation of pemphigoid gestationis, a pregnancy-related autoimmune disease, is typically abdominal pruritus. After the pruritus, a rash develops around the umbilicus and trunk of urticarial papules and plaques that eventually form tense bullae. The mucous membranes are characteristically spared.

Question 3

Smoking cessation

Answer 3

Patients who are interested in cutting down on their smoking but are not committed to fully quit should be offered varenicline or nicotine replacement therapy to start immediately, even if they have not set a quit date. Both pharmacotherapies have been shown to increase long-term smoking abstinence.

Question 4

Physician patient communication

Answer 4

Accepting a longtime patient’s invitation to a significant life event does not violate ethical professional boundaries. Physicians must use professional judgement and cultural sensitivity in responding to social situations outside the professional relationship.

Question 5

Venous thromboembolism

Answer 5

Paradoxical emboli are those that originate in the venous system and enter the arterial system via an intracardiac shunt. They are a more common cause of stroke in the young than in the elderly. They can be diagnosed with an echocardiogram and bubble study.

Question 6

Prostate cancer

Answer 6

Prostate cancer is often indolent, and most men with prostate cancer die from other causes. Screening for prostate cancer with prostate-specific antigen can be considered for men age 55-69, but the absolute benefit is small. Screening is not recommended for those age <55 or greater than or equal to 70 with a life expectancy of <10 years.

Question 7

Pulmonary embolism

Answer 7

Hip fracture, recent surgery or immobilization, and smoking increase the risk of acute pulmonary embolism (PE), and PE can occur despite treatment with prophylactic heparin. In patients with impaired renal function, ventilation-perfusion scan is most appropriate to evaluate for acute PE; in the setting of likely pretest probability, a high-probability ventilation-perfusion scan confirms the diagnosis.

Question 8

Pulmonary embolism

Answer 8

Acute pulmonary embolism is estimated to cause fever in approximately 15% of cases; therefore, fever in these patients is not an indication for antibiotics in the absence of other evidence of infection (consolidation on chest x-ray, incisional purulence, peripheral line erythema, abnormal urinalysis).

Question 9

Osteoporosis

Answer 9

Age is the most important single risk factor for osteoporosis and osteoporotic bone fracture.

Question 10

Community acquired pneumonia

Answer 10

Recurrent pneumonia in an elderly smoker may be the first manifestation of bronchogenic carcinoma (endobronchial obstruction).

Question 11

Lung cancer

Answer 11

*The best diagnostic test for endobronchial obstructive lesions is flexible bronchoscopy. If the question had asked for the next best step in management, then the answer would have been CT scan.

Question 12

Endocarditis

Answer 12

Intravenous drug users are at increased risk for infective endocarditis that is most commonly right-sided and involves the tricuspid valve. Echocardiography (Transthoracic initially, followed by transesophageal if needed) is used for diagnosis.

Question 13

Hearing loss

Answer 13

Hearing loss due to presbycusis is one of the most frequent causes of social withdrawal and isolation in the elderly. It must be differentiated from depression and dementia. Screening can be accomplished through simple hearing tests performed in the office.

Question 14

COPD

Answer 14

COPD can present similarly to decompensated HF, which can be excluded in patients without evidence of intravascular volume overload (JVD). Because BNP is degraded by neprilysin, it is an unreliable marker of volume status in patients being treated with an angiotensin receptor-neprilysin inhibitor (sacubitril-valsartan).

Question 15

Cholecystitis

Answer 15

Acute cholecystitis typically presents with persistent right upper quadrant pain, fever, nausea, vomiting, and leukocytosis. Dx is confirmed when US reveals choleliths with gallbladder wall thickening or sonographic Murphy sign. If US is negative or inconclusive, a HIDA scan is the next diagnostic test of choice and is usually confirmatory.

Question 16

Hearing loss

Answer 16

Sudden hearing loss should be evaluated to determine if it is conductive or sensorineural. Sudden sensorineural hearing loss should be evaluated urgently by otolaryngology with a formal audiogram, MRI, and corticosteroid therapy.