AAFP 1 Flashcards

Question

Elevated levels of _________ are associated with atherosclerosis?

Answer 1

homocysteine Multiple prospective and case-control studies have shown that a moderately elevated plasma homocysteine concentration is an independent risk factor for atherothrombotic vascular disease.

Answer 2

Congestive heart failure Significant predictors of intraoperative and perioperative ventricular arrhythmias include preoperative ventricular (not supraventricular) ectopy, a history of congestive heart failure, and a history of cigarette smoking. Age and a history of hyperthyroidism are not significant predictors of perioperative ventricular arrhythmias.

Answer 3

Enoxaparin (Lovenox) should be administered at a dosage of 1 mg/kg subcutaneously twice a day The use of low-molecular-weight heparin allows patients with acute deep vein thrombosis (DVT) to be managed as outpatients. The dosage is 1 mg/kg subcutaneously twice daily. Patients chosen for outpatient care should have good cardiopulmonary reserve, normal renal function, and no risk for excessive bleeding. Oral anticoagulation with warfarin can be initiated on the first day of treatment after heparin loading is completed. Monotherapy with warfarin is inappropriate. The incidence of thrombocytopenia with low–molecular-weight heparin is lower than with conventional heparin. The INR should be maintained at 2.0–3.0 in this patient. The 2.5–3.5 range is used for patients with mechanical heart valves. The therapeutic INR should be maintained for 3–6 months in a patient with a first DVT related to travel.

Answer 4

Diaphoresis with feeding Symptoms of congestive heart failure in infants are often related to feedings. Only small feedings may be tolerated, and dyspnea may develop with feedings. Profuse perspiration with feedings, is characteristic, and related to adrenergic drive. Older children may have symptoms more similar to adults, but the infant’s greatest exertion is related to feeding.

Answer 5

In a hypertensive patient with symptomatic bradycardia while taking metoprolol (Lopressor) Beta-blockers with intrinsic sympathomimetic activity (ISA) are less beneficial in reducing mortality post myocardial infarction, and for this reason are not recommended for ischemic heart disease. They have a potential advantage in only one clinical situation. Since they tend to lower heart rates less, they may be beneficial in patients with symptomatic bradycardia while taking other beta-blockers. All beta-blockers should be used cautiously in patients with diabetes or asthma. Only sotalol, which delays ventricular depolarization, has been shown to be effective for maintenance of sinus rhythm in patients with chronic atrial fibrillation.

Answer 6

Addition of a fibrate such as gemfibrozil (Lopid) or fenofibrate (Tricor) Although the significance of elevated triglycerides and a low HDL in low-risk patients is somewhat uncertain, in a high-risk patient such as a diabetic, improvement in these results will lower the risk of subsequent cardiac events. In diabetics, metformin and thiazolidinediones (e.g., rosiglitazone) are more likely to improve lipid levels than are sulfonylureas. Nicotinic acid is problematic in diabetics, as it tends to cause deterioration in glucose control. Fibrates are good choices for this patient because they will lower the triglyceride level and raise the HDL level. Exercise and weight loss are likely to be helpful as well.

Answer 7

smoking cessation Patients with peripheral vascular disease who stop smoking have a twofold increase in their 5-year survival rate. Diet modification and lipid-lowering drugs can slow progression, but not as dramatically. Aspirin and pentoxifylline are minimally effective.

Answer 8

His siblings should undergo echocardiography Hypertrophic cardiomyopathy is an autosomal dominant condition and close relatives of affected individuals should be screened. The hypertrophy usually stays the same or worsens with age. This patient should not participate in strenuous sports, even those considered noncontact. Beta-blockers have not been shown to alter the progress of the disease. The mortality rate is believed to be about 1%, with some series estimating 5%. Thus, in most cases lifespan is normal.

Answer 9

5.5 cm Based on recent clinical trials, the most common recommendation for surgical repair is when the aneurysm approaches 5.5 cm in diameter. Two large studies, the Aneurysm Detection and Management (ADAM) Veteran Affairs Cooperative Study, and the United Kingdom Small Aneurysm Trial, failed to show any benefit from early surgery for men with aneurysms less than 5.5 cm in diameter. The risks of aneurysm rupture were 1% or less in both studies, with 6-year cumulative survivals of 74% and 64%, respectively. Interestingly, the risk for aneurysm rupture was four times greater in women, indicating that 5.5 cm may be too high, but a new evidence-based threshold has not yet been defined.

Answer 10

aortic stenosis Syncope with exercise is a manifestation of organic heart disease in which cardiac output is fixed and does not rise (or even fall) with exertion. Syncope, commonly on exertion, is reported in up to 42% of patients with severe aortic stenosis.

Answer 11

ACE-I ACE inhibitors have proven beneficial in patients who have either early or established diabetic renal disease. They are the preferred therapy in patients with diabetes and hypertension, according to guidelines from the American Diabetes Association, the National Kidney Foundation, the World Health Organization, and the JNC VII report.

Answer 12

Aortic valve replacement Since this patient’s mean aortic-valve gradient exceeds 50 mm Hg and the aortic-valve area is not larger than 1 cm2, it is likely that his symptoms are due to aortic stenosis. As patients with symptomatic aortic stenosis have a dismal prognosis without treatment, prompt correction of his mechanical obstruction with aortic valve replacement is indicated. Medical management is not effective, and balloon valvotomy only temporarily relieves the symptoms and does not prolong survival. Patients who present with dyspnea have only a 50% chance of being alive in 2 years unless the valve is promptly replaced. Exercise testing is unwarranted and dangerous in patients with symptomatic aortic stenosis.

Answer 13

Congestive Heart Failure Most decision trees for the evaluation of hyponatremia begin with an assessment of volume status; edema reflects volume overload and increased total body sodium caused by congestive heart failure, cirrhosis, or renal failure. If edema is absent, plasma osmolality should be determined. SIADH, Addison’s disease (hypoadrenalism), diuretic use, and renal artery stenosis all lower serum osmolality. Urine electrolytes help distinguish the other conditions: psychogenic polydipsia causes low urine sodium, while SIADH and hypoadrenalism cause inappropriately elevated urine sodium. Diuretic use, a very common cause of hyponatremia in the geriatric population, causes hypovolemic hyponatremia and can be associated with either high or low urine sodium, but there is often concomitant hypokalemia.

Answer 14

Intravenous heparin for 5–10 days followed by subcutaneous heparin for the duration of the pregnancy The risk of pulmonary embolism is five times higher in pregnant women than in nonpregnant women of similar age, and venous thromboembolism is a leading cause of illness and death during pregnancy. Warfarin, which readily crosses the placenta, should be avoided throughout pregnancy. It is definitely teratogenic during the first trimester, and extensive fetal abnormalities have been associated with exposure to warfarin in any trimester. Because heparin does not cross the placenta, it is considered the safest anticoagulant to use during pregnancy. Initially, patients with venous thromboembolism during pregnancy should be managed with heparin given according to the recommendations for nonpregnant patients. These women should receive intravenous heparin for 5–10 days followed by subcutaneous heparin for the duration of the pregnancy. Warfarin can be given after delivery, since it is not present in breast milk. The indications for placement of an inferior vena cava filter are not changed by pregnancy, and include any contraindication to anticoagulant therapy, the occurrence of heparin-induced thrombocytopenia, and recurrence of pulmonary embolism in a patient receiving adequate anticoagulant therapy. There are no data to support the use of aspirin for treatment or prophylaxis of pulmonary embolism either during or after pregnancy.

Answer 15

symptomatic heart block According to several randomized, controlled trials, mortality rates are improved in patients with heart failure who receive beta-blockers in addition to diuretics, ACE inhibitors, and occasionally, digoxin. Contraindications to beta-blocker use include hemodynamic instability, heart block, bradycardia, and severe asthma. Beta-blockers may be tried in patients with mild asthma or COPD as long as they are monitored for potential exacerbations. Beta-blocker use has been shown to be effective in patients with NYHA Class II or III heart failure. There is no absolute threshold ejection fraction. Beta-blockers have also been shown to decrease mortality in patients with a previous history of myocardial infarction, regardless of their NYHA classification.

Answer 16

Cardiovascular disease is the leading cause of death among women. According to the CDC, 29.3% of deaths in females in the U.S. in 2001 were due to cardiovascular disease and 21.6% were due to cancer, with most resulting from lung cancer. Breast cancer is the third most common cause of cancer death in women, and ovarian cancer is the fifth most common.

Answer 17

12-lead resting EKG The current recommendations from the American College of Cardiology and the American Heart Association on preoperative clearance for noncardiac surgery state that preoperative intervention is rarely needed to lower surgical risk. Patients who are not currently experiencing unstable coronary syndrome, severe valvular disease, uncompensated congestive heart failure, or a significant arrhythmia are not considered at high risk, and should be evaluated for most surgery primarily on the basis of their functional status. If these patients are capable of moderate activity (greater than 4 METs) without cardiac symptoms, they can be cleared with no stress testing or coronary angiography for an elective minor or intermediate-risk operation such as the one this patient is to undergo. A resting 12-lead EKG is recommended for males over 45, females over 55, and patients with diabetes, symptoms of chest pain, or a previous history of cardiac disease.

Answer 18

Radiofrequency catheter ablation of bypass tracts Radiofrequency catheter ablation of bypass tracts is possible in over 90% of patients and is safer and more cost effective than surgery, with a similar success rate. Intravenous and oral digoxin can shorten the refractory period of the accessory pathway, and increase the ventricular rate, causing ventricular fibrillation. Beta-blockers will not control the ventricular response during atrial fibrillation when conduction proceeds over the bypass tract.

Answer 19

Prescribe a diuretic Elevated blood pressure along with physical findings of cardiovascular disease establishes the diagnosis of hypertension in this patient, so it is not necessary to take follow-up blood pressure readings prior to starting treatment. Since he has no symptoms or physical findings suggestive of secondary hypertension it is also not necessary to perform a laboratory workup prior to treatment. Because he has Stage 3 hypertension with evidence of end-organ disease, treatment with antihypertensives is indicated at this point. At least three large clinical trials, including the European Working Party on High Blood Pressure in the Elderly (EWPHE) trial, have shown that diuretics are the most effective single agents for hypertension in the elderly. A low-sodium diet can be added, as can a beta-blocker if the hypertension fails to respond to diuretics alone.

Answer 20

Congenital Heart Disease Cyanotic congenital heart disease can appear at the time of ductus closure. A heart murmur is not usually audible, and murmurs heard this early are usually not due to heart disease. The failure to correct hypoxemia with 100% oxygen is diagnostic for abnormal mixing of blood from the right and left circulations. Transient tachypnea presents earlier, and the hypoxia corrects with supplemental oxygen. Hyaline membrane disease can occur at 36 weeks, but would cause problems in the first hours of life. It can make oxygenation difficult, but would cause extreme distress with CO2 retention in such cases. This patient has the energy to hyperventilate and has slight respiratory alkalosis as a result. Neonatal sepsis can cause V/Q mismatching and hypoxia, and can have a delayed presentation. Concern would be high enough in this case that the patient would probably receive broad-spectrum antibiotics while awaiting culture results. On the other hand, the clinician would not want to be distracted from the evidence for congenital heart disease. The baby is polycythemic from poor intake in the first 2 days of life. The hyperviscosity syndrome can occur when the hematocrit is over 65%. It can cause poor feeding, tachypnea, and sluggishness, but does not cause hypoxia.

Answer 21

Furosemide (Lasix), 40 mg intravenously B-type natriuretic peptide (BNP) is secreted in the ventricles and is sensitive to changes in left ventricular function. Concentrations correlate with end-diastolic pressure, which in turn correlates with dyspnea and congestive heart failure. BNP levels can be useful when trying to determine whether dyspnea is due to cardiac, pulmonary, or deconditioning etiologies. A value of less than 100 pg/mL excludes congestive heart failure as the cause for dyspnea. If it is greater than 400 pg/mL, the likelihood of congestive heart failure is 95%. Patients with values of 100–400 pg/mL need further investigation. There are some pulmonary problems that may elevate BNP, such as lung cancer, cor pulmonale, and pulmonary embolus. However, these patients do not have the same extent of elevation that those with acute left ventricular dysfunction will have. If these problems can be ruled out, then individuals with levels between 100–400 pg/mL most likely have congestive heart failure. Initial therapy should be a loop diuretic. It should be noted that BNP is partially excreted by the kidneys, so levels are inversely proportional to creatinine clearance.

Answer 22

Her leg swelling requires no further evaluation Lower-extremity edema is common in the last trimester of normal pregnancies and can be treated symptomatically with compression stockings. Edema has been associated with preeclampsia, but the majority of women who have lower-extremity edema with no signs of elevated blood pressure will not develop preeclampsia or eclampsia. For this reason, edema has recently been removed from the diagnostic criteria for preeclampsia. Disproportionate swelling in one leg versus another, especially associated with leg pain, should prompt a workup for deep venous thrombosis but is unlikely given this patient’s presentation, as are cardiac or renal conditions.

Answer 23

Intravenous haloperidol (Haldol) in increasing doses every 30 minutes as needed Intravenous haloperidol has been found to be more effective than lorazepam and has minimal physiologic side effects.

Answer 24

Atenolol (Tenormin) A recent development in the prophylaxis of surgery-related cardiac complications is the use of beta-blockers perioperatively for patients with cardiac risk factors. In a randomized, double-blind, placebo-controlled trial involving 200 patients who were undergoing elective noncardiac surgery that required general anesthesia, the effect of atenolol on perioperative cardiac complications was evaluated. Patients were eligible for beta-blocker therapy if they had known coronary artery disease or two or more risk factors. Atenolol was not used if the resting heart rate was

Answer 25

Subcutaneous heparin every 12 hours until delivery Heparin does not cross the placenta and is safe for the fetus, whereas coumarin derivatives can cause fetal bleeding and are teratogenic during weeks 6–12. Therefore, pregnant women with venous thromboembolism should receive intravenous heparin for 5 days, followed by adjusted-dose subcutaneous heparin every 12 hours until delivery. Increasingly, low–molecular-weight heparins are being used instead of unfractionated heparin because of ease of administration and the reduced need for coagulation monitoring. Intravenous heparin is not necessary after the patient leaves the hospital, and aspirin has not been shown to be beneficial.

Answer 26

Hypothyroidism According to the Summary of the National Cholesterol Education Program (NCEP) Adult Treatment Panel III Report of 2001, any person with elevated LDL cholesterol or any other form of hyperlipidemia should undergo clinical or laboratory assessment to rule out secondary dyslipidemia before initiation of lipid-lowering therapy. Causes of secondary dyslipidemia include diabetes mellitus, hypothyroidism, obstructive liver disease, chronic renal failure, and some medications.

Answer 27

Beta-natriuretic peptide (BNP) Beta-natriuretic peptide (BNP) is a 32-amino acid polypeptide secreted from the cardiac ventricles in response to ventricular volume expansion and pressure overload. The major source of BNP is the cardiac ventricles, and because of its minimal presence in storage granules, its release is directly proportional to ventricular dysfunction. It is a simple and rapid test that reliably predicts the presence or absence of left ventricular dysfunction on an echocardiogram.

Answer 28

Torsades de pointes Patients with long QT syndrome that have sudden arrhythmia death syndrome usually have either torsades de pointes or ventricular fibrillation.

Answer 29

A thiazide diuretic Clinical trials support the treatment of systolic hypertension in the older person with a systolic blood pressure of at least 160 mm Hg. (Systolic hypertension is defined as systolic blood pressure of at least 140 mm Hg and a diastolic blood pressure of less than 90 mm Hg.) The studies most strongly support the use of thiazide diuretics and long-acting calcium channel blockers as first-line therapy. Alpha-blockers are not recommended. ACE inhibitors, beta-blockers, and angiotensin receptor blockers are used when certain compelling indications are present, e.g., in a patient with diabetes or who has had a myocardial infarction.

Answer 30

Labetalol (Trandate, Normodyne) intravenously In pregnant women with severe hypertension, the primary objective of treatment is to prevent cerebral complications such as encephalopathy and hemorrhage. Intravenous hydralazine, intravenous labetalol, or oral nifedipine may be used. Sublingual nifedipine can cause severe hypotension, and reserpine is not indicated. Nitroprusside can be used for short intervals in patients with hypertensive encephalopathy, but fetal cyanide toxicity is a risk with infusions lasting more than 4 hours. ACE inhibitors are never indicated for hypertensive therapy during pregnancy.

Answer 31

Recent hospital admission for decompensated heart failure In general, it is advisable to avoid initiating beta-blocker therapy during or immediately after admission for decompensated heart failure.

Answer 32

ACE inhibitors ACE inhibitors are the preferred drugs for congestive heart failure due to left ventricular systolic dysfunction, because they are associated with the lowest mortality. The combination of hydralazine/isosorbide dinitrate is a reasonable alternative, and diuretics should be used cautiously. It is not known whether digoxin affects mortality, although it can help with symptoms.

Answer 33

Renal insufficiency (creatinine 2.0 mg/dL) Clinical predictors of increased perioperative cardiovascular risk for elderly patients include major risk factors such as ● unstable coronary syndrome (acute or recent myocardial infarction, unstable angina) ● decompensated congestive heart failure ● significant arrhythmia (high-grade AV block, symptomatic ventricular arrhythmia ● supraventricular arrhythmias with uncontrolled ventricular rate) ● severe valvular disease ``` Intermediate predictors are: ● mild angina ● previous myocardial infarction ● compensated congestive heart failure ● diabetes mellitus ● renal insufficiency ``` ``` Minor predictors are: ● advanced age ● an abnormal EKG - left ventricular hypertrophy, left bundle-branch block, ST and T-wave abnormalities, rhythm other than sinus, ● low functional capacity ● history of stroke ● uncontrolled hypertension. ```

Answer 34

Has been shown to contribute to significant gains in full neurologic and functional recovery The use of automated external defibrillators (AEDs) by lay persons, trained and otherwise, has been quite successful, with up to 40% of those treated recovering full neurologic and functional capacity. At present, 45 states have passed Good Samaritan laws covering the use of AEDs by well-intentioned lay persons. There are initiatives for widespread placement of AEDs, to include commercial airlines and other public facilities

Answer 35

Treadmill arterial flow studies showing a 20-mm Hg decrease in ankle systolic blood pressure immediately following exercise Peripheral vascular disease (PVD) is a clinical manifestation of atherosclerotic disease and is caused by occlusion of the arteries to the legs. Patients with significant arterial occlusive disease will have a prominent decrease in the ankle-brachial index from baseline following exercise, and usually a 20-mm Hg or greater decrease in systolic blood pressure. Pain during rest and exercise and the presence of swelling and soreness behind the knee and in the calf is found in those with Baker’s cysts. Peripheral nerve pain commonly begins immediately upon walking and is unrelieved by rest. Doppler waveform analysis is useful in the diagnosis of PVD and will reveal attenuated waveforms at a point of decreased blood flow. Employment of the ankle-brachial index is encouraged in daily practice as a simple means to diagnose the presence of PVD. Generally, ankle-brachial indices in the range of 0.91–1.30 are thought to be normal.

Answer 36

A blood pressure of 150/100 mm Hg ``` The criteria for severe preeclampsia is: ● blood pressure of 160/110 mm Hg or above on two occasions, 6 hours apart. Other criteria include ● proteinuria above 5 g/24 hr ● thrombocytopenia with a platelet count ```

Answer 37

Enoxaparin (Lovenox), 30 mg subcutaneously every 12 hours Prophylaxis is indicated with total knee or hip replacements. The two regimens recommended are low–molecular-weight heparin and adjusted-dose warfarin. These may be augmented by intermittent pneumatic compression.

Answer 38

Metoprolol (Lopressor) When treating arrhythmias related to cocaine toxicity, hypertonic sodium bicarbonate and benzodiazepines may be given when the distinction between sodium channel blockade–induced QRS-complex widening and ischemia-induced ventricular tachycardia is unclear. Lidocaine may subsequently be utilized if necessary. Verapamil has been shown to reverse cocaine-induced coronary vasospasm. Beta-adrenergic blocking drugs have been shown to exacerbate coronary vasospasm by resulting in unopposed alpha-adrenergic activity. Beta-blockers are therefore contraindicated in the treatment of cocaine-induced cardiac problems.

Answer 39

Atenolol (Tenormin) Atenolol and propranolol are associated with intrauterine growth retardation when used for prolonged periods during pregnancy. They are class D agents during pregnancy. Other beta-blockers may not share this risk. Methyldopa, hydralazine, and calcium channel blockers have not been associated with intrauterine growth retardation. They are generally acceptable agents to use for established, significant hypertension during pregnancy

Answer 40

NSAIDs, including high-dose aspirin, should be avoided in CHF patients because they can cause fluid retention

Answer 41

NSAIDs, including high-dose aspirin, should be avoided in CHF patients because they can cause fluid retention If possible, NSAIDs should be avoided in patients with heart failure. They cause sodium and water retention, as well as an increase in systemic vascular resistance which may lead to cardiac decompensation. Patients with heart failure who take NSAIDs have a tenfold increased risk of hospitalization for exacerbation of their CHF. NSAIDs alone in patients with normal ventricular function have not been associated with initial episodes of heart failure. NSAIDs, including high-dose aspirin (325 mg/day), may decrease or negate entirely the beneficial unloading effects of ACE inhibition. They have been shown to have a negative impact on the long-term morbidity and mortality benefits that ACE inhibitors provide. Sulindac and low-dose aspirin (81 mg/day) are less likely to cause these negative effects.

Answer 42

Ventricular rate control with a calcium channel blocker or beta-blocker, and warfarin for anticoagulation Five recent randomized, controlled trials have indicated that in most patients with atrial fibrillation, an initial approach of rate control is best. Patients who were stratified to the rhythm control arm of the trials did NOT have a morbidity or mortality benefit and were more likely to suffer from adverse drug effects and increased hospitalizations. The most efficacious drugs for rate control are calcium channel blockers and beta-blockers. Digoxin is less effective for rate control and should be reserved as an add-on option for those not controlled with a beta-blocker or calcium channel blocker, or for patients with significant left ventricular systolic dysfunction. In patients 65 years of age or older or with one or more risk factors for stroke, the best choice for anticoagulation to prevent thromboembolic disease is warfarin. Of note, in patients who are successfully rhythm controlled and maintained in sinus rhythm, the thromboembolic rate is equivalent to those managed with a rate control strategy. Thus, the data suggest that patients who choose a rhythm control strategy should be maintained on anticoagulation regardless of whether they are consistently in sinus rhythm. Ref: Snow V, Weiss K, LeFevre M, et al: Management of newly detected atrial fibrillation: A clinical practice guideline from the AAFP and the ACP.

Answer 43

Congestive heart failure Cilostazol is a drug with phosphodiesterase inhibitor activity introduced for the symptomatic treatment of arterial occlusive disease and intermittent claudication. Cilostazol should be avoided in patients with congestive heart failure. There are no limitations on its use in patients with previous stroke or a history of diabetes. It has been found to have beneficial effects on HDL cholesterol levels and in the treatment of third degree heart block.

Answer 44

Beta-blockers and ACE inhibitors have been found to decrease mortality late after myocardial infarction. Aspirin has been shown to decrease nonfatal myocardial infarction, nonfatal stroke, and vascular events. Nitrates, digoxin, thiazide diuretics, and calcium channel antagonists have not been found to reduce mortality after myocardial infarction.

Answer 45

Captopril (Capoten) ACE inhibitors can significantly worsen renal failure in patients with hypertension caused by renovascular disease. Hyperkalemia is an associated problem. Captopril renography is a useful diagnostic screening test. The other agents are useful for lowering blood pressure but may cause mild creatinine elevations. They do not, however, cause the significant elevations of creatinine seen with ACE inhibitors in cases of significant renovascular disease.

Answer 46

An ACE inhibitor It has been shown that congestive heart failure (CHF) patients treated with ACE inhibitors survive longer, and all such patients should take these agents if tolerated. Warfarin and/or antiarrhythmic drugs should be given only to selected CHF patients. Verapamil may adversely affect cardiac function and should be avoided in patients with CHF. Hydralazine can be used, but because of its side effect profile would be a second-line agent.

Answer 47

Start the patient on subcutaneous enoxaparin (Lovenox), 40 mg 1–2 hr prior to surgery and once a day after surgery A patient with a past history of postoperative venous thromboembolism is at risk for similar events with subsequent major operations. The most appropriate treatment of the choices listed would be subcutaneous enoxaparin. Aspirin is ineffective for prophylaxis of venous thromboembolism. Warfarin is effective at an INR of 2.0–3.0. Full anticoagulation with heparin is unnecessary for prophylaxis and can result in a higher rate of postoperative hemorrhage.

Answer 48

Discontinue the benazepril and monitor closely throughout the pregnancy for signs of preeclampsia or fetal growth restriction Most women with mild, uncomplicated essential hypertension are at minimal risk for cardiac complications within the short time frame of pregnancy. There is no evidence available that treatment of mild essential hypertension during pregnancy provides any benefit to the mother. Given the potential for short- and long-term risk to the fetus from antihypertensive treatment, it is advisable to discontinue antihypertensive treatment, monitor the mother for signs of preeclampsia, and monitor fetal growth and development. Medication is not necessary as long as the systolic blood pressure remains below 160 mm Hg, the diastolic blood pressure remains below 105–110 mm Hg, and there are no signs of preeclampsia or fetal growth restriction. Should the mother develop severe hypertension, treatment can be initiated with long-acting nifedipine, labetalol, a thiazide diuretic, or methyldopa. Atenolol has been associated with reduced fetal growth, and ACE inhibitors are contraindicated in the second and third trimesters.

Answer 49

elevated LDL level With subclinical thyroid dysfunction, TSH is either below or above the normal range, free T3 or T4 levels are normal, and the patient has no symptoms of thyroid disease. Subclinical hypothyroidism (TSH >10 µU/mL) is likely to progress to overt hypothyroidism, and is associated with increased LDL cholesterol. Subclinical hyperthyroidism (TSH

Answer 50

Lithium This patient has classic signs of hypothyroidism. Of the drugs listed, only lithium is associated with the development of hypothyroidism. In patients taking lithium, it is recommended that in addition to regular serum lithium levels, thyroid function tests including total free T4, and TSH be obtained yearly.

Answer 51

Lithium Lithium therapy can elevate calcium levels by elevating parathyroid hormone secretion from the parathyroid gland. This duplicates the laboratory findings seen with mild primary hyperparathyroidism. If possible, lithium should be discontinued for 3 months before reevaluation (SOR C). This is most important for avoiding unnecessary parathyroid surgery. Other choices for this questions were: VitD/Calcium supplementation, Lasix, Raloxifene Vitamin D and calcium supplementation could contribute to hypercalcemia in rare instances, but they would not cause elevation of parathyroid hormone. Raloxifene has actually been shown to mildly reduce elevated calcium levels, and furosemide is used with saline infusions to lower significantly elevated calcium levels ["Loops Lose Ca++"]

Answer 52

Exenatide (Byetta) Delayed gastric emptying may be caused or exacerbated by medications for diabetes, including amylin analogues (e.g., pramlintide) and glucagon-like peptide 1 (e.g., exenatide). Delayed gastric emptying has a direct effect on glucose metabolism, in addition to being a means of reducing the severity of postprandial hyperglycemia. In a clinical trial of exenatide, nausea occurred in 57% of patients and vomiting occurred in 19%, which led to the cessation of treatment in about one-third of patients.

Answer 53

Insulin glargine (Lantus) NOT metformin!! For geriatric patients in long-term care facilities, the predictable glucose control of glargine is the best approach to consider initially. The American Diabetes Association does not recommend a strict diet for frail diabetic patients in nursing homes. Exenatide is not recommended for the frail elderly because of concerns about weight loss and nausea. Heart failure precludes the use of pioglitazone, and renal failure precludes the use of metformin.

Answer 54

Order a free T4 level before adjusting the dose of Levothyroxine Although uncommon, pituitary disease can cause secondary hypothyroidism. The characteristic laboratory findings are a low serum free T4 and a low TSH. A free T4 level is needed to evaluate the proper dosage of replacement therapy in secondary hypothyroidism. The TSH level is not useful for determining the adequacy of thyroid replacement in secondary hypothyroidism since the pituitary is malfunctioning. In the initial evaluation of secondary hypothyroidism, a TRH stimulation test would be useful if TSH failed to rise in response to stimulation. It is not necessary in this case, since the diagnosis has already been made.

Answer 55

Metformin (Glucophage) Metformin is widely accepted as the first-line drug for type 2 diabetes mellitus. It is relatively effective, safe, and inexpensive, and has been used widely for many years. Unlike other oral hypoglycemics and insulin, it does not cause weight gain. It should be started at the same time as lifestyle modifications, rather than waiting to see if a diet and exercise regimen alone will work. If metformin is not effective, a sulfonylurea, a thiazolidinedione, or insulin can be added, with the choice based on the severity of the hyperglycemia.

Answer 56

Metformin (Glucophage) Metformin increases insulin sensitivity much more than sulfonylureas or insulin. This means lower insulin levels achieve the same level of glycemic control, and may be one reason that weight changes are less likely to be seen in diabetic patients on metformin. Acarbose is an α-glucosidase inhibitor that delays glucose absorption.

Answer 57

Diagnose type 2 diabetes mellitus and begin diet and exercise therapy The criteria for diagnosing diabetes mellitus include any one of the following: symptoms of diabetes (polyuria, polydipsia, weight loss) plus a casual glucose level ≥200 mg/dL; a fasting plasma glucose level ≥126 mg/dL; or a 2-hour postprandial glucose level ≥200 mg/dL after a 75 gram glucose load. In the absence of unequivocal hyperglycemia the test must be repeated on a different day. The criteria for impaired glucose homeostasis include either a fasting glucose level of 100-125 mg/dL (impaired fasting glucose) or a 2-hour glucose level of 140-199 mg/dL on an oral glucose tolerance test. Normal values are now considered

Answer 58

Serum parathyroid hormone A patient with a recurrent kidney stone and an elevated serum calcium level most likely has hyperparathyroidism, and a parathyroid hormone (PTH) level would be appropriate. Elevated PTH is caused by a single parathyroid adenoma in approximately 80% of cases. The resultant hypercalcemia is often discovered in asymptomatic persons having laboratory work for other reasons. An elevated PTH by immunoassay confirms the diagnosis. In the past, tests based on renal responses to elevated PTH were used to make the diagnosis. These included blood phosphate, chloride, and magnesium, as well as urinary or nephrogenous cyclic adenosine monophosphate. These tests are not specific for this problem, however, and are therefore not cost-effective. Serum calcitonin levels have no practical clinical use.

Answer 59

An intact parathyroid hormone (PTH) level In primary hyperparathyroidism, hypercalcemia is the result of excessive PTH secretion by one or more abnormal, enlarged parathyroid glands. Laboratory findings in most patients with primary hyperparathyroidism reflect the mild clinical presentation of the disorder. The serum calcium level is often 1 mg/dL or more above the upper limits of normal. Bone radiographs may show the classic changes of subperiosteal bone resorption in the occasional patient with hyperparathyroidism, but in most cases they are normal or may show osteopenia. Osteocalcin is an osteoblast-specific protein. It is a marker of increased skeletal turnover, and it is usually not indicated clinically. The development of highly sensitive and specific assays for intact, largely active PTH has simplified the assessment of parathyroid activity. Bone densitometry is a test to determine the degree of osteoporosis.

Answer 60

f/u testing after discharge The likelihood that this patient has significant thyroid disease is very low given the minimal elevation of TSH, normal clinical examination, and concomitant pneumonia. The elevated TSH level is likely due to her illness rather than to any underlying thyroid condition. Even if she had a palpable thyroid, her risk of hypothyroidism would be on the order of 5%. A TSH level µU/mL in an acutely ill patient reflects true hypothyroidism only about 40% of the time. It is likely that this patient has sick euthyroid syndrome and that follow-up thyroid testing after discharge when she has recovered is appropriate and is very likely to be normal. Free T4, rT3, and TSH levels would be appropriate for subsequent evaluation if the patient’s laboratory values did not return to normal after resolution of the pneumonia.

Answer 61

Metformin (Glucophage) Metformin should be withheld before and after radiographic procedures with contrast, due to its interaction with iodinated contrast materials. This interaction may cause impaired renal function or lactic acidosis.

Answer 62

Hip fracture Women older than 65 years of age who have low serum TSH levels, indicating physiologic hyperthyroidism, are at increased risk for new hip and vertebral fractures. Use of thyroid hormone itself does not increase the risk of fracture if TSH levels are normal.

Answer 63

Low serum ferritin The total iron-binding capacity is elevated, not decreased, in iron deficiency anemia. As an acute-phase reactant, serum iron may be decreased in response to inflammation even when total body stores of iron are not decreased. Microcytosis and hypochromia are both features of iron deficiency anemia occurring late in its development, but both can also be seen in the thalassemias. Serum ferritin is also an acute-phase reactant but is normal or elevated in the face of an inflammatory process. A low serum ferritin, however, is diagnostic for iron deficiency even in its early stages.

Answer 64

Phenylketonuria Aspartame is completely hydrolyzed in the gut to methanol, aspartic acid, and phenylalanine, and is therefore contraindicated in patients with phenylketonuria.

Answer 65

At 24–28 weeks' gestation The recommended time to screen for gestational diabetes is 24–28 weeks' gestation. The patient may be given a 50-g oral glucose load followed by a glucose determination 1 hour later.

Answer 66

Indications for parathyroid surgery include ● Age < 50 ● Kidney stones ● Serum calcium 1.0 mg/dL above the upper limit of normal ● Decreased bone density

Answer 67

Subacute thyroiditis [distractors: Grave's disease, toxic nodule] Thyrotoxicosis with a high 24-hour radioactive iodine uptake (RAIU) is caused by Graves’ disease, toxic multinodular goiter, a solitary hot nodule, a TSH-secreting pituitary tumor, molar pregnancy, and choriocarcinoma. Thyrotoxicosis with a low 24-hour RAIU may be the result of subacute thyroiditis, sporadic silent thyroiditis, postpartum lymphocytic thyroiditis, radiation-induced thyroiditis, iodine-induced thyroiditis, thyrotoxicosis factitia, metastatic follicular thyroid cancer, and struma ovarii.

Answer 68

A previous history of angioneurotic edema [other choices: Renal insufficiency, Asthma, A history of recent myocardial infarction , A cardiac ejection fraction

Answer 69

Continue present management This patient in all probability has the euthyroid-sick syndrome, also known as nonthyroid illness syndrome (NTI)—the association of severe nonthyroidal illness with biochemical parameters indicative of thyroid hypofunction. Low T3 with normal T4 and low T3 with low T4 are the most common variants of this syndrome. TSH is usually normal but may be high or low. A TSH level >20 µU/mL would be inconsistent with NTI and indicates hypothyroidism.

Answer 70

``` When evaluating a patient with a solitary thyroid nodule, red flags indicating possible thyroid cancer include: ● male gender ● age 65 years ● rapid growth of the nodule ● symptoms of local invasion such as dysphagia, neck pain, and hoarseness ● a history of head or neck radiation ● a family history of thyroid cancer ● a hard, fixed nodule >4 cm ● cervical lymphadenopathy. ```

Answer 71

Hydrochlorothiazide While thiazide diuretics do not cause hypercalcemia by themselves, they can exacerbate the hypercalcemia associated with primary hyperparathyroidism. Thiazides decrease the renal clearance of calcium by increasing distal tubular calcium reabsorption. Furosemide tends to lower serum calcium levels and is used in the treatment of hypercalcemia

Answer 72

Metformin (Glucophage) Administration of general anesthesia may cause hypotension, which leads to renal hypoperfusion and peripheral tissue hypoxia, with subsequent lactate accumulation. Therefore, if administration of radiocontrast material is required or urgent surgery is needed, metformin should be withheld and hydration maintained until preserved kidney function is documented at 24 and 48 hours after the intervention.

Answer 73

Hypoglycemia 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.

Answer 74

Sickle cell disease The glycosylated hemoglobin assay is rendered inaccurate by conditions affecting red blood cell survival, such as sickle cell disease or the presence of hemoglobin C.

Answer 75

Hypothyroidism Hypothyroidism is associated with markedly delayed bone age relative to height age and chronologic age. In cystic fibrosis, bone age and height age are equivalent, but both lag behind chronologic age. Children with chromosomal anomalies such as trisomy 21 (Down syndrome) or XO have a height age which is delayed relative to bone age. This pattern is also seen as a result of maternal substance abuse.

Answer 76

Osteoporosis Even mild chronic excess thyroid hormone replacement over many years can cause bone mineral resorption, increase serum calcium levels, and lead to osteoporosis. The elevated calcium decreases parathyroid hormone. Goiter is an indicator, not a cause, for hormone replacement. Osteoarthritis is not related to thyroid hormone replacement.

Answer 77

Continue breastfeeding, evaluate for risk factors, and initiate phototherapy if at risk In 2004 the American Academy of Pediatrics published updated clinical practice guidelines on the management of hyperbilirubinemia in the newborn infant at 35 or more weeks gestation. These guidelines focus on frequent clinical assessment of jaundice, and treatment based on the total serum bilirubin level, the infants age in hours, and risk factors. Phototherapy should not be started based solely on the total serum bilirubin level. The guidelines encourage breastfeeding 8-12 times daily in the first few days of life to prevent dehydration. There is no evidence to support supplementation with water or dextrose in water in a nondehydrated breastfeeding infant. This infant is not dehydrated and is getting an adequate number of feedings, and there is no reason to discontinue breastfeeding at this time.

Answer 78

midgut volvulus (Other choices:Infantile colic , Necrotizing enterocolitis, Hypertrophic pyloric stenosis, Intussusception) Volvulus may present in one of three ways: as a sudden onset of bilious vomiting and abdominal pain in a neonate; as a history of feeding problems with bilious vomiting that appears to be a bowel obstruction; or less commonly, as failure to thrive with severe feeding intolerance. The classic finding on abdominal plain films is the double bubble sign, which shows a paucity of gas (airless abdomen) with two air bubbles, one in the stomach and one in the duodenum. However, the plain film can be entirely normal. The upper gastrointestinal contrast study is considered the gold standard for diagnosing volvulus. Infantile colic usually begins during the second week of life and typically occurs in the evening. It is characterized by screaming episodes and a distended or tight abdomen. Its etiology has yet to be determined. There are no abnormalities on physical examination and ancillary studies, and symptoms usually resolve spontaneously around 12 weeks of age. Necrotizing enterocolitis is typically seen in the distressed neonate in the intensive-care nursery, but it may occasionally be seen in the healthy neonate within the first 2 weeks of life. The child will appear ill, with symptoms including irritability, poor feeding, a distended abdomen, and bloody stools. Abdominal plain films will show pneumatosis intestinalis, caused by gas in the intestinal wall, which is diagnostic of the condition. Hypertrophic pyloric stenosis is a narrowing of the pyloric canal caused by hypertrophy of the musculature. It usually presents during the third to fifth weeks of life. Projectile vomiting after feeding, weight loss, and dehydration are common. The vomitus is always nonbilious, because the obstruction is proximal to the duodenum. If a small olive-size mass cannot be felt in the right upper or middle quadrant, ultrasonography will confirm the diagnosis. Intussusception is seen most frequently between the ages of 3 months and 5 years, with 60% of cases occurring in the first year and a peak incidence at 6-11 months of age. The disorder occurs predominantly in males. The classic triad of intermittent colicky abdominal pain, vomiting, and bloody, mucous stools is encountered in only 20%-40% of cases. At least two of these findings will be present in approximately 60% of patients. The abdomen may be distended and tender, and there may be an elongated mass in the right upper or lower quadrants. Rectal examination may reveal either occult blood or frankly bloody, foul-smelling stool, classically described as currant jelly. An air enema using fluoroscopic guidance is useful for both diagnosis and treatment.

Answer 79

Meckels diverticulum Meckels diverticulum is the most common congenital abnormality of the small intestine. It is prone to bleeding because it may contain heterotopic gastric mucosa. Abdominal pain, distention, and vomiting may develop if obstruction has occurred, and the presentation may mimic appendicitis. Children with appendicitis have right lower quadrant pain, abdominal tenderness, guarding, and vomiting, but not rectal bleeding. With acute viral gastroenteritis, vomiting usually precedes diarrhea (usually without blood) by several hours, and abdominal pain is typically mild and nonfocal with no localized tenderness. The incidence of midgut volvulus peaks during the first month of life, but it can present anytime in childhood. Volvulus may present in one of three ways: as a sudden onset of bilious vomiting and abdominal pain in the neonate; as a history of feeding problems with bilious vomiting that now appears to be due to bowel obstruction; or, less commonly, as a failure to thrive with severe feeding intolerance. Necrotizing enterocolitis is typically seen in the neonatal intensive-care unit, occurring in premature infants in their first few weeks of life. The infants are ill, and signs and symptoms include lethargy, irritability, decreased oral intake, abdominal distention, and bloody stools. A plain abdominal film showing pneumatosis intestinalis, caused by gas in the intestinal wall, is diagnostic of this disease.

Answer 80

initiated at 6-12 weeks of age Rotavirus vaccine (RotaTeq) was licensed in February 2006 to protect against viral gastroenteritis. The Advisory Committee on Immunization Practices recommends the routine vaccination of infants with three doses to be given at 2, 4, and 6 months of age. The first dose should be given between 6 and 12 weeks of age, and subsequent doses should be given at 4- to 10-week intervals, but all three doses should be administered by 32 weeks of age. Unlike the vaccine RotaShield, which was marketed in 1999, RotaTeq is not known to increase the risk for intussusception.

Answer 81

Gallstones Pancreatitis is most closely associated with gallstones, extreme hypertrigliceridemia, and excessive alcohol use. Gastroesophageal reflux disease, pyelonephritis, drug abuse (other than alcohol), and angiotensin receptor blocker use are not risk factors for the development of pancreatitis.

Answer 82

The risk of peptic ulcer bleeding from chronic NSAID therapy Eradication of Helicobacter pylori significantly reduces the risk of ulcer recurrence and rebleeding in patients with duodenal ulcer, and reduces the risk of peptic ulcer development in patients on chronic NSAID therapy. Eradication has minimal or no effect on the symptoms of nonulcer dyspepsia and gastroesophageal reflux disease. Although H. pylori infection is associated with gastric cancer, no trials have shown that eradication of H. pylori purely to prevent gastric cancer is beneficial.

Answer 83

an increased risk of carcinoma of the colon Long-standing ulcerative colitis (UC) is associated with an increased risk of colon cancer. The greater the duration and anatomic extent of involvement, the greater the risk. Initial colonoscopy for patients with pancolitis of 8-10 years duration (regardless of the patient's age) should be followed up with surveillance examinations every 1-2 years, even if the disease is in remission. All of the other options listed are features typically associated with Crohn’s disease. Virtually all patients with UC have rectal involvement, even if that is the only area affected. In Crohn’s disease, rectal involvement is variable. Noncontinuous and transmural inflammation are also more common with Crohn’s disease. Transmural inflammation can lead to eventual fistula formation, which is not seen in UC.

Answer 84

metronidazole (Flagyl) orally Many antibiotics can induce pseudomembranous colitis. Although oral vancomycin was once the initial drug of choice for C. difficile, oral metronidazole is now the first-line agent because of cost considerations and because of concerns about the development of vancomycin-resistant organisms. If the patient has refractory symptoms despite treatment with oral metronidazole, then oral vancomycin would be appropriate. Vancomycin given orally is not absorbed, leading to high intraluminal levels of the drug.

Answer 85

unknown Colic is a frustrating condition for parents and doctors alike. The parents would like an explanation and relief, and physicians would like to offer these things. At this time, however, in spite of numerous studies and theories, the cause of colic remains unknown.

Answer 86

He should consume a normal age-appropriate diet, and continue breastfeeding Continued oral feeding in diarrhea aids in recovery, and an age-appropriate diet should be given. Breastfeeding or regular formula should be continued. Foods with complex carbohydrates (e.g., rice, wheat, potatoes, bread, and cereals), lean meats, yogurt, fruits, and vegetables are well tolerated. Foods high in simple sugars (e.g., juices, carbonated sodas) should be avoided because the osmotic load can worsen the diarrhea. Fatty foods should be avoided as well. The BRAT diet (bananas, rice, applesauce, and toast) has not been shown to be effective.

Answer 87

next step: A technetium-99m blood pool scan In most patients with heavy gastrointestinal bleeding, localizing the bleeding site, rather than diagnosing the cause of the bleeding, is the most important task. A lower GI series is usually nondiagnostic during heavy, active bleeding. A small-bowel radiograph may be helpful after the active bleeding has stopped, but not during the acute phase of the bleeding. A blood pool scan allows repeated scanning over a prolonged period of time, with the goal of permitting enough accumulation of the isotope to direct the arteriographer to the most likely source of the bleeding. If the scan is negative, arteriography would also be unlikely to reveal the active source of bleeding. It is also a more invasive procedure. Exploratory laparotomy may be indicated if a blood pool scan or an arteriogram is nondiagnostic and the patient continues to bleed heavily.

Answer 88

cirrhosis The individual described in this case has symptomatic hyponatremia. Headache, mental confusion, nausea, and malaise are common. Seizures, stupor, and coma generally do not occur until sodium concentrations fall below 120 mEq/L. The presence of significant peripheral edema in this patient indicates extracellular fluid volume expansion, and his serum osmolality is low. In this situation, hyponatremia is usually a manifestation of an edematous state, such as hepatic cirrhosis, congestive heart failure, or the nephrotic syndrome. Although these patients have increased extracellular fluid, their intravascular fluid is depleted, and their body’s attempt to conserve sodium at the level of the kidney produces urine with a sodium concentration 100 mOsm/kg H2O. Patients with the syndrome of inappropriate antidiuretic hormone (SIADH) have normal volume status and urine sodium levels which are typically >20 mEq/L. Patients with primary polydipsia often have an underlying psychiatric disorder. They have normal volume status, and produce large volumes of very dilute urine (20 mEq/L.

Answer 89

Radiation proctitis Chronic radiation proctitis develops months to years after radiation and is characterized by pain with defecation, diarrhea, and sometimes rectal bleeding. On colonoscopy, the mucosa is pale and friable with telangiectases which are sometimes large, multiple, and serpiginous.

Answer 90

Ciprofloxacin (Cipro) Fluoroquinolones such as ciprofloxacin have been shown to significantly reduce the duration and severity of traveler’s diarrhea when given for 1–3 days. Penicillin and erythromycin are not effective against the most common cause of traveler’s diarrhea, enterotoxigenic E. coli.

Answer 91

Hepatitis A vaccine Hepatitis A vaccine should be administered to unvaccinated adolescents who plan to travel to or work in an area of high endemicity of hepatitis A virus infection, those who receive clotting factors, those who have chronic liver disease or use illegal drugs, and males who have sex with males. Routine hepatitis A vaccination of all children has been proposed and implementation strategies are being studied.

Answer 92

Injection drug use Illegal drug use is currently the leading cause of new cases of hepatitis C. It is estimated that 60% of new cases of hepatitis C in the United States are due to injection drug use. Intranasal cocaine use has been associated with hepatitis C, but its importance as a route of transmission is controversial and it occurs at a much lower frequency, if it all. Sexual transmission of hepatitis C is a less frequent cause of initial infection. Hepatitis B and HIV are transmitted more efficiently by sexual contact. Men who engage in homosexual intercourse have rates of hepatitis C similar to those of heterosexuals who engage in high-risk sexual practices. Among partners who are hepatitis C–positive, male-to-female transmission seems to be more efficient. Maternal-child perinatal transmission rates are thought to be less than 6%. Breastfeeding is not thought to be a risk. Occupational transmission is infrequent. No significant household or day-care risk is thought to exist in the absence of blood exposure.

Answer 93

No further intervention Simple renal cysts are incidentally seen on abdominal imaging studies in over 30% of people over age 50, and are present in up to 50% in some autopsy series. No further evaluation is indicated for cysts that meet ultrasound criteria (i.e., thin-walled, homogeneous, fluid-filled). With cysts that appear to be complex, a renal CT with contrast is indicated. MRI has been shown to be statistically superior to CT in correctly characterizing benign lesions, and may be helpful when results of a CT scan are equivocal. Simple cysts do not require aspiration or other treatment. Referral is indicated for symptomatic or complex cysts or solid masses.

Answer 94

Thrombectomy under local anesthesia A thrombosed external hemorrhoid is described as the sudden development of a painful, tender perirectal lump. Because there is somatic innervation, the pain is intense, and increases with edema. Treatment involves excision of the acutely thrombosed tissue under local anesthesia, mild pain medication, and sitz baths. It is inappropriate to use procedures that would increase the pain, such as banding or cryotherapy. Total hemorrhoidectomy is inappropriate and unnecessary.

Answer 95

Serum transferrin saturation Hereditary hemochromatosis is the most common genetic disorder in the United States. Serum transferrin is the best and most sensitive screening test. Liver biopsy, long considered the gold standard for diagnosing hemochromatosis, is far too invasive.

Answer 96

21 mg/dL at 72 hours Bilirubin levels >17 mg/dL in full-term infants are considered pathologic rather than physiologic. In one study, infants with bilirubin concentrations over 21 mg/dL at 18–72 hours after birth had a 40% probability of severe hyperbilirubinemia developing later on. The American Academy of Pediatrics recommends initiating phototherapy for bilirubin levels based on the infant’s age: 15 mg/dL at 25–48 hours, 18 mg/dL at 49–72 hours, and 20 mg/dL at 72 hours or more.

Answer 97

Neutrophil count >300/mL Diagnostic paracentesis is recommended for patients with ascites of recent onset, as well as for those with chronic ascites who present with new clinical findings such as fever or abdominal pain. A neutrophil count >250/mL is diagnostic for peritonitis. Once peritonitis is diagnosed, antibiotic therapy should be started immediately without waiting for culture results. Bloody ascites with abnormal cytology may be seen with hepatoma, but is not typical of peritonitis. The ascitic fluid pH does not become abnormal until well after the neutrophil count has risen, so it is a less reliable finding for treatment purposes. A protein level >1 g/dL is actually evidence against spontaneous bacterial peritonitis.

Answer 98

One long-acting niacin tablet per day Hepatotoxicity resulting from timed-release formulations of niacin has been reported in elderly individuals. Patients may be taking this drug without their physician’s knowledge, feeling it is safe because it is a vitamin.

Answer 99

Clostridium difficile colitis This patient most likely has Clostridium difficile colitis, suggested by semiformed rather than watery stool, fecal leukocytes (not seen in viral gastroenteritis or sprue), and a hospital stay greater than 2 weeks. While this disease has traditionally been associated with antibiotic use, it is posing an increasing threat to patients in hospitals and chronic-care facilities who have not been given antibiotics. The primary sources for infection in such cases have been toilets, bedpans, floors, and the hands of hospital personnel. Prompt recognition and treatment is essential to prevent patient relapse and to minimize intramural epidemics.

Answer 100

Senna Senna has been shown to be safe, free of significant intestinal side effects, and beneficial over the long term. Phenolphthalein and castor oil can cause malabsorption, dehydration, lipoid pneumonia, and cathartic colon. Bisacodyl suppositories used daily can cause rectal burning, and oral bisacodyl can cause hypokalemia, abdominal cramps, and vomiting. Milk of Magnesia is a saline cathartic that can cause elevated magnesium levels and dehydration, watery stools, and fecal incontinence.

Answer 101

Hepatitis B immune globulin (HBIG) and hepatitis B vaccine at birth Infants born to hepatitis B–positive mothers should receive both immune globulin and hepatitis B vaccine. They should receive the entire series of the vaccine, with testing for seroconversion only after completion of the vaccination series; the recommended age for testing is 9–12 months of age.

Answer 102

Perforation Older patients with appendicitis are more likely to present without classic signs and symptoms. Elevated WBC counts, rebound tenderness, guarding, and fever are less reliably seen. As a result of delays in diagnosis, perforation is found in over 65% of elderly patients at the time of diagnosis.

Answer 103

Giardia lamblia Organisms that can persist in water environments and survive disinfection, especially chlorination, are most likely to cause disease outbreaks related to drinking water. Cryptosporidium oocysts and Giardia cysts are resistant to chlorine and are important causes of gastroenteritis from drinking water. Entamoeba histolytica and hepatitis A virus are also relatively chlorine resistant.

Answer 104

Persons with a history of illicit intravenous drug use Patients should be routinely screened for hepatitis C if they have a history of any of the following: intravenous drug abuse no matter how long or how often, receiving clotting factor produced before 1987, persistent alanine aminotransferase elevations, or recent needle stick with HCV-positive blood.

Answer 105

Test the nurse for hepatitis B antibody Postexposure prophylaxis after hepatitis B exposure via the percutaneous route depends upon the source of the exposure and the vaccination status of the exposed person. In the case described, a vaccinated person has been exposed to a known positive individual. The exposed person should be tested for hepatitis B antibodies; if antibody levels are inadequate (

Answer 106

Carcinoembryonic antigen (CEA) Prostate-specific antigen (PSA) is a marker that is used to screen for prostate cancer. It is elevated in more than 70% of organ-confined prostate cancers. Alpha-tetoprotein is a marker for hepatocellular carcinoma and nonseminomatous germ cell tumor, and is elevated in 80% of hepatocellular carcinomas. CA-125 is a marker for ovarian cancer. Although it is elevated in 85% of ovarian cancers, it is elevated in only 50% of early-stage ovarian cancers. Carcinoembryonic antigen (CEA) is a marker for colon, esophageal, and hepatic cancers. It is expressed in normal mucosal cells and is overexpressed in adenocarcinoma, especially colon cancer. Though not specific for colon cancer, levels above 10 ng/mL are rarely due to benign disease. CEA levels typically return to normal within 4–6 weeks after successful surgical resection. CEA elevation occurs in nearly half of patients with a normal preoperative CEA level that have cancer recurrence. Cancer antigen 27.29 (CA 27-29) is a tumor marker for breast cancer. It is elevated in about 33% of early-stage breast cancers and about 67% of late-stage breast cancers. Some tumor markers, such as CEA, alpha-fetoprotein, and CA-125, may be more helpful in monitoring response to therapy than in detecting the primary tumor.

Answer 107

Zenker’s diverticulum The combination of halitosis, late regurgitation of undigested food, and choking suggests Zenker’s diverticulum. Patients may also have dysphagia and weight loss. The diagnosis is usually made with a barium swallow. The treatment is surgical.

Answer 108

Intussusception This case presentation is fairly typical for intussusception, the “telescoping” of a portion of the intestine into itself with obstruction and crampy pain. It generally occurs between the ages of 6 months and 24 months. A sausage-shaped mass is often palpable as a result of the ileum being trapped within the colon. The presence of bloody mucus supports the diagnosis. Pyloric stenosis generally occurs in the first 4–6 weeks of life (although it can occur as late as the fifth month) with a striking first-born male predominance. Emesis is the most prominent feature of pyloric stenosis; it is usually painless, and there are no bloody stools. The small pyloric mass, which feels like an olive, may be palpable at the margin of the right rectus muscle. The onset is more insidious than with intussusception. Duodenal atresia presents shortly after birth with vomiting and a “double-bubble” on a radiograph, indicating a gas-filled stomach and proximal duodenum. A Meckel’s diverticulum may rarely be found at the lead point of an intussusception, but it usually presents as a cause of recurrent abdominal pain in later life. Gastrochisis is an antenatal evisceration through a small paraumbilical defect that is present at birth.

Answer 109

Crohn’s disease (regional enteritis) When Crohn’s disease affects primarily the distal small intestine (regional enteritis), a most characteristic clinical pattern emerges. A young person, usually in the second or third decade, will present with a period of episodic abdominal pain, largely postprandial and often periumbilical, occasionally with low-grade fever and mild diarrhea. Anorexia, nausea, and vomiting may also be present. Weight loss is frequent. Some patients may be aware of tenderness in the right lower quadrant and even of a palpable mass in that region.

Answer 110

max = 4000 mg The maximum daily dosage for all acetaminophen preparations is 4000 mg. Acetaminophen is used in more combination products than any other drug, for a number of different indications. An FDA panel has recommended that stronger warnings about hepatotoxicity be added to the label information for acetaminophen. Because it is used so frequently and is present in so many different preparations, care must be taken not to exceed the maximum 24-hour dosage in order to avoid hepatotoxicity.

Answer 111

Ground beef Recent outbreaks of E. coli 0157:H7-related illnesses have been associated with contaminated ground beef bought either uncooked in supermarkets or as cooked hamburgers at fast-food restaurants.

Answer 112

Hepatitis C (HCV) screening is indicated for: ● recipients of a transfusion prior to July 1992 ● patients with needlestick or mucosal exposure to HCV ● children born to mothers with HCV infection.

Answer 113

Serum antibody testing, especially IgA antiendomysial antibody, is highly sensitive and specific and readily available at a cost of about $100 to $200. Definitive diagnosis generally requires esophagogastroduodenoscopy with a biopsy of the distal duodenum to detect characteristic villous flattening.

Answer 114

Observation Gallstones are frequently discovered on a diagnostic workup for an unrelated problem. Only 1%–2% of persons with asymptomatic gallstones will require cholecystectomy in a given year, and two-thirds of patients with asymptomatic gallstones will remain symptom free over a 20-year period. The longer the patient remains asymptomatic, the more likely that no symptoms will develop in the future. This patient may have had gallstones for several years, and the best management would be to do nothing unless symptoms develop.

Answer 115

Sodium 2 mEq/L, potassium 40 mEq/L Secondary hyperaldosteronism is characterized by sodium retention, and thus decreased urinary sodium excretion, while potassium secretion is normal to increased

Answer 116

A spiral CT scan of the abdomen A retrospective review of 650 patients with suspected appendicitis showed a sensitivity of 97% and a specificity of 98% for spiral CT. In patients in whom the clinical diagnosis was uncertain, sensitivity was 92% and specificity was 85%. Two prospective studies comparing ultrasonography with spiral CT have favored spiral CT. Ultrasonography is used in women who are pregnant and women in whom there is a high degree of suspicion of gynecologic disease. Abdominal radiography has low specificity and sensitivity for the diagnosis of acute appendicitis. Air contrast barium enema also has low accuracy. Limitations of MRI include increased cost, decreased availability, and increased examination time compared to CT.

Answer 117

Gilbert’s syndrome Gilbert’s syndrome is the most common inherited disorder of bilirubin metabolism. In patients with a normal CBC and liver function tests, except for recurrent mildly elevated total and unconjugated hyperbilirubinemia, the most likely diagnosis is Gilbert’s syndrome. Fasting, heavy physical exertion, sickle cell anemia, and drug toxicity can also cause hyperbilirubinemia.

Answer 118

Worsening of symptoms at night Irritable bowel syndrome (IBS) is a benign, chronic symptom complex of altered bowel habits and abdominal pain. It is the most common functional disorder of the gastrointestinal tract. The presence of nocturnal symptoms is a red flag which should alert the physician to an alternate diagnosis and may require further evaluation.

Answer 119

Human rotavirus

Answer 120

All family members may use an antimotility agent such as loperamide (Imodium) for mild disease Loperamide may be used for mild non-dysenteric traveler’s diarrhea in patients greater than 2 years of age. Parasites rarely cause traveler’s diarrhea. Ciprofloxacin is a good choice for self-treatment of severe or dysenteric diarrhea in adults, but should not be used in children. Prophylactic antibiotics are rarely indicated.

Answer 121

GER in infants usually resolves by 1 year of age without treatment Gastroesophageal reflux (GER) is a functional process occuring in a healthy infant. It is common and self-limited, and represents a physiologic process of “spitting up.” GER occurs in the absence of poor weight gain, irritability, cough, pain, or anemia. The majority of infants with GER are thriving. It is important to consider other systemic disorders, and rule them out when appropriate. Possible causes of spitting up include pyloric stenosis, infections (e.g., gastrointestinal, genitourinary), and metabolic disorders. It is not necessary to perform a diagnostic evaluation prior to starting drug therapy unless a structural defect is highly suspected. GER in infants is usually self-limited and resolves by 1 year of age.

Answer 122

She should be offered testing because sexual transmission is possible Key risk factors for hepatitis C infection are long-term hemodialysis, intravenous drug use, blood transfusion or organ transplantation prior to 1992, and receipt of clotting factors before 1987. Sexual transmission is very low but possible, and the likelihood increases with multiple partners. The lifetime transmission risk of hepatitis C in a monogamous relationship is less than 1%, but the patient should be offered testing because she may choose to confirm that her test is negative. If the mother is seronegative, the children are at no risk. Maternal-fetal transmission is rare except in the setting of co-infection with HIV. Hepatitis C is insidious, and symptoms do not correlate with the extent of the disease. Normal liver enzyme levels do not indicate lack of infectivity. There is no risk to household contacts. Current HCV antibody tests are more than 99% sensitive and specific and are recommended for screening at-risk populations.

Answer 123

Chronic calculous cholecystitis (“porcelain” gallbladder) Carcinoma of the gallbladder is a rare condition, and prophylactic cholecystectomy to prevent its occurrence is therefore usually not justified. The exception is when chronic calculous cholecystitis is present. This condition is associated with a 20% incidence of gallbladder carcinoma.

Answer 124

Abdominal ultrasonography The symptom complex presented is typical of cholelithiasis. Plain radiography of the abdomen may reveal radiopaque gallstones, but will not reveal radiolucent stones or biliary dilatation. Although rarely used, oral cholecystography is 98% accurate, but only when compliance is assured, the contrast agent is absorbed, and liver function is normal. Abdominal ultrasonography is considered the best study to confirm this diagnosis because of its high sensitivity and its accuracy in detecting gallstones. A barium swallow will identify some functional and structural esophageal abnormalities, but will not focus on the suspected organ in this case. The same is true of esophagogastroscopy.

Answer 125

Ultrasonography of the abdomen CT has demonstrated superiority over transabdominal ultrasonography for identifying appendicitis, associated abscess, and alternative diagnoses. However, ultrasonography is indicated for the evaluation of women who are pregnant and women in whom there is a high degree of suspicion for gynecologic disease.

Answer 126

hand, foot, and mouth disease Hand, foot, and mouth disease is a mild infection occurring in young children, and is caused by coxsackievirus A16, or occasionally by other strains of coxsackie- or enterovirus. In addition to the oral lesions, vesicular lesions may occur on the feet and nonvesicular lesions may occur on the buttocks. A low-grade fever may also develop. Herpangina is also caused by coxsackieviruses, but it is a more severe illness characterized by severe sore throat and vesiculo-ulcerative lesions limited to the tonsillar pillars, soft palate, and uvula, and occasionally the posterior oropharynx. Temperatures can range to as high as 41°C (106°F).

Answer 127

Acne neonatorum Acne neonatorum occurs in up to 20% of newborns. It typically consists of closed comedones on the forehead, nose, and cheeks, and is thought to result from stimulation of sebaceous glands by maternal and infant androgens. Parents should be counseled that lesions usually resolve spontaneously within 4 months without scarring.

Answer 128

Dog or cat hookworm (Ancylostoma species) This patient has cutaneous larva migrans, a common condition caused by dog and cat hookworms. Fecal matter deposited on soil or sand may contain hookworm eggs that hatch and release larvae, which are infective if they penetrate the skin. Walking barefoot on contaminated ground can lead to infection.

Answer 129

Topical betamethasone dipropionate (Diprolene) applied twice daily to the nail folds for 3-4 weeks Chronic paronychia is a common condition in workers whose hands are exposed to chemical irritants or are wet for long periods of time. This patient is an otherwise healthy hairdresser, with frequent exposure to irritants. The patient should be advised to avoid exposure to harsh chemicals and water. In addition, the use of strong topical corticosteroids over several weeks can greatly reduce the inflammation, allowing the nail folds to return to normal and helping the cuticles recover their natural barrier to infection. Soaking in iodine solution would kill bacteria, but would also perpetuate the chronic irritation. Because the condition is related to chemical and water irritation, a prolonged course of antibiotics should not be the first treatment step, and could have serious side effects.

Answer 130

Frozen shoulder Frozen shoulder is an idiopathic condition that most commonly affects patients between the ages of 40 and 60. Diabetes mellitus is the most common risk factor for frozen shoulder. Symptoms include shoulder stiffness, loss of active and passive shoulder rotation, and severe pain, including night pain. Laboratory tests and plain films are normal; the diagnosis is clinical (SOR C). Frozen shoulder is differentiated from chronic posterior shoulder dislocation and osteoarthritis on the basis of radiologic findings. Both shoulder dislocation and osteoarthritis have characteristic plain film findings. A patient with a rotator cuff tear will have normal passive range of motion. Impingement syndrome does not affect passive range of motion, but there will be pain with elevation of the shoulder

Answer 131

Ventricular tachycardia of torsades de pointes A well-known use of intravenous magnesium is for correcting the uncommon ventricular tachycardia of torsades de pointes. Results of a meta-analysis suggest that 1.2–10.0 g of intravenous magnesium sulfate also is a safe and effective strategy for the acute management of rapid atrial fibrillation.

Answer 132

Antibiotics should be prescribed Antibiotic use in moderately or severely ill patients with a COPD exacerbation reduces the risk of treatment failure or death, and may also help patients with mild exacerbations. Brief courses of systemic corticosteroids shorten hospital stays and decrease treatment failures.

Answer 133

Erythema toxicum neonatorum This infant has the typical “flea-bitten” rash of erythema toxicum neonatorum (ETN). ETN is completely benign and will resolve spontaneously. Other choices: - Transient neonatal pustular melanosis is most common in African-American newborns, and the lesions lack the surrounding erythema typical of ETN. - Acne neonatorum is associated with closed comedones, mostly on the face. - As the infant described is not ill, infectious etiologies are unlikely.

Answer 134

Having the infant sleep in a separate bed Having the infant sleep in a supine position (back to bed) also the risk of SIDS increases with higher room temperatures and soft bedding.

Answer 135

140–180 mg/dL The 2009 consensus guidelines on inpatient glycemic control issued by the American Association of Clinical Endocrinologists and the American Diabetes Association recommend insulin infusion with a target glucose level of 140–180 mg/dL in critically ill patients. This recommendation is based on clinical trials in critically ill patients. In the groups studied, there was no reduction in mortality from intensive treatment targeting near-euglycemic glucose levels compared to conventional management with a target glucose level of

Answer 136

1 year The recommended duration of dual antiplatelet therapy following placement of a drug-eluting coronary artery stent is 1 year (SOR C). The recommended dosages of dual antiplatelet therapy are aspirin, 162–325 mg, and clopidogrel, 75 mg, or prasugrel, 10 mg. Ticlopidine is an option for patients who do not tolerate clopidogrel or prasugrel. The minimum recommended duration of dual antiplatelet therapy is 1 month with bare-metal stents, 3 months with sirolimus-eluting stents, and 6 months with other drug-eluting stents.

Answer 137

ursodiol (Actigall) This patient’s symptoms and laboratory values are most consistent with intrahepatic cholestasis of pregnancy. Ursodiol has been shown to be highly effective in controlling the pruritus and decreased liver function (SOR A) and is safe for mother and fetus. Topical antipruritics and oral antihistamines are not very effective. Cholestyramine may be effective in mild or moderate intrahepatic cholestasis, but is less effective and safe than ursodiol.

Answer 138

It reduces the risk of transmission to others ``` Antibiotic treatment for pertussis is effective for eradicating bacterial infection but not for reducing the duration or severity of the disease. The eradication of infection is important for disease control because it reduces infectivity. Antibiotic treatment is thought to be most effective if started early in the course of the illness, characterized as the catarrhal phase. The paroxysmal stage follows the catarrhal phase. The CDC recommends macrolides for primary treatment of pertussis. The preferred antimicrobial regimen is azithromycin for 3–5 days or clarithromycin for 7 days. These regimens are as effective as longer therapy with erythromycin and have fewer side effects. Children under 1 month of age should be treated with azithromycin. There is an association between erythromycin and hypertrophic pyloric stenosis in young infants. Trimethoprim/sulfamethoxazole can be used in patients who are unable to take macrolides or where macrolide resistance may be an issue, but should not be used in children under the age of 2 months. Fluoroquinolones have been shown to reduce pertussis in vitro but have not been shown to be clinically effective (SOR A). ```

Answer 139

Tarsal coalition Tarsal coalition is the fusion of two or more tarsal bones. It occurs in mid-to late adolescence and is bilateral in 50% of those affected. Pain occurs around the ankle, and there is decreased range of motion of the hindfoot and pain on foot inversion on examination. Os trigonum results from non-ossification of cartilage. It usually is unilateral and causes palpable tenderness of the heel. Sever’s apophysitis is inflammation of the calcaneal apophysis, and causes pain in the heel. Plantar fasciitis causes tenderness over the anteromedial heel. Navicular stress fractures are tender over the dorsomedial navicular.

Answer 140

Breast cancer screening has resulted in an increase in the diagnosis of localized disease without a commensurate decrease in the incidence of more widespread disease. Unfortunately, it cannot predict which of the discovered cancers are more aggressive, and cannot accurately detect premalignant lesions. The decrease in the mortality rate of breast cancer is due both to earlier detection and better follow-up medical care. JAMA 2009

Answer 141

Bupropion (Wellbutrin) Bupropion is the antidepressant least likely to cause weight gain, and may induce modest weight loss. All of the other choices are more likely to cause weight gain. Among SSRIs, paroxetine is associated with the most weight gain and fluoxetine with the least. Mirtazapine has been associated with more weight gain than the SSRIs.

Answer 142

Medicare pays for some preventive measures, including pneumococcal vaccine, influenza vaccine, annual mammography, and a Papanicolaou test every 3 years. Medicare does not pay for custodial care, nursing-home care (except limited skilled nursing care), dentures, routine dental care, eyeglasses, hearing aids, routine physical checkups and related tests, or prescription drugs.

Answer 143

Viral infection The presence of reactive lymphocytes will often be reported on a manual differential, since they have a distinctive appearance. The most common conditions that produce a reactive lymphocytosis are viral infections. Most notable are Epstein-Barr virus, infectious mononucleosis, and cytomegalovirus. Other viral infections known to cause this finding include herpes simplex, herpes zoster, HIV, hepatitis, and adenovirus.

Answer 144

Lumbar spine extension Extension that increases lumbar lordosis decreases the cross-sectional area of the spinal canal, thereby compressing the spinal cord further. Walking downhill can cause this. Spinal flexion that decreases lordosis has the opposite effect, and will usually improve the pain, as will sitting. Pain with internal hip rotation is characteristic of hip arthritis and is often felt in the groin. Pain in the lateral hip is more typical of trochanteric bursitis. Increased pain walking uphill is more typical of vascular claudication.

Answer 145

Their effects begin within 5 minutes and last 4–6 hours The effects of short-acting inhaled β-agonists begin within 5 minutes and last 4–6 hours. In the past, giving inhaled β-agonists just before inhaled corticosteroids was felt to improve the delivery and effectiveness of the corticosteroids. However, this has been proven to be ineffective and is no longer recommended. β-Blockers do diminish the effectiveness of inhaled β-agonists, but this effect is not severe enough to contraindicate using these drugs together. Oral β-agonists are less potent than inhaled forms. Similarly, anticholinergic drugs cause less bronchodilation than inhaled β-agonists and are not recommended as first-line therapy.

Answer 146

They should be avoided in persons with cirrhotic liver disease NSAIDs are prescribed commonly and many are available over the counter. It is important for clinicians to understand when they are not appropriate for clinical use. They should be avoided, if possible, in persons with hepatic cirrhosis (SOR C). While hepatotoxicity with NSAIDs is rare, they can increase the risk of bleeding in cirrhotic patients, as they further impair platelet function. In addition, NSAIDs decrease blood flow to the kidneys and can increase the risk of renal failure in patients with cirrhosis. NSAIDs differ from aspirin in terms of their cardiovascular effects. They have the potential to increase cardiovascular morbidity, worsen heart failure, increase blood pressure, and increase events such as ischemia and acute myocardial infarction. There are no known teratogenic effects of NSAIDs in humans. This drug class is considered to be safe in pregnancy in low, intermittent doses, although discontinuation of NSAID use within 6–8 weeks of term is recommended. Ibuprofen, indomethacin, and naproxen are considered safe for lactating women, according to the American Academy of Pediatrics.

Answer 147

Growth hormone deficiency This patient has delayed bone age coupled with a reduced growth velocity, which suggests an underlying systemic cause. Growth hormone deficiency is one possible cause for this. Although bone age can be delayed with constitutional growth delay, after 24 months of age growth curves are parallel to the 3rd percentile. Bone age would be normal with genetic short stature. Patients with Turner syndrome or skeletal dysplasia have dysmorphic features, and bone age would be normal.

AAFP 1 Flashcards

(173 cards)