AAFP 2 Flashcards

Question

The most appropriate initial treatment for scabies in an 8-year-old male is:

Answer 1

5% permethrin cream (Elimite) In adults and children over 5 years of age, 5% permethrin cream is standard therapy for scabies. This agent is highly effective, minimally absorbed, and minimally toxic.

Answer 2

Excision of the lateral nail plate combined with lateral matricectomy Excision of the lateral nail plate with lateral matricectomy yields the best results in the treatment of painful ingrown toenails that display granulation tissue and lateral nail fold hypertrophy. Antibiotic therapy and cotton-wick elevation are acceptable for very mildly inflamed ingrown toenails. Partial nail avulsion often leaves a spicule of nail that will grow and become an ingrown nail. Phenol produces irregular tissue destruction and significant inflammation and discharge after the matricectomy procedure.

Answer 3

Non-group A Streptococcus Cellulitis in patients after breast lumpectomy is thought to be related to lymphedema. Axillary dissection and radiation predispose to these infections. Non–group A hemolytic Streptococcus is the most common organism associated with this infection. The onset is often several weeks to several months after surgery.

Answer 4

Herpes gladiatorum The most common infection transmitted person-to-person in wrestlers is herpes gladiatorum caused by the herpes simplex virus. Molluscum contagiosum causes keratinized plugs. Human papillomavirus causes warts. Tinea corporis is ringworm, which is manifested by round to oval raised areas with central clearing.

Answer 5

Actinic keratosis Family physicians should advise patients of the dangers of sun exposure especially those with a fair complexion who work outdoors. Although malignant melanoma is the most serious condition of those listed, actinic keratosis may lead to squamous cell carcinoma with significant morbidity

Answer 6

video-electroencephalography (vEEG) monitoring Inpatient video-electroencephalography (vEEG) monitoring is the preferred test for the diagnosis of psychogenic nonepileptic seizures (PNES), and is considered the gold standard (SOR B). Video-EEG monitoring combines extended EEG monitoring with time-locked video acquisition that allows for analysis of clinical and electrographic features during a captured event. Many other types of evidence have been used, including the presence or absence of self-injury and incontinence, the ability to induce seizures by suggestion, psychologic tests, and ambulatory EEG. While useful in some cases, these alternatives have been found to be insufficient for the diagnosis of PNES. Elevated postictal prolactin levels (at least two times the upper limit of normal) have been used to differentiate generalized and complex partial seizures from PNES, but are not reliable (SOR B). While prolactin levels are often elevated after an epileptic seizure, they do not always rise, and the timing of measurement is crucial, making this a less sensitive test than was previously believed. Other serum markers have also been used to help distinguish PNES from epileptic seizures, including creatine phosphokinase, cortisol, WBC counts, lactate dehydrogenase, pCO2 , and neuron-specific enolase. These also are not reliable, as threshold levels for abnormality, sensitivity, and specificity have not been determined. MRI is not reliable because abnormal brain MRIs have been documented in as many as one-third of patients with PNES. In addition, patients with epileptic seizures often have normal brain MRIs.

Answer 7

Herpangina Herpangina is a febrile disease caused by coxsackieviruses and echoviruses. Vesicles and subsequent ulcers develop in the posterior pharyngeal area (SOR C). Herpes infection causes a gingivostomatitis that involves the anterior mouth. Mononucleosis may be associated with petechiae of the soft palate, but does not usually cause pharyngeal lesions. The exanthem in roseola usually coincides with defervescence. Mucosal involvement is not noted. Rubella may cause an enanthem of pinpoint petechiae involving the soft palate (Forschheimer spots), but not the pharynx.

Answer 8

Metronidazole gel (MetroGel) Rosacea is a relatively common condition seen most often in women between the ages of 30 and 60. Central facial erythema and telangiectasias are prominent early features that may progress to a chronic infiltrate with papules and sometimes sterile pustules. Facial edema also may occur. Some patients develop rhinophyma due to hypertrophy of the subcutaneous glands of the nose. The usual presenting symptoms are central facial erythema and flushing that many patients find socially embarrassing. Flushing can be triggered by food, environmental, chemical, or emotional triggers. Ocular problems occur in half of patients with rosacea, often in the form of an intermittent inflammatory conjunctivitis with or without blepharitis. Management includes avoidance of precipitating factors and use of sunscreen. Oral metronidazole, doxycycline, or tetracycline also can be used, especially if there are ocular symptoms. These are often ineffective for the flushing, so low-dose clonidine or a nonselective β-blocker may be added. Topical treatments such as metronidazole and benzoyl peroxide may also be effective, particularly for mild cases. Other illnesses to consider include acne, photodermatitis, systemic lupus erythematosus, seborrheic dermatitis, carcinoid syndrome, and mastocytosis.

Answer 9

Gonorrhea The diagnosis of any sexually transmitted or associated infection in a postnatal prepubescent child should raise immediate suspicion of sexual abuse and prompt a thorough physical evaluation, detailed historical inquiry, and testing for other common sexually transmitted diseases. Gonorrhea, syphilis, and postnatally acquired Chlamydia or HIV are virtually diagnostic of sexual abuse, although it is possible for perinatal transmission of Chlamydia to result in infection that can go unnoticed for as long as 2–3 years. Although a diagnosis of genital herpes, genital warts, or hepatitis B should raise a strong suspicion of possible inappropriate contact and should be reported to the appropriate authorities, other forms of transmission are common. Genital warts or herpes may result from autoinoculation, and most cases of hepatitis B appear to be contracted from nonsexual household contact. Bacterial vaginosis provides only inconclusive evidence for sexual contact, and is the only one of the options listed for which reporting is neither required nor strongly recommended.

Answer 10

Streptococcus The most common pathogens in previously untreated acute superficial foot infections in diabetic patients are aerobic gram-positive Staphylococcus aureus and β-hemolytic streptococci (groups A, B, and others). Previously treated and deep infections are often polymicrobial.

Answer 11

Myoclonic status epilepticus at 24 hours It is difficult to establish a prognosis in a comatose patient after a cardiac arrest. The duration of CPR is not a factor, and the absence of pupillary and corneal reflexes, as well as motor responses to pain, are not reliable predictors before 72 hours. Myoclonic status epilepticus at 24 hours suggests no possibility of a recovery.

Answer 12

Primary hyperparathyroidism Primary hyperparathyroidism and malignancy account for more than 90% of hypercalcemia cases. These conditions must be differentiated early to provide the patient with optimal treatment and an accurate prognosis. Humoral hypercalcemia of malignancy implies a very limited life expectancy—often only a matter of weeks. On the other hand, primary hyperparathyroidism has a relatively benign course. Intact parathyroid hormone (PTH) will be suppressed in cases of malignancy-associated hypercalcemia, except for extremely rare cases of parathyroid carcinoma. Thyrotoxicosis-induced bone resorption elevates serum calcium, which also results in suppression of PTH. Patients with familial hypocalciuric hypercalcemia (FHH) have moderate hypercalcemia but relatively low urinary calcium excretion. PTH levels can be normal or only mildly elevated despite the hypercalcemia. This mild elevation can lead to an erroneous diagnosis of primary hyperparathyroidism. The conditions can be differentiated by a 24-hour urine collection for calcium; calcium levels will be high or normal in patients with hyperparathyroidism and low in patients with FHH.

Answer 13

IGRA differentiates Mycobacterium tuberculosis from nontuberculous mycobacteria In vitro interferon-gamma release assays (IGRAs) are a new way of screening for latent tuberculosis infection. One of the advantages of IGRA is that it targets antigens specific to Mycobacterium tuberculosis. These proteins are absent from the BCG vaccine strains and from commonly encountered nontuberculous mycobacteria. Unlike skin testing, the results of IGRA are objective. It is unnecessary for IGRA to be done in tandem with skin testing, and it eliminates the need for two-step testing in high-risk patients. IGRAs are labor intensive, however, and the blood sample must be received by a qualified laboratory and incubated with the test antigens within 8-16 hours of the time it was drawn,depending upon the brand of cuurently available IGRAs

Answer 14

Stress reduction and participation in usual activities as much as possible The diagnosis of functional abdominal pain is made when no structural, infectious, inflammatory, or biochemical cause for the pain can be found. It is the most common cause of recurrent abdominal pain in children 4–16 years of age. The use of medications may be helpful in reducing (but rarely eradicating) functional symptoms, and remaining open to the possibility of a previously unrecognized organic disorder is appropriate. However, continuing to focus on organic causes, invasive tests, or physician visits can actually perpetuate a child’s complaints and distress. It is estimated that approximately 30%–50% of children with functional abdominal pain will have resolution of their symptoms within 2 weeks of diagnosis. Recommendations for managing this problem include focusing on participation in normal age-appropriate activities, reducing stress and addressing emotional distress, and teaching the family to cope with the symptoms in a way that prevents secondary gain on the part of the child.

Answer 15

Treatment of sustained ventricular tachyarrhythmias in patients with poor hemodynamic stability Amiodarone is one of the most frequently prescribed antiarrhythmic medications in the U.S. It is useful in the acute management of sustained ventricular tachyarrhythmias, regardless of hemodynamic stability. Amiodarone is appropriate first-line treatment for atrial fibrillation only in symptomatic patients with left ventricular dysfunction and heart failure. It has a very limited role in the treatment of atrial flutter. The only role for prophylactic amiodarone is in the perioperative period of cardiac surgery. The use of prophylactic antiarrhythmic agents in the face of “warning dysrhythmias” or after myocardial infarction is no longer recommended. Prophylactic amiodarone is not indicated for primary prevention in patients with nonischemic cardiomyopathy.

Answer 16

Obtain a bone marrow examination This patient has typical symptoms and laboratory findings of multiple myeloma, which accounts for 1% of all malignant diseases and has a mean age at diagnosis of 61 years. The diagnosis is confirmed by a bone marrow examination showing >10% plasma cells in the marrow. The serum level of M-protein is typically >3 g/dL.

Answer 17

Intravenous drug use A young man with weight loss, oral thrush, lymphadenopathy, and ulcerative esophagitis is likely to have HIV infection. Intravenous drug use is responsible for over a quarter of HIV infections in the United States. Esophageal disease develops in more than half of all patients with advanced infection during the course of their illness. The most common pathogens causing esophageal ulceration in HIV-positive patients include Candida, herpes simplex virus, and cytomegalovirus. Identifying the causative agent through culture or tissue sampling is important for providing prompt and specific therapy.

Answer 18

Factor VIII level Hemophilia is X-linked and occurs in approximately 1 in 5000 male births, with 85% having factor VIII deficiency (hemophilia A) and the remaining 15% having factor IX (hemophilia B) and factor XI (hemophilia C) deficiency. Because factor VIII does not cross the placenta, bleeding symptoms may be present from birth, with the most dreaded manifestation being intracranial hemorrhage. About 30% of affected male infants will bleed from the circumcision site. The only “routine” laboratory test that is affected by a reduced level of factor VIII is the activated partial thromboplastin time. Once hemophilia is suspected, the specific assay for factor VIII will confirm the diagnosis. Factor VIII levels in affected persons vary from less than 1% to approximately 25% of normal activity. Clinical severity of the disease varies with the degree of deficiency of factor VIII activity. Recently developed recombinant factor VIII for treating patients with hemophilia can help prevent transfusion-related infections. Deficiencies of antithrombin III, protein S and protein C, and mutations of the gene for factor V (factor V Leiden) are associated with thrombotic conditions, not bleeding.

Answer 19

Zidovudine (Retrovir) for both the mother and neonate Antiretroviral treatment has been proven to reduce vertical transmission of HIV from mother to child. Benefits have been shown for antenatal, intrapartum, and postpartum treatments. Zidovudine and nevirapine have the most well-established track record.

Answer 20

Pneumococcal vaccine (Pneumovax) Asplenic and functionally asplenic patients are susceptible to overwhelming infection from encapsulated organisms, and should be immunized with pneumococcal, meningococcal, and Hib vaccines. The vaccines’ immunogenicity may be reduced when given after splenectomy or during chemotherapy; thus, they should be given at least 2 weeks before performing elective splenectomy or starting chemotherapy if possible.

Answer 21

Vitamin B12 There is no known vegetable source for vitamin B12. If the diet contains milk and eggs, however, the requirement will be satisfied. Vitamin C is present in high concentrations in fruits and vegetables. Vitamin A is found in green, leafy vegetables. Thiamine is present in grains, especially the outer coatings.

Answer 22

HIV infection HIV and HTLV-1 (human T-cell lymphotropic virus) infections are the only infectious diseases that are considered absolute contraindications to breastfeeding in developed countries such as the U.S. The other infections listed may require temporary isolation of the baby from the mother, prophylactic treatment, or immunization of the baby and/or feeding pumped breast milk, but none are absolute contraindications to breastfeeding. For example, if the diagnosis of maternal hepatitis A is made within the period of contagiousness (approximately 3 weeks), careful handwashing by the mother is appropriate, and the infant can receive immunoglobulin and hepatitis A virus vaccine. Studies have shown that in full-term, healthy infants, acquisition of cytomegalovirus from breast milk does not result in significant clinical disease and is considered natural vaccination. Since breast milk does not contain tubercle bacilli, mothers with active tuberculosis may pump their milk to be bottle-fed to the infant by another person. For some common infections, such as the common cold, infants have already been exposed by maternal contact during the prodromal period, and interrupting breastfeeding would be counterproductive given that it provides the infant with antibodies and other anti-inflammatory and immunomodulating substances.

Answer 23

Serum transferrin saturation The diagnosis of hereditary hemochromatosis is based on a combination of clinical, laboratory, and pathologic criteria. Serum transferrin saturation is the best initial screening value. Serum ferritin concentration is a sensitive measure of iron overload, but ferritin is an acute-phase reactant and is therefore elevated in a variety of infectious and inflammatory conditions in the absence of iron overload.

Answer 24

Bleeding history Bleeding time, activated partial thromboplastin time (aPTT), and prothrombin time (PT) are relatively poor predictors of bleeding risk. Studies have shown that baseline coagulation assays do not predict postoperative bleeding in patients undergoing general or vascular surgery who have no history that suggests a bleeding disorder. Obtaining a history for evidence of prior bleeding problems is the most sensitive and accurate method of determining a patient’s risk.

Answer 25

Iron deficiency This child has evidence of a mild microcytic anemia, which is most commonly caused by iron deficiency related to reduced dietary intake. Less common causes are thalassemia and lead poisoning. Hemolysis usually causes a normocytic anemia with an elevated reticulocyte count. Chronic liver disease and hypothyroidism result in macrocytic anemias.

Answer 26

Malrotation and midgut volvulus Infants with malrotation and midgut volvulus often present in the first week of life with symptoms of bilious vomiting and bowel obstruction. Both duodenal and jejunoileal atresia most commonly present within the first 24 hours of life. Vomiting associated with pyloric stenosis is always non-bilious, and the diagnosis is most commonly made after the first week of life. Necrotizing enterocolitis may also be associated with bilious vomiting, but typically occurs at 10–12 days of life and is accompanied by abdominal distention and visible and/or palpable loops of bowel.

Answer 27

Melanosis coli This patient has typical findings of melanosis coli, the term used to describe black or brown discoloration of the mucosa of the colon. It results from the presence of dark pigment in large mononuclear cells or macrophages in the lamina propria of the mucosa. The coloration is usually most intense just inside the anal sphincter and is lighter higher up in the sigmoid colon. The condition is thought to result from fecal stasis and the use of anthracene cathartics such as cascara sagrada, senna, and danthron.

Answer 28

Ectopic (heterotrophic) gastric mucosa causing acid-induced bleeding of ileal mucosa Most bleeding in Meckel’s diverticulum is secondary to heterotrophic gastric mucosa, causing acid-induced ileal ulceration. Helicobacter pylori has not been shown to be an etiologic agent. Intussusception is fairly common in patients with Meckel’s diverticulum but is not a frequent cause of bleeding.

Answer 29

It is associated with an increased risk of adenocarcinoma Barrett’s esophagus is an acquired intestinal metaplasia of the distal esophagus associated with longstanding gastroesophageal acid reflux, although a quarter of patients with Barrett’s esophagus have no reflux symptoms. It is more common in white and Hispanic men over 50 with longstanding severe reflux symptoms, and possible risk factors include obesity and tobacco use. It is a risk factor for adenocarcinoma of the esophagus, with a rate of about one case in every 200 patients with Barrett’s esophagus per year. Treatment is directed at reducing reflux, thus reducing symptoms. Neither medical nor surgical treatment has been shown to reduce the carcinoma risk. One reasonable screening suggestion is to perform esophagoduodenoscopy in all men over 50 with gastroesophageal reflux disease (GERD), but these recommendations are based only on expert opinion (level C evidence), and no outcomes-based guidelines are available.

Answer 30

Iguanas Pet-associated salmonellosis was a significant problem in the 1970s. In 1975, Canada banned the importation of turtles, and in the same year the FDA prohibited the sale of small turtles in the U.S. However, the popularity of iguanas and other reptiles is increasing; these reptiles can also transmit Salmonella to humans. Reptile-associated salmonellosis causes febrile gastroenteritis, septicemia, and meningitis.

Answer 31

Campylobacter jejuni

Answer 32

Elliptical excision of the thrombosed hemorrhoid The appropriate management of a thrombosed hemorrhoid presenting within 48 hours of onset of symptoms is an elliptical excision of the hemorrhoid and overlying skin under local anesthesia (i.e., 0.5% bupivacaine hydrochloride [Marcaine] in 1:200,000 epinephrine) infiltrated slowly with a small (27 gauge) needle for patient comfort. Incision and clot removal may provide inadequate drainage with rehemorrhage and clot reaccumulation. Most thrombosed hemorrhoids contain multilocular clots which may not be accessible through a simple incision. Rubber band ligation is an excellent technique for management of internal hemorrhoids. Banding an external hemorrhoid would cause exquisite pain. When pain is already subsiding or more time has elapsed (in the absence of necrosis or ulceration), measures such as sitz baths, bulk laxatives, stool softeners, and local analgesia may all be helpful. Some local anesthetics carry the risk of sensitization, however counseling to avoid precipitating factors (e.g., prolonged standing/sitting, constipation, delay of defecation) is also appropriate.

Answer 33

Neuroblastoma Tumor markers are useful in determining the diagnosis and sometimes the prognosis of certain tumors. They can aid in assessing response to therapy and detecting tumor recurrence. Serum neuron-specific enolase (NSE) testing, as well as spot urine testing for homovanillic acid (HVA) and vanillylmandelic acid (VMA), should be obtained if neuroblastoma or pheochromocytoma is suspected; both should be collected before surgical intervention. Quantitative beta-human chorionic gonadotropin (hCG) levels can be elevated in liver tumors and germ cells tumors. Alpha-fetoprotein is excreted by many malignant teratomas and by liver and germ cell tumors.

Answer 34

Celiac disease This constellation of symptoms strongly suggests celiac disease, a surprisingly common disease with a prevalence of 1:13 in the U.S. Half the adults in the U.S. with celiac disease or gluten-sensitive enteropathy present with anemia or osteoporosis, without gastrointestinal symptoms. Individuals with more significant mucosal involvement present with watery diarrhea, weight loss, and vitamin and mineral deficiencies.

Answer 35

Markedly decreased activity until the pain lessens, and follow-up in 1 week This patient has suffered a thoracic vertebral compression fracture. Most can be managed conservatively with decreased activity until the pain is tolerable, possibly followed by some bracing. Vertebroplasty is an option when the pain is not improved in 2 weeks. Complete bed rest is unnecessary and could lead to complications. Physical therapy is not indicated, and NSAIDs should be used with caution.

Answer 36

5 years Overuse of colonoscopy has significant costs. In response to these concerns, the American Cancer Society and the U.S. Multi-Society Task Force on Colorectal Cancer collaborated on a consensus guideline on the use of surveillance colonoscopy. According to these guidelines, patients with one or two small (

Answer 37

Metformin (Glucophage) This patient fits the criteria for polycystic ovary syndrome (oligomenorrhea, acne, hirsutism, hyperandrogenism, infertility). Symptoms also include insulin resistance. Evidence of polycystic ovaries is not required for the diagnosis. Metformin has the most evidence supporting its use in this situation, and is the only treatment listed that is likely to decrease hirsutism and improve insulin resistance and menstrual irregularities. Metformin and clomiphene alone or in combination are first-line agents for ovulation induction.

Answer 38

Shorter stays in the emergency department Compared to nebulizers, MDIs with spacers have been shown to lower pulse rates, provide greater improvement in peak-flow rates, lead to greater improvement in arterial blood gases, and decrease required albuterol doses. They have also been shown to lower costs, shorten emergency department stays, and significantly lower relapse rates at 2 and 3 weeks compared to nebulizers. There is no difference in hospital admission rates.

Answer 39

Conversion aphonia This patient has conversion aphonia. In this condition, the patient loses his or her spoken voice, but the whispered voice is maintained. The vocal cords appear normal, but if observed closely by an otolaryngologist, there is a loss of vocal cord adduction during phonation, but normal adduction with coughing or throat clearing. This often occurs after a traumatic event (in this case a divorce) (SOR C). Muscle tension aphonia presents with strained, effortful phonation, vocal fatigue, and normal vocal cords. It is caused by excessive laryngeal or extralaryngeal tension associated with a variety of factors, including poor breath control and stress, for example. The patient with laryngopharyngeal reflux presents with a raspy or harsh voice. The hoarseness is usually worse early in the day and improves as the day goes by. There is usually associated heartburn, dysphagia, and/or throat clearing. The patient with spasmodic dysphonia (also known as laryngeal dystonia) has a halting, strangled vocal quality. It is a distinct neuromuscular disorder of unknown cause. Uncontrolled contractions of the laryngeal muscles cause focal laryngeal spasm. The hoarseness of vocal abuse is usually worse later in the day after effortful singing or talking. The history usually reveals vocal cord abuse, such as with an untrained singer or some other situation that increases demands on the voice. Nodules or cysts may be seen on the vocal cords with this condition.

Answer 40

Acetaminophen Intra-articular injections should not be considered first-line treatment for symptomatic osteoarthritis of the knee. They are recommended for short-term pain control, with the evidence for hyaluronic acid being somewhat weak. Renal dysfunction is a contraindication to the use of NSAIDs. Acetaminophen is the first-line treatment in this case.

Answer 41

Transvaginal ultrasonography The initial evaluation for chronic pelvic pain should include a urinalysis and culture, cervical swabs for gonorrhea and Chlamydia, a CBC, an erythrocyte sedimentation rate, a β-hCG level, and pelvic ultrasonography. CT and MRI are not part of the recommended initial diagnostic workup, but may be helpful in further assessing any abnormalities found on pelvic ultrasonography. Referral for diagnostic laparoscopy is appropriate if the initial workup does not reveal a source of the pain, or if endometriosis or adhesions are suspected. Colonoscopy would be indicated if the history or examination suggests a gastrointestinal source for the pain after the initial evaluation

Answer 42

Yes The patient has a score of 5 under the Modified Centor scoring system for management of sore throat. Patients with a score ≥4 are at highest risk (at least 50%) of having group A β-hemolytic streptococcal (GABHS) pharyngitis, and empiric treatment with antibiotics is warranted. Various national and international organizations disagree about the best way to manage pharyngitis, with no consensus as to when or how to test for GABHS and who should receive treatment.

Answer 43

Flattening of the inspiratory portion of the flow-volume loop, but a normal expiratory phase The diagnosis of vocal cord dysfunction should be considered in patients diagnosed with exercise-induced asthma who do not have a good response to β-agonists before exercise. Pulmonary function testing with a flow-volume loop typically shows a normal expiratory portion but a flattened inspiratory phase (SOR C). A decreased FEV1 and normal FVC would be consistent with asthma.

Answer 44

Immobilization in a cast boot for 3 weeks is indicated The diagnosis of tendinopathy of the posterior tibial tendon is important, in that the tendon’s function is to perform plantar flexion of the foot, invert the foot, and stabilize the medial longitudinal arch. An injury can, over time, elongate the midfoot and hindfoot ligaments, causing a painful flatfoot deformity. The patient usually recalls no trauma, although the injury may occur from twisting the foot by stepping in a hole. This is most commonly seen in women over the age of 40. Without proper treatment, progressive degeneration of the tendon can occur, ultimately leading to tendon rupture. Pain and swelling of the tendon is often noted, and is misdiagnosed as a medial ankle sprain. With the patient standing on tiptoe, the heel should deviate in a varus alignment, but this does not occur on the involved side. A single-leg toe raise should reproduce the pain, and if the process has progressed, this maneuver indicates progression of the problem. While treatment with acetaminophen or NSAIDs provides short-term pain relief, neither affects long-term outcome. Corticosteroid injection into the synovial sheath of the posterior tibial tendon is associated with a high rate of tendon rupture and is not recommended. The best initial treatment is immobilization in a cast boot or short leg cast for 2–3 weeks.

Answer 45

Bilateral renal artery stenosis Classic clinical clues that suggest a diagnosis of renal-artery stenosis include the onset of stage 2 hypertension (blood pressure >160/100 mm Hg) after 50 years of age or in the absence of a family history of hypertension; hypertension associated with renal insufficiency, especially if renal function worsens after the administration of an agent that blocks the renin-angiotensin-aldosterone system; hypertension with repeated hospital admissions for heart failure; and drug-resistant hypertension (defined as blood pressure above the goal despite treatment with three drugs of different classes at optimal doses).

Answer 46

CT angiography would reliably either confirm or rule out PE This patient has a high clinical probability for pulmonary embolism (PE). About 40% of patients with PE will have positive findings for deep-vein thrombosis in the lower extremities on compression ultrasonography. A normal ventilation-perfusion lung scan rules out PE, but inconclusive findings are frequent and are not reassuring. A normal D-dimer level reliably rules out the diagnosis of venous thromboembolism in patients at low or moderate risk of pulmonary embolism, but the negative predictive value of this test is low for high-probability patients. A positive D-dimer test does not confirm the diagnosis; it indicates the need for further testing, and is thus not necessary for this patient. A multidetector CT angiogram or ventilation-perfusion lung scan should be the next test, as these are reliable to confirm or rule out PE.

Answer 47

Placental abruption Late pregnancy bleeding may cause fetal morbidity and/or mortality as a result of uteroplacental insufficiency and/or premature birth. The condition described here is placental abruption (separation of the placenta from the uterine wall before delivery). There are several causes of vaginal bleeding that can occur in late pregnancy that might have consequences for the mother, but not necessarily for the fetus, such as cervicitis, cervical polyps, or cervical cancer. Even advanced cervical cancer would be unlikely to cause the syndrome described here. The other conditions listed may bring harm to the fetus and/or the mother. Uterine rupture usually occurs during active labor in women with a history of a previous cesarean section or with other predisposing factors, such as trauma or obstructed labor. Vaginal bleeding is an unreliable sign of uterine rupture and is present in only about 10% of cases. Fetal distress or demise is the most reliable presenting clinical symptom. Vasa previa (the velamentous insertion of the umbilical cord into the membranes in the lower uterine segment) is typically manifested by the onset of hemorrhage at the time of amniotomy or by spontaneous rupture of the membranes. There are no prior maternal symptoms of distress. The hemorrhage is actually fetal blood, and exsanguination can occur rapidly. Placenta previa (placental implantation that overlies or is within 2 cm of the internal cervical os) is clinically manifested as vaginal bleeding in the late second or third trimester, often after sexual intercourse. The bleeding is typically painless, unless labor or placental abruption occurs.

Answer 48

Iron supplementation This patient has restless legs syndrome, which includes unpleasant sensations in the legs and can cause sleep disturbances. The symptoms are relieved by movement. Recommendations for treatment include lower-body resistance training and avoiding or changing medications that may exacerbate symptoms (e.g., antihistamines, caffeine, SSRIs, tricyclic antidepressants, etc.). It is also recommended that patients with a serum ferritin level below 50 ng/mL take an iron supplement (SOR C). Magnesium supplementation does not improve restless legs syndrome. Ropinirole may be used if nonpharmacologic therapies are ineffective.

Answer 49

CT of the abdomen and pelvis Based on the history and physical examination, this patient most likely has acute diverticulitis. CT has a very high sensitivity and specificity for this diagnosis, provides information on the extent and stage of the disease, and may suggest other diagnoses. Ultrasonography may be helpful in suggesting other diagnoses, but it is not as specific or as sensitive for diverticulitis as CT. Limited-contrast studies of the distal colon and rectum may occasionally be useful in distinguishing between diverticulitis and carcinoma, but would not be the initial procedure of choice. Water-soluble contrast material is used in this situation instead of barium. Colonoscopy to detect other diseases, such as cancer or inflammatory bowel disease, is deferred until the acute process has resolved, usually for 6 weeks. The risk of perforation or exacerbation of the disease is greater if colonoscopy is performed acutely. Diagnostic laparoscopy is rarely needed in this situation. Laparoscopic or open surgery to drain an abscess or resect diseased tissue is reserved for patients who do not respond to medical therapy. Elective sigmoid resection may be considered after recovery in cases of recurrent episodes.

Answer 50

Finding the underlying pathology causing the hiccups Hiccups are caused by a respiratory reflex that originates from the phrenic and vagus nerves, as well as the thoracic sympathetic chain. Hiccups that last a matter of hours are usually benign and self-limited, and may be caused by gastric distention. Treatments usually focus on interrupting the reflex loop of the hiccup, and can include mechanical means (e.g., stimulating the pharynx with a tongue depressor) or medical treatment, although only chlorpromazine is FDA-approved for this indication. If the hiccups have lasted more than a couple of days, and especially if they are waking the patient up at night, there may be an underlying pathology causing the hiccups. In one study, 66% of patients who experienced hiccups for longer than 2 days had an underlying physical cause. Identifying and treating the underlying disorder should be the focus of management for intractable hiccups.

Answer 51

Ischemic colitis This patient most likely has ischemic colitis, given the abdominal pain, bloody diarrhea, and cardiovascular risks. Peptic ulcer disease is unlikely because the nasogastric aspirate was negative. Diverticular bleeding and angiodysplasia are painless. Infectious colitis is associated with fever.

Answer 52

Discontinue heparin and start a non-heparin anticoagulant such as argatroban or desirudin (Iprivask) This patient needs prompt evaluation and treatment for probable heparin-induced thrombocytopenia (HIT). HIT is a potentially life-threatening syndrome that usually occurs within 1–2 weeks of heparin administration and is characterized by the presence of HIT antibodies in the serum, associated with an otherwise unexplained 30%–50% decrease in the platelet count, arterial or venous thrombosis, anaphylactoid reactions immediately following heparin administration, or skin lesions at the site of heparin injections. Postoperative patients receiving subcutaneous unfractionated heparin prophylaxis are at highest risk for HIT. Because of this patient’s high-risk scenario and the presence of acute thrombosis, it is advisable to begin immediate empiric treatment for HIT pending laboratory confirmation. Management should include discontinuation of heparin and treatment with a non-heparin anticoagulant.

Answer 53

Cognitive-behavioral therapy Chronic insomnia is defined as difficulty with initiating or maintaining sleep, or experiencing nonrestorative sleep, for at least 1 month, leading to significant daytime impairment. Primary insomnia is not caused by another sleep disorder, underlying psychiatric or medical condition, or substance abuse disorder. Cognitive-behavioral therapy is effective for managing this problem, and should be used as the initial treatment for chronic insomnia. It has been shown to produce sustained improvement at both 12 and 24 months after treatment is begun. One effective therapy is stimulus control, in which patients are taught to eliminate distractions and associate the bedroom only with sleep and sex. Reading and television watching should occur in a room other than the bedroom. Pharmacotherapy alone does not lead to sustained benefits. SSRIs can cause insomnia, as can alcohol.

Answer 54

Warfarin (Coumadin) The CHADS2 score is a validated clinical prediction rule for determining the risk of stroke and who should be anticoagulated. Points are assigned based on the patient’s comorbidities. One point is given for each of the following: history of congestive heart failure (C), hypertension (H), age ³75 (A), and diabetes mellitus (D). Two points are assigned for a previous stroke or TIA (S2 ). For patients with a score of 0 or 1, the risk of stroke is low and warfarin would not be recommended. Warfarin is the agent of choice for the prevention of stroke in patients with atrial fibrillation and a score ³2. In these patients, the risk of stroke is higher than the risks associated with taking warfarin. Enoxaparin is an expensive injectable anticoagulant and is not indicated for the long-term prevention of stroke.

Answer 55

Vitamin B 12

Answer 56

130/80 mm Hg Hypertension and diabetes mellitus are very common, both separately and in combination. End-organ damage to the heart, brain, and kidneys is more common in patients with both diabetes mellitus and hypertension, occurring at lower blood pressure levels than in patients with only hypertension. JNC 7, an evidence-based consensus report, recommends that patients with diabetes and hypertension be treated to reduce blood pressure to below 130/80 mm Hg, as opposed to 140/90 mm Hg for other adults. It should be noted, however, that the recently published ACCORD blood pressure trial found no significant cardiovascular benefit from targeting systolic blood pressure at

Answer 57

Trough serum levels The best predictor of vancomycin efficacy is the trough serum concentration, which should be over 10 mg/L to prevent development of bacterial resistance. Peak serum concentration is not a predictor of efficacy or toxicity. Monitoring for ototoxicity is not currently recommended. Older vancomycin products had impurities, which apparently caused the ototoxicity seen with these early formulations of the drug.

Answer 58

Impingement Choices: Osteoarthritis, Avascular necrosis, Bursitis, Pathologic fracture Gradually worsening anterolateral hip joint pain that is sharply accentuated when pivoting laterally on the affected hip or moving from a seated to a standing position is consistent with femoroacetabular impingement. Reproduction of the pain on range-of-motion examination by manipulating the hip into a position of flexion, adduction, and internal rotation (FADIR test) is the most sensitive physical finding. Special radiographic imaging of the flexed and adducted hip can emphasize the anatomic abnormalities associated with impingement that may go unnoticed on standard radiographic series views. Although the pain associated with avascular necrosis is similarly insidious and heightened when bearing weight, tenderness is usually evident with hip motion in any direction. Osteoarthritis of the hip generally occurs in individuals of more advanced age than this patient, and the pain produced is typically localized to the groin area and can be elicited by flexion, abduction, and external rotation (FABER test) of the affected hip.Bursitis manifests as soreness after exercise and tenderness over the affected bursa.

Answer 59

intravenous ceftriaxone (Rocephin) Pyelonephritis is the most common medical complication of pregnancy. The diagnosis is usually straightforward, as in this case. Since the patient is quite ill, treatment is best undertaken in the hospital with parenteral agents, at least until the patient is stabilized and cultures are available. Ampicillin plus gentamicin or a cephalosporin is typically used. Sulfonamides are contraindicated late in pregnancy because they may increase the incidence of kernicterus. Tetracyclines are contraindicated because administration late in pregnancy may lead to discoloration of the child’s deciduous teeth. Nitrofurantoin may induce hemolysis in patients who are deficient in G-6-PD, which includes approximately 2% of African-American women. The safety of levofloxacin in pregnancy has not been established, and it should not be used unless the potential benefit outweighs the risk.

Answer 60

Dextromethorphan (Robitussin, Vicks 44 Cough Relief) Dextromethorphan is commonly found in cough and cold remedies, and is associated with serotonin syndrome. SSRIs such as fluoxetine are also associated with serotonin syndrome, and there are many other medications that increase the risk for serotonin syndrome when combined with SSRIs. The other medications listed here are not associated with serotonin syndrome, however.

Answer 61

Heart failure Brain-type natriuretic peptide (BNP) is synthesized, stored, and released by the ventricular myocardium in response to volume expansion and pressure overload. It is a marker for heart failure. This hormone is highly accurate for identifying or excluding heart failure, as it has both high sensitivity and high specificity. BNP is particularly valuable in differentiating cardiac causes of dyspnea from pulmonary causes. In addition, the availability of a bedside assay makes BNP useful for evaluating patients in the emergency department.

Answer 62

morning serum cortisol A single morning serum cortisol level >13µg/dL reliably excludes adrenal insufficiency. If the morning cortisol level is lower than this, further evaluation with a 1µg ACTH stimulation test is necessary, although the test is somewhat difficult. It requires dilution of the ACTH prior to administration, and requires multiple blood draws. The insulin tolerance test and metyrapone test, although historically considered to be “gold standards,” are not widely available or commonly used in clinical practice. MRI does not provide information about adrenal function.

Answer 63

It is safe to continue the oral contraceptives Healthy women may continue combination birth control pills into their fifties, and this patient has no contraindications. Screening for thrombophilic conditions is not indicated due to the low yield. FSH levels are not specific enough to evaluate the effect of stopping the contraceptive

Answer 64

Bilateral shoulder or hip stiffness and aching There must be bilateral shoulder or hip stiffness and aching for at least one month in order to make the diagnosis of polymyalgia rheumatica. The erythrocyte sedimentation rate should be ≥40 mm/hr.

Answer 65

HIV infection The focus of screening for HIV has been shifted from testing only high-risk individuals to routine testing of all individuals in health-care settings. There are an estimated 1.1 million people in the United States with HIV, and 25% are undiagnosed. Only 36.6% of adults have had an HIV test. Screening for hepatitis B and for tuberculosis is recommended only for certain at-risk populations. There is no generally used test for human papillomavirus. The CDC has not made any recommendations regarding screening for high cholesterol.

Answer 66

Glycopyrrolate (Robinul) Glycopyrrolate does not cross the blood-brain barrier, and is therefore least likely to cause central nervous system effects such as sedation. The other medications listed [Atropine, Transdermal scopolamine (Transderm Scop), Hyoscyamine (Levsin)] do cross the blood-brain barrier.

Answer 67

Body dysmorphic disorder Body dysmorphic disorder is an increasingly recognized somatoform disorder that is clinically distinct from obsessive-compulsive disorder, eating disorders, and depression. Patients have a preoccupation with imagined defects in appearance, which causes emotional stress. Body dysmorphic disorder may coexist with anorexia nervosa, atypical depression, obsessive-compulsive disorder, and social anxiety. Cosmetic surgery is often sought. SSRIs and behavior modification may help, but cosmetic procedures are rarely helpful.

Answer 68

next step: Evaluation for underlying coronary artery disease In patients with no known coronary artery disease (CAD), the presence of frequent premature ventricular contractions (PVCs) is linked to acute myocardial infarction and sudden death. The Framingham Heart Study defines frequent as >30 PVCs per hour. The American College of Cardiology and the American Heart Association recommend evaluation for CAD in patients who have frequent PVCs and cardiac risk factors, such as hypertension and smoking (SOR C). Evaluation for CAD may include stress testing, echocardiography, and ambulatory rhythm monitoring (SOR C). Strong evidence from randomized, controlled trials suggests that PVCs should not be suppressed with antiarrhythmic agents. The CAST I trial showed that using encainide or flecainide to suppress PVCs increases mortality (SOR A).

Answer 69

a posterior splint and a repeat radiograph in 1–2 weeks Nondisplaced radial head fractures can be treated by the primary care physician and do not require referral. Conservative therapy includes placing the elbow in a posterior splint for 5–7 days, followed by early mobilization and a sling for comfort. Sometimes the joint effusion may be aspirated for pain relief and to increase mobility. One study compared immediate mobilization with mobilization beginning in 5 days and found no differences at 1 and 3 months, but early mobilization was associated with better function and less pain 1 week after the injury. Radiographs should be repeated in 1–2 weeks to make sure that alignment is appropriate.

Answer 70

Metformin (Glucophage) reduces cardiovascular mortality rates Metformin is the only hypoglycemic agent shown to reduce mortality rates in patients with type 2 diabetes mellitus. A recent systematic review concluded that cardiovascular events are neither increased nor decreased with the use of sulfonylureas. The effect of incretin mimetics and incretin enhancers on cardiovascular events has not been determined. The STOP-NIDDM study suggests that α-glucosidase inhibitors reduce the risk of cardiovascular events in patients with impaired glucose tolerance. (JAMA 2003)

Answer 71

A serum aldosterone-to-renin ratio Primary hyperaldosteronism is relatively common in patients with stage 2 hypertension (160/100 mm Hg or higher) or treatment-resistant hypertension. It has been estimated that 20% of patients referred to a hypertension specialist suffer from this condition. Experts recommend screening for this condition using a ratio of morning plasma aldosterone to plasma renin. A ratio >20:1 with an aldosterone level >15 ng/dL suggests the diagnosis. The level of these two values is affected by several factors, including medications (especially most blood pressure medicines), time of day, position of the patient, and age. Patients who are identified as possibly having this condition should be referred to an endocrinologist for further confirmatory testing.

Answer 72

Acupuncture Most chronic back pain (up to 70%) is nonspecific or idiopathic in origin. Treatment options that have the best evidence for effectiveness include analgesics (acetaminophen, tramadol, NSAIDs), multidisciplinary rehabilitation, and acupuncture (all SOR A). Other treatments likely to be beneficial include herbal medications, tricyclics, antidepressants, exercise therapy, behavior therapy, massage, spinal therapy, opioids, and short-term muscle relaxants (all SOR B). There is conflicting data regarding the effectiveness of back school, low-level laser therapy, lumbar supports, viniyoga, antiepileptic medications, prolotherapy, short-wave diathermy, traction, transcutaneous electrical nerve stimulation, ultrasound, and epidural corticosteroid injections (all SOR C).

Answer 73

Continue the current therapy with routine monitoring The patient is at her LDL and HDL goals and has no complaints, so she should be continued on her current regimen with routine monitoring (SOR C). Research has proven that up to a threefold increase above the upper limit of normal in liver enzymes is acceptable for patients on statins. Too often, slight elevations in liver enzymes lead to unnecessary dosage decreases, discontinuation of statin therapy, or additional testing. Ref: Onusko E: Statins and elevated liver tests: What’s the fuss? J Fam Pract 2008;57(7):449-452.

Answer 74

Elevated levels of ALT Chronic hepatitis B develops in a small percentage of adults who fail to recover from an acute infection, in almost all infants infected at birth, and in up to 50% of children infected between the ages of 1 and 5 years. Chronic hepatitis B has three major phases: immune-tolerant, immune-active, and inactive-carrier.There usually is a linear transition from one phase to the next, but reactivation from immune-carrier phase to immune-active phase also can be seen. Active viral replication occurs during the immune-tolerant phase when there is little or no evidence of disease activity, and this can last for many years before progressing to the immune-active phase (evidenced by elevated liver enzymes, indicating liver inflammation, and the presence of HBeAg, indicating high levels of HBV DNA). Most patients with chronic hepatitis B eventually transition to the inactive-carrier phase, which is characterized by the clearance of HBeAg and the development of anti-HBeAg, accompanied by normalization of liver enzymes and greatly reduced levels of hepatitis B virus in the bloodstream.

Answer 75

Prednisone This patient has signs and symptoms of painful subacute thyroiditis, including a painful thyroid gland, hyperthyroidism, and an elevated erythrocyte sedimentation rate. It is unclear whether there is a viral etiology to this self-limited disorder. Thyroid function returns to normal in most patients after several weeks, and may be followed by a temporary hypothyroid state. Treatment is symptomatic. Although NSAIDs can be helpful for mild pain, high-dose glucocorticoids provide quicker relief for the more severe symptoms. Levothyroxine is not indicated in this hyperthyroid state. Neither thyroidectomy nor antibiotics is indicated for this problem.

Answer 76

Supplemental oxygen This patient with moderate COPD and moderate nonpulmonary arterial hypertension pulmonary hypertension is hypoxic and meets the criteria for use of supplemental oxygen (SOR A). Sildenafil and nifedipine are utilized in pulmonary arterial hypertension, but evidence is lacking for their use in pulmonary hypertension associated with chronic lung disease and/or hypoxemia. Low-dose prednisone may be a future option.

Answer 77

Order CT of the abdomen Perinephric abscess is an elusive diagnostic problem that is defined as a collection of pus in the tissue surrounding the kidney, generally in the space enclosed by Gerota’s fascia. Mortality rates as high as 50% have been reported, usually from failure to diagnose the problem in a timely fashion. The difficulty in making the diagnosis can be attributed to the variable constellation of symptoms and the sometimes indolent course of this disease. The diagnosis should be considered when a patient has fever and persistence of flank pain. Most perinephric infections occur as an extension of an ascending urinary tract infection, commonly in association with renal calculi or urinary tract obstruction. Patients with anatomic urinary tract abnormalities or diabetes mellitus have an increased risk. Clinical features may be quite variable, and the most useful predictive factor in distinguishing uncomplicated pyelonephritis from perinephric abscess is persistence of fever for more than 4 days after initiation of antibiotic therapy. The radiologic study of choice is CT. This can detect perirenal fluid, enlargement of the psoas muscle (both are highly suggestive of the diagnosis), and perirenal gas (which is diagnostic). The sensitivity and specificity of CT is significantly greater than that of either ultrasonography or intravenous pyelography. Drainage, either percutaneously or surgically, along with appropriate antibiotic coverage reduces both morbidity and mortality from this condition.

Answer 78

No testing According to a recent Cochrane review, routine preoperative testing prior to cataract surgery does not decrease intraoperative or postoperative complications (SOR A). The American Heart Association recommends against routine preoperative testing in asymptomatic patients undergoing low-risk procedures, since the cardiac risk associated with such procedures is less than 1%. Routine preoperative medical testing for cataract surgery. Cochrane Database Syst Rev 2009

Answer 79

mild persistent The 2007 update to the guidelines for the diagnosis and management of asthma published by the National Heart, Lung, and Blood Institute outlines clear definitions of asthma severity. Severity is determined by the most severe category in which any feature occurs. This patient has mild persistent asthma, based on her symptoms occurring more than 2 days per week, but not daily, and use of her albuterol inhaler more than 2 days per week, but not daily. Clinicians can use this assessment to help guide therapy.

Answer 80

Abdominal pain A large review of multiple studies identified abdominal pain as the most consistent feature found in irritable bowel syndrome (IBS), and its absence makes the diagnosis less likely. Of the symptoms listed, passage of blood is least likely with IBS, and passage of mucus, constipation, and diarrhea are less consistent than abdominal pain (SOR A).

Answer 81

A fasting plasma glucose level ≥126 mg/dL on two separate occasions The American Diabetes Association (ADA) first published guidelines for the diagnosis of diabetes mellitus in 1997 and updated its diagnostic criteria in 2010. With the increasing incidence of obesity, it is estimated that over 5 million Americans have undiagnosed type 2 diabetes mellitus. Given the long-term risks of microvascular (renal, ocular) and macrovascular (cardiac) complications, clear guidelines for screening are critical. The ADA recommends screening for all asymptomatic adults with a BMI >25.0 kg/m whohave one or more additional risk factors for diabetes mellitus, and screening for all adults with no risk factors every 3 years beginning at age 45. Current criteria for the diagnosis of diabetes mellitus include a hemoglobin A 1c ³6.5%, a fasting plasma glucose level ³126 mg/dL, a 2-hour plasma glucose level ³200 mg/dL, or, in a symptomatic patient, a random blood glucose level ³200 mg/dL. In the absence of unequivocal hyperglycemia, results require confirmation by repeat testing.

Answer 82

Euthyroid sick syndrome The euthyroid sick syndrome refers to alterations in thyroid function tests seen frequently in hospitalized patients, and decreased thyroid function tests may be seen early in sepsis. These changes are statistically much more likely to be secondary to the euthyroid sick syndrome than to unrecognized pituitary or hypothalamic disease (SOR C). Graves’ disease generally is a hyperthyroid condition associated with low TSH and elevated free T4 . Subclinical hypothyroidism is diagnosed by high TSH and normal free T4 levels. Subacute thyroiditis most often is a hyperthyroid condition.

Answer 83

Ultrasonography (not MRI or XRAY) This child meets the criteria for possible septic arthritis. In this case ultrasonography is recommended over other imaging procedures. It is highly sensitive for detecting effusion of the hip joint. If an effusion is present, urgent ultrasound-guided aspiration should be performed. Bone scintigraphy is excellent for evaluating a limping child when the history, physical examination, and radiographic and sonographic findings fail to localize the pathology. CT is indicated when cortical bone must be visualized. MRI provides excellent visualization of joints, soft tissues, cartilage, and medullary bone. It is especially useful for confirming osteomyelitis, delineating the extent of malignancies, identifying stress fractures, and diagnosing early Legg-Calvé-Perthes disease. Plain film radiography is often obtained as an initial imaging modality in any child with a limp. However, films may be normal in patients with septic arthritis, providing a false-negative result.

Answer 84

A history of a stress fracture resulting from minimal trauma The initial definition of the female athlete triad was amenorrhea, osteoporosis, and disordered eating. The American College of Sports Medicine modified this in 2007, emphasizing that the triad components occur on a continuum rather than as individual pathologic conditions. The definitions have therefore expanded. Disordered eating is no longer defined as the formal diagnosis of an eating disorder. Energy availability,defined as dietary energy intake minus exercise energy expenditures, is now considered a risk factor for the triad, as dietary restrictions and substantial energy expenditures disrupt pituitary and ovarian function. Primary amenorrhea is defined as lack of menstruation by age 15 in females with secondary sex characteristics. Secondary amenorrhea is the absence of three or more menstrual cycles in a young woman previously experiencing menses. For those with secondary amenorrhea, a pregnancy test should be performed. If this is not conclusive, a progesterone challenge test may be performed. If there is withdrawal bleeding, the cause would be anovulation. Those who do not experience withdrawal bleeding have hypothalamic amenorrhea, and fit one criterion for the triad. Athletes who have amenorrhea for 6 months, disordered eating, and/or a history of a stress fracture resulting from minimal trauma should have a bone density test. Low bone mineral density for age is the term used to describe at-risk female athletes with a Z-score of –1 to –2. Osteoporosis is defined as having clinical risk factors for experiencing a fracture, along with a Z-score

Answer 85

Penicillin-resistant Streptococcus pneumoniae Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are the most common bacterial isolates from the middle ear fluid of children with acute otitis media. Penicillin-resistant S. pneumoniae is the most common cause of recurrent and persistent acute otitis media.

Answer 86

No limitations on other intake Patients with diverticulosis should increase dietary fiber intake or take fiber supplements to reduce progression of the diverticular disease. Avoidance of nuts, corn, popcorn, and small seeds has not been shown to prevent complications of diverticular disease.

Answer 87

Vasopressin (Pitressin) For persistent ventricular fibrillation (VF), in addition to electrical defibrillation and CPR, patients should be given a vasopressor, which can be either epinephrine or vasopressin. Vasopressin may be substituted for the first or second dose of epinephrine. Amiodarone should be considered for treatment of VF unresponsive to shock delivery, CPR, and a vasopressor. Lidocaine is an alternative antiarrhythmic agent, but should be used only when amiodarone is not available. Magnesium may terminate or prevent torsades de pointes in patients who have a prolonged QT interval during normal sinus rhythm. Adenosine is used for the treatment of narrow complex, regular tachycardias and is not used in the treatment of ventricular fibrillation.

Answer 88

CT CT is the gold standard for the diagnosis of renal colic. Its sensitivity and specificity are superior to those of ultrasonography and intravenous pyelography. Noncalcium stones may be missed by plain radiography but visualized by CT. MRI is a poor tool for visualizing stones.

Answer 89

The absence of calcification Pulmonary nodules are a common finding on routine studies, including plain chest radiographs, and require evaluation. Radiographic features of benign nodules include a diameter 10 mm, an irregular border, a “ground glass” appearance, either no calcification or an eccentric calcification, and a doubling time of 1 month to 1 year (SOR B).

Answer 90

Watchful waiting Watchful waiting is recommended for most patients with asymptomatic aortic stenosis, including those with severe disease (SOR B). This is because the surgical risk of aortic valve replacement outweighs the approximately 1% annual risk of sudden death in asymptomatic patients with aortic stenosis. Peripheral α-blockers, such as prazosin, should be avoided because of the risk of hypotension or syncope. Coronary angiography should be reserved for symptomatic patients who do not have evidence of severe aortic stenosis on echocardiography performed to evaluate their symptoms, or for preoperative evaluation prior to aortic valve replacement. Exercise stress testing is not safe with severe aortic stenosis because of the risk of death during the test.

Answer 91

A trial of a proton pump inhibitor Gastroesophageal reflux disease (GERD) is one of the most common causes of chronic cough. Patients with chronic cough have a high likelihood of having GERD, even in the absence of gastrointestinal symptoms (level of evidence 3). In fact, up to 75% of patients with a cough caused by GERD may have no gastrointestinal symptoms. The cough is thought to be triggered by microaspiration of acidic gastric contents into the larynx and upper bronchial tree. The American College of Chest Physicians states that patients with a chronic cough should be given a trial of antisecretory therapy (SOR B). Aggressive acid reduction using a proton pump inhibitor twice daily before meals for 3–4 months is the best way to demonstrate a causal relationship between GERD and extra-esophageal symptoms (SOR B). Methacholine inhalation testing is not necessary in this patient, since symptomatic asthma has been ruled out by the lack of response to bronchodilator therapy. Chest CT and pulmonary function tests are not indicated given the lack of findings from the history, physical examination, and chest film to suggest underlying pulmonary disease. An initial therapeutic trial of proton pump inhibitors is favored over 24-hour pH monitoring because it is less uncomfortable to the patient and has a better clinical correlation.

Answer 92

An increased risk for the condition in the children of affected individuals Psoriasis is a genetic inflammatory condition that has been associated with a significant risk of cardiovascular morbidity and mortality. Children of patients with the disorder are at increased risk. This is especially true if both parents have the disorder. Life expectancy is somewhat reduced in patients with severe psoriasis, particularly if the disease had an early onset. Plaque psoriasis is usually a lifelong disease; this is in contrast to guttate psoriasis, which may be self-limited and never recur. Cigarette smoking may increase the risk of developing psoriasis. Psoriasis is also associated with an increased likelihood of obesity, diabetes mellitus, and metabolic syndrome.

Answer 93

Increase the levothyroxine dosage Maternal hypothyroidism can have serious effects on the fetus, so thyroid dysfunction should be treated during pregnancy. Because of hormonal and metabolic changes in early pregnancy, the levothyroxine dosage often needs to be increased at 4–6 weeks gestation, and the patient eventually may require a 30%–50% increase in dosage in order to maintain her euthyroid status.

Answer 94

Surgery is most likely to be beneficial if performed less than 6 weeks after the injury Surgery for rotator cuff tears is most beneficial in young, active patients. In cases of acute, traumatic, complete rotator cuff tears, repair is recommended in less than 6 weeks, as muscle atrophy is associated with reduced surgical benefit (SOR B). Advanced age and limited strength are also associated with reduced surgical benefit. NSAIDs are used for analgesia. Their benefit has not been shown to exceed that of other simple analgesics, and the side-effect profile may be higher. Corticosteroid injections will not improve a complete tear. Some experts also recommend avoiding their use in partial or complete tendon tears. Therapeutic ultrasound does not add to the benefit from range-of-motion exercises and exercises to strengthen the involved muscle groups

Answer 95

Lisinopril (Prinivil, Zestril) ACE inhibitors such as lisinopril are indicated for all patients with heart failure due to systolic dysfunction, regardless of severity. ACE inhibitors have been shown to reduce both morbidity and mortality, in both asymptomatic and symptomatic patients, in randomized, controlled trials. Unless absolutely contraindicated, ACE inhibitors should be used in all heart failure patients. No ACE inhibitor has been shown to be superior to another, and no study has failed to show benefit from an ACE inhibitor (SOR A). Direct-acting vasodilators such as isosorbide dinitrate also could be used in this patient, but ACE inhibitors have been shown to be superior in randomized, controlled trials (SOR B). β-Blockers are also recommended in heart failure patients with systolic dysfunction (SOR A), except those who have dyspnea at rest or who are hemodynamically unstable. These agents have been shown to reduce mortality from heart failure. A diuretic such as furosemide may be indicated to relieve congestion in symptomatic patients. Aldosterone antagonists such as spironolactone are also indicated in patients with symptomatic heart failure. In addition, they can be used in patients with a recent myocardial infarction who develop symptomatic systolic dysfunction and in those with diabetes mellitus (SOR B). Digoxin currently is recommended for patients with heart failure and atrial fibrillation, and can be considered in patients who continue to have symptoms despite maximal therapy with other agents.

Answer 96

A short-acting inhaled β-agonist as needed Based on this patient’s reported frequency of asthma symptoms, she should be classified as having intermittent asthma. The preferred first step in managing intermittent asthma is an inhaled short-acting β-agonist as needed. Daily medication is reserved for patients with persistent asthma (symptoms >2 days per week for mild, daily for moderate, and throughout the day for severe) and is initiated in a stepwise approach, starting with a daily low-dose inhaled corticosteroid or leukotriene receptor antagonist and then progressing to a medium-dose inhaled corticosteroid or low-dose inhaled corticosteroid plus a long-acting inhaled β-agonist.

Answer 97

Metformin (Glucophage) Metformin is contraindicated in patients with chronic kidney disease. It should be stopped in females with a creatinine level ≥1.4 mg/dL and in males with a creatinine level ≥1.5 mg/dL. Pioglitazone should not be used in patients with hepatic disease. Acarbose should be avoided in patients with cirrhosis or a creatinine level >2.0 mg/dL. Exenatide is not recommended in patients with a creatinine clearance

Answer 98

fluorinated corticosteroids Lichen sclerosus is a chronic, progressive, inflammatory skin condition found in the anogenital region. It is characterized by intense vulvar itching. The treatment of choice is high-potency topical corticosteroids. Testosterone has been found to be no more effective than petrolatum. Fluorouracil is an antineoplastic agent most frequently used to treat actinic skin changes or superficial basal cell carcinomas.

Answer 99

Reducing the risk of falls There is strong evidence that physical activity will prevent falls in the elderly. The evidence for maintaining weight, improving sleep, and increasing bone density is not as strong.

Answer 100

Females 55–79 years of age The U.S. Preventive Services Task Force (USPSTF) recommends daily aspirin use for males 45–79 years of age when the potential benefit of a reduction in myocardial infarction outweighs the potential harm of an increase in gastrointestinal hemorrhage, and for females 55–79 years of age when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage (SOR A, USPSTF A Recomendation). The USPSTF has concluded that the current evidence is insufficient to assess the balance of benefits and harms of aspirin for cardiovascular disease prevention in men and women 80 years of age or older (USPSTF I Recommendation). It recommends against the use of aspirin for stroke prevention in women younger than 55, and for myocardial infarction prevention in men younger than 45 (USPSTF D Recommendation). Ann Intern Med 2009;

Answer 101

12 months of age AND weighs 20 lb If a child faces forward in a crash, the force is distributed via the harness system across the shoulders, torso, and hips, but the head and neck have no support. Without support, the infant’s head moves rapidly forward in flexion while the body stays restrained, causing potential injury to the neck, spinal cord, and brain. In a rear-facing position, the force of the crash is distributed evenly across the baby’s torso, and the back of the child safety seat supports and protects the head and neck. For these reasons, the rear-facing position should be used until the child is at least 12 months old and weighs at least 20 lb (9 kg). For example, a 13-month-old child who weighs 19 lb should face rearward, and a 6-month-old child who weighs 21 lb should also face rearward.

Answer 102

Amitriptyline (Elavil) A meta-analysis of antidepressant medications for the treatment of fibromyalgia syndrome concluded that short-term use of amitriptyline and duloxetine can be considered for the treatment of pain and sleep disturbance in patients with fibromyalgia. In addition, a 2008 evidence-based review for the management of fibromyalgia syndrome performed for the European League Against Rheumatism recommends heated pool treatment with or without exercise, tramadol for the management of pain, and certain antidepressants,including amitriptyline. Evidence for long-term effectiveness of antidepressants in fibromyalgia syndrome is lacking, however.

Answer 103

ACE inhibitors Secondary prevention of cardiac events consists of long-term treatment to prevent recurrent cardiac morbidity and mortality in patients who have either already had an acute myocardial infarction or are at high risk because of severe coronary artery stenosis, angina, or prior coronary surgical procedures. Effective treatments include aspirin, β-blockers after myocardial infarction, ACE inhibitors in patients at high risk after myocardial infarction, angiotensin II receptor blockers in those with coronary artery disease, and amiodarone in patients who have had a myocardial infarction and have a high risk of death from cardiac arrhythmias. Oral glycoprotein IIb/IIIa receptor inhibitors appear to increase the risk of mortality when compared with aspirin. Calcium channel blockers, class I anti-arrhythmic agents, and sotalol all appear to increase mortality compared with placebo in patients who have had a myocardial infarction. Contrary to decades of large observational studies, multiple randomized, controlled trials show no cardiac benefit from hormone therapy in postmenopausal women.

Answer 104

partial rupture of the thoracic aorta Deceleration-type blows to the chest can produce partial or complete transection of the aorta. A chest radiograph shows an acutely widened mediastinum and/or a pleural effusion when the condition is severe. The other conditions listed would produce mediastinal emphysema (esophageal or bronchial rupture), a widened heart, or pulmonary edema (acute heart failure, myocardial contusion).

Answer 105

painless lymphadenopathy The most common presenting symptom of Hodgkin lymphoma is painless lymphadenopathy. Approximately one-third of patients with Hodgkin lymphoma present with unexplained fever, night sweats, and recent weight loss, collectively known as “B symptoms.” Other common symptoms include cough, chest pain, dyspnea, and superior vena cava obstruction caused by adenopathy in the chest and mediastinum.

Answer 106

Custom-made shoes to protect the hammer toe The treatment of foot problems in the elderly is difficult because of systemic and local infirmities, the most limiting being the poor vascular status of the foot. Conservative, supportive, and palliative therapy replace definitive reconstructive surgical therapy. Surgical correction of a hammer toe and bunionectomy could be disastrous in an elderly patient with a small ulcer and peripheral vascular disease. The best approach with this patient is to prescribe custom-made shoes and a protective shield with a central aperture of foam rubber placed over the hammer toe. Metatarsal pads are not useful in the treatment of hallux valgus and a rigid hammer toe.

Answer 107

mice Hantavirus pulmonary syndrome results from exposure to rodent droppings, mainly the deer mouse in the southwestern U.S. About 10% of deer mice are estimated to be infected with hantavirus. In other parts of the country the virus is carried by the white-footed mouse. While other rodents are carriers of the virus, they are less likely to live near dwellings, and populations are less dense.

Answer 108

cyclic administration of progesterone for 3 months Abnormal uterine bleeding is a relatively common disorder that may be due to functional disorders of the hypothalamus, pituitary, or ovary, as well as uterine lesions. However, the patient who is younger than 30 years of age will rarely be found to have a structural uterine defect. Once pregnancy, hematologic disease, and renal impairment are excluded, administration of intramuscular or oral progesterone will usually produce definitive flow and control the bleeding. No further evaluation should be necessary unless the bleeding recurs. Endometrial aspiration, dilatation and curettage, and other diagnostic procedures are appropriate for recurrent problems or for older women. Estrogen would only increase the problem, which is usually due to anovulation with prolonged estrogen secretion, producing a hypertrophic endometrium.

Answer 109

Concurrent abuse of alcohol or illicit drugs The use of narcotics for chronic nonmalignant pain is becoming more commonplace. Guidelines have been developed to help direct the use of these medications when clinically appropriate. However, even when given appropriately, the use of opioid medications for pain relief can cause both the physician and the patient to be concerned about the possibility of addiction. Addiction is a neurobiologic, multifactorial disease characterized by impaired control, compulsive drug use, and continued use despite harm. Pseudoaddiction is a term used to describe patient behaviors that may occur when pain is undertreated. Patients with unrelieved pain may become focused on obtaining specific medications, seem to watch the clock, or engage in other behaviors that appear to be due to inappropriate drug seeking. Pseudoaddiction can be distinguished from true addiction because the behaviors will resolve when the pain is effectively treated. The concurrent use of alcohol and/or illicit drugs complicates the management of chronic pain in patients. If these are known problems, patients should be referred for psychiatric or pain specialty evaluation before the decision is made to use opioids. Agreements for use of chronic opioids should include the expectation that alcohol and illicit drugs will not be used concurrently, and doing so suggests addiction rather than pseudoaddiction.

Answer 110

A trial of nebulized albuterol (AccuNeb) The American Academy of Pediatrics guideline on the diagnosis and management of bronchiolitis recommends against the use of laboratory or radiographic studies to make the diagnosis, although additional testing may be appropriate if there is no improvement. Bronchiolitis can be caused by a number of different viruses, alone or in combination, and the knowledge gained from virologic testing rarely influences management decisions or outcomes for the vast majority of children. While the guideline does not support routine use of bronchodilators in the management of bronchiolitis, it does allow for a trial of bronchodilators as an option in selected cases, and continuation of the treatment if the patient shows objective improvement in respiratory status. Bronchodilators have not been shown to affect the course of bronchiolitis with respect to outcomes. The guideline places considerable emphasis on hygienic practices, including the use of alcohol-based hand sanitizers before and after contact with the patient or inanimate objects in the immediate vicinity. Education of the family about hygienic practices is recommended as well. Returning the child to day care the next day is potentially harmful.

Answer 111

Both bone formation and bone resorption are increased Paget’s disease of bone is a focal disorder of skeletal metabolism in which all elements of skeletal remodeling (resorption, formation, and mineralization) are increased. There is no known relationship between Paget’s disease and multiple myeloma, although most cases of sarcoma in patients over 50 arise in pagetic bone. The preferred treatment for nearly all patients with symptomatic disease is one of the newer bisphosphonates. Treatment of bone pain resulting from Paget’s disease is generally very satisfactory, and in fact, relief may continue for many months or years after treatment is stopped, lending support for intermittent symptomatic therapy. Finally, despite the massive bone turnover, extracellular calcium homeostasis is almost invariably normal.

Answer 112

2 years In 2008 the FDA issued a public health advisory for parents and caregivers, recommending that over-the-counter cough and cold products not be used to treat infants and children younger than 2 years of age, because serious and potentially life-threatening side effects can occur from such use. These products include decongestants, expectorants, antihistamines, and antitussives.

Answer 113

Milk Reducing consumption of red meat, seafood, and alcohol may help reduce the risk of a gout attack. Dairy products, in contrast to other foods high in protein, decrease the risk of another attack. Nuts and beans are high in purines and will worsen gout.

Answer 114

Transdermal absorption of medications changes very little with age. Due to an increase in the ratio of fat to lean body weight, the volume of distribution changes with aging, especially for fat-soluble drugs. Both liver metabolism and renal excretion of drugs decrease with aging, increasing serum concentrations.

Answer 115

Excision with a 1-mm margin The diagnosis of melanoma should be made by simple excision with clear margins. A shave biopsy should be avoided because determining the thickness of the lesion is critical for staging. Wide excision with or without node dissection is indicated for confirmed melanoma, depending on the findings from the initial excisional biopsy.

Answer 116

Cognitive-behavioral therapy has been shown to be at least as effective as medication for treatment of generalized anxiety disorder (GAD), but with less attrition and more durable effects. Many SSRIs and SNRIs have proven effective for GAD in clinical trials, but only paroxetine, escitalopram, duloxetine, and venlafaxine are approved by the FDA for this indication. Benzodiazepines have been widely used because of their rapid onset of action and proven effectiveness in managing GAD symptoms. SSRI or SNRI therapy is more beneficial than benzodiazepine or buspirone therapy for patients with GAD and comorbid depression.

Answer 117

Amoxicillin This patient has acute bilateral otitis media, with presumed tympanic membrane perforation, and qualifies by any criterion for treatment with antibiotics. Amoxicillin, 80–90 mg/kg/day, should be the first-line antibiotic for most children with acute otitis media (SOR B). The other medications listed are either ineffective because of resistance (e.g., penicillin), are second-line treatments (e.g., amoxicillin/clavulanate), or should be used in patients with a penicillin allergy or in other special situations.

Answer 118

Abdominal ultrasonography The U.S. Preventive Services Task Force (USPSTF) recommends one-time screening for abdominal aortic aneurysm (AAA) by ultrasonography in men aged 65–75 who have ever smoked (SOR B, USPSTF B Recommendation). The USPSTF found good evidence that screening these patients for AAA and surgical repair of large AAAs (≥5.5 cm) leads to decreased AAA-specific mortality. There is good evidence that abdominal ultrasonography, performed in a setting with adequate quality assurance (i.e., in an accredited facility with credentialed technologists), is an accurate screening test for AAA. There is also good evidence of important harms from screening and early treatment, including an increased number of operations, with associated clinically significant morbidity and mortality, and short-term psychological harms. Based on the moderate magnitude of net benefit, the USPSTF concluded that the benefits of screening for AAA in men aged 65–75 who have ever smoked outweighs the potential harm. While they may be considered for making the diagnosis in patients who have symptoms, none of the other tests listed have evidence to support a net benefit from their use as routine screening tools in patients like the one described here.

Answer 119

Increase the rosuvastatin dosage This patient’s goal LDL-cholesterol level is 70 mg/dL, and he is not at the maximum dosage of a potent statin. There is no data that shows that adding a different statin will be beneficial, and outcomes data for the other actions is lacking. For patients not at their goal LDL-cholesterol level, the maximum dosage of a statin should be reached before alternative therapy is chosen.

Answer 120

154 mg/dL A hemoglobin A1c(HbA1c) of 6.0% correlates with a mean plasma glucose level of 126 mg/dL or 7.0 1c 1c mmol/dL. A calculator to convert HbA1clevels into estimated average glucose levels is available at http://professional.diabetes.org/eAG. A rough guide for estimating average plasma glucose levels assumes that an 1cof 6.0% equals an average glucose level of 120 mg/dL. Each percentage point increase in 1c is equivalent to a 30-mg/dL rise in average glucose. An HbA1cof 7.0% is therefore roughly equivalent to an average glucose level of 150 mg/dL, and an HbA1c of 8.0% translates to an average glucose level of 180 mg/dL.

Answer 121

anxiety disorder with hyperventilation The elevated pH, normal oxygen saturation, and low pCO2 are characteristic of acute respiratory alkalosis, as seen with acute hyperventilation states. In patients with a pulmonary embolism, pO2 and pCO2 are decreased, while the pH is elevated, indicating the acute nature of the disorder. With the other diagnoses, findings on the physical examination would be different than those seen in this patient. Vital signs would be normal with carbon monoxide poisoning, and patients with an asthma exacerbation have a prominent cough and wheezing, and possibly other abnormalities. Tension pneumothorax causes severe cardiac and respiratory distress, with significant physical findings including tachycardia, hypotension, and decreased mental activity.

Answer 122

Frontotemporal dementia Frontotemporal dementia is the second most common cause of early-onset dementia. It often presents with behavioral and personality changes. Examples include disinhibition, impairment of personal conduct, loss of emotional sensitivity, loss of insight, and executive dysfunctions. Alzheimer’s disease presents with memory loss and visuospatial problems. Vascular dementia is associated with risk factors for stroke, or occurs in relation to a stroke, with a stepwise progression. Alzheimer’s disease and vascular dementia can occur together, with features of both. Progressive supranuclear palsy is characterized by early falls, vertical (especially downward) gaze, axial rigidity greater than appendicular rigidity, and levodopa resistance.

Answer 123

Tolerance to morphine This patient has become tolerant to morphine. The intravenous dose should be a third of the oral dose, so the starting intravenous dose was adequate. Addiction is compulsive narcotic use. Pseudoaddiction is inadequate narcotic dosing that mimics addiction because of unrelieved pain. Physical dependence is seen with abrupt narcotic withdrawal.

Answer 124

Acute angle-closure glaucoma This patient presents with acute angle-closure glaucoma, manifested by an acute onset of severe pain, blurred vision, halos around lights, increased intraocular pressure, red conjunctiva, a mid-dilated and sluggish pupil, and a normal or hazy cornea. Findings with retinal detachment include either normal vision or peripheral or central vision loss; absence of pain; increasing floaters; and a normal conjunctiva, cornea, and pupil. Central retinal artery occlusion findings include amaurosis fugax, a red conjunctiva, a pale fundus, a cherry-red spot at the fovea, and “boxcarring” of the retinal vessels. In patients with mechanical injury to the globe, findings include moderate to severe pain, normal or decreased vision, subconjunctival hemorrhage completely surrounding the cornea, and a pupil that is irregular or deviated toward the injury (SOR B).

Answer 125

Dermatomyositis One of the most characteristic findings in dermatomyositis is Gottron’s papules, which are flat-topped, sometimes violaceous papules that often occur on most, if not all, of the knuckles and interphalangeal joints

Answer 126

Adenosine (Adenocard) After vagal maneuvers are attempted in a stable patient with supraventricular tachycardia, the patient should be given a 6-mg dose of adenosine by rapid intravenous push. If conversion does not occur, a 12-mg dose should be given. This dose may be repeated once. If the patient is unstable, immediate synchronized cardioversion should be administered.

Answer 127

25-hydroxyvitamin D Serum 25-hydroxyvitamin D should be obtained in any patient with suspected vitamin D deficiency because it is the major circulating form of vitamin D (SOR A). 1,25-Dihydroxyvitamin D is the most active metabolite, but levels can be increased by secondary hyperparathyroidism. In persons with vitamin D deficiency, ergocalciferol (vitamin D ) or cholecalciferol (vitamin D ) can be used to replenish stores (SOR 2 3B).

Answer 128

Pain in the maleolar zone and bone tenderness of the posterior medial malleolus The Ottawa ankle and foot rules are prospectively validated decision rules that help clinicians decrease the use of radiographs for foot and ankle injuries without increasing the rate of missed fracture. The rules apply in the case of blunt trauma, including twisting injuries, falls, and direct blows. According to these guidelines, an ankle radiograph series is required only if there is pain in the malleolar zone and bone tenderness of either the distal 6 cm of the posterior edge or the tip of either the lateral malleolus or the medial malleolus. Inability to bear weight for four steps, both immediately after the injury and in the emergency department, is also an indication for ankle radiographs. Foot radiographs are required only if there is pain in the midfoot zone and bone tenderness at the base of the 5th metatarsal or the navicular, or if the patient is unable to bear weight both immediately after the injury and in the emergency department. A positive Thompson sign, seen with Achilles tendon rupture, is the absence of passive plantar foot flexion when the calf is squeezed.

Answer 129

Detrusor instability In elderly patients, detrusor instability is the most common cause of urinary incontinence in both men and women. Incontinence may actually become worse after surgical relief of obstructive prostatic hypertrophy. Infection is unlikely as the cause of persistent incontinence in this patient in the absence of fever or symptoms of urinary tract infection. Overflow is unlikely in the absence of residual urine. Impaction is a relatively rare cause of urinary incontinence, and associated findings would be present on rectal examination. Normalization of the urinary stream and the absence of residual urine reduce the likelihood of recurrent obstruction. The prostate would be expected to remain enlarged on rectal examination after transurethral resection of the prostate (TURP).

Answer 130

Rifaximin (Xifaxan) While prophylactic antibiotics are not generally recommended for prevention of traveler’s diarrhea, they may be useful under special circumstances for certain high-risk hosts, such as the immunocompromised, or for those embarking on critical short trips for which even a short period of diarrhea might cause undue hardship. Rifaximin, a nonabsorbable antibiotic, has been shown to reduce the risk for traveler’s diarrhea by 77%. Trimethoprim/sulfamethoxazole and doxycycline are no longer considered effective antimicrobial agents against enteric bacterial pathogens. Increasing resistance to the fluoroquinolones, especially among Campylobacter species, is limiting their use as prophylactic agents.

Answer 131

Spironolactone (Aldactone) Antiandrogens such as spironolactone, along with oral contraceptives, are recommended for treatment of hirsutism in premenopausal women (SOR C). In addition to having side effects, prednisone is only minimally helpful for reducing hirsutism by suppressing adrenal androgens. Leuprolide, although better than placebo, has many side effects and is expensive. Metformin can be used to treat patients with polycystic ovarian syndrome, but this patient does not meet the criteria for this diagnosis.

Answer 132

Ceftazidime (Fortaz), imipenem/cilastatin (Primaxin), and vancomycin (Vancocin) Empiric coverage for methicillin-resistant Staphylococcus aureus and double coverage for pseudomonal pneumonia should be prescribed in patients with nursing home–acquired pneumonia requiring intensive-care unit admission (SOR B).

Answer 133

Raloxifene (Evista) Raloxifene is a selective estrogen receptor modulator. While it increases the risk of venous thromboembolism, it is indicated in this patient to decrease the risk of invasive breast cancer (SOR A). Bisphosphonates inhibit osteoclastic activity. Zoledronic acid, alendronate, and risedronate decrease both hip and vertebral fractures, whereas ibandronate decreases fracture risk at the spine only. Calcitonin nasal spray is an antiresorptive spray that decreases the incidence of vertebral compression fractures. Teriparatide is a recombinant human parathyroid hormone with potent bone anabolic activity, effective against vertebral and nonvertebral fractures. Hormone replacement therapy is recommended for osteoporosis only in women with moderate or severe vasomotor symptoms. The lowest possible dose should be used for the shortest amount of time possible (SOR C).

Answer 134

An excisional biopsy of the mass In the ideal setting, the accuracy of fine-needle aspiration may be over 90%. Clinical information is critical for interpreting the results of fine-needle aspiration, especially given the fact that the tissue sample is more limited than with a tissue biopsy. It is crucial to determine whether the findings on fine-needle aspiration explain the clinical findings. Although the report from the mammogram and the biopsy are not ominous in this patient, they do not explain the clinical findings. Immediate repeat fine-needle aspiration or, preferably, a tissue biopsy is indicated. Proceeding directly to therapy, whether surgery or irradiation, is inappropriate because the diagnosis is not clearly established. Likewise, any delay in establishing the diagnosis is not appropriate

Answer 135

Retinal detachment In a patient complaining of flashes of light and a visual field defect, retinal detachment is the most likely diagnosis. Many cases of vitreous detachment are asymptomatic, and it does not cause sudden visual field defects in the absence of a retinal detachment. A vitreous hemorrhage would cause more blurring of vision in the entire field of vision. Ocular migraine causes binocular symptoms.

Answer 136

Azithromycin (Zithromax) Azithromycin is the drug of choice for Chlamydia trachomatis infections in pregnant patients. Metronidazole is used to treat trichomoniasis and Gardnerella vaginitis after 12 weeks gestation. The use of tetracycline is not appropriate in pregnant women, and miconazole is used to treat vaginal candidiasis.

Answer 137

normal pressure hydrocephalus In normal pressure hydrocephalus a mild impairment of memory typically develops gradually over weeks or months, accompanied by mental and physical slowness. The condition progresses insidiously to severe dementia. Patients also develop an unsteady gait and urinary incontinence, but there are no signs of increased intracranial pressure. In Alzheimer’s disease the brain very gradually atrophies. A disturbance in memory for recent events is usually the first symptom, along with some disorientation to time and place; otherwise, there are no symptoms for some period of time. Subacute sclerosing panencephalitis usually occurs in children and young adults between the ages of 4 and 20 years and is characterized by deterioration in behavior and work. The most characteristic neurologic sign is mild clonus. Multiple sclerosis is characteristically marked by recurrent attacks of demyelinization. The clinical picture is pleomorphic, but there are usually sufficient typical features of incoordination, paresthesias, and visual complaints. Mental changes may occur in the advanced stages of the disease. About two-thirds of those affected are between the ages of 20 and 40.

Answer 138

Hemoglobin electrophoresis This patient has a microcytic, hypochromic anemia, which can be caused by iron deficiency, thalassemia, sideroblastic anemia, and lead poisoning. In a child with a microcytic anemia who does not respond to iron therapy, hemoglobin electrophoresis is appropriate to diagnose thalassemia. Hypothyroidism, vitamin B12 deficiency, and folate deficiency result in macrocytic anemias.

Answer 139

adult respiratory distress syndrome (ARDS) Acute respiratory failure following severe injury and critical illness has received increasing attention over the last decade. With advances in the management of hemorrhagic shock and support of circulatory and renal function in injured patients, it has become apparent that 1%–2% of significantly injured patients develop acute respiratory failure in the post-injury period. Initially this lung injury was thought to be related to a particular clinical situation. This is implied by such names as “shock lung” and “traumatic wet lung,” which have been applied to acute respiratory insufficiency. It is now recognized that the pulmonary problems that follow a variety of insults have many similarities in their clinical presentation and physiologic and pathologic findings. This has led to the theory that the lung has a limited number of ways of reacting to injury and that several different types of acute, diffuse lung injury result in a similar pathophysiologic response. The common denominator of this response appears to be injury at the alveolar-capillary interface, with resulting leakage of proteinaceous fluid from the intravascular space into the interstitium and subsequently into alveolar spaces. It has become acceptable to describe this entire spectrum of acute diffuse injury as adult respiratory distress syndrome (ARDS). The syndrome of ARDS can occur under a variety of circumstances and produces a spectrum of clinical severity from mild dysfunction to progressive, eventually fatal, pulmonary failure. Fortunately, with proper management, pulmonary failure is far less frequent than milder abnormalities.

Answer 140

Cluster Headache Cluster headache is predominantly a male disorder. The mean age of onset is 27–30 years. Attacks often occur in cycles and are unilateral. Migraine headaches are more common in women, start at an earlier age (second or third decade), and last longer (4–24 hours). Temporal arteritis occurs in patients above age 50. Trigeminal neuralgia usually occurs in paroxysms lasting 20–30 seconds.

Answer 141

Oseltamivir (Tamiflu) The currently circulating novel influenza A H1N1 virus is almost always susceptible to neuraminidase inhibitors (oseltamivir and zanamivir) and resistant to the adamantanes (amantadine and rimantadine). Zanamivir should not be used in patients with COPD, asthma, or respiratory distress. Antiviral treatment of influenza is recommended for all persons with clinical deterioration requiring hospitalization, even if the illness started more than 48 hours before admission. Antiviral treatment should be started as soon as possible. Waiting for laboratory confirmation is not recommended.

Answer 142

Enalapril (Vasotec) NOT HCTZ or Propanolol Because of their favorable side-effect profile, ACE inhibitors (e.g., enalapril) may be the drugs of first choice for the majority of unselected hypertensive patients. ACE inhibitors are not associated with depression or sedation, and they are safe to use in patients with diabetes mellitus. Centrally-acting α-blockers can be associated with depression. Calcium-channel blockers, β-blockers, and other sympatholytic drugs affect cardiac conductivity.β-Blockers are contraindicated in patients with asthma, and are also associated with impotence. Thiazide diuretics raise uric acid and blood glucose levels.

Answer 143

INH, ethambutol, rifampin (Rifadin), and pyrazinamide Leading authorities, including experts from the American Thoracic Society, CDC, and Infectious Diseases Society of America, mandate aggressive initial four-drug treatment when tuberculosis is suspected. Delays in diagnosis and treatment not only increase the possibility of disease transmission, but also lead to higher morbidity and mortality. Standard regimens including INH, ethambutol, rifampin, and pyrazinamide are recommended, although one regimen does not include pyrazinamide but extends coverage with the other antibiotics. Treatment regimens can be modified once culture results are available.

Answer 144

Evaluation for adrenal hormonal secretion The incidental discovery of adrenal masses presents a common clinical challenge. Such masses are found on abdominal CT in 4% of cases, and the incidence of adrenal masses increases to 7% in adults over 70 years of age. While the majority of masses are benign, as many as 11% are hypersecreting tumors and approximately 7% are malignant tumors; the size of the mass and its appearance on imaging are major predictors of malignancy. Once an adrenal mass is identified, adrenal function must be assessed with an overnight dexamethasone suppression test. A morning cortisol level >5 μg/dL after a 1-mg dose indicates adrenal hyperfunction. Additional testing should include 24-hour fractionated metanephrines and catecholamines to rule out pheochromocytoma. If the patient has hypertension, morning plasma aldosterone activity and plasma renin activity should be assessed to rule out a primary aldosterone-secreting adenoma. Nonfunctioning masses require assessment with CT attenuation, chemical shift MRI, and/or scintigraphy to distinguish malignant masses. PET scanning is useful to verify malignant disease. Nonfunctioning benign masses can be monitored for changes in size and for the onset of hypersecretory states, although the appropriate interval and studies are controversial. MRI may be preferred over CT because of concerns about excessive radiation exposure. Fine-needle aspiration of the mass can be performed to differentiate between adrenal and non-adrenal tissue after malignancy and pheochromocytoma have been excluded.

Answer 145

Women who are pregnant Clinical guidelines published by the U.S. Preventive Services Task Force in 2008 reaffirmed the 2004 recommendations regarding screening for asymptomatic bacteriuria in adults. The only group in which screening is recommended is asymptomatic pregnant women at 12–16 weeks gestation, or at the first prenatal visit if it occurs later (SOR A).

Answer 146

Ferritin low, TIBC high, serum iron low Ferritin and serum iron levels fall with iron deficiency. Total iron binding capacity rises, indicating a greater capacity for iron to bind to transferrin (the plasma protein that binds to iron for transport throughout the body) when iron levels are low.

Answer 147

acute rheumatic fever Acute rheumatic fever is very common in developing nations. It was previously rare in the U.S., but had a resurgence in the mid-1980s. It is most common in children ages 5–15 years. The diagnosis is based on the Jones criteria. Two major criteria, or one major criterion and two minor criteria, plus evidence of a preceding streptococcal infection, indicate a high probability of the disease. Major criteria include carditis, migratory polyarthritis, erythema marginatum, chorea, and subcutaneous nodules. Minor criteria include fever, arthralgia, an elevated erythrocyte sedimentation rate or C-reactive protein (CRP) level, and a prolonged pulse rate interval on EKG. The differential diagnosis is extensive and there is no single laboratory test to confirm the diagnosis. This patient meets one major criterion (erythema marginatum rash) and three minor criteria (fever, elevated CRP levels, and arthralgia). Echocardiography should be performed if the patient has cardiac symptoms or an abnormal cardiac examination, to rule out rheumatic carditis.

Answer 148

Echocardiography This patient’s history and clinical examination suggest heart failure. The most important distinction to make is whether it is diastolic or systolic, as the drug treatment may be somewhat different. Physical findings and chest radiographs do not distinguish systolic from diastolic heart failure. An echocardiogram is the study of choice, as it will assess left ventricular function. In diastolic dysfunction, the left ventricular ejection fraction is normal or slightly elevated. Diastolic failure is more common in elderly females and patients with hypertension, and less common in patients with a previous history of coronary artery disease. Diuretics and angiotensin receptor blockers (ARBs) are useful treatments. Because of their effects on diastolic filling times, tachycardia and atrial fibrillation often cause decompensation in patients with diastolic heart failure. At this time, cardiac catheterization is not indicated, and a stress test will not provide useful information. If the patient had systolic failure, a workup for ischemic disease would be needed, but most cases of diastolic dysfunction are not caused by ischemia. While hyperthyroidism can cause tachycardia and atrial fibrillation, the more immediate issue in this patient is the heart failure, which requires diagnosis and treatment. A pulmonary embolus can cause shortness of breath but usually has an acute onset, so a D-dimer level would not help at this time.

Answer 149

A skin biopsy is diagnostic This patient has gadolinium-associated nephrogenic systemic fibrosis, which is associated with the use of gadolinium-based contrast material in patients with severe renal dysfunction, often on dialysis. Associated proinflammatory states, such as recent surgery, malignancy, and ischemia, are often present as well. This condition occurs without regard to gender, race, or age. Dermatologic manifestations are usually seen, but multiple organ systems may be involved. There is no effective treatment, and mortality is approximately 30%. A deep biopsy of the affected skin is diagnostic.

Answer 150

Oral activated charcoal A single dose of activated charcoal is the decontamination treatment of choice for most medication ingestions. It should be used within 1 hour of ingestion of a potentially toxic amount of medication (SOR C). Gastric lavage, cathartics, or whole bowel irrigation is best for ingestion of medications that are poorly absorbed by activated charcoal (iron, lithium) or medications in sustained-release or enteric-coated formulations. Ipecac has no role in home use or in the health care setting (SOR C).

Answer 151

A combination of intermediate-acting insulin (e.g., NPH) and a short-acting insulin (e.g., lispro) twice daily In addition to an appropriate diet and exercise regimen, pharmacologic therapy should be initiated in pregnant women with gestational diabetes mellitus whose fasting plasma glucose levels remain above 100 mg/dL despite diet and exercise. There is strong evidence that such treatment to maintain fasting plasma glucose levels below 95 mg/dL and 1-hour postprandial levels below 140 mg/dL results in improved fetal well-being and neonatal outcomes. While oral therapy with metformin or glyburide is considered safe and possibly effective, insulin therapy is the best option for the pharmacologic treatment of gestational diabetes. Thiazolidinediones such as pioglitazone have not been shown to be effective or safe in pregnancy. The use of long-acting basal insulin analogues, such as glargine and detemir, has not been sufficiently evaluated in pregnancy. Sliding-scale coverage with ultra-short-acting insulin or insulin analogues, such as lispro and aspart, is generally not required in most women with gestational diabetes. While it may be effective, it involves four daily glucose checks and injections. Most patients are successfully treated with a twice-daily combination of an intermediate-acting insulin and a short-acting insulin while continuing a diet and exercise program.

Answer 152

Prolonged QT interval Ziprasidone is a second-generation antipsychotic used in the treatment of schizophrenia. These drugs cause QT-interval prolongation, which can in turn lead to torsades de pointes and sudden cardiac death. This risk is further increased when these drugs are combined with certain antibiotics (e.g., clarithromycin), antiarrhythmics (class I and III), and tricyclic antidepressants. The FDA has issued a black box warning for both first- and second-generation antipsychotic drugs due to a 1.6- to 1.7-fold increase in the risk of sudden cardiac death and cerebrovascular accidents associated with their use in the elderly population (SOR A). None of the other conditions listed is associated with this drug combination.

Answer 153

Sjögren’s syndrome Sjögren’s syndrome is one of the three most common systemic autoimmune diseases. It results from lymphocytic infiltration of exocrine glands and leads to acinar gland degeneration, necrosis, atrophy, and decreased function. A positive anti-SS-A or anti-SS-B antigen test or a positive salivary gland biopsy is a criterion for classification of this diagnosis. In addition to ocular and oral complaints, clinical manifestations include arthralgias, thyroiditis, pulmonary disease, and GERD. Most patients with sarcoidosis present with shortness of breath or skin manifestations, and patients with lupus generally have fatigue and joint pain. Ocular rosacea causes eye symptoms very similar to those of Sjögren’s syndrome, but oral findings would not be expected. Drugs such as anticholinergics can cause a dry mouth, but this would be unlikely a month after the medication was discontinued (SOR B).

Answer 154

cognitive-behavioral therapy This patient has multiple risk factors for depression: the hormonal changes of puberty, a family history of depression, and psychosocial stressors. Cognitive-behavioral therapy is effective in treating mild to moderate depression in children and adolescents (SOR A). SSRIs are an adjunctive treatment reserved for treatment of severe depression, and have limited evidence for effectiveness in children and adolescents. Amitriptyline should not be used because of its limited effectiveness and adverse effects (SOR A). Methylphenidate is used for treating attention deficit disorder, not depression. Divalproex sodium is used to treat bipolar disorder.

AAFP 2 Flashcards

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