Questions 201-240 Flashcards
(40 cards)
- A 22-year-old female has a 4-month history of suprapubic pain, urinary frequency, urinary urgency, dysuria, and dyspareunia. She has been empirically treated with antibiotics for a urinary tract infection despite the fact that multiple urine tests have been negative for infection or other abnormalities. You suspect the patient has interstitial cystitis.
Which one of the following would be most appropriate at this point?
A) Fluoxetine (Prozac) B) Ibuprofen C) Nitrofurantoin (Macrobid) D) Pentosan polysulfate sodium (Elmiron) E) Trimethoprim/sulfamethoxazole (Bactrim, Septra)
ANSWER: D
The only FDA-approved oral medication for the treatment of interstitial cystitis is pentosan polysulfate sodium, which is thought to repair the urothelium (SOR B). Trimethoprim/sulfamethoxazole and nitrofurantoin are indicated for urinary tract infections (UTIs), but usually not in cases of cystitis with no infection. In addition, this patient has already received empiric treatment for a UTI despite having multiple negative urine cultures. Ibuprofen is an anti-inflammatory medication commonly used to treat pain but is not specifically indicated for interstitial cystitis. While tricyclic antidepressants such as amitriptyline have been used to treat interstitial cystitis, fluoxetine is not generally recommended.
- Which one of the following is a risk factor for depression during pregnancy?
A) High socioeconomic status B) Nonsmoking C) Age over 25 D) A family history of hyperthyroidism E) Childhood abuse
ANSWER: E
A previous history of depression is the strongest risk factor for depression during pregnancy. Other risk factors include childhood abuse, smoking, age under 20, and low socioeconomic status, especially without social support. A family history of hyperthyroidism is not a risk factor.
- A 62-year-old female presents with painful lesions at both corners of her mouth characterized by redness, scaling, and deep cracks. The cracks sometimes bleed when she opens her mouth. She has treated them with bacitracin/neomycin/polymyxin B ointment (Neosporin) but says it has not helped.
Which one of the following would be most appropriate at this point?
A) A biopsy of the lesions
B) An anticandidal medication
C) Bacitracin
D) Vitamin B12
ANSWER: B
This patient has perlèche, or angular cheilitis. Most cases are secondary to moisture from patients licking their lips, promoting a monilial or staphylococcal infection. Other causes include contact and irritant dermatitis. Underlying HIV infection, celiac disease, or vitamin B12 and iron deficiencies have also been reported. Treatment may include appropriate topical creams such as mupirocin or antifungal agents, or low-potency nonfluorinated corticosteroid creams for irritant or contact causes.
- A 40-year-old male presents with right eye pain and redness. There is no history of trauma or injury.
Which one of the following should be done initially?
A) Irrigation B) Funduscopic examination C) Visual acuity testing D) Fluorescein staining E) Application of a local anesthetic
ANSWER: C
Almost all patients with ocular problems should have visual acuity testing before anything else is done (level of evidence 3, SOR A). If this is difficult, a local anesthetic may be applied. The main exception to this rule is a chemical burn of the eye, which should be irrigated for 30 minutes before further evaluation or treatment is undertaken.
- While vacationing, a 27-year-old white male was exposed to poison ivy. Between 48 and 72 hours after exposure he developed a pruritic, erythematous, papulovesicular eruption on his arms and neck. He began treating himself with an over-the-counter topical hydrocortisone cream, and when the eruption did not improve after 24 hours of treatment he sought help from the local emergency department. He was given oral methylprednisolone (Medrol Dosepak), starting with 24 mg/day and tapered by 4 mg/day over 6 days. His condition began to improve, but on day 6 he noted a dramatic exacerbation of the eruption with intense pruritus, erythema, and vesiculation, involving extensive areas of his arms, neck, and face.
The most appropriate management at this time would be to
A) prescribe a superpotent topical corticosteroid
B) repeat the oral methylprednisolone treatment
C) begin diphenhydramine (Benadryl), 4 times a day
D) begin high-dose oral prednisone and taper over 2 weeks
E) discontinue all medications and recommend cool compresses
ANSWER: D
Systemic corticosteroids are recognized for their dramatic impact on both the subjective and objective course of poison ivy dermatitis. Oral prednisone at an initial dosage of 1 mg/kg/day tapered over 14–21 days is the standard regimen. Complications can result from the use of shorter prepackaged courses of corticosteroid therapy, resulting in significant rebound flares. These products usually begin with an initial dosage approximately half that of the recommended dosage, with the course tapering too rapidly. Over-the-counter topical hydrocortisone is ineffective for all but the mildest cases, and once the disease is established, superpotent topical corticosteroids do little to alter the overall course and natural history. Antihistamines and compresses provide some symptomatic relief, but do little to alter the course of established disease.
- A 56-year-old male sees you for a health maintenance visit. He inquires about the options for colon cancer screening. He has not had any screening tests performed in the past and has no personal or family history of colon cancer. You tell him that there are several alternatives, but according to the U.S. Preventive Services Task Force, recommendations regarding the optimal screening intervals vary by test. He opts for fecal occult blood testing.
You recommend he repeat this test at which one of the following intervals?
A) Yearly B) Every 5 years C) Every 7 years D) Every 10 years E) Never, if the results are negative
ANSWER: A
The U.S. Preventive Services Task Force recommends that all adults be screened for colon cancer beginning at age 50 and continue regular screening until age 75 (SOR A). They recommend against continued routine screening in previously screened adults 75–85 years of age and against any screening in adults over 85 (SOR A). Most organizations do not recommend a particular screening method, but instead list screening options, including fecal occult blood testing, flexible sigmoidoscopy, and colonoscopy. The recommended interval for fecal occult blood testing is every year. There is new evidence based on randomized, controlled trials that participation and detection rates for advanced adenomas and cancer are higher for immunochemical fecal testing than for stool guaiac testing (SOR A). As long as results are normal, screening colonoscopy is recommended at 10-year intervals and screening sigmoidoscopy at 5-year intervals.
- Which one of the following is the leading cause of death among adolescents age 12–19 in the United States?
A) Accidents B) Suicide C) Homicide D) Cancer E) Heart disease
ANSWER: A
Teenage mortality is an important public health issue because the majority of deaths among teenagers are caused by external causes of injury such as accidents, homicide, and suicide. The leading causes of death for the teenage population remained constant throughout the period 1999–2006: accidents (48% of deaths), homicide (13%), suicide (11%), cancer (6%), and heart disease (3%). Motor vehicle accidents accounted for 73% of all deaths from unintentional injury.
- An 80-year-old female who lives independently at home is admitted to the hospital with acute pyelonephritis. When she is taken to her hospital room she is incontinent, unsteady when walking, and somewhat disoriented. Her past medical history includes hypertension with evidence of diastolic dysfunction on echocardiography and asymptomatic glucose intolerance.
Which one of the following orders would be appropriate for this patient?
A) Telemetry B) Continuous pulse oximetry C) Foley catheter placement D) A regular diet E) Bed rest
ANSWER: D
Interventions recommended for hospitalized older patients to reduce the risk of hospital-induced disability include minimizing restricted diets. Bed rest orders should be avoided, with recommendations that the patient ambulate 3–4 times/day and be out of bed and in a chair for all meals. This patient is disoriented and probably has delirium. Restraints should be avoided if possible, and should be limited if they become necessary. This would also apply to functional restraints, such as indwelling urinary catheters, IV poles, nasal cannulas, continuous pulse oximetry, and telemetry, which all increase the risk of delirium.
- A 70-year-old male sees you because his left leg feels tender and swollen. Questioning reveals that a few days ago he returned from a long road trip with his wife, and that they had spent several days driving to visit relatives. On examination there is marked asymmetry between his left calf and his right calf; there is also a slight discoloration around the area of his left calf where it is most tender.
You suspect the edema may be due to a deep-vein thrombosis (DVT). The patient has no personal or family history of blood clots. Further investigation reveals a high pretest probability score on the Wells Clinical Prediction Rule test for DVT.
Which one of the following would be the most appropriate diagnostic test at this point?
A) D-dimer B) Contrast venography C) Compression ultrasonography D) Helical CT E) MRI
ANSWER: C
The first step in diagnosing deep-vein thrombosis (DVT) is to complete a validated clinical prediction inquiry such as the Wells Clinical Prediction Rule in order to estimate the pretest probability of DVT. The Wells criteria include such factors as active cancer, calf swelling, pitting edema, prolonged inactivity, or major surgery within the previous 12 weeks.
The next step for patients with a low pretest probability of DVT is a high-sensitivity D-dimer assay, with a negative result indicating a low likelihood of DVT (SOR A). D-dimer is a degradation product of cross-linked fibrin blood clots and is usually elevated in patients with DVT, although it can also be elevated with other conditions such as recent surgery, hemorrhage, trauma, pregnancy, or cancer. If the assay is negative, the likelihood of DVT is very small.
In this case, the patient has several factors listed in the Wells criteria, indicating a high pretest probability of DVT. D-dimer testing would not be useful, as the next step in this patient’s evaluation should be imaging. Ultrasonography is the best test for symptomatic proximal-vein thrombosis, with a sensitivity ranging between 89% and 96% (SOR A). Although ultrasonography is the most appropriate first imaging test, contrast venography is considered the definitive test to rule out the diagnosis of DVT if there is still a high degree of suspicion after negative ultrasonography.
Helical CT is commonly used to detect pulmonary embolism but is not routinely recommended to diagnose DVT. Similarly, MRI is not routinely recommended for detecting DVT.
- A 45-year-old female with type 1 diabetes mellitus currently takes NPH insulin (Humulin, Novolin) twice a day. She expresses a desire to change to insulin glargine (Lantus). Her diabetes has always been well controlled, and her current hemoglobin A1c of 7.4% is typical for her.
Which one of the following is most likely to be reduced if this change is made?
A) Quality of life B) Hemoglobin A1c C) Morbidity from all causes D) Treatment costs E) Her risk for hypoglycemia
ANSWER: E
The extended flat pharmacokinetic curve of long-acting insulin analogues makes once-daily administration of larger doses of insulin possible. Such treatment should, in theory, provide increased flexibility with regard to the timing of injections and improve compliance. This should improve control of the patient’s diabetes, reduce the risk of hypoglycemia, and improve overall patient satisfaction. To date, however, the only proven benefit of treatment with insulin analogues is a reduction in the low rate of symptomatic, nocturnal, and overt hypoglycemia experienced by patients treated with isophane insulin. Although the total cost of treatment with insulin analogues is higher, a Cochrane review of the limited number of studies comparing insulin treatments showed no statistically significant differences in the hemoglobin A1c levels measured at the end of the studies in any treatment group (SOR C). Significant changes in morbidity, mortality, or quality of life have not been demonstrated (SOR C).
- A 52-year-old female sees you for the first time to establish care for her stable COPD. Since losing her insurance 4 months ago she has been off all medications except for a short-acting bronchodilator. She stopped smoking 2 years ago. She has a frequent, chronic cough and is dyspneic when climbing stairs. Pulmonary function testing reveals an FEV1 of 55%. Her O2 saturation is 90% on room air.
In addition to the short-acting inhaled bronchodilator, recommended maintenance monotherapy for this patient would be either an inhaled long-acting anticholinergic agent or an inhaled
A) corticosteroid
B) long-acting B-agonist
C) mast-cell stabilizer
D) antihistamine
ANSWER: B
In 2011, the American College of Physicians published new guidelines on COPD management. For patients with COPD who are symptomatic and have an FEV1 less than 60% of predicted, the recommendation is monotherapy with either a long-acting inhaled anticholinergic (tiotropium) or a long-acting inhaled B-agonist such as salmeterol or formoterol. This is in addition to rescue therapy with a short-acting inhaled bronchodilator such as albuterol. Long-acting inhaled anticholinergics and long-acting inhaled B-agonists reduce exacerbations and improve quality of life. The evidence is inconclusive with regard to their effect on mortality, hospitalizations, and dyspnea.
Inhaled corticosteroids have been found to be better than placebo for decreasing COPD exacerbations, but their side-effect profile keeps them from being preferred as monotherapy. Neither inhaled mast-cell stabilizers nor inhaled antihistamines are recommended as first-line agents for the treatment of COPD.
- A 62-year-old female presents to your office because of painless rectal bleeding. Over the past several months she has occasionally noted blood on the toilet tissue and in her stool after bowel movements. She also reports periodic anal itching and discharge, and protrusion of rectal tissue during bowel movements that resolves spontaneously. She had a normal colonoscopy at age 50.
An abdominal examination is normal and a digital rectal examination is not painful and no mass is palpated. However, her stool is positive for occult blood. Anoscopy demonstrates dilated purplish-blue veins above the dentate line.
Which one of the following has the best evidence for reducing symptoms in this situation?
A) Sitz baths B) Fiber supplementation C) Topical 1% hydrocortisone D) Topical diltiazem (Cardizem) E) Topical lidocaine cream (LidaMantle)
ANSWER: B
This patient has grade 2 internal hemorrhoids. These protrude with defecation but reduce spontaneously. Sitz baths are commonly recommended, but a review of studies found no benefit from sitz baths for various anorectal disorders, including hemorrhoids. A meta-analysis of seven randomized trials of patients with symptomatic hemorrhoids showed that fiber supplementation with psyllium, sterculia, or unprocessed bran decreased bleeding, pain, prolapse, and itching. No randomized, controlled trials support the use of corticosteroid creams for treating hemorrhoidal disease. Topical diltiazem and topical lidocaine have been shown to provide pain relief postoperatively following excision of external hemorrhoids.
- Which one of the following reflects the percentage of patients with a disease who have a positive test for the disease in question?
A) Likelihood ratio B) Sensitivity C) Specificity D) Positive predictive value E) Negative predictive value
ANSWER: B
Sensitivity is defined as the percentage of patients with a disease who have a positive test for the disease in question. Specificity is the percentage of patients without the disease who have a negative test. The positive predictive value is the percentage of patients with a positive or abnormal test who have the disease in question. The negative predictive value is the percentage of patients with a negative or normal test who do not have the disease in question. Likelihood ratios correspond to the clinical impression of how well a test rules in or rules out a given disease.
- Patients with which one of the following platelet disorders should be hospitalized and treated emergently?
A) Drug-induced thrombocytopenia B) Congenital thrombocytopenia C) Gestational thrombocytopenia D) Thrombotic thrombocytopenic purpura E) Thrombocytopenia associated with Lyme disease
ANSWER: D
Thrombotic thrombocytopenic purpura (TTP) is an emergent condition that can result in up to 30% mortality. Prompt hospitalization with plasma exchange is the preferred treatment. Patients with TTP present with nonspecific symptoms such as fever, abdominal pain, nausea, and weakness. Patients may also exhibit neurologic deficits. Microangiopathic anemia is also likely to be present, as evidenced by schistocytes on a peripheral smear and elevated levels of LDH and nucleated RBCs.
Congenital thrombocytopenia is a benign condition in which patients have long-standing low platelet counts and/or a family history of thrombocytopenia. It is usually asymptomatic but a concomitant bleeding diathesis may occur.
Gestational thrombocytopenia is also benign and asymptomatic. It is often confused with mild immune thrombocytopenic purpura. Platelet counts rarely drop below 70,000/mm3. There is no associated fetal thrombocytopenia. Preeclampsia and HELLP syndrome should also be ruled out. Platelet counts return to normal after delivery (SOR C).
Drug-induced thrombocytopenia can be severe, but platelet counts do not usually drop below 20,000/mm3. It is characterized by an abrupt drop in the platelet count within a week of starting the offending medication and resolves within 2 weeks after the medication is stopped.
Lyme disease can be associated with a transient thrombocytopenia. Patients present with common symptoms of Lyme disease, such as fever, myalgias, and rash. The thrombocytopenia resolves with treatment of the underlying infection.
- A 12-year-old male presents to the office with a 2-day history of fever, myalgias, and rhinorrhea. He is otherwise healthy, and you suspect influenza.
Which one of the following is the most appropriate next step in the management of this patient?
A) Symptomatic treatment only
B) Diagnostic testing to confirm influenza infection
C) Oseltamivir (Tamiflu)
D) Amantadine (Symmetrel)
E) Antibiotics to prevent bacterial coinfection
ANSWER: A
Influenza should be diagnosed on the basis of clinical signs and symptoms rather than diagnostic testing. Antiviral treatment is not recommended in otherwise healthy adults and children. Symptomatic treatment should be initiated with over-the-counter antipyretics and anti-inflammatory medications, and aspirin should be avoided due to the risk of Reye’s syndrome. Antibiotics are indicated only when a bacterial coinfection is diagnosed and not for prophylaxis.
- A 40-year-old male with diabetes mellitus has the following fasting lipid profile:
Totalcholesterol . . . . . . . . . . . . . . . . 204mg/dL
Triglycerides . . . . . . . . . . . . . . . . . . 223mg/dL
Low-density lipoprotein (LDL). . . . . 112 mg/dL
High-density lipoprotein (HDL). . . . .42 mg/dL
The patient is currently on simvastatin (Zocor), 40 mg, for management of his dyslipidemia. Which one of the following would be most appropriate?
A) Continuing the current medication regimen
B) Increasing the dosage of simvastatin
C) Switching to atorvastatin (Lipitor)
D) Adding gemfibrozil (Lopid)
ANSWER: C
This patient does not meet the LDL-cholesterol goals for a diabetic patient and therefore needs adjustment of his antihyperlipidemic regimen. In June 2011, the Food and Drug Administration recommended limiting the use of the highest dosage of simvastatin (80 mg/day) because of concerns about an increased risk of muscle damage. This dosage should only be used in patients who have already been taking 80 mg/day for 12 months or more without evidence of muscle injury, and it should not be started in new patients. This patient should be switched to an alternative medication that provides a greater reduction of LDL-cholesterol, such as atorvastatin. Gemfibrozil is contraindicated for use with simvastatin because it can raise simvastatin drug levels and increase the risk of myopathy.
- An obese 32-year-old female has not conceived after more than 4 years of unprotected intercourse. You perform an appropriate workup and diagnose polycystic ovary syndrome.
Of the following, the most effective management for her infertility would be
A) spironolactone (Aldactone) B) luteinizing hormone C) basal body temperature monitoring D) clomiphene (Clomid) E) bromocriptine (Parlodel)
ANSWER: D
Polycystic ovary syndrome may be the most common cause of female infertility, affecting 6%–8% of women. Some patients with polycystic ovary syndrome have hyperandrogenism, elevated levels of luteinizing hormone, and hyperinsulinemia. While early studies supported the use of metformin to increase fertility, a more recent study has shown that only 7% of women treated with metformin were able to conceive, whereas 22% of women treated with clomiphene citrate had a live birth. Spironolactone is useful for treating hirsutism, but not infertility. Since levels of other hormones are already elevated, the other measures listed would not be of benefit.
- A patient has fatigue and joint pain and is concerned about the possibility of systemic lupus erythematosus (SLE) after reading about this condition on the Internet. After taking a brief history you decide that further evaluation is appropriate.
In addition to the history and physical findings, which one of the following laboratory findings would most support the diagnosis of SLE?
A) An abnormal C-reactive protein level
B) An erythrocyte sedimentation rate of 48 mm/hr
C) A positive antimicrosomal antibody test
D) A positive test for antiphospholipid antibodies
E) A positive test for rheumatoid factor
ANSWER: D
The American College of Rheumatology criteria for the diagnosis of systemic lupus erythematosus (SLE) includes the presence of 4 of 11 criteria. One criterion is evidence of the presence of an immunologic disorder. Evidence of an immunologic disorder includes a positive finding of antiphospholipid antibodies, based upon one of the following: an abnormal serum level of immunoglobulin G or M anticardiolipin antibodies, a positive lupus anticoagulant test, or a false-positive serologic test for syphilis. The other test results listed are not criteria for the diagnosis of SLE.
- A 54-year-old female presents with a new onset of headaches. She rates her pain as severe and reports that the headaches frequently awaken her in the early morning. The patient has a history of hypertension and stage 4 chronic kidney disease. Her glomerular filtration rate is 24 mL/min.
You suspect the patient has a brain tumor and order gadolinium-enhanced MRI of the head. Which one of the following is the patient at high risk for developing with the use of gadolinium contrast?
A) Nephrogenic systemic fibrosis B) Anaphylaxis to contrast dye C) Dermatomyositis D) Focal seizures E) Hypertensive crisis
ANSWER: A
This patient has stage 4 chronic kidney disease with a glomerular filtration rate (GFR) less than 30 mL/min. This puts her at high risk for developing nephrogenic systemic fibrosis. The FDA recommends against using gadolinium-based contrast agents in patients with acute or chronic kidney disease and a GFR less than 30 mL/min.
While anaphylaxis is possible, this patient would not be at a high risk for this. Dermatomyositis, focal seizures, and hypertensive crisis are not associated with gadolinium-based contrast agents.
- You suspect mild Pneumocystis jiroveci pneumonia in a patient whose past medical history is significant for HIV infection. He has not been compliant with his disease management and is not on any medications.
What is the recommended treatment for this patient’s pneumonia?
A) Azithromycin (Zithromax)
B) Clindamycin (Cleocin)
C) Rifampin (Rifadin)
D) Trimethoprim/sulfamethoxazole (Bactrim, Septra)
ANSWER: D
Trimethoprim/sulfamethoxazole is the drug of choice for treating Pneumocystis jiroveci pneumonia. Atovaquone has been shown to be very effective for treating mild to moderate Pneumocystis jiroveci pneumonia and is also very well tolerated, and would be the first choice for a patient with a sulfa allergy. Clindamycin plus primaquine is also effective therapy, but clindamycin is not effective as monotherapy. Azithromycin and rifampin are not effective against this organism. Other treatment options include pentamidine, dapsone plus trimethoprim, and clindamycin plus primaquine.
- A 66-year-old white female presents to your office for a routine physical examination. Her medical problems include hypertension, diabetes mellitus, hypercholesterolemia, and gastroesophageal reflux, all controlled with medications. A bone density study is consistent with osteopenia. She is taking a multivitamin and calcium carbonate, 1200 mg daily.
Which one of her medications would reduce her calcium carbonate absorption?
A) Atorvastatin (Lipitor) B) Hydrochlorothiazide C) Lisinopril (Prinivil, Zestril) D) Metformin (Glucophage) E) Omeprazole (Prilosec)
ANSWER: E
Because of the high prevalence of reduced gastric acidity related to either endogenous causes or medications such as proton pump inhibitors, calcium carbonate is best taken with meals to optimize absorption. Calcium citrate, which is well absorbed regardless of gastric acidity, may be taken with or without food. The other medications listed do not impair calcium absorption.
- A 3-year-old male is brought to your office by his father for evaluation of 5 days of knee pain and fever up to 101.6°F. There was no known trauma preceding these symptoms. The pain and fever respond well to oral acetaminophen but continue to recur 4 hours after each dose.
On examination the child appears well and is afebrile. He had a dose of acetaminophen about 2 hours ago. There are no signs of upper respiratory infection. Examination of the knee reveals no redness, warmth, or swelling, and you see no other skin changes. He has full range of motion of both the knee and hip without pain. You note tenderness to firm palpation of the proximal tibia. He is able to bear weight and walk but refuses to jump due to anticipation of pain in his knee. Plain films of the knee are normal.
The next step in the evaluation of this patient should include which one of the following?
A) Close monitoring at home
B) A CBC, a C-reactive protein level, and an erythrocyte sedimentation rate
C) Ultrasonography of the hip
D) Knee joint aspiration
E) MRI of the knee
ANSWER: B
Joint pain in the presence of fever with no apparent source indicates a possible infection, malignancy, or rheumatologic condition and requires further workup. Laboratory evaluation, including a CBC, a C-reactive protein level, and an erythrocyte sedimentation rate can help assess for these conditions, even though none of the tests is sufficiently sensitive to rule out these diseases, and they are not specific to a single disease entity. Knee joint aspiration would be indicated to rule out septic arthritis in the presence of a joint effusion. If the hip were painful or had decreased range of motion, then ultrasonography could help identify a hip joint effusion, which would need to be aspirated. MRI may be needed in this patient, but it would likely require sedation and thus is more invasive. Starting with laboratory work is a good first step toward identifying the source of his pain and fever.
- A 58-year-old female with diabetes mellitus complains of 2 years of right shoulder pain, which is worse with activity. There has been no trauma. She tells you one of her friends had a similar problem and was treated successfully with “some sort of shock wave treatments.”
Which one of the following diagnoses is most likely to be successfully treated with extracorporeal shock wave therapy?
A) Calcific tendinitis B) Gout C) Partial rotator cuff tear D) Frozen shoulder E) Hooked acromion
ANSWER: A
Extracorporeal shock wave therapy is effective for calcific tendinitis of the rotator cuff. Side effects include bruising and pain. Needling and irrigation, physical therapy, and cortisone injections are sometimes used in patients with acute symptoms. Endoscopic and open surgical treatments are alternatives to extracorporeal shock wave therapy in refractory cases. Extracorporeal shock wave therapy does not have an established role in gout, rotator cuff tear, frozen shoulder, or hooked acromion.
- A 24-year-old female presents with a 10-day history of cough productive of green sputum. Her past medical history is unremarkable and she is up to date on all immunizations. The patient’s temperature is 37.2°C (98.9°F), blood pressure 127/76 mm Hg, pulse rate 89 beats/min, respiratory rate 24/min, and O2 saturation 95% on room air. Her physical examination is unremarkable except for a loose cough.
Which one of the following is best supported by evidence for management of this patient’s condition?
A) A macrolide antibiotic such as azithromycin (Zithromax)
B) An oral corticosteroid such as prednisone
C) An inhaled B-agonist such as albuterol (Proventil, Ventolin)
D) An expectorant such as guaifenesin
E) Reassurance that symptoms will likely resolve on their own within 3 weeks
ANSWER: E
This patient has acute bronchitis. The most appropriate management option is to provide reassurance that symptoms will likely resolve on their own within 3 weeks. Approximately 90% of cases are caused by viruses, and antibiotics do not significantly change the course of the condition. For this reason, and because of concerns about antibiotic resistance and side effects from antibiotic use, antibiotics should not be used routinely for the treatment of acute bronchitis (SOR B). Despite this, approximately two-thirds of patients in the United States diagnosed with bronchitis are still treated with antibiotics. Corticosteroids and B-agonists are not indicated in the absence of asthma or wheezing on examination. Expectorants have not been shown to be effective in the treatment of bronchitis (SOR B).
