101. When evaluating a patient with menorrhagia, which one of the following laboratory findings would be most consistent with von Willebrand disease?
A) An isolated prolonged prothrombin time
B) An isolated prolonged partial thromboplastin time
C) A low serum iron level
D) A low platelet count
E) A low fibrinogen level
Von Willebrand disease (vWD) is a common coagulation disorder generally due to a hereditary reduction in the quality or quantity of a protein complex required for platelet adhesion, known as von Willebrand factor (vWF). The extent of deficiency varies greatly, resulting in vWD subtypes ranging from asymptomatic to serious. A common problem associated with vWD is menorrhagia, and the diagnosis should always be entertained in women who experience excessive menstrual blood loss. Although tests measuring vWF are easily obtained, interpretation of the results can be challenging since vWF levels can be affected by blood type, inflammation, infection, trauma, and emotional stress. Confirmation of vWD often requires the expertise of a hematologist. Although the results for all laboratory tests listed can fall within their reference ranges in a patient with vWD, the finding most suggestive of this diagnosis is an isolated prolonged partial thromboplastin time.
102. A 68-year-old female with well-controlled hypertension presents for a routine evaluation. The physical examination is significant for a BMI of 35.4 kg/m2. A comprehensive metabolic panel prior to the visit revealed the following:
Serum calcium . . . . . . . 9.2 mg/dL (N 8.5–10.2)
Albumin . . . . . . . . . . . . 4.0 g/dL (N 3.5–5.4)
Creatinine . . . . . . . . . . 0.6 mg/dL (N 0.6–1.1)
25-hydroxyvitamin D . . . . . 9 ng/mL (N >20)
Alkaline phosphatase . . . . 151 U/L (N 47–147)
Which one of the following is true, based on these findings?
A) She has primary hyperparathyroidism
B) She should take 1,25-dihydroxyvitamin D (calcitriol)
C) She should take vitamin D supplements
D) She should take calcium supplements
E) She has rickets
This patient has slight elevations of her alkaline phosphatase along with a deficiency of vitamin D and normal calcium levels. This constellation of findings is most consistent with secondary hyperparathyroidism related to vitamin D deficiency. Vitamin D storage is best reflected by the serum 25-hydroxyvitamin D level. While there is some disagreement regarding normal levels, a level <10 ng/mL is clearly deficient. This would put the patient at risk for osteomalacia but not rickets, which is a clinical diagnosis based on the effects of insufficient bone mineralization secondary to low vitamin D activity before the closure of growth plates. Supplementation with activated vitamin D (calcitriol) is generally only necessary in patients with renal failure or other conditions associated with inadequate activation of the storage forms of vitamin D. Supplementation with vitamin D should decrease PTH activity and thus bone turnover in this patient, which would likely normalize the alkaline phosphatase.
103. A 16-year-old male presents with acute testicular pain that has been constant for the last 2 hours. He has nausea and vomiting that started about the same time. On examination you note that the left testis is situated higher in the scrotum than the right testis. The left hemiscrotum is erythematous, slightly warm, and indurated. The patient is currently afebrile.
Which one of the following is the most appropriate management at this time?
A) NSAIDs and scrotal support
B) Doxycycline plus intravenous ceftriaxone (Rocephin)
C) Rotating the testicle from lateral to medial (like closing a book)
D) Immediate urologic consultation for surgical exploration
This patient presents with a classic description of torsion of the left testicle, and not an infectious process requiring antibiotics. Surgical exploration is the immediate priority, with ischemic damage starting between 4 and 8 hours after onset. Attempts at manual detorsion should not delay surgical exploration and often require analgesia or sedation. If surgery is not an immediate option, manual detorsion is performed by rotating the testicle from medial to lateral, like opening a book. Doppler ultrasonography is the imaging modality of choice, but it delays surgical exploration and should be used only when the history and physical examination make the diagnosis questionable.
104. U.S. federal labor law requires companies with >50 employees to provide which one of the following benefits for employees who are nursing mothers?
A) Extended Family and Medical Leave Act protection for a total of 6 months
B) Reasonable unpaid break time to express milk
C) Extended bathroom access time to express milk
D) A refrigerator dedicated to storage of expressed milk
The Patient Protection and Affordable Care Act amended the Federal Labor Standards Act of 1938 to require employers of >50 employees to provide nursing mothers reasonable break time to express milk for up to 1 year following the birth of their children. The employer is not required to compensate nursing mothers during the breaks and is not required to provide refrigerated storage for the expressed milk. The law also requires that the employer provide a place to express milk, other than a bathroom, that is shielded from view and free from intrusion from coworkers and the public.
105. A 30-year-old ICU nurse has been caring for several patients infected with Clostridium difficile. She is asymptomatic but is worried that she may also be infected.
Which one of the following is the most appropriate recommendation for this nurse?
A) No testing and no treatment
B) Testing for C. difficile toxin
C) Testing for C. difficile antigen
D) Empiric treatment with metronidazole
Laboratory testing for Clostridium difficile should be done only on symptomatic patients. A diagnosis of C. difficile infection requires the presence of diarrhea (greater than or equal to 3 unformed stools in a 24-hour period) or radiographic evidence of ileus and toxic megacolon. In addition, the diagnosis requires a positive stool test for toxigenic C. difficile or its toxins, or colonoscopic or histopathologic findings showing pseudomembranous colitis. Laboratory testing cannot distinguish between asymptomatic colonization and symptomatic infection. Test of cure is not recommended after C. difficile treatment. Probiotics may prevent antibiotic-associated diarrhea and may also reduce C. difficile diarrhea in children and adults younger than 65, but are not specifically recommended for preventing or treating C. difficile infection.
106. A 36-year-old white male complains of episodic pain in the rectum over the past several years. The pain occurs every 3–6 weeks and is sharp, cramp-like, and severe. It lasts from 1 to 15 minutes. He has no other gastrointestinal complaints. A physical examination, including a digital rectal examination and anoscopy, is normal.
The most likely diagnosis is
A) fecal impaction
C) anal fissure
D) proctalgia fugax
E) sacral nerve neuralgia
Symptoms consistent with proctalgia fugax occur in 13%–19% of the general population. These consist of episodic, sudden, sharp pains in the anorectal area lasting several seconds to minutes. The diagnosis is based on a history that fits the classic picture in a patient with a normal examination. All the other diagnoses listed would be evident from the physical examination, except for sacral nerve neuralgia, which would not be intermittent for years and the pain would not be transitory.
107. A patient presents with a lesion on her forearm that first appeared 6 months ago. The lesion is shown on the page at left.
Which one of the following is the most likely diagnosis?
A) A cutaneous horn
C) Pyogenic granuloma
D) Seborrheic keratosis
E) Verruca vulgaris
This is a cutaneous horn, sometimes referred to as a hypertrophic actinic keratosis. It is a horn-like projection of keratin on a slightly raised base. These usually arise in areas subject to photoaging, including the forearms. The differential diagnosis often includes keratoacanthoma, which occurs most commonly on the face, grows very rapidly, and often is more nodular with a central pit. Pyogenic granulomas are fleshy appearing, and a wart or seborrheic keratosis would both look slightly different but would rarely become so large in just months. Cutaneous horns should be removed due to the possible development of in situ or invasive squamous cell carcinoma (SOR A).
108. An 82-year-old female sees you for follow-up 6 weeks after fracturing her hip when she tripped on a hose and fell in her garden. She underwent surgical repair and acute inpatient rehabilitation. She has successfully recovered, is participating in an outpatient physical therapy program, and is now walking with a cane. She reports gastroesophageal reflux controlled with over-the-counter ranitidine (Zantac) as her only chronic medical condition. She recalls having been told that she had only mild bone loss on a bone density test last year. She has been taking a calcium and vitamin D supplement since then. She is concerned about sustaining another fracture.
Which one of the following should you do now to reduce her risk of recurrent fracture?
A) Prescribe alendronate, 70 mg weekly
B) Prescribe raloxifene (Evista), 60 mg daily
C) Prescribe teriparatide (Forteo), 20 :g daily
D) Discontinue ranitidine
Undertreatment of osteoporosis occurs frequently after a hip fracture. Unless a contraindication exists, patients should be treated with a bisphosphonate after a hip fracture, regardless of bone mineral density (SOR C). Controlled gastroesophageal reflux is not a contraindication to bisphosphonate therapy. Proton pump inhibitor use, but not H2-blocker use, is also a modifiable risk factor for osteoporosis. Raloxifene and teriparatide are not bisphosphonates or first-line therapy for prevention of recurrent hip fracture. Raloxifene has not been shown to reduce the rate of nonvertebral fractures.
109. A 28-year-old male hospital employee sees you for a mandatory workplace influenza vaccination. He has never received influenza vaccine and is apprehensive about it because of a history of egg allergy. He says he developed hives on his trunk after eating scrambled eggs on several occasions when he was in high school and since then has avoided eating cooked eggs, but not all egg-containing food items. He has had no cases of hives since making this change in his diet.
According to the Advisory Committee on Immunization Practices, which one of the following would be the most appropriate action?
A) Administer live attenuated influenza vaccine
B) Administer an intradermal test dose of inactivated influenza vaccine and if the patient
does not develop hives administer a full dose of inactivated influenza vaccine 2 or
more hours later
C) Administer inactivated influenza vaccine
D) Administer oral diphenhydramine (Benadryl) 1 hour before inactivated influenza
E) Do not vaccinate for influenza
All currently available influenza vaccines, with the exceptions of recombinant and cell-culture–based inactivated influenza vaccines, are prepared using embryonated egg culture and can potentially provoke allergic and anaphylactic reactions. Large studies of influenza vaccine administration to egg-allergic patients have resulted in a few mild reactions but no documented occurrences of anaphylaxis, although there are reports of serious reactions. The data collected from these studies provided sufficient confidence for the Advisory Committee on Immunization Practices to develop guidelines for administration of influenza vaccine in individuals with egg allergy.
For those who report that they can eat lightly cooked scrambled eggs, vaccination can proceed without precaution or observation. Those who have experienced only hives can also receive any influenza vaccine appropriate for their age and health status. In the past the CDC recommended observing these patients for 30 minutes afterward, but this recommendation was changed in 2016. People who have experienced symptoms such as hypotension, wheezing, nausea, or vomiting, or reactions requiring emergency attention or epinephrine after eating eggs or egg-containing foods can also receive any influenza vaccine appropriate for their age and health status and also do not need to be observed. However, the vaccine should be administered by a provider who can recognize and manage severe allergic reactions. Withholding vaccination because of egg-induced hives is not recommended.
110. A 65-year-old female presents to your office with a 1-day history of severe low back pain that began acutely after she moved some furniture. She is in good health otherwise, has no previous history of back problems, and has not had a fever. She is having pain in the bilateral low back region, bilateral buttock region, and upper thigh. She has not been able to void since the pain started.
Which one of the following diagnoses should be considered in this patient?
A) Acute lumbar strain
B) Lumbar muscle spasm
C) Mechanical low back pain
D) Large midline disc herniation
Patients with low back pain should be evaluated for the presence of neurologic deficits. Urinary retention is the most frequent finding in cauda equina syndrome (90% sensitivity), caused by compression of nerve roots from the lower cord segments. This is usually due to a massive, centrally herniated disc, which can result in urinary retention or incontinence from loss of sphincter function, bilateral motor weakness of the lower extremities, and saddle anesthesia. This problem should be addressed urgently. In patients without urinary retention, the probability of the cauda equina syndrome is approximately 1 in 10,000.
111. A 35-year-old male has a 5-day history of cough and has had one episode of blood-streaked sputum. He is otherwise healthy and has never smoked. He is afebrile and has normal findings on examination. A chest radiograph is normal.
Which one of the following would be most appropriate at this point?
B) CT of the chest
C) Pulmonary function studies
E) A trial of antibiotics
This patient has a low risk of cancer, based upon his age and medical history, and no suggestion of a lower respiratory infection. With this presentation, a chest radiograph is recommended as the first step in the workup, and if findings are normal he should be observed for 2–6 weeks (SOR A). If there is a recurrence of hemoptysis further evaluation is indicated, which should include an interval history, a repeat examination, and CT of the chest.
112. The Timed Up and Go test is used to evaluate geriatric patients for which one of the following?
A) Risk of falling
B) Effects of peripheral neuropathy
C) Kinetic tremor
D) Neurocardiogenic syncope
E) Central causes of vertigo
The Timed Up and Go test is the most frequently recommended screening test for mobility. It takes less than a minute to perform and involves asking the patient to rise from a chair, walk 10 feet, turn, return to the chair, and sit down. Any unsafe or ineffective movement with this test suggests balance or gait impairment and an increased risk of falling. If the test is abnormal, referral to physical therapy for complete evaluation and assessment should be considered. Other interventions should also be considered, such as a medication review for factors related to the risk of falling.
113. Which one of the following can falsely elevate hemoglobin A1c?
A) Antiretroviral treatment for HIV infection
B) Chronic liver disease
C) Hemolytic anemia
D) Iron deficiency anemia
Hemoglobin A1c (HbA1c) testing measures the percentage of glycosylation of the HbA1c chain, and correlates to average blood glucose levels over the previous 2–3 months. However, hypertriglyceridemia, hyperbilirubinemia, iron deficiency anemia, splenectomy, renal failure, and aplastic anemia can all falsely elevate HbA1c levels. The other factors listed can all falsely lower HbA1c levels, as can vitamins C and E, and acute blood loss.
114. A 62-year-old male presents for a routine health maintenance visit. He has osteoarthritis and controlled hypertension, but is otherwise healthy. He does not smoke and his alcohol consumption consists of 2–3 drinks a week. His medications include lisinopril (Prinivil, Zestril) and acetaminophen. His wife just had a DXA scan and he asks if he should also be screened for osteoporosis.
For this patient, the U.S. Preventive Services Task Force
A) makes no recommendation for or against DXA
B) recommends DXA at this visit
C) recommends DXA at age 65
D) recommends DXA at age 70
The U.S. Preventive Services Task Force has a grade I recommendation for routine screening for osteoporosis in men, meaning there is insufficient evidence to recommend for or against routine screening. Men older than 50 with a minimal-trauma fracture and men with conditions associated with bone loss could be considered for screening. The National Osteoporosis Foundation recommends screening all men age 70 and above for osteoporosis.
115. A healthy 45-year-old female presents to your office to establish care. She has no significant past medical history and is up to date on her immunizations. She has no chest pain, shortness of breath, or exercise intolerance. She does not take any prescribed medications but does take a low-dose aspirin daily for prevention of coronary artery disease. She does not smoke and she exercises by walking for 45 minutes 4–5 times a week. She is concerned because her mother had a fatal cardiac arrest at age 63 and her father was recently diagnosed with end-stage renal disease at age 75.
On examination the patient’s blood pressure is 120/75 mm Hg and her BMI is 22.1 kg/m2. Her cardiovascular and pulmonary examinations are unremarkable.
Which one of the following would you recommend to this patient?
A) A resting EKG
B) An exercise EKG
C) Discontinuing aspirin therapy
D) Increasing aspirin to 325 mg daily
E) A basic metabolic panel to screen for chronic kidney disease
Although this patient has a family history of coronary artery disease, she is under the age of 50 and thus aspirin therapy as primary prevention is not recommended and may increase the risk for gastrointestinal bleeding, regardless of the dosage. The U.S. Preventive Services Task Force found insufficient evidence for screening for chronic kidney disease even in individuals with a positive family history. Neither a resting nor exercise EKG is recommended for asymptomatic individuals to detect or prevent coronary artery disease.
116. A 19-year-old female comes to your office with lower abdominal pain that has increased over the past 2 days. Her last menstrual period was 4 days ago. She has been nauseated and has been vomiting. The physical examination reveals a temperature of 38.0°C (100.4°F) and lower abdominal tenderness with mild rebound. She has a mucopurulent cervical discharge, tenderness with cervical motion, a normal-size uterus, and left adnexal fullness. A serum hCG is negative.
Which one of the following is the most appropriate management?
A) Ceftriaxone (Rocephin), 250 mg intramuscularly
B) Hospitalization for intravenous antibiotics
C) Surgical consultation for immediate appendectomy
This patient has signs and symptoms of acute salpingitis. This condition is commonly confused with appendicitis, ectopic pregnancy, and other pelvic pathology. In this case the findings are clearly pelvic in origin. Endocervical inflammation with a mucopurulent discharge is noted in almost every case of acute salpingitis. The acute nature of this presentation and the adnexal fullness suggest gonorrhea rather than chlamydial infection, although the antibiotic regimen should probably cover Chlamydia as well. Admission to the hospital and treatment with parenteral antibiotics is most appropriate in this case because of the severity of the illness, the desire to maintain reproductive function, and the adnexal fullness.
Routine laparoscopy for every case of salpingitis is considered too costly and dangerous. The choice of intravenous antibiotic may vary, but usually consists of a $-lactam antibiotic (cefoxitin or ceftriaxone) plus doxycycline, or gentamicin and clindamycin. Ceftriaxone, 250 mg intramuscularly, is appropriate for uncomplicated gonococcal infection.
117. An 18-year-old female presents with an intensely pruritic papular eruption in the vicinity of her waist that began shortly after she spent a day walking in the woods with her boyfriend. Her rash consists of multiple small excoriated papules and welts along her beltline. She says she was wearing jeans and sandals.
Which one of the following is the most likely cause of her rash?
D) Deer ticks
Mite larvae called chiggers cause itchy bites. The chiggers crawl on skin until they reach constrictive clothing like belts or socks and then bite there. Flea bites are usually at ankle height because fleas jump. Mosquito bites would be diffuse on exposed areas. Bedbugs tend to bite on the upper body and neck. This is not a typical presentation for Lyme disease, which has an initial rash that is localized and not pruritic (SOR C).
118. A homeless 47-year-old male visits the local health department and asks to be screened for tuberculosis. He is not aware of any definite exposure to tuberculosis and is asymptomatic. The nurse asks whether the patient should be screened with a tuberculin skin test or an interferon-gamma release assay (IGRA, QuantiFERON-TB Gold).
Which one of the following would be an advantage of IGRA in this patient?
A) It helps to distinguish latent tuberculosis from active tuberculosis
B) The patient’s blood can be stored for up to 36 hours if needed, to allow transport to
a qualified laboratory to run the test
C) A follow-up visit is not required to obtain results
D) The IGRA will be positive within 2 weeks of exposure to an individual with active
E) The IGRA can simultaneously detect resistance to rifampin (Rifadin)
It is important for health care professionals to be familiar with the various options for screening and testing for latent or active tuberculosis. In the United States the tuberculin skin test (TST) is the traditional screening test for tuberculosis. The interferon-gamma release assay (IGRA) is a blood test that can also aid in the diagnosis of latent tuberculosis. Advantages of IGRA include the ability to get results without follow-up and the fact that prior bacille Calmette-Guérin (BCG) vaccination does not cause a false-positive test. With TST testing, prior BCG vaccination, especially if given within the last 10 years, can result in a false-positive test.
As with the TST, conversion (i.e., a positive test) of IGRA may not occur within the first 8–12 weeks following exposure to an individual with active tuberculosis. In addition, neither the TST nor the IGRA can distinguish between latent and active tuberculosis.
There are two IGRA tests available for use in the United States and both tests need to be processed within 8–30 hours, depending on the specific test used. Although there is now a test available that can detect Mycobacterium tuberculosis complex (MTBC) and resistance to rifampin, it is a separate test called the Xpert MTB/RIF assay.
119. During a routine health maintenance visit, a 24-year-old female admits that she is not feeling well due to being overwhelmed with stress. She feels she has always worried more than most people, but recent troubles at home and at work have made things much worse. She says she is irritable with people around her, has trouble focusing at work, and feels fatigued late in the day. Despite her fatigue, she has difficulty falling asleep at night. The patient denies anhedonia, suicidal thoughts, or a persistently depressed mood. She limits her caffeine intake, does not smoke or drink alcohol, and is not using any illicit drugs.
In addition to psychotherapy, which one of the following medications is recommended for this patient?
A) Alprazolam extended release (Xanax XR)
B) Clonazepam (Klonopin)
C) Gabapentin (Neurontin)
D) Quetiapine (Seroquel)
E) Sertraline (Zoloft)
This patient’s symptoms are consistent with the DSM-5 criteria for generalized anxiety disorder. First-line treatments for this condition are SSRIs, SNRIs, and tricyclic antidepressants. Quetiapine and gabapentin are considered second-line medications for anxiety if control cannot be obtained with more traditional agents. Benzodiazepines such as alprazolam and clonazepam are sometimes necessary for short-term control of anxiety symptoms but are generally discouraged due to sedating side effects, the potential for abuse or diversion, and gradual tolerance.
120. A 35-year-old female who is approximately 90 kg (200 lb) above her ideal body weight comes to you for weight loss recommendations. Her mother, who had a BMI of 37.0 kg/m2, recently suffered a fatal heart attack and the patient would like to avoid this. She has no other medical problems except for well-controlled hypertension. Her medication list includes lisinopril (Prinivil, Zestril), 20 mg daily, and an etonogestrel subdermal (Nexplanon) implant for contraception.
Which one of the following strategies would be most effective for reducing her cardiac risk?
A) A low-fat diet
B) A high-protein diet
C) Orlistat (Xenical), 120 mg 3 times daily with meals
D) Phentermine (Suprenza), 30 mg daily
E) Referral for bariatric surgery
Bariatric surgery has been shown to reduce all-cause mortality in patients with morbid obesity, mostly from reduced myocardial infarctions. Although orlistat and phentermine, along with other weight loss drugs, have been shown to be associated with moderate weight loss, there is no evidence that any of these agents reduce morbidity or mortality. A low-carbohydrate diet has been associated with increased HDL-cholesterol levels and decreased triglyceride levels when compared to a low-fat diet, which may indicate a reduction in cardiac risk. No particular diet strategy has been shown to be more effective for weight loss than any other strategy.
121. Which one of the following is most likely to improve outcomes in schizophrenia?
A) Combining antipsychotic medication with psychosocial treatment
B) Prescribing two second-generation antipsychotic medications together in small dosages
C) Initial treatment in the outpatient rather than inpatient setting
D) Using only one first-generation, or typical, antipsychotic medication combined with
an antidepressant medication
The combination of antipsychotic medication and psychosocial treatments, including cognitive-behavioral therapy, family therapy, and social skills training, is associated with the best outcomes in patients with schizophrenia (SOR B). Antipsychotic medications should not be combined. Hospitalization, especially for the first episode of schizophrenia, is also recommended for the best outcome (SOR C). Antidepressant medication will treat depression associated with schizophrenia but will not necessarily improve the symptoms of schizophrenia.
122. The preferred method for diagnosing psychogenic nonepileptic seizures (pseudoseizures) is
A) inducing seizures by suggestion
B) postictal prolactin levels
C) EEG monitoring
D) video-electroencephalography (vEEG) monitoring
E) MRI of the brain
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.
123. A 27-year-old male calls and reports that he has an elevated temperature of 101.5°F (38.6°C). He underwent a surgical splenectomy following an automobile accident 5 months ago. He has no allergies and is otherwise healthy.
Which one of the following would be the most appropriate recommendation for this patient?
A) Temperature monitoring with follow-up if it exceeds 39.0°C (102.2°F)
B) Antipyretics to maintain a temperature <39.0°C (102.2°F)
C) Oral antibiotics, with follow-up if the elevated temperature persists
D) Urgent parenteral antibiotic therapy
In an asplenic patient, fever might be an initial manifestation of a catastrophic infection and must be treated immediately with a parenteral antibiotic agent. Quick administration of antibiotics might prevent sepsis. Mortality can be as high as 50% among patients with postsplenectomy sepsis. Intravenous or intramuscular ceftriaxone is recommended for patients who have normal laboratory test results and who do not appear ill. If the patient lives more than 2 hours from a medical facility that can administer parenteral antibiotic therapy, oral antibiotics should be given.
124. A 4-year-old female is brought to your office with a 6-day history of fever to a maximum temperature of 103.2°F. She was seen 2 days ago and treated empirically for streptococcal pharyngitis because she has a close contact who had a streptococcal infection. She has a mild cough, rhinorrhea, and a sore throat. On examination she is febrile and fussy. She has a maculopapular rash over her trunk, bilateral eye injection, shotty bilateral lymphadenopathy, erythematous lips, a strawberry tongue, and pharyngeal erythema. Her examination is otherwise unremarkable.
WBCs . . . . . . . . . . 16,200/mm3 (N 4500–11,000)
Hemoglobin . . . . . 10.9 g/dL (N 14.0–17.5)
Hamatocrit . . . . . . . 32.3% (N 41.0–50.0)
Platelets . . . . . . . . . 495,000/mm3 (N 150,000–350,000)
AST (SGOT) . . . . . . . 78 U/L (N 10–30)
ALT (SGPT) . . . . . . . . 66 U/L (N 10–40)
Alkaline phosphate . . . 165 U/L (N 30–120)
Albumin . . . . . . . . . . . . . 2.8 g/dL (N 3.5–5.5)
C-reactive protein . . . . . 12.9 mg/L (N 0.08–3.1)
Urine dipstick . . . . . . . . normal
A full urinalysis with a microscopic examination reveals 20–25 WBCs/hpf, 0–4 RBCs/hpf, 0–4 bacteria/hpf, and 0–10 epithelial cells/hpf. Additional laboratory tests are ordered, with the following results:
Sodium . . . . . . . . . 132mEq/L(N136–142)
Potassium . . . . . . . 4.0 mEq/L (N 3.5–5.0)
Chloride . . . . . . . . . 104 mEq/L (N 96–106)
Bicarbonate . . . . . . 22 mEq/L (N 21–28)
BUN . . . . . . . . . . . . . 9 mg/dL (N 8–23)
Creatinine . . . . . . . . 0.6 mg/dL (N 0.6–1.2)
Which one of the following would be the most appropriate management of this patient?
A) Supportive measures only
B) Ceftriaxone (Rocephin)
C) Intramuscular penicillin
D) Aspirin and intravenous immunoglobulin
This child has atypical Kawasaki disease. The diagnostic criteria for classic Kawasaki disease is fever for at least 5 days and at least four of five principal clinical features. The clinical features include:
-Changes of the oral cavity and lips: cracked erythematous lips, strawberry tongue
-Polymorphous rash: maculopapular, erythema multiforme–like or scarlitiniform rash, involving the extremities, trunk, and perineal regions
-Bilateral nonpurulent conjunctivitis
-Changes in the extremities (erythema of the hands and feet, desquamation of the hands and toes in weeks 2 and 3)
-Cervical lymphadenopathy (>1.5 cm in diameter and generally unilateral)
Some patients do not meet the classic criteria but are labeled as having incomplete or atypical disease. While Kawasaki disease is generally a clinical diagnosis and there are no specific diagnostic tests, supplemental laboratory testing can help in the diagnosis of these atypical cases. The supplemental laboratory criteria include:
-Cerebrospinal fluid pleocytosis
-Elevated C-reactive protein and erythrocyte sedimentation rate
-Elevated liver enzymes
-Platelets >450,000/mm3 after 5 weeks
-WBCs greater than or equal to 15,000/mm3
Patients who have a fever for 5 days or more and two or three of the classic criteria should be treated for atypical Kawasaki’s disease if the C-reactive protein level is elevated and they have three or more associated laboratory abnormalities. The treatment of choice is IVIG and high-dose aspirin to reduce the risk of coronary abnormalities. Corticosteroids have been used as an adjunct in refractory cases or with IVIG, but not alone.
125. A 22-year-old male presents to the emergency department with a debilitating headache that occurs 3–4 times per month. Over the past 6 hours he has developed a throbbing, sharp pain over the right side of his head, with significant nausea and vomiting. Previous headaches have not lasted more than 1 day. He did not get any relief with ibuprofen, 600 mg taken 2 hours ago.
Which one of the following is the most appropriate next step in the management of this patient’s headache?
A) Oral acetaminophen
B) Oral butalbital/aspirin/caffeine (Fiorinal)
C) Intravenous hydromorphone (Dilaudid)
D) Intravenous metoclopramide
E) Supplemental oxygen
This patient has an acute migraine headache that did not respond to NSAIDs. Metoclopramide is an effective treatment for migraine beyond its antiemetic benefit (SOR B) and intravenous administration may be helpful for the patient unable to tolerate oral medications. Acetaminophen has not been proven to be effective for migraine. Opiates and barbiturate-containing medications should only be used for patients who have failed multiple other treatments (SOR C). Supplemental oxygen has shown efficacy in the treatment of cluster headaches. Triptan medications would be another evidence-based choice for abortive therapy of migraine.
126. A 25-year-old female presents to your office to discuss abnormal menstrual periods. She says that her cycles have always been irregular but she has not had any bleeding in 3 months. She also says she has gained 20 lb over the past 6 months. She is not taking any medications. You perform an examination and order laboratory tests. Her blood pressure is 110/72 mm Hg, heart rate 84 beats/min, respiratory rate 12/min, and weight 78.0 kg (172 lb) with a BMI of 29.5 kg/m2. She is noted to have moderate cystic acne. Her examination is otherwise unremarkable. A serum hCG measurement is negative and TSH, FSH, and LH levels are normal. Follow-up laboratory evaluation is significant for a total testosterone level 3 times the upper limit of normal and a normal 17-hydroxyprogesterone level.
Which one of the following would be most appropriate at this point?
A) An estradiol level
B) A dexamethasone suppression test
D) CT of the abdomen and pelvis
E) MRI of the brain
This patient presents with mild symptoms of hyperandrogenism. Her initial laboratory results rule out pregnancy, thyroid disorders, and primary ovarian failure. The follow-up laboratory evaluation indicates significant hyperandrogenism. The rapid onset and high testosterone level suggest an ovarian or adrenal tumor that should be evaluated by abdominal/pelvic imaging.
MRI of the brain is not helpful in evaluating hyperandrogenism. It would be appropriate in evaluating hypothalamic and pituitary causes of secondary amenorrhea such as the female athlete triad or other causes of stress and malnutrition that are associated with weight loss. A karyotype would be helpful in identifying the cause of primary amenorrhea. An estradiol level is not helpful in evaluating hyperandrogenism. A dexamethasone suppression test aids in the diagnosis of Cushing syndrome, which generally does not cause amenorrhea and is usually associated with stigmata of hypercortisolism, which this patient does not have.
127. Which one of the following is the most prevalent form of elder abuse?
A) Financial exploitation
B) Verbal abuse
C) Physical abuse
D) Sexual abuse
Recent studies suggest that financial exploitation is emerging as the most prevalent form of elder abuse. By the time cases are detected the older adult’s financial resources have often been drastically reduced, so early detection and intervention are critical. Financial exploitation of older adults, which was explored only minimally in previous studies, has recently been identified as a virtual epidemic and is a problem that may be detected or suspected by an alert physician.
128. A 45-year-old female complains of debilitating fatigue that seemed to start suddenly 8 months ago, associated with symptoms of a viral infection. She denies symptoms of depression or substance abuse.
Which one of the following, if present, would indicate a diagnosis other than chronic fatigue syndrome (myalgic encephalomyelitis)?
A) Impairment of focus and concentration
B) Joint erythema
C) Orthostatic intolerance
D) Post-exertional malaise
E) Tender lymph nodes
The diagnosis of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is made by determining that a patient’s symptoms are consistent with a standard definition of this disorder and by ruling out the presence of other systemic diseases that can result in similar symptoms. Currently suggested criteria for ME/CFS require at least 6 months of pathologic fatigue, along with a combination of other symptoms including post-exertional fatigue, impaired focus/concentration, orthostatic intolerance, and unrefreshing sleep. Other symptoms frequently encountered in patients with this condition include headache, diffuse myalgias, tender lymph nodes, and gastrointestinal or genitourinary impairments. The diagnosis of ME/CFS should not be considered in patients with red flag symptoms of a potentially more severe condition, such as chest pain, focal neurologic deficits, joint erythema/swelling, enlarged lymph nodes, or shortness of breath.
129. A previously healthy 6-month-old female is admitted to the hospital with bronchiolitis. Which one of the following would be an appropriate treatment for this patient?
A) Albuterol (Proventil, Ventolin)
C) Nebulized hypertonic saline
D) Systemic corticosteroids
The American Academy of Pediatrics (AAP) recommends nebulized hypertonic saline for infants and children hospitalized with bronchiolitis (SOR B). They do not recommend nebulized hypertonic saline for infants in the emergency department with a diagnosis of bronchiolitis.
The AAP guideline also recommends that clinicians do not administer albuterol or epinephrine to infants and children with a diagnosis of bronchiolitis (SOR B). In addition, clinicians should not administer systemic corticosteroids to infants with a diagnosis of bronchiolitis in any setting (SOR A).
130. A 41-year-old premenopausal female presents to your office with amenorrhea, headache, and abnormal vision. Visual field testing reveals bitemporal hemianopsia. You order laboratory tests and MRI of the brain. The MRI reveals a 15-mm mass in the pituitary gland.
Which one of the following laboratory results would suggest an ACTH-secreting adenoma?
A) Elevated LH and FSH
B) Elevated serum prolactin
C) Elevated serum insulin-like growth factor 1
D) Low free T4 with a normal TSH level
E) Elevated 24-hour urine free cortisol
Pituitary adenomas are the most common disorder of the pituitary gland and are responsible for 10%–15% of all intracranial masses. They present with symptoms of hormone secretion or a neurologic mass effect, or as an incidental finding on CT/MRI. Premenopausal women often experience amenorrhea, while the most common neurologic symptoms are headache and vision changes (classically bitemporal hemianopsia) due to compression of the optic chiasm.
Tumors secreting prolactin (lactotrophs) are the most common, comprising 40%–57% of all pituitary adenomas. Nonsecreting tumors make up 28%–37%, growth hormone–secreting adenomas (somatotrophs) 11%–13%, and ACTH-secreting adenomas (corticotrophs) 1%–2%. FSH-, LH-, and TSH-secreting tumors are rare. ACTH-secreting tumors result in an increase in circulating cortisol, and the diagnosis is confirmed by 24-hour urine cortisol, late-night salivary cortisol, or overnight dexamethasone suppression testing.
Gonadotrophs cause a resulting elevation of FSH and LH. Lactotrophs increase serum prolactin, and somatotrophs increase serum insulin-like growth factor. Thyrotrophs result in normal TSH with low free T4.