Case Files 1-6 (C)

Question 1

Screening tests for cardiovascular conditions

Answer 1

1. Blood pressure measurement (HTN)
2. Lipid measurement (dyslipidemia)

Question 2

Recommendations for:

Influenza vaccine

Tetanus vaccine

Answer 2

Annually and every 10 years, respectively

Question 3

Intervention designed to prevent a disease before it occurs

Answer 3

Primary prevention

Examples:

Statin medication to reduce LDL in order to lower the risk of CAD

Removal of colon polyps to prevent the development of colon cancer

Question 4

Intervention intended to reduce the recurrence or exacerbation of a disease

Answer 4

Secondary prevention

Example:

Use of a statin medication after a person has had a MI

Question 5

Criteria for effective screening

Answer 5

1. Disease should be of high enough prevalence to make the effort worthwhile
2. Time frame during which the person is asymptomatic, but during which the disease/risk factor can be identified
3. Available test that sufficient sensitivity and specificity, is cost-efective, and is acceptable to patients
4. Must be an intervention that can be made during the asymptomatic period that will prevent the development of the disease or reduce the morbidity/mortality

Question 6

Gold standard for clinical preventive medicine

Answer 6

USPSTF

(United States Preventive Services Task Force)

Question 7

USPSTF grades

Answer 7

A: offer/provide this service

B: offer/provide this service

C: offer/provide only if there are other considerations that support offering/providing

D: discourage use of this service

I: insufficient evidence

Question 8

When should screening begin for lipid disorders?

Answer 8

Level A:

Men >35

Women >45

Level B:

Adults >20 who are at increased risk for cardiovascular disease

Question 9

Screening recommendation for abdominal aortic aneurysm

Answer 9

Level B for men 65-75 who have smoked at any point

Level C (no recommendation) for men who have never smoked

Level D for women, regardless of smoking status

Question 10

Screening for colorectal cancer

Answer 10

Men and women older than 50

FOBT annually, sigmoidoscopy every 3-5 years, and colonoscopy every 10 years

*An abnormal FOBT or sigmoidoscopy leads to the performance of a colonoscopy

Question 11

Tdap recommendation

Answer 11

All adults between 19 and 65 should receive a booster of Tdap in place of a scheduled dose of Td due to waning immunity against pertussis

Question 12

Pneumococcal polysaccharide vaccination

Answer 12

Recommended as a single dose for all adults >65

*Recommended at a younger age for adults who are alcoholics/smokers, have chronic cardiovascular/pulmonary/renal/heptic disease, diabetes, an immunodeficiency, or who are functionally asplenic

Question 13

62M with recently diagnosed emphysema presents to your office for a routine exam. He has not had any immunizations in more than 10 years. Which immunizations would be most appropriate for this individual?

Answer 13

Tdap

Pneumococcal (d/t chronic lung disease)

Influenza

Question 14

Two most common causes of dyspnea and wheezing in adults

Answer 14

1. COPD
2. Asthma

Question 15

Presents earlier in life, may or may not be associated with cigarette smoking, and is characterized by episodic exacerbations with return to relatively normal baseline lung functioning

Answer 15

Asthma

Question 16

Presents in midlife or later, is usually the result of a long history of smoking, and is a slowly progressive disorder in which measured pulmonary functioning never returns to normal.

Answer 16

COPD

Question 17

Mainstays of medical therapy for both asthma and COPD

Answer 17

1. Oxygen
2. Bronchodilators
3. Steroids

Question 18

Cough and sputum production on most days for at least 3 months during at least 2 consecutive years

Answer 18

Chronic bronchitis

Question 19

Shortness of breath caused by the enlargement of respiratory bronchioles and alveoli (destruction of lung tissue and elastin)

Answer 19

Emphysema

Pink puffer: pink from polycythemia (2/2 chronic hypoxia), enlarged chest b/c lungs cannot deflate, and puffing because slow breaths = less obstruction

Question 20

A rare cause of COPD that should be considered when emphysema develops at younger ages (<45), especially in nonsmokers

Answer 20

α₁-antitrypsin deficiency

Question 21

Pathologic changes in COPD

Answer 21

Mucous gland hypertrophy with hypersecretion, ciliary dysfunction, destruction of lung parenchyma, and airway remodeling

By the time dyspnea develops, lung function has been reduced by about half and the COPD has been present for years

Question 22

Barrel Chest + Distant Heart Sounds

Answer 22

COPD

A result of hyperinflation of the lungs

Question 23

FVC and FEV₁ in COPD

Answer 23

Both the FVC and FEV₁ are reduced, but the ratio of FEV₁ to FVC is less than 0.7

*Reversibility is defined as an increase in FEV₁ of greater than 12% or 200 mL

• Mild: FEV₁ > 80*
• Moderate: FEV₁ 50-80*
• Severe: FEV₁ 30-50*
• Very Severe: FEV₁ < 30*

Question 24

Treatment for:

Mild COPD (FEV₁ >80%)

Moderate COPD (FEV₁ 50-80%)

Severe COPD (FEV₁ 30-50%)

Very severe COPD (FEV₁ <30%)

Answer 24

Mild: short-acting bronchodilators

Moderate: long-acting bronchodilators

Severe: inhaled steroids

Very severe: long-term oxygen therapy and consider surgical interventions

Question 25

Albuterol Ipratropium

Answer 25

Short-acting bronchodilators for Stage I COPD Albuterol = β₂-agonist Ipratropium = anticholinergic Inhaled medications are preferred over oral

Question 26

Salmeterol Tiotropium

Answer 26

Long-acting bronchodilator for Stage II COPD Salmeterol = inhaled β2-agonist Tiotropium = inhaled anticholinergic

Question 27

Fluticasone Triamcinolone Mometasone

Answer 27

Inhaled steroids for Stage III COPD They do not affect the rate of decline of lung function, but do reduce the frequency of exacerbations. Long-term treatment with oral steroids is not recommended (use inhaled).

Question 28

Should also consider when seeing a patient with suspected acute exacerbation of COPD

Answer 28

Pulmonary embolism CHF MI \*Systemic steroids shorten the course of exacerbation and may reduce the risk of relapse (40 mg prednisolone for 10-14 days is recommended)

Question 29

59M with a known history of COPD presents with worsening dyspnea. On exam he is afebrile. His breath sounds are decreased bilaterally. He is noted to have JVD and 2+ pitting edema of the lower extremities. What is the most likely cause of his increasing dyspnea?

Answer 29

Cor pulmonale AKA right heart failure due to chronically elevated pressures in the pulmonary circulation

Question 30

45M presents with sudden onset of monoarticular joint pain. The first diagnosis that needs to be excluded is...

Answer 30

Infected Joint Cartilage can be destroyed within the first 24 hrs of infection

Question 31

Most gout attacks occur between the ages of ___ and ___ in men, with a later onset in postmenopausal women (\_\_\_ -\_\_\_ years of age)

Answer 31

30-50 men 50-70 women Exacerbating factor for gout (anything that may induce hyperuricemia): -Alcohol, trauma, surgery, large meals (high in purines such as red meat, liver, or seafood), **thiazide diuretics**

Question 32

Joint Aspirate: WBC 2000-60,000 w/ \<90% neutrophils vs WBC 100,000 w/ \>90% neutrophils

Answer 32

Crystal-induced (must culture to rule out a coexisting infection) Septic Joint

Question 33

Monosodium Urate (MSU) Crystals

Answer 33

Gout Needles and strong negative birefringence

Question 34

Rod-shaped, rhomboid, weakly positive

Answer 34

Calcium pyrophosphate dehydrate

Question 35

Seen by electron microscopy, cytoplasmic inclusion that are nonbirefringent

Answer 35

Calcium hydroxyapatite

Question 36

Bipyramidal appearance, strongly positive birefringence; seen mostly in end-stage renal disease patients

Answer 36

Calcium oxalate

Question 37

Condition of excess uric acid leading to deposition of MSU crystals in joints

Answer 37

Gouty Arthritis

Question 38

Crystal analysis: rod-shaped, rhomboid, weakly positive birefringent

Answer 38

Pseudogout: calcium pyrophosphate dehyrdate crystals

Question 39

Podagra

Answer 39

Classic presentation of gout (swelling and pain, accompanied by erythema and warmth, involving the metatarsophalangeal joint of the first toe)

Question 40

What will the uric acid levels be during an acute attack of Gout?

Answer 40

Normal or low (likely as a result of the existing deposition of the urate crystals) Uric acid levels are useful in monitoring hypouricemic therapy between attacks

Question 41

An infection involving one joint is usually... Chronic monarticular or 2-3 joints... More than 3 joints...

Answer 41

1 joint = bacterial (usually knee, hip, or shoulder) chronic or 2-3 = fungi of mycobacteria acute polyarticular (more than 3) = endocarditis or disseminated gonoccal infection

Question 42

Rheumatoid arthritis patients are predisposed to what type of joint infections?

Answer 42

Staph aureus Due to chronic inflammation + steroids HIV positive patients think H influenza IV drug users think Pseudomonas

Question 43

How does ROM differ between patients with septic joint vs patients with cellulitis?

Answer 43

septic = very limited ROM cellulitis/bursitis/osteomyelitis = maintained ROM

Question 44

What lab tests may be abnormal in a patient with RA?

Answer 44

**+ RF** and **anti-CCP** ↑ ESR and CRP Anemia, Thrombocytosis, and **low Albumin** \*the level of hypoalbuminemia usually correlates with the severity of the disease; anti-CCP is more specific than RF; a positive anti-CCP may precede the clinical manifestation of disease by many years

Question 45

A 44-year-old woman has a 5-month history of malaise and stiff hands in the morning that improve as the day goes by. She notes that both hands are involved at the wrists. Initial lab tests show an elevated ESR and high positive anti-CCP. Which treatment is most likely to lead to the best long-term disease outcome for this patient?

Answer 45

Methotrexate (DMARD) Would alter the natural history of the disease rather than just treating the symptoms

Question 46

A 52-year-old man complains of bilateral knee pain for about 1 year. He is noted to have a BMI of 40. Other than weight loss, what is the best initial therapy?

Answer 46

Ibuprofen (NSAID)

Question 47

A 35-year-old man with HTN presents with the sudden onset of right big toe pain. What medication was he taking that predisposed him to this condition and how would you treat it?

Answer 47

HCTZ (used to treat HTN) can increase the risk of gouty arthritis. **Treat with Colchicine.**

Question 48

Indications for ultrasound in pregnancy

Answer 48

According to ACOG, an ultrasound is not mandatory in routine, low-risk prenatal care Indicated for: uncertain gestational age, size/date discrepancies, vaginal bleeding, multiple gestations, or other high-risk situations

Question 49

Laboratory studies recommended at the initial prenatal visit

Answer 49

CBC HBsAg HIV testing Syphilis screening with RPR UA and UCx Rubella antibody Bloody type and Rh status w/ antibody screen Pap smear Cervical swab for gonorrhea and Chlamydia

Question 50

Risk to the pregnancy based on the radiation exposure from dental x-rays

Answer 50

Risk for the baby is increased once the radiation exposure is greater than 5 rad; the radiation exposure from routine dental x-rays is 0.00017 rad

Question 51

Optimal time for the trisomy screen

Answer 51

10-13 weeks: nuchal transluceny + serum hCG and PAPP-A **16-18 weeks**: triple (ACG, hCG, estriol) or quadruple (triple + inhibin-A)

Question 52

For low-risk women, what is recommended to reduce the risk of neural tube defects?

Answer 52

400 to 800 μG of folic acid daily \*Women with DM or epilepsy should take 1 mg and a woman who has had a child with a NT defect should take 4 mg

Question 53

Naegele's rule

Answer 53

To determine EDD, subtract 3 months from LMP and add 7 days

Question 54

When should heart tones be obtainable using a handheld Doppler fetoscope?

Answer 54

10 weeks

Question 55

When should RhoGAM be given?

Answer 55

1 dose at 28 weeks gestation or within 72 hours of trauma, complication, procedure, or delivery \*Antibody screen: Lewis lives, Kell kills, Duffy dies

Question 56

What is the most common cause of a false-positive serum screen (i.e., false-positive trisomy screen)

Answer 56

Incorrect gestational age dating Triple screen has a sensitivity of 65-69% and a specificity of 95% \*Although the risk for trisomy 21 increases with maternal age, an estimated 75% of affected fetuses are born to mothers younger than age 35 at time of delivery

Question 57

When should mother's be screened for gestational diabetes?

Answer 57

24-28 weeks with a 1-hour 50-g glucose challenge (a value above 140 mg/dL is considered abnormal, and a value of 200 mg/dL is generally diagnostic) If 1-hour is positive, then do 3-hour 100-g glucose challenge

Question 58

A 28-year-old woman with a history of epilepsy presents for a preconception consultation visit. What is the most important advice to give this patient?

Answer 58

She should receive 1 mg of folic acid supplementation daily to help prevent neural tube defects

Question 59

A 28-year-old G1P0 woman at 16 weeks' gestation is noted to be Rh negative. What is the most appropriate next step for this patient?

Answer 59

Indirect Coombs test (antibody screen) If the antibody screen is negative, there is no isoimmunization, and RhoGAM is given at 28 weeks' gestation and again at delivery if the baby is confirmed as Rh positive

Question 60

Reduction or loss of vision in one eye from lack of use

Answer 60

Amblyopia

Question 61

The most common cause of amblyopia

Answer 61

Strabismus (aka Ocular misalignment)

Question 62

How is failure to thrive defined?

Answer 62

Weight below the 3rd or 5th percentile for age OR Decelerations of growth that have crossed two major growth percentiles in a short period of time

Question 63

What two tests do all states require for newborns?

Answer 63

Testing for phenylketonuria (PKU) and congenital hypothyroidism Early treatment can prevent the development of profound mental retardation

Question 64

Most common cause of anemia in children

Answer 64

Iron deficiency (kid who drinks a lot of cow's milk) ↓H&H, ↓ferritin, ↑TIBC Treat with oral ferrous salts

Question 65

Presence of red reflexes

Answer 65

Helps to rule out the possibility of congenital cataracts and retinoblastoma

Question 66

How to test for strabismus?

Answer 66

Asymmetric light reflex Cover-uncover test (child focuses on an object with both eyes and the examiner covers one eye. Strabismus is suggested when the uncovered eye deviates to focus on the object)

Question 67

Leading cause of death in children older than age 1 year

Answer 67

Accidents and injuries (all states now require car seats) A child should sit in a rear-facing car seat until they are both 1 year old and weigh at least 20 lbs A child may use a booster-type seat when they weigh more than 40 lbs

Question 68

Leading cause of death of infants younger than 1 year

Answer 68

Sudden Infant Death Syndrome (SIDS) Ways to reduce risk: sleep on back with nothing else in the crib and pacifiers

Question 69

Inflammation of the nasal passages caused by allergic reaction to airborne substances

Answer 69

Allergic Rhinitis Perennial vs Seasonal vs Occupational \*Response to treatment with antihistamines supports the diagnosis of allergic rhinitis

Question 70

Common PE findings in a patient with allergic rhintis

Answer 70

Allergic shiners (dark circles around the eyes) Allergic salute (horizontal crease across the lower half of the nose) Thin and water nasal secretions Swollen/boggy, pale nasal turbinates Dennie-Morgan lines (prominent creases below the inferior eyelid) Cobblestoning of the posterior pharynx

Question 71

Diphenhydramine Chlorpheniramine Hydroxyzine

Answer 71

First-generation anti-histamines Side effects include sedation and the anticholinergic effects (dry mouth, dry eyes, blurred vision, and urinary retention)

Question 72

Loratadine Desloratadine Fexofenadine Cetirizine

Answer 72

Second-generation antihistamines (look for -dine) Much less penetration into the CNS, resulting in a lower incidence of sedation as a side effect (except for cetirizine). They also have fewer anticholinergic effects.

Question 73

Pseudoephedrine

Answer 73

Decongestant (α-adrenoreceptor agonist) Constrict blood vessels in the nasal mucosa and reduce the overall volume of the mucosa Side effects: tachycardia, tremors, insomnia, and rebound hyperemia/worsening of symptoms (with chronic use)

Question 74

First-line therapy for the long-term management of mild-moderate persistent symptoms of allergic rhinitis

Answer 74

Corticosteroid nasal sprays (eg, Flonase) Reach maximal effectiveness after 2-4 weeks of use

Question 75

Zafirlukast Montelukast Zileuton

Answer 75

Leukotriene inhibitors Indicated for both allergic rhinitis and for maintenance therapy for persistent asthma

Question 76

Why are oral corticosteroid reserved only for severe allergies?

Answer 76

Suppression of the HPA axis and hyperglycemia Long-term use can lead to peptic ulcer formation, increased susceptibility to infection, poor wound healing, and the reduciton of bone density

Question 77

The most commonly isolated organisms in bacterial conjunctivitis are...

Answer 77

Staph, Strep, Haemophilus, Moraxella, and Pseudo \*Epidemic keratoconjunctivitis (pink eye) is highly contagious and spread by person-to-person contact or fomites (most common cause is adenovirus)

Question 78

A 30-year-old man has both mild persistent asthma and chronic environmental allergies. Which medication is indicated for the management of both conditions?

Answer 78

Oral montelukast (leukotriene modifier)