Questions 51-100 Flashcards
- Traveler’s diarrhea can be effectively treated in the great majority of cases with which one of the following?
A) Erythromycin
B) Penicillin V
C) Sulfacetamide
D) Ciprofloxacin (Cipro)
ANSWER: D
Fluoroquinolones such as ciprofloxacin have been shown to significantly reduce the duration and severity of traveler’s diarrhea when given for 1–3 days. Sulfacetamide is available only in a topical form for use in the eye. Penicillin and erythromycin are not effective against the most common cause of traveler’s diarrhea, enterotoxigenic Escherichia coli.
- The primary indication for joint replacement surgery in patients with osteoarthritis is
A) intractable pain
B) joint laxity
C) limited range of motion
D) recurrent subluxation
ANSWER: A
The primary indication for joint replacement surgery in patients with osteoarthritis is intractable pain, which is almost always relieved by the surgery. Joint replacement may also be appropriate for patients with significant limitations of joint function or with altered limb alignment. Range of motion, joint laxity, and recurrent subluxation relate to musculotendinous function, and are not reliably improved by joint replacement.
- In a child, which one of the following findings on cardiac auscultation is most likely to be associated with structural heart disease?
A) Increased murmur intensity with standing B) An early systolic murmur C) A murmur limited to a small area D) An S2 with a variable split duration E) A musical or low pitch
ANSWER: A
Heart murmurs are common in children and adolescents. Often the murmur is innocent, but it may also be the only finding in an asymptomatic child with structural heart disease. Physical findings that should lead one to consider evaluation for structural heart disease include increased intensity with standing, a holosystolic murmur, a grade of 3 or higher, a harsh quality, an abnormal S2, maximal intensity at the upper left sternal border, a diastolic murmur, or a systolic click.
Characteristics that are more likely to be associated with innocent murmurs include a systolic murmur, a soft sound, a short duration, a musical or low pitch, intensity that varies with phases of respiration, increased loudness in the supine position, and increased loudness with exercise, anxiety, or fear. If the diagnosis of an innocent murmur cannot be made from physical findings, an echocardiogram is the most appropriate study. A chest radiograph and EKG rarely assist in the diagnosis of heart murmurs in children (SOR B) and should not routinely be ordered.
- A 7-year-old white male is brought to your office about 5 hours after a dog bit him on the forearm. You examine the wound and decide not to suture it. His last tetanus immunization brought him up to date at 4 years of age.
Which one of the following is most appropriate?
A) Culture the wound
B) Scrub the wound with povidone-iodine (Betadine) surgical scrub
C) Irrigate the wound
D) Administer tetanus immune globulin and DTaP immunization
ANSWER: C
Dog and cat bite wounds may appear trivial, but if they are not managed appropriately they can become infected and may result in functional impairment. Cultures are recommended for wounds that are clinically infected. Because it can be toxic to tissue, povidone-iodine surgical scrub should not be used. Irrigation with either normal saline or Ringer’s lactate solution may reduce the rate of infection by up to twentyfold. Tetanus immune globulin is not needed, and DTaP is not given to children 7 years of age or older.
- A 50-year-old female is hospitalized with severe, diffuse abdominal pain without nausea or vomiting. Vital signs on admission include a pulse rate of 110 beats/min, a respiratory rate of 35/min, and a temperature of 38.2°C (100.8°F). Laboratory findings include a WBC count of 21,000/mm3 (N 4300–10,800) with 80% segmented neutrophils, and a serum amylase level of 4000 U/L (N 53–123). CT of the abdomen is consistent with cholelithiasis and necrotizing pancreatitis without an abscess.
Which one of the following measures is best supported by evidence?
A) Corticosteroids
B) Placement of a nasogastric tube
C) Intravenous antibiotics
D) Surgery if repeat CT shows development of a pseudocyst
ANSWER: C
Intravenous antibiotics, especially imipenem, have been shown to be beneficial in patients with pancreatitis. Patients with pancreatitis who are not vomiting do not require nasogastric tube placement. Corticosteroids are not indicated in the management of acute pancreatitis, and pseudocysts can be managed initially with percutaneous aspiration.
- In your role as team physician, you are attending a high-school basketball game. A player suffers an inversion injury of her ankle while coming down after reaching for a rebound. You examine her immediately and diagnose a grade 2 ankle sprain.
Which one of the following is the most successful treatment for this injury?
A) Use of a weight-bearing short leg cast for 2 weeks, then progressively increased activity
B) Non–weight bearing, with crutches and an elastic wrap for 2 weeks
C) Ankle taping, an elastic wrap, and partial weight bearing for 6 weeks
D) Icing, a gel or air splint, and mobilization within 48 hours
ANSWER: D
Conservative treatment of grade 1 and 2 ankle sprains in athletes, consisting of the use of leg casts for 2 weeks followed by progressive increases in activity, has been found to lead to a loss of playing time of 4–6 weeks. Treatment consisting of an elastic wrap and use of a crutch until pain resolves produces similar results. Early mobilization after aggressive control of inflammation is recommended. Typical treatment includes extensive icing, compression, and elevation, followed by the application of air or gel splints. In the first 48 hours, physical therapy begins with early mobilization, strengthening, and proprioception retraining. In one study utilizing this more aggressive approach, athletes were able to return to functional status in 9 days after grade 1 sprains and in 12 days after grade 2 injuries.
- Which one of the following features in an elderly patient with cognitive problems is more suggestive of depression than of Alzheimer’s disease?
A) A long duration of cognitive problems
B) A slow progression of cognitive problems
C) Delusions that are congruent with mood
D) No past history of psychiatric problems
ANSWER: C
Cognitive problems are often a feature of depression in older patients, which can make it difficult to distinguish depression from dementia. Congruence of mood with delusions is more typical of depression. A longer duration of cognitive problems, slow progression of cognitive problems, and no past history of psychiatric problems are more typical of dementia.
- You are considering adding sitagliptin (Januvia) to the regimen of a patient with type 2 diabetes mellitus. Which one of the following best describes the mechanism of action of this drug?
A) It increases glucagon levels
B) It slows inactivation of incretin hormones
C) It reduces the absorption of glucose in the gastrointestinal tract
D) It reduces insulin resistance in skeletal muscle
E) It reduces insulin resistance in the liver
ANSWER: B
Sitagliptin is a DPP-4 inhibitor. These agents slow the inactivation of incretin hormones, prolonging their action and thereby increasing insulin release and decreasing glucagon. Sitagliptin decreases hemoglobin A1c levels by 0.7%, but there is no data on patient-oriented outcomes or long-term safety with this medication.
- Examination of a patient with COPD and a complaint of increased shortness of breath reveals dullness to percussion in the left lower lung field, with decreased fremitus and decreased breath sounds. This is most compatible with
A) pulmonary consolidation
B) pleural effusion
C) emphysematous bleb formation
D) pneumothorax
ANSWER: B
Pleural fluid is associated with a dull-to-flat percussion note, decreased-to-absent tactile fremitus, and decreased-to-absent breath sounds. A consolidation would be indicated by bronchial breath sounds and increased fremitus. Emphysematous blebs and pneumothorax are hyperresonant to percussion.
- In patients with mild to moderate allergic rhinitis, which one of the following is the most effective treatment?
A) First-generation antihistamines such as diphenhydramine (Benadryl)
B) Second-generation antihistamines such as fexofenadine (Allegra)
C) Montelukast (Singulair)
D) Intranasal corticosteroids
E) Prednisone
ANSWER: D
Intranasal corticosteroids are the most effective treatment for mild to moderate allergic rhinitis and should be first-line therapy. Second-line therapies that can be used for symptoms that do not respond to initial treatment include antihistamines, decongestants, cromolyn, and leukotriene receptor antagonists. Nonpharmacologic measures that may be helpful include nasal irrigation and avoiding irritants.
- A 58-year-old female presents with significant nausea and abdominal cramping 1 month after beginning lithium carbonate. Her symptoms have not been relieved by multiple doses of antacids. A physical examination is remarkable only for the appearance of discomfort and a resting pulse rate of 92 beats/min.
You suspect lithium toxicity and advise her to discontinue the lithium immediately and submit blood samples for a lithium level and complete metabolic panel. When you review her results that afternoon you find that her lithium level is in the mid-therapeutic range and the only abnormal laboratory findings are a calcium level of 13.0 mg/dL (N 8.8–10.0), an albumin level of 3.0 g/dL (N 3.8–5.0), a BUN level of 35 mg/dL (N 7–18), and a creatinine level of 1.6 mg/dL (N 0.6–1.2).
Of the options listed below, the best immediate intervention is
A) cinacalcet (Sensipar) B) furosemide (Lasix) C) glucocorticoids D) intravenous saline infusion E) intravenous zoledronic acid (Zometa)
ANSWER: D
Drugs such as lithium, thiazide diuretics, sex hormones, and vitamins A and D can increase the serum ionized calcium level. The gastrointestinal symptoms associated with lithium toxicity are also the most common presenting symptoms of hypercalcemia. Hypercalcemic patients may also complain of constipation, fatigue, lethargy, polyuria, and weakness, all the result of an increased serum level of ionized calcium (roughly calculated to be 40% of the total serum calcium level plus 0.8 g/dL for each 1 g/dL decrease in serum albumin below 4 g/dL). The most common causes of hypercalcemia are malignancy and hyperparathyroidism, together accounting for over 80% of all cases. Excessive ingestion of antacids can result in milk-alkali syndrome, another cause of hypercalcemia. Granulomatous disease and renal diseases are other possible causes.
Although additional details are required in this case to determine the cause, primary hyperparathyroidism augmented by medications is highly likely given the patient’s age and sex, and measurement of her parathyroid hormone level must be included in the workup. No matter the cause, the treatment of symptomatic hypercalcemia should be immediate and directed at lowering the serum calcium level. The safest and most effective way to accomplish this is with intravenous normal saline volume replacement, reducing the need for reabsorption of salt, water, and, coincidentally, calcium in the proximal tubules. Because hypercalcemia often results in volume depletion, aggressive fluid replacement is often ideal, provided there is no contraindication to doing so. Once the volume depletion is corrected the addition of loop diuretics such as furosemide can facilitate excretion of calcium. Each of the other options has a place in the longer term treatment of hypercalcemia in appropriate situations: bisphosphonates for malignancy, glucocorticoids for granulomatous disease, and cinacalcet for hyperparathyroidism.
- A 57-year-old male with a BMI of 37.1 kg/m2 was found to have a fasting blood glucose level of 115 mg/dL on a screening test. His mother and three siblings have type 2 diabetes mellitus. A follow-up hemoglobin A1c (HbA1c) level is 6.2%. Six months later, after lifestyle interventions, the patient’s BMI is 35.5 kg/m2 and his HbA1c is 6.1%. On a lipid panel, his triglyceride level is 457 mg/dL and his HDL-cholesterol level is 32 mg/dL. His serum creatinine level is 1.0 mg/dL (N 0.6–1.2). You consider the use of pharmacologic therapy.
Which one of the following would be the best initial medication?
A) Acarbose (Precose) B) Exenatide (Byetta) C) Glipizide (Glucotrol) D) Metformin (Glucophage) E) Pioglitazone (Actos)
ANSWER: D
Metformin is well tolerated and there is good data to show it helps prevent type 2 diabetes mellitus in high-risk patients. Pioglitazone has been shown to slow the progression from prediabetes to diabetes, but it has more side effects and is more expensive than metformin. Neither glipizide nor exenatide is currently recommended as a treatment for prediabetes. Acarbose has a high discontinuation rate due to side effects.
- A 16-year-old male comes to your office with a 1-month history of increasingly severe lower back pain. He plays on his school’s soccer team, but denies any history of injury. Hyperextension is particularly painful, and now the pain occurs during normal daily activities.
Examination reveals a hyperlordotic posture, limited range of motion, and tight hamstrings. The remainder of the examination is unremarkable.
Which one of the following should be done initially?
A) A complete blood profile B) Rheumatoid factor and HLA-B27 testing C) Plain radiography D) MRI E) A radionuclide bone scan
ANSWER: C
While spondylolysis occurs in 6% of the general population, it may be the cause of 50% of back pain in young adults. This unilateral or bilateral vertebral defect of the pars interarticularis is likely due to repetitive hyperextension of the posterior spine that results in a fracture or stress injury. This usually occurs at L4-L5. Sports that put increased demands on the spine include football, gymnastics, weightlifting, soccer, volleyball, and ballet.
The recommended initial study for athletes with back pain of more than 3 weeks’ duration is lumbar spine radiographs, including anterior/posterior, lateral, and oblique views bilaterally. The “Scotty dog with a collar” sign can be noted on the oblique view. This may not be present in early spondylolysis, so a SPECT scan may be appropriate.
Treatment for spondylolysis consists of discontinuing the offending activity, medication for pain, physical therapy, and possibly bracing. Healing may take 9–12 months.
- A 2-year-old female visiting with her parents from Mexico presents with a 1-week history of repeated episodes of forceful coughing followed by emesis. Her immunization status is unknown. Her mother reports that a runny nose and “cold” preceded the onset of the cough. The child is currently afebrile and appears mildly ill; her lungs are clear.
Your management would include which one of the following?
A) Hospitalization for ribavirin aerosol therapy
B) Reassurance that the cough will abate over the next week
C) Oral erythromycin therapy for 2 weeks
D) Administration of immune serum globulin intramuscularly
ANSWER: C
This child’s presentation is highly suspicious for pertussis, given the severe coughing paroxysms and the possibility of inadequate immunization. Two weeks of oral erythromycin is recommended for children with mild to moderate illness, principally to halt the spread of the infection. Ribavirin is used for respiratory syncytial virus infection, which is generally seen in much younger children with more respiratory distress. The cough of pertussis often lasts several weeks. Immune globulin is not recommended.
- The fluid of choice for resuscitation after a significant burn injury is
A) lactated Ringer’s solution B) hypertonic saline C) packed RBCs D) whole blood E) 5% albumin
ANSWER: A
Crystalloids are the essential component of fluid resuscitation in patients with severe burn injuries, with lactated Ringer’s solution being the most commonly used. Substantial early loss of blood is unusual, and transfusions are not often required. The use of colloids in these patients has not been shown to be helpful and may be harmful. Hypertonic saline solution may be useful in selected patients but requires careful monitoring and may be detrimental.
- A 52-year-old male comes to your office with a 2-month history of hoarseness that began with the onset of a head cold. His other symptoms resolved but the hoarseness has continued. He has smoked for 32 years and drinks 4 beers per day, and has had gastroesophageal reflux disease (GERD) for several years.
Which one of the following would be most appropriate at this point?
A) Voice rest B) Laryngoscopy C) Upper endoscopy D) Inhaled corticosteroids E) High doses of a proton pump inhibitor
ANSWER: B
Patients with hoarseness lasting longer than 2 weeks with risk factors for dysplasia or carcinoma, such as smoking, heavy alcohol use, or long-standing gastroesophageal reflux disease, should be evaluated with laryngoscopy. Inhaled corticosteroids can contribute to hoarseness.
- Four weeks after successful initial treatment of unilateral otitis media in a 2-year-old white male enrolled in a local day-care center, you reevaluate the child. He is asymptomatic, but you detect a middle ear effusion in the affected ear. The tympanic membrane is otherwise normal.
The best management at this time would be
A) inflation of the eustachian tube by the Valsalva maneuver
B) an antihistamine daily for 30 days
C) low-dose corticosteroids for 30 days
D) referral to an ENT specialist
E) no further treatment, with reevaluation in 2 months
ANSWER: E
Otitis media is a major health problem in the United States; it is the number one reason children visit doctors and accounts for one-fourth of all antibiotic prescriptions. With appropriate antibiotics most patients will improve in 2–3 days. Persistence or worsening of symptoms requires immediate reevaluation, since complications such as bacterial resistance or meningitis may be developing. Occasionally a persistent middle ear effusion will be found on reexamination 10–14 days after initial treatment. Inflation of the eustachian tube using the method of Politzer or employing the Valsalva maneuver has been shown to be ineffective, as have antihistamines and systemic steroids. Most asymptomatic effusions with mild hearing loss will clear in 90 days if left alone.
- A previously healthy 26-year-old white male carpenter reports episodes of chest tightness and dyspnea. He states that he feels better on weekends.
He most likely has
A) hypersensitivity pneumonitis B) toxic pneumonitis C) byssinosis D) benign pleural effusion E) occupational asthma
ANSWER: E
The diagnosis of occupational asthma can be made when both bronchospasm and its relationship to the work environment can be demonstrated. A history of cough, wheezing, chest tightness, or episodic dyspnea in varying combinations or singly should lead one to suspect bronchospasm. Relating bronchospasm to the work environment can be done in several ways. A history of exposure to a known sensitizer is helpful, as is a pattern of symptoms occurring after exposure. With many agents the onset of symptoms may be delayed up to several hours. A 10% decrease in FEV1 measured before and after a work shift supports the diagnosis. Improvement of bronchospasm with removal from exposure also suggests the diagnosis. Treatment includes both standard pharmacologic therapy and removal from exposure as soon as possible.
Hypersensitivity pneumonitis is an immune-mediated syndrome that is not as common as occupational asthma. It begins with malaise, fever, and myalgias 4–6 hours after exposure to an antigen to which the person has become sensitized. Byssinosis is due to exposure to the dust of hemp, flax, or cotton. Symptoms vary from reversible chest tightness on one or more days early in the work week to chronic bronchitis and permanent obstructive lung disease. Toxic pneumonitis or pulmonary edema is the result of very high exposure to irritant gases, metal dust, or metal fumes, usually associated with unusual circumstances such as a fire, explosion, or spill. Benign pleural effusions are the most common sequela during the first 20 years after asbestos exposure. The diagnosis is one of exclusion, made by ruling out other causes of exudative effusions in workers with known asbestos exposure.
- A 67-year-old female who is a recently retired college professor takes warfarin (Coumadin) because of chronic atrial fibrillation. She asks you about the possibility for self-management of her anticoagulation using a portable monitor at home.
Which one of the following is true regarding self-management of anticoagulation therapy compared to standard monitoring?
A) It decreases the number of thromboembolic events
B) It increases the number of bleeding events
C) It increases all-cause mortality
D) It increases the patient’s level of anxiety
E) When cost, complication rates, and mortality rates are considered, it is inferior to standard monitoring
ANSWER: A
When self-management and standard management of anticoagulation therapy are compared, self-management improves the rate of minor hemorrhage, with no difference in the rate of major hemorrhage. Self-monitoring also improves the rate of thromboembolism. Both self-monitoring and self-management improve the rate of all-cause mortality. When studied, patients who self-managed their anticoagulation therapy perceived greater self-efficacy compared to patients receiving standard care, and self-management did not increase their levels of anxiety. When all factors are considered, self-monitoring and self-management have outcomes superior to those of standard monitoring and management.
- You are following a 60-year-old female for osteopenia. Which one of the following tests is best for assessing her vitamin D status?
A) 1,25-Dihydroxyvitamin D B) 24,25-Dihydroxyvitamin D C) 25-Hydroxyvitamin D D) Parathyroid hormone E) Phosphate
ANSWER: C
The serum 25-hydroxyvitamin D level is the best indicator of overall vitamin D status because it reflects total vitamin D from dietary intake and sunlight, as well as conversion from adipose stores in the liver. Measurement of 1,25-dihydroxyvitamin D, the active form of vitamin D formed in the kidney, may be necessary in advanced chronic kidney disease. 24,25-Dihydroxyvitamin D is not biologically active. Phosphate and parathyroid hormone are involved in the regulation of vitamin D levels, but are not helpful in determining overall vitamin D status.
