Quiz 58 Flashcards
A 52-year-old male requests “everything you’ve got” to help him stop smoking. You review common barriers to quitting and the benefits of cessation with him, and develop a plan that includes follow-up. He chooses to start varenicline (Chantix) to assist with his efforts, and asks about also using nicotine replacement.
Which one of the following would be accurate advice?
(check one)
A. Combining these medications has not proven to be beneficial
B. The addition of transdermal nicotine, but not nicotine gum, has proven benefits
C. The combination is highly efficacious
D. Nicotine replacement doses need to be doubled in a patient taking varenicline
E. The combination of nicotine and varenicline is potentially lethal
Combining these medications has not proven to be beneficial
Varenicline works by binding to nicotine receptors in the brain, providing much lower stimulation than nicotine itself would. This has the effect of reducing the reinforcement and reward that smoking provides to the brain. However, this medication also blocks the benefit a patient would receive from nicotine replacement products. Studies have shown that using nicotine replacement products concurrently with varenicline leads to an increase in nausea, headaches, dizziness, and fatigue.
Which one of the following is more likely to occur with glipizide (Glucotrol) than with metformin (Glucophage)? (check one) A. Lactic acidosis B. Hypoglycemia C. Weight loss D. Gastrointestinal distress
Metformin is a biguanide used as an oral antidiabetic agent. One of its main advantages over some other oral agents is that it does not cause hypoglycemia. Lactic acidosis, while rare, can occur in patients with renal impairment. In contrast to most other agents for the control of elevated glucose, which often cause weight gain, metformin reduces insulin levels and more frequently has a weight-maintaining or even a weight loss effect. Gastrointestinal distress is a common side effect of metformin, particularly early in therapy.
Typically, a high-grade squamous intraepithelial lesion (HSIL) of the cervix is treated with ablation or excision. In which one of the following can treatment be deferred? (check one)
A. Adolescents
B. Patients attempting to conceive
C. Patients with a history of three previous normal Papanicolaou smears
D. Patients with a negative DNA test for HPV
E. Patients over the age of 70
Patients attempting to conceive are not candidates for conservative management of cervical dysplasia, because treatment of progressive disease during pregnancy may be harmful. When possible, the problem should be resolved before conception. Patients who have had three normal Papanicolaou (Pap) smears in succession are candidates for lengthened screening intervals according to some recommendations. However, once a problem is found, they should be managed the same as other cases. A negative test for HPV can be used to assess the risk of patients with atypical squamous cells of undetermined significance (ASC-US) or a low-grade squamous intraepithelial lesion (LSIL); it does not change the management of patients with a high-grade intraepithelial lesion (HSIL). HPV infection is common and transient in most young women in their first few years of sexual activity. With careful follow-up, they can be observed rather than treated for HSIL. Patients over 70 years of age no longer require screening if they have a long history of normal Pap smears, but when an abnormality is found it should be treated.
A 14-year-old female is brought to your office by her parents because of concerns regarding her low food intake, excessive exercise, and weight loss. Her weight is less than 75% of ideal for her height.
Which one of the following sets of additional findings would indicate that the patient suffers from severe anorexia nervosa?
(check one)
A. Hypertension, tachycardia, and hyperthermia
B. Hypertension, tachycardia, and hypothermia
C. Hypotension, tachycardia, and hypothermia
D. Hypotension, bradycardia, and hyperthermia
E. Hypotension, bradycardia, and hypothermia
Characteristic vital signs in patients with severe anorexia nervosa include hypotension, bradycardia, and hypothermia. Criteria for hospital admission include a heart rate <40 beats/min, blood pressure <80/50 mm Hg, and temperature <36°C (97°F). Increased cardiac vagal hyperactivity is thought to cause the bradycardia.
A 55-year-old female has severe symptoms of gastroesophageal reflux disease. Upper endoscopy with a biopsy shows severe esophagitis and Barrett’s esophagus.
Which one of the following is true regarding this patient?
(check one)
A. The severity of her symptoms is due to the presence of Barrett’s esophagus
B. Follow-up screening endoscopy will reduce her risk of death from esophageal cancer
C. Her risk of developing esophageal adenocarcinoma is >90%
D. Her risk of developing esophageal adenocarcinoma is <1%
The actual risk of adenocarcinoma from Barrett’s esophagus is less than 1%. Endoscopy does nothing to reduce the risk of death. Patients with Barrett’s esophagus can have minimal symptoms.
A 45-year-old male presents with a complaint of recent headaches. He has had four headaches this week, and his description indicates that they are moderate to severe, bilateral, frontal, and nonthrobbing. There is no associated aura. He has had similar episodes of recurring headachesin the past. Based on this limited history, which one of the following headache types can be eliminated from the differential diagnosis? (check one) A. Tension-type headache B. Sinus headache C. Migraine headache D. Cluster headache E. Headache of intracranial neoplasm
Cluster headache can be removed from the differential because it is always unilateral, although the affected side can vary. The remainder of these headache types can be bilateral, frontal, and nonthrobbing. Brain tumor headaches may be similar in character to previous headaches, but are often more severe or frequent.
A 69-year-old female sees you for an annual examination. She asks you to look at her toes, and you note a fungal infection in five toenails. She says the condition is painful and limits her ability to complete her morning walks. She asks for treatment that will allow her to resume her daily walks as soon as possible. Her only other medical problem is allergic rhinitis which is well controlled. (check one)
A. Oral griseofulvin ultramicrosize (Gris-PEG) daily for 12 weeks
B. Oral terbinafine (Lamisil) daily for 12 weeks
C. Topical terbinafine (Lamisil AT) daily for 12 weeks
D. Topical ciclopirox (Penlac Nail Lacquer) daily for 12 weeks
E. Toenail removal
Correct.
Continuous therapy with oral terbinafine for 12 weeks has the highest cure rate and best long-term resolution rate of the therapies listed. Other agents and pulsed dosing regimens have lower cure rates. Topical creams are not appropriate for onychomycosis because the infection resides in the cell of the toenail. Antifungal nail lacquers have a lower cure rate than systemic therapy and should be used only when oral agents would not be safe. Toenail removal is reserved for patients with an isolated infected nail or in cases involving a dermatophytoma.
A 39-year-old female presents with a 4-month history of gradually worsening left elbow pain.
She does not recall an injury but frequently lifts and holds her 10-month-old son in her left arm.
She has tenderness over the lateral epicondyle. Her elbow range of motion is normal but she has
pain with supination and pronation. The remainder of the examination is normal.
For long-term pain relief, the best evidence supports which one of the following?
Expectant/conservative management
Lateral epicondylitis is a common condition characterized by degeneration of the extensor carpi radialis
muscle tendon originating in the lateral epicondyle. It is a self-limited condition and usually resolves within
12–18 months without treatment. It is not an inflammatory condition and anti-inflammatory agents have
not been found to be beneficial. Corticosteroid injections have been found to be associated with poor
long-term outcomes, as well as high recurrence rates. Neither physical therapy, bracing, nor splinting is
proven to provide long-term pain relief. Approximately 90%–95% of all patients with lateral epicondylitis
show improvement at 1 year despite the type of therapy utilized
An 80-year-old male presents with a 10-day history of intermittent colicky abdominal pain. The
pain is low and central and seems to be worse after eating. He has no associated fever or
vomiting but does feel nauseated when the pain is present. He says that prior to this episode he
had hard stools once or twice a week that were difficult to pass. For the past several days he has
had only watery stools, several times a day.
On examination there is fullness in his left lower quadrant with nonspecific tenderness diffusely
and no guarding or rebound. A urine dipstick is normal.
Which one of the following is the most likely diagnosis?
The Rome criteria define constipation as the presence of two or more of the following: straining on
defecation, hard stools, incomplete evacuation, or less than three bowel movements per week. This patient
has multiple symptoms on this list. The presence of watery bowel movements does not rule out the
diagnosis of constipation, as it is common for liquid stool to pass an obstructive source.
