Questions 201-240 Flashcards
(40 cards)
- Which one of the following nutritional management strategies is associated with better outcomes in patients with mild acute pancreatitis whose pain and nausea have resolved?
A) Waiting until lipase has normalized before beginning oral intake
B) Early initiation of a clear liquid diet
C) Early initiation of a low-fat diet
D) Early initiation of tube feeding
E) Early initiation of total parenteral nutrition
Item 240
ANSWER: C
Historically, patients with acute pancreatitis were kept NPO to rest the pancreas. Evidence now shows that bowel rest is associated with intestinal mucosal atrophy and increased infectious complications because of bacterial translocation from the gut. Multiple studies have shown that patients who are provided oral feeding early in the course of acute pancreatitis have a shorter hospital stay, decreased infectious complications, decreased morbidity, and decreased mortality. Starting with a low-fat solid diet has been shown to be safe compared with clear liquids, providing more calories and shortening hospital stays.
Total parenteral nutrition should be avoided in patients with mild or severe acute pancreatitis. There have been multiple randomized trials showing that total parenteral nutrition is associated with infectious and other line-related complications.
- A 45-year-old male with diabetes mellitus sees you for the first time. If the patient has not previously received it, which one of the following vaccines is recommended for him by the Advisory Committee on Immunization Practices?
A) Hepatitis A
B) Hepatitis B
C) Meningococcal
D) Varicella zoster
Item 239
ANSWER: B
Late in 2012, the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention recommended hepatitis B vaccine for all previously unvaccinated adults between the ages of 19 and 59 with diabetes mellitus, as soon as possible after the diagnosis of diabetes is made. Vaccination should be considered for patients ≥ age 60, after assessing their risk and the likelihood of an adequate immune response.
- A 34-year-old female with a history of type 2 diabetes mellitus requests your advice regarding influenza vaccine. She is concerned because 6 months ago she developed hives after ingesting eggs and another physician suggested that she avoid influenza vaccine. She has not experienced wheezing, vomiting, or swelling in her throat after ingesting eggs.
Which one of the following would be the best strategy for this patient?
A) Avoid giving influenza vaccine
B) Administer the live-attenuated influenza vaccine and observe for 30 minutes
C) Administer trivalent inactivated vaccine and observe for 30 minutes
D) Have the patient take prednisone, 20 mg for 3 days, then administer the live-attenuated influenza vaccine and observe for 30 minutes
E) Have the patient take prednisone, 20 mg for 3 days, and then administer the trivalent inactivated vaccine and observe for 30 minutes
Item 238
ANSWER: C
For patients with a history of egg allergy who have experienced only hives, the Advisory Committee on Immunization Practices recommends influenza vaccination with inactivated vaccine rather than live-attenuated vaccine. The vaccine should be administered by a health care professional proficient in potential manifestations of egg allergy, and the patient observed for at least 30 minutes afterward. Persons who have had allergic reactions to egg proteins that include angioedema, respiratory distress, lightheadedness, or recurrent emesis, or who required epinephrine or other emergency medical interventions, are more likely to have a systemic or anaphylactic reaction to the vaccine. A previous severe reaction to influenza vaccine is a contraindication to future vaccination. Prednisone is not appropriate as a preventive measure.
- As part of routine care for a 31-year-old female you obtain a Papanicolaou (Pap) test for cervical cancer screening. The cytology results are normal, and the sample is positive for the presence of HPV but negative for serotypes 16 and 18.
Which one of the following is the most appropriate management for this patient?
A) Immediate colposcopy
B) Repeat Pap and HPV testing in 3 months
C) Repeat Pap and HPV testing in 6 months
D) Repeat Pap and HPV testing in 1 year
E) Repeat Pap and HPV testing in 3 years
Item 237
ANSWER: D
According to the American Society for Colposcopy and Cervical Pathology, a Papanicolaou test with co- testing for HPV is the preferred cervical cancer screening strategy for women age 30–64. This is because despite negative cytology, women with oncogenic HPV are at higher risk for later CIN 3+ than women with negative HPV tests. The risk of CIN 3+ in HPV-positive but cytology-negative women is sufficient to justify an earlier return for retesting. However, most HPV infections are cleared spontaneously, which reduces the risk of CIN 3+, so observing patients to allow time for this to happen is an attractive option.
Guidelines must balance the risks arising from interventions for HPV that may clear spontaneously against the risks of disease. Women with HPV 16 are at particular risk for CIN 3+. HPV 18 merits special consideration because of its association with cervical adenocarcinomas, which are less efficiently detected by cytology than squamous cell cancers. The patient described here should be advised to return for co- testing in 1 year. If her cytology remains negative but her HPV test remains positive, she should be advised to have colposcopy at that time regardless of the serotype of the HPV. If her current test had shown evidence of either strain 16 or 18 immediate colposcopy would be indicated.
- A 51-year-old female has resistant hypertension, and you decide to test her for primary hyperaldosteronism.
Which one of the following is the preferred initial test for this condition?
A) A morning serum cortisol level B) A morning serum renin to aldosterone ratio C) A morning urinary potassium level D) A salt suppression test E) Abdominal MRI
Item 236
ANSWER: B
Primary hyperaldosteronism is a relatively common cause of resistant hypertension. Because there are effective treatments, it is reasonable to consider testing for hyperaldosteronism in patients with resistant hypertension. This is true even for patients with a normal potassium level. The preferred initial test is a morning renin to aldosterone ratio. A ratio less than 20 (when plasma aldosterone is reported in ng/dL and plasma renin activity is in ng/mL/hr) effectively rules out primary hyperaldosteronism. A ratio greater than or equal to 20 with a serum aldosterone level greater than 15 ng/dL suggests aldosteronism, but a salt suppression test must be done for confirmation. Although abdominal MRI may detect an adrenal mass, it is not recommended as a test for hyperaldosteronism. Urinary potassium levels do not play a role in the diagnosis of primary hyperaldosteronism.
- A 52-year-old male with diabetes mellitus reports that he ran out of insulin a week ago. He is drowsy but responds to your verbal commands, and the remainder of his examination is unremarkable.
Laboratory Findings
Bloodglucose. …………….625mg/dL
Serum sodium……………..128 mEq/L (N 135–145) Serum potassium…………………… 5.9 mEq/L (N 3.5–5.0) Serum bicarbonate …………………12 mEq/L (N 22–26)
BUN…………………………….. 52mg/dL(N8–25)
Which one of the laboratory abnormalities is an indication that he has severe diabetic ketoacidosis?
A) Glucose B) Sodium C) Potassium D) Bicarbonate E) BUN
Item 235
ANSWER: D
The diagnosis of diabetic ketoacidosis (DKA) is based on an elevated serum glucose level (greater than 250 mg/dL), an elevated serum ketone level, a pH less than 7.3, and a serum bicarbonate level less than 18 mEq/L. The severity of DKA is determined by the arterial pH, bicarbonate level, anion gap, and mental status of the patient. Elevation of BUN and serum creatinine levels reflects intravascular volume loss. The measured serum sodium is reduced as a result of the hyperglycemia, as serum sodium is reduced by 1.6 mEq/L for each 100 mg/dL rise in serum glucose. The degree of hyperglycemia does not necessarily correlate closely with the degree of DKA since a variety of factors determine the level of hyperglycemia, such as oral intake and urinary glucose loss (SOR C).
- A previously healthy 50-year-old male presents with a heart rate of 156 beats/min and a blood pressure of 126/84 mm Hg. An EKG shows a regular, narrow-complex tachycardia. Vagal maneuvers have no effect, and the patient appears anxious.
Administration of which one of the following medications is the best initial treatment?
A) Vasopressin (Pitressin) B) Verapamil (Calan) C) Diltiazem D) Adenosine (Adenocard) E) Digoxin
Item 234
ANSWER: D
Patients with persistent supraventricular tachycardias require immediate medical attention. A patient who has no underlying heart disease and a regular, narrow complex tachycardia should be treated with adenosine. If the patient does not respond to this treatment, cardioversion should be considered. Vasopressin would be useful if the patient were unstable with a ventricular tachycardia.
- A 54-year-old male presents to your office with a 10-day history of increasing cough. A physical examination reveals coarse crackles in the left lower lobe. You make a diagnosis of pneumonia. The patient’s only current medication is simvastatin (Zocor).
Which one of the following is CONTRAINDICATED in this patient?
A) Amoxicillin/clavulanate (Augmentin) B) Azithromycin (Zithromax) C) Clarithromycin (Biaxin) D) Doxycycline E) Levofloxacin (Levaquin)
Item 233
ANSWER: C
In older adults, coprescription of clarithromycin or erythromycin with a statin that is metabolized by CYP 3A4 (atorvastatin, simvastatin, lovastatin) increases the risk of statin toxicity. The other antibiotics listed do not interact with statins.
- A 65-year-old male comes to your office with symptoms consistent with intermittent claudication in both lower extremities. These symptoms are making it difficult for him to walk any significant distance and to manage his daily activities. He has smoked one pack of cigarettes per day for the past 40 years and has moderate hypertension, an elevated LDL-cholesterol level, and a low HDL-cholesterol level.
On examination you note that the skin on the patient’s lower legs is cool and shiny, with sparse hair. Distal pulses are not palpable and capillary refill is prolonged. His ankle-brachial index is 0.85 (N 1.0–1.4). His cardiac examination is normal, with no evidence of heart failure.
Which one of the following pharmacologic options for improving this patient’s claudication symptoms is supported by the best available evidence?
A) Aspirin B) Warfarin (Coumadin) C) Clopidogrel (Plavix) D) Pentoxifylline E) Cilostazol (Pletal)
Item 232
ANSWER: E
A trial of cilostazol is recommended by the American College of Cardiology and the American Heart Association as initial treatment for peripheral arterial disease (PAD) that limits the lifestyle of patients without heart failure (SOR A). Cilostazol has been shown to increase walking distance and improve health-related quality of life (level of evidence 2). Although neither aspirin nor clopidogrel improves claudication symptoms, antiplatelet therapy is recommended to reduce the risk of myocardial infarction, stroke, or vascular death in patients with symptomatic PAD. Warfarin has not been shown to improve cardiovascular outcomes in patients with PAD, but may increase bleeding without clinical benefit. The available evidence indicates that the benefit of pentoxifylline is marginal, and it is, at best, a second-line alternative to cilostazol.
- A 54-year-old male presents with hearing loss associated with tinnitus. Which one of the following additional characteristics would be an indication for MRI of the brain to assess for an intracranial tumor?
A) A rapid onset of symptoms
B) Unilateral symptoms
C) Association with pain and otorrhea in the affected ear
D) Exposure to loud noise shortly before the symptoms began
Item 231
ANSWER: B
Hearing loss and tinnitus are both common and typically benign complaints in primary care. If both are present in only one ear, the diagnosis of acoustic neuroma, also known as vestibular schwannoma, should be considered. Acoustic neuroma is a slow-growing benign tumor of the Schwann cells surrounding the vestibular cochlear (8th cranial) nerve. Hearing loss associated with acoustic neuroma is typically slow in onset. The presence of vertigo on the affected side is another symptom of abnormal function of the vestibular cochlear nerve and should further raise suspicion of acoustic neuroma or another process affecting that nerve. MRI is the preferred imaging study for diagnosing acoustic neuroma (SOR A). Bilateral hearing loss is more common and is less likely to be caused by an intracranial mass. Exposure to loud sounds can cause hearing loss unrelated to an intracranial mass. Pain and otorrhea suggest infection rather than an intracranial tumor.
- A 13-year-old male presents with a 3-week history of left lower thigh and knee pain. There is no history of a specific injury, and his past medical history is negative. He has had no fevers, night sweats, or weight loss, and the pain does not awaken him at night. He tried out for his school’s basketball team but had to quit because of the pain, which was worse when he tried to run.
Which one of the following physical examination findings would be pathognomonic for slipped capital femoral epiphysis?
A) Excessive forward passive motion of the tibia with the knee flexed
B) Lateral displacement of the patella with active knee flexion
C) Limited internal rotation of the flexed hip
D) Reduced hip abduction with the hip flexed
E) An inability to extend the hip past the neutral position
Item 230
ANSWER: C
Slipped capital femoral epiphysis (SCFE) typically occurs in young adolescents during the growth spurt, when the femoral head is displaced posteriorly through the growth plate. Physical activity, obesity, and male sex are predisposing factors for the development of this condition. There is pain with physical activity, most commonly in the upper thigh anteriorly, but one-third of patients present with referred lower thigh or knee pain, which can make accurate and timely diagnosis more difficult.
The hallmark of SCFE on examination is limited internal rotation of the hip. Specific to SCFE is the even greater limitation of internal rotation when the hip is flexed to 90°. No other pediatric condition has this physical finding, which makes the maneuver very useful in children with lower extremity pain. Orthopedic consultation is advised if SCFE is suspected.
Hip extension and abduction are also limited in SCFE, but these findings are nonspecific. Displacement of the patella is not associated with SCFE.
- A 72-year-old female who remains very active and engaged in the community comes to your office concerned by urinary symptoms that disrupt her life. She reports that she often has a strong, abrupt desire to void that frequently causes her to leak urine involuntarily. She also reports occasional episodes of urinary frequency and nocturia.
Which one of the following is the first-line treatment for her condition?
A) Anticholinergic drugs such as oxybutynin or solifenacin (Vesicare)
B) B-Adrenergic agonists such as mirabegron (Myrbetriq)
C) Duloxetine (Cymbalta)
D) Bladder training
E) A pessary
Item 229
ANSWER: D
This patient suffers from urge urinary incontinence, defined as the loss of urine accompanied or preceded by a strong impulse to void. It may be accompanied by frequency and nocturia, and is common in older adults. Conservative therapies such as behavioral therapy, including bladder training and lifestyle modification, should be the first-line treatment for both stress and urge urinary incontinence (SOR C). Pharmacologic interventions should be used as an adjunct to behavioral therapies for refractory urge incontinence (SOR C). Vaginal inserts, such as pessaries, can be used for treating stress incontinence but not urge incontinence.
- Which one of the following is NOT a risk factor for stillbirth?
A) Smoking B) Advanced maternal age C) Congenital anomalies D) Vigorous exercise E) BMI >30 kg/m2
Item 228
ANSWER: D
Risk factors for stillbirth include advanced maternal age, smoking >1/2 pack of cigarettes a day, congenital anomalies, and a BMI >30 kg/m2. Excessive exercise has not been shown to increase the risk for stillbirth.
- A 62-year-old female presents to your office with diarrhea and signs and symptoms of dehydration. She has a temperature of 38.6°C (101.5°F) and a WBC count of 17,000/mm3 (N 5300–10,800). You admit her to the hospital, and a Clostridium difficile toxin assay is positive. Because of the severity of her infection, you initiate oral vancomycin (Vancocin), 125 mg 4 times daily. She has a poor clinical response and you decide to alter the antibiotic regimen to include intravenous coverage.
Which one of the following intravenous antibiotics would be most appropriate?
A) Ciprofloxacin (Cipro) B) Imipenem/cilastatin (Primaxin) C) Meropenem (Merrem) D) Metronidazole E) Vancomycin
Item 227
ANSWER: D
Metronidazole, vancomycin, and fidaxomicin are the three medications recommended for treatment of Clostridium difficile colitis infections. Only metronidazole is effective intravenously, because its biliary excretion and possibly exudation through the colonic mucosa allows it to reach the colon via the bloodstream. Treatment for this condition with vancomycin and fidaxomicin is oral. Imipenem/cilastatin, ciprofloxacin, and meropenem have not been shown to be effective for C. difficile infection.
- A 45-year-old male who has been complaining of dyspnea undergoes pulmonary function testing. The results show an FEV1/FVC ratio of 85% and an FVC below the lower limits of normal.
Based on these results, which one of the following possible causes of dyspnea is most likely?
A) Asthma B) Bronchiectasis C) A1-Antitrypsin deficiency D) COPD E) Idiopathic pulmonary fibrosis
Item 226
ANSWER: E
This patient has a restrictive pattern on pulmonary function testing as evidenced by an FEV1/FVC ratio >70% and an FVC below the lower limits of normal. Of the diagnostic options listed, idiopathic pulmonary fibrosis is the only restrictive cause of lung disease. All of the other conditions listed are obstructive causes of lung disease.
- Staff members in your practice often complain about one of your patients. He exhibits odd behaviors and beliefs, and is always very anxious about his visit and about when he will be seen, despite long familiarity with your practice.
Which one of the following personality disorders best fits the description of this patient?
A) Antisocial B) Borderline C) Dependent D) Narcissistic E) Schizotypal
Item 225
ANSWER: E
This patient most likely has schizotypal personality disorder. These patients have problems with social and interpersonal relationships, which are marked by significant anxiety and discomfort, and they also exhibit odd thinking, speech, and perceptions. This disorder is classified as being in the cluster A personality disorder group. Patients with disorders in this group exhibit odd or eccentric personalities, and the group includes paranoid, schizoid, and schizotypal personality disorders.
Cluster B disorders are characterized by dramatic, emotional, or erratic personalities, and include antisocial, borderline, histrionic, and narcissistic personality disorders. Cluster C disorders include avoidant, obsessive-compulsive, and dependent personality disorders. Patients with disorders in this group exhibit mainly anxious or fearful behaviors.
- In which one of the following cardiac emergency cases should atropine be used?
A) Symptomatic Mobitz type II atrioventricular block
B) Cardiac arrest with pulseless electrical activity
C) Asystolic cardiac arrest
D) Acute cardiac ischemia and a heart rate less than 60 beats/min
E) Sinus bradycardia with hypotension
Item 224
ANSWER: E
The main use of atropine in cases of cardiac arrest is for symptomatic bradycardia. It has little effect with complete heart block and Mobitz type II atrioventricular block. It is not recommended or effective for cardiac arrest with pulseless electrical activity or in cases of asystole. It has been removed from these algorithms by the ACLS committee. During an acute myocardial infarction or acute cardiac ischemia, an increase in heart rate may increase the amount of ischemia.
- In a patient with chronic, severe, noncancer pain, which one of the following would be most appropriate for initial opioid therapy?
A) Buprenorphine (Buprenex) B) Transdermal fentanyl (Duragesic) C) Hydromorphone (Dilaudid) D) Methadone (Dolophine) E) Morphine
Item 223
ANSWER: E
Morphine is the best first choice for chronic potent opioid therapy (SOR B). It is reliable and inexpensive, and equivalent doses can be easily calculated if the patient must later be switched to another medication. Transdermal fentanyl and hydromorphone are reasonable second-line choices; however, they are not recommended as first-line therapy because they are expensive and can produce tolerance relatively quickly (SOR B). Methadone is another second-line option and tolerance is usually less of a problem. It is inexpensive and long-acting but also has unique pharmacokinetics. It has a very long elimination half-life, and its morphine-equivalent equianalgesic conversion ratio increases as dosages increase. Methadone can prolong the QT interval, especially in patients who are taking other QT-prolonging medications (SOR B). Buprenorphine is a partial opioid agonist that is usually used for treatment of patients with opioid addictions. Although it can be effective for treatment of pain, it is expensive and requires special prescriber training, so it is currently not recommended as a first-line agent for treatment of chronic pain (SOR C).
- A 54-year-old female concert pianist presents to your office with a 9-month history of searing pain and bilateral paresthesias in the distribution of her median nerve. She says that the pain frequently radiates as far as her shoulder, and that her fingers feel swollen even though they look normal. She states that she has worsening paresthesias at night and often finds herself flicking her wrist in an attempt to alleviate her symptoms.
The patient’s symptoms are reproducible with wrist flexion and she exhibits mild weakness of the abductor pollicis brevis on examination. She has been wearing neutral wrist splints at night for the last 8 weeks and has also been taking oral NSAIDs, resulting in only minimal relief. She is in the middle of her concert season and is unable to take time off for a surgical procedure.
Which one of the following therapies will provide this patient with the longest symptom relief?
A) Full rest for 8 weeks B) Full-time cock-up splinting for 8 weeks C) Physical therapy D) Oral corticosteroids E) Local corticosteroid injection
Item 222
ANSWER: E
This patient has carpal tunnel syndrome. Initial conservative approaches for mild to moderate symptom relief include full-time splinting for 8 weeks (SOR B) and oral corticosteroids. However, studies suggest that local corticosteroid injections offer symptom relief for 1 month longer than oral corticosteroid therapy and some individuals experience relief for up to 1 year. Severe or chronic symptoms usually require surgical intervention for nerve decompression. Physical therapy is not recommended, and full rest is unlikely in a person in a high-risk occupation for overuse syndromes.
- A 72-year-old white female is admitted to the hospital with her first episode of acute heart failure. She has a history of hypertension treated with a thiazide diuretic. An echocardiogram reveals no evidence of valvular disease and no segmental wall motion abnormalities. Left ventricular hypertrophy is noted, and her ejection fraction is 55%. Her pulse rate is 72 beats/min.
The most likely cause of her heart failure is
A) systolic dysfunction
B) diastolic dysfunction
C) hypertrophic cardiomyopathy
D) high-output failure
Item 221
ANSWER: B
Diastolic dysfunction is now recognized as an important cause of heart failure. It is due to left ventricular hypertrophy as a response to chronic systolic hypertension. The ventricle becomes stiff and unable to relax or fill adequately, thus limiting its forward output. The typical patient is an elderly person who has systolic hypertension, left ventricular hypertrophy, and a normal ejection fraction (50%–55%).
- A 46-year-old perimenopausal female complains of hot flashes, which are very troubling to her. She would like treatment for these symptoms, but has a history of deep vein thrombosis while taking oral contraceptives.
Which one of the following treatments has evidence of benefit for her symptoms with the least potential for causing deep vein thrombosis?
A) Vaginal estradiol
B) Oral estradiol combined with progestin
C) Oral phytoestrogens such as soy protein
D) Oral venlafaxine (Effexor XR)
E) Topical bio-identical hormones
Item 220
ANSWER: D
Vasomotor symptoms associated with menopause are best controlled with oral or topical estrogens. However, one of the known risks of systemic estrogen treatment is an increased rate of developing deep vein thrombosis (DVT). This risk is not lessened by the addition of progestin. Bio-identical hormones are not FDA-regulated and are highly variable in their hormonal potency. For this reason their efficacy and safety cannot be determined. Vaginal estrogen treatment results in very little circulating estrogen. Its use has not been associated with venous thrombosis, but it does not provide relief from vasomotor symptoms. A Cochrane meta-analysis reviewed multiple small studies using phytoestrogens and found no benefit for control of menopausal symptoms.
Oral SSRIs and SNRIs, including venlafaxine, are effective for menopausal vasomotor symptoms, and paroxetine is FDA-approved for this purpose without an associated risk for developing a DVT. Other nonhormonal treatments that have evidence of benefit include gabapentin and clonidine.
- CT imaging for which one of the following conditions is best done without contrast?
A) Acute appendicitis
B) Diverticulitis
C) Pulmonary embolism
D) Nephrolithiasis
Item 219
ANSWER: D
Common indications for CT without contrast include suspected stroke within the first 3 hours of symptom onset; closed head injury; diffuse lung disease; chronic dyspnea; soft-tissue swelling, infection, or trauma of the extremities; suspected kidney stone; and suspected spinal trauma. Evaluation using contrast-enhanced CT is indicated in the following common scenarios: acute appendicitis, cancer staging, diverticulitis, suspected complications of inflammatory bowel disease, pancreatitis, and suspected pulmonary embolism.
- Which one of the following tests is recommended for the detection and diagnosis of gestational diabetes mellitus?
A) Hemoglobin A1c B) Fasting blood glucose C) 2-hour postprandial glucose D) An oral glucose tolerance test E) A fasting insulin/glucagon ratio
Item 218
ANSWER: D
In pregnant women not known to have diabetes mellitus, screening for gestational diabetes mellitus should be done at 24–28 weeks gestation. There are two acceptable screening strategies. The one-step 2-hour 75-g oral glucose tolerance test should be performed in the morning after a minimum 8-hour fast. The diagnosis of gestational diabetes mellitus is made if the fasting plasma glucose level is ≥92 mg/dL, if the level at 1 hour is ≥180 mg/dL, or if the level at 2 hours is ≥153 mg/dL.
A two-step approach may also be used, consisting of a nonfasting 1-hour 50-g oral glucose tolerance test. If the 1-hour glucose level is ≥140 mg/dL, a 3-hour 100-mg glucose tolerance test should be performed. (ACOG recommends 135 mg/dL in ethnic minorities with a higher risk of diabetes mellitus, and some experts recommend 130 mg/dL.) The 3-hour test should be performed when the patient is fasting. A diagnosis of gestational diabetes is made when at least two of the following four plasma glucose levels are met or exceeded:
Carpenter/Coustan National Diabetes Group Fasting 95 mg/dL 105 mg/dL 1h 180 mg/dL 190 mg/dL 2h 155 mg/dL 165 mg/dL 3h 140 mg/dL 145 mg/dL
Women with risk factors for diabetes mellitus should also be screened for undiagnosed diabetes at their first prenatal visit.
- A 45-year-old male with Down syndrome is brought to your office because of complaints of increased aggression toward the staff and peers at his group home. He is usually pleasant and compliant but he has been acting out for the last 2 1/2 weeks. He is not considered to be a danger to himself or others at this point. He is minimally verbal and unable to give a history for himself. Staff members report no change in appetite or urination, and no signs of outward illness. His vital signs in your office are within normal limits.
Which one of the following would be most appropriate at this point?
A) A complete history, physical examination, and basic laboratory tests B) CT of the head C) Risperidone (Risperdal) D) Sertraline (Zoloft) E) Valproic acid (Depakene)
Item 217
ANSWER: A
In mentally handicapped patients it is important to avoid the use of psychotropic medications for managing new behaviors until an attempt has been made to rule out potential medical and environmental causes, except in patients with a high potential for harm to themselves or others. The underlying cause of behaviors may be an undiagnosed medical condition, such as tooth pain, a urinary tract infection, or an electrolyte disturbance. It is also important to consider environmental factors such as loss of a regular staff member, a change in living environment, or family dynamics. If pharmacologic intervention is deemed necessary the treatment should be aimed at minimizing emotional trauma and maximizing community integration. Medication to restrict behaviors should not be used on a long-term basis. The history in this patient does not suggest that imaging is needed.
