Questions 151-200 Flashcards Preview

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Flashcards in Questions 151-200 Deck (50)
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1

151.  An 85-year-old female with hypertension and chronic kidney disease was admitted to the hospital for a total knee replacement. The next evening she becomes agitated and disoriented to place and time.

Which one of the following interventions would be most appropriate in this patient’s management?

A)  Haloperidol

B)  Zolpidem (Ambien)

C)  Avoiding opioids

D)  Removing hearing aids

E)  Early mobilization 

ANSWER: E

Sedative hypnotics such as zolpidem are associated with increased delirium symptoms and should not be used as first-line therapy (SOR C). Behavioral interventions such as early and recurrent mobilization, continuous observation, improving sensory perception (such as with hearing aids), initial reorientation, and removal of unnecessary irritations such as intravenous lines and catheters have been shown to decrease symptoms of delirium (SOR B). While opioids can affect mental status, untreated pain is also associated with delirium, and opioids are likely indicated in this postoperative patient. Antipsychotic medications such as haloperidol, as well as physical restraints, should be used as last resorts and only after an appropriate medical evaluation (SOR A). 

2

152. You are evaluating a 7-year-old male for long-standing nighttime bed wetting. He has no daytime symptoms and no other health problems. A thorough physical examination is normal.

Which one of the following would be most appropriate at this point?

A)  Urinalysis alone

B)  Urinalysis and a serum metabolic panel

C)  Urinalysis and a lumbosacral radiograph

D)  Urinalysis and renal ultrasonography 

ANSWER: A

This child has monosymptomatic enuresis, meaning there are no other symptoms except nighttime bed wetting. His physical examination is normal. In this setting, the recommended initial workup is a urinalysis alone. If the results are normal and there are no other symptoms suggestive of underlying behavioral or medical conditions, reassurance and instruction on possible behavioral interventions is appropriate without further evaluation. 

3

153.  Which one of the following is the only intervention shown to be effective in the prevention and treatment of pressure ulcers?

A)  Vitamin C supplements

B)  Protein supplements

C)  Topical collagen dressings

D)  Dextranomer paste applied to wounds

E)  Negative-pressure wound therapy 

ANSWER: B

The American College of Physicians recently published clinical practice guidelines for the treatment of pressure ulcers. Many modalities were evaluated, but good studies and evidence were available only for a few treatments. Several good-quality studies indicate that protein supplementation improves wound healing and also appears to have some benefit in prevention as well. Vitamin C supplementation made no difference in wound healing. Dextranomer paste applied to wounds actually worsened wound healing compared to standard wound dressings. Topical collagen dressings and negative-pressure wound therapy yielded no improvement in wound healing compared to usual care. 

4

154.  A healthy 30-year-old male presents to your office with a 2-cm abscess on his leg. There is no surrounding erythema and he is afebrile. You incise and drain the abscess.

Which one of the following would be the most appropriate management for this patient?

A)  Observation only

B)  Amoxicillin/clavulanate (Augmentin)

C)  Cephalexin (Keflex)

D)  Clindamycin (Cleocin)

E)  Trimethoprim/sulfamethoxazole (Bactrim) 

ANSWER: A

A simple abscess with no overlying cellulitis that is treated with incision and drainage does not require antibiotics. If there were overlying cellulitis, antibiotic use would be appropriate. Purulent infections have a higher likelihood of being caused by MRSA, so coverage with trimethoprim/sulfamethoxazole or clindamycin would be appropriate. In nonpurulent skin infections, amoxicillin/clavulanate or cephalexin would be appropriate choices. 

5

155. Which one of the following is most effective for treating fibromyalgia?

A)  Tricyclic antidepressants

B)  SSRIs

C)  NSAIDs

D)  Opioid analgesics

E)  Corticosteroids 

ANSWER: A

Pain in fibromyalgia is thought to be due to a centralized pain state. Medications that reduce the activity of neurotransmitters or increase the activity of inhibitory neurotransmitters such as norepinephrine and serotonin work best, and tricyclic antidepressants appear to be most effective (SOR A). Older SSRIs have limited benefit. Oral analgesics only work in about one-third of patients, and opioids may increase hyperalgesia. Corticosteroids are ineffective. 

6

156.  An 84-year-old female sees you for a follow-up visit for cardiovascular issues, including a previous myocardial infarction. Her current medication regimen consists of lisinopril (Prinivil, Zestril) and carvedilol (Coreg). While she is not dyspneic at rest, she now becomes short of breath after walking half a block. On examination her blood pressure is 122/74 mm Hg, pulse rate 72 beats/min, respirations 18/min, and oxygen saturation 97% on room air. She has no jugular venous distention and her lungs are clear. No edema is noted. A recent echocardiogram showed a left ventricular ejection fraction of 30%.

Adding which one of the following would help to decrease both mortality and the risk of hospitalization?

A)  Digoxin

B)  Furosemide

C)  Isosorbide dinitrate/hydralazine (BiDil)

D)  Losartan (Cozaar)

E)  Spironolactone (Aldactone) 

ANSWER: E

Systolic heart failure, or heart failure with a reduced left ventricular ejection fraction (<40%), should be managed with an ACE inhibitor and a B-blocker. If there is volume overload, a diuretic should be added. For those who cannot tolerate an ACE inhibitor, an angiotensin receptor blocker can be used. However, an ACE inhibitor should not be given with an angiotensin receptor blocker, as this combination increases mortality.

Digoxin will decrease symptoms and lessen the chance of hospitalization, but mortality is not reduced. Mortality and hospitalization can be reduced by the addition of an aldosterone antagonist such as spironolactone. In African-American patients, using a combination of hydralazine and isosorbide dinitrate improves both symptoms and mortality for those with New York Heart Association class III or IV heart failure with a reduced ejection fraction. 

7

157.  In a healthy full-term infant who is exclusively breastfed, iron supplementation should begin at what age in order to prevent iron deficiency anemia?

A)  1 month

B)  4 months

C)  6 months

D)  9 months

E)  12 months 

ANSWER: B

Healthy full-term infants receive 60%–80% of their iron stores from their mothers during the third trimester of pregnancy. Thus, even an exclusively breastfed infant will not typically be at risk of developing iron deficiency anemia until the age of 4 months. Iron supplementation should then be started and continued until the child is eating foods containing sufficient dietary iron. Preterm babies who are exclusively breastfed should begin iron supplementation at 1 month of age due to a foreshortened third trimester. 

8

158.  A previously healthy 46-year-old female presents with a 1-month history of leg swelling and weight gain. She denies chest pain and shortness of breath. She takes no medications, has never smoked, and drinks only an occasional glass of wine.

The physical examination is notable for 2+ pitting edema to the mid-thigh on both legs, and mild ascites. The remainder of her examination is normal. A dipstick urinalysis shows 3+ protein. You suspect primary nephrotic syndrome.

In addition to proteinuria and low albumin, which one of the following is the most common finding in patients with primary nephrotic syndrome?

A) Coagulopathy B) Hypercalcemia C) Hyperglycemia

D) Hyperlipidemia E) Infection 

ANSWER: D

Nephrotic syndrome is the triad of edema, proteinuria, and hypoalbuminemia, and it usually is also associated with hyperlipidemia. The initial evaluation of this patient should include testing for hyperlipidemia. Nephrotic syndrome is associated with an increased risk of deep vein thrombosis but does not cause a coagulopathy. Diabetes mellitus can be a secondary cause of nephrotic syndrome but is not a finding in primary nephrotic syndrome. Relative hypocalcemia may be found in patients with nephrotic syndrome due to low protein, but hypercalcemia is not associated with nephrotic syndrome. Children and patients with relapses of nephrotic syndrome have an increased risk of infection. 

9

159.  A 62-year-old male with type 2 diabetes mellitus, hypertension, and hypercholesterolemia is found to have a low serum vitamin B12 level. Which one of his current medications is most likely to cause this?

A)  Aspirin

B)  Enalapril (Vasotec)

C)  Metformin (Glucophage)

D)  Simvastatin (Zocor)

E)  Hydrochlorothiazide 

ANSWER: C

Low vitamin B12 is seen with prolonged use of metformin, H2-blockers, and proton pump inhibitors. The mechanism is unclear, and it is not known whether prophylactic supplementation prevents deficiency. Metformin reduces absorption of vitamin B12 in 30% of patients and reduces vitamin B12 concentrations in 5%–10% of those taking it. The dosage and duration of metformin therapy is correlated with the risk of vitamin B12 deficiency. Given this risk, it seems prudent to monitor vitamin B12 levels periodically in patients taking metformin. 

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160.  A 25-year-old gravida 1 para 0 presents for follow-up of gestational diabetes mellitus. She had a positive screening test at her 24-week visit last week and has been checking her blood glucose at home twice daily since that time. She is not currently on any diabetes medications and has a nutrition visit scheduled for later today. She is currently unclear on what her glucose level should be at various times throughout the day.

Which one of the following is the goal fasting blood glucose in this patient?  Less than or equal to...

A)  75 mg/dL

B)  95 mg/dL

C)  120 mg/dL

D)  140 mg/dL

E)  180 mg/dL 

ANSWER: B

Clinicians who care for pregnant women need to be familiar with the diagnosis and monitoring parameters for gestational diabetes mellitus, as these help to determine the need for management strategies outside of diet and exercise. The goal is less than or equal to 95 mg/dL for fasting blood glucose, less than or equal to 140 mg/dL for 1-hour postprandial glucose, and less than or equal to 120 mg/dL for 2-hour postprandial glucose. 

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161.  Which one of the following is the strongest risk factor for primary hypertension in children and adolescents?

A)  A family history of hypertension

B)  Elevated BMI

C)  Male sex

D)  African-American ethnicity 

ANSWER: B

There is an increasing prevalence of hypertension in children and adolescents. BMI is the strongest risk factor for hypertension in this age group. Other risk factors include a family history of hypertension, low birth weight, male sex, and certain ethnic backgrounds. The prevalence of hypertension in obese children is 11%, which is more than double that of the general pediatric population (reported at 1%–5%). 

12

162.  A 75-year-old female presents with a 6-week history of the gradual onset of pain behind her right knee. She has a previous history of osteoarthritis and mild hypertension, but no other significant problems. Examination of the knee reveals a soft mass in the medial popliteal fossa that is present when the knee is extended, but is much smaller when the knee is flexed to 45°, which also causes the pain to subside.

Which one of the following would be most appropriate to diagnose this problem?

A)  A plain radiograph

B)  MRI

C)  Ultrasonography

D)  Arteriography

E)  No imaging 

ANSWER: E

Popliteal cysts cause posterior knee pain, and are thought to be a result of increased intra-articular pressure forcing fluid into the bursa and causing expansion and subsequent pain. Risk factors include rheumatoid arthritis or osteoarthritis and advanced age. With the patient lying down, a mass can be palpated in the medial popliteal fossa while the knee is extended. When the knee is flexed to 45° the pain subsides and the mass is reduced in size or disappears.

Imaging is generally not needed for the diagnosis. Plain radiographs are obtained if there is a possible fracture. Ultrasonography can be used if deep vein thrombosis is a consideration. If significant internal derangement of the knee is suspected, MRI may be useful. An arteriogram would be an option if aneurysm of the popliteal artery were suspected.

Treatment is generally conservative, although addressing the underlying knee pathology will prevent the cyst from recurring. Pain is often decreased by keeping the knee in flexion and the use of ice and NSAIDs. If this is not successful, intra-articular corticosteroids or cyst aspiration is often effective. 

13

163.  Which one of the following screening measures does the U.S. Preventive Services Task Force recommend against (USPSTF D recommendation)?

A)  Abdominal ultrasonography to evaluate for an abdominal aortic aneurysm in a 65-year-old male smoker

B)  BRCA testing in a high-risk 40-year-old female

C)  A Papanicolaou test in a 58-year-old female who previously had an abdominal

hysterectomy for fibroids

D)  Colonoscopy for a 70-year-old male with no history of rectal bleeding 

ANSWER: C

Overscreening has become increasingly common. This inappropriate care costs the health care system while providing no benefit and possibly causing harm to patients. All of the listed screenings are appropriate with the exception of cervical cancer screening for a patient who has had a hysterectomy. The U.S. Preventive Services Task Force recommends against screening for cervical cancer in women over 65 who have had adequate recent screening, and in women who have had a hysterectomy for benign disease (SOR A). 

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164.  A 52-year-old male was admitted to the hospital with evidence of an acute myocardial infarction. He underwent cardiac catheterization and percutaneous coronary intervention with placement of two drug-eluting stents. Echocardiography revealed a left ventricular ejection fraction of 30%. By the time of his discharge the patient had been started on several new medications, including aspirin.

Which one of the following medications is more useful for symptom control than for improving mortality in this situation?

A)  Atorvastatin (Lipitor)

B)  Clopidogrel (Plavix)

C)  Lisinopril (Prinivil, Zestril)

D)  Metoprolol tartrate (Lopressor)

E)  Nitroglycerin 

ANSWER: E

Evidence-based guidelines for the treatment of patients with acute coronary syndrome support several medications in the subacute period. Dual antiplatelet therapy, such as clopidogrel combined with aspirin, has been shown to reduce cardiovascular mortality (SOR B). ACE inhibitors and statins should be initiated immediately after a myocardial infarction and continued indefinitely to reduce mortality and the risk of repeat infarction (SOR A). B-Blockers have been shown to improve mortality in patients with a left ventricular ejection fraction <40% (SOR A). Nitroglycerin is often used to manage angina but has no demonstrated mortality benefit. 

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165.  A 24-year-old female sees you for follow-up of her chronic abdominal pain. You have diagnosed her with somatization disorder. You have scheduled regular, frequent visits and she has been in counseling for a few months. She still has significant anxiety about her symptoms and you would like to start her on a medication.

Which one of the following medications would be most appropriate for this patient?

A)  Amitriptyline

B)  Aripiprazole (Abilify)

C)  Bupropion (Wellbutrin)

D)  Carbamazepine (Tegretol)

E)  Lamotrigine (Lamictal) 

ANSWER: A

Somatic disorders usually require a multifaceted approach to treatment. It is important to schedule regular visits at short intervals to establish a collaborative relationship with the patient. It is also important to limit diagnostic testing and reassure the patient that serious diseases have already been ruled out, and to screen for other mental illnesses. Referral for counseling using cognitive-behavioral therapy and mindfulness-based therapies is also effective. SSRIs and tricyclic antidepressants have been found to be the most effective pharmacotherapy (SOR B) for somatic symptom disorders. Amitripityline is the most studied tricyclic antidepressant, and trials have shown that it has a greater likelihood of success compared to SSRIs. Other antidepressants, anticonvulsants, and antipsychotic medications are ineffective and should be avoided (SOR B). 

16

166.  A 27-year-old male complains of severe back and left leg pain that started yesterday afternoon. He states that just before the pain began he was moving some patio furniture around his back porch when he felt a sudden “pop” in his left lumbar region. Over the subsequent few hours he developed gradually increasing pain in his low back that radiates down the posterolateral side of his left leg and onto the top of his left foot. He describes the pain as lancinating and knife-like, rating it as 10/10 on a pain scale. He is unable to stand up straight or sit down comfortably for an examination. He denies any bowel or bladder dysfunction and appears to have otherwise intact strength and sensation. Prior to this event he was in good health and took no routine medications.

Which one of the following is recommended at this time?

A)  No imaging

B)  Radiographs of the lumbar spine only

C)  CT of the lumbar spine without contrast

D)  MRI of the lumbar spine without contrast

E)  MRI of the lumbar spine with contrast 

ANSWER: A

This case can be best described as acute lumbar pain with radiculopathy. There are no red flags that would suggest the presence of a time-sensitive condition such as cauda equina syndrome, cancer, infection, or fracture. In cases like this, consensus agreements recommend against any imaging studies. Instead, a 6-week course of pain medication, manipulation, physical therapy, and self-care should be undertaken. 

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167.  The son of a 76-year-old female with metastatic cancer calls you stating that the patient is having uncontrollable nausea. She takes long-acting morphine for pain and he has already tried giving her promethazine and ondansetron (Zofran) without significant benefit. She has been able to drink fluids, but feels “full” and has not eaten more than a few bites of food each day. She has not been vomiting and her urine output has been normal. However, the son reports that she has not had a bowel movement in about 5 days, which he assumes is due to her low intake of food.

Which one of the following would be most appropriate at this point?

A)  Increasing the dosage of oral morphine

B)  Initiating subcutaneous hydration

C)  Assessing for possible fecal impaction

D)  Inserting a nasogastric tube

E)  Suggesting oral or inhaled marijuana 

ANSWER: C

Nausea is a common symptom near the end of life and can have many causes. One of the first objectives in the palliative care of nausea is to identify and address the underlying cause. This patient is taking a long-acting opiate that predisposes her to constipation. Furthermore, the family seems to accept the fact that she is not having any bowel movements because she is not eating very much, which is an incorrect understanding. There are no signs of dehydration to warrant subcutaneous hydration, nor are there signs of bowel obstruction that would warrant a nasogastric tube. 

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168.  A 90-year-old female is being considered for transcatheter aortic valve replacement due to severely symptomatic critical aortic stenosis. In addition to a medication review, which one of the following tests would be best to assess for frailty as a component of the preoperative assessment?

A)  Gait speed

B)  The Geriatric Depression Scale

C)  The Confusion Assessment Method (CAM)

D)  The Mini-Cognitive Assessment Instrument (Mini-Cog) 

ANSWER: A

Frailty is an age-related, multidimensional state of decreased physiologic reserves. Frail patients are at increased risk of decline as a result of illness or stressors such as surgery. The definition and assessment of frailty are still not uniformly agreed upon, but gait speed is recognized as a highly reliable single measurement tool. The other options listed are useful components of a geriatric assessment but are not used as a single test for the evaluation of frailty. 

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169.  Which one of the following topical antibiotics used in the treatment of acne vulgaris is not known to increase bacterial resistance?

A)  Benzoyl peroxide

B)  Clindamycin (Cleocin)

C)  Dapsone (Aczone)

D)  Erythromycin

E)  Metronidazole 

ANSWER: A

Benzoyl peroxide is the only topical antibiotic without evidence to suggest that its use contributes to bacterial antimicrobial resistance. For this reason it is recommended as first-line therapy in mild to moderate inflammatory acne and as an adjunctive agent with other topical antibiotics that can induce bacterial resistance, such as clindamycin and erythromycin. Dapsone is an antibiotic but is thought to primarily improve acne via its anti-inflammatory effect. Metronidazole is used chiefly in acne rosacea rather than acne vulgaris and it may contribute to antimicrobial resistance. 

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170.  Which one of the following therapies is most likely to reduce abdominal cramping in a patient with irritable bowel syndrome?

A)  Peppermint oil

B)  Polyethylene glycol (MiraLAX)

C) Probiotics

D) Wheat bran 

ANSWER: A

Peppermint oil is an antispasmodic that has moderate evidence of benefit in the relief of abdominal cramping in patients with irritable bowel syndrome (IBS). Probiotics as a group have some evidence of benefit in improving global IBS symptoms, but the studies have used different probiotic preparations so it is difficult to draw definite conclusions about their effectiveness or to recommend a specific preparation. Polyethylene glycol is an osmotic laxative that has evidence of benefit for bowel symptoms, including improvement in stool frequency and consistency, but it does not improve abdominal pain. Wheat bran is an insoluble fiber that contains fructans that can exacerbate IBS symptoms and should be avoided in patients with IBS. 

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171.  A 4-year-old male is brought to your office by his neighbor with a 1-day history of fever, lethargy, stiff neck, and rash. You suspect meningitis. The neighbor reports that the patient’s father is on his way to the office and should arrive within 30 minutes.

Which one of the following would be most appropriate in this situation?

A)  Initiate treatment now

B)  Obtain informed consent to treat from the neighbor

C)  Call the father to obtain informed consent to treat

D)  Wait until the father arrives to obtain informed consent to treat 

ANSWER: A

The American Academy of Pediatrics recommends that medical care for children with an urgent or emergent condition never be withheld or delayed because of problems obtaining consent. All efforts to obtain consent should be documented. In the case of a 4-year-old male who is suspected to have meningitis, even a brief delay in treatment could result in a bad outcome for the patient. 

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172.  A 35-year-old female is concerned about a persistent rash on her face. It waxes and wanes in severity but she has persistent redness over her forehead, nose, cheeks, and chin. She also reports an occasional flush that usually lasts less than 5 minutes, sometimes spreads to her neck and chest, and is accompanied by a sensation of warmth. In addition to redness and flushing, the affected areas often contain papules, pustules, and small red streaks. Your examination confirms erythema over her centrofacial features with accompanying papulopustular lesions on her nose and telangiectasia on her chin and nose.

Which one of the following agents is an FDA-approved first-line topical therapy for this patient’s condition?

A)  Benzoyl peroxide

B)  Clindamycin (Cleocin)

C)  Metronidazole

D)  Selenium sulfide

E)  Tretinoin 

ANSWER: C

This patient presents with the classic symptoms and signs of rosacea. FDA-approved first-line agents for treating rosacea include metronidazole 0.75% lotion, 0.75% cream, and 1% gel; azelaic acid 15% gel; sulfacetamide 10%/sulfur 5% cream, foam, lotion, and suspension; brimonidine 0.33% gel; and ivermectin 1% cream (SOR A). 

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173.  A 19-year-old female college student is referred to you by her dentist for a medical evaluation related to dental problems. The patient states that she feels well and exercises at least 2–3 hours every day. On examination her teeth are stained and there are enamel erosions. She has nontender enlargement of both parotid glands. The remainder of the examination is normal.

Which one of the following is associated with these findings?

A)  Bacterial parotitis

B)  Bulimia nervosa

C)  Cat scratch disease

D)  Mononucleosis

E)  Mumps 

ANSWER: B

Bulimia nervosa is an eating disorder associated with recurrent binge eating and induced vomiting. There is also a history of excessive physical activity in many cases. Because of vomiting, the teeth are stained and there is destruction of the enamel from stomach acid. Parotid swelling is also noted frequently. With mumps and bacterial parotitis the patient feels sick and parotid glands are tender. Cat scratch disease and mononucleosis affect lymph glands. 

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174.  A drug available for over 20 years has been noted to have beneficial effects for a common disease. Because it is a cheap, generically available drug, no pharmaceutical firm is willing to fund a clinical trial.

What type of study would be best suited to evaluate this treatment?

A)  A double-blind crossover study

B)  A meta-analysis

C)  A non-inferiority trial

D)  A case-control study

E)  A single-blind trial 

ANSWER: C

A new treatment may not be more effective than available treatments but it may have lower costs, fewer adverse effects, or greater convenience compared to standard treatment. A treatment with other advantages might be preferred to standard treatment for some patients. A non-inferiority trial rigorously evaluates a treatment against accepted and effective treatments, with the goal of demonstrating that it is at least almost as good. Single- and double-blind studies (with or without crossover of the control and experimental groups) can be done to demonstrate the drug is effective, but showing that a new treatment is not inferior to standard treatments can be rigorously demonstrated by a non-inferiority trial. A non-inferiority trial does not distinguish between a new treatment that is not inferior and one that is truly superior, and cannot demonstrate equivalence. A case-control trial is not appropriate to compare one medication to another; its retrospective design is better for evaluating risk factors or exposures as possible causes or contributors to a disease or illness, as it involves no intervention in either the control or the experimental group. 

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175.  While working yesterday, a 53-year-old roofer stepped on a nail that went through his shoe and penetrated the sole of his foot. He irrigated his foot thoroughly with water when he got home. He comes to your office today because he has developed some erythema and pain in his foot, with a small amount of drainage.

While Staphylococcus aureus and Streptococcus species are the most common causes of skin and soft-tissue infection, which organism should also be considered in this situation?

A)  Corynebacterium

B)  Klebsiella

C)  Pasteurella multocida

D)  Pseudomonas aeruginosa

E)  Vibrio vulnificus 

ANSWER: D

Streptococcus species and Staphylococcus aureus are the most common causes of skin and soft-tissue infections. With a puncture wound caused by an object penetrating the sole of the shoe, another organism that should be considered as a possible cause of the infection is Pseudomonas aeruginosa. Klebsiella is not a common cause of these infections. Pasteurella multocida is a common cause of infection from a cat bite, and can also be seen in dog bites. Corynebacterium is also associated with infections from animal bites. Vibrio vulnificus should be considered when there is a skin infection after exposure to salt water. 

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176.  A newborn female is found to have constricted ear deformity (cup ears). Her mother had gestational diabetes mellitus.

Which one of the following studies would be most appropriate for this patient?

A)  A single-view chest radiograph

B)  Long bone radiographs

C)  Echocardiography

D)  Renal ultrasonography

E)  Unenhanced head CT 

ANSWER: D

If isolated ear anomalies such as cup ears, preauricular skin tags, or ear pits are associated with maternal gestational diabetes mellitus, ultrasonography is warranted to screen for renal abnormalities. Ear malformations are also associated with renal abnormalities in children with other malformations, dysmorphic features, a family history of deafness, or teratogenic exposures (SOR C). 

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177.  The U.S. Preventive Services Task Force recommends routine screening for which one of the following in adolescents?

A)  Alcohol use

B)  Cervical cancer

C)  Chlamydia infection

D)  Depression

E)  Scoliosis 

ANSWER: D

According to the U.S. Preventive Services Task Force, screening for major depression is recommended if adequate treatment and follow-up can be provided. Sexually active females should be screened for Chlamydia infection. Cervical cancer screening begins at age 21. Because of undue harm from unnecessary treatment, scoliosis screening is not recommended. There is insufficient evidence to recommend for or against routine screening for alcohol use (SOR A, B). 

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178.  In an adult patient with significant depression and no other health problems, which one of the following is the best initial choice for pharmacotherapy?

A)  Amitriptyline

B)  Duloxetine (Cymbalta)

C)  Fluoxetine (Prozac)

D)  Mirtazapine (Remeron)

E)  Trazodone (Oleptro) 

ANSWER: C

Depression can be treated with counseling and/or medication. The choice of medication depends on many factors including side effects, dosing schedule, cost, patient preference, and comorbidities. In a patient with significant depression and no comorbidities, a second-generation SSRI should be the initial medication choice. Fluoxetine is the only SSRI choice listed.

Duloxetine is an SNRI that may lead to sweating, tachycardia, urinary retention, and elevation of blood pressure. It is indicated if the patient has fibromyalgia. Trazodone is associated with somnolence, orthostatic hypotension, and priapism. It may be used in low doses as an adjuvant in patients with insomnia. Mirtazapine can cause sedation, weight gain, increased appetite, dry mouth, dizziness, and constipation. It is helpful for patients with significant insomnia and loss of appetite. Amitriptyline is a tricyclic antidepressant and has significant anticholinergic side effects. It is also associated with conduction abnormalities that can lead to arrhythmias. 

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179.  A 29-year-old male presents with a 3-week history of multiple small, brownish-red macules in his left inguinal fold that are now coalescing into larger macules. The rash does not itch, and he has not used any new bath or laundry products. Wood’s lamp illumination of the area reveals a reddish fluorescence.

Which one of the following topical treatments would be most appropriate for this patient’s rash?

A)  Erythromycin

B)  Hydrocortisone

C)  Nystatin

D)  Selenium sulfide

E)  Zinc oxide 

ANSWER: A

An intertriginous rash of brownish-red macules that often coalesce is characteristic of a bacterial infection caused by Corynebacterium minutissimum known as cutaneous erythrasma. Coral-red fluorescence under a Wood’s lamp confirms the diagnosis. The best treatment for erythrasma is oral or topical erythromycin, with the oral form being most effective. Topical clindamycin and antibacterial soaps may also be of some benefit. 

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180.  Which one of the following is routinely required to establish a diagnosis of chronic lymphocytic leukemia?

A)  A lymph node biopsy

B)  A bone marrow biopsy and aspirate

C)  CT of the chest, abdomen, and pelvis

D)  Flow cytometry and immunophenotyping of peripheral blood

E)  Weight loss of more than 10%, unexplained fever, and night sweats 

ANSWER: D

Flow cytometry and immunophenotyping of peripheral blood demonstrate clonality of the circulating lymphocytes in chronic lymphocytic leukemia (CLL). Absolute lymphocytosis is defined as >5000 cells/mm3.

Ninety percent of CLL patients are asymptomatic at the time of diagnosis. Imaging procedures are not necessary for establishing the diagnosis. While a bone marrow biopsy or aspiration and/or a lymph node biopsy may be necessary as the disease progresses, they are not routinely needed to establish a CLL diagnosis.