Questions
Each of the following questions or incomplete statements is followed by four or five suggested answers or completions. Select the ONE BEST ANSWER in each case.
1. Which of the following is considered first-line therapy for primary dysmenorrhea?
A) Nonsteroidal anti-inflammatories (NSAIDs)
B) Selective serotonin receptor inhibitors (SSRIs)
C) Antiestrogens
D) Acupuncture
E) Tricyclic antidepressants
Answer and Discussion
Primary dysmenorrhea is associated with cramping pain in the lower abdomen occurring just before and/or during menstruation, in the absence of other conditions such as endometriosis. The initial presentation of primary dysmenorrhea typically occurs in adolescence. The condition is associated with increased production of endometrial prostaglandin, resulting in increased uterine tone and stronger, more frequent uterine contractions. A diagnostic evaluation is unnecessary in women with typical symptoms and in the absence of risk factors for secondary causes. NSAIDs are the most effective treatment, with the addition of oral contraceptive pills when necessary. About 10% of affected women do not respond to these measures. In these cases it is important to consider secondary causes of dysmenorrhea in women affected. Acupuncture is also used as an alternative treatment.The answer is A.
Rakel RE, Bope ET. Conn's Current Therapy 2005. Philadelphia: Elsevier/Saunders; 2005:1213–1214.
Nonsteroidal anti-inflammatory medications are the most effective treatment for primary dysmenorrhea.
2. You are called to see an infant in the newborn nursery. The child was delivered 60 hours prior to your visit. The child appears jaundiced but otherwise healthy. A total serum bilirubin level is measured at 18 mg/dL. Appropriate treatment includes
A) observation
B) stop breast feeding and switch to formula feedings
C) begin phototherapy
D) perform a septic workup
E) start IV hydration
Answer and Discussion
Hyperbilirubinemia is very common in term newborns. Current recommendations include the following: phototherapy should be instituted when the total serum bilirubin level is >=15 mg/dL (257 µmol/L) in infants 25 to 48 hours old, 18 mg/dL (308 µmol / L) in infants 49 to 72 hours old, and 20 mg/dL (342 µmol/L) in infants older than 72 hours. It is unlikely that term newborns with hyperbilirubinemia have serious underlying pathology. Physiologic jaundice peaks on the third or fourth day and declines over the first week following birth. Infants who are breast fed are more likely to develop physiologic jaundice because of relative caloric deprivation in the first few days of life. If jaundice occurs in breast-fed infants, feedings should be increased to more than ten times/day. In some cases formula supplementation may be necessary. Pathologic jaundice occurs if it presents within the first 24 hours after birth, the total serum bilirubin level rises by >5 mg/dL (86 µmol/L) per day or is >17 mg/dL (290 µmol/L), or an infant has signs and symptoms suggestive of serious illness. The management consists of excluding pathologic causes of hyperbilirubinemia and initiating treatment to prevent harmful neurotoxicity.The answer is C.
Porter ML, Dennis BL. Hyperbilirubinemia in term newborn. Am Fam Physician. 2002;65:599–606, 613–614.
3. Which of the following p values reflects the best chance that the findings are not the result of chance?
A) p value <0.005
B) p value <0.001
C) p value <0.05
D) p value <0.01
E) p value = 1
Answer and Discussion
The p value is defined as the measured probability of a finding occurring (i.e., rejecting the null hypothesis) by chance alone given that the null hypothesis is actually true. By convention, a p value <0.05 is often considered significant. [“There is less than a 5% probability that the finding (null hypothesis rejected) was due to chance alone.”]The answer is B.
Rind DM. Proof, p-values, and hypothesis testing. Up to Date version 14.1. Accessed 6/6/06. Available at http://uptodateonline.com.
4. Which of the following statements is true regarding influenza?
A) Treatment with antivirals should be initiated within 48 hours of the onset of symptoms.
B) Anitiviral agents reduce the duration of fever by 1 week.
C) Amantadine is effective for both influenza types A and B.
D) Prophylactic therapy is the single most important measure to prevent influenza outbreaks.
E) Amantadine is the only agent approved for prophylaxis.
Answer and Discussion
Influenza causes significant morbidity and mortality and is responsible for considerable medical expenditures especially in the elderly. Vaccination is the single most important public health measure to prevent this illness. Amantadine (Symmetrel) and rimantadine (Flumadine) are older antiviral agents (called M2 inhibitors) that have been important medications in the prevention and treatment of influenza A outbreaks. They are not effective for influenza B. Zanamivir (Relenza) and oseltamivir (Tamiflu) are newer agents (neuraminidase inhibitors) indicated for the treatment of both influenza A and B. Oseltamivir (Tamiflu) is the only neuraminidase inhibitor currently approved for prophylaxis. For antiviral agents to be effective, they must be initiated within 48 hours of the onset of influenza symptoms. Antiviral agents reduce the duration of fever and illness by 1 day and also reduce the severity of some symptoms. Use of amantadine or rimantadine is appropriate if influenza virus A is determined to be the predominant agent in a particular year or location. For optimal use of antiviral agents, patients with influenza symptoms must present early, and family physicians must accurately and rapidly diagnose the illness. Rimantadine is metabolized in the liver and therefore should be used with caution in patients with liver disease. The answer is A.
Montalto NJ, Gum KD, Ashley JV. Updated treatment for influenza A and B. Am Fam Physician. 2000;62:2467–2476.
5. Primary insomnia is usually associated with
A) sleep apnea
B) restless legs syndrome
C) periodic limb movements
D) circadian rhythm sleep disorders
E) none of the above
Answer and Discussion
Insomnia is defined as inadequate or poor-quality sleep characterized by one or more of the following: difficulty falling asleep, difficulty maintaining sleep, waking up too early in the morning, or sleep that is not refreshing. Insomnia also involves daytime consequences such as fatigue, difficulty concentrating, and irritability. Periods of insomnia lasting between 1 night and a few weeks are defined as acute insomnia. Chronic insomnia refers to sleep difficulty occurring at least 3 nights per week for 1 month or more. Insomnia may be associated with specific sleep disorders, including restless legs syndrome, periodic limb movement disorder, sleep apnea, and circadian rhythm sleep disorders. Restless legs syndrome is characterized by unpleasant sensations in the legs or feet that are temporarily relieved by movement. Symptoms are worse in the evening, especially when a person is lying down and remaining still. The sensations cause difficulty falling asleep and are often accompanied by periodic limb movements. Periodic limb movement disorder is characterized by bilateral repeated and rhythmic, small-amplitude jerking or twitching movements in the lower extremities and, less frequently, in the arms. These movements occur every 20 to 90 seconds and can lead to awakenings, which are usually not noticed by the patient. Often the patient reports that sleep is not refreshing. In many cases, the bed partner is more likely to report the movement problem. Obstructive sleep apnea is most commonly associated with snoring, daytime sleepiness and obesity but occasionally presents with insomnia. Circadian rhythm sleep disorders including sleep-work insomnia are characterized by an inability to sleep because of a disturbance between the circadian sleep rhythm and the desired or required sleep schedule. Primary insomnia occurs in the absence of the previously mentioned conditions. When the insomnia persists beyond 1 or 2 nights or becomes predictable, treatment should be considered. Pharmacologic treatment is usually effective, especially short-acting hypnotics. Sleep hygiene measures may also be useful. Chronic insomnia may be more difficult to treat. Because chronic insomnia is often multifactorial in etiology, a patient may need multiple treatment modalities, including medication (antidepressants, antihistamines, melatonin) and behavioral therapy. If an underlying medical or psychiatric condition is identified, this condition should be treated first. The answer is E.
National Heart, Lung, and Blood Institute Working Group on Insomnia. Insomnia: assessment and management in primary care. Am Fam Physician. 1999; 59(11):3029–3039.
6. A 65-year-old man presents to your office and reports urinary incontinence. Examination reveals an enlarged prostate. You suspect overflow incontinence. Which of the following measurements of post-void residual (PVR) volumes would represent the threshold for a normal amount?
A) 50 ml
B) 100 ml
C) 200 ml
D) 500 ml
E) 1000 ml
Answer and Discussion
Urge incontinence results from bladder contractions that exceed the ability of the brain to prevent them. Causes include inflammation or irritation within the bladder resulting from calculi, malignancy, infection, or atrophic vaginitis–urethritis. Other central causes include stroke, Parkinson's disease or dementia, drugs such as hypnotics or narcotics, or metabolic disorders such as hypoxemia and encephalopathy. Additionally, urge incontinence can occur when ambulation is impaired, making it difficult for patients to get to the bathroom in time. This condition is referred to as “functional” incontinence.
Stress incontinence is caused by a malfunction of the urethral sphincter that causes urine to leak from the bladder when intra-abdominal pressure increases, such as during coughing or sneezing. Causes for stress incontinence include pelvic prolapse, urethral hypermobility, or displacement of the urethra and bladder neck from their normal anatomic alignment. Stress incontinence can also occur as a result of intrinsic sphincter deficiency, in which the sphincter is weak because of a congenital condition or denervation resulting from alpha-adrenergic blocking drugs, surgical trauma, or radiation damage. Overflow bladder incontinence occurs as a result of urine retention with bladder distention. Urine collects in the bladder until maximum bladder capacity is reached. It then leaks as a result of “overflow,” usually manifesting as dribbling. Increased intra-abdominal pressure may also cause loss of urine, so that overflow incontinence sometimes mimics stress incontinence.
Overflow incontinence can be caused by medications that relax the bladder detrusor muscle (e.g., anticholinergic agents, calcium-channel blockers). It can also be caused by denervation of the detrusor resulting from a neurologic abnormality that affects bladder innervation (e.g., diabetic neuropathy) or because of damage to bladder innervation (e.g., tumors, radiation, surgery). Additionally, overflow incontinence can be caused by obstructed urinary outflow resulting from prostate enlargement, fecal impaction, urethral stricture, or urethral constriction related to alpha-adrenergic agonist medications.
The workup should include a urinalysis, which can identify acute urinary tract infection and diabetes-induced glycosuria, both of which can cause or aggravate urge incontinence. These conditions are reversible with treatment. If appropriate, a urine culture should also be obtained. The basic evaluation of urinary incontinence should also include measurement of PVR urine volume to detect urinary retention (i.e., overflow bladder). PVR volume measurement can detect retention caused by potentially reversible factors (e.g., anticholinergic or other drugs, fecal impaction). Urinary retention not obviously resulting from a transient cause generally requires further evaluation, including cystometry, to determine why the bladder does not empty properly. The PVR urine volume can be measured by one of two methods. The first and most common method is “in and out” urethral catheterization after the patient has urinated to empty the bladder. The quantity of urine obtained is measured. PVR volume can also be measured with pelvic ultrasonography. Ultrasonography is a useful alternative to catheterization, especially for measuring the PVR volume in men with suspected prostate obstruction, because catheterizing these patients may cause urinary infection or obstruction. Normally, <50 mL of residual urine is present after voiding. Volumes of >200 mL are abnormal. Intermediate volumes (50 to 200 mL) are considered equivocal, and the test should be repeated. Other tests include office cystometry and office stress testing. Office cystometry consists of aliquots of sterile saline that are infused into the bladder via a catheter with an open syringe attached to the catheter. Contractions are detected by monitoring the fluid level that appears in the syringe after several aliquots of water have been instilled. A rise and fall in the fluid level indicates pressure changes (i.e., contractions) within the bladder. Severe feelings of urgency or bladder contractions at <300 mL of bladder volume constitute a presumptive diagnosis of urge incontinence. For the diagnosis of urge incontinence, simple cystometry can be used. In this test the patient lies supine on the examination table with a full bladder and coughs forcefully. The physician places a gauze pad in front of the perineum. If urine leaks onto the gauze pad during coughing, a presumptive diagnosis of stress incontinence is made. The physician then places his or her fingers on either side of the patient's urethra and elevates the structure. The patient is then asked to cough. In patients with stress incontinence, urethral elevation prevents further urine leakage. If no incontinence is noted in the supine position, the maneuvers should be repeated with the patient standing. If no incontinence occurs in either position, the patient probably does not have stress incontinence. The answer is A.
Weiss BD. Diagnostic evaluation of urinary incontinence in geriatric patients. Am Fam Physician. 1998;57:2675–2688.
7. Which of the following is considered a risk factor for retinal detachment?
A) Glaucoma
B) Diabetic retinopathy
C) Hyphema
D) Myopia
Answer and Discussion
Retinal detachment is a preventable cause of vision loss. It is relatively common after the age of 60. There are three types of retinal detachments: exudative, tractional, and rhegmatogenous. The most common type is rhegmatogenous, which results from retinal breaks caused by vitreoretinal traction. Exudative (or serous) retinal detachment results from the accumulation of serous and/or hemorrhagic fluid in the subretinal space because of hydrostatic factors (e.g., severe acute hypertension), or inflammation (e.g., sarcoid uveitis), or neoplastic effusions. Exudative retinal detachment generally resolves with adequate treatment of the underlying disease, and restoration of normal vision is often excellent. Tractional retinal detachment occurs via centripetal mechanical forces on the retina, usually mediated by fibrotic tissue resulting from previous hemorrhage, injury, surgery, infection, or inflammation. Risk factors for retinal detachment include advancing age, previous cataract surgery, myopia, and trauma. Other eye conditions including hyphema, glaucoma, and diabetic retinopathy are not considered risk factors for retinal detachment. Patients typically present with symptoms such as light flashes, floaters, peripheral visual field loss, and blurred vision. Retinal tears may occur without symptoms, but often photopsia (light flashes) is noted. Photopsia results from vitreoretinal traction. When the retina tears, blood and retinal pigment epithelium cells may enter the vitreous cavity and are perceived as “floaters.” Immediate intervention can prevent retinal detachment. Patients with the acute onset of flashes or floaters should be referred to an ophthalmologist. The answer is D.
Gariano RF, Chang-hee K. Evaluation and management of suspected retinal detachment. Am Fam Physician. 2004;69: 1691–1698.
8. Which of the following medications is considered the treatment of choice for Bordetella pertussis infection?
A) Penicillin
B) Ciprofloxacin
C) Azithromycin
D) Tetracycline
E) Cefuroxime
Answer and Discussion
Recent epidemiologic studies have shown that the incidence and prevalence of Bordetella pertussis infection in adults are much greater than previously reported. In studies of adults with chronic cough, 20% to 25% were found to have serologic evidence of recent B. pertussis infection. However, pertussis is rarely considered in adults because the signs and symptoms are nonspecific. Apart from a prolonged cough, there are no specific symptoms suggestive of pertussis in older individuals who have been immunized. With this in mind, pertussis should be considered in the differential diagnosis of persistent cough in previously immunized children and adults. Administration of erythromycin or other macrolide (azithromycin or clarithromycin) may be a consideration in patients presenting with persistent cough. Prophylaxis of exposed persons before culture or serologic results are available would be another consideration. Early treatment with a macrolide should limit the spread of infection to persons whose immunity has waned or in unimmunized children. The acellular vaccine may allow booster immunization, which can be a method of preventing B. pertussis infection after immunity from the pertussis vaccination has waned. The answer is C.
Yaari E, Yafe-Zimerman Y, Schwartz SB, et al. Clinical manifestations of Bordetella pertussis infection in immunized children and young adults. Chest. 1999;115:1254–1258.
9. Which of the following is associated with reducing the risk of falls in elderly patients?
A) Vitamin C
B) Vitamin D
C) Folate
D) Vitamin B12
E) Calcium
Answer and Discussion
Falls are a major cause of injury-related visits to emergency departments in the United States, and the primary cause of accidental deaths in persons older than 65 years. The mortality rate for falls increases dramatically with age in both sexes and in all racial and ethnic groups. Falls can be an indication of poor health and declining function, and they are often associated with significant morbidity. More than 90% of hip fractures occur as a result of falls, with most of these fractures occurring in persons older than 70 years of age. Risk factors for falls in the elderly include increasing age, arthritis, medication use (more than four medications, including tricyclic antidepressants, neuroleptics, benzodiazepines, and type IA antiarrythmics), cognitive impairment (dementia and depression), and sensory deficits. Outpatient evaluation of a patient who has fallen includes a focused history with an emphasis on medications, a directed physical examination, and tests of postural control and overall physical function. Treatment is directed at the underlying cause of the fall, with the goal to return the patient to baseline function. Vitamin D deficiency has been associated with an increased risk of falls, and empiric supplementation can reduce the risk. The answer is B.
Fuller GF. Falls in the elderly. Am Fam Physician. 2000; 61:2159–2168, 2173–2174.
10. An 18-year-old high school student presents with her mother to your office. Mom reports her daughter is binge eating and purging in order to lose weight. You suspect bulimia. Of the medications listed, which would be best indicated in treatment of the condition?
A) Sertraline (Zoloft)
B) Paroxetine (Paxil)
C) Fluoxitene (Prozac)
D) Venlafaxine (Effexor)
E) Buproprion (Wellbutrin)
Answer and Discussion
Persons affected by anorexia nervosa eventually become visibly recognizable because of their severely underweight status. In contrast, those affected by bulimia are typically of normal weight and are not as easily detected. This disorder is characterized by binge eating and purging. Bulimia is most common in late adolescent females. Associations with other psychiatric disorders is common, and patients with personality disorders (e.g., borderline, narcissistic, and antisocial disorders) have a worse prognosis. Most bulimics purge by vomiting, although abuse of laxatives or diuretics can also occur. The number of times a bulimic patient purges can vary widely, from as seldom as once or twice weekly to as often as ten times per day. Repeatedly induced vomiting can lead to the loss of dental enamel, increased dental caries, swollen salivary glands, Mallory–Weiss esophageal tears, and gastroesophageal reflux. Laxative abusers can develop constipation on withdrawal of laxatives. The typical electrolyte abnormalities associated with bulimia are hypokalemia and metabolic acidosis. Although severe hypokalemia in an otherwise healthy young female suggests bulimia, most patients who purge do not develop electrolyte abnormalities. As a result, screening for hypokalemia or other electrolyte disturbances is not a sensitive means for detecting bulimia. Treatment of the complications associated with bulimia is usually possible, but the underlying disorder can be challenging to treat successfully. Fluoridated mouthwash and toothpaste can help prevent dental caries, and the use of sour candies may decrease salivary gland swelling. Antacid medications help reduce gastroesophageal reflux symptoms, and nonstimulant laxatives may be used to decrease constipation in those with stimulant laxative abuse. Oral replacement of potassium is typically accomplished with 40 to 80 mEq per day of supplementary potassium, until a normal serum potassium level is achieved. Patients with severe hypokalemia and metabolic alkalosis need volume repletion with intravenous normal saline to allow normalization of potassium levels. Cognitive–behavioral therapy has demonstrated efficacy in the treatment of bulimia, but relapse is common. Disturbances in serotonergic systems have been suggested as contributing to bulimia. The selective serotonin reuptake inhibitor fluoxetine is the only medication that has been approved by the U.S. Food and Drug Administration for treatment of bulimia. Higher dosages of fluoxetine (more than required to treat depression), up to 60 mg daily, may be necessary for effective control. Even with a combination of psychotherapy and pharmacologic treatment, remission rates are high. The answer is C.
Mehler PS. Bulimia nervosa. N Engl J Med. 2003;349:875–881.
The selective serotonin reuptake inhibitor fluoxetine is the only medication that has been approved by the U.S. Food and Drug Administration for treatment of bulimia.
11. The Health Insurance Portability and Accountability Act (HIPAA) standards ensure that
A) patients have control and access to their medical records
B) insurance companies have unlimited access to health information
C) physicians can protect themselves from liability
D) attorneys have unrestricted access to health-care records
Answer and Discussion
HIPAA is three sets of standards (1. Transactions and Code Sets; 2. Privacy; and 3. Security) developed by the Department of Health and Human Services in 1996. The goals of the standards are to simplify the administration of health insurance claims and lower costs; give patients more control and access to their medical information; and protect individually identifiable medical information from real or potential threats of disclosure or loss. Privacy and security are closely related. Privacy is the patient's right over the use and disclosure of his or her own personal health information. Privacy includes the right to determine when, how, and to what extent personal information is shared with others. The HIPAA privacy rules grant new rights to patients to gain access to and control the use and disclosure of their personal health information. Security is the specific measures a health-care provider must take to protect personal health information from unauthorized breaches of privacy, as in situations where information is stolen or sent to the wrong person in error. Security also includes measures taken to ensure against the loss of personal health information, as in situations where a patient's records are lost or destroyed by accident. The HIPAA privacy rules require general security measures be put in place, and the proposed security rules follow a detailed and comprehensive set of activities to guard against unauthorized disclosure of personal health information stored or transmitted electronically or on paper. The answer is A.
Kibbe DC. A problem-oriented approach to the HIPAA security standards family practice management. Fam Pract Manag. July/August. 2001;8(7):37–43.
12. Which statement regarding visual screening in children is correct?
A) Visual screening is not indicated until age 5.
B) Visual acuity can be assessed by the Random Dot E test.
C) Stereopsis can be measured by the Tumbling E test.
D) Strabismus can be assessed with the cover test during the first year of life.
E) Visual screening can be reliably assessed at age 2.
Answer and Discussion
The U.S. Preventive Services Task Force (USPSTF) recommends screening to detect amblyopia, strabismus, and defects in visual acuity in children younger than age 5 years. The USPSTF found no evidence of harm associated with screening, and concluded that the benefits of screening are likely to outweigh any potential harms. The most common causes of visual impairment in children are (1) amblyopia and its risk factors and (2) refractive error not associated with amblyopia. Amblyopia refers to reduced visual acuity without a detectable organic lesion of the eye and is associated with risk factors that interfere with normal binocular vision, such as strabismus (ocular misalignment), anisometropia (a large difference in refractive power between the two eyes), cataract (lens opacity), and ptosis (eyelid drooping). Refractive error not associated with amblyopia principally includes myopia (nearsightedness) and hyperopia (farsightedness). Various tests are used to identify visual defects in children, and the choice of tests is determined by the child's age. During the first year of life, strabismus can be assessed by the cover test and the Hirschberg light reflex test. Screening children younger than age 3 years for visual acuity is more challenging than screening older children, and typically requires testing by specially trained personnel. Traditional vision testing requires a cooperative, conversive child and cannot be performed reliably until ages 3 to 4 years. In children older than age 3 years, stereopsis (the ability of both eyes to function together) can be assessed with the Random Dot E test or Titmus Fly Stereotest; visual acuity can be assessed by tests such as the HOTV chart, Lea symbols, or the tumbling E. The answer is D.
U.S. Preventive Services Task Force. Screening for visual impairment in children younger than five years: recommendation statement. Ann Fam Med. 2004;2:263–266.
13. Which of the following tumor markers is correct for the condition?
A) CA (cancer antigen) 27.29 for metastatic cervical cancer
B) CA (cancer antigen) 125 for hepatic carcinoma
C) AFP (alpha-fetoprotein) for ovarian carcinoma
D) CA (cancer antigen) 19-9 for pancreatic cancer
E) β-hCG (beta unit of human chorionic gonadotropin) for ovarian cancer
Answer and Discussion
Recognized tumor markers are most appropriate for monitoring response to therapy and detecting early recurrence. Cancer antigen (CA) 27.29 is most often used to follow response to therapy in patients with metastatic breast cancer. CA 27.29 is highly associated with breast cancer, although levels are elevated in several other malignancies (colon, gastric, hepatic, lung, pancreatic, ovarian, and prostate cancers). CA 27.29 also can be found in patients with benign disorders of the breast, liver, and kidney, and in patients with ovarian cysts. CA 27.29 levels higher than 100 units per mL are rare in benign conditions.
Carcinoembryonic antigen (CEA) is used to detect relapse of colorectal cancer. CEA elevations also occur with other malignancies. Nonmalignant conditions associated with elevated CEA levels include cigarette smoking, peptic ulcer disease, inflammatory bowel disease, pancreatitis, hypothyroidism, biliary obstruction, and cirrhosis. Levels exceeding 10 ng/mL are rarely due to benign disease. Fewer than 25% of patients with disease confined to the colon have an elevated CEA level. Therefore, CEA is not useful in screening for colorectal cancer or in the diagnostic evaluation of an undiagnosed illness. A CEA level should be utilized only after malignancy has been diagnosed.
CA 19-9 may be helpful in diagnosing pancreatic abnormalities. Levels >1,000 units/mL are correlated with pancreatic cancer. Benign conditions such as cirrhosis, cholestasis, cholangitis, and pancreatitis can also result in CA 19-9 elevations, although values are usually <1,000 units/mL.
CA 125 is useful for evaluating pelvic masses in postmenopausal women, monitoring response to therapy in women with ovarian cancer, and detecting recurrence of ovarian carcinoma. Postmenopausal women with asymptomatic palpable pelvic masses and CA 125 levels >65 units/mL likely have ovarian cancer. Because premenopausal women have more benign causes of elevated CA 125 levels, testing for the marker is less useful in this population.
Alpha-fetoprotein (AFP) is a marker for hepatocellular carcinoma. It is used to screen highly selected populations and to assess hepatic masses in patients at particular risk for developing hepatic malignancy.
Testing for the β-subunit of human chorionic gonadotropin (β-hCG) is an integral part of the diagnosis and management of gestational trophoblastic disease. Combined AFP and β-hCG testing is an essential adjunct in the evaluation and treatment of nonseminomatous germ cell tumors, and in monitoring the response to therapy. AFP and β-hCG are useful in evaluating potential origins of poorly differentiated metastatic cancer.
PSA is used to screen for prostate cancer and detects recurrence of the malignancy. The answer is D.
Perkins GL, Slater ED, Sanders GK, et al. Serum tumor markers. Am Fam Physician. 2003;68:1075–1082.
14. A 27-year-old female presents for her annual examination. Her BMI is 31 and she has hirsutism and reports difficulty with conception. Her periods are irregular. Based on her likely diagnosis, which of the following malignancies is she most at increased risk for?
A) Ovarian carcinoma
B) Colon cancer
C) Pancreatic cancer
D) Endometrial carcinoma
E) Breast cancer
Answer and Discussion
Polycystic ovary syndrome (PCOS) is the most common endocrine abnormality in women of reproductive age. The syndrome is associated with chronic anovulation, abnormal menstrual bleeding, and infertility. Macrovascular diseases such as type 2 diabetes mellitus, hypertension, and atherosclerotic heart disease are more likely in women with PCOS. In addition, chronic anovulation predisposes women to endometrial hyperplasia and carcinoma. Symptoms that prompt females to seek attention include irregular menses, hirsutism, or infertility. The earliest manifestations of PCOS are noted around the time of puberty. Adolescent girls affected with PCOS often have early puberty and show hyperandrogenism and insulin resistance. In the early reproductive period, chronic anovulation results in difficulty with fertility. If pregnancy is achieved, it frequently terminates in spontaneous, first-trimester loss or is associated with gestational diabetes. More than 50% of those affected are obese. Abnormal androgen production declines as menopause approaches (as it does in women without PCOS), and menstrual patterns may normalize. However perimenopausal and postmenopausal women with a history of PCOS have increased rates of type 2 diabetes, hypertension, and coronary artery disease compared with control patients. PCOS appears to follow a familial distribution. LH and FSH levels are often elevated in PCOS, with the LH:FSH ratio greater than 3:1. Individualized therapy should incorporate steroid hormones, antiandrogens, and insulin-sensitizing agents (metformin). Weight loss by way of reduced carbohydrate intake and exercise is the most important intervention; this step alone can restore menstrual regularity and fertility, and provide long-term prevention against diabetes and heart disease. The answer is D.
Richardson MR. Current perspectives in polycystic ovary syndrome. Am Fam Physician. 2003;68:697–704.
15. Most cases of infant botulism are related to the ingestion of
A) honey
B) peanut butter
C) whole milk
D) mayonnaise
E) eggs
Answer and Discussion
Although rare, the majority of cases of infant botulism are diagnosed in the United States. An infant acquires botulism by ingesting Clostridium botulinum spores, which are found in soil or honey products. The spores develop into bacteria that colonize the bowel and produce toxin. As the toxin is absorbed, it irreversibly binds to acetylcholine receptors on motor nerve terminals at neuromuscular junctions, leading to progressive weakness, hypotonia, and hyporeflexia, with associated bulbar and spinal nerve abnormalities. Symptoms of infant botulism include constipation, lethargy, a weak cry, poor feeding, and dehydration. A high level of suspicion is important for the diagnosis and prompt treatment of infant botulism, because this disease can quickly progress to respiratory failure and possibly death. Diagnosis is confirmed by isolating the organism or toxin in the stool and finding the classic triad of electromyogram patterns, including the following:
· Compound muscle action potentials of decreased amplitude in at least two muscle groups
· Tetanic and post-tetanic facilitation defined by an amplitude >120% of baseline
· Prolonged post-tetanic facilitation >120 seconds and absence of post-tetanic exhaustion
Treatment consists of nutritional and respiratory support until new motor endplates are regenerated, which results in spontaneous recovery. Neurologic sequelae are seldom seen. The answer is A.
Cox N, Hinkle R. Infant botulism. Am Fam Physician. 2002; 65:1388–1392.
16. Of the following conditions, which is related to the development of osteoporosis in men?
A) Prolactinoma
B) Hypogonadism
C) Prostate cancer
D) Renal stones
E) Inguinal hernia
Answer and Discussion
Men, like women, are at risk of developing osteoporosis that may lead to increased risk of fractures. According to bone density studies in men with low levels of testosterone, hypogonadism is an independent risk factor for osteoporosis. When testosterone is replaced, bone density has been shown to increase. Bone density is a popular and easy way to measure the degree of osteoporosis, but it does not provide complete information about fracture risk. Alterations of bone architecture represent increased risk of fracture, even in men with minimal evidence of osteoporosis. Alternative ways to examine bone microarchitecture include quantitative computed tomography and high-resolution magnetic resonance microimaging (µMRI). The latter test has been called “the virtual bone biopsy,” and better demonstrates the integrity of the trabecular network. The only approved treatments for male osteoporosis are alendronate (Fosamax) and recombinant parathyroid hormone. Testosterone is often prescribed, but should not be used in men with a history of prostate cancer for obvious reasons. The answer is B.
Benito M, Gomberg B, Wehrli FW. Deterioration of trabecular architecture in hypogonadal men. J Clin Endocrinol Metab. 2003;88:1497–1502.
17. In patients treated with disulfiram (Antabuse) for alcohol abuse, which test is necessary for monitoring during treatment?
A) Alkaline phosphatase
B) Amylase
C) Creatinine
D) Alanine aminotransferase (ALT)
E) Ammonia level
Answer and Discussion
In the United States, disulfiram (Antabuse), acamprosate (Campral), and naltrexone (Revia) are approved for the treatment of alcohol dependence. Although disulfiram is reported to be effective as an aversive drug, placebo-controlled clinical trials have been inconclusive. Disulfiram inhibits the metabolism of anticoagulant drugs, phenytoin, and isoniazid. This drug should be used cautiously in patients with liver disease and is contraindicated during pregnancy and in patients with ischemic heart disease. Disulfiram can cause hepatitis, and therefore monitoring of liver function studies is essential. Acamprosate is a newer agent that works by its affect on the GABA system. Side effects include diarrhea, insomnia, anxiety, depression, pruritus, and dizziness. The third drug approved for use in the treatment of alcohol dependence is the opioid antagonist naltrexone. Naltrexone is believed to reduce consumption of alcohol and increase abstinence by reducing the craving for alcohol. The rate of relapse is highest within the first 90 days of abstinence, and it is during this time that naltrexone may be beneficial. Daily dosages may range from 25 to 100 mg. Side effects include nausea, headache, anxiety, and sedation. Naltrexone can be hepatotoxic at higher dosages and should be used with caution in patients with chronic liver disease. Selective serotonin reuptake inhibitors (SSRIs), including fluoxetine and sertraline, have been found to decrease alcohol intake in heavy drinkers without a history of depression. However, in some trials SSRIs were found to be no more effective than a placebo. Any drug therapy should be combined with psychotherapy or group therapy to help address the social and psychologic aspects of alcohol dependence. The answer is D.
Swift RM. Drug therapy for alcohol dependence. N Engl J Med. 1999;340:1482–1490.
Disulfiram can cause hepatitis and therefore monitoring of liver function studies is essential.
18. The test of choice for the diagnosis of ureteral obstruction secondary to renal lithiasis is
A) noncontrast helical computed tomography
B) ultrasound
C) intravenous pyelogram
D) magnetic resonance imaging
E) plain radiographs
Answer and Discussion
The most common cause of the sudden onset of flank pain in adults is acute urolithiasis. Identification of a stone in the ureter with resultant partial or complete ureteral obstruction confirms the suspected diagnosis. In the past, intravenous pyelography (IVP) has been the classic diagnostic test of choice. Noncontrast helical computed tomography (CT), which was introduced in 1994, has the advantages of avoiding contrast exposure, identifying radiolucent calculi, evaluating nearby structures, and requiring a shorter time for examination. Intravenous urograms provide only gross images of the kidneys and miss other local pathology. When noncontrast helical CT is readily available, the amount of time required to evaluate patients is reduced, and potential contrast complications that may occur with conventional radiologic imaging are avoided. As a result, helical CT is a better test for assessing acute urolithiasis. Abdominal ultrasound has a high specificity in evaluating stones but its sensitivity is lower than helical CT. Plain films are used to follow patients with known radiopaque (i.e., calcium) stones. The answer is A.
Worster A, Preyra I, Weaver B. The accuracy of noncontrast helical computed tomography versus intravenous pyelography in the diagnosis of suspected acute urolithiasis: a meta-analysis. Ann Emerg Med. 2002;40:280–286.
19. Which of the following infections is least likely in a patient with chronic obstructive pulmonary disease (COPD)?
A) Streptococcus pneumoniae
B) Haemophilus influenzae
C) Moraxella catarrhalis
D) Mycoplasma pneumoniae
Answer and Discussion
The American Thoracic Society (ATS) defines COPD as a disease process involving progressive chronic airflow obstruction because of chronic bronchitis, emphysema, or both. Chronic bronchitis is defined clinically as excessive cough and sputum production on most days for at least 3 months during at least 2 consecutive years. Emphysema is characterized by chronic dyspnea resulting from the destruction of lung tissue and the enlargement of air spaces. Asthma, which features airflow obstruction, airway inflammation, and increased airway responsiveness to various stimuli, may be distinguished from COPD by reversibility of pulmonary function deficits. Acute exacerbations of COPD are treated with oxygen (in hypoxemic patients), inhaled β2 agonists, inhaled anticholinergics, antibiotics, and systemic corticosteroids. Theophylline may be considered in patients who do not respond to other bronchodilators.
Antibiotic therapy is directed at the most common pathogens, including Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Mild to moderate exacerbations of COPD are usually treated with broad-spectrum antibiotics such as doxycycline, trimethoprim–sulfamethoxazole, and amoxicillin–clavulanate potassium. Treatment with extended-spectrum penicillins, fluoroquinolones, third-generation cephalosporins, or aminoglycosides may be considered in patients with severe exacerbations. The management of chronic stable COPD includes smoking cessation and oxygen therapy. Inhaled β2 agonists, inhaled anticholinergics, and systemic corticosteroids are also used in patients with chronic stable disease. Inhaled corticosteroids decrease airway reactivity and can reduce the use of health-care services for management of respiratory symptoms. Avoiding acute exacerbations helps to reduce long-term complications. Long-term oxygen therapy, regular monitoring of pulmonary function, and referral for pulmonary rehabilitation are often utilized and can improve the quality of life and reduce hospitalizations. Influenza and pneumococcal vaccines should be administered. Selected patients who do not respond to standard therapies may benefit from lung reduction surgery. The answer is D.
Hunter MH, King DE. COPD: management of acute exacerbations and chronic stable disease. Am Fam Physician. 2001; 64:603–612, 621–622.
20. A 2-year-old child is brought into your office. Mom reports the boy fell off his bed and has been limping for the last 3 days. He did hit his head, but had no loss of consciousness and has been acting normally since his fall. You note retinal hemorrhages and several areas of bruising on the head, legs, thighs, and arms in varying stages of healing. The most likely cause is
A) autism
B) abuse
C) hemophilia
D) leukemia
E) poor coordination
Answer and Discussion
Determining whether head injuries in children are accidental or a result of physical abuse is very important. Children with head injuries related to abuse tend to be younger than those with accidental injuries. Boys are more frequently affected. Subdural hematoma, subarachnoid hemorrhage, and retinal hemorrhage are more common in abused children. Child abuse should be strongly suspected when such injuries are present in a child without a history of a fall or with a history of a fall from a relatively low height. Multiple injuries in various stages of healing should also alert the clinician to the possibility of abuse. A skeletal survey for children younger than 3 years should be performed when inflicted head injuries are suspected. The answer is B.
Reece RM, Sege R. Childhood head injuries: accidental or inflicted? Arch Pediatr Adolesc Med. 2000;154:11–15.
21. A 65-year-old with a history of chronic atrial fibrillation is being monitored while on warfarin therapy. The nurse calls to inform you the patient's International Normalized Ratio (INR) is measured at 7. He has no active signs of bleeding, but is at increased risk of bleeding. Appropriate management at this time includes
A) stop warfarin, observe, and repeat INR in 3 days
B) stop warfarin and observe; repeat INR in 24 hours
C) stop warfarin, give vitamin K, and repeat INR in 24 hours
D) stop warfarin, give vitamin K and fresh frozen plasma with daily INRs
Answer and Discussion
Warfarin inhibits the formation of clotting factors II, VII, IX, and X. The drug is highly protein-bound to albumin. Because of this inverse relationship between the levels of albumin and free warfarin, acutely ill with poor nutritional states and postoperative patients may need lower dosages of warfarin. The INR is the patient's prothrombin time divided by the mean of the normal prothrombin time, with this ratio raised to the international sensitivity index. After starting warfarin therapy, a steady-state response is not typically achieved for approximately 2 weeks. A dosage of 4 to 5 mg/day is typical, although the required dosage may be variable (as low as 0.5 mg or as high as 50 mg/day). Elderly patients should start at a lower dosage. Checking the INR approximately 24 hours after the first dose can help determine the second dose. If there has been little or no rise in the INR (which is to be expected), a 5-mg dose on the second day should be safe. If an INR is not available on the day after the first dose, it can be obtained on days 2, 3, or 4. If the initial INR (on days 1 through 4) is high, the patient is likely sensitive to warfarin's effects; therefore, a lower dose should be given. Patients who are restarting warfarin therapy after a time off the drug can safely begin with their previous maintenance dose. Guidelines recommend that the INR be checked at least four times during the first week of therapy. This frequency could then be gradually decreased, based on the stability of the INR. Because the risk of bleeding is greatest in the first 6 to 12 weeks of treatment, checking the INR weekly is appropriate. The maximum time between tests should be no more than 4 to 6 weeks. If a patient's INR has been stable and then fluctuates by more than 0.2 below or 0.4 above the goal INR, the patient should be evaluated for the cause of the change. Associated causes include laboratory error, noncompliance, drug interactions with warfarin, dietary interactions, or a change in the patient's health. If no reversible cause is found, a change in dosage may be made, with a repeat INR within 2 weeks. Close follow-up with repeated testing is needed, because the patients who have the most variation in results are most likely to develop bleeding or thromboembolism. In asymptomatic patients whose INR is elevated, temporary discontinuation of the drug is often used, but administration of vitamin K shortens the time to return to the target INR. There is indirect evidence that use of vitamin K is associated with a lower incidence of hemorrhage. Oral vitamin K is effective and may have fewer risks than the parenterally administered form. When a patient's INR is between 5 and 9, the recommendations include temporary discontinuation of warfarin therapy. If the patient is at risk for hemorrhage (e.g., is taking NSAIDs), low-dose oral vitamin K (1.0 to 2.5 mg) also should be given. However, the lowest dose available in tablet form is 5 mg, and often only 1 or 2 mg is needed. The parenteral form can be given orally and mixed in a flavored drink if needed. If the patient cannot be treated orally, 0.5 to 1 mg of intravenous vitamin K should be administered. For INRs of 9 or higher, vitamin K also should be given at a higher dose (2.5 mg intravenously or 5 mg orally). A repeat INR should be obtained within 24 hours. Additional vitamin K may be needed, depending on the result of the repeat INR. If the INR is elevated and the patient is bleeding, fresh-frozen plasma or a concentrate of clotting factors should be administered. A repeat INR should be obtained shortly after the fresh-frozen plasma is given. Additional fresh-frozen plasma may be needed because of its short duration of action. A large dose of vitamin K (10 mg) should also be given. Additional vitamin K may be necessary because the half-life of warfarin is longer than the half-life of vitamin K. Daily INR measurements should be instituted. The answer is C.
Gage BF, Fihn SD, White RH. Management and dosing of warfarin therapy. Am J Med. 2000;109:481–488.
22. A 55-year-old man is returning to discuss blood tests from his recent general examination. His PSA increased from 2.6 to 3.4. He does report a mild decrease in his urinary flow and gets up two times a night. Examination confirms a mildly enlarged prostate without nodules. Appropriate management at this time includes
A) further evaluation to exclude malignancy
B) observation and reassurance
C) use of alpha blockers to improve urinary flow
D) use of a 5-alpha reductase inhibitor
Answer and Discussion
Prostate cancer screening should be performed at the age of 50 years in those who wish to undergo evaluation and at normal risk for development of disease. Annual examinations can then be considered. In patients with PSA values between 4 and 10 ng/mL, the PSA velocity and percentage of free PSA can be used in making clinical decisions. A velocity of 0.75 ng/mL per year is predictive of cancer. When <10% of PSA is unbound, the positive predictive value for prostate cancer is 55%, compared with 8% when >25% of PSA is unbound. Prostate cancer screening probably should not be done once patients are over the age of 70 or if they develop a significant underlying medical illness or other incurable malignancy that decreases their life expectancy to <10 years. The issue of screening for prostate cancer remains very controversial and should be individualized to each patient. The answer is A.
Perkins GL. Serum tumor markers. Am Fam Physician. 2003; 68:1075–1082.
23. Type II renal tubular acidosis is associated with
A) the proximal tubules have decreased ability to absorb bicarbonate
B) urine pH that is normal when plasma bicarbonate levels are normal
C) chronic metabolic alkalosis
D) plasma bicarbonate levels that are easily restored with supplementation
E) hyperkalemia
Answer and Discussion
Type I (distal) renal tubular acidosis (RTA) is a disorder that affects adults and is considered a familial disorder in children. Sporadic cases may be primary (especially in women) or secondary (e.g., to an autoimmune disease such as Sjögren's syndrome; medications including amphotericin B or lithium therapy; kidney transplantation; nephrocalcinosis; renal medullary sponge kidney; chronic renal obstruction). Familial cases may be autosomal dominant and are often associated with hypercalciuria. In type I RTA, the urine pH is never <5.5.
Type II (proximal) RTA is associated with several inherited diseases (e.g., Fanconi's syndrome, fructose intolerance, Wilson's disease, Lowe's syndrome), multiple myeloma, vitamin D deficiency, and chronic hypocalcemia with secondary hyperparathyroidism. It may occur after renal transplant, exposure to heavy metals, and after treatment with certain medications, including acetazolamide, sulfonamides, tetracycline, and streptozocin.
In type II RTA, the ability of the proximal tubules to reabsorb HCO3- is decreased, so that urine pH is >7 at normal levels of plasma HCO3-, but may be <5.5 at low levels of plasma HCO3- Type III RTA is a combination of types I and II and is seldom seen.
Type IV RTA is a condition associated with mild renal insufficiency in adults with diabetes mellitus, HIV nephropathy, or interstitial renal damage [systemic lupus erythematosus (SLE), obstructive uropathy, sickle cell disease]. It also may be produced by drugs that interfere with the renin–aldosterone system (e.g., NSAIDs, ACE inhibitors, potassium-sparing diuretics, trimethoprim). Aldosterone deficiency or unresponsiveness of the distal tubule to aldosterone results in type IV RTA. This reduces potassium excretion, causing hyperkalemia, which reduces ammonia production and acid excretion by the kidney. Urine pH is usually normal.
Types I and II RTA are associated with chronic metabolic acidosis, mild volume loss, and hypokalemia. Hypokalemia may lead to muscle weakness, hyporeflexia, and paralysis. Type I RTA has decreased citrate excretion in the urine, increased mobilization of bone calcium, and hypercalciuria, which results in osteopenia, bone pain, and kidney stones or nephrocalcinosis. Renal parenchymal damage and chronic renal failure may develop. Type IV RTA is usually asymptomatic with only mild acidosis, but cardiac arrhythmias or paralysis may develop if hyperkalemia is extreme. Sodium bicarbonate relieves symptoms and prevents or stabilizes renal failure and bone disease. In adults with type I RTA, sodium bicarbonate eliminates acidosis and reduces the occurrence of kidney stones. In type II RTA, the plasma HCO3- cannot be restored to the normal range. HCO3- replacement should exceed the acid load of the diet. Additional HCO3- replacement increases potassium bicarbonate losses in the urine. Bicitra or Polycitra-K can be substituted for sodium bicarbonate and may be better tolerated. Potassium supplements may be required in patients who become hypokalemic when given sodium bicarbonate, but are not recommended in patients with normal or high serum potassium levels. In type IV RTA, the hyperkalemia is treated with fluid administration and potassium-depleting diuretics. A few patients may need mineralocorticoid replacement therapy. The answer is A.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2026–2028.
24. Which of the following is considered a first line medication in the treatment of hypertension?
A) Chlorthalidone
B) Lisinopril
C) Clonidine
D) Losartan
E) Amlodipine
Answer and Discussion
The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) was a randomized, double-blind, multicenter clinical trial comparing the efficacies of various antihypertensive treatments in decreasing rates of coronary heart disease (CHD). The antihypertensives used in the trial included amlodipine, a calcium-channel blocker; lisinopril, an angiotensin-converting enzyme (ACE) inhibitor; doxazosin, an alpha-blocker; and chlorthalidone, a thiazide diuretic. The study showed similar mortality rates and no improvement in CHD risk in all treatment groups. Chlorthalidone (a diuretic) was found to be superior in preventing one or more major forms of cardiovascular disease, including stroke and heart failure. These findings resulted in the recommendation that diuretics be the first line drug of choice and a part of any multidrug antihypertensive regimen. Although the rates of primary outcomes, including fatal CHD and nonfatal myocardial infarction, were the same in the chlorthalidone, amlodipine, and lisinopril groups, the study's secondary endpoints such as heart failure showed the superiority of diuretics, specifically chlorthalidone. The diuretic users had a small increase in serum glucose levels, but this increase did not affect adverse outcomes. Thiazide-associated diabetes also has been shown to be reversible with good potassium balance, weight control, and increased physical activity. Thiazide-based treatments for hypertension are less expensive, and the additional laboratory monitoring for hypokalemia or hypoglycemia is probably no more than that required during ACE-inhibitor administration. Although ALLHAT has legitimate limitations, its conclusions appear valid. The newer antihypertensive agents tested are not superior to diuretics in the prevention of cardiovascular disease. These newer drugs are more expensive and appear to be less effective in preventing heart failure. Diuretics appear to be the preferred first-step drug and an important part of any multidrug regimen for the treatment of hypertension. The answer is A.
Davis BR, Furberg CD, Wright JT Jr. ALLHAT: setting the record straight. Ann Intern Med. 2004;141:39–46.
Based on the ALLHAT trial, diuretics should be the first-line drug of choice when treating hypertension and a part of any multidrug antihypertensive regimen.
25. Which of the following drugs offers protection from osteoporosis?
A) Hydrochlorothiazide
B) Metoprolol
C) Enalapril
D) Verapamil
E) Losartan
Answer and Discussion
In healthy elderly adults, low-dose hydrochlorothiazide preserves bone mineral density at the hip and spine. Although the effects appear modest at 3 years, if accumulated over 10 to 20 years, the use of diuretics provides one-third reduction in risk for hip fracture. Of the following list, none of the others provides this protection. The answer is A.
LaCroix AZ, Ott SM, Ichikawa L, et al. Low-dose hydrochlorothiazide and preservation of bone mineral density in older adults, a randomized, double-blind, placebo-controlled trial. Ann Int Med. 2000; 133(7):516–526.
26. Obsessive–compulsive disorder (OCD) is characterized by recurrent obsessions and compulsive behaviors such as repeated hand washing and checking routines. Which of the following statements regarding the disorder is true?
A) Patients affected rarely know they are affected.
B) Serotonin reuptake inhibitors are often first-line therapy.
C) Cognitive–behavioral therapy is rarely helpful in treatment.
D) Structural changes are not found in the brain.
E) Successful treatment leads to symptom resolution.
Answer and Discussion
OCD typically appears during the young adult years and has a chronic variable course. Although treatment can lessen the severity of the disorder, patients typically have some residual symptoms. It often is many years before affected patients are properly diagnosed and treated. OCD appears to have a genetic basis. Although some neurologic findings have been associated with OCD, such as increased gray matter and decreased white matter on brain imaging, the diagnosis remains a clinical one. Patients with OCD are plagued by recurrent obsessions and often perform compulsive washing and checking rituals in an attempt to deal with the anxiety provoked by their obsessions. Those affected by OCD usually are aware that their behavior is irrational and may spend a lot of effort to hide their symptoms from others. Cognitive–behavioral therapy usually is utilized in the treatment of OCD. In most patients, combining medication with behavioral therapy produces the best results. Selective serotonin reuptake inhibitors (SSRIs) generally are utilized first, with other psychotropic agents added if initial therapy fails. The optimal SSRI dosage for OCD tends to be higher than the dosage used to treat depression, and an adequate trial of medication may take up to 12 weeks. The answer is B.
Jenike MA. Obsessive–compulsive disorder. N Engl J Med. 2004;350:259–265.
27. An ankle–brachial index of _____ is considered normal.
A) 0.95
B) 0.75
C) 0.50
D) 0.25
E) 0.15
Answer and Discussion
Symptoms of claudication include a pain, ache, cramp, or tired feeling that occurs on walking. They are most common in the calf but may occur in the foot, thigh, hip, or buttocks. The condition is worsened by walking rapidly or uphill and usually relieved in 1 to 5 minutes by rest (sitting is not necessary); the patient can walk the same distance again before pain recurs. Disease progression is indicated by a reduction in the distance that the patient can walk without symptoms. Eventually, ischemic pain may occur at rest, beginning in the most distal parts of a limb as a severe, unrelenting pain aggravated by elevation and often interfering with sleep. If intermittent claudication is the only symptom, the extremity may appear normal, but the pulses are reduced or absent. The level of arterial occlusion and the location of intermittent claudication closely correlate (e.g., aortoiliac disease frequently causes claudication in the buttocks, hips, and calves, and the femoral pulses are reduced or absent). In males, impotence is common and depends on the location and extent of occlusion. In femoropopliteal disease, claudication is typically in the calf, and all pulses below the femoral are absent. In patients with small vessel disease (e.g., thromboangiitis obliterans, diabetes mellitus), femoropopliteal pulses may be present, but foot pulses are absent. Pallor of the involved foot after 1 to 2 minutes of elevation, followed by redness on dependency, helps confirm arterial insufficiency. Normal venous filling time with dependency after elevation is 15 seconds. If symptoms of claudication occur with good distal pulses, spinal stenosis should be considered. A severely ischemic foot is painful, cold, and often numb. In chronic cases, the skin may be dry and scaly, with poor nail and hair growth. As ischemia worsens, ulceration may appear (typically on the toes or heel, occasionally on the leg), especially after local trauma. Edema is usually not present unless the patient has kept the leg in a dependent position for pain relief. More extensive blockage may compromise tissue viability, leading to necrosis or gangrene. Ischemia with redness, pain, and swelling of the foot on dependency may mimic cellulitis or venous insufficiency. Although arterial occlusion in the extremities can usually be diagnosed clinically, noninvasive tests confirm the diagnosis and are useful in follow-up. Invasive tests can document the location and extent of disease if angioplasty, local fibrinolytic therapy, or surgical bypass is contemplated. Doppler ultrasonography is most widely used. Arterial stenosis and occlusion can be detected using a velocity detector (Doppler probe). A colored signal shows the direction of flow (color Doppler). The simplest method for estimating blood flow to the lower extremities is to compare systolic BP at the level of the ankle with brachial systolic pressure (ankle–brachial indices). During this procedure, a blood pressure cuff is applied to the ankle, inflated above brachial systolic pressure, and deflated slowly. Ankle systolic blood pressure can be obtained accurately with a Doppler probe placed over the dorsalis pedis or posterior tibial arteries. This blood pressure at rest normally is >= 90% of the brachial systolic pressure; with mild arterial insufficiency, it is 70% to 90%; with moderate insufficiency, 50% to 70%; and with severe insufficiency, <50%. The answer is A.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:749–750.
28. A secondary cause of restless legs syndrome (RLS) is
A) vitamin B12 deficiency
B) heavy metal intoxication
C) alcohol abuse
D) iron deficiency
E) bismuth overdose
Answer and Discussion
RLS is a neurologic movement disorder that is often associated with a sleep disturbance. Patients with RLS have an irresistible urge to move their legs, which is usually secondary to uncomfortable sensations that are worse during periods of inactivity and often interfere with sleep. It is estimated that between 2% and 15% of the population may experience symptoms of RLS. Primary RLS may have a genetic origin. Secondary causes of RLS include iron deficiency, neurologic lesions, pregnancy, and uremia. RLS also may occur secondarily to the use of certain medications. The diagnosis of RLS is based primarily on the patient's history. Pharmacologic treatment of RLS includes dopaminergic agents, opioids, benzodiazepines, and anticonvulsants. The answer is D.
National Heart, Lung, and Blood Institute Working Group on Restless Legs Syndrome. Restless legs syndrome: detection and management in primary care. Am Fam Physician. 2000;62:108–114.
29. In appropriate patients, thrombolytic therapy can be given up to ______ after onset of stroke symptoms.
A) 1 hour
B) 2 hours
C) 3 hours
D) 24 hours
E) 36 hours
Answer and Discussion
Transient ischemic attack (TIA) is considered a significant warning sign of impending stroke. It is crucial to recognize these events to prevent permanent disability or death in affected individuals. The 90-day risk of stroke after a TIA has been estimated to be approximately 10%, with one half of strokes occurring within the first 2 days of the attack. The 90-day stroke risk is even higher when a TIA results from internal carotid artery disease. Most patients reporting symptoms of TIA should be referred to an emergency department for further evaluation. Patients who arrive at the emergency department within 180 minutes of symptom onset should undergo evaluation to determine if they are candidates for thrombolytic therapy. Initial testing should include complete blood count with platelet count, prothrombin time, International Normalized Ratio, partial thromboplastin time, and electrolyte and glucose levels. Computed tomographic scanning of the head should be performed immediately to ensure that there is no evidence of brain hemorrhage or mass. Risk factors for stroke should be evaluated in patients who have had a TIA. Blood pressure, lipid levels, and diabetes mellitus should be controlled. If indicated, smoking cessation and weight loss are also important. Angiotensin-converting enzyme inhibitor therapy may help prevent stroke. Aspirin is the treatment of choice for stroke prevention in patients who do not require anticoagulation. Clopidogrel (Plavix) is an alternative therapy in patients who do not tolerate aspirin. Atrial fibrillation, a known cardioembolic source (confirmed thrombus), or a highly suspected cardioembolic source (e.g., recent large myocardial infarction, dilated cardiomyopathy, mechanical valve, rheumatic mitral valve stenosis) are indications for anticoagulation with warfarin therapy. The answer is C.
Solenski NJ. Transient ischemic attacks: Part I. Diagnosis and evaluation. Am Fam Physician. 2004;69:1665–1674, 1679–1680.
Solenski NJ. Transient ischemic attacks: Part II. Treatment. Am Fam Physician. 2004;69:1681–1688.
30. Of the following, which is least likely to be seen in strep throat?
A) Fever
B) Malaise
C) Tonsilar exudates
D) Palatine petechiae
E) Rhinorrhea
Answer and Discussion
Sore throat is one of the most common reasons for visits to family physicians. Although most patients with sore throat have an infectious cause (pharyngitis), <20% have a clear indication for antibiotic therapy (i.e., group A β—hemolytic streptococcal infection). Viral pharyngitis is the most common cause of sore throat. Infectious mononucleosis is most common in patients 15 to 30 years of age. Patients typically present with fever, sore throat, and malaise. On examination, there is pharyngeal redness with exudates. Posterior cervical lymphadenopathy is common in patients with infectious mononucleosis, and its absence makes the diagnosis much less likely. Hepatosplenomegaly also may be present. If these patients are treated with amoxicillin or ampicillin, 90% develop a classic maculopapular rash. Patients with bacterial pharyngitis generally do not have rhinorrhea, cough, or conjunctivitis. Children younger than 15 are more likely to have strep throat. Symptoms of strep throat may include pharyngeal erythema and swelling, tonsillar exudate, edematous uvula, palatine petechiae, and anterior cervical lymphadenopathy. Untreated, strep pharyngitis lasts 7 to 10 days. Patients with untreated streptococcal pharyngitis are infectious during the acute phase of the illness and for 1 additional week. Antibiotic therapy shortens the infectious period to 24 hours, reduces the duration of symptoms by about 1 day, and prevents most complications. The incidence of complications with strep infection, such as rheumatic fever and peritonsillar abscess, is low. Peritonsillar abscess occurs in <1% of patients treated with antibiotics. Patients with peritonsillar abscess typically have a toxic appearance and may present with a muffled voice, fluctuant peritonsillar mass, and asymmetric deviation of the uvula. The answer is E.
Vincent MT, Celestin N, Hussain AN. Pharyngitis. Am Fam Physician. 2004;69:1465–1470.
31. Angioneurotic edema is associated with the use of
A) ACE inhibitors
B) beta blockers
C) loop diuretics
D) alpha-receptor blockers
E) calcium-channel blockers
Answer and Discussion
Angioneurotic edema, which occurs in 0.1% to 0.2% of patients, usually develops within the first week of therapy but can occur at any time. This life-threatening adverse effect also occurs with angiotensin II–receptor blockers, but to a lesser extent. Any patient with a history of angioneurotic edema, whether related to an ACE inhibitor, angiotensin-receptor blockers, or another cause, should not be given an ACE inhibitor. Other contraindications include pregnancy, renal artery stenosis, and previous allergy to ACE inhibitors. The answer is A.
Bicket DP. Using ACE inhibitors appropriately. Am Fam Physician. 2002;66:461–468, 473.
32. Genital warts
A) rarely resolve spontaneously
B) are treated based on cost, convenience, and adverse affects
C) do not remain in tissue after treatment
D) are treated with an alternative method if a single treatment fails to eradicate the wart
Answer and Discussion
Untreated visible genital warts may resolve spontaneously, remain the same, or increase in size. The primary treatment goal is removal of symptomatic warts. Some evidence suggests that treatment also may reduce the persistence of human papillomavirus (HPV) DNA in genital tissue, and therefore may reduce the incidence of cervical cancer. The choice of therapy is based on the number, size, site, and morphology of lesions, as well as patient preference, treatment cost, convenience, adverse effects, and physician experience. Assuming that the diagnosis is certain, switching to a new treatment modality is appropriate if there is no response after three treatment cycles. Routine follow-up at 2 to 3 months is advised to monitor response to therapy and evaluate for recurrence. Treatment methods can be chemical or ablative. The answer is B.
Kodnar CM, Nasraty S. Management of genital warts. Am Fam Physician. 2004;70:2335–2342, 2345–2346.
33. When is a comprehensive evaluation necessary when a patient is affected by a deep venous thrombosis (DVT)?
A) 45-year-old male with an idiopathic DVT
B) 65-year-old with a recent transatlantic flight and DVT of left thigh
C) 55-year-old who develops a calf DVT after a 4-hour car ride
D) 75-year-old with a history of non-small-cell cancer of lung with left leg DVT
E) 72-year-old with a right thigh DVT and no history of travel
Answer and Discussion
Treatment goals for DVT include stopping clot propagation and preventing the recurrence of thrombus, the occurrence of pulmonary embolism, and the development of pulmonary hypertension, which can be a complication of multiple recurrent pulmonary emboli. About 30% of patients with DVT or pulmonary embolism have a thrombophilia. A comprehensive evaluation is suggested in patients younger than 50 years with an idiopathic episode of DVT, patients with recurrent thrombosis, and patients with a family history of thromboembolism. Intravenous administration of unfractionated heparin followed by oral administration of warfarin remains the mainstay of treatment for deep venous thrombosis. Subcutaneous low-molecular-weight (LMW) heparin is at least as effective as unfractionated heparin given in a continuous intravenous route. LMW heparin is the agent of choice for treating DVT in pregnant women and patients with cancer. Based on validated protocols, warfarin can be started at a dosage of 5 or 10 mg/day. The intensity and duration of warfarin therapy depends on the individual patient, but treatment of at least 3 months usually is required. Some patients with thrombophilias require lifetime anticoagulation. Treatment for pulmonary embolism is similar to that for DVT. Because of the risk of respiratory failure and hemodynamic instability, in-hospital management is advised. Unfractionated heparin commonly is used, although LMW heparin is safe and effective. Thrombolysis is used in patients with massive pulmonary embolism. Subcutaneous heparin, LMW heparin, and warfarin have been approved for use in surgical prophylaxis. Elastic compression stockings are useful in patients at lowest risk for thromboembolism. Intermittent pneumatic leg compression is a useful adjunct to anticoagulation and an alternative when anticoagulation is contraindicated. The answer is A.
Razmi DW, Leeper KV. DVT and pulmonary embolism: Part II. Treatment and prevention. Am Fam Physician. 2004;69:2841–2848.
34. Which of the following statements is correct concerning hepatitis C virus (HCV)?
A) There is no risk to infants if the mother is affected.
B) There is no risk associated with sexual intercourse with an individual with hepatitis C.
C) Cesarean section should be performed on mothers who test positive for hepatitis C to prevent transmission to the newborn.
D) Hepatitis C can be spread by contaminated water supplies.
E) Hepatitis C does not appear to be transmitted in breast milk.
Answer and Discussion
In an effort to reduce the risk of transmission to others, HCV positive patients should be advised not to donate blood, organs, tissue, or semen; not to share toothbrushes, dental appliances, razors, or other personal care articles that might have blood on them; and to cover cuts and sores on the skin to keep from spreading infectious blood or secretions. HCV positive patients with one long-term, steady sex partner do not need to change their sexual practices. They should, however, discuss the risk (which is low but not absent) with their partner. If they want to lower the small chance of spreading HCV to their partner, they may decide to use barrier precautions such as latex condoms. HCV positive women do not need to avoid pregnancy or breast feeding. Potential, expectant, and new parents should be advised that about 5 of every 100 infants born to HCV infected women become infected. This infection occurs at the time of birth, and no treatment has been shown to prevent the transmission. There is no evidence that the method of delivery is related to transmission; therefore, the need for cesarean section versus vaginal delivery should not be determined on the basis of HCV infection status. Limited data on breast feeding indicate that it does not transmit HCV, although it may be prudent for HCV-positive mothers to abstain from breast feeding if their nipples are cracked or bleeding. Infants born to HCV positive women should be tested for HCV infection and, if positive, evaluated for the presence or development of chronic liver disease. HCV is not spread by sneezing, hugging, coughing, food or water, sharing eating utensils or drinking glasses, or casual contact. Persons should not be excluded from work, school, play, child care, or other settings on the basis of HCV infection status. HCV positive persons should be evaluated to assess for biochemical evidence of chronic liver disease. These patients should be assessed for severity of disease and possible treatment according to current practice guidelines in consultation with, or by referral to, a specialist knowledgeable in this field. The answer is E.
Moyer LA, Mast EE, Alter MJ. Hepatitis C: Part II. Prevention, counseling and medical evaluation. Am Fam Physician. 1999;59:349.
HCV-positive women do not need to avoid pregnancy or breast-feeding.
35. Which of the following classes of drugs can be used safely with nonsteroidal anti-inflammatory drugs (NSAIDs) without needing to closely monitor the patient's renal function, potassium levels, and / or blood pressure?
A) Angiotensin-converting enzyme (ACE) inhibitors
B) Calcium-channel blockers
C) Diuretics
D) β-Blockers
Answer and Discussion
Combined use of NSAIDs and hypertensive medication (i.e., diuretics, β-blockers α-blockers, and ACE inhibitors) may decrease the effectiveness of antihypertensive medication and cause serious complications. Thus, when using the two in combination, renal function, potassium levels, and blood pressure should be monitored. Calcium-channel blockers and central α agonists can usually be used without these concerns. The answer is B.
Oparil S, Calhoun DA. Managing the patient with hard-to-control hypertension. Am Fam Physician. 1998;57:1018.
36. Which of the following statements about sunscreens and sun exposure is true?
A) The most dangerous rays are the ultraviolet A (UVA) type.
B) Sunscreens with a skin protection factor of 10 are adequate protection.
C) Patients allergic to thiazide diuretics may react adversely to para-aminobenzoic acid (PABA).
D) Steroids should be avoided in patients with sunburns because of their immunosuppressant properties.
E) Repeated use of sunscreens can increase the risk of sun poisoning.
Answer and Discussion
Sun-produced UV light is divided into two types of rays: UVA (2,800 to 3,200 nm) and UVB (280 to 320 nm). The dangerous rays are in the UVB range. Sunscreens of at least skin protection factor 15 (and preferably SPF-30) should be used when persons are exposed to the sun. para-aminobenzoic acid, which is used in many sunscreens, is very effective at preventing sunburns. Unfortunately, patients with sensitivities to thiazides, benzocaine, or sulfonamides may react adversely to para-aminobenzoic acid. In most cases, sunburn is prevented with simple precautions. Sunburn (usually a first-degree burn) appears within the first 24 hours and can be very painful. Sunburn is treated with cold-water compresses. In severe cases, sunburns can be treated with steroids. The answer is C.
Medical Letter Consultants. Sunscreens: are they safe and effective? Med Lett Drugs Ther. 1999;41(1052):43–44.
37. Which of the following tests can be used in the diagnosis of celiac sprue?
A) Shilling's test
B) String test
C) Xylose absorption test
D) Withdrawal of lactose from the diet to monitor for improvement of symptoms
E) Scotch tape test
Answer and Discussion
Celiac sprue is an inherited disorder that is characterized by an intolerance to gluten, a cereal-type protein found in wheat, rye, oats, and barley. Symptoms in infancy include colic, failure to thrive, and, in severe cases, iron deficiency anemia with the development of edema. In adults, symptoms include abdominal bloating and discomfort, with diarrhea, anemia, weight loss, arthralgias, and edema. Laboratory findings usually include iron deficiency anemia (in children), folate deficiency anemia (in adults), low protein levels, and electrolyte abnormalities. Antigliadin IgA and IgG antibodies are elevated in >90% of patients; however, they are nonspecific. IgA endomysial antibodies are more specific for celiac sprue and are the best screening test for celiac disease. Tissue transglutinase autoantibody by ELISA is a newer serologic test for celiac sprue. Steatorrhea is usually present, and coagulation studies may be abnormal. Diagnosis is accomplished through the following:
· Biopsy of the jejunum, which shows a flat mucosa with a loss of intestinal villi
· A D-xylose absorption test, which shows an abnormal result indicating malabsorption
· Withdrawal of gluten from the diet, which results in a significant improvement in symptoms
· Fecal fat estimation for 72 hours is elevated (>7 g/day)
Treatment involves dietary counseling to avoid gluten-containing foods and supplementary vitamins. In severe cases, corticosteroids are used to induce a refractory stage. The answer is C.
Ferri F. Ferri's Clinical Advisor, Instant Diagnosis and Treatment. Philadelphia: Elsevier/Mosby; 2006:529.
38. Pregnant women should avoid contact with cat litter because of the risk for developing
A) Cryptococcus
B) Cytomegalovirus
C) Toxoplasmosis
D) Coccidioidomycosis
E) Erythema infectiosum
Answer and Discussion
Toxoplasmosis is a granulomatous disease caused by the protozoan Toxoplasmosis gondii, which affects the CNS. The disease is extremely common, and affected patients are usually asymptomatic. Symptoms, when present, mimic mononucleosis and include malaise, fever, myalgias, rashes, and cervical and axillary lymphadenopathy. Laboratory and physical findings include mild anemia, leukopenia, lymphocytosis, elevated liver function tests, and hypotension. A more severe form may occur in patients with AIDS or other patients who are immunocompromised; complications include hepatitis, pneumonitis, meningoencephalitis, and myocarditis. Chronic toxoplasmosis can lead to retinochoroiditis, persistent diarrhea, muscular weakness, and headache. Congenital toxoplasmosis can lead to spontaneous abortion or stillbirths. A multitude of congenital defects may occur, including blindness and severe mental retardation. Diagnosis is usually made by serologic tests with fluorescent antibody techniques. CT examination of the brain may show enhancing lesions, and biopsies can be taken to look for the organisms microscopically. Treatment is reserved for more severe cases and consists of the combined use of pyrimethamine, sulfadiazine, and folinic acid (leucovorin). Immunocompromised patients require maintenance treatment for life. Because the protozoan is found in cat feces, pregnant women should avoid handling cat litter. The answer is C.
Goldman L, Ausiello D, eds. Cecil textbook of medicine, 22nd ed. Philadelphia: WB Saunders; 2004:2088–2092.
39. Pain associated with the distal second metatarsal head is most likely a result of
A) Morton's neuroma
B) Jones fracture
C) March fracture
D) metatarsalgia
E) gout
Answer and Discussion
Metatarsalgia is characterized by pain and sometimes swelling associated with the second (and, less commonly, the third) metatarsal head. The pain is secondary to a synovitis that affects the joint. Patients with hammertoes are at an increased risk because of stress placed at the head of the metatarsals. In most cases, radiographs are normal; however, more severe cases may show subluxation or dislocation of the metacarpal joint. NSAIDs, hot soaks, and metatarsal pads may help; however, if subluxation or dislocation is present, surgery may be necessary. The answer is D.
Ferri F. Ferri's Clinical Advisor, Instant Diagnosis and Treatment. Philadelphia: Elsevier/Mosby; 2006:529.
40. Desensitization immunotherapy may be used in the treatment of
A) chronic urticaria
B) hymenoptera allergies
C) atopic dermatitis
D) milk allergy
E) none of the above
Answer and Discussion
Desensitization immunotherapy is used in the treatment of severe allergic rhinitis and bee-sting (hymenoptera) allergies. The patient is given gradually increasing concentrations of the allergen over an increasing period. Typically, there is a decrease in the mast cell response with a decrease in histamine production when the patient is exposed to the allergen. In addition, IgE levels decrease. In most cases, the injections are continued year-round and may be spaced out as the desired response occurs. Injections should always be given in the presence of a physician, and appropriate equipment must be available to treat potential anaphylaxis. Patients must be observed for at least 30 minutes after administration of the injections. Desensitization immunotherapy is not appropriate for the treatment of chronic urticaria, milk allergies, or atopic dermatitis. The answer is B.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1356–1357.
41. A 16-year-old boy is brought to the emergency room after suffering a seizure. He is tachycardic and hypertensive, and has a temperature of 38.6°C. Physical examination shows that the patient is in a postictal state and has a nasal septum perforation. Electrocardiogram (ECG) findings suggest acute myocardial infarction. Friends of the patient report recent cocaine use. Which of the following drugs is indicated?
A) Flumazenil
B) Phentolamine
C) Dexfenfluramine
D) Propranolol
E) Phenytoin
Answer and Discussion
Cocaine is a strong narcotic stimulant that is often abused. Its mechanism of action involves the increased release of norepinephrine and the blockage of its reuptake. Effects of cocaine begin within 3 to 5 minutes (within 8 to 10 seconds with smoking “crack” cocaine), and peak effects occur at 10 to 20 minutes. The effects rarely last more than 1 hour. Cocaine toxicity is characterized by seizures; hyperpyrexia; tachycardia; mental status changes, including paranoid behavior; hypertension; cerebrovascular accidents; myocardial infarctions; and rhabdomyolysis. Nasal septum perforation may also occur. In most cases, treatment involves the use of diazepam for neurologic symptoms and phentolamine for severe tachyarrhythmias and observation. Nitroprusside can be used for hypertensive crisis. The use of β-blockers is not recommended; other complications, such as cerebrovascular accidents, rhabdomyolysis, and myocardial infarctions, should be managed in a conventional manner. Fortunately, cocaine has a short half-life and symptoms are usually self-limited. Individuals who use cocaine may become rapidly addicted. The answer is B.
Rakel RE, Bope ET. Conn's Current Therapy 2005. Philadelphia: Elsevier/Saunders; 2005:1352–1353.
42. Goodpasture's syndrome is associated with
A) osteoporosis and renal lithiasis
B) pathologic fractures and thyroiditis
C) hepatitis and recurrent cystitis
D) pulmonary hemorrhage and glomerulonephritis
E) pica and angioedema
Answer and Discussion
Goodpasture's syndrome is a condition manifested by pulmonary hemorrhages and progressive glomerulonephritis. Circulating basement membrane antibodies are responsible for the renal and pulmonary abnormalities. Patients with Goodpasture's syndrome are typically young males (5 to 40 years; male:female ratio of 6:1); however, there is a bimodal peak at approximately 60 years of age. Men and women are equally affected at older ages. Symptoms include severe hemoptysis, shortness of breath, and renal failure. Laboratory findings include iron deficiency anemia, hematuria, proteinuria, cellular and granular casts in the urine, and circulating antiglomerular antibodies. Chest radiographs show progressive, bilateral, fluffy infiltrates that may migrate and are asymmetrical. Renal biopsy may be necessary to make the diagnosis. Treatment involves high-dose steroids, immunosuppression, and plasmapheresis, which may help preserve renal function. If significant injury to the kidneys occurs, then dialysis or transplant may be necessary. Untreated, Goodpasture's syndrome can be fatal. The answer is D.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:1560, 1676–1683.
Goodpasture's syndrome is a condition manifested by pulmonary hemorrhages and progressive glomerulonephritis. Circulating basement membrane antibodies are responsible for the renal and pulmonary abnormalities.
43. Black cohosh has been advocated to treat
A) muscle and joint pain
B) the common cold
C) depression
D) menopausal symptoms
E) osteoporosis
Answer and Discussion
The herb black cohosh, or Actaea racemosa (formerly named Cimicifuga racemosa), is native to North America. The roots and rhizomes of this herb are widely used in the treatment of menopausal symptoms and menstrual dysfunction. Although the clinical trials on black cohosh are of insufficient quality to support definitive statements, this herbal medicine may be effective in the short-term treatment of menopausal symptoms. The mechanism of action is unclear, and early reports of an estrogenic effect have not been proved in recent studies. Although black cohosh may be useful in treating some menopausal symptoms, there is currently no evidence regarding any protective effect of black cohosh against the development of osteoporosis. Adverse effects are extremely uncommon, and there are no known significant adverse drug interactions. The answer is D.
Kligler B. Black cohosh. Am Fam Physician. 2003;68:114–116.
44. Smoking “crack cocaine”
A) has become a major health problem in urban middle-class populations
B) leads to physical dependence
C) is more common than snorting cocaine
D) can lead to tolerance
E) produces a stereotypical withdrawal syndrome
Answer and Discussion
Although the majority of cocaine in the United States is snorted intranasally, smoking crack cocaine has been widely publicized. The imported hydrochloride salt is converted to a more volatile form, usually by adding sodium bicarbonate, water, and heat. The converted material is combusted, and the resultant smoke inhaled. The onset of effect is faster, and intensity of the “high” is increased. Tolerance occurs, but physical dependence has not been confirmed; no stereotypical withdrawal syndrome occurs when the drug is discontinued. However, the tendency to continue taking the drug is strong. Use of crack by the urban poor and the criminal market for crack have become one of the most feared problems of drug abuse. Despite frequent predictions, crack use has not expanded to the suburbs or the urban middle class. Its continued use still occurs primarily in poor Americans. The answer is D.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1693–1694.
45. A recognized complication of sleep apnea is
A) hyperlipidemia
B) diabetes mellitus
C) restless legs syndrome
D) migraines
E) congestive heart failure
Answer and Discussion
Obstructive sleep apnea occurs most often in moderately or severely obese persons. Men are affected more often than women (4% of men and 2% of women in middle age). Upper airway narrowing leads to obstruction during sleep. In severely obese persons, a combination of hypoxemia and hypercapnia may induce central apnea as well. By definition, apneic periods last at least 10 seconds (some for 2 minutes). Repeated nocturnal obstruction may cause recurring cycles of sleep, obstructive choking, and arousal with gasping for air. Daytime drowsiness usually results from the repeated cycles. Similar but less-pronounced cycles occur in non-obese persons, possibly secondary to developmental or congenital abnormalities of the upper airway. Complications of sleep apnea include cardiac abnormalities (e.g., sinus arrhythmias, extreme bradycardia, atrial flutter, ventricular tachycardia, heart failure), hypertension, excessive daytime sleepiness, morning headache, and slowed mentation. The mortality rate from stroke and MIs is significantly higher in persons with obstructive sleep apnea than in the general population. The answer is E.
Rakel RE, Bope ET. Conn's Current Therapy 2005. Philadelphia: Elsevier/Saunders; 2005:262–265.
46. Which of the following medications is effective for restless legs syndrome?
A) Levodopa/carbidopa
B) Diltiazem
C) Phenytoin
D) Haloperidol
E) Vitamin B6
Answer and Discussion
The answer is A. Restless legs syndrome (RLS) is a relatively common problem seen by family physicians. The condition is characterized by repeated movements and paresthesias of the lower extremities (occasionally the arms). Patients may describe a tingling irritation or a drawing or crawling sensation that prevents the onset of sleep or they may disturb sleep. The symptoms are often relieved by movement. Laboratory and neurologic tests are normal. Associated conditions include iron deficiency, diabetes, uremia, pregnancy, rheumatoid arthritis, vitamin B12 deficiency, and polyneuropathy. Treatment includes the use of ropinirole (Requip), pramipexole (Mirapex), pergolide (Permax), levodopa/carbidopa (Sinemet), gabapentin (Neurontin), carbamazepine (Carbatrol), and other antiepileptics, opiates, and benzodiazepines.
Ferri F. Ferri's Clinical Advisor, Instant Diagnosis and Treatment. Philadelphia: Elsevier/Mosby; 2006:731–732.
47. Which of the following forms of hepatitis does NOT have a chronic state?
A) Hepatitis A
B) Hepatitis B
C) Hepatitis C
D) Hepatitis D
Answer and Discussion
The answer is A. Hepatitis is an inflammation of the liver that is characterized by nausea, anorexia, fever, right-upper abdominal discomfort, jaundice, and marked elevation of liver function tests. The condition is usually classified into the following types:
· Hepatitis A. Also known as infectious hepatitis, the causative agent is an RNA virus. The disease is common and often presents subclinically. It is estimated that as much as 75% of the U.S. population has positive antibodies to hepatitis A. The onset of clinical symptoms is usually acute, and children and young adults are usually affected. The transmission is via a fecal–oral route and has been linked to the consumption of contaminated shellfish (e.g., raw oysters). The course of the disease is usually mild, and the prognosis is usually excellent. There is neither an associated chronic state nor a carrier state. The diagnosis is made by the detection of elevated levels of IgM antibodies, which indicate active disease, and IgG antibodies, which indicate previous disease. Most cases require no special treatment other than supportive care, and symptoms usually resolve after several weeks. The disease can be prevented by administering Ig to those who are in close contact with those affected. Immunization, especially for travelers, is recommended to specifically prevent hepatitis A.
· Hepatitis B. This DNA viral disease is more severe than hepatitis A and causes more complications. It affects as much as 10% of the U.S. population. The infective Dane particle consists of a viral core and outer surface coat. The disease often develops insidiously and can affect persons of all ages. It is transmitted parenterally (through infected blood transfusions or infected needles used by intravenous drug abusers) and through sexual contact (especially in sexually active young adults and homosexuals). The symptoms are often severe and can be devastating to elderly patients or those who are debilitated. Approximately 10% of cases become chronic; up to 30% of affected patients become carriers of the virus after they are infected. The detection of the hepatitis B surface antigen (formerly known as the Australian antigen) supports the diagnosis of acute illness, and values become positive between 1 and 7 weeks before the symptoms become evident. The hepatitis B antibody appears weeks to months after the development of the clinical symptoms. The presence of a hepatitis B surface antibody indicates previous disease and represents immunity. Those who have received hepatitis B vaccination also have positive titers if they are immune. An anticore antibody (IgM) usually develops at the onset of the illness, and the IgG anticore antibody (which develops shortly after IgM appears) can be used as a marker for the disease during the “window period,” which occurs when the hepatitis B surface antigen disappears and before the hepatitis B surface antibodies appear. The hepatitis B e antigen is found in those who are hepatitis B surface antigen–positive; its presence is associated with greater infectivity and a greater chance of progression to the chronic state. The delta agent (hepatitis D) is a separate virus that may coexist with hepatitis B; it is usually associated with a more severe case of hepatitis B and in cases of chronic hepatitis B in which there is reactivation of the virus. Prophylaxis of hepatitis B can be achieved with hepatitis B vaccine given at 1 month and 6 months after the initial injection, for a total of three injections. Persons exposed to hepatitis B (e.g., by needle stick) should also receive hepatitis B Ig at the time of exposure.
· Hepatitis C. This disease (also known as non-A, non-B hepatitis, or post-transfusion hepatitis) accounts for as many as 40% of the cases of hepatitis in the United States. It is the main indication for liver transplant in the United States when cirrhosis is present. The disease is transmitted by infected blood, and is commonly seen in intravenous drug abusers and those who had blood transfusions infected with the virus. The disease is usually insidious in its presentation, and the severity is variable. As many as 50% of these patients may develop chronic disease, which may eventually lead to cirrhosis. The diagnosis is made by serologic means, and pegylated α-interferon and ribavirin have been used for treatment.
· Hepatitis E. The transmission is similar to the hepatitis A virus. The disease is found in India and Southeast Asia, Africa, and Mexico. Cases in the United States are usually related to travel to these endemic areas. Hepatitis E virus is associated with a high fatality in pregnant women.
· Chemical hepatitis. This condition has been associated with the use of excessive alcohol, high-dose acetaminophen, halothane, carbon tetrachloride, INH, and birth control pills.
Ferri F. Ferri's Clinical Advisor, Instant Diagnosis and Treatment. Philadelphia: Elsevier/Mosby; 2006:372–379.
48. Which of the following factors is included in the criteria for administering streptokinase with myocardial infarction?
A) Cardiogenic chest pain lasting at least 6 hours
B) ECG changes of at least 1 to 2 mm of ST elevation in two adjacent precordial leads
C) Streptokinase should not be administered 6 hours after the onset of chest pain
D) Q waves noted in the lateral precordial leads
Answer and Discussion
The answer is B. Streptokinase is a thrombolytic agent administered during myocardial infarction. In the Second International Study of Infarct Survival, there was a 23% reduction in vascular death for those given streptokinase compared with those given a placebo. Allergic reactions consisting of skin rashes and fever may be seen in 1% to 2%. Hypotension occurs in 10% of patients. Because of the development of antibodies, patients previously treated with streptokinase should be given recombinant tissue-plasminogen activator (alteplase) or reteplase plasminogen activator. The criteria for consideration of thrombolytics include chest pain (consistent with cardiogenic pain) for at least 30 minutes' duration and ECG changes that show at least 1 to 2 mm of ST elevation in two adjacent precordial leads. Medication should be given within 12 hours for maximal benefit. Although extremely variable depending on the source, the following is a list of absolute contraindications to thrombolytics:
· History of intracranial hemorrhage
· Uncontrolled hypertension defined as systolic blood pressure (SBP) >180 mm Hg or diastolic blood pressure (DBP) >100 mm Hg
· Recent surgery (1 month or less)
· Recent vascular puncture in a noncompressible region (<2 weeks)
· Unclear mental status
· Active gastrointestinal (GI) bleeding
· Aortic dissection
· Acute pericarditis
· Prolonged (>10 minutes) cardiopulmonary resuscitation
Relative contraindications include:
· Prior stroke (nonhemorrhagic)
· Major surgery (3 months or less)
· Pregnancy
· Bleeding diasthesis
· Active peptic ulcer disease
Minor hemorrhage, menstruation, and diabetic retinopathy are not contraindications to fibrinolytic therapy. Of the list of thrombolytic medications, streptokinase is the least expensive but has the highest incidence of side effects, including allergic reactions and hypotension.
Rakel RE, Bope ET. Conn's Current Therapy 2005. Philadelphia: Elsevier/Saunders; 2005:404.
49. A 48-year-old alcoholic stops drinking 2 days before presenting to his physician. He is diaphoretic, nauseated, tachycardic, anxious, and hypertensive. The most appropriate management is to
A) prescribe diazepam and refer the patient to a drug treatment program
B) hospitalize the patient, administer diazepam, and closely observe his condition
C) administer disulfiram and diazepam and follow up with the patient in 1 week
D) reassure the patient, compliment his decision to stop drinking, and explain the symptoms that are to be expected
E) refer the patient to psychiatry
Answer and Discussion
The answer is B. Symptoms of alcohol withdrawal usually occur 6 to 48 hours after the last alcoholic drink. These symptoms include sweating, anxiety, tremor, weakness, gastrointestinal (GI) discomfort, hypertension, tachycardia, fever, and hyperreflexia. Other symptoms include hallucinations and, in severe cases, delirium tremens that are characterized by disorientation with hallucinations, drenching sweats, severe tremors, and electrolyte disturbances that can lead to seizures. Treatment involves hospitalization and close observation. Antianxiety medications, including chlordiazepoxide, lorazepam, diazepam, midazolam, and oxazepam, are used for treatment and are slowly tapered to prevent withdrawal-related symptoms. Oral multivitamin supplementation with thiamine, folate, and pyridoxine is also recommended. Disulfiram is not used for alcohol withdrawal but can be used in the treatment of alcoholism to help discourage further drinking.
Ferri F. Ferri's Clinical Advisor, Instant Diagnosis and Treatment. Philadelphia: Elsevier/Mosby; 2006:36–38.
50. Which of the following statements about Burner's syndrome is true?
A) The mechanism of injury involves acute hyperextension of the shoulder while the neck and head are forced in the same direction.
B) Symptoms include temporary weakness, pain, paresthesias, and decreased sensation of the distal extremity.
C) The injury involves traction forces on the spinal cord's dorsal columns.
D) Most cases cause permanent neurologic deficits.
E) The condition is associated with overuse injury of the knees.
Answer and Discussion
The answer is B. Burner's syndrome is seen mostly in football players and results from a tackling or blocking injury. The injury occurs when the contact shoulder is depressed and the head and neck are forced in the opposite direction of contact. The traction-type forces placed on the brachial plexus lead to variable symptoms of weakness, pain, paresthesias, limited motion, and decreased sensation of the affected extremity. Diminished reflexes may also be seen. The condition should be treated with caution, and cervical disc or bony injury should be ruled out. In most cases, the symptoms last only a few minutes; however, the athlete should not return to play until a complete evaluation can be performed and the symptoms resolve.
Kuhlman GS, McKeag DB. The “Burner”: A common nerve injury in contact sports. Am Fam Physician. 1999;60:2035–2042.
Burner's syndrome occurs when the contact shoulder is depressed and the head and neck are forced in the opposite direction of contact. The traction-type forces placed on the brachial plexus lead to variable symptoms of weakness, pain, paresthesias, limited motion, and decreased sensation of the affected extremity.
51. Which of the following indicates a therapeutic effect for β-blockers
A) Pupillary constriction
B) Drug level within the acceptable range
C) Heart rate between 60 and 70 bpm
D) Generalized fatigue
E) Peripheral cyanosis
Answer and Discussion
The answer is C. β-Blockers (e.g., propranolol, metoprolol, labetalol, nadolol) are used in the treatment of hypertension. They are considered a negative inotrope and chronotrope. In most cases, they are best suited for young patients who have a hyperdynamic cardiac status. β-Blockers should be used cautiously in patients with the following:
· Asthma and COPD, because nonselective β-blockers can induce bronchoconstriction
· Diabetes, because β-blockers can blunt the response of hypoglycemia
· History of CHF, because β-blockers can decrease cardiac output (however, recent evidence supports cardioselective β-blocker use in CHF with systolic dysfunction)
· Bradycardia or heart block
Other side effects include fatigue, impotence, impaired glucose tolerance, and rebound tachycardia and hypertension (if the drug is abruptly discontinued). β-Blockers are also used for migraine prophylaxis and to treat performance anxiety and tachycardia. Newer evidence supports that β-blockers are not deleterious for patients with depression as once thought. Finally, β-blockers are also used after myocardial infarction to improve survival; they reduce myocardial oxygen demand by decreasing heart rate and contractility. Additionally, they should be given prior to surgery in those at risk for cardiac events. A therapeutic dose is determined by a recorded heart rate of 60 to 70 bpm.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:387.
52. A 54-year-old woman presents to your office with complaints of frequent sweating episodes, palpitations, nervousness, and sensitivity to heat with increased appetite and weight loss. The most likely diagnosis is
A) hypothyroidism
B) menopause
C) Addison's disease
D) hyperthyroidism
E) Cushing's disease
Answer and Discussion
The answer is D. The manifestations of hyperthyroidism are numerous and include the following: goiter; widened pulse pressure; tachycardia; warm, moist skin; tremor; atrial fibrillation; nervousness; frequent diaphoresis; sensitivity to heat; palpitations; exophthalmos; pretibial myxedema; increased appetite with weight loss; diarrhea; and insomnia. The hallmark findings of Graves' disease include the triad of goiter, exophthalmos, and pretibial myxedema. Anemia, present with hypothyroidism, is not seen with hyperthyroidism.
Ferri F. Ferri's Clinical Advisor, Instant Diagnosis and Treatment. Philadelphia: Elsevier/Mosby; 2006:432.
53. Which of the following statements about altitude sickness is true?
A) Most people are affected at altitudes between 5,000 and 7,500 ft.
B) Dehydration is rarely an associated condition.
C) The most common symptom is headache.
D) Hydrochlorothiazide is used for prophylaxis.
E) A high carbohydrate diet can help prevent symptoms.
Answer and Discussion
The answer is C. As altitude increases, the partial pressure of oxygen decreases. Approximately 20% of people experience symptoms ascending to more than 8,000 ft in less than 1 day, and 80% show some symptoms at altitudes higher than 12,700 ft. Symptoms include headache (most common), impaired concentration, nausea, vomiting, fatigue, dyspnea and hyperventilation, palpitations, and insomnia. Any type of physical exertion usually aggravates the symptoms, and excessive hyperventilation leads to dehydration. In severe cases, pulmonary and cerebral edema can occur. Treatment involves hydration and usually only symptomatic measures, along with the avoidance of alcohol and a high carbohydrate diet. Prophylaxis with acetazolamide (a carbonic anhydrase inhibitor) helps prevent respiratory alkalosis, which contributes to the symptoms.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:205, 1617.
54. Anemia that is seen in patients with chronic renal disease is usually caused by insufficient
A) iron stores
B) vitamin B12
C) renin levels
D) erythropoietin levels
E) folate stores
Answer and Discussion
The answer is D. Serum recombinant erythropoietin is used to treat refractory anemia in patients with chronic renal disease. The synthetic drug replaces erythropoietin that is normally produced by the kidneys. Although extremely expensive, the drug may be indicated if the patient has significant anemia that is not caused by other factors. The major side effect is hypertension, which must be monitored at regular intervals. Other side effects include polycythemia, with the possible development of thromboembolism, stroke, and myocardial infarction. The drug does not appear to accelerate the preexisting renal disease. Close monitoring of serum Hb is necessary with the use of erythropoietin. Iron supplementation must be given to achieve an adequate erythropoietin response.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1031.
55. Which of the following statements is true of Lyme disease?
A) The disease is transmitted by the bite of a common wood tick.
B) The second stage may be characterized by fever, malaise, a stiff neck, back pain, and erythema chronicum migrans.
C) The first stage may involve carditis with atrioventricular (AV) block or pericarditis, peripheral neuropathies, and meningitis.
D) Treatment may be accomplished with tetracycline or doxycycline.
E) It is predominant in the South Central and Western regions of the United States.
Answer and Discussion
The answer is D. Caused by the spirochete Borrelia burgdorferi, Lyme disease is transmitted by the bite of the deer tick (Ixodes dammini). Although reported in most states, it appears to be predominant in the Great Lakes area and the western and northeastern United States. The symptoms occur in three stages:
· First stage. This stage usually begins with malaise, fever, headache, stiff neck, and back pain. Generalized lymphadenopathy with splenomegaly occurs, and a large annular erythematous lesion forms at the bite site and shows central clearing (erythema chronicum migrans). Multiple lesions may occur and affect other areas of the body. The lesions are warm but not often painful. As many as 25% may not exhibit skin manifestations. These symptoms usually appear within a few days to up to 1 month after the tick bite.
· Second stage. This is the disseminated stage. Complications include carditis with AV block, palpitations, dyspnea, chest pain, and syncope. Pericarditis may also occur. Neurologic manifestations, including peripheral neuropathies and meningitis, are sometimes present. Large-joint arthritis is also common.
· Chronic phase. After the second stage, a chronic phase may result. This phase is predominantly characterized with intermittent attacks of oligoarthritis lasting weeks to months. Other symptoms include subtle neurologic abnormalities (e.g., memory problems, mood or sleep disorders). Diagnosis is usually made by the clinical presentation; however, an enzyme-linked immunosorbent assay followed by Western blot for positive results can help in the diagnosis but is somewhat unreliable.
Treatments for early disease include tetracycline, cefuroxime axetil, doxycycline, and amoxicillin. Azithromycin is less effective than other medications. Ceftriaxone is recommended for late disease. A single dose of doxycycline has been shown to reduce the likelihood of Lyme disease after a deer tick bite. A moderately effective recombinant vaccine for the prevention of Lyme disease has been removed from the market.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:995.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1480.
56. Which of the following conditions would disqualify a patient from passing a Department of Transportation (DOT) examination?
A) Diabetic taking insulin
B) Blood pressure reading of 160/90 mm Hg
C) Vision 20/40 in both eyes
D) Use of a hearing aid
E) Field of vision measured at 70 degrees in each eye
Answer and Discussion
The answer is A. Many physicians perform DOT physical examinations. The following are disqualifying conditions: A diabetic patient taking insulin cannot be certified for interstate driving. However, a driver who has diabetes controlled by oral medications and diet may be qualified if the disease is well controlled and the driver is under medical supervision. If diabetes is untreated or uncontrolled, certification should not be given.
From a cardiac standpoint, any condition known to be accompanied by sudden and unexpected syncope, collapse, or congestive heart failure is disqualifying. Conditions such as myocardial infarction, angina, and cardiac dysrhythmias should, in most cases, be evaluated by a cardiologist before certification is issued. Holter monitors and exercise stress tests may be needed when a driver has multiple risk factors. Tachycardia or bradycardia should be investigated to rule out underlying cardiac disease. Asymptomatic dysrhythmia with no underlying disease process should not be disqualifying.
From a pulmonary perspective, if a driver has clear symptoms of significant pulmonary disease, basic spirometry and lung volume tests are recommended. If the forced expiratory volume in 1 second (FEV1) is <65% of predicted value, the forced vital capacity (FVC) is less <60% of predicted, or the ratio of FEV1 to FVC is <65%, pulse oximetry should be performed. If pulse oximetry on room air is <92%, an arterial blood gas measurement is recommended. If the partial pressure of arterial oxygen is <65 mm Hg or the partial pressure of arterial carbon dioxide is >45 mm Hg, disqualification is recommended.
With regards to blood pressure: If the blood pressure is 160/90 mm Hg or lower, a full 2-year certification is appropriate. If the blood pressure is >160/90 mm Hg (either systolic or diastolic) but <181/105 mm Hg, temporary certification may be granted for 3 months to allow time for the driver to be evaluated and treated. If the initial pressure is 181/105 mm Hg or higher, the driver should not be certified. Once the driver's blood pressure is under control, certification can be issued for no more than 1 year at a time. Several readings should be taken over several days to rule out “white coat” hypertension. Significant target organ damage and additional risk factors increase the risk of sudden collapse and should be disqualifying.
Vision must be at least 20/40 in each eye with or without correction. Certification can be given once vision has been corrected, but not until. The driver should be advised to have his or her eyes evaluated, obtain corrective lenses, and then return for certification. Field of vision must be at least 70 degrees in each eye. Color vision must allow recognition of standard traffic signals (i.e., red, green, and amber).
The driver should pass a whispered voice test at 5 feet in at least one ear. A hearing aid may be worn for the test. If the test result is questionable, an audiogram is recommended. The better ear must not have an average hearing loss of more than 40 dB at 500, 1,000, and 2,000 Hz (to obtain an average, add the three decibel losses together and divide by 3).
Pommerenke F, Hegmann K, Hartenbaum NP. DOT examinations: practical aspects and regulatory review. Am Fam Physician. 1998;58(2):415–426.
57. A 45-year-old female presents to your office with petechiae noted on the lower extremities. A platelet count is obtained and noted to be 10,000. Which of the following conditions would not be associated with her thrombocytopenia?
A) Epistaxis
B) Hemarthrosis
C) Vaginal bleeding
D) Mucosal bleeding in the mouth
E) Ecchymosis at the site of minor trauma
Answer and Discussion
The answer is B. Thrombocytopenia is caused by decreased platelet production, splenic sequestration of platelets, increased platelet destruction or use, or dilution of platelets. Severe thrombocytopenia results in a characteristic pattern of bleeding: multiple petechiae in the skin, often most evident on the lower legs; scattered small ecchymoses at sites of minor trauma; mucosal bleeding [epistaxis, bleeding in the GI and genitourinary (GU) tracts, vaginal bleeding]; and excessive bleeding following surgical procedures. Heavy GI bleeding and bleeding into the central nervous system (CNS) may be life threatening. Thrombocytopenia does not cause massive bleeding into tissues (e.g., deep visceral hematomas, hemarthroses), which is characteristic of bleeding secondary to coagulation disorders such as hemophilia. Medications associated with thrombocytopenia include: heparin (up to 5%, even with very low doses), quinidine, quinine, sulfa preparations, oral antidiabetic drugs, gold salts, and rifampin.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1064–1072.
58. Iron deficiency anemia is associated with
A) hyperchromic, macrocytic features
B) elevated serum iron levels
C) increased total iron-binding capacity (TIBC)
D) increased ferritin levels
E) normal bone marrow biopsy results
Answer and Discussion
The answer is C. Iron deficiency anemia produces a hypochromic, microcytic anemia. Causes include excessive menstruation, GI blood loss, inadequate iron consumption, malabsorption, pregnancy, or excessive growth in the absence of adequate iron consumption during infancy. Symptoms may include generalized weakness and fatigue, facial pallor, glossitis, cheilosis, and angular stomatitis. In chronic, severe cases patients may have pica (e.g., craving for dirt, paint), pagophagia (craving for ice), or dysphagia associated with a postcricoid esophageal web. Physical examination may show skin pallor, dry brittle nails, and tachycardia with perhaps a flow murmur. Laboratory tests show a depressed Hb with microcytic, hypochromic features; low serum iron concentration; low ferritin; and increased transferrin (TIBC). Bone marrow aspiration shows diminished iron stores with small, pale red blood cells. Only when the hematocrit falls below 31% to 32% do the red blood cell (RBC) indices become microcytic. Treatment is the administration of iron replacement for 6 to 12 months until iron stores are replenished. The addition of ascorbic acid enhances iron absorption without increasing gastric distress.
Goldman L, Ausiello D, eds. Cecil textbook of medicine, 22nd ed. Philadelphia: WB Saunders; 2004:1003–1006.
59. Which of the following is not indicated in the emergent treatment of thyroid storm?
A) Propylthiouracil
B) Supersaturated potassium iodine
C) Propranolol
D) Aspirin
E) Acetaminophen
Answer and Discussion
The answer is D. Thyroid storm is a life-threatening condition seen in patients with hyperthyroidism. The condition is usually precipitated by stress, illness, or manipulation of the thyroid during surgery. Signs and symptoms include diaphoresis, tachycardia, palpitations, weight loss, diarrhea, fever, mental status changes, weakness, and shock. Treatment should be provided immediately and includes propylthiouracil, supersaturated potassium iodine, and propranolol. Other measures involve fluid replacement and control of fever with acetaminophen and cooling blankets. Avoid aspirin, because it may increase T3 and T4 by reducing protein binding. Steroids may also be given to help prevent the conversion of T3 and T4 peripherally. The definitive therapy after control of the thyroid storm involves ablation of the thyroid gland with iodine-131 or surgery. After treatment, many patients become hypothyroid and may require replacement therapy.
Goldman L, Ausiello D, eds. Cecil textbook of medicine, 22nd ed. Philadelphia: WB Saunders; 2004:1401.
60. Which of the following ECG findings is associated with sudden cardiac death?
A) Prolonged QT interval
B) First-degree AV block
C) Sinus arrhythmia
D) Right bundle branch block
E) Premature ventricular contractions
Answer and Discussion
The answer is A. A prolonged QT interval is a common entity associated with sudden arrhythmia death syndrome. Arrhythmias may be induced in normal hearts by medications; electrolyte abnormalities (e.g., hypokalemia, hypomagnesemia); myocarditis; and endocrine, central nervous system, or nutritional disorders. These arrhythmias are associated with prolongation of the QT interval. A group of inherited gene mutations has been identified associated with cardiac ion channels that cause long QT syndrome and carry an increased risk for sudden death. Some of the highest rates of inherited long QT syndrome occur in Southeast Asian and Pacific Rim countries. The average age of persons who die of long QT syndrome is 32 years; men are more commonly affected. In addition to a prolonged QT interval, which occurs in some but not all persons with long QT syndrome, another characteristic electrocardiographic abnormality is the so-called Brugada sign (an upward deflection of the terminal portion of the QRS complex). Most cardiac events are precipitated by vigorous exercise or emotional stress, but they also can occur during sleep. Torsades de pointes and ventricular fibrillation are the usual fatal arrhythmias. Long QT syndrome should be suspected in patients with recurrent syncope during exertion and those with family histories of sudden, unexpected death. Not all persons with long QT syndrome have warning symptoms or identifiable electrocardiographic abnormalities, and they may present with sudden death. β-Blockers, potassium supplements, and implantable defibrillators have been used for treatment of long QT syndrome. Identifying the specific gene mutation in a given patient with long QT syndrome can help guide prophylactic therapy.
Meyer JS, Mehdirad A, Salem BI, et al. Sudden arrhythmia death syndrome: importance of the long QT syndrome. Am Fam Physician. 2003;68:483–488.
Long QT syndrome should be suspected in patients with recurrent syncope during exertion and those with family histories of sudden, unexpected death.
61. A felon is defined as a
A) infection of the distal pulp space of a phalanx
B) herpetic infection associated with a phalanx
C) fracture involving the proximal fifth metatarsal
D) superficial infection of the nail bed
E) hypertrophic changes noted in gout
Answer and Discussion
The answer is A. A felon is an infection of the pulp space of a phalanx. A felon usually is caused by inoculation of bacteria into the fingertip through a penetrating trauma. The most commonly affected digits are the thumb and index finger. Predisposing causes include splinters, bits of glass, abrasions, and minor trauma. A felon also may arise when an untreated paronychia spreads into the pad of the fingertip. The most common site is the distal pulp, which may be involved centrally, laterally, and apically. The septa between pulp spaces ordinarily limit the spread of infection, resulting in an abscess, which creates pressure and necrosis of adjacent tissues. The underlying bone, joint, or flexor tendons may become infected, and intense throbbing pain and a swollen pulp are present. If diagnosed in the early stages of cellulitis, a felon may be treated with elevation, oral antibiotics, and warm water or saline soaks. Radiographs should be obtained to evaluate for osteomyelitis or a foreign body. Tetanus prophylaxis should be administered when necessary. If fluctuance is present, incision and drainage are appropriate along with administration of appropriate antibiotics (usually a cephalosporin or anti-staphylococcal penicillin).
Clark DC. Common acute hand infections. Am Fam Physician. 2003;68:2167–2176.
62. Which of the following statements about hyperglycemic hyperosmolar nonketotic coma is true?
A) It is usually associated with type I adult-onset diabetes mellitus.
B) It is associated with fluid overload.
C) Associated laboratory findings include elevated serum lactate.
D) Treatment involves intravenous administration of glucose.
E) Treatment involves fluid administration.
Answer and Discussion
The answer is E. Hyperosmolar nonketotic coma secondary to hyperglycemia usually occurs in patients with type II adult-onset diabetes mellitus. The condition occurs when serum glucose is elevated, leading to osmotic diuresis and the development of dehydration without ketosis. In most cases, the condition affects elderly, mildly obese patients who fail to keep adequate fluid intake to make up for the osmotic diuresis. Complications include mental status changes with the development of coma, acute renal failure, thrombosis, shock, and lactic acidosis. Diagnosis depends on the detection of plasma glucose >600 mg/dL, serum lactate >5 mmol, and a serum osmolality >320 mOsmol/kg. Sodium and potassium levels are usually normal; however, BUN and creatinine are markedly elevated. Treatment consists of fluid replacement (usually approximately 10 L) with potassium supplementation and the cautious administration of insulin. Triggering conditions such as infection, myocardial infarction, or stroke should be ruled out. Unfortunately, the mortality rate for hyperglycemic hyperosmolar nonketotic coma approaches 50% if not treated immediately.
Goldman L, Ausiello D, eds. Cecil textbook of medicine, 22nd ed. Philadelphia: WB Saunders; 2004:1442.
63. Which of the following statements about giardiasis is true?
A) Transmission occurs through fecal–oral contamination.
B) Chlorination of drinking water kills the cyst.
C) Diagnosis can be achieved by peripheral blood smears.
D) The cyst form is responsible for symptoms.
E) Asymptomatic carriers do not require treatment.
Answer and Discussion
The answer is A. Giardia lamblia is the causative agent in parasitic giardiasis. Most cases are asymptomatic. However, these patients pass infective cysts and must be treated. Symptoms occur 1 to 3 weeks after infection and include foul-smelling watery diarrhea, flatulence, abdominal cramps and distention, and anorexia. Outbreaks in day schools, nursing homes, and institutions for the mentally retarded are common. Transmission is through a fecal–oral route. The infective form is the cyst, and trophozoites are responsible for the symptoms. Cysts are transmitted in contaminated food or water. Giardia cysts are resistant to chlorination; therefore, filtration is used to clear cysts from drinking water supplies. Giardia is sensitive to heat, thus bringing water to a boil is effective before consumption. Diagnosis is accomplished by detecting cysts or the parasite in the stool (usually three samples) or in duodenal contents (by using endoscopy, the swallowed-string test, or Enterotest). Treatment includes metronidazole and furazolidone. The medication is available in suspension, making it useful for children. Close contacts should also be tested, especially when recurrent infections are found. Although Giardia is most commonly associated with beavers, there is evidence of sporadic transmission between infected dogs and people.
Goldman L, Ausiello D, eds. Cecil textbook of medicine, 22nd ed. Philadelphia: WB Saunders; 2004:2095–2096.
64. A 32-year-old sportsman who recently attended a wild-game feed banquet consumed summer sausage made from bear meat. He complains of abdominal discomfort, diarrhea, and muscle tenderness. The most likely diagnosis is
A) trichinosis
B) salmonellosis
C) giardiasis
D) ascariasis
E) shigellosis
Answer and Discussion
The answer is A. Trichinosis is a parasitic infection caused by the roundworm Trichinella spiralis. The condition results from eating inadequately prepared or raw pork, bear, or walrus meat that contains the encysted larva. Many cases are linked to the consumption of contaminated summer sausage. Many patients are asymptomatic; however, some may exhibit diarrhea, abdominal discomfort, and a low-grade fever. Ocular symptoms may also occur with edema of the eyelids, photophobia, and retinal or subconjunctival hemorrhages. Muscle soreness and urticaria may also be associated with the parasitic infection. Laboratory studies show an increasing eosinophilia with a leukocytosis. Diagnosis can be made by muscle biopsy showing the larva or cysts, serologic tests, or enzyme-linked immunosorbent assay (ELISA) tests. Treatment is accomplished with thiabendazole with variable response. For severe cases, corticosteroids may be indicated. Complications include myocarditis, meningitis, and pneumonitis. The prognosis is usually good. Most cases can be avoided by thoroughly cooking pork before consumption.
Goldman L, Ausiello D, eds. Cecil textbook of medicine, 22nd ed. Philadelphia: WB Saunders; 2004:2116.
65. A 24-year-old long-distance runner has been training for a track meet. He reports localized pain, especially at night, and mild swelling over his proximal left tibia that has not responded to anti-inflammatory agents or ice therapy. Radiographs of the area are normal. The most likely diagnosis is
A) stress fracture
B) shin splints
C) osteoid osteoma
D) gastrocnemius tear
E) iliotibial band (ITB) syndrome
Answer and Discussion
The answer is A. Stress fractures usually involve the tibia (commonly in the proximal two-thirds of the bone) and fibula (usually 5 to 7 cm above the lateral malleolus) after prolonged and repeated use. Stress fractures account for up to 10% of all sports injuries. Long-distance runners or athletes who are inadequately conditioned are frequently affected. Symptoms include pain over the lower leg in the affected area; the pain usually improves with rest but recurs with repeated activity. Localized erythema and swelling may occur over the fracture site. Night pain is a common feature, which should alert the clinician to the possibility of a stress fracture. Radiographs are normal in many cases; however, technetium bone scans can be used to demonstrate the fracture. Bone scans are the most cost-effective means to diagnose stress fractures. The MRI is also very sensitive but is more expensive. Treatment of stress fractures includes rest from exercise or competition for 6 to 8 weeks. Those who experience pain with ambulation or cannot adhere to limited activity for 6 to 8 weeks should be in a walking cast for 4 to 6 weeks. When patients resume their activity, they should begin slowly and gradually work back to their normal routines. If pain should recur, nonunion of the fracture should be suspected and the athlete should be referred to an orthopedist. The athlete may return to competition after 14 days without pain and no pain with gradual return to activity.
Johnson R. Sports Medicine in Primary Care. Philadelphia: WB Saunders Company; 2000:174–181.
66. Which of the following statements about familial periodic paralysis is true?
A) It is an autosomal-recessive transmitted disorder.
B) It involves disturbances of potassium regulation.
C) It is associated with permanent muscle weakness.
D) It is aggravated by administration of acetazolamide.
E) It most commonly affects the elderly.
Answer and Discussion
The answer is B. Familial periodic paralysis is an autosomal-dominant transmitted disorder that is characterized by episodes of paralysis, loss of deep tendon reflexes, and failure of the muscles to respond to electrical stimulation. Onset is usually early in life; episodic weakness beginning after age 25 years is almost never due to periodic paralysis. There is no alteration in mental status—patients remain alert during attacks. Muscle strength is normal between attacks. There are two basic types:
· Hypokalemic. Attacks usually begin in adolescence. Symptoms occur the day after vigorous exercise. The symptoms are usually mild and may affect particular muscle groups (proximal muscles) or involve all extremities at once. Oropharyngeal and respiratory muscles are unaffected. The weakness usually lasts 24 to 48 hours. Meals high in carbohydrates and sodium may precipitate the attacks.
· Hyperkalemic. Attacks usually occur earlier in childhood. They are shorter in duration, more frequent, and less severe. Attacks are usually associated with myotonia. Most patients are actually normokalemic during the attacks; however, the administration of potassium can precipitate the attack—thus the name.
Diagnosis is made by the history, and serum potassium levels should be drawn during the attacks to determine the specific type of paralysis. Provocative testing with glucose and insulin can be used (in hypokalemic forms) with caution in those who have infrequent attacks. The treatment of choice for both types is acetazolamide. Potassium chloride may help abort hypokalemic attacks; calcium gluconate and furosemide may help abort hyperkalemic attacks.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1245, 1248.
67. Crohn's disease is associated with which of the following?
A) Inflammation limited to the superficial layer of the bowel wall
B) The affinity to involve the rectosigmoid junction
C) Decreased risk of colon cancer
D) Continuous mucosal areas of ulceration that affect the anus
E) Fistula formation
Answer and Discussion
The answer is E. Crohn's disease is characterized by a transmural inflammation of the GI tract. It may affect any part of the GI tract but is usually associated with the terminal ileum, the colon, or both. On colonoscopy, areas of ulceration and submucosal thickening give the bowel a cobblestone appearance, with some skipped areas of normal bowel. In addition to the transmural inflammation, there are granulomas, abscesses, fissures, and fistula formation. Symptoms include fever, weight loss, abdominal pain (usually the right-lower quadrant), diarrhea (rarely with associated blood), and growth retardation in children. In children, Crohn's disease is more common than ulcerative colitis. Complications include intestinal obstruction; toxic megacolon, which is usually more common in ulcerative colitis; malabsorption, particularly associated with fat-soluble vitamins and especially vitamin B12; intestinal perforation; fistula formation; and development of gall and kidney stones. There is also an increased risk—five times the average—for bowel cancer. Other areas may be affected, including the following:
· Joints: arthritis, ankylosing spondylitis
· Skin: erythema nodosum, aphthous ulcers, pyoderma gangrenosum
· Eyes: episcleritis, iritis, uveitis
· Liver: fatty liver, pericholangitis
The diagnosis is usually made with colonoscopy or flexible sigmoidoscopy with biopsy or with x-ray contrast studies (usually avoided in acute stages because of the risk of developing toxic megacolon with barium). Treatment involves the use of oral corticosteroids or steroid enemas, ciprofloxacin, metronidazole, antidiarrheal agents, and sulfasalazine (Azulfidine), olsalazine (Dipentum), or mesalamine (Asacol, Pentasa, Rowasa), all three of which contain 5-aminosalicylic acid. Infliximab (Remicade) is a new drug that has been approved for the treatment of Crohn's disease. The drug is a potent antibody to tumor necrosis factor that is elevated in patients with Crohn's disease and can help close fistulas in up to 60% of patients. In severe cases, total parenteral nutrition may be necessary with surgery to remove the ulcerated bowel.
Knutson D, Greenberg G, Cronau H. Management of Crohn's disease. Am Fam Physician. 2003;68:707–714, 717–718.
Goldman L, Ausiello D, eds. Cecil textbook of medicine, 22nd ed. Philadelphia: WB Saunders; 2004:861–867.
68. A 68-year-old patient is seen for a general examination. Current recommendations for immunizations include
A) tetanus booster every 5 years
B) influenza vaccination yearly
C) pneumococcal vaccination yearly
D) hepatitis booster every 5 years
E) meningococcal vaccination
Answer and Discussion
The answer is B. Adult immunizations should include tetanus immunization every 10 years and influenza vaccination yearly beginning at age 50. Pneumococcal immunization should be given at age 65 years. Those at high risk receiving pneumococcal vaccination before age 65 years and after 5 years may require boosters. Vaccination can be started earlier in patients at high risk for disease (e.g., patients who are immunocompromised, those with chronic lung disease or diabetes). Patients who do not have functional spleens should receive pneumococcal, meningococcal, and influenza immunization.
Centers for Disease Control and Prevention website. Summary of adolescent/adult immunization recommendations. Available at: http://www.cdc.gov/nip/recs/adult-schedule.pdf. Accessed 6/5/06.
69. A 10-year-old female is brought in by her mother. The child was bitten on the finger by the neighbor's cat 1 hour ago. There are small puncture bites with minimal inflammation at the site. She is allergic to penicillin. Appropriate management at this time includes
A) observation only
B) topical antibiotic ointment
C) oral doxycycline (Vibramycin)
D) IV ceftriaxone (Rocephin)
E) oral amoxicillin–clavulanate (Augmentin)
Answer and Discussion
The answer is C. The oral flora of humans and animals contains a mixture of potential pathogens: Eikenella corrodens is frequently isolated from human bites, and Pasteurella multocida from many animal bites, particularly those of cats. Amoxicillin–clavulanate potassium (Augmentin) is the antibiotic of choice for both dog and cat bites when infection is present. For patients who are allergic to penicillin, doxycycline (Vibramycin) is an acceptable alternative, except for children younger than 8 years and pregnant women. Erythromycin can also be used, but the risk of treatment failure is greater because of antimicrobial resistance. Other acceptable combinations include clindamycin (Cleocin) and a fluoroquinolone in adults or clindamycin and trimethoprim–sulfamethoxazole (Bactrim, Septra) in children. When compliance is a concern, daily intramuscular injections of ceftriaxone (Rocephin) are appropriate. All bite injuries are potentially dangerous and can cause significant infection. They should be debrided surgically, with the wounds left open. Currently there is insufficient evidence to support antibiotic prophylaxis in dog and cat bites, and minimal evidence supports its use for human bites. However, there is evidence that antibiotics reduce the risk of infection in hand bites.
Turner TW. Do mammalian bites require antibiotic prophylaxis? Ann Emerg Med. 2004;44:274–246.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2638–2639.
70. The treatment of choice for leishmaniasis is
A) mebendazole
B) quinine
C) doxycycline
D) ciprofloxacin
E) antimonial compound
Answer and Discussion
The answer is E. The condition leishmaniasis refers to various clinical syndromes caused by a protozoa species. Leishmaniasis is endemic in many of the tropics, the subtropics, and southern Europe. It is typically a vector-borne disease, with rodents and canids as common reservoir hosts and humans as incidental hosts. In humans, visceral, cutaneous, and mucosal leishmaniasis results from infection of macrophages throughout the reticuloendothelial system, in the skin, and in the nasal and oropharyngeal mucosa. Leishmania parasites are transmitted by the bite of female sandflies. The transmission of Leishmania species typically is localized because of the limited area that sandflies inhabit. Typically these insects remain within a few hundred yards of their breeding ground. They are found in dark, moist places in areas ranging from deserts to rain forests. Many reside in debris or rubble near structures. The primary lesion at the site of an infected sandfly bite is small and usually not noticed. Parasites travel from the skin through the bloodstream to the lymph nodes, spleen, liver, and bone marrow. Clinical signs develop gradually after 2 weeks up to 1 year later. The typical syndrome consists of fevers, hepatosplenomegaly, pancytopenia, and polyclonal hypergammaglobulinemia with reversed albumin/globulin ratio. In up to 10% of patients, twice-daily temperature spikes occur. Death can occur within 1 to 2 years in a majority of untreated symptomatic patients. A subclinical form with vague minor symptoms resolves spontaneously in a majority of patients and can progress to full-blown visceral leishmaniasis in one-third of cases. Those infected are resistant to further attacks unless they are immunocompromised. One to 2 years after apparent cure, some patients develop nodular cutaneous lesions full of parasites, which can last for years and is often treated as folliculitis. Treatment consists of a regimen of antimonial compounds. Toxicity including myalgia, arthralgia, fatigue, elevated liver function tests, pancreatitis, and electrocardiographic abnormalities are more common as the length of treatment progresses but usually does not limit treatment and is reversible. Alternatives include amphotericin B and pentamidine. Many other agents have been recommended as alternatives or adjuncts to antimonial compounds often on the basis of suboptimal data.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:1233, 1236–1237.
Treatment of leishmaniasis consists of a regimen of antimonial compounds.
71. Which of the following statements is true regarding glaucoma?
A) Intraocular pressure is diagnostic for glaucoma.
B) Glaucoma suspects have normal intraocular pressure.
C) Measurement of intraocular pressures by primary care physicians to screen for glaucoma is not recommended.
D) Prostaglandin eye drops are contraindicated in the treatment of glaucoma.
E) Laser treatment is the treatment of choice once glaucoma is identified.
Answer and Discussion
The answer is C. Glaucoma is the second most common cause of legal blindness in the United States. Open-angle glaucoma is a condition that involves progressive optic neuropathy characterized by enlarging optic disc cupping and visual field loss. Most patients are asymptomatic. Patients at increased risk for open-angle glaucoma include African Americans over 40 years of age, Whites older than 65 years, a personal history of diabetes or severe myopia, and persons with a family history of glaucoma. Elevated intraocular pressure is a risk factor for open-angle glaucoma, but it is not diagnostic. Some patients with glaucoma have normal intraocular pressure (i.e., normal-pressure glaucoma), and many patients with elevated intraocular pressure do not have glaucoma (i.e., glaucoma suspects). Screening patients for glaucoma by the primary physician is not recommended. Formal visual field testing (perimetry) by vision care is the mainstay of glaucoma diagnosis and management. Nonspecific β-blocker or prostaglandin analog eye drops generally are the first-line treatment to reduce intraocular pressure. Laser treatment and surgery usually are reserved for patients in whom medical treatment has failed. Without treatment, open-angle glaucoma can result in irreversible vision loss.
Distelhorst JS, Hughes GM. Open-angle glaucoma. Am Fam Physician. 2003;67:1937–1944, 1950.
72. Which of the following statements about acetaminophen overdose is correct?
A) Symptoms include extremity pain with physical findings of peripheral neuropathy.
B) Toxic effects rarely occur with ingestion of greater than 140 to 150 mg/kg of acetaminophen.
C) Elevations in liver tests peak 3 to 4 hours after ingestion.
D) Blood levels obtained 4 hours after ingestion determine treatment.
E) Treatment involves the use of deferoxamine.
Answer and Discussion
The answer is D. Acetaminophen overdose is not uncommon. Most cases involve children younger than 6 years. Toxic effects occur when the doses exceed 140 to 150 mg/kg or a total dose of 7.5 g. The drug primarily affects the liver 24 to 72 hours after ingestion by depleting glutathione stores and causing hepatocellular necrosis. Symptoms include nausea, vomiting, and right-upper quadrant abdominal pain. Acetaminophen levels should be checked 4 hours after ingestion and plotted on the Rumack–Matthew nomogram. Peak aspartate aminotransferase, alanine aminotransferase (ALT), bilirubin, and prothrombin time (PT) values are seen 3 to 4 days after ingestion. Treatment, including emesis induced by syrup of ipecac, gastric lavage, and administration of activated charcoal, should be initiated as soon as possible. A 4-hour acetaminophen level greater than 150 µg/mL requires administration of the antidote acetylcysteine (Mucomyst). For maximal therapeutic effect, N-acetylcysteine should be administered within 8 hours of acetaminophen ingestion.
Linden CH, Rumack BH. Acetaminophen overdose. Emerg Med Clin North Am. 1984;2:103–115.
Goldman L, Ausiello D, eds. Cecil textbook of medicine, 22nd ed. Philadelphia: Saunders; 2004:908–909.
73. Which of the following statements about chronic fatigue syndrome is true?
A) Antibiotics may be beneficial.
B) Antidepressants may be beneficial.
C) The disease is most likely linked to the Epstein–Barr virus (EBV).
D) Symptoms rarely improve.
E) Bed rest is usually beneficial.
Answer and Discussion
The answer is B. Chronic fatigue syndrome is a poorly understood constellation of symptoms that includes generalized fatigue, sore throat, tender lymphadenopathy, headaches, and generalized myalgias. The disease does not appear to be associated with chronic infections of EBV or Lyme disease. It does appear to be associated with underlying psychiatric disorders, such as somatization disorder, depression, and anxiety. Chronic fatigue syndrome has no pathognomic features and remains a constellation of symptoms and a diagnosis of exclusion. Patients with this constellation of symptoms should receive supportive therapy and be encouraged to gradually increase their exercise program within their limits and participate in their usual activities. Alternative medicines and vitamins are popular with many chronic fatigue syndrome patients but generally are not very helpful. The use of antibiotics or antiviral agents is contraindicated. In some cases, patients may respond to antidepressant medications. Given enough time, most patients improve.
Ferri F. Ferri's Clinical Advisor, Instant Diagnosis and Treatment. Philadelphia: Elsevier/Mosby; 2006:57.
74. Chronic gingivitis as a result of chronic plaque buildup can initially lead to
A) periodontitis
B) dental caries
C) glossitis
D) oropharyngeal cancer
E) oropharyngeal candidiasis
Answer and Discussion
The answer is A. Periodontitis is the most common cause of tooth loss. It occurs when chronic gingivitis (a result of bacterial plaque buildup) leads to loss of supporting bone around the tooth root. Symptoms include deepening of the gingival pockets between the teeth with the accumulation of calculus deposits. The gums soon lose their attachment to the tooth, and bone loss occurs. Bacteria accumulate in the gingival pockets and can lead to progression of the disease. Later in the course of the disease, the gums recede and eventually tooth loss occurs. Treatment involves dental referral and, in severe cases, surgery. Regular dental visits twice yearly and proper brushing and flossing techniques help prevent plaque buildup.
Douglass AB, Douglass JM. Common dental emergencies. Am Fam Physician. 2003;67:511–516.
75. Which of the following medications is contraindicated in pregnancy?
A) Lisinopril
B) Penicillin
C) Acetominophen
D) Alpha methyldopa
Answer and Discussion
The answer is A. Women of childbearing age should be warned to notify their physicians as soon as possible if they become pregnant during ACE-inhibitor therapy. ACE inhibitors are not considered teratogenic if they are discontinued during the first trimester (class C), but they are considered teratogenic in the second and third trimesters (class D).
Bicket DB. Using ACE inhibitors appropriately. Am Fam Physician. 2002;66:461–468, 473.
76. A 48-year-old woman presents to your office complaining of blurred vision and pain associated with the right eye. The patient also reports seeing halos around light sources as well as nausea, abdominal pain, and vomiting. Physical examination shows her right eye is red and the pupil is dilated. The most likely diagnosis is
A) angle-closure glaucoma
B) Graves' disease
C) digoxin toxicity
D) hyphema
E) atropine poisoning
Answer and Discussion
The answer is A. Glaucoma is classified into two types: open-angle and angle-closure.
· Open-angle type (90% of cases) results when the rate of aqueous fluid outflow is decreased and the ocular pressure is consistently increased, giving rise to optic atrophy with loss of vision. The disease usually is bilateral, affects African Americans more commonly than Whites, and appears to have genetic predisposition. Examination may show optic disc cupping and an increase in intraocular pressure (normal: 10 to 21 mm Hg). The diagnosis should not be based on one reading. Treatment involves the use of intraocular β-blockers, such as timolol and pilocarpine. Surgical therapy may be necessary for patients whose conditions do not respond appropriately to medical treatment.
· Angle-closure glaucoma is less common, often more acute in onset, and is associated with a narrow anterior chamber and pupillary dilation that obstructs the normal flow of aqueous fluid. The condition constitutes an ophthalmologic emergency and is associated with stress, dark rooms, and pupillary dilation by medication used to perform eye examinations. Most patients experience pain and blurred vision with halos around lights. They may also present with abdominal pain and vomiting. Physical examination shows an eye that is red with the pupil dilated and unresponsive to light. Untreated, the condition can lead to blindness in 2 to 5 days. Treatment involves medication (miotics and carbonic anhydrase inhibitors) and laser peripheral iridectomy.
Patients older than 65 years should be screened for glaucoma every 1 to 2 years, or every year if there is a strong family history for glaucoma. African-American individuals should be screened at an earlier age (40 years). The report of the United States Preventative Services Task Force does not recommend the routine performance of tonometry by primary care physicians. Instead, primary care physicians are encouraged to refer to an eye specialist for screening.
Goldman L, Ausiello D, eds. Cecil textbook of medicine, 22nd ed. Philadelphia: WB Saunders; 2004:2414.
77. The ligament most commonly injured with an ankle sprain is the
A) anterior talofibular ligament
B) fibulocalcaneal ligament
C) posterior talofibular ligament
D) deltoid ligament
Answer and Discussion
The answer is A. Ankle sprains are graded according to the following criteria:
· Grade 1: Mild sprain with no evidence of ligamentous tear; associated with mild pain and swelling
· Grade 2: Moderate sprain with evidence of partial tear of ligaments; associated with moderate swelling, ecchymosis, and difficulty ambulating
· Grade 3: Severe sprain with evidence of a complete tear of the ligament; associated with significant swelling, ecchymosis, ankle instability, and the inability to walk
The ligaments involved include the anterior talofibular (which is the most commonly affected), the fibulocalcaneal, and the posterior talofibular ligament. A positive drawer sign (movement of the talus forward) indicates rupture of the anterior talofibular ligament. Treatment for grades 1 and 2 sprains involves rest, ice, compression, elevation (RICE), use of air casts and splints, and NSAIDs followed by early mobilization and physical therapy, which emphasizes strengthening and proprioceptive training. Grade 3 sprains require surgical referral. High-ankle sprains involve injury to the syndesmosis, the thick ligament between the distal tibia and fibula. Recovery time is increased with these injuries.
Snider RK, ed. Essentials of musculoskeletal care. Rosemont, IL: American Academy of Orthopedic Surgeons; 1997:390–393.
78. Of the following, the medication of choice for refractive hiccups is
A) chlorpromazine
B) acetazolamide
C) gabapentin
D) chloral hydrate
E) clonidine
Answer and Discussion
The answer is A. Hiccups are sudden, repeated, involuntary contractions of the diaphragm followed by abrupt closure of the glottis. They result from stimulation of the efferent and afferent nerves that innervate the diaphragm. Causes include excitement, alcohol consumption, and gastric distention caused by overeating. Low CO2 levels tend to accentuate hiccups, and high levels tend to prevent them. Advocated symptomatic treatment includes breathing into a paper bag, rapidly drinking a glass of water, swallowing dry bread, holding one's breath, or consuming crushed ice. In addition, gastric decompression may provide relief. For refractive hiccups, chlorpromazine may be given orally or intravenously. Other medications include phenobarbital, scopolamine, chlorpromazine, metoclopramide, and narcotics. In severe cases, surgery to disrupt the phrenic nerve or to inject the phrenic nerve with a procaine solution may be performed.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:70.
79. Which of the following organisms is responsible for the development of pseudomembranous colitis?
A) Escherichia coli
B) Clostridium difficile
C) Pseudomonas aeruginosa
D) Methicillin-resistant Staphylococcus aureus
E) Enterococcus faecalis
Answer and Discussion
The answer is B. Pseudomembranous colitis is characterized by profuse, watery diarrhea; abdominal cramps; low-grade fevers; and, occasionally, hematochezia. The etiologic agent is C. difficile, which produces a toxin that causes the lesions affecting the colon. The condition is thought to be associated with antibiotic use in the preceding 2 to 3 weeks (in some cases up to 6 weeks); however, antibiotic use is not necessary for the condition to occur. The diagnosis may be achieved by a laboratory stool test, which isolates the C. difficile toxin. Sigmoidoscopy or colonoscopy usually shows characteristic yellowish-white plaques. Treatment includes the use of metronidazole or vancomycin (which is more expensive). Complications include dehydration, electrolyte imbalances, intestinal perforation, toxic megacolon, and, in severe cases, death. Relapse may occur in up to one-third of patients after treatment.
Goldman L, Ausiello D, eds. Cecil textbook of medicine, 22nd ed. Philadelphia: WB Saunders; 2004:1836–1838.
80. Dermatomyositis is associated with which of the following?
A) Generalized morbilliform rash
B) Underlying malignancy
C) Elevated lipids
D) Distal muscle weakness
E) Inflammatory bowel disease
Answer and Discussion
The answer is B. Dermatomyositis is a systemic connective tissue disease that involves inflammation and degeneration of the muscles. Females are affected more than males at a 2:1 ratio. Although the disease may occur at any age, it occurs most commonly in adults 40 to 60 years of age and in children 5 to 15 years of age. The cause is unknown. In adult cases (15% of men older than 50 and a smaller proportion affecting women), there is an underlying malignant tumor, which may give rise to an autoimmune reaction and lead to an attack of tumor antigens with similar muscle antigens. Symptoms include symmetric proximal muscle weakness, muscular pain, violaceous, flat-topped papules over the dorsal interphalangeal joints (Gottron's papules), purple-red discoloration of the upper eyelids (heliotropic rash), polyarthralgia, dysphagia, Raynaud's phenomenon, fever, and weight loss. Interstitial pneumonitis with dyspnea and cough may occur and precedes the development of myositis. Cardiac involvement may be detected when ECG tracings show arrhythmias or conduction disturbances. Laboratory findings include increased erythrocyte sedimentation rate (ESR), positive antinuclear antibodies and/or lupus erythematosus (LE) preparation test, and elevated creatinine kinase (most sensitive and useful marker) and aldolase. Diagnosis is confirmed by electromyography and muscle biopsy. Initial treatment consists of steroids. Patients who fail to respond can be given immunosuppressive agents such as methotrexate, cyclophosphamide, and chlorambucil. After the diagnosis of dermatomyositis is made, an effort should be made to uncover an occult malignancy. Dermatomyositis associated with malignancy often remits once the tumor is removed.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:2540.
After the diagnosis of dermatomyositis is made, an effort should be made to uncover an occult malignancy.
81. Of the following medications, which is most effective in relieving premenstrual dysphoric disorder?
A) Spironolactone
B) Bromocriptine
C) Amitryptyline
D) Fluoxetine
E) Oral contraceptives
Answer and Discussion
The answer is D. Treatment of premenstrual syndrome involves multiple treatment options. Fluid retention may be treated by reducing sodium intake and using a thiazide diuretic starting just before symptoms are expected. Counseling may help the woman and her partner cope with PMS, and the woman's activities can be modified to reduce stress. Hormonal manipulation is effective in some cases. Medications include oral contraceptives; progesterone by vaginal suppository or by injection for 10 to 12 days premenstrually; a long-acting progestin; or a gonadotropin-releasing hormone agonist with low-dose estrogen-progestin “add-back” therapy to eliminate cyclic changes. Benzodiazepines may be used for anxiety, irritability, nervousness, and lack of control, especially if patients cannot alter their stressful environments. Spironolactone, bromocriptine, and monoamine oxidase inhibitors are not beneficial. Selective serotonin reuptake inhibitors (e.g., fluoxetine or sertraline 50 mg) are the most effective drugs in the management of premenstrual dysphoric disorder.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2080.
82. A 65-year-old woman presents with glossitis, weight loss, paresthesias, and diarrhea. Laboratory tests show a macrocytic anemia. The most likely cause is
A) iron deficiency anemia
B) thalassemia
C) pernicious anemia
D) multiple myeloma
E) colon cancer
Answer and Discussion
The answer is C. Vitamin B12 (cobalamin) deficiency is associated with several different conditions, including pernicious anemia (lack of intrinsic factor required for vitamin B12 absorption), celiac sprue, Crohn's disease, and previous gastrectomy. Causes for vitamin B12 deficiency include inadequate diet, inadequate absorption, inadequate use, increased requirement, and increased excretion. Symptoms include glossitis, anorexia, weight loss, paresthesias, ataxia, dementia, neuropsychiatric changes, and diarrhea. Signs include a macrocytic anemia, tachycardia, abnormal reflexes, positive Romberg sign, and abnormal positional and vibratory sensation. Laboratory findings show low vitamin B12 levels and reticulocyte counts. Mild thrombocytopenia, leukopenia, elevated lactate dehydrogenase, and indirect bilirubin levels due to ineffective erythropoiesis are seen. The Shilling test is used for additional information in the diagnosis. Treatment consists of removing the underlying cause of vitamin B12 deficiency. Vitamin replacement therapy can be used. Iron deficiency, which coexists in up to one-third of patients, should be ruled out. The recommended daily allowance is 2 µg. Vitamin B12 is usually used slowly and, unless there is absence of the vitamin for months, there are sufficient stores to prevent deficiency. A strict vegetarian diet avoids the consumption of meat, dairy products, seafood, and poultry (including eggs). Unfortunately, vegetarians often lack adequate vitamin B12; physicians should look for deficiencies in this population. Meat substitutes, enriched yeast, and soybean milk are alternative sources for vitamin B12.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:2404.
Ferri F. Ferri's Clinical Advisor, Instant Diagnosis and Treatment. Philadelphia: Elsevier/Mosby, 2006:57.
83. Which of the following is NOT considered a risk factor for myocardial infarction?
A) Alcoholism
B) Homocystinemia
C) Type A personality
D) Male sex
E) Obesity
Answer and Discussion
The answer is A. Risk factors for myocardial infarction include
· Hypertension
· Hyperlipidemia—particularly high total cholesterol, high LDL cholesterol, and low HDL cholesterol
· Cigarette smoking
· Diabetes mellitus
· Obesity (increased weight for height)
· Male gender
· Family history of coronary artery disease (CAD)
· Sedentary lifestyle
· Type A personality
· Increased age
· Postmenopausal
· Homocystinemia
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:1430–1433.
84. A 55-year-old business executive presents to your office complaining of a 4-week history of daily headaches. He describes the headache as being pronounced in the morning on awakening, associated with nausea and vomiting. The most likely diagnosis is
A) classic migraine headache
B) cluster headache
C) brain tumor
D) sinus headache
E) muscle tension headache
Answer and Discussion
The answer is C. There are several types of headache associated with specific clinical histories. The following are some common types and their distinguishing features:
· Migraine headaches. These usually affect young women (but can affect men) and are pulsating and unilateral in location. They occur infrequently, are throbbing, and are associated with photophobia (in some cases an aura preceding the headache), nausea, and vomiting; sleep usually provides relief. They typically last 4 to 72 hours.
· Headaches associated with tumors. Pain occurs daily, becomes more frequent and severe as time passes, and may be associated with focal neurologic deficits or visual disturbances. Patients may report pain more in the morning on awakening, nausea, vomiting, or the pain may be worse with bending over.
· Headaches associated with sinus headaches. These are usually associated with facial pain or pressure in the sinus area, fever, and purulent sinus drainage.
· Muscle-tension headaches. These are associated with a bandlike tightness that encircles the scalp area, usually occurring on a daily basis and usually worse at the end of a workday.
· Cluster headaches. More common in middle-age men, these headaches are usually described as a unilateral, sharp (i.e., “feels like an ice pick”), agonizing pain located in the orbital area, in many cases occurring 2 to 3 hours after the patient falls asleep; they are associated with tearing, nasal congestion, rhinorrhea, and autonomic symptoms on the same side as the headaches. Frequency of attacks ranges from one to eight daily.
Ferri F. Ferri's Clinical Advisor, Instant Diagnosis and Treatment. Philadelphia: Elsevier/Mosby; 2006:358–361.
85. Which of the following statements about sickle cell anemia is true?
A) The disease is a sex-linked, recessive, inherited disorder.
B) The condition is related to a defective β chain with sickling under conditions of low CO2.
C) Hydroxyurea is contraindicated for patients with sickle cell anemia.
D) Patients with sickle cell should receive pneumococcal vaccination.
E) Individuals with sickle cell should avoid influenza vaccination.
Answer and Discussion
The answer is D. Sickle cell anemia is an autosomal-dominant inherited hemolytic anemia that predominantly affects African Americans (approximately 8% of the African-American population). Because of a defective β chain (valine is substituted for a glutamic acid in the sixth position of the β chain), blood cells tend to sickle under conditions of low PO2. The condition is manifested in a milder heterozygote form (referred to as sickle cell trait) and in the more severe homozygote form. Signs and symptoms include anemia, jaundice, arthralgias, fever, painful aplastic crises that are characterized by severe abdominal and joint pain, poor-healing ulcers associated with the pretibial area, nausea, vomiting, hemiplegia, and cranial nerve palsies. Other manifestations include pulmonary and renal dysfunction, cardiomegaly, hepatosplenomegaly, cholelithiasis, and aseptic necrosis of the femoral heads. Heterozygous individuals are usually unaffected by these complications. Laboratory findings include normocytic, normochromic anemia with a peripheral smear showing sickled red cells with Howell–Jolly bodies and target cells; leukocytosis with a left shift; thrombocytosis; elevated bilirubin levels; and elevated urinary and fecal urobilinogen. ESRs are usually normal. Diagnosis is usually made by Hb electrophoresis demonstrating HbS chains. Heterozygous individuals usually show HbA and HbS chains. Treatment is symptomatic and may include transfusions in severe cases, hydration, pain control, and possible corticosteroids. More recently, hydroxyurea has been used in the treatment of sickle cell anemia. Most crises are precipitated by infections, and treatment should provide coverage for these infections. Because of splenic dysfunction, those affected are at an increased risk for bacterial infections, particularly pneumococcal and Salmonella infections; therefore, they should receive the pneumococcal (Pneumovax) vaccine. Genetic counseling should also be instituted for those affected. Life spans may be shortened for those affected but have been increasing.
Steinberg MH, Barton F, Castro O. Effect of hydroxyurea on mortality and morbidity in adult sickle cell anemia. Risks and benefits up to 9 years of treatment. JAMA. 2003; 289:1645–1651.
Ferri F. Ferri's Clinical Advisor, Instant Diagnosis and Treatment. Philadelphia: Elsevier/Mosby; 2006:779–780.
86. Which of the following statements about hereditary angioedema is true?
A) It is related to excessive amyloid deposition.
B) It is caused by a deficiency of the C1 esterase inhibitor.
C) Attacks are triggered by antihistamines.
D) Treatment involves dehydroepiandrosterone (DHEA) administration.
Answer and Discussion
The answer is B. Hereditary angioedema is an autosomal-dominant transmitted genetic disorder that is related to a deficiency of C1 esterase inhibitor or, less commonly, to inactive C1 esterase inhibitor that is involved in the first step of complement activation. Symptoms include pruritus; urticarial rashes; abdominal pain; and, in severe cases, bronchoconstriction, which can be life threatening. Attacks are usually triggered by stress, trauma, or illnesses. Diagnosis is made by detection of low C4 levels or deficiency of the C1 esterase inhibitor by immunoassay. Treatment involves the use of antihistamines, glucocorticoids, and epinephrine (in severe cases). Fresh frozen plasma given before procedures can be used for short-term prophylaxis. Other medications used to prevent attacks include the androgens: methyltestosterone, danazol, and stanozolol. In addition, the C1 esterase inhibitor concentrate may be given directly in life-threatening cases.
Ferri F. Ferri's Clinical Advisor, Instant Diagnosis and Treatment. Philadelphia: Elsevier/Mosby; 2006:65–66.
87. Which of the following statements best describes astereognosis?
A) Loss of the ability to carry out movements in the absence of paralysis or sensory deficits.
B) Inability to recognize smells.
C) Loss of the ability to express oneself by speech.
D) Loss of the ability to recognize objects by touch.
E) Loss of ocular coordination.
Answer and Discussion
The answer is D. Astereognosis is the loss of the ability to recognize objects by the sense of touch. The loss of the ability to carry out movements in the absence of paralysis or sensory deficits is called apraxia. Inability to recognize sensory stimuli is called agnosia; subgroups include auditory, visual, olfactory, gustatory, and tactile agnosias. The loss of the ability to express oneself by speech or written language is called aphasia.
Wiebers DO, Dale AJD, Kokmen E, et al., eds. Mayo Clinic examinations in neurology. New York: Mosby; 1998:44, 52, 54, 80–81.
88. Which of the following lung cancers is most commonly associated with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH)?
A) Squamous cell carcinoma
B) Small-cell (oat-cell) carcinoma
C) Large-cell carcinoma
D) Adenocarcinoma
E) Mesothelioma
Answer and Discussion
The answer is B. Lung cancer is often associated with a paraneoplastic syndrome, which occurs as a result of cancer and is extrapulmonary. The following are some common neoplastic syndromes:
· Squamous cell: hypercalcemia
· Small cell: Cushing's syndrome, SIADH with hyponatremia, myasthenic syndrome, Eaton–Lambert syndrome, peripheral neuropathy, subacute cerebellar degeneration
· Large cell: gynecomastia
· Adenocarcinoma: clubbing, thrombophlebitis, marantic endocarditis, periostitis, or hypertrophic osteoarthropathy
In addition, all of the previously mentioned lung cancers may be associated with dermatomyositis, disseminated intravascular coagulation, eosinophilia, thrombocytosis, and acanthosis nigricans.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1150–1153.
89. The best medication to use in the emergent treatment of supraventricular tachycardia is
A) digoxin
B) verapamil
C) adenosine
D) diltiazem
E) isoproterenol
Answer and Discussion
The answer is C. Treatments for stable patients with supraventricular tachycardia (also referred to as regular narrow QRS tachycardias) include vagal maneuvers such as Valsalva maneuvers; coughing; activation of gag reflex; carotid sinus massage; and placing an ice bag to the face or swallowing ice-cold water, which can be extremely effective. Unilateral carotid sinus massage, one of the more common methods used, should be given at the angle of the jaw on one side for 3 to 5 seconds. Patients with a history of carotid artery disease are at increased risk for the dislodgment of plaque, which may lead to stroke. Adenosine (Adenocard) and verapamil (Isoptin) administered intravenously are also effective if the previously mentioned measures fail to succeed. Adenosine is preferred because of its rapid onset of action and short half-life. For unstable patients, low-energy electrical cardioversion is the treatment of choice. Most patients troubled by this arrhythmia are candidates for radiofrequency ablation.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:700–702.
Adenosine is the preferred treatment of supraventricular tachycardia (SVT) because of its rapid onset of action and short half-life.
90. Which of the following effects distinguishes aspirin from acetaminophen?
A) Analgesic properties
B) Antipyretic properties
C) Anti-inflammatory properties
D) Amnestic properties
E) Antipruritic properties
Answer and Discussion
The answer is C. Aspirin (acetylsalicylic acid) is the drug of choice for mild-to-moderate pain. It has antipyretic and anti-inflammatory properties (unlike acetaminophen, which has no anti-inflammatory properties). The major side effect is gastric irritation, which can be reduced by using an enteric-coated aspirin and taking the medication with meals. Tinnitus has also been associated with chronic aspirin use. Aspirin's mode of action is accomplished by the inhibition of prostaglandin synthesis by permanently acetylating cyclooxygenase. Because platelet function is irreversibly inhibited, bleeding times are prolonged as much as 1 to 2 weeks. Aspirin can evoke an anaphylactic response in some individuals, especially in those with a history of asthma and nasal polyps, and, thus, should be avoided. Aspirin use should also be avoided in children and teenagers with viral febrile illnesses (e.g., chickenpox, infectious mononucleosis, viral influenza) because of the risk of Reye's syndrome. Some studies have suggested aspirin use may help prevent adenomatous colon polyp development or regression. Also, prophylactic aspirin use has been advocated to help prevent myocardial infarction and stroke.
Rakel RE, Bope ET. Conn's Current Therapy 2005. Philadelphia: Elsevier/Saunders; 2005:30–31, 402, 406.
91. A 56-year-old man presents to your office with complaints of “chronic” diarrhea. He states that he has had loose stools for the last 2 days. He denies blood in the stool, fever, and has no weight loss and no recent travel. Appropriate management at this time includes
A) observation
B) check stool cultures
C) colonoscopy
D) stool fat studies
Answer and Discussion
The answer is A. Chronic diarrhea is a common and sometimes difficult problem encountered by physicians and patients. The condition is defined as diarrhea that continues for >4 weeks. The problem occurs in 1% to 5% of the population. Patients often present late in their course, after other symptoms such as weight loss, rectal bleeding, and abdominal pain have developed. Diarrhea results from incomplete absorption of water from the bowel lumen because of a reduced rate of water absorption or osmotically induced luminal retention of water. Even mild changes in absorption can cause loose stools. The three available management strategies are test and treat; categorize, test, and treat; and empiric therapy. The “test and treat” plan is useful when the history and physical examination yield a high probability of a specific diagnosis. When the evaluation is less clear, it is impractical to test for every possible etiology. A “categorize, test, and treat” plan is useful because the presentation often is nonspecific. Diarrhea can be categorized as watery, fatty, or inflammatory based on gross stool or microscopic examination. Once the diarrhea is categorized, further testing becomes more specific. An “empiric therapy” plan avoids determining a diagnosis and simply treats the symptoms. This is a reasonable approach, assuming serious causes for the diarrhea have been excluded. Patients must be monitored closely when this plan is followed.
Schiller LR. Chronic diarrhea. Gastroenterology. 2004;127:287–293.
92. A 20-year-old otherwise healthy woman presents with cloudy urine, burning on urination, and urinary frequency. The patient has no allergies. Physical examination shows the patient is afebrile. She has mild suprapubic pain with palpation but no costovertebral angle tenderness. Urinalysis is positive for nitrites and leukocyte esterase. Which of the following is the most appropriate treatment?
A) Hospitalize the patient and administer intravenous antibiotics.
B) Administer macrolide-containing antibiotics on an outpatient basis.
C) Administer sulfa-containing antibiotics plus phenazopyridine (Pyridium) on an outpatient basis.
D) Advise the patient to increase fluid intake, especially with cranberry juice.
E) Arrange for an intravenous pyelogram.
Answer and Discussion
The answer is C. Urinary tract infections are more common in sexually active women. Symptoms include dysuria, urinary frequency, enuresis, incontinence, suprapubic tenderness, flank pain, or costovertebral angle tenderness (which usually indicates pyelonephritis). Gram-negative bacteria that originate from the intestinal tract (i.e., Escherichia coli, Staphylococcus saprophyticus, Klebsiella, Enterobacter, Proteus, Pseudomonas) are usually the causative organisms. Diagnosis is accomplished by microscopic or dipstick evaluation of a clean-catch midstream urine sample. Urine culture confirms the diagnosis. Treatment is oral (and in most cases sulfa-containing) antibiotics. With no complicating clinical factors, reasonable empiric treatment for presumed cystitis before organism identification is a 3-day regimen of any of the following: oral TMP-SMX, TMP, norfloxacin, ciprofloxacin, ofloxacin, lomefloxacin, or enoxacin. With complicating factors of diabetes, symptoms for more than 7 days, recent urinary tract infection, use of diaphragm, and postmenopausal women, a 7-day regimen can be considered using the same antibiotics. Phenazopyridine hydrochloride (Pyridium) may be necessary for 1 to 3 days if significant dysuria is present. Affected patients should also be encouraged to increase their fluid intake.
Mehnert-Kay SA. Diagnosis and management of uncomplicated urinary tract infections. Am Fam Physician. 2005;72:451–456, 458.
93. Treatment of severely infected diabetic foot ulcers should involve
A) topical antibiotics
B) débridement only
C) débridement with systemic antibiotics
D) débridement with topical antibiotics
E) none of the above
Answer and Discussion
The answer is C. Diabetic foot ulcers usually result from large vessel disease, microvascular disease, neuropathies, or a combination of all three. Ulcers associated with large vessel disease tend to affect the distal tips of the toes, whereas those secondary to neuropathy typically occur on the weight-bearing surfaces. Smoking and heavy alcohol abuse can increase the risk of diabetic ulcers. Prevention is the key to treatment. All diabetic patients should be instructed about foot care, and their feet should be examined regularly. Organisms that typically infect diabetic ulcers includeStaphylococcus, Streptococcus, anaerobes, and gram-negative organisms. Severe infections may involve methicillin-resistant Staphylococcus aureus and Pseudomonas infections. Cultures should be taken from the débrided ulcer base or from purulent drainage. Oral antibiotics may be adequate for mild infections. However, if the infection is severe, débridement and systemic antibiotics are usually necessary. Topical antibiotics provide little help in the treatment of such infections.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:2169.
94. A 13-year-old boy with asthma complains of shortness of breath and wheezing during physical education class. Otherwise the child has no symptoms. The most appropriate treatment is
A) oral steroid therapy
B) inhaled steroids before exercise
C) inhaled β agonist before exercise
D) long-acting β agonist
E) anxiolytic medication
Answer and Discussion
The answer is C. Exercise-induced asthma occurs mainly in patients already diagnosed with asthma. Wheezing usually begins shortly after the initiation of exercise and can be debilitating and limit participation. Use of β2-agonist inhalers before exercise is one of the most beneficial preventive measures for wheezing. Other preventive measures include a slow warm-up and the avoidance of very warm and very cold conditions. Many professional and Olympic athletes are affected with exercise-induced asthma but are able to compete with little or no problem.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:1511.
95. A 30-year-old man with human immunodeficiency virus (HIV) infection and a CD4 count of 150/mm3 should
A) start antiviral medication
B) have additional follow-up tests in 1 month
C) have additional follow-up tests in 3 months
D) have additional follow-up tests in 6 months
E) have tests repeated in 1 year
Answer and Discussion
The answer is A. The CD4 count is a marker for T-helper cells and is used in the treatment of HIV. Once the patient has been diagnosed with HIV, the CD4 count should be measured and followed. Typically, there is a diurnal variation in the CD4 count; therefore, it should be measured at the same time with each determination. Plasma viral load (PVL) is also used to determine treatment in HIV. The major guidelines vary slightly in the PVL and CD4+ cell cutoff values that are used for recommendations on starting, considering, or deferring antiretroviral drug therapy (ART). ART is recommended for all patients with a history of AIDS-defining illness or severe symptoms of HIV infection regardless of CD4 cell count. ART is also recommended for asymptomatic patients with a CD4 count <200 cells/µL. Therapy should be offered to asymptomatic patients with CD4 cell counts of 201 to 350 cells/µL. The urgency of treatment recommendations may be based on various factors, including
· Rate of CD4 cell decline
· Plasma HIV RNA >100,000 copies/mL
· Patient interest
· Risk of toxicity
Therapy should probably be deferred for asymptomatic patients with CD4 cell counts of >350 cells/µL and plasma HIV RNA <100,000 copies/mL.
The question of when to initiate ART in asymptomatic patients remains an area of research and debate. It is clear that ART should be initiated before the CD4 count declines to <200 cells/µL, if at all possible. However, it is not yet known at what CD4 threshold >200 cells/µL, therapy should be started, as the long-term risks of ARVs may be substantial in some patients. With the increasing availability of ARV regimens that are more tolerable, are composed of fewer pills, and have easier dosing schedules, some clinicians are choosing to initiate therapy earlier in the course of HIV infection. CD4+ cell counts and HIV RNA levels are important tools for evaluating treatment response. A minimum of two CD4+ cell counts and PVL measurements should be obtained on separate visits before treatment is changed. Ideally, the HIV RNA level should decline rapidly after antiretroviral drug therapy is initiated. Guidelines on the expected PVL reductions vary. A typical goal is a 1- to 2-log reduction within 4 to 8 weeks (e.g., from 50,000 copies/mL to 500 copies/mL). Failure to achieve the target level of <50 copies/mL after 16 to 24 weeks of treatment should prompt consideration of drug resistance, inadequate drug absorption, or poor compliance. Maximal viral suppression often takes longer in patients with higher baseline HIV RNA levels (e.g., >100,000 copies/mL). HIV RNA levels should be obtained periodically during antiretroviral drug therapy, although precise data are not available on the optimal frequency of such monitoring.
Data from HIV/AIDS Treatment Information Service website. Guidelines for the use of antiretroviral agents in HIV-infected adults and adolescents. Available at: http://www.hivatis.org. Accessed 6/5/06.
96. Which of the following factors is associated with dysplastic nevi syndrome?
A) No genetically related transmission.
B) Scattered moles with benign appearance.
C) Increased risk for malignant transformation.
D) The number of lesions noted at birth remains the same over time.
E) Excessive vitamin A ingestion.
Answer and Discussion
The answer is C. Dysplastic nevi syndrome is a condition that is inherited as an autosomal-dominant disease. Usually more than two family members are affected; however, sporadic cases do occur. Patients are affected with numerous (in some cases >100) irregular, large moles. These moles are abnormal in appearance and show variegation of color. The moles more commonly occur on covered areas such as the breast, buttocks, and scalp. Unlike common moles, dysplastic nevi continue to appear as the patient ages. These patients are at increased risk for the development of melanoma. Patients should be counseled to avoid sun exposure, and any suspicious lesion or change in nevi should warrant a biopsy. Photographs of the patients can help determine if there are any changes in nevi.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:498–500.
97. The proportion of patients with a disease in whom a test result is positive is referred to as
A) the p value
B) sensitivity
C) specificity
D) reliability
E) variability
Answer and Discussion
The answer is B. Sensitivity is defined as the proportion of people who are affected by a given disease and who also test positive for that disease. For example, the proportion of patients who actually have coronary artery disease (CAD) and also test positive with a treadmill exercise test would be defined as the sensitivity. Typically, the sensitivity for treadmill exercise testing is 72% to 96%.
Mark DB. Chapter 2: Decision-making in clinical medicine. Available at Harrison's Online website (http://www.harrisonsonline.com). Accessed 6/5/06.
Sensitivity is defined as the proportion of people who are affected by a given disease and who also test positive for that disease.
98. An intensely pruritic, vesicular rash that is localized to the upper extremity is most likely
A) herpes zoster
B) poison ivy
C) Staphylococcus infection
D) atopic dermatitis
E) varicella
Answer and Discussion
The answer is B. Exposure to poison ivy, poison oak, or poison sumac can cause an intensely pruritic vesicular rash. The patient often recalls an exposure to the plants within 24 to 48 hours, and the extremities are often affected. The condition is a result of a delayed hypersensitivity reaction that may take several days to appear. Management should include thorough washing with soap and water, preferably within 10 minutes of exposure, as this may prevent dermatitis. All contaminated clothes should be removed as soon as possible and cleaned. Frequent baths using colloidal oatmeal also relieve symptoms. Treatment of mild to moderate rash includes application of cool compresses or diluted aluminum acetate solution such as Burow's solution or calamine lotion. Use of topical antihistamines and anesthetics should be avoided because of the possibility of increased sensitization. Early application of topical steroids is useful to limit erythema and pruritus. However, occlusive dressings should be avoided on moist lesions. Refractory dermatitis can be treated with oral corticosteroids such as prednisone, with an initial dosage of 1 mg/kg/day, slowly tapering the dosage over 2 to 3 weeks. Shorter courses of steroids may be followed by severe rebound exacerbations shortly after drug therapy is discontinued. Oral antihistamines may help reduce pruritus and provide sedation, when needed.
Lee NP, Arriola ER. Poison ivy, oak, and sumac dermatitis. West J Med. 1999;171:354–355.
99. The presence of polymorphonuclear cells in stool samples most likely supports the diagnosis of a
A) bacterial infection
B) viral infection
C) parasitic infection
D) fungal infection
Answer and Discussion
The answer is A. Acute diarrhea is defined as stools occurring with increased frequency or decreased consistency. There are many different organisms. Bacterial agents include E. coli, Salmonella, Shigella, Campylobacter, Clostridium, Yersinia, and Vibrio cholera. Viral agents include rotavirus, enterovirus, and Norwalk agent. Parasitic infections include Giardia lamblia, Entamoeba histolytica, Cryptosporidium, and Strongyloides. Fungal agents include Candida, Histoplasma, and Actinomyces. Diagnosis is accomplished with stool culture and sensitivity studies; however, the presence of polymorphonuclear cells supports a bacterial cause. In most cases of acute diarrhea, the use of antibiotics is unnecessary; however, the empiric use of antibiotics, including TMP-SMX, ciprofloxacin, or erythromycin, may be appropriate (although controversial) in severe cases in which stool cultures are pending, especially for those at risk for transmitting the offending organism to others.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:77–80.
100. Café-au-lait spots are associated with which of the following disorders?
A) Peutz–Jeghers syndrome
B) Neurofibromatosis
C) Dysplastic nevus syndrome
D) Addison's disease
Answer and Discussion
The answer is B. The following are skin abnormalities noted in patients affected with the following disease processes:
|
Neurofibromatosis (von Recklinghausen's disease) |
Café-au-lait spots |
|
Peutz–Jeghers syndrome |
Hyperpigmentation around the oral cavity, hamartomas of the intestine |
|
Dysplastic nevus syndrome |
Multiple pigmented nevi |
|
Hypoadrenocorticism (Addison's disease) |
Hyperpigmentation of the gin giva, areola of the nipples, labia, and linea alba of the abdomen |
Fitzpatrick TB, Johnson RA, Polano MK, et al., eds. Color atlas and synopsis of clinical dermatology, common and serious diseases, 2nd ed. New York: McGraw-Hill; 1994:448–492.
101. Which of the following tests is most helpful in distinguishing fever of unknown origin (FUO) from factitious fever?
A) Urinalysis
B) Chest x-ray
C) Rheumatoid factor
D) Blood cultures
E) Sedimentation rate
Answer and Discussion
The answer is E. FUO is defined as a fever higher than 101°F (38.3°C) on at least three occasions, accompanied by an illness that lasts longer than 3 weeks, and the diagnosis is uncertain after 3 days of hospitalization, although most workups are now done in the outpatient setting. Causes include infection, neoplasm, drugs, collagen vascular disease, vasculitis, and factious fever. Laboratory tests include CBC, urinalysis with culture, blood cultures, chest radiography, HIV testing, serum protein electrophoresis, sedimentation rate, serology tests, ANA, rheumatoid factor, and thyroid tests. The ESR may be helpful in distinguishing real disease from a factious fever. A good history and physical examination are imperative in the evaluation of a patient with FUO and helps direct further testing. Observing the temperature pattern can be helpful. Disease states such as malaria, babesiosis, Hodgkin's disease, and cyclic neutropenia have patterns, whereas factitious fever often has no pattern.
Ferri F. Ferri's Clinical Advisor, Instant Diagnosis and Treatment. Philadelphia: Elsevier/Mosby; 2006:318.
102. Which of the following test results supports the diagnosis of Graves' disease?
A) Decreased thyroid-stimulating hormone (TSH)
B) Increased TSH
C) Decreased thyroxine (T4) levels
D) Decreased triiodothyronine (T3) levels
E) None of the above
Answer and Discussion
The answer is A. Graves' disease is the most common form of hyperthyroidism seen predominantly in women between 20 and 40 years of age. The condition, also known as toxic diffuse goiter, is characterized by a triad of symptoms, including goiter, exophthalmos, and pretibial edema. Patients affected may report palpitations, tachycardia, heat intolerance with excessive sweating, weight loss, emotional lability, weakness and fatigue, diarrhea, or menstrual irregularities. Laboratory findings include a decreased sensitive TSH (sTSH) and positive thyroid-stimulating antibodies (which are thought to bind to the TSH receptors and stimulate the gland to hyperfunction). T4 levels are usually elevated, but in rare cases may be normal with increased T3 levels. Treatment involves the use of propylthiouracil or methimazole, inorganic iodine, propranolol (especially in thyroid storm), radioactive iodine (but not in pregnant patients), and surgery.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1195–1200.
103. A 45-year-old man is seen in your clinic. The patient has known cirrhosis, diabetes, and complains of multiple joint pain. Examination shows a bronze discoloration of the skin and testicular atrophy. Laboratory values show a serum iron of 500 µg/dL, serum ferritin of 2,000 ng/mL, and a transferrin saturation of 80%. The most likely diagnosis is
A) alcoholism
B) hemochromatosis
C) Wilson's disease
D) Gilbert's disease
E) Hepatitis C
Answer and Discussion
The answer is B. Hemochromatosis is a result of excessive iron deposition in the body (hemosiderosis) that leads to damage of bodily tissues. Primary hereditary hemochromatosis is an autosomal-recessive trait that is associated with defects on chromosome 6. It is the most common form of hemochromatosis, affecting approximately 5 in 1,000 persons. Complications include
· Cirrhosis
· Diabetes mellitus
· Multiple joint pain
· Abdominal pain
· Chondrocalcinosis
· Bronze discoloration of the skin
· Cardiomyopathy that may result in cardiac enlargement, CHF, and cardiac arrhythmias
· Hepatomas
· Pituitary dysfunction leading to testicular atrophy and decreased sexual drive
The onset is usually in the fourth and fifth decades of life. The condition is rare before middle age. Diagnosis in women usually occurs after menopause, because menstrual blood loss helps provide protection from iron overload. Laboratory findings show serum iron >300 mg/dL, serum ferritin >1,000 ng/mL, and transferrin saturation >50%. Liver biopsy confirms the diagnosis when hepatic siderosis and cirrhosis is suspected. Treatment involves phlebotomy (500 mL/week = 200 to 250 mg iron) to remove excess iron from the body and the chelating agent deferoxamine in severe cases, which promotes urinary excretion of iron. Family members of those affected should be screened for hemochromatosis with HLA typing and iron studies.
Brandhagen DJ, Fairbanks VF, Baldus W. Recognition and management of hereditary hemochromatosis. Am Fam Physician. 2002;65:853–860, 865–866.
104. Acromegaly is associated with which of the following factors?
A) Excessive cortisol secretion
B) Lack of adequate parathyroid hormone
C) Excessive growth hormone
D) Thyroid dysfunction
E) Excessive gastrin secretion
Answer and Discussion
The answer is C. The condition of acromegaly is associated with an excessive amount of growth hormone, which in most cases is caused by a pituitary tumor. If there is excessive growth hormone secretion before closure of the epiphyses during childhood, then the condition of excessive skeletal growth is referred to as gigantism. When excessive growth hormone occurs in adulthood, it is usually between the third and fifth decades and is referred to as acromegaly. Associated conditions include coarsening of facial features with increased hand, foot, jaw, and cranial size; macroglossia; wide spacing of the teeth; deep voice; excessive coarse hair growth; thickening of the skin; excessive sweating as a result of increased number of sweat glands; and neurologic symptoms, including headaches, peripheral neuropathies, muscle weakness, and arthralgias. Insulin resistance is common; diabetes occurs in 25% of patients. CAD, cardiomyopathy with arrhythmias, left ventricular dysfunction, and hypertension occur in 30% of patients. Sleep apnea occurs in 60%. Acromegaly is also associated with an increased risk of colon polyps and colonic malignancy. The diagnosis is made by detecting elevated levels of growth hormone after the administration of a 100-g glucose load. Because of the pulsatility of growth hormone secretion, a single random growth hormone level is not useful. Further diagnostic tests include MRI and CT scanning. Treatment is usually surgery; however, radiation is considered in some patients to treat pituitary tumors. Bromocriptine and a long-acting somatostatin analog (e.g., octreotide acetate) may also be used as adjuncts to surgery to help shrink the tumor.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:2090.
105. Which of the following signs is associated with Achilles tendonitis?
A) Hyperpronation
B) Gynecoid pelvis
C) Increased Q angle
D) Lateral collateral ligament instability
Answer and Discussion
The answer is A. Achilles tendonitis occurs with repeated stress to the Achilles tendon. Precipitating factors include brisk walking, running, jumping, or hiking. Although known as Achilles tendonitis, it is usually the tissue surrounding the tendon that is responsible for the inflammation and pain. Persons who exercise or compete in low-heel shoes and those who hyperpronate their feet are at increased risk for Achilles tendonitis. Patients report pain in the heel and leg discomfort when the Achilles tendon is used. Physical findings include pain with palpation over the Achilles tendon approximately 3 cm above the insertion site on the calcaneus. Treatment goals are to decrease the inflammation associated with the inflamed structures and to reduce the stress on the Achilles tendon. Treatment includes NSAIDs, 1/2-in. heel lifts, and strengthening and stretching exercises of the gastrocnemius and soleus muscles. For patients with hyperpronation, a soft navicular pad and 1/8-in. medial wedge may help prevent excessive pronation.
Mazzone MF, McCue T. Common conditions of the Achilles tendon. Am Fam Physician. 2002;65:1805–1810.
106. Which of the following statements about systolic hypertension is true?
A) It represents relatively little risk to the patient.
B) It is defined as a systolic pressure >140 mm Hg with a diastolic pressure >100 mm Hg.
C) It does not increase the risk of stroke.
D) It is often caused by mitral regurgitation.
E) It is more dangerous to elderly patients than an elevated diastolic pressure.
Answer and Discussion
The answer is E. Systolic hypertension is a condition that usually affects the elderly. The condition is defined as a systolic blood pressure >140 mm Hg and diastolic pressure <90 mm Hg. The cause is the loss of elasticity of the arteries that occurs with aging. Other causes include thyrotoxicosis, arteriovenous fistulas, or aortic regurgitation. Untreated systolic hypertension can lead to an increased risk for stroke and cardiovascular disease. Data from the Framingham study and the Multiple Risk Factor Intervention Trial indicated the importance of isolated systolic hypertension in the development of coronary heart disease (CHD). These trials concluded that elevated systolic blood pressure in the elderly was probably of more significance than elevated diastolic blood pressure. In other words, a systolic blood pressure of 160 mm Hg with a diastolic blood pressure of 85 mm Hg posed a greater risk for cardiovascular disease than a systolic blood pressure of 135 to 140 mm Hg and a diastolic blood pressure of 95 mm Hg. Isolated systolic hypertension, defined as a blood pressure of >140 mm Hg systolic and <90 mm Hg diastolic, occurs in more than 30% of women older than 65 years and in more than 20% of men of the same age. Treatment involves lifestyle changes (e.g., exercise, sodium restriction, weight loss) and the use of hypertensive medications. In most instances, low-dose diuretic therapy should be used as initial antihypertensive therapy in the elderly. A long-acting dihydropyridine calcium channel blocker may be used as alternative therapy in elderly patients with isolated systolic hypertension. Diabetics benefit from ACE inhibitors. In some cases, systolic hypertension may be more difficult to control than essential hypertension.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:1468.
107. Which of the following statements is true regarding pneumococcal (Pneumovax) vaccination?
A) Healthy individuals older than 50 years should receive the vaccine.
B) Medicare does not cover the cost of pneumococcal (Pneumovax) vaccination.
C) Adults with previous splenectomy should not receive pneumococcal (Pneumovax) vaccination.
D) Children younger than 2 years with sickle cell anemia should receive pneumococcal (Pneumovax) vaccination.
E) Boosters are recommended for individuals older than 65 years if they received their first dose more than 5 years prior to their last injection.
Answer and Discussion
The answer is E. The pneumococcal (Pneumovax) vaccine is made from the polysaccharides of 23 different strains of bacterial pneumonia. The vaccine is recommended for patients older than 65 years, individuals with underlying pulmonary disease or chronic debilitating diseases (e.g., diabetes, liver and renal disease, cardiac disease, lymphoma, transplant patients, HIV patients), and those without a spleen. The vaccine is given intramuscularly or subcutaneously and is not recommended during an acute illness. Antigenic response occurs 2 to 3 weeks after vaccination. Adverse reactions include local irritation or soreness, erythema, induration, low-grade fever, rash, myalgia, and arthralgia; in severe reactions (less than 1%), anaphylaxis or nerve disorders may occur. Children younger than 2 years should not receive the vaccine. Since 1981, Medicare has covered the cost of pneumococcal vaccine (Pneumovax). One-time boosters are recommended for individuals older than 65 years if they received their first dose more than 5 years prior. Other individuals at high risk who received pneumococcal vaccination more than 5 to 10 years prior may require boosters. The vaccine has been determined to be cost-effective for all ages.
Centers for Disease Control and Prevention website. Summary of adolescent/adult immunization recommendations. Available at: http://www.cdc.gov/nip/recs/adult-schedule.pdf. Accessed 6/5/06.
108. Cigarette smoking is associated with increased risk of all of the following EXCEPT:
A) bladder cancer
B) osteoporosis
C) peptic ulcer disease
D) Alzheimer's disease
E) cervical cancer
Answer and Discussion
The answer is D. Cigarette smoking is a severe health-related problem throughout the world. Smokers typically live 5 to 8 years less than nonsmokers. They have an increased risk of cancer of the lung, mouth, throat, esophagus, pancreas, kidney, bladder, and cervix. In addition, they are at increased risk for the development of peptic ulcer disease and osteoporosis. Furthermore, they have an increased risk of heart diseases and chronic lung disease. Mothers who smoke during their pregnancy typically have smaller babies. All patients who smoke should be encouraged to stop. The physician should always ask about smoking; if the patient does smoke, there should be an attempt by the physician to motivate the patient to stop. Setting a stop date may be helpful, and follow-up is necessary to provide support and reinforce the patient's commitment to stop. Nicotine-containing patches and gum can also be used to wean people from their nicotine dependence. Bupropion (Zyban) also has been used to help relieve nicotine withdrawal. Bupropion hydrochloride, also marketed as an antidepressant, has been reintroduced in a sustained-release formulation to be used as a smoking cessation aid. Bupropion potentiates the effects of norepinephrine and dopamine. Dopamine has been associated with the rewarding effects of addictive substances. It is postulated that inhibition of norepinephrine reuptake might lead to a decrease in withdrawal symptoms. Bupropion does not have a sedating effect, although agitation and insomnia have been commonly reported in patients taking the drug for depression. It is not frequently associated with sexual dysfunction, weight gain, or anticholinergic effects. Tremor, rash, and a few anaphylactoid reactions have been reported. Panic symptoms and psychotic reactions have been reported in patients taking bupropion and fluoxetine concurrently. Bupropion is contraindicated in patients taking monoamine oxidase inhibitors or ritonavir. Carbamazepine increases the metabolism and decreases the antidepressant effect of bupropion. The recommended dosage in patients attempting smoking cessation is 150 mg once daily for 3 days and then twice daily for 7 to 12 weeks or longer. This regimen may be accompanied by nicotine replacement therapy. Patients are advised to stop smoking during the second week of treatment. The manufacturer offers a counseling and support service.
Medical Letter Consultants. Bupropion (Zyban) for smoking cessation. Med Lett Drugs Ther. 1997;39(1007);77–78.
Bupropion hydrochloride, also marketed as an antidepressant, has been reintroduced in a sustained-release formulation to be used as a smoking cessation aid.
109. A 45-year-old female presents with persistent nasal symptoms for the last 6 weeks. She has been treated with an extended course of antibiotics but despite therapy her symptoms remain. She is afebrile and otherwise looks well. Appropriate management at this time includes
A) additional 2-week course of antibiotic therapy
B) plain films of the sinuses
C) CT scan of the sinuses
D) MRI of the sinuses
E) laboratory evaluation including a CBC and blood cultures
Answer and Discussion
The answer is C. Rhinosinusitis is typically divided among four subtypes: acute, recurrent acute, subacute, and chronic, based on patient history and a limited physical examination. In most cases, therapy is administered based on this classification. Antibiotic therapy along with hydration and decongestants is indicated for 7 to 14 days in patients with acute, recurrent acute, or subacute bacterial rhinosinusitis. For patients with chronic disease, the same treatment regimen is indicated for an additional 4 weeks or more, and a nasal steroid may also be prescribed if inhalant allergies are suspected as an etiologic agent. Nasal endoscopy and computed tomography of the sinuses are reserved for circumstances that include a failure to respond to therapy as expected, spread of infection outside the sinuses, a question of diagnosis, and when surgery is being considered. Laboratory tests are rarely needed and are reserved for patients with suspected allergies, cystic fibrosis, immune deficiencies, mucociliary disorders, and similar disease states. Findings on endoscopically guided culture obtained from the middle meatus correlate 80% to 85% of the time with results from the more painful antral puncture technique, and is performed in patients who fail to respond to the initial antibiotic selection. Surgery is indicated for extranasal spread of infection, evidence of mucocele or pyocele, fungal sinusitis, or obstructive nasal polyposis, and is often performed in patients with recurrent or persistent infection not resolved by drug therapy.
Osguthorpe JD. Adult rhinosinusitis: diagnosis and management. Am Fam Physician. 2001;63:69–76.
110. A 56-year-old smoker with recently diagnosed small-cell carcinoma of the lung presents with increasing muscle contraction with repeated nerve stimulation. The most likely diagnosis is
A) Eaton–Lambert syndrome
B) myasthenia gravis
C) tetanus
D) polymyalgia rheumatica
E) Parkinson's disease
Answer and Discussion
The answer is A. Eaton–Lambert syndrome is a neurologic disorder that results from inadequate release of acetylcholine from the presynaptic nerve endings. Often associated with a paraneoplastic syndrome (e.g., small-cell or oat-cell carcinoma of the lung), the condition causes weakness and sometimes pain associated with the proximal muscles, paresthesia, impotence, and ptosis. Reflexes are usually reduced or absent. Diagnosis is made by showing increasing muscle contraction with repeated nerve stimulation, unlike myasthenia gravis, in which decreased muscle contraction with repeated nerve stimulation is seen. Special care must be taken to rule out underlying malignancy. The treatment is to identify and treat any underlying malignancy. Guanidine has also been shown to help acetylcholine release from the presynaptic membrane; however, side effects (bone marrow suppression) may limit its use. Other treatment includes the use of immunosuppressant medication (e.g., steroids, azathioprine) and plasmapheresis. Anticholinesterase medications (e.g., pyridostigmine, neostigmine) are variably effective.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1184.
111. Which is not generally a characteristic of a suspicious skin lesion?
A) Asymmetric border
B) Bleeding
C) Color change
D) Variegation of color
E) Diameter less than 5 mm
Answer and Discussion
The answer is E. Skin lesions that represent concern usually possess certain characteristics, including
· = Asymmetric and irregular borders
· = Bleeding or ulceration; persistent itching or tenderness
· = Color change or variegation of color
· = Diameter >6 mm
If any of these criteria are met, the lesion should be biopsied and sent for pathologic examination. Large, raised, and pigmented congenital lesions should also be biopsied. Patients who have a history of dysplastic nevi syndrome are at increased risk for the development of melanoma, particularly if a family member has been affected.
Jerant AF, Johnson JT, Sheridan CD, et al. Early detection and treatment of skin cancer. Am Fam Physician. 2000;62:357–368, 375–376, 381–382.
112. Which of the following conditions is a contraindication to influenza vaccination?
A) Allergy to eggs
B) Allergy to red dye
C) Allergy to penicillin
D) Allergy to milk
E) Allergy to dust mites
Answer and Discussion
The answer is A. Influenza immunizations are administered yearly to help prevent outbreaks of different strains of viral influenza. The inactivated vaccine is derived from purified egg protein, which harbors the viral protein. The vaccine is developed based on the preceding year's outbreak of virus, those viruses seen in other parts of the world, and the antibody response of persons previously vaccinated. Persons who are allergic to eggs or neomycin (a component of the vaccine) should not receive the vaccine. In those individuals, amantadine may be considered. Protective vaccine should be administered to immunocompromised individuals; individuals with underlying medical conditions such as asthma, COPD, and diabetes; and individuals older than 50 years. (Other recommendations follow.) Otherwise healthy patients may also elect to receive vaccination. Side effects, including fever, fatigue, cough, and headache, are no more common in those who received a placebo in double-blinded studies; however, arm soreness was reported more frequently in vaccine recipients.
Recommendations for the administration of influenza vaccine include the following categories and specific indications:
Age
· Persons 6 months or older with an underlying medical condition (e.g., cardiac, pulmonary) who are at increased risk for complications of influenza or who required regular medical follow-up or hospitalization during the preceding year (see Medical conditions as follows)
· Healthy children ages 6–23 months and close contacts of healthy children ages 6–23 months
· Persons 50 years or older
· Any person 6 months or older to reduce the chance of influenza infection
Occupations
· Physicians, nurses, and other personnel in hospital and outpatient care settings, including emergency response workers
· Employees of health-care facilities (e.g., nursing homes, chronic care facilities) who have contact with residents
· Persons who provide home care to people in high-risk groups
Medical conditions
· Alcoholism and alcoholic cirrhosis
· Long-term aspirin therapy in children and teenagers (6 months to 18 years of age) who may be at risk for Reye's syndrome after influenza virus infection
· Chronic cardiovascular disorders in adults and children
· Hemoglobinopathies
· Immunocompromised conditions (e.g., congenital immunodeficiency, malignancy, HIV infection, organ transplantation, immunosuppressive therapy)
· Chronic metabolic diseases (e.g., diabetes)
· Chronic pulmonary diseases, including asthma and COPD
· Chronic renal dysfunction
· Pregnancy beyond 14 weeks of gestation during the influenza season
· Pregnancy in women with medical conditions that increase their risk for complications from influenza, regardless of trimester
· Persons who can transmit influenza to high-risk individuals
· Household members (including children) in close contact with persons who are at high risk for influenza
· Residents of nursing homes and other chronic care facilities, regardless of age, who have chronic medical conditions
Vaccination ideally should occur approximately 2 weeks before chemotherapy or immunosuppressive therapy is started. If a patient is vaccinated during or within 2 weeks before the initiation of immunosuppressive therapy, influenza vaccine should be given again approximately 3 months after treatment ends.
Data from Advisory Committee on Immunization Practices. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). CDC website at www.cdc.gov, accessed 6/5/06.
Montalto NJ, Gum KB, Ashley JV. Updated treatment for influenza A and B. Am Fam Physician. 2000;62:2467–2476.
113. A 41-year-old business executive presents to your office and complains of palpitations and shortness of breath. After further questioning, he admits to heavy alcohol consumption the previous evening. On examination, he is found to have an irregular heartbeat of 130 bpm. The most likely diagnosis is
A) ventricular tachycardia
B) ventricular fibrillation
C) premature ventricular contractions (PVCs)
D) atrial fibrillation
E) Wolff-Parkinson-White syndrome
Answer and Discussion
The answer is D. Atrial fibrillation is the most common cardiac arrhythmia. It is characterized on ECG by the absence of P waves and an irregular ventricular rhythm. The atrial rate can range from 400 to 600 bpm, whereas the ventricular rate usually ranges from 80 to 180 bpm in the untreated state. Causes include thyrotoxicosis, rheumatic or ischemic heart disease, hypertension, pericarditis, chest trauma, or excessive alcohol intake. The major risk associated with atrial fibrillation is stroke secondary to embolic complications. Rapid ventricular response of atrial fibrillation requires treatment with rate-controlling calcium-channel blockers, β-blockers, or digoxin to achieve rate control. Elective medical cardioversion may be considered for stable patients. Patients in whom medical conversion fails or whose conditions are unstable may need electrical cardioversion. Patients with long-standing atrial fibrillation (longer than 6 months) have less chance for success than those who have new or relatively new onset. Anticoagulation therapy with warfarin can decrease the risk of stroke and is recommended before any attempt at cardioversion if there is risk for thrombus formation. Patients with chronic atrial fibrillation who are at low risk for bleeding may be treated with warfarin; others may be treated with aspirin therapy. Antiarrhythmics may be needed to treat resistant cases. The risk of embolism during cardioversion in unanticogulated patients is 1% to 7%; however, this risk can be minimized with anticoagulation for 4 weeks before and after cardioversion. Recent studies demonstrate no reductions in either mortality or stroke rates between those patients managed with simple rate control and anticoagulation, compared with those receiving cardioversion with rhythm maintenance using antiarrhythmic medication.
Rakel RE, Bope ET. Conn's Current Therapy 2005. Philadelphia: Elsevier/Saunders; 2005:340–344.
114. The most common cause of superior vena cava syndrome is
A) carcinoma of the lung
B) aortic aneurysm
C) tuberculosis
D) metastatic carcinoma from a distant site
E) constrictive pericarditis
Answer and Discussion
The answer is A. Superior vena cava syndrome results from compression of the superior vena cava by a neoplastic process (90% of cases) and less commonly by inflammatory states. Other causes include benign tumors, aortic aneurysm, thyroid enlargement, thrombosis of a central venous line, and fibrosing mediastinitis. Lung cancer, particularly small-cell and squamous-cell type, is the most common associated malignancy. The condition causes the obstruction of venous drainage to the heart and leads to dilation of collateral veins of the upper chest and neck. Signs include plethora and swelling of the face, neck, and upper torso. Edema of the conjunctiva, shortness of breath in a supine position, and CNS disturbances, including headache, dizziness, stupor, and syncope, may be seen. Acute development of symptoms indicates a poor prognosis. The diagnosis of superior vena cava syndrome is essentially a clinical one. Chest x-rays may show widening of the mediastinum, particularly on the right, but the best confirmatory test is CT. The MRI has no advantages over CT. The one potentially life-threatening complication of a superior mediastinal mass is tracheal obstruction. Treatment includes steroids, chemotherapy, and radiation to the tumor. Although the most common cause of this syndrome is metastasized carcinoma of the lung, other less common infectious causes include tuberculosis, histoplasmosis, and constrictive pericarditis.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:575–576.
115. A construction worker presents with pain over the lateral elbow. He reports that he has been using a hammer more often, and this seems to aggravate his discomfort. The most likely diagnosis is
A) carpal tunnel syndrome
B) rotator cuff dysfunction
C) lateral epicondylitis
D) ulnar nerve entrapment
E) biceps tendonitis
Answer and Discussion
The answer is C. Tennis elbow is usually caused by overuse, repeated trauma, strain, or exercise that involves the upper extremity and a gripping motion. Although associated with playing tennis, it may affect baseball players, golfers, and racquetball enthusiasts, as well as carpenters, assembly-line workers, and electricians, all of whom repeatedly extend the wrist and rotate the forearm. The cause of pain originates at the extensor origin of the extensor carpi radialis brevis in the area of the lateral epicondyle. Symptoms include pain in the area of the lateral epicondyle but may also include the extensor surface of the forearm. In more severe cases, swelling and erythema may be noted. Pain is exacerbated by passively flexing the fingers and wrist with the elbow fully extended. Radiographs are usually negative; however, calcification may be noted in chronic cases. The condition should be distinguished from radial nerve entrapment syndrome (pain with middle finger extension and forearm supination with the elbow fully extended) and posterior interosseous nerve syndrome (pain located more distally over the forearm supinator muscle). Treatment includes NSAIDs, rest of the affected arm, ice therapy, and a volar wrist splint that immobilizes the wrist and prevents flexion and extension. If this treatment does not provide relief, a steroid injection of 1 mL of 1% lidocaine and 0.5 mL of corticosteroid should be attempted. Once the inflammation has been controlled, a constricting band can be used over the proximal forearm to help prevent recurrence. In addition, rehabilitation exercises should be instituted. In severe cases, orthopedic referral may be necessary for possible surgical treatment.
Chumbley EM, O'Connor FG, Nirschl RP. Evaluation of overuse elbow injuries. Am Fam Physician; 2000;61:691–700.
116. Which of the following is a characteristic of Marfan's syndrome?
A) Autosomal-recessive transmission
B) Decreased mobility of joints
C) Arm span less than height
D) Aortic dilatation with possible rupture
E) Café-au-lait spots
Answer and Discussion
The answer is D. Marfan's syndrome is an autosomal-dominant transmitted disorder that affects the connective tissue and results in abnormalities associated with the eyes, bones, and cardiovascular system. Up to 25% of all cases may develop from spontaneous mutations. Symptoms include tall stature with arm span exceeding height, arachnodactyly, dislocation of the ocular lens, high-arched palate, pectus excavatum, and hyperextensibility of joints. Complications of the condition include myopia; spontaneous detachment of the lens; and cardiac defects, including aortic regurgitation, mitral valve prolapse (MVP), mitral regurgitation, and aortic dilatation with aortic dissection and rupture (the most common cause of cardiovascular death). Patients affected are at increased risk of endocarditis. Treatment is directed toward the cardiovascular findings. An echocardiogram can help determine cardiac involvement. In some cases, β-blockers may help protect the aorta. Surgery is reserved for those with aortic dilatation or aortic valve dysfunction. New DNA diagnostic tests for mutations in fibrillin-1 and fibrillin-2 can help determine which patients affected with Marfan's are at increased risk for aortic aneurysm. Scoliosis may require bracing or surgery for severe cases.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:2329.
117. Third-generation cephalosporins differ from first-generation cephalosporins in their increased effectiveness against
A) gram-positive organisms
B) gram-negative organisms
C) anaerobic organisms
D) parasites
E) fungi
Answer and Discussion
The answer is B. Cephalosporins are antibiotics that have a similar chemical structure as the penicillins. They are bacteriocidal and cover gram-positive organisms; second-generation and third-generation cephalosporins also cover gram-negative organisms. As a group, the cephalosporins' mechanism of action is the inhibition of cell wall synthesis. Inflammation increases their absorption, and they are active against a wide spectrum of organisms with relatively few side effects. Some of the cephalosporins, especially third-generation ones, are concentrated enough in the CSF to treat meningitis. Because of their similarity to penicillin, there is a 2% to 3% cross-reactivity in those allergic to penicillin. Unfortunately, there are no predictable skin tests that can test for allergic reactions. Therefore, use of cephalosporins in patients with penicillin allergies should be monitored closely. If the patient has had a severe, immediate reaction to any of the cillin-type medications, it is necessary to use extreme caution prescribing cephalosporins; alternative antibiotics should be strongly considered.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1427–1428.
Because of their similarity to penicillin, there is a 2%–3% cross-reactivity in those patients taking cephalosporins who are allergic to penicillin.
118. During which of the following stages of sleep does most dreaming occur?
A) Stage 1 non–rapid eye movement (REM) sleep
B) Stage 2 non-REM sleep
C) Stage 3 non-REM sleep
D) Stage 4 non-REM sleep
E) REM sleep
Answer and Discussion
The answer is E. There are two distinct states of sleep: REM sleep and non-REM sleep, which make up 75% to 80% of sleep. Based on electroencephalographic (EEG) patterns, non-REM sleep can be classified into stages 1, 2, 3, and 4. Necessary for survival, sleep is a cyclical phenomenon. There are four to five REM periods nightly that always follow non-REM sleep and end each cycle. REM sleep, which accounts for 25% (or 1.5 to 2 hours) of the night's sleep, is the period of sleep in which most dreaming occurs. The first period of REM sleep occurs approximately 1.5 to 2 hours after sleep has occurred and lasts approximately 10 minutes. A night's sleep cycles through the different stages and reenters REM stage three or four times for longer periods (15 to 45 minutes), usually in the last several hours of sleep. Non-REM sleep is characterized by slow waves on EEG, with stage 4 being the deepest stage of sleep. REM sleep is characterized by low-voltage, fast activity on EEG. Most night terrors, sleep walking, and sleep talking occur during stage 4 sleep. In REM, sleep muscle tone is decreased, but depth of respiration is increased. As patients become older, the length of REM sleep remains the same; however, there are significant decreases in stages 3 and 4 sleep and an increase in wakeful periods during the night. In addition, it takes elderly patients a longer period to fall asleep. Wakefulness is characterized by alpha wave activity on EEG.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:153–154.
119. Treatment for uncomplicated infectious mononucleosis should be
A) intravenous antiviral medication
B) oral antiviral therapy (acyclovir or ganciclovir)
C) oral steroids
D) empiric antibiotic treatment
E) symptomatic treatment only
Answer and Discussion
The answer is E. Infectious mononucleosis is caused by the double-stranded EBV, a member of the Herpesviridae family. The incidence is highest in young adults 15 to 35 years of age. Asymptomatic infections are common, and most adults are seropositive to the EBV. Symptoms include fever, headache, generalized fatigue, and malaise. Signs include lymphadenopathy (especially the posterior cervical chain), splenomegaly, hepatomegaly, jaundice, periorbital edema, exudative pharyngitis, palatine petechiae, and rash. Laboratory findings show a lymphocytosis with 20% or more atypical lymphocytes (Downey lymphocytes), a positive heterophile agglutination (Monospot) test after the second week of illness, and a heterophile titer greater than 1:56. Liver function tests are usually elevated. Other laboratory findings may include granulocytopenia, thrombocytopenia, and hemolytic anemia in complicated cases. No specific treatment is recommended for mild cases, and symptoms usually improve in 2 to 4 weeks. In severe cases in which the pharyngitis threatens to obstruct the patient's airway, a 5-day course of steroids may be beneficial. Specific antiviral therapies (acyclovir or ganciclovir) do not appear to be clinically beneficial. Treatment with amoxicillin or ampicillin may lead to a severe maculopapular rash and should be avoided. If the patient has evidence of splenomegaly, contact sports should be avoided until the splenomegaly has resolved. Mononucleosis-type infections may occur more than once but are generally caused by sequential infections with different pathogens rather than by reactivated EBV infections. EBV infections can become reactivated when patients are immunosuppressed (during corticosteroid or cyclosporine therapy) or develop immune deficiencies (e.g., HIV).
Ebell MH. Epstein Barr virus infectious mononucleosis. Am Fam Physician. 2004;70:1279–87, 1289–1290.
120. A 65-year-old man presents with increasing shortness of breath over the previous 5 years. Further history reveals that the patient worked for many years in a factory that produced fluorescent lights. On examination, the patient has granulomas affecting the skin and conjunctiva. A chest radiograph shows evidence of parenchymal infiltrates and intra-alveolar edema with mediastinal lymphadenopathy. The most likely diagnosis is
A) coccidioidomycosis
B) berylliosis
C) tuberculosis
D) sarcoidosis
E) asbestosis
Answer and Discussion
The answer is B. Chronic inhalation of beryllium compounds and their products can result in a disease characterized by granulomas that affect primarily the lungs but also the skin and conjunctivae. Beryllium is found in electronics and chemical plants, aerospace factories, beryllium-mining sites, and industries in which fluorescent lights are manufactured. Changes that occur in the lungs include diffuse parenchymal inflammatory infiltrates with the development of intra-alveolar edema. The hallmark finding is a granulomatous reaction involving the hilar lymph nodes and pulmonary parenchyma, which is indistinguishable from sarcoidosis. Symptoms of the disease include dyspnea with shortness of breath, cough, and weight loss. Chest radiographs usually show diffuse alveolar consolidation with hilar lymphadenopathy. The prognosis of the disease is variable and ranges from mild pulmonary symptoms to extreme respiratory compromise and even death. Chronic exposure tends to cause a progressive decrease in pulmonary function with the development of right heart failure and cor pulmonale. Treatment is usually supportive. Steroids have been used with little benefit in chronic cases but may be used for acute berylliosis. Those exposed to beryllium dust should be counseled to protect themselves with masks and should take measures to avoid exposure. A pulmonary function test may be helpful in determining the extent of damage and the progression of disease.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:472–473.
121. Which of the following drugs is associated with drug-induced lupus erythematosus (LE)?
A) Hydralazine
B) Azithromycin
C) Metoprolol
D) Digoxin
E) Penicillin
Answer and Discussion
The answer is A. Drug-induced LE is associated with the use of procainamide (most common), hydralazine, INH, penicillamine, sulfonamides, quinidine, thiouracil, methyldopa, and cephalosporins. All patients with drug-induced LE have positive reactions to ANA testing; however, they usually do not have positive reactions to antibodies to double-stranded DNA. Other laboratory findings supporting drug-induced lupus include anemia, leukopenia, thrombocytopenia, positive rheumatoid factor, positive cryoglobulins, positive lupus anticoagulants, false-positive Venereal Disease Research Laboratory (VDRL) test results, and positive results on a direct Coombs' test. Signs and symptoms include polyarthralgias, fever, butterfly rash affecting the facial area, alopecia, photosensitivity, pleurisy, proteinuria, and glomerulonephritis. In most cases, the symptoms disappear when the medication is discontinued. Steroids may be necessary for severe cases.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:1960.
122. Which of the following medications is used for the treatment of pseudomembranous colitis?
A) Metronidazole
B) Amphotericin B
C) Ketoconazole
D) Acyclovir
E) Intravenous vancomycin
Answer and Discussion
The answer is A. Overgrowth of Clostridium difficile in the intestine gives rise to a condition known as pseudomembranous colitis. The condition results from the use of antibiotics (especially clindamycin, ampicillin, and cephalosporins) usually 2 days to 6 weeks after administration. In some cases, it may occur without recent antibiotic use. Symptoms include watery diarrhea, abdominal cramps, tenesmus, low-grade fever, and, in some cases, hematochezia. Physical findings may include a tender, distended abdomen with hyperactive bowel sounds. C. difficile may be present in as much as 3% to 8% of healthy asymptomatic carriers. Diagnosis is made by the detection ofC. difficile toxin in the stool and sigmoidoscopy or colonoscopy findings consisting of yellowish-white plaques of exudate with alternating areas of normal bowel mucosa. If the exudate is removed, bleeding often occurs from the affected mucosa. Not all affected patients have the identifiable lesions. Treatment involves the use of metronidazole. For infections unresponsive to metronidazole, oral vancomycin can be used. Mild cases can be treated with cholestyramine resin. Saccharomyces boullardii yeast may also be helpful in treatment. Complications include dehydration with electrolyte imbalances, intestinal perforation, toxic megacolon, and, in severe cases, death. Relapses may occur in up to 20% of cases.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1500.
123. Which of the following is a distinguishing feature between drug-induced and idiopathic systemic lupus erythematosis (SLE)?
A) In drug-induced lupus, there is an absence of antibodies to double-stranded DNA.
B) In drug-induced lupus, there are increased levels of complement.
C) In idiopathic SLE, a butterfly facial rash is seen.
D) Renal and central nervous system (CNS) involvement are common with drug-induced SLE.
E) There are no differences seen between the two conditions.
Answer and Discussion
The answer is A. Several drugs are known to cause a lupus-like syndrome; two of the most common are procainamide and hydralazine. Approximately 50% of patients receiving procainamide are ANA positive, and approximately 50% of those develop lupus-like symptoms. Most patients with drug-induced SLE do not have antibodies to double-stranded DNA, and they rarely have depressed levels of complement, which can distinguish drug-induced SLE from idiopathic SLE. Other laboratory abnormalities seen with drug-induced SLE include anemia, thrombocytopenia, and leukopenia. Additional findings include a positive rheumatoid factor, false-positive VDRL result, and positive direct Coombs' test. In most cases, the symptoms resolve once the medication is discontinued; however, steroid administration may be needed in severe cases. Most symptoms are completely resolved in 6 months, but ANA test results may remain positive for years. Most affected patients complain of arthralgias, myalgias, fever, and pleuritic chest pain. Renal and CNS involvement are rare with drug-induced SLE. Other medications associated with drug-induced lupus include chlorpromazine, methyldopa, and INH.
Klippel JH, ed. Primer on the rheumatic diseases, 11th ed. Atlanta: Arthritis Foundation; 1997:255–256.
124. The drug of choice to treat methicillin-resistant S. aureus is
A) penicillin
B) dicloxacillin
C) cefuroxime
D) vancomycin
E) metronidazole
Answer and Discussion
The answer is D. Methicillin-resistant S. aureus infection is becoming more common in hospitals and nursing homes. Increasingly, S. aureus infections are resistant to methicillin treatment. Burn victims, intravenous drug abusers with endocarditis, and elderly immunocompromised patients in institutionalized nursing homes are the most frequently affected groups. The most common reservoir is the nasal mucosa and oropharynx. Isolates are usually resistant to all the -cillin-type antibiotics and the cephalosporins. Intravenous vancomycin is the drug of choice for severe infections until results of susceptibility testing are known. Other medications used include trimethoprim–sulfamethoxazole (TMP-SMX), linezolid, doxycycline, and clindamycin. Duration of therapy is based on the patient's response but is usually 2 to 4 weeks. Colonization occurs in approximately 50% of treated patients. Asymptomatic colonization with methicillin-resistant S. aureus does not require systemic treatment; however, patients affected should be isolated.
Mouton CP, Bazalda OV, Pierce B, et al. Common infections in older adults. Am Fam Physician. 2001;63:257–268.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:1539.
125. Ramsay Hunt syndrome is associated with
A) herpes zoster infection affecting the geniculate ganglion of the facial nerve
B) spinothalamic disruption leading to loss of motor function in the lower extremities
C) spontaneous progressive demyelination of motor neurons
D) autoimmune destruction of norepinephrine receptors in the thalamus
Answer and Discussion
The answer is A. Ramsay Hunt syndrome is a disorder caused by the herpes zoster virus that affects the geniculate ganglion of the facial nerve. The syndrome can give rise to ipsilateral facial nerve palsy and can be distinguished from Bell's palsy by the development of vesicular herpetic lesions that affect the pharynx, external auditory canal, and, occasionally, the eighth cranial nerve. Patients report painful lesions and lose their sense of taste associated with the anterior two-thirds of the tongue.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:195, 1043, 2436.
Ramsay Hunt syndrome is a disorder caused by the herpes zoster virus that affects the geniculate ganglion of the facial nerve.
126. A 10-year-old jumped off the high dive at a local swimming pool and presents to your office complaining of severe right-sided ear pain after landing on that side when he hit the water. You have seen him for this problem for the last 12 weeks, but a small perforation remains in the tympanic membrane. There is no sign of infection. Appropriate treatment at this point consists of
A) continued observation
B) an audiogram to document hearing
C) steroid otic drops
D) antibiotic ear drops and no water exposure
E) referral to an ear-nose-throat specialist
Answer and Discussion
The answer is E. Rupture of the tympanic membrane can be caused by placing objects (e.g., cotton swabs, twigs, pencils) in the ear canal, excessive positive pressure applied to the ear (e.g., explosions, loud noises), swimming, diving, or excessive negative pressure (e.g., kiss over the ear); it can be iatrogenically produced by a ventilating tube. Symptoms of traumatic rupture include a sudden severe pain followed by, in some cases, bleeding from the ear. Hearing loss and tinnitus are also usually present. Vertigo suggests damage to the inner ear. Treatment involves gentle removal of debris and blood from the otic canal and earplugs to provide protection when bathing or shampooing. Antibiotic eardrops are indicated only if there has been contamination by water or debris. Oral antibiotics can be used prophylactically to prevent infection but are generally unnecessary. Pain medication may be necessary for the first few days. Persistent perforation for more than 10 to 12 weeks is an indication for otolaryngology referral. An audiogram should be performed after treatment to document the return of hearing.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:802.
127. A 50-year-old woman presents to your office complaining of nausea, diarrhea, muscle pains, urticaria, and generalized fatigue. Laboratory results show an eosinophilia. Further history reveals she has been eating summer sausage. The most likely diagnosis is
A) Salmonella infection
B) Giardia infection
C) trichinosis
D) pinworm infection
E) tularemia
Answer and Discussion
The answer is C. Trichinosis is a parasitic infection caused by the roundworm T. spiralis. The parasite's larvae are sometimes found in pork and occasionally in beef. The condition results from ingestion of inadequately cooked pork, wild boar, or bear products. The infection occurs worldwide but is relatively rare in the United States. Outbreaks have been linked to the consumption of inadequately prepared summer sausage. The life span of the parasite includes a larval phase that is found in inadequately cooked food. The larvae mature once in the host and mate. The females then burrow into the intestines and begin producing thousands of larvae daily. The larvae are carried to the lymphatics and by the bloodstream to multiple organs and tissues. Only the larvae that reach skeletal muscle survive. In the muscle they grow, coil up, and become encysted. Eventually they may calcify. Symptoms may be absent or mild and include nausea, diarrhea, abdominal discomfort, fever, eye pain, periorbital edema, muscle soreness and pain, urticaria, subungual hemorrhages, weakness, and generalized fatigue. Eye pain and photophobia usually precede myalgias. Laboratory results show eosinophilia, and a muscle biopsy may show the larvae or cysts. Creatine phosphokinase and lactate dehydrogenase are elevated in 50% of patients and correlate with abnormal EMGs. An enzyme-linked immunosorbent assay (ELISA) and bentonite flocculation test are highly sensitive and specific for the detection of trichinosis after 2 to 3 weeks. The parasite is rarely found in stool, blood, or CSF. Treatment involves symptomatic measures to control muscle discomfort. In most cases the infection is self-limited, often requiring only symptomatic and supportive treatment. Corticosteroids may be used in severe cases with myocardial involvement. Thiabendazole or mebendazole eliminate the adult worms from the GI tract but they have no effect on encysted larvae. In most cases, the prognosis is good. Those with myocardial involvement are at greater risk for complications.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1554–1555.
128. A 62-year-old woman presents to your office complaining of unilateral headache, temporal area tenderness, and visual disturbances. Laboratory tests show mild anemia and a sedimentation rate of 110 mm/hour. The most appropriate management includes
A) CT scan of the head
B) initiation of high-dose steroids
C) referral to an ophthalmologist
D) MRI of the head
E) initiation of NSAIDs
Answer and Discussion
The answer is B. Polymyalgia rheumatica is a generalized inflammatory disorder that tends to affect middle-age and elderly patients (usually older than 50 years). Onset of symptoms is usually rapid and includes fever, generalized fatigue, weight loss, and pain and stiffness associated with the shoulder girdle that may extend to involve other areas, including the pelvis. Laboratory tests invariably show signs of anemia and an elevated sedimentation rate usually exceeding 100 mm/hour (especially with temporal arteritis). Creatine phosphokinase levels are normal, ruling out muscle destruction. One-fourth to one-half of patients with polymyalgia rheumatica have temporal arteritis.
In many cases, temporal arteritis coexists with but usually develops after the onset of polymyalgia rheumatica. Symptoms of temporal arteritis (giant-cell arteritis) include unilateral headache, temporal area tenderness, visual disturbances, and jaw claudication. Women are more commonly affected than men. Whenever temporal arteritis is suspected, corticosteroids (60 mg/day of prednisone) should immediately be prescribed to prevent blindness, which is secondary to inflammation and occlusion of the ophthalmic arteries. Corticosteroids are also used to treat polymyalgia rheumatica, but in smaller doses (10 to 20 mg/day of prednisone) than that required for temporal arteritis. The diagnosis of polymyalgia rheumatica is usually based on clinical findings supported by the laboratory test; however, temporal arteritis is usually confirmed with a temporal artery biopsy. Treatment usually requires months of a slow, gradual taper of steroids while following the sedimentation rate. In some cases, medication may be needed for extended periods (up to 1 year); relapses requiring extended courses are not unusual.
Ferri F. Ferri's Clinical Advisor, Instant Diagnosis and Treatment. Philadelphia: Elsevier/Mosby; 2006:668.
129. Which of the following has been shown in multiple cohort studies to reduce the risk of colon cancer?
A) Folic acid
B) B complex vitamin
C) Aspirin
D) Vitamin C
E) Vitamin E
Answer and Discussion
The answer is C. Daily intake of aspirin has been demonstrated to decrease the risk of colorectal cancer in multiple cohort and case-control studies, although the benefit varies slightly among the studies. Considering the potential toxicity of aspirin, further information about which subgroups would benefit most from its regular use would be helpful.
Benamouzig R, Deyra J, Martin A. Daily soluble aspirin and prevention of colorectal adenoma recurrence: one-year results of the APACC trial. Gastroenterology. 2003;125:328–336.
130. Which of the following may prevent the development of Alzheimer's disease?
A) Ibuprofen
B) Folic acid
C) β—carotene
D) Aluminum exposure
E) Iron
Answer and Discussion
The answer is A. Observational studies suggest that the use of NSAIDs may prevent the development of Alzheimer's disease, but it is not clear if the benefit is a class effect or limited to specific agents. The role of aspirin has yet to be determined. There appears to be a consistent reduction in risk of Alzheimer's disease in patients who use NSAIDs, with greater benefit related to longer duration of use. Although aspirin also may have a protective effect, the evidence for this agent is not as evident as that for NSAIDs.
Etminan M, Gill S, Samii A. Effect of non-steroidal anti-inflammatory drugs on risk of Alzheimer's disease: systematic review and meta-analysis of observational studies. BMJ. 2003;327:128–131.
131. Which of the following statements about Charcot-Marie-Tooth syndrome is true?
A) Decreased pain, temperature, and vibratory sense are usually seen.
B) Symptoms include the development of a foot drop.
C) Symptoms are commonly noted at birth.
D) Hypertrophy of the distal leg muscles is common.
E) Hyperactive reflexes are noted.
Answer and Discussion
The answer is B. Charcot-Marie-Tooth syndrome (or peroneal muscular atrophy) is an inherited disorder, usually autosomal dominant, affecting the peripheral nervous system. Manifestations include weakness and atrophy of the peroneal and distal leg muscles. The condition affects motor and sensory nerves. Other features include impaired sensation and absent or hypoactive deep tendon reflexes. There are two types:
· Type 1: Usually occurs in middle childhood. Features include the development of a foot drop; decrease in pain, temperature, and vibratory sense; slow nerve conduction velocities; and loss of reflexes.
· Type 2: Usually occurs later in life and is slower in its clinical course than type 1. Nerve conduction velocities are usually normal. Patients with Charcot-Marie-Tooth syndrome typically present with abnormal high-stepped gait with frequent tripping or falling. Despite involvement with sensory nerves, complaints of limb pain and sensory disturbance are unusual. Treatment consists of braces to help prevent the associated foot drop. Surgery is reserved for those with severe foot deformities. Chemotherapeutic agents known to affect peripheral nerves should be used with great caution. Vincristine use should be avoided.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:2510.
132. Indications for pacemaker placement include which of the following?
A) Asymptomatic bradyarrhythmias
B) Mobitz II AV block
C) Atrial fibrillation
D) Atrial flutter
E) Mobitz I AV block
Answer and Discussion
The answer is B. The use of a permanent pacemaker is indicated if the patient suffers from symptomatic bradyarrhythmias, asymptomatic Mobitz II AV block, and complete heart block. First-degree AV block, thought to be a relatively benign arrhythmia, can be associated with severe symptoms that may benefit from permanent pacing. Specifically, some uncontrolled trials have shown a benefit from pacing in patients with a PR interval longer than 0.3 seconds. Type I second-degree AV block does not usually require permanent pacing, because progression to a higher degree AV block is not common. Permanent pacing is known to improve survival in patients with complete heart block, especially if they have had syncope. Single and dual chamber pacemakers are available and can be used depending on the patient's diagnosis. Typically, pacemakers are monitored on a regular basis by the patient's cardiologist with telephonic monitoring.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:1336–1356.
133. Which of the following statements about zidovudine (AZT) is true?
A) AZT is a macrolide antibiotic.
B) AZT inhibits cell wall synthesis.
C) AZT administration requires monitoring of complete blood cell counts (CBCs).
D) AZT is classified as an antifungal medication.
E) AZT does not prevent opportunistic infections in acquired immunodeficiency syndrome (AIDS) patients.
Answer and Discussion
The answer is C. AZT (Zidovudine) was the first drug approved for the treatment of HIV and AIDS. Also known as Retrovir, AZT is a thymidine analog that inhibits reverse transcriptase, an enzyme necessary for retroviral DNA synthesis, as well as viral replication. Side effects of the medication include suppression of blood elements, including erythrocytes, leukocytes (particularly granulocytes), and platelets. Because of this, frequent CBCs are necessary for monitoring; alterations in the dosage of the drug or its discontinuation may be necessary. The drug dramatically reduces perinatal transmission from HIV-infected mothers to their newborn. Combination therapy with other antiviral medications is superior to treatment with AZT alone for HIV individuals. Other side effects of the medication include headache, restlessness, malaise, dizziness, paresthesias, nausea, vomiting, and anorexia. Other drugs metabolized by the liver, including acetaminophen and TMP-SMX, may increase the risk of AZT toxicity.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:1124.
134. Which of the following medications is acceptable treatment for leishmaniasis?
A) Penicillin G
B) Tetracycline
C) Sodium antimony gluconate
D) Metronidazole
E) Acyclovir
Answer and Discussion
The answer is C. Leishmaniasis is a disease seen predominantly in Third-World countries and is transmitted by the bite of the sandfly. There are four types of this disease:
· Visceral leishmaniasis (also known as kala-azar or Leishmania donovani) symptoms include cutaneous lesions, fever, diarrhea, cough, lymphadenopathy, pancytopenia, cirrhosis, splenomegaly, superinfections, hyperpigmentation, and GI bleeding.
· Old-World cutaneous leishmaniasis (Leishmania tropica, Leishmania major, and Leishmania aethiopica) is usually associated with a papule that develops into a necrotic lesion, followed by a hypopigmented scar on the face or legs.
· New-World cutaneous leishmaniasis (Leishmania braziliensis or Leishmania mexicana) is associated with nodular or ulcerating lesions on the hands, face, or ears that usually resolve. Lesions associated with L. braziliensis may resolve or cause metastatic ulcers in the nasopharyngeal area months to years later.
· Massive cutaneous leishmaniasis is associated with massive cutaneous lesions without involvement of the visceral organs.
Diagnosis of the condition is accomplished with biopsy of skin lesions. A leishmanin skin test can be used for diagnosis but is not widely available. Treatment is accomplished with the administration of sodium antimony gluconate, amphotericin B, or pentamidine. Itraconazole may become the drug of choice. Interferon (gamma) is used for refractive cases.
Ferri F. Ferri's Clinical Advisor, Instant Diagnosis and Treatment. Philadelphia: Elsevier/Mosby; 2006:477.
135. A 36-year-old construction worker is brought to the emergency room. He has been working in the sun all day and, on arrival, he exhibits hyperventilation, profuse sweating, subnormal body temperature, and hypotension. The most likely diagnosis is
A) heat stroke
B) hypothermia
C) heat exhaustion
D) thyroid storm
E) organophosphate poisoning
Answer and Discussion
The answer is C. Heat stroke is a medical emergency. Symptoms include headache, vertigo, fatigue, and increased body temperature (>40°C). Sweating is usually absent. The skin is hot and dry. Patients may exhibit bizarre and confused behavior, hallucinations, loss of consciousness, and seizures. Other manifestations include tachycardia and tachypnea; blood pressure is usually preserved. If circulatory collapse occurs, patients may suffer brain damage and even death. Patients should immediately be treated with cool water or wet dressings. Careful monitoring of body core temperature should be instituted to avoid conversion of hyperpyrexia to hypothermia. Once hospitalized, fluid replacement and further temperature management can be instituted. Complications include renal failure, cardiac failure, and the development of disseminated intravascular coagulopathy.
Heat exhaustion is different in that individuals affected usually exhibit hyperventilation, profuse sweating with substantial bodily fluid loss, and low blood pressure. Body temperature is usually normal and when elevated does not exceed 40°C. Mental status is usually normal, unlike in heat stroke. Treatment for heat exhaustion is similar to heat stroke and consists mainly of fluid resuscitation.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2608–2609.
Heat exhaustion is different from heat stroke in that individuals affected usually exhibit hyperventilation, profuse sweating with substantial bodily fluid loss, and low blood pressure. Body temperature is usually normal and when elevated does not exceed 40°C. Mental status is usually normal, unlike in heat stroke.
136. Which of the following statements about diabetic retinopathy is true?
A) Proliferative retinopathy is associated with a poorer prognosis than nonproliferative retinopathy.
B) Nonproliferative retinopathy is associated with neovascularization.
C) Symptoms of retinopathy usually begin with eye pain.
D) Diabetics should have eye examinations every 3 years.
E) Unfortunately, there is no treatment for diabetic retinopathy.
Answer and Discussion
The answer is A. Diabetic retinopathy is the leading cause of blindness in middle-age Americans. The degree of retinopathy is highly correlated with the duration of the diabetes. The disease process is divided into the following:
· Nonproliferative retinopathy: characterized by dilated retinal veins, retinal hemorrhages, microaneurysms, retinal edema, and soft exudates (cotton-wool spots). Hard exudates are usually yellow in appearance and caused by chronic edema. Visual symptoms generally do not occur in the early stages of nonproliferative retinopathy.
· Proliferative retinopathy: associated with neovascularization and proliferation of blood vessels into the vitreous with resulting fibrosis and retinal detachment and hemorrhage.
Symptoms of diabetic retinopathy usually begin with a decrease in visual acuity. Diagnosis can be made with ophthalmologic examination and fluorescein angiography. Treatment involves panretinal laser coagulation and vitrectomy, as well as active management to control the diabetes and, if present, hypertension. The prognosis of proliferative retinopathy is worse than that of nonproliferative retinopathy. Diabetics should be encouraged to have yearly eye examinations.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:918–919.
137. Which of the following findings characterize(s) aortic stenosis?
A) Lack of pressure gradient across the aortic valve
B) Angina, dyspnea, and syncope
C) Diastolic murmur that radiates to the axilla
D) Palpitations
E) Crescendo murmur with mid-systolic click
Answer and Discussion
The answer is B. Aortic stenosis occurs when there is obstruction in the blood flow through the aortic valve. Typically, there is a pressure gradient >10 mm Hg across the obstruction. The causes for aortic stenosis include previous rheumatic fever with associated damage to the valves, excessive calcification of the valves leading to narrowing, or congenital causes (e.g., bifid aortic valve). Men are more commonly affected than women. Cardiac output is usually maintained until the stenosis is severe. Once the condition becomes severe, symptoms may include the classic triad (i.e., angina, dyspnea, and syncope), especially with physical exertion. The classic symptoms of angina, exertional syncope, and dyspnea generally follow an extended latent period during which the patient is asymptomatic. The survival of patients with aortic stenosis is nearly normal until the onset of symptoms when survival rates decrease sharply. After the onset of symptoms, average survival is typically 5 years or less. Although the rate of progression of aortic stenosis is variable and difficult to predict, approximately 75% of patients with aortic stenosis die within 3 years after the onset of symptoms if the aortic valve is not replaced. Some patients with severe aortic stenosis remain asymptomatic, whereas others with moderate stenosis have symptoms attributable to the condition. The normal aortic valve area averages 2.5 cm2, and there should normally be no gradient. A valve area of <0.8 cm2 or a gradient of >50 mm Hg represents critical stenosis capable of causing symptoms or death. Severe cases can result in sudden death. Physical findings include a harsh systolic ejection murmur found at the left sternal border that radiates to the carotids, a palpable left ventricular heave, and delayed carotid pulse upstroke. Some patients may present with findings of CHF. Diagnosis is usually made with echocardiogram or cardiac catheterization. Severe cases should be referred for possible valve replacement. Those patients with severe aortic stenosis should avoid strenuous activity.
Shipton B, Wahba H. Valvular heart disease: review and update. Am Fam Physician. 2001;63:2201–2208.
138. Which of the following signs and symptoms are associated with Sjögren's syndrome?
A) Hepatomegaly, chronic rhinitis, and palmar erythema
B) Keratoconjunctivitis, parotid gland enlargement, and xerostomia
C) Confusion, tremors, and peripheral neuropathies
D) Polycythemia, leukocytosis, and negative rheumatoid factor
E) Hyperextensibility of joints, iriditis, and glossitis
Answer and Discussion
The answer is B. Sjögren's syndrome is a rare chronic inflammatory disorder that leads to dry mouth, dry eyes (keratoconjunctivitis sicca), dryness of other mucous membranes, and joint pain. Women are more commonly affected. The disease is often found in conjunction with autoimmune disorders such as scleroderma, rheumatoid arthritis, and lupus. The cause is unknown, but there has been a genetic link with the HLA-DR3 focus. Signs include keratoconjunctivitis, parotid gland enlargement, xerostomia, and loss of taste and smell. Other complications include alopecia, increased risk of pulmonary infections, pancreatitis, pericarditis, sensory neuropathies, interstitial nephritis, and renal tubular acidosis. Laboratory findings include positive rheumatoid factor (seen in 70% of affected patients), elevated ESR (70% of affected patients), anemia (33% of affected patients), and leukopenia and eosinophilia (25% of affected patients). Diagnosis is accomplished with the Schirmer test, which measures the quantity of tears secreted in 5 minutes in response to irritation from a filter paper strip placed under each lower eyelid. Many patients affected with Sjögren's are at increased risk for lymphoma and Waldenström's macroglobulinemia. Treatment is aimed at control of symptoms. In some cases, steroids and immunosuppressants may be used.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:264–266.
139. Which of the following is the most appropriate medication for the treatment of hypertension in a diabetic patient?
A) β-Blocker
B) ACE inhibitor
C) Diuretic
D) Calcium-channel blocker
E) α-Blocker
Answer and Discussion
The answer is B. ACE inhibitors (e.g., captopril, enalapril, lisinopril, ramipril) function as afterload reducers by inhibiting the renin-angiotensin-aldosterone system. They have been shown to reduce mortality rates in patients with CHF. They are also widely used as a first-choice drug in the management of hypertension because of their favorable side effect profile. The mechanism of action involves the blockage of angiotensin I to angiotensin II, resulting in a decrease in aldosterone production, which leads to increased sodium and water excretion. Hemodynamic effects include decreased peripheral resistance, increased renal blood flow, and minimal effects on cardiac output and glomerular filtration rate. Adverse effects include headaches, nausea, dizziness, skin rashes, nonproductive irritative cough (10% to 20% of patients), acute renal failure in patients with renal artery stenosis, and angioneurotic edema. ACE inhibitors are generally not associated with depression, sedation, fatigue, or impotence. They can be useful in preserving renal function in patients with diabetes. Those patients with preexisting renal insufficiency or renal artery stenosis require close monitoring of renal function when ACE inhibitors are administered. Patients with CHF, diabetes, peripheral vascular disease, history of recent MI, hyperlipidemia, and renal insufficiency are good candidates for ACE inhibitors.
Kermani M, Dua A, Gradman AH. Underutilization and clinical benefits of angiotensin-converting enzyme inhibitors in patients with asymptomatic left ventricular dysfunction. Am J Cardiol. 2000;86:644–648.
Rakel RE, Bope ET. Conn's Current Therapy 2005. Philadelphia: Elsevier/Saunders; 2005:889, 36–37, 333–334, 833.
140. Which of the following factors is an absolute contraindication for the use of thrombolytics in the treatment of myocardial infarction?
A) Altered mental status
B) More than 4 hours has elapsed since the onset of the chest pain
C) Current menstruation
D) The patient has renal insufficiency
E) The patient has a history of diabetic retinopathy
Answer and Discussion
The answer is A. Every patient with an evolving myocardial infarction should be evaluated for thrombolytic therapy. Thrombolytic therapy reduces in-hospital and 1-year mortality by 25%. The criteria for an evolving myocardial infarction include the following:
· Thirty minutes of cardiogenic chest pain.
· At least 1 mm of ST elevation in at least two adjacent limbs or at least 2 mm elevation of precordial chest leads noted on ECG tracings.
· New left bundle branch block.
· Patients with complete bundle branch block and cardiogenic chest pain may also benefit from thrombolytics.
Patients with only ST segment depression do not benefit from thrombolytics, nor do patients with normal ECGs.
Medications such as tissue-type plasminogen activator (tPA), also known as alteplase, tenecteplase (TNK) and reteplase (rPA), and streptokinase, which are fibrin-specific agents, should be administered as soon as possible up to 12 hours after the onset of chest pain. Those who receive medication within the first 6 hours have the best outcome. Absolute contraindications to thrombolytics include recent surgery (within 4 weeks) or biopsy of a noncompressible site within 2 weeks, any history of hemorrhagic stroke, unclear mental status, the possibility of aortic dissection, active bleeding, pericarditis, prolonged (more than 10 minutes) of cardiopulmonary resuscitation, and antibodies to streptokinase or its use within the previous 12 months (in which case tissue-type plasminogen activator should be given). Relative contraindications include history of GI or GU hemorrhage within the past 6 months; trauma; history of cardiopulmonary resuscitation within the previous month; uncontrolled hypertension (systolic BP >180 mm Hg and diastolic BP >110 mm Hg); intracranial or systemic neoplasm; prior (nonhemorrhagic) stroke; pregnancy; or liver dysfunction. Minor hemorrhage, menstruation, and diabetic retinopathy are not contraindications to fibrinolytic therapy.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:1453–1454.
141. Which of the following tests is considered routine (recommended) in the initial evaluation of a patient with hypertension?
A) Chest x-ray
B) TSH
C) Uric acid level
D) 24-hour urine protein
E) ECG
Answer and Discussion
The answer is E. The initial evaluation of a patient with hypertension should include a thorough history and a number of tests, including the following:
Routine tests
· CBC
· Chemistry panel, including fasting, glucose, potassium, creatinine, and BUN
· Cholesterol panel (total cholesterol and HDL [LDL] cholesterol)
· 12-lead ECG
· Urinalysis
Optional tests
· Creatinine clearance
· 24-hour urinary protein
· Uric acid
· Glycosylated Hb
· TSH
· Limited echocardiography
· Chest x-ray
Hypertension exists when the diastolic blood pressure is consistently measured >90 mm Hg and a systolic blood pressure remains >140 mm Hg. Initial management should consist of sodium restriction, limitation of alcohol consumption, and a regular exercise program. Overweight patients should be counseled to lose weight. Other tests to assess kidney function, cardiac performance, or endocrine abnormalities (e.g., pheochromocytoma) are usually unnecessary. JNC 7 strongly recommends that physicians intervene with lifestyle modifications that can prevent or delay the onset of hypertension in patients. That recommendation takes on special importance in the definition of the new class of “prehypertension,” those patients who have systolic pressures between 120 and 139 mm Hg or diastolic pressures between 80 and 89 mm Hg, who are at increased risk of bad outcomes and high risk for development of diagnosed hypertension. Furthermore, JNC 7 emphasizes that proper lifestyle intervention in hypertension should serve as the equivalent of one drug in a multidrug regimen.
Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7) Express. National Heart, Lung, and Blood Institute. Bethesda, Md. 2003. JAMA. 2003;289:2560–2571.
142. A 62-year-old business executive with a history of migraines is noted to have hypertension; otherwise, he is healthy. Which of the following is the best medication for the treatment of his hypertension?
A) β-Blocker
B) Angiotensin-receptor blocker
C) α-Blocker
D) ACE inhibitor
E) Thiazide diuretic
Answer and Discussion
The answer is A. β-Blockers are used as first-line therapy for the treatment of uncomplicated hypertension. These agents decrease the heart rate and cardiac output. β1-Adrenergic receptors are located in the cardiac muscle, whereas β2-adrenergic receptors are located in the bronchial musculature. Adverse effects include exacerbation of bronchoconstriction in asthmatics because of β2-receptor blockade, bradycardia, left ventricular failure, nasal congestion, nightmares, Raynaud's phenomenon, fatigue, depression, cold extremities, and impotence. β-Blockers are also associated with elevated triglycerides and decreased HDL cholesterol; however, there is not enough effect on lipids to discourage their use in select cases. These agents are contraindicated in patients with poorly controlled diabetes, second- or third-degree heart block, or moderate to severe asthma; however, these agents have been shown to improve survival after myocardial infarction and in select patients with CHF. These agents have also been used for the treatment of “stage fright” and as migraine prophylaxis. β-Blockers should not be discontinued abruptly because of the risk of rebound hypertension.
Ko DT, Hebert PR, Coffey CS. Adverse effects of β-blocker therapy for patients with heart failure. A quantitative overview of randomized trials. Arch Intern Med. 2004;164:1389–1394.
Weir MR, Moser M. Diuretics and β-blockers: is there a risk for dyslipidemia? Am Heart J. 2000;139:174–184.
Salpeter SR, Ormiston TM, Salpeter EE. Cardioselective β-blockers in patients with reactive airway disease: a meta-analysis. Ann Intern Med. 2002;137:715–725.
Epstein PE. Fresh air and β-blockade [Editorial]. Ann Intern Med. 2002;137:766–767.
143. Which of the following combinations would be best utilized in the treatment of diastolic heart failure?
A) Calcium-channel blocker + α-blocker
B) β-blocker + diuretic
C) ACE inhibitor + α-blocker
D) Calcium-channel blocker + diuretic
E) Angiotensin-receptor blocker + calcium-channel blocker
Answer and Discussion
The answer is B. Diastolic heart failure is a major contributor of morbidity and mortality. The condition is defined as symptoms of heart failure in a patient with a normal left ventricular function. It is characterized by a stiff left ventricle with decreased compliance and impaired relaxation, which leads to increased end diastolic pressure. Signs and symptoms are similar to those of heart failure with systolic dysfunction. The diagnosis of diastolic heart failure is made with transthoracic echocardiography. Treatment of diastolic heart failure should include normalizing blood pressure, promoting regression of left ventricular hypertrophy, avoiding tachycardia, treating symptoms of congestion, and maintaining normal atrial contraction when possible. Diuretic therapy is the mainstay of treatment for preventing pulmonary congestion, while β blockers appear to be useful in preventing tachycardia and thereby prolonging left ventricular diastolic filling time. Angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers may be beneficial in patients with diastolic dysfunction, especially those with hypertension.
Gutierriez C, Blanchard DG. Diastolic heart failure: challenges of diagnosis and treatment. Am Fam Physician. 2004;69:2609–2616.
144. A 58-year-old man presents to your office 4 weeks after being hospitalized for myocardial infarction. He is complaining of chest pain, fever, and multiple joint pain. Laboratory tests do not show an increase in cardiac enzymes. The most likely diagnosis is
A) Dressler's syndrome
B) costochondritis
C) Meigs' syndrome
D) recurrent myocardial infarction
E) pneumonia
Answer and Discussion
The answer is A. Dressler's syndrome, or postmyocardial infarction syndrome, occurs several days to several weeks after myocardial infarction. The condition is characterized by chest pain, fever, pericarditis with a pericardial friction rub, pericardial effusion, pleurisy, pleural effusions, and multiple joint pain. The cause is thought to be an autoimmune response to the damaged myocardial tissue and pericardium. The difference between Dressler's syndrome and recurrent myocardial infarction is difficult to determine; however, in Dressler's syndrome, there is minimal or no increase in cardiac enzymes. Treatment includes the use of aspirin, NSAIDs, and, in some cases, corticosteroids.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:651–652, 732–737.
145. A patient transferred from an outlying hospital after being involved in a serious motor vehicle accident has a positive dipstick for hemoglobinuria, but erythrocytes are not noted on microscopic examination. The most likely diagnosis is
A) myocardial contusion
B) rhabdomyolysis
C) intravascular hemolysis
D) renal contusion
E) laceration of the spleen
Answer and Discussion
The answer is B. A positive urine dipstick for hemoglobin results from free hemoglobin or myoglobin in the urine. Free hemoglobin appears in the urine when there is intravascular hemolysis. Once haptoglobin becomes saturated, free hemoglobin spills into the urine. A common cause is a transfusion reaction. Myoglobinuria is associated with rhabdomyolysis and occurs when there is significant muscle injury with the release of myoglobin into the bloodstream. Causes include electrical shock or massive muscle trauma. Other causes may include toxin exposures, metabolic disorders, inflammatory conditions, and infection. Myoglobinuria causes a positive urine test for blood in the absence of urinary erythrocytes.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1930.
Myoglobinuria causes a positive urine test for blood in the absence of urinary erythrocytes.
146. Positive results for which of the following tests support the diagnosis of de Quervain's tenosynovitis?
A) Allen's test
B) Finkelstein's test
C) Lachman's test
D) Anterior–posterior drawer test
E) Phalen's test
Answer and Discussion
The answer is B. The abductor pollicis longus and the extensor pollicis brevis share a common protective sheath that can become inflamed, giving rise to de Quervain's tenosynovitis. Patients usually report pain with movement of the fibrous bands that make up the first dorsal compartment over the radial styloid. Paresthesia and pain that radiates distally into the thumb and dorsal part of the hand and index finger may occur. In most cases, the patient has a history of repetitive motions of the hand or thumb. A positive Finkelstein's test is the hallmark test finding: Pain occurs when a fist is made over the thumb and the wrist is placed in ulnar deviation. Long-standing inflammation may lead to calcification of the tendon and its sheath and is visible on a radiograph. Treatment options involve rest, anti-inflammatory agents, immobilization of the affected area with a thumb spica splint, and injection of the compartment with 0.5 mL of steroid and 1 mL of 1% lidocaine. The splint is to be worn for 3 weeks; surgery is rarely necessary but can be considered in refractive cases.
Rakel RE, Bope ET. Conn's Current Therapy 2005. Philadelphia: Elsevier/Saunders; 2005:1134.
147. Which of the following statements about testicular tumors is true?
A) Boys ages 10 to 15 years are most commonly affected.
B) African-American men are more commonly affected.
C) Seminomas are the most common type.
D) The prognosis is extremely poor.
E) Carcinoembryonic antigen levels are elevated.
Answer and Discussion
The answer is C. Testicular tumors are usually found in men between 20 and 35 years of age. They are relatively uncommon and tend to affect white men more than African-American men. Cryptorchidism is associated with a higher incidence of tumor formation. The tumors are categorized as seminomas (most common) or nonseminomatous germ cell tumors. Symptoms include painless swelling or enlargement of the testicle and testicular heaviness. Diagnosis is confirmed with testicular ultrasound examination. Tumor markers, including human chorionic gonadotropin and α-fetoprotein, may be elevated in affected patients. In most cases, treatment involves surgical removal of the testicle or radiation therapy. If diagnosed in the early stages, the prognosis is usually excellent; therefore, young men should perform monthly testicular self-examinations.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:550–552.
148. Olecranon bursitis is usually the result of
A) deposition of negative birefringent crystals in the bursa
B) repeated trauma to the elbow
C) autoimmune destruction of the joint leading to a reactive bursitis
D) referred pain from the wrist
E) staphylococcal infection
Answer and Discussion
The answer is B. Olecranon bursitis (also known as miner's elbow) is an inflammation that affects the olecranon bursa. The inflammation is usually caused by repeated trauma to the affected area, such as repeated weightbearing on the elbow. Patients usually report pain, discomfort, and swelling of the elbow area. In some cases, the bursa may harbor an infection, which may require antibiotic treatment; in most cases, there is no associated infection. Treatment involves anti-inflammatories, aspiration of the fluid, and, in some cases, steroid injection followed by the use of a pressure dressing to help prevent reaccumulation of fluid. Infection should be excluded before administering steroid medication. The avoidance of trauma to the elbow should also be emphasized for treatment. Surgery may be necessary for resistant and debilitating cases.
Chumbley EM, O'Conner FG, Nirschl RB. Evaluation of overuse elbow injuries. Am Fam Physician. 2000;61:691–700.
149. The most effective drug for the treatment of traveler's diarrhea is
A) metronidazole
B) tetracycline
C) ciprofloxacin
D) trimethoprim–sulfamethoxazole (TMP-SMX)
E) doxycycline
Answer and Discussion
The answer is C. Travel to Third-World countries can be complicated by traveler's diarrhea. The incidence ranges from 4% to >50%. The most common pathogens are enteropathogens (e.g., E. coli) in approximately 80% of cases; occasionally, viruses such as the Norwalk agent or rotavirus are causative. Traditionally, the problem was treated with TMP-SMX and bismuth subsalicylate (Pepto-Bismol). However, the quinolones (e.g., ciprofloxacin, levofloxacin, norfloxacin) are now the most effective drugs in the treatment of traveler's diarrhea. Loperamide (Imodium) can also be used if fever or bloody diarrhea is not present. The traveler should also take precautions by eating only freshly prepared foods that are adequately cooked, eating freshly peeled fruits, drinking only boiled or bottled water, and avoiding tap water and ice made from tap water (even in alcoholic drinks). Bismuth subsalicylate (Pepto-Bismol) is a helpful prophylaxis, but it must be taken four times daily (60 mL or 2 tablets). The use of prophylactic antibiotics is controversial, but, in most cases, is discouraged because of the risk of developing resistant organisms.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:727–728.
150. Which of the following statements about orthostatic hypotension is true?
A) It is a decrease in systolic blood pressure that occurs when moving from a standing to a sitting position.
B) It is commonly associated with a decrease in pulse rate.
C) In some cases, it is associated with antidepressant medications.
D) It is rarely associated with symptoms.
E) The condition results from volume overload.
Answer and Discussion
The answer is C. Orthostatic hypotension is defined as a decrease in systolic blood pressure of at least 20 mm Hg (systolic) and at least 10 mm Hg (diastolic) that occurs when moving from a supine to an upright position. Also, orthostatic tachycardia is defined as an increase in heart rate >27 bpm or to a level >108 bpm. Measurements of blood pressure and pulse rate should be taken after the individual has been in an upright position for 3 minutes. Causes of orthostatic hypotension include volume depletion, medications (e.g., tricyclic antidepressants, antihypertensive agents), and autonomic dysfunction (as seen in diabetic patients). Elderly patients are at increased risk, and syncope may result. Treatment involves volume replacement, discontinuation of offending pharmacologic medications, and slow positional changes.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:581–584.
151. A 17-year-old woman arrives in the emergency room with carpal–pedal spasms and circumoral paresthesias. She was brought in by paramedics after she fainted at a rock concert. The most likely diagnosis is
A) cardiac arrhythmia
B) seizure disorder
C) hyperventilation
D) heat exhaustion
E) cocaine overdose
Answer and Discussion
The answer is C. Hyperventilation can lead to a significant respiratory alkalosis and is frequently the result of anxiety or extreme excitement. Other less common causes include drug effects, CNS dysfunction, alcohol withdrawal, asthma, heart failure, pulmonary embolus, exposure to high altitudes, intense exercise, and chronic pain. Symptoms include carpal–pedal spasms, circumoral and extremity paresthesias, light-headedness, giddiness, and sometimes syncope. Blood gases usually show low CO2 (20 to 25 mm Hg) and elevated pH. Treatment can be accomplished by breathing into a paper bag. Other efforts should be directed at the treatment of anxiety or underlying contributing factors; relaxation training may be beneficial.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:358–359.
152. Which of the following statements about herpes infections is true?
A) Type 1 is most commonly associated with genital infections.
B) Topical acyclovir is used for prophylaxis.
C) Recurrent outbreaks are usually more severe than an initial outbreak.
D) The rash usually consists of pustules, papules, and macules.
E) Multinucleated giant cells are seen with Tzanck smears.
Answer and Discussion
The answer is E. Herpes simplex infections are divided into type 1, which usually affects the oral mucosa, and type 2, which usually affects the genitals. The virus invades the nervous tissue and remains dormant in the skin or nerve ganglia. Symptoms include recurrent, clear vesicles that usually occur in clusters and are extremely painful; fever; arthralgias; and adenopathy. Initial attacks are usually more severe and longer in duration than repeated attacks. Before the appearance of the vesicles, the patient may report paresthesias or tingling at the site of the outbreak. Transmission occurs by direct contact and is usually sexually transmitted, particularly for type 2. Repeated attacks are usually precipitated by excessive sunlight exposure, menstruation, stress, and febrile illnesses. Laboratory tests include positive Tzanck smears (with the presence of multinucleated giant cells), cultures (gold standard for diagnosis), and rapid immunofluorescent antibody tests. The treatment of choice involves the use of topical and oral antiviral medication (acyclovir, valacyclovir, and famciclovir). Oral administration is more effective and should be begun at the initial onset of clinical symptoms. For severe cases, intravenous acyclovir may be used. In some cases, daily prophylactic oral therapy may be necessary.
Ferri F. Ferri's Clinical Advisor, Instant Diagnosis and Treatment. Philadelphia: Elsevier/Mosby; 2006:385–386.
153. A 42-year-old male presents with multiple pigmented skin lesions, ataxia, and decreased hearing. Other family members are similarly affected. The most likely diagnosis is
A) hemochromatosis
B) malignant melanoma
C) neurofibromatosis
D) Sturge–Weber syndrome
E) measles
Answer and Discussion
The answer is C. Neurofibromatosis (also known as von Recklinghausen's disease) is an autosomal-dominant disorder that is characterized by pigmented skin lesions (café-au-lait spots) and neuromas affecting the skin and nerves. As many as 33% of patients are asymptomatic. Symptomatic patients may have blindness, dizziness, ataxia, deafness secondary to acoustic neuromas, or other symptoms related to nerve compression from neuromas. The diagnosis of neurofibromatosis is supported by the detection of more than six pigmented lesions or one lesion larger than 1.5 cm. Asymptomatic patients do not require further therapy; however, those who exhibit symptoms may require surgery or radiation to remove offending neuromas. Genetic counseling is recommended.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2377–2379.
154. Guillain-Barré syndrome is most closely associated with
A) normal electromyogram (EMG) findings found late in the course
B) descending asymmetric paralysis
C) previous trauma
D) symptoms that usually begin in the lower extremities
E) low levels of protein in the cerebrospinal fluid (CSF)
Answer and Discussion
The answer is D. Guillain-Barré syndrome is an acute or subacute demyelinating polyradiculopathy that often follows an infection (two-thirds of patients recall a recent viral infection), vaccinations (rabies, influenza), malignancy (lymphomas), medications (streptokinase, captopril, danazol), or surgical procedure. Although it is believed to be associated with an immunologic response, the exact mechanism is unknown. The presenting complaint is usually weakness associated with the proximal muscles in a symmetric distribution that varies in severity. Paresthesias of the toes and fingers may also occur. The symptoms usually begin in the lower extremity and may progress to involve the arms and face (ascending symmetric paralysis). In severe cases, the respiratory muscles may be affected, and the patient may require mechanical ventilation. Sensory-related paresthesias are common. Other symptoms include tachycardia, hypotension, hypertension, diaphoresis, hyporeflexia, and loss of sphincter control. Laboratory findings include elevated protein levels and minimal lymphocytic pleocytosis in CSF samples, altered electromyelogram (EMG) findings, and evidence of demyelination on nerve biopsies. Treatment involving the use of plasmapheresis and intravenous Ig has been shown to be beneficial, particularly early in the course of the disease (i.e., within the first few days). Steroids have not been shown to be beneficial and may actually worsen the outcome. Most cases resolve spontaneously, but recovery may take months. Mortality is approximately 10%. Up to 20% of patients may be left with persisting deficits. Approximately 3% may develop relapses, sometimes years later.
Ferri F. Ferri's Clinical Advisor, Instant Diagnosis and Treatment. Philadelphia: Elsevier/Mosby; 2006:355.
The symptoms of Guillain-Barré syndrome usually begin in the lower extremities and may progress to involve the arms and face (ascending symmetric paralysis).
155. An obese, hypertensive woman is involved in a motor vehicle accident. Skull films show an enlarged sella turcica. Further questioning reveals that the patient has also complained of galactorrhea, and results of a recent prolactin test were abnormal. The most likely diagnosis is
A) Sheehan's syndrome
B) empty sella syndrome
C) subdural hematoma
D) subarachnoid hemorrhage
E) undetected pregnancy at 12 to 16 weeks' gestation
Answer and Discussion
The answer is B. Empty sella syndrome is a congenital abnormality that results in abnormal formation of the sella turcica, in which the hypothalamus and pituitary gland are found. In many cases, an enlarged sella turcica is seen by chance on a skull radiograph. Diagnosis is confirmed by a CT scan or MRI. Those affected are usually obese women who have hypertension and benign intracranial hypertension. In most cases, the individual is asymptomatic. However, patients may have persistent rhinorrhea or pituitary disorders, including tumors releasing growth hormone, ACTH, or prolactin. No treatment is required if empty sella syndrome is present without other abnormalities.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1179.
156. Which of the following medications would improve survival following a myocardial infarction?
A) Metoprolol
B) Hydrochlorothiazide
C) Warfarin
D) Nitroglycerin
E) Morphine
Answer and Discussion
The answer is A. β-Blockers reduce mortality during both acute and long-term management of myocardial infarction. Administration of intravenous β-blockers within 12 to 24 hours of infarction, followed by oral therapy, has been found to significantly reduce the mortality rate within the first week of infarction. The most marked reduction occurs in the first 2 days after infarction. Initiation of β-blocker therapy within days to weeks after infarction and continuation of therapy has been shown to reduce total mortality, nonfatal myocardial infarction and sudden death. This has been shown regardless of the patient's age or sex, infarct location, and initial heart rate, or the presence or absence of ventricular arrhythmias. The greatest benefit occurs in high-risk patients, including the elderly and those with large anterior infarctions, arrhythmias, or left ventricular dysfunction.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:1452, 1455.
157. A 72-year-old female presents to the emergency room with the acute onset of right-sided hemiplegia. She is conscious but confused and agitated. Blood pressure is measured at 210/110. She has no cardiac findings. Appropriate management at this time should be
A) the administration of IV labetatolol
B) oral administration of clonidine
C) additional dose of her calcium channel blocker
D) sublingual nifedipine
E) observation
Answer and Discussion
The answer is E. Unless systolic blood pressure >20 mm Hg or diastolic pressure >120 mm Hg (sustained on repeated measurement), elevated blood pressure should not be treated within the first days after ischemic stroke. The reason is that perfusion is directly linked to mean arterial pressure. Acute elevations in blood pressure are often transient, and spontaneous declines are common. Aggressive treatment of hypertension following acute ischemic stroke can convert vulnerable areas of the brain into an infarct. The two exceptions to this general recommendation are (1) after use of tissue plasminogen activator (tPA), blood pressure should be maintained below 185/110 mm Hg; and (2) in the presence of myocardial infarction, heart failure, or aortic dissection, elevated blood pressure should be treated aggressively. If antihypertensive therapy is necessary, agents that have a rapid onset and predictable response should be used.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:2373–2375.
158. Which of the following medications should be avoided in patients with hypertrophic obstructive cardiomyopathy?
A) Aspirin
B) Digoxin
C) Disopyramide
D) Acetaminophen
E) Atenolol
Answer and Discussion
The answer is B. Hypertrophic obstructive cardiomyopathy is an autosomal-dominant transmitted disorder that is characterized by an enlarged cardiac septum, which obstructs blood flow from the left ventricle. Symptoms include dizziness, light-headedness, palpitations, chest pain, dyspnea, or syncope with physical exertion. The most important complication of the disease is sudden death. The condition has an annual incidence of 4% to 6% in children and 2% of adults affected. Signs include pulses that are bifid and brisk in upstroke and a systolic-ejection-type murmur positioned along the left sternal border, which becomes louder with movements that decrease venous return (afterload), such as standing or Valsalva's maneuver. Movements that increase venous return (afterload), such as squatting, reduce the murmur. ECG usually shows evidence of left ventricular hypertrophy and septal Q waves in the lateral leads. Diagnosis is accomplished by echocardiogram. First-line treatment is accomplished with the use of β-blockers. Disopyramide (Norpace) may be used as an alternative. Verapamil has also been used frequently on an empiric basis especially in atrial fibrillation but its effect is unpredictable and acute hemodynamic collapse is described in patients with substantial gradients or severe diastolic dysfunction. Digoxin should be avoided. Because of the risk for sudden death, extreme physical exertion should be avoided.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:1410.
159. Which of the following statements regarding aminoglycosides is true?
A) Liver function should be followed closely during administration.
B) Volume of distribution is increased in obese patients.
C) Nephrotoxic effects can occur with administration.
D) Lupus-like syndrome can occur with prolonged use.
E) Respiratory depression is not associated with aminoglycosides.
Answer and Discussion
The answer is C. Toxicity associated with the use of aminoglycosides (e.g., gentamycin) includes ototoxicity with clinically apparent hearing loss (<1% of cases), tinnitus, and vertigo, as well as nephrotoxic effects (5% to 10% of adults who receive therapy for 10 to 14 days), including renal failure. Rarely, respiratory depression can occur. Drug levels should be followed after a steady state is achieved—every 3 to 5 days or more often if increases in serum creatinine are noted. Patients with decreased renal function may need an adjustment of medication based on their creatinine clearance. Some data suggest that once-daily administration may cause less nephrotoxicity. Aminoglycosides have low solubility in lipids; therefore, the volume of distribution is decreased in obese patients. Patients with trauma, burns, cancer, and postoperative septic shock have increased volumes of distribution. Neuromuscular depression from aminoglycosides is caused by reduced acetylcholine activity at postsynaptic membranes and can result in rare but severe respiratory depression. This can be largely avoided if the aminoglycoside is given intravenously over 30 minutes or by intramuscular injection. If respiratory depression does occur, it can be reversed by the administration of calcium.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:801–802.
160. Which of the following best describes migraine headaches?
A) Aura following the resolution of the headache
B) Recurrent headaches lasting less than 4 hours
C) Unilateral, throbbing headache
D) Bilateral band-like headache
E) Rhinitis with facial pain
Answer and Discussion
The answer is C. There are basically two types of migraine headaches: those with an aura (classic migraine) and those without an aura (common migraine). A classic migraine is characterized by recurrent attacks of a moderate to severe unilateral, throbbing headache that is usually preceded by visual prodrome, which may include scotomata, zigzag lines, photopsia, or visual distortions. Patients also report nausea, vomiting, photophobia, mood swings, food cravings, and heightened perception of smell. The unilateral “throbbing” headache may become generalized and usually lasts 4 to 72 hours. Patients usually report a positive family history. Migraines usually begin at 10 to 40 years of age and are more common in women. The pathophysiology is not fully understood. Whether vasodilation or vasoconstriction is a cause or an effect of the migraine is unclear.
Tryptans such as sumatriptan (Imitrex) that activate serotonin receptors (5-hydroxytryptamine) block neurogenic inflammation and can abort migraine pain in approximately 70% of patients. Additionally, vasoconstrictors, such as ergotamines, have also been used to treat migraines. Other medications used include NSAIDs and narcotic analgesics. Migraine attacks may be triggered by emotional or physical stress, lack of sleep, specific foods (e.g., chocolate, cheese), alcohol, oral contraceptives, or menstruation. Migraines usually disappear during pregnancy. Antiemetics and intravenous hydration may be needed if associated vomiting is severe. β-Blockers, low-dose amitriptyline, topiramate (Topamax) and other antiseizure medications, and calcium-channel blockers may be used for prophylaxis—particularly if patients have more than one migraine per week. Most patients experience a decrease in the number and intensity of headaches as they age. Common migraines are identical to classic migraines except the patient does not have an aura, and the headache may last longer.
Aukerman G, Knutson D, Miser WF. Management of acute migraine. Am Fam Physician. 2002;66:2123–2130, 2140–2141.
161. Which of the following can improve survival in patients with severe COPD?
A) Supplemental oxygen
B) Beta agonist
C) Inhaled corticosteroids
D) Smoking cessation
E) Pulse antibiotic therapy
Answer and Discussion
The answer is A. For patients with the diagnosis of severe COPD only the administration of supplemental oxygen has been shown to positively affect survival, reduce dyspnea, and reduce pulmonary artery pressure. B agonist and inhaled corticosteroids can lower the rate of exacerbations but have no direct effect on survival. Discontinuation of smoking can slow the decline in lung function but has no effect on survival. Pulse antibiotic therapy does not directly affect mortality.
Sin DD, McAlister FA, Man SF, et al. Contemporary management of chronic obstructive pulmonary disease: Scientific review. JAMA. 2003; 290(17):2301–2312.
162. Which of the following sequences represents how a typical anteroseptal myocardial infarction progresses on ECG?
A) Q-wave development, peaked T-waves, ST-segment elevation, T-wave inversion
B) T-wave inversion, Q-wave development, ST-segment elevation, peaked T-waves
C) Peaked T-waves, ST-segment elevation, Q-wave development, T-wave inversion
D) Peaked T waves, Q-wave development, ST-segment elevation, T-wave inversion
E) ST-segment elevation, T-wave inversion, Q-wave development, peaked T-waves
Answer and Discussion
The answer is C. The natural progression of ECG changes seen with myocardial infarction include peaked hyperacute T waves to ST-segment elevation, to Q-wave development, and to T-wave inversion. In anteroseptal infarction, ECG changes are usually noted in leads V1 through V3. Q waves indicate a transmural infarct.
Schroeder SA, Krupp MA, Tierney LM Jr, et al. Current Medical Diagnosis and Treatment. Norwalk, CT: Appleton & Lange; 1990:259.
163. The presence of a “bamboo spine” on spine radiographs, elevated erythrocyte sedimentation rate (ESR), and a positive test for HLA-B27 support the diagnosis of
A) multiple myeloma
B) Reiter's syndrome
C) ankylosing spondylitis
D) rheumatoid arthritis
E) Pott's disease
Answer and Discussion
The answer is C. Ankylosing spondylitis is an inflammatory condition that usually affects the axial skeleton of young men. The exact cause is not known. Symptoms include low-back pain or stiffness that radiates to the posterior thighs, decreased range of motion in the back or hips, and decreased range of motion of the chest wall. Sacroiliitis is usually one of the earliest manifestations. Other joints may be painful or swollen. Patients often report that the symptoms are worse with rest and improve with activity. Radiographs show periarticular destructive changes, destruction of the sacroiliac joint, development of syndesmophytes on the margins of the vertebral bodies, and bridging of osteophytes between the vertebral bodies, giving rise to the appearance of a “bamboo spine.” Acute anterior uveitis (iritis) occurs in approximately 20% of these patients. Laboratory tests show an elevated ESR and a positive test for HLA-B27 antigen in approximately 90% of those affected. The course of the disease is variable. Some patients may have no symptoms or only mild stiffness, whereas others may experience chronic pain and significant disabilities. Most patients with ankylosing spondylitis can remain gainfully employed. Treatment includes the use of NSAIDs and physical therapy. Attacks of iritis are effectively managed with local glucocorticoids in conjunction with mydriatic agents. In severe cases, systemic steroids or immunosuppressive drugs may be used.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:1993.
164. Which of the following statements is a common feature of fibromyalgia?
A) Men are more commonly affected than women.
B) Alcohol abuse is commonly associated.
C) Joint inflammation and erythema
D) Aggravation of the condition with lack of sleep, trauma, or cold exposure
E) Normal autonomic and neuroendocrine regulation
Answer and Discussion
The answer is D. Fibromyalgia/fibromyositis is characterized by generalized pain, tenderness, and muscle stiffness. Pain at the point of tendon insertion (“trigger points”) and surrounding soft tissue may also be present. Inflammation of joints is not characteristic. Although the etiology remains unclear, characteristic alterations in the pattern of sleep and changes in neuroendocrine transmitters such as serotonin, substance P, growth hormone, and cortisol suggest that dysregulation of the autonomic and neuroendocrine system appears to be the basis of the syndrome.
The condition may be aggravated by stress (both physical and mental), lack of sleep, trauma, exposure to cold, and sometimes infection. Primary fibromyalgia syndrome is more likely to affect young women who are tense, depressed, or anxious. Symptoms of stiffness and pain are usually diffuse and have an “achy” quality that comes on gradually. Localized symptoms tend to occur more abruptly. Other diseases (e.g., rheumatoid arthritis, hypothyroidism, polymyositis, polymyalgia rheumatica) must be excluded before the diagnosis is made. Myofascial pain syndrome is very similar to fibromyalgia/fibromyositis; however, the painful areas are usually regional, and men are as equally affected as women. In addition, fatigue is not a major finding. Treatment for fibromyalgia/fibromyositis includes low-dose tricyclic antidepressants (e.g., amitriptyline), acupuncture, and muscle relaxants (e.g., cyclobenzaprine). NSAIDS, although commonly used, have not been shown to be effective. Stress reduction counseling, exercise programs, and improved sleep habits can also be beneficial. American College of Rheumatology criteria for classification of fibromyalgia are as follows:
· Widespread pain for at least 3 months, defined as the presence of all of the following:
· Pain on the right and left sides of the body
· Pain above and below the waist (including shoulder and buttock pain)
· Pain in the axial skeleton (cervical, thoracic, or lumbar spine; anterior chest)
· Pain on palpation with a 4-kg force in 11 of the following 18 sites (9 bilateral sites, for a total of 18 sites):
o Occiput: at the insertions of one or more of the following muscles: trapezius, sternocleidomastoid, splenius capitis, semispinalis capitis
o Low cervical: at the anterior aspect of the interspaces between the transverse processes of C5–C7
o Trapezius: at the midpoint of the upper border
o Supraspinatus: above the scapular spine near the medial border
o Second rib: just lateral to the second costochondral junctions
o Lateral epicondyle: 2 cm distal to the lateral epicondyle
o Gluteal: at the upper outer quadrant of the buttocks at the anterior edge of the gluteus maximus muscle
o Greater trochanter: posterior to the greater trochanteric prominence
o Knee: at the medial fat pad proximal to the joint line
Adapted with permission from Wolfe F, Smythe HA, Yunas MD, et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum. 1990;33:160–172.
Millea PJ, Holloway RL. Treating fibromyalgia. Am Fam Physician. 2000;62:1575–1582, 1587.
Myofascial pain syndrome is similar to fibromyalgia/fibromyositis; however, the painful areas are usually regional, and men are as equally affected as women.
165. A known HIV-positive patient presents to your office with a violaceous skin lesion. Further examination shows generalized lymphadenopathy. Microscopic examination of a skin punch biopsy shows spindle cells mixed with vascular tissue. The most likely diagnosis is
A) malignant melanoma
B) Kaposi's sarcoma
C) tinea corpora
D) cherry hemangioma
E) cryptococcal granuloma
Answer and Discussion
The answer is B. Kaposi's sarcoma is a malignant skin lesion that was once rare but is now seen more commonly in AIDS patients. The lesion is characterized histologically by spindle cells mixed with vascular tissue. Before the detection of AIDS, the disease was predominantly found in Eastern Europe, Italy, and equatorial Africa and affected mostly Italian or Jewish men. Symptoms include pink, violaceous, or red papules or plaques that affect any body surface and become widely disseminated with time and give rise to generalized lymphadenopathy. Serious cases can progress to visceral involvement. Treatment involves excision, cryotherapy, laser ablation, intralesional chemotherapy, external beam radiation, and the use of vincristine. Unfortunately, successful treatment and remission of Kaposi's sarcoma does not affect the overall survival of AIDS patients.
Rose LC. Recognizing neoplastic skin lesions. Am Fam Physician. 1998;58:873.
166. A 31-year-old woman presents with high fever, dysuria, flank pain, nausea, and vomiting. The most appropriate treatment is
A) hospitalization with administration of intravenous fluids and antibiotics
B) oral rehydration and oral antibiotics for 10 days
C) surgical consultation for exploratory laparotomy
D) extracorporeal shock wave lithotripsy
E) nothing given orally and nasogastric suction
Answer and Discussion
The answer is A. Acute pyelonephritis is an infection of the upper urinary tract. It affects the kidneys' collecting system and renal parenchyma. The most common causative agent is E. coli. Other causative agents include Proteus, Pseudomonas, Enterobacter, Klebsiella, Staphylococcus, and Enterococcus. Symptoms include lower abdominal pain, flank tenderness, fevers, chills, nausea, and vomiting. Physical findings include tenderness of the costovertebral angle and the abdomen. Laboratory findings include elevated white blood cell count, elevated ESR, pyuria, bacteriuria, hematuria, proteinuria, and possible white blood cell cast. Severe cases may cause bacteremia (20% of patients).
Treatment is accomplished with antibiotics—usually ampicillin and gentamicin—directed at gram-negative organisms, third-generation cephalosporins for inpatients, and TMP-SMX or fluoroquinolones for outpatients. Patients with mild to moderate symptoms can be managed as outpatients. Hospitalization is required if the patient has a high fever, dehydration, or other complicating medical conditions (e.g., pregnancy, diabetes). Duration of antibiotic therapy depends on clinical response but should be at least 10 to 14 days. Intravenous antibiotics should be continued until the patient is afebrile. Repeat cultures after treatment should be performed; if the patient has had repeated infections, further workup, including an intravenous pyelogram or voiding cystourethrogram, may be necessary.
Orenstein R, Wong ES. Urinary tract infections in adults. Am Fam Physician. 1999;59:1225–1234.
167. Which of the following is the medication of choice for the treatment of Legionnaire's disease?
A) Penicillin
B) Cefuroxime
C) Azithromycin
D) Gentamycin
E) Amphotericin
Answer and Discussion
The answer is C. Legionnaire's disease is caused by Legionella pneumophila. It was discovered after an outbreak in Philadelphia in 1976 that affected many American Legion members. The condition represents one of the atypical pneumonias that usually affects immunocompromised patients, diabetic patients, patients with renal disease, smokers, and patients with chronic lung disease. It also is a relatively common nosocomial infection. Most affected individuals are middle-aged or elderly men. Although the disease can strike healthy individuals, risk factors include immunosuppression, cigarette smoking, COPD, cardiac or renal disease, or diabetes. The Legionella bacteria are found in water supplies, air conditioners, showers, condensers, and aerosol nebulizers. Transmission occurs by inhalation of aerosolized bacteria. Symptoms include a nonproductive cough that becomes productive, high fevers with relative bradycardia, pleuritic chest pain, diarrhea, and a toxic appearance. Laboratory tests usually show a moderate leukocytosis (10,000 to 15,000 per mm3), hyponatremia (50% of patients), hypophosphatemia, and elevated liver function tests. Sputum smears often show many polymorphonuclear neutrophils but do not show organisms. Chest radiographs show patchy infiltrates, which may progress to consolidations in the lobes. Pleural effusions are common. Diagnosis is achieved by culture, serologies, and direct and indirect antibody assays. The treatment of choice is typically oral erythromycin or similar macrolide antibiotic. More severe cases may require intravenous antibiotics and the addition of rifampin. Alternative medication includes clarithromycin, azithromycin, doxycycline, TMP-SMX, tetracycline, and ciprofloxacin.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1464.
168. Which of the following statements about babesiosis is true?
A) The disease is transmitted by fecal-oral contamination.
B) The disease is caused by a rickettsial organism.
C) Affected patients without spleens usually have a better prognosis.
D) Diagnosis is made with a peripheral blood smear.
E) Generalized paralysis occurs in those affected.
Answer and Discussion
The answer is D. Babesiosis is a tick-borne disease caused by Babesia microti and rarely affects humans. Most reported cases in the United States have been mild and were found on islands off the New York and Massachusetts coasts. Isolated cases have also been reported in Wisconsin, Georgia, and California. The disease is caused by a parasite that attacks the red blood cells. The symptoms of the disease resemble Falciparum malaria and include high fevers, hemolytic anemia, hemoglobinuria, jaundice, and renal failure. Those patients without spleens have a more severe course of symptoms. The diagnosis is obtained by observing the parasites (tetrad forms) in peripheral blood smears. Serologies can also be used for diagnosis. Treatment is usually unnecessary for those with intact spleens; however, for severe cases or cases that affect splenectomized patients, intravenous clindamycin and oral quinine are used for treatment.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1571–1572.
169. The drug of choice for cold-induced urticaria is
A) verapamil
B) cimetidine
C) diphenhydramine
D) cyproheptadine
E) hydroxyzine
Answer and Discussion
The answer is D. Urticaria is defined as an erythematous, pruritic rash that is often raised and occurs as discrete wheals and hives. The condition affects approximately 20% of the population. The rash involves the superficial layers of skin. The center of the wheal is usually pale, and the rash blanches with pressure. Involvement of the deeper layers is referred to as angioedema. The causes include allergen exposure; heat, cold, or sunlight exposure; and trauma. In many cases, a cause is never detected. The response is thought to be mediated by an IgE antibody. Those affected by cold may have cryoglobulins or cryofibrinogen, which become activated. In extreme cases, bronchoconstriction and anaphylaxis can occur. Unfortunately, an underlying cause is identified in only approximately 20% of cases. Treatment involves avoiding factors that trigger the response. Other treatment involves the use of antihistamine (H1) medications and histamine blockers (H2) such as cimetidine. Doxepin may also be beneficial. The drug of choice for cold-induced urticaria is cyproheptadine. Other causes of urticaria include medication use, malignancy, endocrinopathies, autoimmune diseases, insect bites, and infestations; psychogenic causes should also be investigated in complicated or persistent cases. Severe cases may require systemic steroids or the use of danazol.
Ferri F. Ferri's Clinical Advisor, Instant Diagnosis and Treatment. Philadelphia: Elsevier/Mosby; 2006:886.
170. In most situations, which of the following screening tests would be recommended for an otherwise healthy woman older than 50 years?
A) Chest radiograph
B) Mammogram
C) Treadmill exercise test
D) Urinalysis
E) CA 125 level
Answer and Discussion
The answer is B. Routine screening tests during general examinations should be focused according to the patient's age and gender. Annual mammograms should be performed for women older than 40 years. Chest radiographs (even for smokers), the treadmill exercise test, and urinalysis are not cost-effective for screening purposes. For cervical cancer screening, most organizations recommend a Papanicolaou test and pelvic examination at least every 3 years in patients between 20 (or when a woman first becomes sexually active) and 65 years of age. Annual fecal occult blood testing, or flexible sigmoidoscopy at 5 intervals or colonoscopy every 10 years are the standard recommendations for colorectal cancer screening in patients older than 50 years. Screening for prostate cancer remains an issue of debate. Some organizations recommend digital rectal examination and a serum prostate–specific antigen test for men older than 50 years, whereas others do not. In the absence of compelling evidence to indicate a high risk of endometrial cancer, lung cancer, oral cancer, and ovarian cancer, almost no medical organizations have developed cancer-screening guidelines for these types of cancer.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1150.
171. A 28-year-old man with no history of allergy to Hymenoptera stings presents to the emergency room after being stung by a yellow jacket. Other than local swelling at the site, he has no other symptoms. The most appropriate treatment involves
A) administration of epinephrine and antihistamine as well as hospitalization
B) ice therapy, administration of antihistamine, and observation at home
C) meat tenderizer sprinkled over the sting site, warm-water soaks, and aspirin
D) administration of steroids, epinephrine, intravenous hydration, and β2 agonist
E) immediate removal of the stinger using tweezers
Answer and Discussion
The answer is B. Stings by a Hymenoptera (e.g., bees, wasps, yellow jackets, hornets, and ants) may be fatal in a hypersensitive patient. Each year in the United States, more patients die of bee stings than of snakebites. Patients with a history of hypersensitivity may experience severe swelling at the site of the sting with the development of shock, often within minutes. Treatment should be immediate and includes application of ice to the sting site, administration of intramuscular epinephrine and oral antihistamine, and prompt transfer to the hospital. Removal of the stinger by tweezers is usually avoided because of the possibility of injecting further venom at the site. All patients with Hymenoptera-sting hypersensitivity should receive a prescription for an epinephrine kit and carry this with them whenever they are outdoors. Patients should also be counseled to receive hymenoptera desensitization immunotherapy. Individuals with no history of anaphylaxis may be treated by application of ice to the sting, administration of oral antihistamine, and observation at home. Large local reactions may be treated with glucocorticoids. Application of meat tenderizer containing papain is of no proven value.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:2605.
172. A 72-year-old farmer is admitted to the emergency room with symptoms of palpitations and shortness of breath. He denies chest pain. ECG findings show a rapid and irregular rhythm measured at 130 beats/minute. Appropriate treatment at this time includes
A) nifedipine
B) amiodorone
C) adenosine
D) diltiazem
E) flecainide
Answer and Discussion
The answer is D. Atrial fibrillation (AF) is the most common sustained arrhythmia. The following recommendations do not apply to patients with postoperative or post-MI AF, class IV heart failure, existing antiarrhythmic-drug therapy, or valvular disease. The majority of patients with newly detected AF should be managed with pharmacologic rate control (rather than rhythm control) plus ongoing anticoagulation therapy. (The expense and risk of antiarrhythmic drugs give rate control a slight advantage, despite equivalent efficacy.) Rhythm control is appropriate for specific subgroups, including patients with severe symptoms and those with a preference for this strategy. Recommended drugs for rate control are atenolol, metoprolol, diltiazem, and verapamil. Because digoxin is effective for rate control only at rest, it should be considered second-line therapy. Unless contraindicated, adjusted-dose warfarin should be used for ongoing anticoagulation therapy in AF patients with stroke risk factors. If a patient elects to undergo acute cardioversion to sinus rhythm, electrocardioversion and pharmacologic options are each appropriate. The most effective drugs are ibutilide, flecainide, dofetilide, propafenone, and amiodarone. Two anticoagulation strategies are appropriate for preventing thromboembolism: (1) 3 to 4 weeks of anticoagulation before and after cardioversion; and (2) early cardioversion guided by transesophageal echocardiography plus 3 weeks of anticoagulation after cardioversion. Most patients who undergo cardioversion should not receive long-term antiarrhythmic maintenance therapy. However, such therapy is indicated in some patients, based on symptoms and patient preference. The most effective maintenance drugs are amiodarone, disopyramide, propafenone, and sotalol.
Snow V, Weiss KB, LeFevre M. et al. Management of newly detected atrial fibrillation: A clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians. Ann Intern Med. 2003; 139:1009–1017.
McNamara RL, Tarariz LJ, Segal JB, et al. Management of atrial fibrillation: Review of the evidence for the role of pharmacologic therapy, electrical cardioversion, and echocardiography. Ann Intern Med. 2003;139:1018–1033.
173. A 58-year-old secretary presents with asthenia and hyperpigmented changes on her elbows and inner cheek. She also has noted her blood pressure is low and she is dizzy when she stands. She has lost 10 pounds and has some nausea but no vomiting. A recent test for coccidioidomycosis was positive. Appropriate testing at this time includes
A) CT of the abdomen
B) esophagoduodenoscopy
C) glucose tolerance test
D) ACTH stimulation test
E) colonoscopy
Answer and Discussion
The answer is D. Addison's disease results from a progressive destruction of the adrenal glands, which must involve the majority of the glands before adrenal insufficiency appears. The adrenal is a frequent site for chronic granulomatous diseases, predominantly tuberculosis but also histoplasmosis, coccidioidomycosis, and cryptococcosis. Although infection with tuberculosis at one time was the most common cause of Addison's disease, now the most frequent cause is ideopathic atrophy, related to an autoimmune mechanism. Adrenocortical insufficiency caused by gradual adrenal destruction is characterized by a gradual onset of fatigability, weakness, anorexia, nausea and vomiting, weight loss, skin and mucous membrane pigmentation, hypotension, and in some cases hypoglycemia depending on the duration and degree of adrenal insufficiency. The manifestations vary from mild chronic fatigue to life threatening shock associated with acute destruction of the glands. Asthenia is the major presenting symptom. Early in the course it may be sporadic, occurring at times of stress. Late in the course the patient is continuously fatigued. Hyperpigmentation can occur. It commonly appears as a diffuse brown, tan, or bronze darkening of parts such as the elbows or creases of the hand and pigmented areas such as the areolae around the nipples. Bluish-black patches may appear on the mucous membranes. Some patients develop dark freckles and a persistent tan following sun exposure can occur. Hypotension with orthostasis is frequent, and blood pressure may be in the range of 80/50 mm Hg or less. Abnormalities of the gastrointestinal tract are often the presenting complaint. Symptoms include anorexia with weight loss to severe nausea, vomiting, diarrhea, and vague and sometimes severe abdominal pain. Patients may also exhibit personality changes, usually consisting of excessive irritability and restlessness. Axillary and pubic hair may be decreased in women due to loss of adrenal androgens. The diagnosis of adrenal insufficiency is made with the ACTH stimulation testing to assess adrenal reserve capacity for steroid production. The best screening test is the cortisol response 60 minutes after cosyntropin is given intramuscularly or intravenously. Cortisol levels should increase appropriately. If the response is abnormal, then primary and secondary adrenal insufficiency can be distinguished by measuring aldosterone levels from the same blood samples. In secondary, but not primary, adrenal insufficiency the aldosterone level is normal. In primary adrenal insufficiency, plasma ACTH and associated peptides are elevated because of loss of the usual cortisol-hypothalamic-pituitary feedback loop, whereas in secondary adrenal insufficiency, plasma ACTH values are low or “inappropriately” normal.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:2097–2099.
174. A 17-year-old surfer presents to your office complaining of an intensely pruritic, serpinginous type rash that has formed on the sole of his foot. The rash appears to be spreading and is forming bullae at the affected site. The most likely diagnosis is
A) tinea pedis
B) bathing suit dermatitis
C) leishmaniasis
D) ascariasis
E) cutaneous larva migrans
Answer and Discussion
The answer is E. Cutaneous larva migrans, also known as the creeping eruption, is a common, self-limited, parasitic infection seen in patients who live in warm climates or have recently traveled to tropical regions, particularly if they have been to beaches and shady areas. The most common infective agent is a dog and cat hookworm, Ancylostoma caninum and Ancylostoma braziliense, respectively. Familial outbreaks of cutaneous larva migrans have been noted where the infection began with the household pet. When the animal defecates, the hookworms are shed and the larvae are picked up by humans through breaks in the skin, hair follicles, and even through intact skin. The areas most often affected include the feet, hands, buttocks, thighs, and chest. The eruption begins as a pruritic lesion at the site of entry and progresses within a few hours into an inflamed papular or papulovesicular eruption. Serpinginous tracks left by the larvae's migration may also be seen. The eruption may spread up to 1 to 2 cm per day. Severe pruritus, vesicular and bullous lesions, local swelling, erosions, and folliculitis may be seen. Biopsy is generally not useful, and blood tests rarely show eosinophilia or elevated immunoglobulin E levels. Destructive therapies, such as cryotherapy, are often ineffective. Isolated cutaneous cases are treated with topical thiabendazole, especially when applied ahead of the advancing lesions. Because of the risk of systemic infection and the ease of oral treatment, some recommend routine systemic treatment with oral thiabendazole, albendazole, or ivermectin. Although thiabendazole has significant side effects that include nausea, vomiting, diarrhea, and dizziness, albendazole and ivermectin are reliable and have fewer adverse effects. Ivermectin may be given as a single dose with no known toxic side effects.
Loughrey MB, Irvine AD, Girdwood RW, et al. Cutaneous larva migrans: the case for routine oral treatment. Br J Dermatol. 1997;137:155–156.
Van den Enden E, Stevens A, Van Gompel A. Treatment of cutaneous larva migrans. N Engl J Med. 1998;339:1246–1247.
175. The most common cause of a community-acquired pneumonia in a 45-year-old otherwise healthy man is
A) Streptococcus pneumoniae
B) Haemophilus influenzae
C) Mycoplasma pneumoniae
D) Legionella pneumoniae
E) Klebsiella pneumoniae
Answer and Discussion
The answer is A. In young adults, causes for pneumonia include Mycoplasma, Chlamydia pneumoniae (formerly termed the TWAR strain), influenza, adenovirus, Pneumocystis carinii (in immunocompromised patients), and other community-acquired organisms including Streptococcus, Haemophilus, and, occasionally, Legionella. Pneumonia in adults with no underlying disease is usually caused by S. pneumoniae, representing more than 50% of community-acquired pneumonias that require hospitalization. Other causes in this patient group include H. influenzae, Legionella, Mycoplasma (more commonly seen in young adults), and influenza viruses. If the patient is older than 60 years and has other significant medical problems (e.g., diabetes, COPD, heart disease, alcoholism), the most common pathogens include the previously mentioned organisms as well as Klebsiella, Enterobacteriaceae, Chlamydia, and S. aureus. For patients with aspiration or nosocomial infections, the causative organisms include the previously mentioned organisms and the gram-negative organisms (including Pseudomonas) and anaerobes.
Ferri F. Ferri's Clinical Advisor, Instant Diagnosis and Treatment. Philadelphia: Elsevier/Mosby; 2006:652–660.
Pneumonia in adults with no underlying disease is usually caused by Streptococcus pneumoniae, representing more than 50% of community-acquired pneumonias that require hospitalization.
176. Which of the following factors is NOT associated with diabetic ketoacidosis?
A) Hyperglycemia
B) Acidosis
C) Dehydration
D) Hyperkalemia
E) Hyperosmolarity
Answer and Discussion
The answer is D. Diabetic ketoacidosis occurs in diabetics when a severe lack of insulin leads to (1) a breakdown of free fatty acids and (2) the production of acetoacetic acid, β-hydroxybutyric acid, and acetone, resulting in severe and life-threatening acidosis. The condition usually occurs in patients with type I diabetes mellitus and is often seen as the initial presentation. Triggering factors include infection, trauma, poor compliance with insulin administration, myocardial infarction, cerebrovascular accident, alcohol intoxication, or dehydration. Diabetic ketoacidosis is characterized by the following conditions:
· Hyperglycemia
· Acidosis
· Dehydration (secondary to osmotic diuresis)
· Hyperosmolarity
· Potassium loss
Symptoms include mental status changes, tachypnea, fruity breath (secondary to acetones), and nausea and vomiting with abdominal pain. In severe cases, coma may occur. Treatment involves the administration of insulin to lower glucose levels, fluid rehydration (usually >5 L), and replacement of potassium and other electrolyte losses. If the condition is severe, cardiovascular collapse may occur. Close follow-up with frequent monitoring of serum pH, electrolytes, and urine output is necessary during treatment. Further tests should be conducted to rule out infection as a precipitating cause. Unfortunately, the white blood cell count is not a reliable indicator for the presence of infection in those with diabetic ketoacidosis, because the stress of the illness often causes the white blood cell count to increase to 15,000 to 30,000 cells/µL.
Ferri F. Ferri's Clinical Advisor, Instant Diagnosis and Treatment. Philadelphia: Elsevier/Mosby; 2006:255–256.
177. Which of the following findings is consistent with the syndrome of inappropriate ADH secretion (SIADH)?
A) Hypernatremia
B) Hypertonic urine
C) Hypovolemia
D) Increased glomerular filtration rate
E) Hyperosmolality
Answer and Discussion
The answer is B. SIADH is defined as less than maximally dilute urine in the presence of plasma hypoosmolality and hyponatremia. The condition is associated with a number of disorders, including small cell carcinoma of the lung, Guillain-Barré syndrome, acute intermittent porphyria, other pulmonary disorders (e.g., pneumonia, tuberculosis), and neurologic disorders (e.g., meningitis, tumors, trauma, stroke). In many cases, the condition may be idiopathic. The cause is the inappropriate release of ADH with respect to the body's fluid osmolality. Findings include
· Hyponatremia and hypoosmolality of body fluids
· Normal glomerular filtration rate
· Urine hypertonicity (usually >300 mOsmol/kg) despite a subnormal plasma osmolality and serum sodium concentration
· Isovolemia or hypervolemia without the presence of edema
· Urinary sodium wasting that increases with salt loading
Symptoms include confusion, anorexia, lethargy, and muscle cramps. Treatment involves fluid restriction—often <1 L daily. More severe cases may require replacement of sodium and potassium deficits. Care should be taken not to replace deficits too quickly because of the risk of central pontine myelinolysis. Other treatments involve the long-term use of demeclocycline, which antagonizes the effect of ADH on the kidney and produces a nephrogenic diabetes insipidus and helps to correct hyponatremia.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1239,1240.
178. A 40-year-old woman complains of diffuse symmetric joint pain that is worse in the morning but improves as the day progresses. Examination shows inflammation of the proximal interphalangeal and metacarpophalangeal (MCP) joints. The most likely diagnosis is
A) Reiter's syndrome
B) Rheumatoid arthritis
C) polymyalgia rheumatica
D) lupus erythematosis
E) osteoarthritis
Answer and Discussion
The answer is B. Rheumatoid arthritis is a chronic, symmetric, and inflammatory condition that may involve multiple joints. Women are affected two to three times more often than are men, and family members of affected individuals are at increased risk. Onset is usually between the fourth and sixth decade, but may occur at any age. Synovial inflammation leads to the destruction of articular and periarticular structures and proliferation of the synovial tissue (termed pannus), all of which causes chronic joint pain. In 30% to 40% of patients, subcutaneous rheumatoid nodules may form at sites subject to trauma and are usually associated with more severe conditions. Patients often complain of multiple joint pain, low-grade fever, fatigue, weight loss, and depression. Symmetric swelling of the hands (especially the proximal interphalangeal and MCP joints), wrists, elbows, shoulder, neck, and ankles is typical; however, any joint may be affected. Patients usually report morning stiffness that involves the small joints of the hands. This stiffness improves as the day progresses. Carpal tunnel syndrome may also occur. Other manifestations, including vasculitis, pericarditis, and interstitial fibrosis, may be found in more severe cases. Laboratory findings include elevated ESR (90% of cases), mild anemia, and a positive rheumatoid factor (85% of cases). Radiographs show periarticular osteoporosis, joint-space narrowing, and joint erosion in more severe cases. However, no laboratory test, histologic finding, or radiographic feature confirms the diagnosis. Treatment consists of NSAIDs (first-line therapy), interarticular and systemic steroids, etanercept (Enbrel) (a tumor necrosis factor α-blocker), disease-modifying antirheumatic drugs, and antimalarials (primarily hydroxychloroquine, which requires eye examinations every 6 months because of the risk of vision loss), sulfasalazine, azathioprine, cyclosporine, and methotrexate with folate supplementation (which requires close monitoring of liver and renal function). Other agents (e.g., penicillamine, cyclophosphamide, gold compounds) are less widely used because of side effects. Traditional drug combinations for RA commonly include an NSAID, a disease-modifying antirheumatic drug, and short intermittent courses of oral corticosteroids. The use of etanercept and methotrexate has been effective and promising in the treatment of rheumatoid arthritis. Other associated conditions include Felty's syndrome (arthritis, splenomegaly, lymphadenopathy, anemia, neutropenia, and thrombocytopenia) and Sjögren's syndrome (arthritis; dry eyes and mucous membranes).
Ferri F. Ferri's Clinical Advisor, Instant Diagnosis and Treatment. Philadelphia: Elsevier/Mosby; 2006:88–89.
179. A high urinary sodium concentration in the presence of a low plasma osmolality is most closely associated with
A) syndrome of inappropriate antidiuretic hormone (SIADH)
B) third-degree burns
C) hyperglycemia
D) prolonged diarrhea
E) water overload
Answer and Discussion
The answer is A. Hyponatremia is a common electrolyte abnormality seen in patients. Common causes include medications (e.g., diuretics, SSRIs) and SIADH syndrome. Hyponatremia can be classified according to the volume status of the patient as hypovolemic, hypervolemic, or euvolemic. Hypervolemic hyponatremia may be caused by congestive heart failure, cirrhosis, and kidney disease. Distinguishing between euvolemia and hypovolemia can be determined by measurement of plasma osmolality. Hyponatremia with a high plasma osmolality is caused by hyperglycemia, whereas a normal plasma osmolality indicates pseudohyponatremia. The urinary sodium concentration helps in diagnosing patients with low plasma osmolality. High urinary sodium concentration in the presence of low plasma osmolality can be caused by renal disorders, endocrine deficiencies, reset osmostat syndrome, SIADH, and medications. Low urinary sodium concentration is caused by severe burns, gastrointestinal losses, and water overload. Management includes emergent treatment in patients with acute severe hyponatremia because of the risk of cerebral edema and hyponatremic encephalopathy. In patients with chronic hyponatremia, fluid restriction is the mainstay of treatment, with the use of demeclocycline in persistent cases. Rapid correction of hyponatremia should be avoided to reduce the risk of central pontine myelinolysis. Loop diuretics are useful in the treatment of edema in hyponatremic states and in chronic SIADH. In all cases, identifying the etiology of hyponatremia remains an important part of treatment.
Goh KP. Management of hyponatremia. Am Fam Physician. 2004;69:2387–2394.
180. When comparing Bell's palsy with a CNS lesion (e.g., stroke, tumor), the distinguishing feature of Bell's palsy is
A) involvement of the forehead muscles
B) involvement of the extremities
C) lack of involvement below the eyes
D) slurred speech
Answer and Discussion
The answer is A. Bell's palsy is characterized by a sudden onset of unilateral facial paralysis. It is thought to be the result of an infection (usually viral) affecting the facial nerve, which involves compression of the nerve within the temporal bone. Symptoms usually develop as pain behind the ear preceding the facial paralysis. In some cases, the patient cannot close the affected eye because of widening of the palpebral fissures. In 80% to 90% of cases, the physical findings resolve completely within weeks to months after onset; however, in some isolated cases, permanent deficits may occur. The distinguishing feature between Bell's palsy and CNS lesions (e.g., strokes, tumors) is that Bell's palsy involves the entire face (including muscles of the forehead), whereas CNS lesions tend to affect the face below the eyes and other areas including the arms and legs. Treatment involves the use of steroids, but they are somewhat controversial and are of questionable proven benefit. If
P.56
the patient has difficulty closing the affected eye, it should be patched for protection against excessive drying.
Ferri F. Ferri's Clinical Advisor, Instant Diagnosis and Treatment. Philadelphia: Elsevier/Mosby; 2006:120.
181. A 30-year-old woman from Minneapolis presents to your office complaining of paresthesias, weakness, lack of coordination, and difficulty with gait. Her symptoms are worse after a hot shower. Examination of the cerebral spinal fluid shows oligoclonal bands of immunoglobulin G (IgG). The most likely diagnosis is
A) multiple sclerosis
B) Huntington's disease
C) Parkinson's disease
D) neurofibromatosis
E) amyotrophic lateral sclerosis (ALS)
Answer and Discussion
The answer is A. Multiple sclerosis is a slowly demyelinating disease that affects the CNS. It is characterized by remissions and exacerbations that are separated in time and involve different areas of the CNS. A second form identified is progressive. The cause is unknown but may be related to a combination of genetic factors and perhaps infection with a slow or latent virus. Women are affected more than men (2:1), and there appears to be a geographic predominance, with those in the northern United States affected more than those in the southern United States. The onset is usually between 20 and 40 years of age, and the geographic factor is present even if the individual relocates to a tropical climate (as long as they spent their first 15 years in the north). The pathology involves multiple plaques of demyelination that are found throughout the CNS. Symptoms include paresthesias, including Lhermitte's symptom (sensation of a momentary electrical current or shock when the neck is flexed), weakness, loss of coordination, or visual disturbances (monocular visual loss), initially followed by emotional lability, gait disturbances, and spasticity in more severe cases. Signs include optic neuritis, speech difficulties, cranial-nerve palsies, increased deep tendon reflexes, nystagmus, tremor, urinary incontinence, and impotence. Symptoms increase with exposure to heat. Diagnosis is usually made by the history, appearance of oligoclonal bands of IgG in the CSF, and MRI scans showing plaques of demyelination in the paraventricular white matter. Evoked potential nerve tests may also be abnormal. Treatment is usually supportive; however, steroids and immunosuppressive drugs have been used. Newer medications include interferon β-1b (Betaseron), interferon β-1a (Avonex), and glatiramer acetate (Copaxone), which are interferon-type medications used in the relapsing-remitting forms. In addition, antispasmodic drugs such as Baclofen have been used to treat the spasticity.
Johnson KP, Baringer JR. Current therapy of multiple sclerosis. Hosp Pract. 2001;36(4):21–22, 25–28; discussion 28–29.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:2461.
182. A 17-year-old boy is seen in the emergency room. He has miosis, bronchoconstriction, and diarrhea. He is also sweating, excessively salivating, and vomiting. His breath has a garlic odor. The most likely diagnosis is
A) alcohol overdose
B) organophosphate poisoning
C) cyanide ingestion
D) diabetic ketoacidosis
E) cocaine overdose
Answer and Discussion
The answer is B. Organophosphate insecticides are inhibitors of acetylcholinesterase and result in an accumulation of acetylcholine at the synaptic junction. Organophosphate poisoning is characterized by miosis, bronchoconstriction, sweating, salivation, headache, vomiting, diarrhea, muscle weakness, and convulsions. The patient's breath typically has a garlic odor. Treatment involves gastric lavage followed by activated charcoal or adequate cleansing if skin exposure occurs. Parasympathetic stimulation can be counteracted by the administration of atropine sulfate until symptoms disappear or until signs of atropine use occur (e.g., dilated pupils, dry mouth). Also, pralidoxime helps remove the organophosphate from the cholinesterase.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:226.
183. Which of the following statements about polycythemia vera is true?
A) It is a chronic myeloproliferative disorder that is associated with increased levels of hemoglobin (Hb) concentration and red blood cell mass (erythrocytosis).
B) It is associated with a neurodegenerative condition of the thalamus.
C) Physical examination usually shows decreased peripheral reflexes.
D) Leukopenia and thrombocytopenia are common.
E) The disease is associated with an increased life span of the red blood cell.
Answer and Discussion
The answer is A. Polycythemia vera is a rare, chronic myeloproliferative disorder that is associated with increased levels of hemoglobin concentration and increased red blood cell mass (erythrocytosis). The cause is unknown, and the condition is seen more commonly in men older than 60 years and in the Jewish population. The condition is associated with an increased production and turnover of red blood cells. As many as one-fourth of those affected develop a reduction in the red blood cell life span, an associated anemia, and sometimes myelofibrosis. Symptoms are associated with an increased viscosity and volume of blood and include headaches, visual disturbances, shortness of breath, weakness, and fatigue. Patients may also report generalized pruritus, particularly after bathing in warm water. Hepatosplenomegaly is common. Associated conditions include peptic ulcer disease, thrombosis, bone pain, renal lithiasis, and gout. The diagnosis should be considered when the hematocrit is >54% for men and >49% for women. Elevations in all three blood components (i.e., red blood cells, white blood cells, and platelets) are common. If the condition goes untreated, as many as 50% of those affected die within 1.5 years. Thrombosis is the most common cause of death, followed by complications of myeloid dysplasia, hemorrhage, and leukemia. With therapy, survival time is between 7 and 15 years. Treatment involves phlebotomy (especially for pregnant women and individuals younger than the age of 40 years) and, in some cases, myelosuppressive agents, including hydroxyurea. Hyperuricemia may also be treated with allopurinol.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co., 2006:1102–1105.
184. Which of the following drugs is commonly used in the treatment of congestive heart failure (CHF) related to systolic dysfunction?
A) Verapamil
B) Diltiazem
C) Ramipril
D) Nifedipine
E) Isoproterenol
Answer and Discussion
The answer is C. The causes of CHF are numerous and include CAD (most common), dilated cardiomyopathy arising from toxins such as alcohol and doxorubicin, idiopathic causes, infection, and collagen vascular disorders. Other causes include hypertension, cardiac arrhythmias, cardiac valvular disorders, hypertrophic cardiomyopathy, and restrictive cardiomyopathies (caused by disorders such as amyloidosis, hemochromatosis, and sarcoidosis). CHF occurs when there is a decrease in cardiac contractility, which leads to decreased cardiac output that does not keep up with the body's physiologic demands. Initially, this inability to keep up with physiologic demands may only be seen with exercise. However, as the disease progresses, signs may also occur at a resting state. Symptoms include shortness of breath; paroxysmal nocturnal dyspnea, which awakens the patient and causes severe shortness of breath and diaphoresis, causing the patient to sit up for prolonged periods; orthopnea (dyspnea in the recumbent position); and peripheral swelling. Signs include jugular venous distention more than 4 cm elevated from the sternal angle with the patient's head elevated at a 45-degree angle, hepatomegaly, hepatojugular reflux, S3 heart sound, peripheral edema, and pulmonary rales (the most common finding).
Treatment consists of a low-sodium diet, diuretics, ACE inhibitors (ramipril, enalapril, lisinopril) or angiotensin II–receptor blockers (losartan, candesartan) if unable to tolerate ACE inhibitors, β-blockers (carvedilol, long-acting metoprolol succinate), digoxin (particularly in CHF complicated with atrial fibrillation), and other afterload-reducing medications (e.g., hydralazine, isosorbide dinitrate). Calcium-channel blockers, especially verapamil, should be avoided because of their negative inotropic effect on the heart; however, they are useful in cases of CHF caused by diastolic dysfunction and hypertrophic cardiomyopathy.
Ferri F. Ferri's Clinical Advisor, Instant Diagnosis and Treatment. Philadelphia: Elsevier/Mosby; 2006:211–213.
185. Which of the following statements about influenza is true?
A) Symptoms rarely include cough and coryza.
B) Influenza C is the most common cause of the epidemic flu.
C) Diagnosis requires acute and convalescent titers.
D) Immunization for healthy adults should begin at 65 years of age.
E) Neuroaminidase inhibitors can shorten the course of illness if given within the first 48 hours of the onset of symptoms.
Answer and Discussion
The answer is E. Influenza is an acute viral illness characterized by fever, cough, coryza, headache, myalgias, and fatigue. The usual symptoms last 3 to 7 days. On average, illnesses tend to cause 5 to 6 days of restricted activity, 3 to 4 days in bed, and 3 days lost from work or school. Residual symptoms (nonproductive cough, weakness) may last for several weeks. Epidemics usually occur in the winter months. The disease usually spreads through school-age children first. Those with underlying medical problems (e.g., diabetes, COPD, CHF, chronic renal disease, immunodeficiencies) are at higher risk. The causative agent is an RNA orthomyxovirus. There are three different types of influenza:
· Influenza A is the most common cause of the flu.
· Influenza B is usually caused by paramyxovirus, rhinovirus, or echovirus.
· Influenza C is an endemic virus that occasionally causes mild respiratory disease.
Only types A and B cause epidemics.
Diagnosis is usually made clinically; however, rapid tests are now readily available. Treatment is usually symptomatic. In severe cases, antimembrane drugs [amantadine (Symmetrel) or rimantadine (Flumadine)] are used for influenza A (not influenza B), but are effective only if administered early in the course of the disease. Newer drugs (neuraminidase inhibitors) zanamivir (Relenza) and oseltamivir (Tamiflu), approved in 1999, work by inhibiting neuraminidase, a protein found on the surface of the virus that plays a role in the release of progeny virus from infected cells, and are effective for both influenza A and B. Zanamivir and oseltamivir shorten the duration of the influenzal febrile illness by 2 days and cause a reduction in viral titers within 2 days of administration, resulting in decreased transmission rate. Neuraminidase inhibitors appear to be more effective (compared to antimembrane drugs) for the treatment of influenza virus infection when given within 48 hours from the onset of symptoms. Unfortunately, however, antiviral agents are only slightly effective in preventing confirmed influenza or influenza-like illness. When given in the first few days of illness, the M2 ion blockers [amantadine (Symmetrel) and rimantadine (Flumadine)] and neuraminidase inhibitors [zanamivir (Relenza) and oseltamivir (Tamiflu)] reduce the duration of illness by approximately 1 day. Vaccination should begin at age 50 years and earlier in patients at high risk or with underlying medical problems. Young children should also receive vaccination.
Ferri F. Ferri's Clinical Advisor, Instant Diagnosis and Treatment. Philadelphia: Elsevier/Mosby; 2006:453–454.
In severe cases, antimembrane drugs amantadine (Symmetrel) or rimantadine (Flumadine) are used for influenza A (not influenza B) but are only effective if administered early in the course of the disease.
186. Which of the following medications is the most appropriate to use in the emergent treatment of anaphylaxis?
A) Diphenhydramine
B) Isoproterenol
C) Epinephrine
D) Prednisone
E) Atropine
Answer and Discussion
The answer is C. Anaphylaxis may be caused by a variety of factors, including ingestion of certain foods, insect bites or stings, drugs, and contrast dyes. Symptoms include urticaria, angioedema, dyspnea, cough, hoarseness, wheezing, a sense of impending doom, abdominal pain, hypotension, and syncope. Death occurs in 3% of patients. The cause is a massive IgE-mediated response, which results in the release of large amounts of histamine from mast cells. Treatment must be prompt and includes
· Securing the patient's airway
· Administering intravenous fluids
· Administering epinephrine, 0.2 to 0.5 mL of 1:1,000 subcutaneously, every 15 to 20 minutes, repeated three times if the patient is stable; if the patient is unstable, epinephrine should be administered intravenously
After the administration of epinephrine, diphenhydramine (H1-receptor blocker) should also be initiated; in severe reactions, cimetidine or ranitidine (H2-receptor blockers) should be initiated. All patients with anaphylaxis should be hospitalized and monitored for 24 hours. Corticosteroids have no role in the acute treatment of anaphylaxis but should be initiated to prevent a late-phase reaction. Bronchodilators such as albuterol and theophylline (if necessary) should also be used. Studies show that atopic individuals are not at increased risk for the development of IgE-mediated anaphylaxis as a result of drug reactions or insect stings.
Rakel RE, Bope ET. Conn's Current Therapy 2005. Philadelphia: Elsevier/Saunders; 2005:863–865.
187. Calcium supplementation appears to reduce the risk of which of the following conditions?
A) Ovarian cancer
B) Lung cancer
C) Breast cancer
D) Colon cancer
E) Prostate cancer
Answer and Discussion
The answer is D. Dietary calcium supplementation appears to reduce the risk of colon cancer in some studies. Combined evidence from two clinical trials of calcium supplementation lasting for several years revealed a reduced rate of recurrent colorectal adenoma. However, evidence is insufficient to recommend supplementation with dietary calcium for patients who have never had an adenoma. Although it would be beneficial to identify a simple, inexpensive, and safe dietary supplement to prevent colon cancer, comprehensive programs for healthy living are more likely to be effective. For prevention of colon cancer, the American Cancer Society recommends increasing the intensity and duration of physical activity; eating more vegetables and fruits; limiting intake of red meat; avoiding obesity; and avoiding excess alcohol consumption.
Weingarten MA, Zalmanovici A, Yaphe J. Dietary calcium supplementation for preventing colorectal cancer and adenomatous polyps. Cochrane Database Syst Rev. 2004;(3):CD003548.
Martinez ME, Willett WC. Calcium, vitamin D, and colorectal cancer: a review of the epidemiologic evidence. Cancer Epidemiol Biomarkers Prev. 1998;7:163–168.
Byers T, Nestle M, McTiernan A, et al. American Cancer Society guidelines on nutrition and physical activity for cancer prevention: reducing the risk of cancer with healthy food choices and physical activity. CA Cancer J Clin. 2002;52:92–119.
188. A 10-year-old boy is brought to the emergency room after suffering a bee sting on the hand. The patient complains of dizziness and shortness of breath. The appropriate course of action should be
A) to reassure patient and family and discharge patient with antihistamines
B) to intubate immediately, remove stinger with forceps, and monitor patient in an intensive care unit
C) to administer intravenous epinephrine, antihistamines, and fluids and observe closely
D) to provide ice therapy, sprinkle meat tenderizer on the sting site, and elevate the affected extremity
E) to prescribe an oral steroid taper, discharge the patient, and follow up with the child the following day in the office
Answer and Discussion
The answer is C. Bee stings are common, particularly in children. Each year, bee stings cause 3 to 4 times more deaths because of anaphylaxis than snakebites. The average person can safely tolerate 10 stings per lb of body weight; the average adult can withstand >1,000 stings, whereas 500 stings can kill a child. However, 1 sting can cause a fatal anaphylactic reaction in a hypersensitive person. Symptoms include local pain, swelling, and redness. In some patients, bee stings can lead to anaphylaxis with bronchoconstriction and shock. These patients require immediate attention with life-supporting measures and the administration of epinephrine. These patients should also be prescribed an epinephrine kit, which contains injectable epinephrine and diphenhydramine tablets, to carry with them whenever they are outdoors. For patients with mild reactions (local swelling and pain), ice should be applied, and the site should be gently rubbed to remove the stinger; the person removing the stinger should be careful not to pinch or grasp the stinger with forceps, because it may inject more venom at the site. Most symptoms increase over 24 to 48 hours but subside in 5 to 7 days. Antihistamines and anti-inflammatories may help to decrease reactions.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2639–2640.
189. Which of the following relationships between toxin exposure and symptoms is correct?
A) Vinyl chloride—behavioral changes
B) Mercury, lead, and pesticides—acroosteolysis
C) Iron, lithium, and lead—pulmonary fibrosis
D) Chromate and cocaine—nasal septal perforations
Answer and Discussion
The answer is D. Ingestion of toxins can cause a multitude of symptoms. However, there are specific symptoms particularly associated with specific toxins. The following are some toxins and their common identifiable symptoms:
· Mercury, lead, and pesticides—change of behavior
· Asbestos exposure—pulmonary fibrosis
· Vinyl chloride—acroosteolysis
· Chromate and cocaine—nasal septal perforations
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2651–2695.
190. Side effects of 3-hydroxy-3-methylglutaryl coenzyme A (HMG CoA) reductase inhibitors include
A) chronic rhinitis
B) infertility
C) rhabdomyolysis
D) orthostatic hypotension
E) cataracts
Answer and Discussion
The answer is C. HMG CoA reductase inhibitors (also referred to as statins) are used for the treatment of moderate to severe hypercholesterolemia. The drugs (atorvastatin, pravastatin, cerivastatin, fluvastatin, lovastatin, simvastatin) inhibit HMG CoA reductase, the rate-limiting step in cholesterol production. Statin drugs decrease the patient's total and LDL cholesterol and increase the patient's HDL cholesterol. The drugs can cause elevation of liver function tests; therefore, serum transaminases should be performed before the initiation of treatment, and 12 weeks after initiation of therapy, or at increase of dose and periodically thereafter. Elevations more than three times the normal levels are an indication to discontinue the drug. Statin drugs should be used with caution in patients with underlying liver dysfunction and heavy alcohol use. Rhabdomyolysis with renal failure is also a potential side effect. Routine eye examinations for the detection of lens opacities are no longer recommended.
Rakel RE, Bope ET. Conn's Current Therapy 2005. Philadelphia: Elsevier/Saunders; 2005:407–408, 670, 692.
191. Which of the following statements about rheumatic fever (RF) is correct?
A) It is a complication of a group B streptococcal infection.
B) It most commonly affects the aortic valve.
C) It is most commonly seen in patients younger than 4 years.
D) Prophylaxis against recurrent attacks with monthly penicillin administration is indicated after an acute attack.
E) It usually follows a streptococcal skin infection.
Answer and Discussion
The answer is D. Rheumatic fever is an inflammatory complication of a group A streptococcal pharyngitis. In the early 1900s, it was not uncommon; however, since the advent of antibiotics, the condition is seen much less frequently. More virulent strains of streptococci appear to be returning to the United States, and the incidence may increase in the next few years. The condition continues to flourish in developing countries. Rheumatic fever can give rise to
· Migratory polyarthritis
· Chorea
· Carditis
· Subcutaneous nodules
· Erythema marginatum
Rheumatic fever affects mostly school-age children and is rare before age 4 years and after 18 years of age. The most dangerous lesion of rheumatic fever involves the cardiac valves. The mitral valve is most commonly affected, followed by the aortic valve. Diagnosis is made by fulfillment of the modified Jones criteria, which involves (1) one and preferably two of the five major manifestations listed previously in the presence of a recent streptococcal infection; and (2) minor manifestations such as fever, arthralgias, history of RF, elevated white blood cell count, an elevation in the ESR or C-reactive protein, and a prolonged PR interval. Treatment is directed toward the relief of pain and includes analgesics (e.g., aspirin) and, in some cases, steroids for carditis. Sedimentation rate is used to monitor treatment. Mild cases require treatment only with anti-inflammatories; however, patients with carditis should be treated with steroids continued for at least 1 week after the ESR normalizes—at that time steroids may be slowly tapered. Bed rest has no proven value in treatment. Physical restrictions to reduce or eliminate symptoms seem advisable only in patients with symptomatic heart failure. Antistreptococcal prophylaxis is indicated after an attack of RF to prevent recurrent attacks; monthly benzathine penicillin G or oral sulfadiazine is used and is usually continued until early adulthood (25 years of age); however, the duration of antistreptococcal prophylaxis is controversial.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2358–2363.
192. Gilbert's disease is associated with
A) overproduction of glucuronyl transferase
B) mild (benign) elevations of indirect (unconjugated) bilirubin
C) intravascular hemolysis
D) increased risk for liver disease
Answer and Discussion
The answer is B. Gilbert's disease is a persistent, lifelong condition that involves the deficiency of glucuronyl transferase. It affects as much as 5% of the population. There may be a familial component. Patients exhibit a persistent elevation in indirect (unconjugated) bilirubin. Stressful states and fasting may increase bilirubin levels. Patients do not exhibit symptoms, and there is no evidence of hemolysis. Gilbert's syndrome can be distinguished from hepatitis by normal liver function tests, absence of urinary bile, and predominantly unconjugated bilirubin fractionation. Hemolysis is differentiated by the absence of anemia or reticulocytosis. Liver histology is normal but biopsy is not needed for the diagnosis. No treatment is required, and no untoward effects are noted. Patients should be reassured that they do not have liver disease.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:191, 195, 202.
193. Which of the following drugs used in the treatment of CHF has been shown to increase survival?
A) Digoxin
B) Furosemide
C) Hydralazine
D) Enalapril
E) Isosorbide dinitrate
Answer and Discussion
The answer is D. Medications for the treatment of CHF (related to systolic failure) include the following:
· Diuretics. Thiazide diuretics have been shown to be useful in decreasing fluid overload in patients with mild CHF by inhibiting sodium chloride reabsorption at the distal tubule; however, they are not usually effective in patients with advanced symptomatology. In moderate and severe cases, the loop diuretics (e.g., furosemide, bumetanide) are indicated; these agents inhibit solute resorption in the loop of Henle. Spironolactone (a potassium-sparing diuretic) can also be used in the treatment of CHF. Electrolytes should be monitored because of changes in serum potassium, as well as in sodium, magnesium, and calcium.
· ACE inhibitors (captopril, enalapril, lisinopril, ramipril). These medications serve as preload and afterload reducers by blocking (1) the production of angiotensin II, a potent vasoconstrictor, and (2) the release of aldosterone. ACE inhibitors are effective in the treatment of CHF and have been shown to increase survival in affected patients. Electrolytes should be monitored because of the possibility of hyperkalemia and renal insufficiency (especially in patients with renal artery stenosis). ACE inhibitors have also been shown to be beneficial in promoting renal blood flow in diabetes.
· Angiotensin II–receptor blockers (losartan, valsartan, candesartan) have similar effects to those of ACE inhibitors, although conclusive trials have not been reported regarding equal effectiveness.
· Digoxin. This medication has been shown to be effective in severe CHF and in CHF complicated by atrial fibrillation. Its mechanism of action involves the energy-dependent sodium–potassium pump, leading to increased intracellular calcium and a positive inotropic effect. Elderly patients and those taking other medication (e.g., quinidine, amiodarone) are at increased risk for toxicity and need close follow-up with monitoring of digoxin levels. Potassium levels should also be monitored closely; hypokalemia can precipitate arrhythmias in patients taking digoxin.
· β-Blockers (carvedilol, metoprololol) can reduce mortality in select patients—especially in patients with idiopathic dilated cardiomyopathy. With slower heart rates, diastolic function improves. Ventricular filling improves and the ejection fraction may improve over 6 to 12 months, giving rise to improved exercise capacity. Randomized control trials have shown significant reduction in all-cause mortality and cardiac events in patients taking carvedilol with mildly symptomatic CHF and an ejection fraction less than or equal to 35%.
· Vasodilators (e.g., hydralazine, isosorbide dinitrate) can be used if patients are unable to tolerate ACE inhibitors. They work by decreasing preload as a result of vasodilation.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:652–665.
Ramahi TM. Beta blocker therapy for chronic heart failure. Am Fam Physician. 2000;62:2267–2274.
194. Which of the following statements regarding pneumococcal vaccination is true?
A) Immunosuppressed patients should not be immunized.
B) Indian populations are at high risk for complications and should be avoided.
C) Revaccination should occur every 10 years.
D) A one-time booster is given to patients over age 65 if they were vaccinated more than 5 years previously and they were over 65 at the time of their primary vaccination.
E) Sickle cell patients should be revaccinated every 5 years.
Answer and Discussion
The answer is D. Medical indications for pneumococcal vaccination include chronic disorders of the pulmonary system; cardiovascular diseases; diabetes mellitus; chronic liver diseases, including liver disease as a result of alcohol abuse (e.g., cirrhosis); chronic renal failure or nephrotic syndrome; functional or anatomic asplenia (e.g., sickle cell disease, splenectomy); immunosuppressive conditions (e.g., congenital immunodeficiency, HIV infection, leukemia, lymphoma, multiple myeloma, Hodgkin's disease, generalized malignancy, organ or bone marrow transplantation); chemotherapy with alkylating agents, antimetabolites, or long-term systemic corticosteroids; or cochlear implants. Geographic and other indications include Alaska Natives and certain American Indian populations. Other indications include residents of nursing homes and other long-term-care facilities. A one-time revaccination after 5 years is recommended for persons with chronic renal failure or nephrotic syndrome; functional or anatomic asplenia (e.g., sickle cell disease or splenectomy); immunosuppressive conditions (e.g., congenital immunodeficiency, HIV infection, leukemia, lymphoma, multiple myeloma, Hodgkin's disease, generalized malignancy, or organ or bone marrow transplantation); or chemotherapy with alkylating agents, antimetabolites, or long-term systemic corticosteroids. For persons older than 65 years, a one-time revaccination is recommended if they were vaccinated <5 years previously and were older than 65 years at the time of primary vaccination.
MMWR. Indications for pneumococcol vaccination. 2003;53 (MM43):1007.
195. A 24-year-old poorly controlled diabetic patient presents to your emergency room with ketoacidosis, fever, pain, and purulent drainage of the sinuses with black eschar formation affecting the nasal septum. The most likely diagnosis is
A) mucormycosis
B) cocaine use
C) chronic sinusitis
D) Pseudomonas infection
E) Staphylococcus infection
Answer and Discussion
The answer is A. Mucormycosis (phycomycosis) is a fungal infection that can be fulminant and lethal. It affects the nose, sinus, and orbit and is seen in patients with poorly controlled diabetes, diabetic ketoacidosis, or immunodeficiency. Symptoms include dull sinus pain; fever; orbital cellulitis; proptosis; nasal congestion and purulent or bloody nasal discharge; and gangrenous destruction of the nasal septum, orbits, or palate. In many cases, a black eschar is formed in the nasal area. If the fungus invades the cerebral vessels, then convulsions, blindness, and death can result. Diagnosis almost always involves biopsy. CT or MRI can help evaluate the extent of the disease. Treatment is accomplished with diabetic control, amphotericin B, and surgical débridement. The prognosis is poor, with up to a 50% mortality rate in disseminated cases.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:1190.
Mucormycosis affects the nose, sinus, and orbit and is seen in patients with poorly controlled diabetes, diabetic ketoacidosis, or immunodeficiency.
196. Pterygium is associated with
A) an increased risk of glaucoma
B) involvement of the pupillary area, which may require surgical excision if affected
C) improvement with the use of topical anesthetics
D) trauma to the retina
E) macular degeneration
Answer and Discussion
The answer is B. Pinguecula are hyaline, elastic nodules that appear yellow and affect both sides of the cornea but usually more on the nasal side. Occasionally they become inflamed and require treatment with topical steroids. However, in most cases no treatment is required. Pterygium is a fleshy, triangular growth of a pinguecula that involves the cornea. In some cases, it may involve the pupillary area and requires surgical removal. The causes include irritation from UV sunlight; allergens; and excessive drying, sandy, or windy conditions that cause chronic irritation. In most cases, treatment is supportive with topical vasoconstrictors, saline drops, and protection from sunlight. Surgery is reserved for more severe cases in which vision is compromised.
Stein HA, Slatt BJ, Stein RM. The Ophthalmic Assistant, a Guide for Ophthalmic Medical Personnel. St. Louis: Mosby; 2000:454.
197. Which of the following statements about Hodgkin's disease is true?
A) Lymphocyte-predominant disease has a better prognosis than mixed-cellularity type.
B) Lymphocyte-depleted Hodgkin's disease is the most common type.
C) Stages A and B are distinguished by the presence of metastatic disease to regional lymph nodes.
D) The disease most commonly affects patients between 40 and 50 years of age.
E) Treatment for stages 1A and 2A involves chemotherapy.
Answer and Discussion
The answer is A. Hodgkin's disease is a type of lymphoma that involves the presence of Reed-Sternberg cells. This type of cell is a large, abnormal macrophage-like cell with two prominent nuclei and surrounding halos that look like owl eyes. The disease has a bimodal distribution with a peak in individuals in their mid-20s and another peak in individuals older than 50 years. Symptoms include fever, weight loss, night sweats, and occasionally pain associated with involved lymph nodes with the ingestion of alcohol. Most patients affected present with painless lymphadenopathy in the neck. Metastasis is usually to local lymph nodes, with hematogenous spread late in the course of the disease. Chest radiographs may show asymmetric mediastinal lymphadenopathy (compared with sarcoidosis, which usually involves symmetric lymphadenopathy). The disease is classified into four different types:
· Lymphocyte predominant
· Nodular sclerosis (most common type)
· Mixed cellularity
· Lymphocyte depleted
Once the diagnosis is made, the disease is staged based on extent. Staging determines the modality of treatment:
· Stage 1: one lymph node region involved
· Stage 2: two areas of lymph nodes involved on the same side of the diaphragm
· Stage 3: lymph node involvement on both sides of the diaphragm
· Stage 4: disseminated disease with bone marrow or liver involvement
Further criteria involves stages of symptoms:
· Stage A: lack of constitutional symptoms
· Stage B: weight loss, fever, and night sweats are present
Treatment of stages 1A and 2A involves radiation. Stages 3B and 4 are treated with combination chemotherapy (i.e., the use of mechlorethamine vincristine [Oncovin], procarbazine, and prednisone). Treatment of stages 2B and 3A is controversial, but usually involves combined chemotherapy and radiotherapy. The prognosis is variable. Those with localized disease have excellent prognoses, whereas those with disseminated disease have poorer prognoses. In addition, those who have lymphocyte-predominant and nodular-sclerosing type fare better than those with mixed cellularity and lymphocyte-depleted forms.
Rakel RE, Bope ET. Conn's Ccurrent Therapy 2005. Philadelphia: Elsevier/Saunders; 2005:492–500.
198. Gamekeeper's thumb is associated with a sprain of the
A) extensor pollicis brevis tendon
B) extensor pollicis longus tendon
C) ulnar collateral ligament
D) flexor carpi ulnaris tendon
E) flexor retinaculum
Answer and Discussion
The answer is C. Gamekeeper's thumb (also known as skier's thumb) occurs when there is a sprain or traumatic rupture of the ulnar collateral ligament in the area of the thumb MCP joint. The injury occurs when there is hyperextension and hyperabduction of the thumb, usually as the result of a fall. The injury results in ulnar laxity of the MCP joint and often dorsal subluxation of the proximal thumb at the MCP joint. Patients often complain of weakness and pain when using the thumb to pinch and to perform activities such as opening car doors or jars or turning the key in a door lock. Other physical findings include swelling, erythema, ecchymosis, and tenderness over the MCP joint of the thumb on the ulnar side. As much as 95% of the injuries to the MCP joint occur on the ulnar side. Radiographs may show ulnar deviation of the proximal thumb and avulsion fracture of the ulnar collateral ligament at the base of the proximal phalanx. If the avulsed fragment is displaced more than 1 mm or involves more than 10% of the articular surface, surgery is indicated for repair. Also, if stress radiographs show laxity of the ulnar collateral ligament greater than 35 degrees on an anteroposterior radiograph, patients should be referred to an orthopedist. However, in less severe cases, immobilization in a thumb spica cast for 4 to 6 weeks is indicated.
Taylor RB, David AK, Johnson TA Jr, et al., eds. Family medicine: principles and practice, 5th ed. New York: Springer-Verlag; 1998:971–972.
199. Chronic alcohol consumption is associated with which of the following laboratory findings?
A) Increased high-density lipoprotein (HDL) cholesterol
B) Decreased aspartate transaminase
C) Decreased γ-glutamyl transferase
D) Increased testosterone
E) Microcytic anemia
Answer and Discussion
The answer is A. Fifteen percent of patients seen in family practice and 10% to 20% of patients in the hospital have an alcohol problem requiring at least minimal intervention. Chronic alcohol consumption can lead to a number of laboratory findings, including increased levels of HDL cholesterol; mild elevations of aspartate transaminase and, more specifically, γ-glutamyl transferase; megaloblastic anemia as a result of folate deficiency; thiamine deficiency; decreased serum calcium; and decreased testosterone levels. In most cases, cessation of alcohol consumption corrects the abnormal laboratory results, except in cases in which permanent damage has occurred. Screening for alcohol abuse may be accomplished quickly in the office setting with the CAGE questions. This acronym is used to remind the examiner of the following questions:
· Have you ever felt the need to Cut down on your drinking?
· Have you ever been Annoyed by others' criticism of your drinking?
· Have you ever felt Guilty about your drinking?
· Have you ever had an “Eye opener” in the early morning?
A positive response to any of these questions should alert the examiner to ask more questions about the patient's alcohol consumption.
Ewing JA. Detecting alcoholism: the CAGE questionnaire. JAMA. 1984;252:1905–1907.
Rakel RE, Bope ET. Conn's Current Therapy 2005. Philadelphia: Elsevier/Saunders; 2005:1253, 1254.
200. A 55-year-old patient with a history of hypertriglyceridemia and severe abdominal pain with vomiting over the previous 6 hours is transferred from the emergency room to the hospital ward with the following laboratory findings:
· White blood cell count: 20,000
· Glucose: 295 mg/dL
· Aspartate aminotransferase: 333 IU/L
· Lactate dehydrogenase: 375 IU/L
The most likely diagnosis is
A) acute cholecystitis
B) acute pancreatitis
C) hepatitis
D) infectious mononucleosis
E) diabetic ketoacidosis
Answer and Discussion
The answer is B. Acute pancreatitis is caused by biliary tract disease, alcoholism, hyperlipidemia, hypercalcemia, hyperparathyroidism, trauma, medications (e.g., furosemide, valproic acid, sulfasalazine), infections, and structural abnormalities of the biliary tract. Symptoms include constant, boring, abdominal pain that radiates to the back; nausea; and repeated vomiting with a low-grade fever. Physical examination shows a distended rigid abdomen with positive peritoneal signs, tachycardia, tachypnea, and signs of dehydration and shock. Laboratory tests show an elevation in serum lipase (more sensitive) and amylase, elevated white blood cell count (12,000 to 20,000/mm3), elevated liver function tests, increased bilirubin, hyperglycemia, and hypocalcemia. Chest radiographs may show pleural effusions. Abdominal films may show the presence of a sentinel loop (ileus of the transverse colon). Ultrasound or CT examination may show evidence of gallstones, dilation of the common bile duct, or edema of the pancreas. Pancreatitis associated with hemorrhage or necrosis of the pancreas has a mortality rate that approaches 50%. Hemorrhage is suspected if there is a grayish-blue discoloration of the back or flanks of the patient's body (Grey Turner's sign) or affecting the periumbilical area (Cullen's sign). Treatment involves bowel rest with nasogastric suction and fluid resuscitation with correction of electrolyte disturbances. Ranson's criteria are used to predict outcome at the time of admission:
· Older than 55 years
· White blood cell count >16,000/mm3
· Serum glucose >200 mg/dL
· Lactate dehydrogenase >350 IU/L
· Aspartate aminotransferase level >250 IU/L
48 hours after admission:
· Greater than 10% decrease in hematocrit
· Elevation in BUN >5 mg/dL
· Serum calcium levels <8 mg/dL
· Base deficit >4 mEq/L
· Arterial PO2 <60 mm Hg
· Greater than an estimated 6 L of fluid deposition in the body's interstitial spaces
If less than three signs are present at the time of admission, the mortality rate is <5%. The presence of three or more signs on admission has an associated mortality rate of 15% to 20%. If seven or more signs total are present, the mortality rate approaches 100%.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:129–132.
201. A 40-year-old florist presents to your office complaining of a nontender nodule that formed on his hand, then enlarged, and finally ulcerated. In the days that followed, the patient developed similar nodules in the area of the axillary lymphatics. Otherwise he has had no other symptoms. The most likely diagnosis is
A) cat-scratch fever
B) sporotrichosis
C) tuberculosis
D) blastomycosis
E) histoplasmosis
Answer and Discussion
The answer is B. Sporotrichosis is a disease caused by inoculation of the plant Sporothrix schenckii when patients prick themselves with a thorn. The condition is associated with the formation of nodules, ulcers, and abscesses affecting the skin and lymphatic system. Farm workers and those who work around plants (i.e., florists, gardeners, nursery workers, and horticulturists) such as sphagnum moss, rosebushes, and barberry bushes are the most likely to be affected. Most patients present with a nontender nodule that forms on an arm or hand. The nodule enlarges, becomes erythematous (blush red), and finally ulcerates. In the following days, other nodules may form in the area of the draining lymphatics. Local pain and constitutional symptoms are usually absent. Other areas such as lungs, spleen, liver, kidney, genitalia, muscle, joints, and eyes may become involved. Diagnosis is usually achieved by culturing the organism from the nodules. Treatment is accomplished with itraconazole, extended courses of saturated solution of potassium iodide; in severe disseminated cases, intravenous amphotericin B or ketoconazole (less effective) is used.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:1193.
202. A hemodynamically unstable patient is noted to have supraventricular tachycardia. The most appropriate treatment is
A) electrical synchronized cardioversion
B) carotid massage
C) adenosine
D) verapamil
E) digoxin
Answer and Discussion
The answer is A. Supraventricular tachycardia is characterized by a rapid regular rhythm with a narrow QRS complex and abnormal P waves. The heart rate is usually 100 to 200 bpm. Some patients may be asymptomatic; others may experience chest pain, palpitations, and shortness of breath. Hemodynamically unstable patients with supraventricular tachycardia require immediate treatment with electrical synchronized cardioversion. For those patients who are stable, vagal stimulation can be attempted with carotid massage (but not in patients with previous cerebrovascular accidents or carotid bruits), Valsalva maneuvers, activation of the gag reflex, or placing a cold ice bag on the face. If these measures are unsuccessful, medication including adenosine, verapamil, diltiazem, or a β-blocker, can be used. Untreated supraventricular tachycardia may lead to heart failure.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:17.
203. The most common cause of tinnitus is
A) infection (otitis media)
B) chronic use of salicylates
C) sensorineural hearing loss
D) hypertension
E) acoustic neuroma
Answer and Discussion
The answer is C. Tinnitus is a common condition that is characterized by a ringing, roaring, rushing, buzzing, or whistling sound in the ears. The condition may be continuous or pulsatile with each heartbeat. In most cases, there is an associated hearing loss. In fact, the major cause of tinnitus is a sensorineural hearing loss. The list of associated conditions is extensive and includes obstruction of the canals, eustachian tube dysfunction, otosclerosis, Meniere's disease, aminoglycoside toxicity, chronic use of salicylates, anemia, hypertension, hypothyroidism, hyperlipidemia, noise-induced hearing loss, and tumors associated with the inner ear (e.g., acoustic neuroma). The evaluation of a patient with tinnitus includes an audiogram and CT scan or MRI of the head, with special emphasis given to the temporal area. Pulsatile tinnitus may require vascular studies to rule out aneurysm formation. Treatment depends on the diagnosis, but in most cases if the underlying disease is controlled, the tinnitus disappears. If no underlying disease process is present, background music or amplification may help to relieve symptoms.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:182–184.
204. A 65-year-old man is admitted to the hospital with complaints of shortness of breath. He has no prior medical care. The laboratory notifies you of a B-natriuretic peptide (BNP) value of 1500 pg/dL. You suspect the following diagnosis:
A) asthma exacerbation
B) COPD exacerbation
C) pulmonary embolism
D) deep venous thrombosis
E) congestive heart failure
Answer and Discussion
The answer is D. B-natriuretic peptide (BNP) is secreted by the heart's ventricles and is sensitive to changes in left ventricular function. Elevated levels are associated with elevated levels of end-diastolic pressure. BNP can be helpful in determining whether shortness of breath is due to cardiac versus a pulmonary etiology. A value <100 pg/mL is considered normal, whereas a value >400 pg/dL represents a >95% chance of congestive heart failure. Some pulmonary processes are associated with elevated BNP including lung cancer, cor pulmonale, and pulmonary embolism; however, elevations are usually not as high as seen in CHF. Decreased creatinine clearance is associated with higher levels of BNP.
Maisel AS, Zoorob R. B-type natriuretic peptide in congestive heart failure: diagnosis and management. CME Bulletin. 2004;3(3):1–10.
205. Which of the following toxin exposure–antidote associations is correct?
A) Cyanide–calcium carbonate
B) Ethylene glycol–ethanol and pyridoxine
C) Magnesium–amyl nitrite
D) Organic phosphates–epinephrine
Answer and Discussion
The answer is B. Toxin exposure is often treated by family physicians. The following are the drugs of choice for treating the associated toxin exposures:
|
Toxin |
Treatment |
|
Atropine |
Physostigmine |
|
Cyanide |
Amyl nitrite |
|
Magnesium |
Calcium carbonate |
|
Ethylene glycol |
Ethanol and pyridoxine |
|
Organic phosphates |
Atropine |
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2652–2653.
206. Guttate psoriasis
A) are thick, scaly plaque-like lesions that are commonly identified as psoriasis
B) are not associated with respiratory illnesses
C) are not usually associated with skin creases
D) are insidious in their outbreak with large “bull's-eye” type lesions
Answer and Discussion
The answer is C. The condition of guttate psoriasis is characterized by numerous small, oval (teardrop-shaped) lesions that develop after an acute upper respiratory tract infection. These lesions are often not as scaly or as erythematous as the classic lesions of plaque-type psoriasis. Usually, guttate psoriasis must be differentiated from pityriasis rosea, another condition characterized by the sudden outbreak of red scaly lesions. Compared with pityriasis rosea, psoriatic lesions are thicker and scalier, and the lesions are not usually distributed along skin creases.
Pardasani AG, Feldman SR, Clark AR. Treatment of psoriasis: an algorthm-based approach for primary care physicians. Am Fam Physician. 2000;61:725–33, 736
The condition of guttate psoriasis is characterized by numerous small, oval (teardrop-shaped) lesions that develop after an acute upper respiratory tract infection.
207. In the treatment of external genital warts, it is important to
A) biopsy the visible lesions
B) aceto-white stain the areas to identify the affected lesions
C) obtain viral-typing of the lesions
D) remove visible warts
Answer and Discussion
The answer is D. Genital warts caused by human papillomavirus infection are frequently seen in primary care. Evidence-based treatment recommendations are limited, but treatment guidelines recently have changed. Biopsy, viral typing, aceto-white staining, and other diagnostic measures are not routinely required. The goal of treatment is removal of visible warts; some evidence exists that treatment reduces infectivity, but there is no evidence that treatment reduces the incidence of cervical and genital cancer. The choice of therapy is based on the number, size, site, and appearance of lesions, as well as patient preferences, cost, convenience, adverse effects, and clinician preference. Patient-applied therapy such as imiquimod cream or podofilox is increasingly recommended. Podofilox, imiquimod, surgical excision, and cryotherapy are the most convenient and effective options. Fluorouracil and interferon are no longer recommended for routine use.
Kodner CM, Nasraty S. Management of genital warts. Am Fam Physician. 2004;70:2335–2342, 2345–2346.
208. Silo filler's disease is caused by chronic inhalation of
A) carbon monoxide
B) nitrogen dioxide
C) nitrogen mustard
D) nitrous oxide
E) carbon dioxide
Answer and Discussion
The answer is B. Silo filler's disease is a pulmonary disease that is caused by the inhalation of nitrogen dioxide. Those affected are usually farmers who are exposed to the toxic gas, which is produced from moldy hay found in silos and grain bins. Because of the irritant effects, the gas can lead to the development of pulmonary edema, usually 10 to 12 hours after exposure to the gas. In severe cases, exposure can lead to bronchiolitis obliterans with associated respiratory failure and death. Symptoms include irritation to the mucous membranes and eyes, cough, hemoptysis, wheezing, nausea, vomiting, and dyspnea. Chest radiographs usually show alveolar infiltrates and pulmonary edema. Bacterial superinfections can occur and can lead to serious complications. Treatment usually involves bronchodilators, intravenous fluids, mechanical ventilation, and steroids. Chronic exposure may lead to chronic bronchitis.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:1522.
209. Which of the following is an effect of niacin use?
A) Increased LDL cholesterol
B) Increased triglyceride levels
C) Increased HDL cholesterol
D) Hypoglycemia
E) Decreased uric acid levels
Answer and Discussion
The answer is C. Niacin (nicotinic acid) is used to treat hyperlipidemia. It lowers LDL cholesterol and triglyceride levels and increases HDL cholesterol levels. It is the most effective drug for increasing HDLs. The medication is available without a prescription. Side effects include flushing, pruritus, hepatotoxicity, elevated glucose and uric acid levels, and GI irritation. Doses range from 500 mg/day to a maximum of 3 g/day. Aspirin taken approximately 45 minutes before the administration of niacin may help to decrease flushing episodes. Liver function tests should be periodically monitored when patients are taking the medication.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1308.
210. Which of the following tests is most sensitive for detecting maxillary sinusitis?
A) Plain radiographs
B) CT scan
C) Transillumination
D) Ultrasound
E) Tomograms
Answer and Discussion
The answer is B. Acute sinusitis is usually precipitated by an upper respiratory infection. Because sinusitis is rarely present without an associated inflammation of the nasal passageways, it is best referred to as rhinosinusitis.Rhinosinusitis occurs if there is insufficient draining of the sinus, which predisposes to development of purulent, infected fluid. In most cases, edematous sinus tissue is the cause of impaired drainage and the development of a bacterial infection. Typical pathogens include S. pneumoniae, H. influenzae, and other organisms such as S. aureus and Moraxella catarrhalis. Symptoms include purulent rhinorrhea, nasal congestion, impaired sense of smell, pain over the sinus area, and pressure behind the eyes, as well as pain associated with the upper dental area. Low-grade fevers may be present. In some cases, a dental infection or abscess may be the cause.
The diagnosis of acute rhinosinusitis is made primarily by a careful clinical history. Radiologic studies do not have a significant role in the diagnosis of acute rhinosinusitis. Although plain radiographs of the sinuses may show opacification, which supports the diagnosis, coronal CT scan of the sinuses is the most sensitive test for complicated cases. Cultures of nasal discharge are unreliable and are not useful in the diagnosis. Most cases of acute sinusitis have a viral cause and resolve within 2 weeks without antibiotic coverage. Antibiotics should be reserved for those with moderate to severe symptoms. When selecting an antibiotic, amoxicillin has better sinus penetration than ampicillin and is the medication of choice as a first-line drug. TMP-SMX is also effective as a first-line treatment. Duration of therapy is typically 10 to 14 days, although success can be achieved with shorter courses. The use of adjunctive treatments such as antihistamines has no proven benefit. Complications, although rare, include osteomyelitis, mucocele, and cavernous sinus thrombosis. Persistent epistaxis, pain, and recurrent sinusitis should alert the practitioner to the possibility of paranasal sinus cancer.
Ferri F. Ferri's Clinical Advisor, Instant Diagnosis and Treatment. Philadelphia: Elsevier/Mosby; 2006:782–783.
211. Which of the following statements best describes a case-control study?
A) It is an observational design-type study that begins with an outcome and then looks for common aspects among those who are affected.
B) It is a study that categorizes subjects into groups and observes outcomes.
C) It is a study that identifies outcomes and predictors of outcomes simultaneously.
D) It is a study that records information, activities, and observations but does not provide explanations.
Answer and Discussion
The answer is A. The following are types of studies encountered in the medical literature:
· Case-control study: This is an observational design–type study that begins with an outcome and then looks for common aspects among those who are affected.
· Cohort study: This is a prospective design study. Subjects with similar characteristics are categorized into groups and then researchers observe the outcome.
· Cross-sectional study: This is an observational design–type study that takes a subject group and identifies outcomes and their predictors simultaneously.
· Clinical series study: This is a descriptive-type study that records information, activities, and observations but provides no explanations. These studies usually lead to further explanatory-type studies.
Gehlbach SH. Interpreting the Medical Literature: a Clinician's Guide. New York: Collamore Press; 1981:18, 24, 30.
212. A 50-year-old man complains of gradual increasing shortness of breath, and evidence of honeycombing of pulmonary architecture is seen on a chest radiograph. Pulmonary function tests show both decreased vital and diffusing capacities as well as reduced total lung volumes with a normal forced expiratory volume in 1 second to forced vital capacity ratio. The most likely diagnosis is
A) chronic obstructive pulmonary disease (COPD)
B) tuberculosis
C) asthma
D) idiopathic pulmonary fibrosis
E) chronic pulmonary embolism
Answer and Discussion
The answer is D. Idiopathic pulmonary fibrosis, a form of interstitial lung disease, results when there is inflammation of the lung tissue with resulting fibrosis. A toxic exposure or antigenic response is thought to precipitate the inflammatory process. Affected patients may report a gradual, increasing shortness of breath; a dry cough; and generalized fatigue with lack of endurance with physical exercise. Physical examination shows bibasilar dry rales, clubbing, and, occasionally, cyanosis. In advanced disease, chest radiographs show honeycombing, and pulmonary function tests show a restrictive pattern with reduced vital capacity, diffusing capacity for carbon monoxide, and total lung volume. In addition, there is a normal or increased forced expiratory volume in 1 second to forced vital capacity ratio. Arterial blood gases may show mild hypoxemia, but hypercarbia is rare. The patient's ESR may be increased. Transthoracic or transbronchial biopsy is usually needed for a definitive diagnosis. The treatment of idiopathic pulmonary fibrosis is controversial because of a lack of understanding of the natural history of the disease. Only 10% to 15% of patients improve with corticosteroid therapy, and 26% of patients develop serious complications from the steroid therapy. Indicators of good response to steroid therapy include young age, female gender, ground-glass lesions on CT scan, and active inflammation on lung biopsy samples. Azathioprine, cyclophosphamide, and other cytotoxic drugs have been used as second-line agents or in combination with steroids as first-line therapy. Although the general prognosis was poor, combined treatment improved 3-year survival rates. Selected patients with idiopathic pulmonary fibrosis have been treated with lung transplantation.
Karnani NG, Reisfield GM, Wilson GR. Evaluation of chronic dyspnea. Am Fam Physician. 2005;71:1529–1537, 1538.
213. A 52-year-old man who is otherwise healthy is found to have a deep venous thrombosis (DVT) affecting his left lower extremity below the knee. Appropriate management includes
A) administration of clopidogrel (Plavix)
B) initiation of aspirin as an outpatient
C) observation with serial ultrasound examinations
D) intravascular thrombolysis
E) administration of low-molecular-weight heparin as an outpatient
Answer and Discussion
The answer is C. DVT is a condition that involves thrombus formation, usually in the lower-extremity veins. Predisposing conditions include lack of activity; previous DVT; recent surgery; smoking; and hypercoagulable states, including antithrombin III deficiency, protein C or S deficiency, lupus, cancer, and estrogen use. Symptoms include pain and swelling, as well as erythema and warmth of the lower extremity. Physical examination may be normal, and a positive Homans' sign is not a reliable predictor for DVT. Diagnosis is usually made with Doppler ultrasound (duplex) studies, which is operator-dependent and does not detect thrombi below the knee very well. The gold standard test is contrast venography. A D-dimer is often elevated in patients with venous thrombosis. It is sensitive but not specific. Impedance plethysmography is highly sensitive for thrombi above the knee but less sensitive if the thrombosis is below the knee. Treatment for DVT above the knee involves intravenous heparin or low-molecular-weight heparin and oral warfarin. It is important to overlap heparin treatment with oral warfarin for at least 4 to 5 days because the full anticoagulant effect of warfarin is delayed. Warfarin should be continued for at least 3 to 6 months, although the optimal treatment time is controversial. Age and a history of thromboembolic events are strong risk factors for recurrence.
Treatment of DVT below the knee is controversial. Calf vein thrombosis should be either treated with anticoagulants or followed with serial Doppler studies to rule out propagation. DVT prophylaxis regimens depend on the level of risk:
· Low risk. Individuals who are at low risk include those who have major surgery requiring anesthesia for at least 30 minutes, immobilized patients, patients with myocardial infarction or CHF, and women after cesarean section. The prophylaxis is heparin at 5,000 U (given subcutaneously every 12 hours) and intermittent compressive devices (at least once per minute).
· High risk. Individuals who are at high risk include those who have pelvic or lower extremity surgery, including hip or knee replacement, or a previous DVT or pulmonary embolism. The prophylaxis is a combination of compression devices plus low-molecular weight heparin or warfarin.
The use of low-molecular-weight heparin is becoming more common in the treatment of DVT because it offers the advantages of having a more predictable anticoagulant effect, avoids the need for anticoagulation testing, and allows the patient to be treated at home. It is also associated with less antibody formation, a lower risk of heparin-induced thrombocytopenia, and a decreased overall mortality. Patients being treated at home must learn to give themselves subcutaneous injections and should have close follow-up. Warfarin therapy should be initiated on day 1 when using unfractionated or low-molecular-weight heparin. After 4 to 5 days and when the INR is greater than 2 for 2 consecutive days, the heparin therapy can be discontinued.
Patients who are at risk for bleeding may be candidates for inferior vena caval filter placement. There is little use in aggressive cancer workup in patients after an initial episode of DVT. A thorough history, physical examination, and age-appropriate cancer screening are adequate.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:1491–1492.
214. Which of the following statements is true regarding ulcerative colitis?
A) There is transmural involvement of the bowel wall.
B) There are skipped areas of inflammation that may have a cobblestone appearance on colonoscopy.
C) There is a smaller risk of developing intestinal cancer in comparison to Crohn's disease.
D) The area of involvement is localized to the colon and rectosigmoid area.
E) Aminosalicylic acid compounds are not effective in the treatment of ulcerative colitis.
Answer and Discussion
The answer is D. Ulcerative colitis is characterized by inflammation of the bowel that is limited to the mucosal surface and submucosa of the bowel wall (i.e., it is not transmural like Crohn's disease). The area of involvement is localized to the colon and rectosigmoid area in a continuous fashion; this is unlike Crohn's disease, which shows skipped areas of involvement. Symptoms include bloody diarrhea, abdominal pain, fever, and tenesmus. Complications include intestinal perforation, the development of toxic megacolon, and the development of cancer (which is more commonly seen in patients with ulcerative colitis than in those with Crohn's disease). Extracolonic involvement affects the skin, eyes, joints, and liver; however, the kidneys are not involved (as they are in Crohn's disease). Diagnosis is accomplished in the same manner as in Crohn's disease (i.e., colonoscopy or flexible sigmoidoscopy with biopsy or with x-ray contrast studies). Treatment of ulcerative colitis is similar to that for Crohn's disease; however, the oral forms of 5-aminosalicylic acid (e.g., sulfasalazine, olsalazine, mesalamine) are more effective in controlling recurrences and the severity of outbreaks in ulcerative colitis. Close follow-up is necessary for ulcerative colitis and Crohn's disease because of the increased risk of developing bowel cancer.
Ferri F. Ferri's Clinical Advisor, Instant Diagnosis and Treatment. Philadelphia: Elsevier/Mosby; 2006:879.
215. A 60-year-old man presents with pain, swelling, and redness of the first metatarsal phalangeal joint. His cardiologist recently prescribed hydrochlorothiazide for his hypertension. The most likely diagnosis is
A) podagra
B) degenerative joint disease
C) rheumatoid arthritis
D) osteomyelitis
E) Morton's neuroma
Answer and Discussion
The answer is A. Gout is a condition characterized by recurrent pain associated with peripheral joints. The cause is attributed to the development of monosodium urate crystals, which cause acute arthritis. Long-standing gout can lead to chronic, deforming arthritis. The greater the degree of hyperuricemia, the more likely is the development of gouty attacks. Most hyperuricemia is asymptomatic. Hyperuricemia may result from disorders of purine metabolism, which may be genetic or acquired. Disorders causing hyperuricemia include proliferative hematologic disorders, psoriasis, myxedema, parathyroid disorders, enzyme deficiencies, and renal disease; obesity and medications such as thiazide diuretics are also causative. Middle-age and elderly men are usually affected more frequently than women; however, menopause is associated with a sharp increase in incidence in women (especially in those using thiazides and those with renal impairment). Symptoms include severe, throbbing pain with redness and swelling that is usually monoarticular and affects the metatarsophalangeal joint of the great toe (podagra). However, other joints, including the ankle, knee, wrist, and elbow, may also be affected. Other symptoms include fever and malaise. Later attacks may become more frequent and affect multiple joints with resolution between attacks less complete. Precipitating factors include trauma, overindulgence of foods (processed meats), alcohol, surgery, fatigue, stress, infection, or the administration of medications (e.g., penicillin, insulin, thiazide diuretics). Diagnosis is usually made based on history and physical exam. Absolute confirmation involves joint aspiration with the detection of needle-shaped urate crystals that are negatively birefringent under a polarizing microscope. Asymptomatic treatment of hyperuricemia is generally not treated with medication. Treatment of gout involves the use of ice, rest, NSAIDs (e.g., indomethacin, naproxen, ibuprofen), colchicine (which may provide dramatic relief in the acute phase), and allopurinol (xanthine oxidase inhibitor) for patients who have chronically elevated uric acid levels after the acute attack has resolved (low-dose colchicine can also be used). In addition, uricosuric agents, including probenecid and sulfinpyrazone, may be helpful but should be used with caution in patients with renal problems. Prednisone may also be helpful in patients who cannot tolerate other medications. Transplantation recipients and those undergoing chemotherapy are usually protected with the use of allopurinol.
Ferri F. Ferri's Clinical Advisor, Instant Diagnosis and Treatment. Philadelphia: Elsevier/Mosby; 2006:350–351.
216. The use of proton pump inhibitors can result in
A) vitamin C deficiency
B) vitamin D deficiency
C) vitamin B12 deficiency
D) folate deficiency
Answer and Discussion
The answer is C. Vitamin B12 (cobalamin) deficiency is a common cause of macrocytic anemia and has been implicated in a host of neuropsychiatric conditions. The widespread use of gastric acid–blocking agents, which can lead to decreased vitamin B12 levels, may contribute to the development of vitamin B12 deficiency. Given the widespread use of these agents and the aging of the U.S. population, the actual prevalence of vitamin B12 deficiency may be even higher than statistics indicate. Vitamin B12 deficiency is associated with hematologic, neurologic, and psychiatric symptoms. Neurologic manifestations from vitamin B12 deficiency include paresthesias, peripheral neuropathy, and demyelination of the corticospinal tract and dorsal columns (subacute combined systems disease). Vitamin B12 deficiency also has been linked to psychiatric disorders, including impaired memory, irritability, depression, dementia and, rarely, psychosis. Dietary sources of vitamin B12 are primarily meats and dairy products. In a typical Western diet, a person obtains approximately 5 to 15 mcg of vitamin B12 daily, which is far greater than the recommended daily allowance of 2 mcg. Normally, individuals maintain a large vitamin B12 reserve, which can last 2 to 5 years even in the presence of severe malabsorption. However, nutritional deficiency can occur in specific populations. Elderly patients and chronic alcoholics are at especially high risk. The dietary restrictions of strict vegans make them another, less common at-risk population. The role of B12 deficiency in hyperhomocysteinemia and the promotion of atherosclerosis are under investigation. Diagnosis of vitamin B12 deficiency is based on measurement of serum vitamin B12 levels; however, about half of patients with subclinical disease have normal B12 levels. A more sensitive method of screening for vitamin B12 deficiency is measurement of serum methylmalonic acid and homocysteine levels, which are increased early in vitamin B12 deficiency. Use of the Schilling test for detection of pernicious anemia has been replaced for the most part by serologic testing for parietal cell and intrinsic factor antibodies. Contrary to prevailing medical practice, supplementation with oral vitamin B12 is a safe and effective treatment for the B12deficiency state. Even when intrinsic factor is not present to aid in the absorption of vitamin B12 (pernicious anemia) or in other diseases that affect the usual absorption sites in the terminal ileum, oral therapy remains effective.
Oh RC, Brown DL. Vitamin B12 deficiency. Am Fam Physician. 2003;67:979–986, 993–994.
217. A 32-year-old man presents to your office. Approximately 5 days ago he was cleaning out his dark, undisturbed attic. That day he noticed an erythematous lesion with a clear center on his arm. Since then the lesion has necrosed in the center, giving rise to a crater-like eschar lesion. The most likely diagnosis is
A) Lyme disease
B) brown recluse spider bite
C) psittacosis
D) black widow spider bite
E) scorpion sting
Answer and Discussion
The answer is B. The brown recluse spider (violin spider) may be identified by a dark, violin-shaped design on its back. These spiders are usually found in dark areas, woodpiles, attics, and other undisturbed locations. The bite is initially mild (burning at site) and goes unnoticed, although some localized pain develops within 30 to 60 minutes. Within 1 to 4 hours, an erythematous, pruritic area with an ischemic pale center develops, giving the appearance of a bull's-eye target lesion. The central zone may progress to form a pustule that eventually fills with blood and ruptures; within 3 to 4 days, a crater-like lesion with necrosis develops. Large tissue defects may occur and include muscle. Healing usually requires extended periods; if large areas are involved, skin grafting may be necessary in some cases. Symptoms include headache, nausea and vomiting, low-grade fever, chills and sweats, generalized pruritus, malaise, arthralgias, severe pain (late in the course), and rash. Rare fatalities (none in the United States) have been reported with complications such as massive intravascular hemolysis with hemoglobinuria, renal failure, and disseminated intravascular coagulopathy. Treatment with dapsone has been recommended. Because dapsone can cause agranulocytosis and hemolytic anemia, which may be exaggerated in patients with G6PD deficiency, a G6PD test and CBC should be done before starting therapy. Systemic corticosteroids have shown no consistent or reliable benefit. Surgical débridement should be delayed until the area of necrosis is fully demarcated. Incision and suction is not recommended. Most bites require only local treatment. Ice therapy to the site may help reduce pain.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2648–2649.
218. A 60-year-old alcoholic man, currently being treated for gastritis, presents to the office with painful breasts that appear enlarged. The most likely cause is
A) breast cancer
B) excessive calcium carbonate ingestion
C) cimetidine use
D) trauma
E) prolactinoma
Answer and Discussion
The answer is C. Gynecomastia is a condition characterized by enlargement of the breasts in men. It occurs when there is hypertrophy of breast tissue beneath the areola. In young adolescents, it is a natural response to the body's hormones. During this time, the breast may be tender. Patients and their parents should be reassured this is a natural response and will eventually resolve (usually within 3 years). Gynecomastia in older males can result from medication use (e.g., cimetidine, INH, digitalis, phenothiazine, testosterone), substance abuse (e.g., alcohol; illegal drugs, including marijuana and heroin), endocrine disorders (e.g., hypogonadism, hyperthyroidism), Klinefelter's syndrome, liver disease, and neoplasm. The workup of gynecomastia should include a chest radiograph, β-human chorionic gonadotropin determination, luteinizing hormone, follicle-stimulating hormone, estrogen and testosterone levels, liver function tests, and thyroid function tests. Typically, the estrogen:testosterone ratio is high. If the human chorionic gonadotropin is elevated, then a testicular ultrasound should be performed to look for testicular tumor. Additionally, if the testes are small, a karyotype should be obtained to look for Klinefelter's syndrome. Other testing may be necessary, if indicated. Treatment involves correcting the underlying abnormality. If the condition does not resolve, suppressive medication or surgery may be indicated.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:2192.
Gynecomastia in older males can result from medication use (e.g., cimetidine, INH, digitalis, phenothiazine, testosterone), substance abuse (e.g., alcohol; illegal drugs, including marijuana and heroin), endocrine disorders (e.g., hypogonadism, hyperthyroidism), Klinefelter's syndrome, liver disease, and neoplasm.
219. Which of the following can distinguish atrial flutter from sinus tachycardia?
A) Carotid sinus massage
B) Administration of diltiazem
C) Administration of isoproterenol
D) Temporal artery massage
E) Administration of adenosine
Answer and Discussion
The answer is A. Atrial flutter is a regular, rapid cardiac rhythm characterized by an ectopic focus that gives rise to atrial rates from 280 to 350 impulses per minute. Usually, impulses are only transmitted to the ventricles every second, third, or fourth impulse. The heart rate is usually approximately 150 bpm. In many cases, atrial flutter is difficult to distinguish from sinus tachycardia; however, carotid sinus massage or Valsalva maneuvers may help distinguish the characteristic (sawtooth) flutter waves seen with atrial flutter. ECG shows flutter waves best in the inferior leads II, III, aVF, and in V1. RR interval may be regular, reflecting a fixed ratio AV block (2:1, 3:1), or may be variable, reflecting a Wenckebach periodicity. Limited data suggest that the risk of thromboembolism, although smaller than with atrial fibrillation, is increased, suggesting anticoagulation should be considered. Treatment consists of verapamil, diltiazem, β-blockers, or digoxin, which slows conduction through the AV node. Electric cardioversion (low energy) is indicated for patients who are unstable and show signs of CHF (e.g., pulmonary rales, hepatojugular reflux, distended neck veins).
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:1344, 1347.
220. The drug of choice for the treatment of trigeminal neuralgia is
A) naproxen
B) prednisone
C) carbamazepine
D) valproic acid
E) phenobarbital
Answer and Discussion
The answer is C. Trigeminal neuralgia is a disorder that involves the trigeminal nucleus of the trigeminal nerve. This disorder is characterized by severe, unilateral, sharp, lancinating-type pain that occurs in the distribution of the trigeminal nerve. Most patients are of middle age or elderly. The symptoms usually occur in recurrent bouts and can be incapacitating. Women tend to be more frequently affected than men. Precipitating factors include touching the affected area and movement of the face (as with eating, talking, and brushing one's teeth), shaving, or feeling a cool breeze on the face. Patients afflicted with trigeminal neuralgia show no physical signs. If deficits are noted during neurologic examination, then alternative diagnosis, including masses impinging on the trigeminal nerve, demyelinating processes, or vascular malformation, should be considered. In most cases, the momentary bouts of pain become more and more frequent and remissions become shorter and shorter. A dull ache that is persistent between the episodes of severe stabbing pain may develop. Remissions may occur and last weeks or even months. The treatment of choice is carbamazepine, which requires monitoring of serial blood counts and liver function tests. Alternative medications include phenytoin and baclofen. Other treatments include injecting glycerol into the offending nerve, surgery to decompress nerve fibers from blood vessels and bony structures, and radiofrequency rhizotomy if medical therapy fails.
Ferri F. Ferri's Clinical Advisor, Instant Diagnosis and Treatment. Philadelphia: Elsevier/Mosby; 2006:865.
The treatment of choice for trigeminal neuralgia is carbamazepine, which requires monitoring of serial blood counts and liver function tests.
221. A 27-year-old woman reports a previous reaction to penicillin. She has had recurrent sinus and respiratory infections. Appropriate management would consist of
A) having the patient tested for penicillin allergies
B) using a cephalosporin if patient has had previous anaphylactoid response
C) administering amoxicillin instead of penicillin
D) administering diphenhydramine with penicillin
E) substituting imipenem for penicillin
Answer and Discussion
The answer is A. An allergy to penicillin is related to penicilloic acid—a breakdown product—and other degradation products that are involved in the metabolism of penicillin. All penicillins are cross-reactive and cross-sensitizing. As many as 25% of patients who report previous penicillin allergies have no reaction when given penicillin. Therefore, it is obvious that many patients are labeled with a penicillin allergy when, in fact, they can take penicillin safely. The incidence of penicillin allergy is approximately 1% to 4% of adults. Symptoms include characteristic anaphylactoid symptoms with shock and bronchoconstriction in type 1 hypersensitivity reactions. Other symptoms include rashes, oral lesions, fever, joint swelling, pruritus, and respiratory distress. Methicillin and nafcillin have caused interstitial nephritis with renal tubular acidosis. The decision to use penicillin in patients with previous reactions should be based on the severity of previous reactions. If the patient has had a severe anaphylactic reaction in the past, penicillins should be avoided. In addition, there is a 2% cross-reactivity
P.69
between cephalosporins in patients with penicillin allergies; thus cephalosporins should be avoided in patients who have had an immediate reaction to penicillin. The same is true for imipenem. Skin tests that use penicilloyl–polylysine and undegraded penicillin may be used to detect patients who have true penicillin allergies.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:801, 1950.
222. Which of the following would best help to stop bleeding in a patient with von Willebrand's disease?
A) Fresh frozen plasma
B) Cryoprecipitate
C) Vitamin K
D) Platelets
E) Protamine sulfate
Answer and Discussion
The answer is B. von Willebrand's disease is an autosomal-dominant transmitted disorder that can lead to abnormal bleeding tendencies. Men and women are equally affected. It is the most common congenital bleeding disorder. The disease is due to a lack of production of von Willebrand factor (type 1) or when the von Willebrand factor is not synthesized properly and is nonfunctional (type 2). The result is a decreased ability of platelets to adhere to collagen. Symptoms include mild to moderate bleeding from small cuts, bruising, epistaxis, excessive menstrual blood loss, GI blood loss, and excessive bleeding during surgery. Laboratory results show an increased bleeding time with a slightly prolonged partial thromboplastin time (PTT) if factor VIII is below 25% to 30%. In most cases, the PT, PTT, and platelet count are normal. Definitive diagnosis for von Willebrand's disease type 1 is made by measuring the levels of (1) von Willebrand factor, (2) antibody response to von Willebrand's antigen, (3) factor VIII, and (4) ristocetin cofactor activity. In patients with type 1 disease, all four measurements are decreased; in patients with type 2 disease, electrophoresis studies may be needed for the diagnosis. Treatment involves the administration of cryoprecipitate, which replaces the von Willebrand factor and stops bleeding. A pasteurized intermediate-purity factor VIII concentrate contains large multimers of von Willebrand factor and is a safe (no HIV or hepatitis) alternative cryoprecipitate. Desmopressin acetate, a synthetic analog of vasopressin, stimulates the release of von Willebrand factor from endothelial cells and can be used in the treatment of mild type 1 disease (but not of type 2). Oral contraceptives can also increase the levels of factor VIII and may be beneficial for women with menorrhagia.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:340–341, 676.
223. Which of the following values is acceptable for a 65-year-old man who had a previous coronary artery bypass graft?
A) Total cholesterol of 215 mg/dL
B) HDL cholesterol of 32 mg/dL
C) LDL cholesterol of 68 mg/dL
D) Triglycerides of 228 mg/dL
E) Blood glucose of 130 mg/dL
Answer and Discussion
The answer is C. Guidelines have been published to help treat patients with hyperlipidemia. Total cholesterol levels should be kept <200 mg/dL, with HDL cholesterol (good cholesterol) >40 mg/dL. Further recommendations are divided into those for patients with CHD and those without CHD. CHD equivalents include peripheral arterial disease, abdominal aortic aneurysm, symptomatic carotid arterial disease and diabetes mellitus. For patients without CHD and fewer than two risk factors, LDL cholesterol should be kept <160 mg/dL. For those with two or more risk factors and no CAD, the goal is an LDL level <130 mg/dL. For patients who have CAD, the new recommendations give a goal for LDL cholesterol <100 mg/dL with <70 mg/dL as being optimal. Triglyceride levels are not as strongly associated with CAD but should be kept <150 mg/dL. Risk factors for CHD include the following:
· Age: men older than 45 years; women older than 55 years or with premature menopause without estrogen replacement
· Family history of premature CHD in first-degree relative
· Smoking
· Hypertension
· HDL cholesterol <35 mg/dL
· Diabetes
· Obesity
· History of cerebral or peripheral vascular disease
A negative risk factor includes an HDL cholesterol level higher than 60 mg/dL.
National Cholesterol Education Program. Third report of the expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III). Accessed online 6/5/06, at: http://www.nhlbi.nih.gov/guidelines/cholesterol/ index.htm.
224. Which of the following statements about Still's murmur is true?
A) It is benign and resolves over time.
B) It is common in the elderly and results from decreased ventricular compliance.
C) It is associated with severe chronic aortic regurgitation.
D) It should always be assessed with an echocardiogram.
E) CHF is usually coexistent.
Answer and Discussion
The answer is A. Some murmurs are specific to certain cardiac conditions:
· Austin Flint murmur is associated with severe chronic aortic regurgitation and may be middiastolic or presystolic. The murmur occurs when there is backflow of blood from the aorta into the left ventricle and flow into the left ventricle from the left atrium. The regurgitant stream often prevents the full opening of the mitral valve, thus obstructing flow into the ventricle.
· Still's murmur affects children and is described as a humming or musical-sounding systolic murmur that is loudest at the left sternal border. It is a benign murmur. The murmur is usually heard in children 3 to 7 years of age and disappears before the onset of puberty.
· Physiologic S3 murmur affects approximately 33% of children younger than 16 years who have a physiologic S3 heart sound that disappears before 30 years of age. The sound is best heard with the patient in the left lateral decubitus position, with the bell of the stethoscope over the point of maximal impulse. The sound is usually a low-frequency thud that occurs in early diastole.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:575–579.
Still's murmur affects children and is described as a humming or musical-sounding systolic murmur that is loudest at the left sternal border. It is a benign murmur. The murmur is usually heard in children 3 to 7 years of age and disappears before the onset of puberty.
225. A hospitalized patient is receiving a blood transfusion. The floor nurse reports that the patient is flushed, is complaining of abdominal discomfort, and has a temperature of 101°F. The most appropriate management is to
A) give the patient acetaminophen and continue the transfusion at a slower rate
B) administer diphenhydramine and continue the transfusion
C) administer 100 mg of hydrocortisone intravenously and reduce the rate of the transfusion
D) stop the transfusion and increase intravenous fluids
E) administer intravenous ranitidine and order an abdominal series x-ray
Answer and Discussion
The answer is D. Many hemolytic transfusion reactions are caused by human error in the laboratory during the matching process or during the administration of blood. Symptoms may include anxiety, dyspnea, tachycardia, flushing, headache, chest or abdominal pain, nausea, vomiting, and shock with an acute decrease in blood pressure. In most cases, the severity of symptoms and the prognosis depend on the amount of transfusion, rate of delivery, degree of incompatibility, and overall health of the patient. The laboratory evaluation for hemolysis consists of measurements of serum haptoglobin, lactate dehydrogenase, and indirect bilirubin levels. The immune complexes that result in RBC lysis can cause renal dysfunction and failure. Treatment consists of stopping the transfusion as soon as possible, vigorous diuresis with furosemide or mannitol, and possible dialysis if renal failure occurs. With multiple transfusions, the patient may develop antibodies to white blood cell antigens, which cause febrile reactions that are manifested by chills and temperatures higher than 100.4°F. Using washed red blood cells helps prevent these reactions.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:665.
226. Which of the following statements regarding the reduction of stroke risk is true?
A) Vitamin E should be recommended to help reduce the risk of stroke.
B) Vitamin C has been shown to reduce the risk of stroke in multiple meta-analysis studies.
C) Dietary prevention of stroke should include increased intake of fruits and vegetables.
D) Risk factor modification has little impact on the risk for stroke.
Answer and Discussion
The answer is C. The use of vitamin E or vitamin C supplements is unlikely to reduce stroke risk in adult men with no history of cardiovascular disease or diabetes. Although some carotenoids may reduce stroke risk, there is insufficient evidence to recommend an increased intake of specific supplements. Dietary prevention of stroke should include increased intake of fruit and vegetables, as previous studies have suggested.
Ascherio A, Rimm EB, Hernan MA. Relation of consumption of vitamin E, vitamin C, and carotenoids to risk for stroke among men in the United States. Ann Intern Med. 1999;130:963–970.
227. A 24-year-old presents to your office with numbness noted in her feet bilaterally. She also complains of severe premenstrual syndrome (PMS) symptoms. The most likely cause for her symptoms related to her feet is
A) excessive use of ibuprofen
B) hysterical psychosis
C) folate deficiency
D) iron deficiency anemia
E) excessive vitamin B6 intake
Answer and Discussion
The answer is E. Women frequently take large daily doses of vitamin B6 for premenstrual syndrome (PMS), even though nutritional deficiency of this vitamin is rare. The recommended dietary allowance is about 2 mg/day; high intake has been associated with severe toxicity, including neuropathy. An intake of 200 mg/day may cause reversible damage, and an intake of 2,000 mg/day or greater is associated with peripheral neuropathy. In some European countries, the quantity of vitamin B6 that may be purchased or prescribed has been restricted to reduce the risk of toxicity from excessive use.
Wyatt KM, Dimmock PW, Jones PW. Efficacy of vitamin B-6 in the treatment of premenstrual syndrome: systematic review. BMJ. 1999;318:1375–1381.
228. A 71-year-old presents to the emergency room with shortness of breath, hemoptysis, and chest pain. Further tests include an ECG with findings of right axis deviation, an S1-Q3-T3 pattern and right bundle branch block. The most likely diagnosis is
A) acute myocardial infarction
B) community-acquired pneumonia
C) bronchogenic carcinoma
D) pulmonary embolism
E) pericarditis
Answer and Discussion
The answer is D. A pulmonary embolism is a thrombus that lodges in the pulmonary vasculature and may give rise to a pulmonary infarction. In most cases, the thrombus forms in the leg or pelvic veins. The most dangerous thrombi form in the iliofemoral vein. Other causes of emboli include fat emboli after fractures and amniotic fluid emboli, which are rare. Risk factors for pulmonary embolism include malignancy, hereditary impaired coagulation, estrogen therapy, obesity, CHF, orthopedic or pelvic surgery, and prolonged anesthesia. Signs and symptoms include tachypnea, cough, hemoptysis, chest pain, fever, and cyanosis (in severe cases). Diagnosis is based on the clinical history and supportive tests, including a ventilation–perfusion scan and pulmonary arteriogram. Arterial blood tests show hypoxia (PO2 <60 mm Hg), and ECG findings are nonspecific (T-wave abnormalities in the precordial leads and sinus tachycardia). In addition, right-axis deviation, an S1-Q3-T3 pattern, and a right bundle branch block may be observed. Further testing may include venous studies of the lower extremities to look for thrombus; however, >20% of patients may have no evidence of venous embolism. Chest radiographs are usually normal; however, a homogenous, wedge-shaped density based in the pleura and pointing to the hilum (Hampton's hump) is highly suggestive of pulmonary embolism. Treatment involves anticoagulation for 3 to 6 months with oral warfarin or thrombolytic therapy and embolectomy if the patient has hypotension and continuing hypoxemia while receiving high fractions of inspired oxygen. Thrombolytic therapy is not indicated for the routine treatment of patients with PE. A stepwise approach to the diagnosis of pulmonary embolus consists of a ventilation-perfusion scan. A high-probability ventilation-perfusion scan provides sufficient evidence for the initiation of treatment for PE. Likewise, a normal scan should be considered sufficient to exclude PE. Unfortunately, 50% to 70% of scans are indeterminate (low or intermediate probability). If the results show a high probability of PE, treatment with anticoagulants is indicated. If the ventilation–perfusion scan is normal, treatment is not indicated. If the lung scan shows intermediate or low probability of pulmonary embolus, a noninvasive leg test (ultrasound) for proximal DVT should be obtained. If the leg test is positive, then treatment is indicated. If the leg test is negative and suspicion is high, then a pulmonary angiogram or another ultrasound and D-dimer test can be repeated in 5 to 7 days. If the test is negative, the risk for pulmonary embolus is low. A spiral CT of the chest can also be used for rapid diagnosis.
Ramzi DW, Leeper KV. DVT and pulmonary embolism: Part I. Diagnosis. Am Fam Physician. 2004;69:2829–2836.
229. Which of the following statements about macular degeneration is true?
A) The wet form is usually more severe than the dry form.
B) Neovascularization is typically associated with drusen and the dry form.
C) It typically affects only peripheral vision.
D) The condition is more common in African-American individuals.
E) The condition is rarely progressive.
Answer and Discussion
The answer is A. Macular degeneration associated with aging is a leading cause of blindness in the elderly. The condition is more common in whites, appears to be hereditary, and is associated with atrophy or degeneration of the macular disc. There are basically two types: atrophic or dry and exudative or wet. Both types usually occur bilaterally and are progressive. The dry form usually progresses slowly and affects the outer retina, retinal pigment epithelium, choriocapillaries, and Bruch's membrane. The wet form of macular degeneration is more severe and progressive, usually affects the eyes sequentially, and is responsible for approximately 90% of blindness in those affected with macular degeneration. The wet form occurs when there is drusen (i.e., degeneration of the pigment epithelium and Bruch's membrane) and accumulation of serous fluid or blood in the retina that produces elevation of the retinal pigment membrane from Bruch's membrane. Neovascularization may then occur, giving rise to a subretinal neovascular membrane that causes permanent vision loss. There is no specific treatment for macular degeneration; however, laser photocoagulation may help stop neovascularization in select cases, and vision aids may help acuity. Macular degeneration affects central vision and does not affect peripheral vision.
Fine SL, Berger JW, Maguire MG. Age-related macular degeneration. N Engl J Med. 2000;342:483–491.
230. Hypersplenism is associated with all of the following EXCEPT
A) lymphoma
B) polycythemia vera
C) infectious mononucleosis
D) hereditary spherocytosis
E) congestive heart failure
Answer and Discussion
The answer is E. Hypersplenism is associated with a number of disorders that lead to a reduction in one or more blood constituents leading to leukopenia, thrombocytopenia, or a combination of both. Most cases of chronic hemolytic anemias are associated with splenomegaly. Causes of splenomegaly include lymphoma, leukemia, polycythemia vera, myelofibrosis, infectious mononucleosis, psittacosis, subacute bacterial endocarditis, tuberculosis, malaria, syphilis, kala-azar, brucellosis, sarcoidosis, amyloidosis, SLE, Felty's syndrome, hereditary spherocytosis, thalassemias, cirrhosis, Gaucher's disease, Niemann-Pick disease, Schüller-Christian disease, Letterer-Siwe disease, and thrombosis or compression of the portal or splenic veins. Patients may exhibit bleeding disorders, palpable splenomegaly, left-upper abdominal discomfort, or splenic bruits. Management usually involves treatment of the underlying disorder; elective splenectomy is reserved for refractory cases. Asplenic patients are at increased risk for infection secondary to encapsulated bacteria and should receive pneumococcal immunization.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:347.
231. Which of the following laboratory results best support the diagnosis of subclinical hypothyroidism?
A) Normal T4, low TSH
B) Normal T4, high TSH
C) Low T4, high TSH
D) Normal T4, normal TSH
E) Low T4, borderline low TSH
Answer and Discussion
The answer is B. The following are laboratory findings associated with thyroid dysfunction:
|
Diagnosis |
Laboratory Findings |
|
Overt hypothyroidism |
Low T4, high sTSH |
|
Subclinical hypothyroidism |
Normal T4, high sTSH |
|
Hypothyroidism secondary to hypopituitarism |
Low T4, normal or borderline low sTSH |
|
Euthyroid |
Normal T4, normal sTSH |
|
Subclinical hyperthyroidism |
Normal T4, low sTSH |
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1192–1206.
232. The proportion of disease-free patients in whom a test result is negative is referred to as
A) the p value
B) sensitivity
C) specificity
D) reliability
E) variability
Answer and Discussion
The answer is C. Specificity is defined as the proportion of people who are not affected by a given disease and who also test negative for that disease. For example, the proportion of patients who do not have CAD and also test negative with a treadmill exercise test would be defined as the specificity. This specificity, as mentioned in the answer to question 234, is up to 95%. If this percentage is high, it is a highly specific test.
Mark DB. Chapter 2: Decision-making in clinical medicine. Available at Harrison's Online website (http://www.harrisonsonline.com). Accessed 6/4/06.
Specificity is defined as the proportion of people who are not affected by a given disease and who also test negative for that disease.
233. Inflammation and necrosis of the muscular tissue supplied by small- and medium-size arteries is known as
A) polyarteritis nodosa
B) pyoderma gangrenosum
C) polymyositis
D) giant cell arteritis
E) dermatomyositis
Answer and Discussion
The answer is A. Polyarteritis nodosa is a condition characterized by inflammation and necrosis of the muscular tissue supplied by small- and medium-size arteries. The cause is unknown but may be associated with an autoimmune response, medication (e.g., sulfonamides, iodide, thiazides, bismuth, penicillins), and infections. Involvement of the renal and visceral arteries is characteristic, but pulmonary arteries are usually spared. Affected individuals are usually between 40 and 50 years of age; men are more commonly affected. Symptoms include fever, abdominal pain, peripheral neuropathy, headaches, seizures, weakness, and weight loss. Those with renal involvement may show hypertension, edema, azotemia, and oligouria. Other symptoms include angina, nausea, vomiting, diarrhea, myalgias, and arthralgias. Palpable subcutaneous lesions that sometimes necrose may be found in the area of an affected artery. Laboratory studies show leukocytosis, proteinuria, microscopic hematuria, thrombocytosis, and an elevated ESR. Diagnosis is usually made with a biopsy of affected tissue, which shows necrotizing arteritis. Treatment involves avoidance of the offending agent and often long-term, high-dose steroid therapy and cyclophosphamide for severe cases and steroids alone for milder cases. The disease can be fatal if untreated.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:2007.
234. Which of the following symptoms is usually absent in a 5-year-old patient with streptococcal pharyngitis?
A) Rhinorrhea
B) Fever
C) Malaise
D) Abdominal discomfort
E) Sore throat
Answer and Discussion
The answer is A. Streptococcus pharyngitis is caused by group A β-hemolytic streptococcus. It is one of the most common childhood infections and accounts for up to 40% of exudative pharyngitis in children usually older than 3 years. Symptoms include sore throat, fever, malaise, and sometimes abdominal pain with nausea and vomiting (particularly in children). Rhinorrhea, a prominent cough, and hoarseness are typically not present in uncomplicated cases. Signs include erythema associated with the tonsillar pillars and associated exudates that may also involve the posterior pharynx, as well as tender cervical lymphadenopathy. Scarlet fever, which is characterized by an erythematous rash that blanches with pressure and has the appearance of fine sandpaper, may also be present with streptococcal pharyngitis. Diagnosis is made with a throat culture or a latex agglutination test, which is faster and widely available. The latex agglutination test (“rapid strep test”) has a specificity of approximately 95%, with a sensitivity of approximately 76% to 87%; therefore, negative rapid Streptococcus tests should be sent for culture. Treatment of streptococcal pharyngitis usually does not shorten the course of the disease but does prevent complications, including the development of rheumatic fever. The treatment is 10 days of an appropriate antibiotic; penicillin (oral or intramuscular benzathine penicillin G) is usually used, and erythromycin is used if the patient is allergic to penicillin. Complications include the development of peritonsillar or retropharyngeal abscesses, cervical lymphadenitis, sinusitis, otitis, meningitis, endocarditis, and pneumonia. As much as 20% of the population may be an asymptomatic carrier of Streptococcus. In most cases, treatment should be limited to only those who are symptomatic, unless the carrier is transmitting the infection to others. Those who are asymptomatic carriers are not likely to develop complications such as rheumatic fever. Patients with streptococcal pharyngitis are considered contagious until they have been taking an antibiotic for 24 hours. Children should not go back to their daycare center or school until their temperature returns to normal and they have had at least 24 hours of antibiotic therapy. Group A β-hemolytic streptococci persist for up to 15 days on unrinsed toothbrushes and removable orthodontic appliances. The pathogens are not isolated from rinsed toothbrushes after 3 days. Instructing patients to rinse toothbrushes and removable orthodontic appliances thoroughly may help prevent recurrent infections. Transmission of group A β-hemolytic streptococci occurs principally through contact with respiratory secretions from an infected person. Although anecdotes are numerous and a few cases have been reported, family pets are rare reservoirs of group A β-hemolytic streptococci.
Hayes CS, Williamson H. Management of group A beta-hemolytic streptococcal pharyngitis. Am Fam Physician. 2001;63:1557–1564.
235. A 17-year-old girl presents to your office. She had an upper respiratory viral infection approximately 1 week before her visit. She now complains of severe vertigo. She has no other symptoms. The most likely diagnosis is
A) Meniere's disease
B) cholesteatoma
P.73
C) vestibular neuronitis
D) benign positional vertigo
E) acoustic neuroma
Answer and Discussion
The answer is C. Vestibular neuronitis is characterized by severe episodes of vertigo that may recur. The condition tends to affect young people and is thought to be secondary to a viral infection, which affects the eighth nerve. The first episode is usually associated with severe vertigo that lasts approximately 1 week, followed by spontaneous remission. Subsequent attacks may occur up to 18 months after the initial episode. In most cases, the subsequent attacks are less severe than the original attack. There is no loss of hearing or tinnitus, which is usually seen with Meniere's disease. The diagnosis is usually accomplished after other causes are eliminated. Severe cases can be treated with anticholinergic medication, antihistamines, antiemetics, steroids, and benzodiazepines. In most cases, symptoms are self-limited and resolve spontaneously. Vestibular neuronitis is a cause of peripheral vertigo. Symptoms associated with peripheral vertigo include tinnitus, nystagmus, and hearing loss; dysphagia, vomiting, and headache are more associated with a central cause of dizziness.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:795.
236. The most common location for the development of Morton's neuroma is
A) the trigeminal nerve
B) interdigital nerves between the fourth and fifth metacarpal heads
C) interdigital nerves between the third and fourth metatarsal heads
D) the median nerve
E) the sural nerve
Answer and Discussion
The answer is C. Morton's neuroma is a common type of forefoot pain. The condition arises from entrapment of the common interdigital nerves between the metatarsal heads. This nerve entrapment leads to inflammation, edema, pain, and the formation of perineural fibrosis and demyelination, which causes a neuroma. The most common location for the neuroma is between the third and fourth metatarsal heads; they also commonly occur between the second and third metatarsal heads. Women are more commonly affected than men (5:1 ratio). Patients report pain, paresthesias, or occasionally a catching sensation in these locations, which may extend distally to the toes or proximally to the midfoot. Many patients report their symptoms are worse when wearing shoes. The distinguishing feature in the differential between metatarsalgia and Morton's neuroma is pain between the metatarsal heads. Radiographs are normal; however, MRIs may show the offending neuroma but are rarely necessary to make the diagnosis. Treatment involves NSAIDs, metatarsal footpads, wide shoes, and steroid injections (using a dorsal approach between the metatarsals); in severe cases, surgical excision of the neuroma is indicated, although persistent pain remains for approximately 33% of patients after surgery.
Tallia AF, Cardone DA. Diagnostic and therapeutic injection of the ankle and foot. Am Fam Physician. 2003;68:1356–1362.
237. Which of the following is associated with chronic fatigue syndrome?
A) Temporal artery tenderness
B) Minimal (less than 10%) impairment of normal activity
C) High incidence of associated psychiatric disorders
D) Muscle weakness
E) Recent EBV infection
Answer and Discussion
The answer is C. Fatigue is a common complaint heard in a family physician's office. As many as 25% of patients may complain of fatigue when asked. Broadly defined, the condition is described as long-standing severe fatigue without substantial muscle weakness and without proven psychologic or physical causes. More specifically defined, the syndrome consists of recurrent attacks of fatigue lasting at least 6 months, with 50% of impairment of activity and with other symptoms that include
· Exudative pharyngitis/sore throat
· Painful lymphadenopathy
· Headache
· Myalgias
· Low-grade fever/chills
· Generalized weakness
· Migratory arthralgias
· Neurologic complaints/poor concentration
· Sleep disturbance
· Abdominal pain
These symptoms may develop acutely. Typically, there are no signs of muscle weakness, arthritis, neuropathy, or organomegaly. Women are more often affected than men. The syndrome has not been proven to be associated with EBV; however, some believe it may be linked to a viral infection. Prior studies have shown that faulty blood pressure control may be linked to the development of chronic fatigue syndrome. There appears to be a high incidence of associated psychiatric disorders such as anxiety, depression, and somatization disorder. Although no placebo-controlled trials have supported the treatment antidepressants have shown some anecdotal benefits in those affected. Antiviral medication, immunologic treatments (steroids, immunoglobin, interferon), and vitamin therapy are used, but their effectiveness has not been proved. Psychological therapy may be beneficial. Patients should be encouraged to maintain a gradually increasing program of activity.
Craig T, Kakumanu S. Chronic fatigue syndrome: evaluation and treatment. Am Fam Physician. 2002;65:1083–1090, 1095.
238. Which of the following statements about PVCs is correct?
A) They are narrow electrocardiographic wave (QRS) complexes that are preceded by P waves.
B) In most cases, they disappear with exercise.
C) They are treated with type IC antiarrhythmics.
D) They may represent a risk for sudden death in healthy patients.
E) Caffeine use is not associated with PVCs.
Answer and Discussion
The answer is B. PVCs are abnormal ventricular beats that are characterized by wide QRS complexes, which are usually not preceded by P waves. In patients with normal hearts, PVCs usually disappear with exercise. If the patient remains asymptomatic and there is no organic heart disease, no further treatment is necessary. If PVCs are frequent, electrolyte abnormalities and heart disease should be excluded. Patients with frequent, repetitive, or multiform PVCs and underlying heart disease are at increased risk for sudden death because of cardiac arrhythmia (particularly ventricular fibrillation). Without underlying cardiac disease, bigeminy and trigeminy are considered benign rhythms. Treatment of PVCs is controversial but should be reserved for symptomatic patients. If MVP, hypertrophic obstructive cardiomyopathy, prolonged Q-T interval, left ventricular hypertrophy, or CAD is present, a trial of β blockers can be used. Types IA (quinidine, procainamide) and IB (lidocaine, mexiletine) antiarrhythmic agents may be used; however, they are associated with a high incidence of side effects and can make the arrhythmias worse. Type IC agents (flecainide, propafenone) should not be used because of their potential for increased mortality rates. Elimination of exogenous catecholamines, sympathomimetic amines, alcohol, and caffeine may decrease symptoms. In general, antiarrhythmic drug therapy is rarely necessary.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:705.
239. Which of the following statements about lung cancer is true?
A) Squamous cell and small cell tumors are rarely associated with smoking.
B) Squamous cell tumors typically arise in central bronchi and may be diagnosed with sputum cytology.
C) Large cell tumors are common, arise centrally, and typically metastasize locally.
D) Small cell carcinoma is usually located peripherally and rarely metastasizes.
E) Yearly chest x-rays are recommended for smokers over age 50.
Answer and Discussion
The answer is B. Lung cancer caused by tobacco abuse is a significant health problem that accounts for approximately 150,000 deaths yearly in the United States. Most cases appear between 50 and 70 years of age. Unfortunately, at the time of diagnosis, only approximately 20% of patients have localized disease. The following are the most common types (typically the cancers are divided into small cell cancers and non-small cell cancers:
· Squamous cell (epidermoid). As much as 30% to 35% of lung cancers. One of the most common types seen in men, these tumors tend to arise from the central (larger) bronchi and are the most easily diagnosed with sputum cytology. Most of these tumors metastasize locally to the regional lymph nodes and are more localized at the time of diagnosis.
· Large cell. As much as 10% to 15% of lung cancers. Less common in incidence, these tumors usually metastasize through the bloodstream. Approximately 20% of patients may develop cavitary lesions. These tumors are usually located peripherally.
· Adenocarcinoma. As much as 25% to 35% of lung cancers. One of the more common types, these tumors are usually located peripherally and are usually advanced at the time of diagnosis. It spreads through the bloodstream and lymphatics. A subset of tumors referred to as bronchoalveolar is growing in incidence.
· Small cell (oat cell). Approximately 15% of lung cancers. This type also tends to occur centrally and is usually widespread at the time of diagnosis.
Chest radiographs for asymptomatic smokers may identify patients with early disease; however, routine screening with yearly chest radiographs is not recommended. In most cases, lung cancers are divided into small cell tumors and non-small cell tumors (which include squamous cell, large cell, and adenocarcinomas). Stage I or II non-small cell tumors can be treated with surgical resection; small cell tumors respond to chemotherapy and radiation therapy (cures are rare). Squamous cell tumors and small cell tumors are most often linked with cigarette smoking.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:503–509.
240. Which of the following is a potentially severe complication of using warfarin that is unrelated to excessive bleeding?
A) Pancreatic neoplasm
B) Hepatitis
C) Skin necrosis
D) Peripheral neuropathy
E) Pulmonary fibrosis
Answer and Discussion
The answer is C. Warfarin is classified as an anticoagulant. Its mechanism of action is the inhibition of vitamin K–dependent clotting factors (i.e., factors II, VII, IX, and X). The medication is used in stroke prophylaxis for patients with prior neurologic events, atrial fibrillation, mechanical heart valves, or previous DVT or PE. Warfarin interacts with many medications, so concomitant use with other drugs should be monitored carefully. Most complications are related to bleeding; however, other side effects, including nausea, vomiting, fever, burning of the feet, and rashes, may occur. The most common complication unrelated to excessive bleeding is skin necrosis, which usually occurs within the first week of therapy. Some cases may be severe enough to require surgical débridement or even amputation. Patients treated with warfarin should have their PTs and INRs followed to ensure proper levels of anticoagulation.
Ansell J, Hirsh J, Poller L, et al. The pharmacology and management of the vitamin K antagonists: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126(3 suppl):204S–233S.
Warfarin's mechanism of action is the inhibition of vitamin K–dependent clotting factors (i.e., factors II, VII, IX, and X).
241. Which of the following is not in the diagnostic criteria for the presence of diabetes mellitus?
A) Random plasma glucose >200 mg/dL
B) Fasting plasma glucose of 140 mg/dL
C) Abnormal glucose tolerance test
D) Hemoglobin A1C (HbA1c) of 7.5
Answer and Discussion
The answer is A. The diagnostic criteria for diabetes mellitus are (1) symptoms of diabetes mellitus plus a random plasma glucose concentration of at least 200 mg/dL (11.1 mmol/L); (2) a fasting plasma glucose level of 126 mg/dL (7.0 mmol/L) or higher; or (3) a 2-hour plasma glucose level of 200 mg/dL or more during an oral glucose tolerance test. However, the oral glucose tolerance test is not recommended as a test for diabetes mellitus. Repeat testing on a different day is needed to confirm these findings. Although somewhat controversial the use of hemoglobin HbA1c is not used in the diagnosis of diabetes mellitus.
Davidson MB, Schriger DL, Peters AL. Relationship between fasting plasma glucose and glycosylated hemoglobin. Potential for false-positive diagnoses of type 2 diabetes using new diagnostic criteria. JAMA. 1999;281:1203–1210.
American Diabetes Association. Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care. 1997;20:1183–1197.
242. Which of the following is indicated in the treatment of chronic congestive heart failure?
A) Atenolol
B) Metoprolol
C) Propanolol
D) Acebutolol
E) Timolol
Answer and Discussion
The answer is B. The U.S. Food and Drug Administration (FDA) has labeled only extended-release metoprolol succinate (Toprol XL) and carvedilol for the treatment of chronic heart failure. Metoprolol is β1 selective, and carvedilol is nonselective. Extended-release metoprolol succinate can be started in a dosage of 25 mg/day in patients with New York Heart Association class II failure; in patients with more severe heart failure, the starting dosage should be 12.5 mg/day. The recommended starting dosage of carvedilol is 3.125 mg twice daily. The mortality benefits of metoprolol have been proven only for the extended-release form. A number of major trials have evaluated the mortality benefits of β-blockers in patients with chronic heart failure. The mortality benefit of β-blocker therapy in patients with chronic heart failure is clear. Studies continue to show less than ideal use of these medications in patients with chronic heart failure. Current expert guidelines recommend the use of β-blockers in all stable patients who have evidence of left ventricular systolic dysfunction (generally defined as an ejection fraction of less than 40%), unless there is a contraindication to their use.
Kukin ML. Beta-Blockers in chronic heart failure: considerations for selecting an agent. Mayo Clin Proc. 2002;77:1199–1206.
243. Which of the following would best help to prevent shin splints?
A) Change in running surfaces
B) Ice therapy
C) Running on inclined surfaces
D) More intensive training schedule
E) Stretching before exercise
Answer and Discussion
The answer is E. Shin splints (medial tibial stress syndrome) are a common condition caused by overuse of the lower extremity muscles. The condition is caused by a periosteitis of the tibia. They typically occur when an athlete's running surface (e.g., hills, inclines, stairs) is changed, when a different type of shoe is used, when an athlete's running style is altered, or when excessive training that does not allow adequate time for the muscles to recover is undertaken. Most affected athletes report pain over the lower tibial area that may be referred to the foot or knee. Any type of movement or exercise that works these muscle groups tends to make the pain worse. In addition to pain, mild diffuse swelling or redness may be noted over the tibia. The differential diagnosis includes stress fractures, exertional compartment syndrome, and tenosynovitis. Diagnosis is usually based on history and physical examination. In severe cases that are refractive to ice, rest, and NSAIDs, plain radiographs and perhaps a bone scan should be performed to rule out a stress fracture. If fractures are not noted, there may be diffuse increased uptake of technetium along the tibia in the area of the periosteum. If the patient is only mildly affected, exercise can be continued; however, more severe cases may require restriction of activity. When the pain and inflammation subsides, the athlete should be instructed in stretching exercises for the muscles of the lower extremity. If shin splints are recurrent, examination to rule out excessive pronation should be performed; if present, orthotics should be used to correct hyperpronation. It is now thought that medial tibial stress syndrome represents one end of a continuum of bony stress injury, with a focal stress fracture representing the other.
Sanderlin BW, Raspa RF. Common stress fractures. Am Fam Physician. 2003;68:1527–1532.
244. Which of the following is the treatment of choice for pyoderma gangrenosum?
A) Steroid therapy
B) Topical antibiotics
C) Oral antibiotics that treat methicillin-resistant S. aureus
D) Methotrexate
E) Plasmapheresis
Answer and Discussion
The answer is A. Pyoderma gangrenosum is a rapidly evolving and severely debilitating skin disease that is characterized by a painful hemorrhagic pustule that breaks down to form a chronic ulcer. The ulcer is associated with pus production, and there is usually a dusky red or purple halo around the ulcer. The cause of the lesions is unknown, but they tend to form at the sites of trauma (most commonly the legs). The borders of the lesions are usually irregular, and the lesions are boggy and usually quite painful. Although as many as 50% of cases have no associated underlying abnormality, other diseases associated with pyoderma gangrenosum include Crohn's disease, ulcerative colitis, leukemia, paraproteinemia, multiple myeloma, rheumatoid arthritis, hepatitis, and Behçet's disease. The diagnosis of pyoderma gangrenosum is usually made by the history and clinical findings. Laboratory tests show elevated ESR and leukocytosis. Treatment involves correction of underlying disease and the use of high-dose oral steroids or intravenous pulse steroid therapy. Additional findings in these patients include cutaneous anergy and benign monoclonal gammopathy.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:310–311.
245. Which of the following is acceptable treatment for Helicobacter pylori infection?
A) Bismuth, amoxicillin, and metronidazole
B) TMP-sulfamethoxazole, sucralfate, and metronidazole
C) Omeprazole, clindamycin, and sucralfate
D) Docusate, tetracycline, and metronidazole
E) Ranitidine, metronidazole, and ampicillin
Answer and Discussion
The answer is A. Helicobacter pylori is a bacteria found in the stomach that is present in >80% of patients with duodenal ulcers and up to 60% of those with gastric ulcers. The prevalence of H. pylori in the United States is approximately 30%. The incidence appears to increase with increasing age. Most H. pylori colonization is asymptomatic. Diagnosis is accomplished by biopsy and histologic examination, the urea breath test for H. pylori, stool antigen test, or cultures of endoscopy-obtained samples. Serologic blood test can also be used to determine a history of H. pylori infection. To decrease the incidence of recurrent ulcers, H. pylori is treated with a 2-week regimen consisting of bismuth (Pepto-Bismol), tetracycline or amoxicillin, and metronidazole. Other regimens include clarithromycin and omeprazole. Treatment of nonulcer dyspepsia thought secondary to H. pylori is controversial.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:886–888.
246. Which of the following treatments is the treatment of choice for chronic allergic rhinitis?
A) Systemic antihistamines
B) Intranasal steroids
C) Topical decongestants
D) Cromolyn sodium
E) Bee pollen extract
Answer and Discussion
The answer is B. Allergic rhinitis is characterized by nasal congestion, clear rhinorrhea, mucosal thickening, and conjunctivitis with the absence of fever or sinus tenderness. Patients may exhibit a bluish discoloration below the eyelids (“allergic shiners”) as a result of venous congestion. Constant nose rubbing is known as the “allergic salute” and can result in a crease across the bridge of the nose. Treatment involves avoiding the triggering factors such as pollens, molds, cigarette smoke, animal dander, and dust mites. Many patients report symptoms related to seasons (Spring, Summer, or Fall). The best treatment is the administration of intranasal steroids, which have few associated side effects. Other treatment options include montelukast (Singulair), azelastine (Astelin nasal spray) cromolyn sodium, ipratropium bromide, and second-generation (nonsedating) systemic antihistamines such as loratadine (Claritin), fexofenadine (Allegra), and cetirizine (Zyrtec). The chronic use of topical decongestants can lead to rebound congestion known as rhinitis medicamentosa and should be used only on a temporary basis (i.e., no more than 3 days). Immunotherapy may also be an alternative treatment for debilitating symptoms.
Ferri F. Ferri's Clinical Advisor, Instant Diagnosis and Treatment. Philadelphia: Elsevier/Mosby; 2006:742.
247. A 24-year-old intravenous drug abuser presents with fever, night sweats, chest pain, and arthralgias. On examination, painless erythematous lesions are noted on the palms of the hands; round, erythematous lesions with central clearing are noted in the retina; and splinter hemorrhages are noted on the fingernails. The most likely diagnosis is
A) HIV infection
B) bacterial endocarditis
C) syphilis
D) infectious hepatitis
E) Lyme disease
Answer and Discussion
The answer is B. Bacterial endocarditis is an infection of the endocardium and heart valves. It is characterized by fever, anemia, valvular dysfunction, cardiac murmurs, petechiae, emboli, and cardiac vegetations that may result in valve incompetence, abscesses, or aneurysms. The most serious complication is CHF. The aortic and mitral valves are the most commonly affected. Infections are usually caused by S. aureus or Streptococcus species (e.g., Streptococcus viridans, S. pneumoniae). Infections of prosthetic valves are of particular concern and usually require removal of the artificial valve. Splenomegaly is often seen in conjunction with endocarditis. Other symptoms include night sweats, malaise, weight loss, arthralgias, and chest pain. Painful erythematous nodules at the distal tips of the fingers are called Osler's nodes. Round, erythematous lesions with central clearing (Roth spots) can affect the retina. Painless erythematous lesions (Janeway lesions) can affect the palms or soles. Subungual “splinter hemorrhages” can affect the fingernails. Laboratory findings are usually nonspecific and may show anemia, reticulocytopenia, hypergammaglobulinemia, circulating immune complexes, and positive rheumatoid factor. The patient's ESR may be elevated. Urinalysis frequently shows proteinuria and microscopic hematuria.
Intravenous drug abuse is a major cause of endocarditis, which usually affects the right side (tricuspid valve) of the heart. If treated early, the prognosis is usually good. Echocardiography is the best diagnostic test for bacterial endocarditis. Transthoracic echocardiography detects vegetations in 50% of patients with endocarditis, whereas transesophageal echocardiography detects vegetations in >90% of cases. Blood cultures can determine the causative organism; however, 15% to 20% of patients with clinical endocarditis may test negative, usually as a result of recent antibiotic therapy.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:724–731.
248. In diagnosing a pulmonary embolism (PE), which of the following tests is considered the “gold standard” test?
A) Ventilation/perfusion (V/Q) lung scan
B) Venous compression ultrasonography of the legs
C) Pulmonary angiography
D) Spiral computed tomography (CT) of the chest
E) D-dimer blood test
Answer and Discussion
The answer is C. Pulmonary embolism is potentially fatal, yet it's the determination of a PE that remains difficult because clinical features are often nonspecific, and available diagnostic tests have significant limitations. Pulmonary angiography is the accepted “gold standard” test, but it is invasive and difficult to interpret, and can give false-negative results. Many other tests have been developed and used in combination to assess the probability of pulmonary embolism in individual patients, including ventilation–perfusion (V/Q) lung scanning, venous compression ultrasonography of the legs, and contrast-enhanced spiral computed tomography (CT) of the chest. Initially, spiral CT was thought to have high sensitivity and specificity, but it is now known that the sensitivity is too low to reliably rule out pulmonary embolism without further testing. Nevertheless, the combination of spiral CT and leg compression ultrasonography might have sufficient sensitivity and specificity to safely exclude pulmonary embolism and avoid unnecessary anticoagulation in many patients. Experts advise that anticoagulant therapy can safely be withheld in patients with a low or intermediate probability of pulmonary embolism and negative spiral CT and ultrasonography. Anticoagulation can probably also be avoided in high-probability patients with negative testing if more advanced screening such as V/Q lung scan or pulmonary angiography also is negative.
Musset D, Parent F, Meyer G. Diagnostic strategy for patients with suspected pulmonary embolism: a prospective multicentre outcome study. Lancet. 2002;360:1914–1920.
249. Which of the following findings is associated with chronic myelocytic leukemia (CML)?
A) Leukopenia
B) Philadelphia chromosome
C) Elevated leukocyte alkaline phosphatase level
D) Thrombocytopenia
E) Decreased vitamin B12 levels
Answer and Discussion
The answer is B. CML is a clonal myeloproliferative disorder that results in the overproduction of granulocytes from the bone marrow, liver, and spleen. The average age of onset is approximately 45 years. In most cases, the CML clone has the potential to progress into an accelerated phase and final blast crisis but usually remains stable for years before transformation. Symptoms are usually nonspecific and include low-grade fever, weight loss, night sweats, fatigue, anorexia, and, in some cases, abdominal fullness secondary to splenomegaly. Physical examination may show significant splenomegaly and generalized lymphadenopathy (ominous signs). Laboratory findings include significant elevation in the white blood cell count (200,000 at the time of diagnosis) and thrombocytosis. Bone marrow studies show hypercellularity with a significant left shift and low leukocyte alkaline phosphatase value. Vitamin B12 levels and serum vitamin B12–binding capacity are usually elevated as a result of increased granulocyte production of transcobalamin I, and there is almost always a Philadelphia chromosome (translocation of part of chromosome 9 to chromosome 22) present.
Treatment involves the use of chemotherapy medications such as hydroxyurea. In most cases, the patient may be kept asymptomatic for long periods while maintaining the white blood cell count at <50,000. True remission does not occur because of the persistence of the Philadelphia chromosome in the bone marrow. Median survival after the clinical onset is approximately 3 to 4 years. If a blast crisis occurs, the average survival is approximately 2 months but can be improved with adequate treatment. α-Interferon produces remission in 20% to 25%. Bone marrow transplantation has been shown to improve survival in select patients.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1113–1114.
250. The definition of chronic bronchitis is
A) a chronic productive cough of at least 3 months' duration that occurs for 2 consecutive years
B) a chronic productive cough that fails to respond to antibiotics
C) a condition associated with the destruction of lung tissue and the development of blebs
D) a chronic productive cough of at least 6 months' duration that occurs for 5 consecutive years
E) a reduction in lung compliance by 30% or more
Answer and Discussion
The answer is A. COPD is divided into two categories: chronic bronchitis (“blue bloaters”) and emphysema (“pink puffers”). The basic underlying abnormality is an increased resistance to airflow during expiration. It is estimated that COPD develops in up to 15% of smokers.
Chronic bronchitis is a condition in which the patient has a chronic productive cough of at least 3 months' duration that occurs for at least 2 consecutive years. It is almost always caused by cigarette smoking, but also has been associated with pollution exposure and recurrent infections. Patients usually appear edematous, and diffuse rhonchi are heard on physical examination. There appears to be hypoxia with CO2 retention early in the disease process. Lung compliance is usually normal, and the development of cor pulmonale is common. Infections are common in these patients. Chest radiographs may show increased markings, and blood tests may show an elevated hematocrit.
Emphysema is a condition associated with the destruction of lung tissue and the development of blebs (coalescence of alveoli). Emphysema is subclassified as follows:
· Panlobular, which is associated with an α1-antitrypsin deficiency
· Centrilobular, which is associated with smoking and chronic bronchitis
Patients tend to have a thin habitus and decreased breath sounds on physical examination. These patients usually do not exhibit hypoxia or CO2 retention until late in the disease process. Diffusing capacity of the lungs is usually decreased; lung compliance is usually increased. Chest radiographs usually show decreased markings with hyperinflation and possibly bullae. Cor pulmonale usually does not develop until late in the disease course. Blood tests usually show a normal hematocrit. In most cases, chronic bronchitis and emphysema exist simultaneously; thus the term COPD.
Snow V, Lascher S, Mottur-Pilson C. The evidence base for management of acute exacerbations of COPD. Clinical practice guideline, part 1. Chest. 2001;119:1185–1189.
Emphysema is a condition associated with the destruction of lung tissue and the development of blebs (coalescence of alveoli).
251. A 72-year-old smoker with a positive history of severe degenerative arthritis, diabetes, and cardiovascular disease presents to your office complaining of bilateral leg pain that occurs after walking 200 yards. He reports that rest improves his symptoms. Which of the following would be appropriate?
A) Ankle/brachial indices
B) MRI of the lumbar spine
C) Ultrasonography of the lower extremities
D) Electromyogram of the lower extremities
E) Arteriogram of the lower extremities
Answer and Discussion
The answer is A. Claudication occurs when there is arterial insufficiency of the lower extremities. It usually occurs in the calf muscles, thighs, and buttocks and is bilateral and progressive. Symptoms include pain, fatigue or weakness associated with the lower legs that typically occurs after walking predictable distances, and, occasionally, impotence in men. If the pain or discomfort occurs with varying distances, a workup for other causes is necessary. Patients who experience significant restriction in their activities may be considered for surgery; however, their overall health status should be considered first. Many patients have underlying cardiovascular disease that may put them at surgical risk. Ankle/brachial indices (usually <0.90 with peripheral arterial disease) are the simplest method to estimate blood flow to the lower extremities. The use of arteriogram is not necessary unless the patient is considering surgery. Treatment involves
· Walking programs that gradually reduce the pain of claudication and promote adequate blood flow
· Pentoxifylline, a medication that promotes red blood cell flexibility to surpass obstructions
· Cessation of all tobacco products
· Surgery for severe cases unresponsive to medical therapy
Ischemic pain at rest usually affects the feet and toe area as opposed to the other proximal locations involved in claudication.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co., 2006:462–469.
252. A 65-year-old man presents complaining of back pain and generalized fatigue. Laboratory findings include anemia with Rouleau formation, a monoclonal spike seen with serum protein electrophoresis, and hypercalcemia. Radiographs of the lumbar spine show lytic lesions. The most likely diagnosis is
A) metastatic prostate cancer
B) Paget's disease
C) osteitis fibrosa cystica
D) multiple myeloma
E) colon cancer
Answer and Discussion
The answer is D. Multiple myeloma is a malignancy associated with plasma cells and involves replacement of the bone marrow, bone destruction, and the formation of paraproteins that are found in the blood and urine. It is the most common primary malignancy that affects the spine. Affected patients are usually older than 60 years and present with anemia, bone pain, and an elevated sedimentation rate. Other manifestations include renal failure; spinal cord compression; or symptoms of hyperviscosity, including mucosal bleeding, vertigo, visual abnormalities, and alterations in mental status. Laboratory abnormalities include an anemia with Rouleau formation, abnormal serum and urine protein electrophoresis with a monoclonal spike in the β or γ region, hypercalcemia as a result of bone destruction, and radiographs showing lytic lesions associated with the skeletal bones (bone scans are inferior to conventional radiographs). Diagnosis is made by bone marrow biopsy showing more than 10% of plasma cells in the bone marrow. Treatment is aimed at palliation and involves chemotherapy and correction of hypercalcemia. Patients are at increased risk of infection caused by encapsulated organisms, such as S. pneumoniae and H. influenzae, because of impaired immune response. The median survival time is 3 to 5 years.
Ferri F. Ferri's Clinical Advisor, Instant Diagnosis and Treatment. Philadelphia: Elsevier/Mosby; 2006:541–542.
253. A true statement regarding the use of probiotics is
A) Probiotics should always be separated from antibiotics by a couple of hours.
B) Their use has not been shown to be useful.
C) Require a prescription for a licensed physician.
D) The microorganisms are heat-killed before packaging.
Answer and Discussion
The answer is A. Probiotics are living microorganisms used to colonize the intestine to prevent or treat disease. The most common probiotics are Lactobacillus spp. and Saccharomyces spp. Probiotics that contain species ofLactobacillus or Saccharomyces decrease the likelihood of diarrhea from antibiotics in children or adults. These products can be obtained over the counter. A typical dosage is 5 billion to 10 billion viable organisms administered three to four times a day. The probiotics should be separated from the antibiotics by a couple of hours.
Cremonini F, DiCaro S, Nista EC. Meta-analysis: the effect of probiotic administration on antibiotic-associated diarrhoea. Aliment Pharmacol Ther. 2002;16:1461–1467.
254. The anticoagulation effects associated with heparin therapy are best reversed with the use of
A) vitamin K
B) fresh frozen plasma
C) cryoprecipitate
D) protamine sulfate
E) platelet administration
Answer and Discussion
The answer is D. Heparin is an anticoagulant used to prevent thrombosis. Heparin works by binding to and activating antithrombin III, an extremely potent anticoagulant that prevents thrombin generation and fibrin formation. The drug is administered intravenously and subcutaneously. The major side effect is bleeding. If needed, protamine sulfate may be administered to rapidly reverse heparin's anticoagulant effect; in most cases, this measure is unnecessary and the discontinuation of heparin is adequate. Other complications include heparin-induced thrombocytopenia, which occurs in 10% of patients taking the medication. The thrombocytopenia can actually lead to a paradoxical arterial thrombosis, which can be life threatening. Discontinuation of the medication usually reverses the thrombocytopenia. When administering intravenous heparin, the PTT should be monitored. Any increase in heparin dose is usually detected 4 hours later (as noted with a prolonged PTT) and vice versa with decreased doses of heparin. The goal for anticoagulation is usually 1.5 to 2.0 times the normal value, but may depend on the individual case. Patients should not take aspirin while taking heparin; intramuscular injections should also be avoided. Chronic use of heparin may increase the risk of osteoporosis. Low-molecular-weight heparin is now available and is used for anticoagulation. PTT and thrombin times are minimally affected by typical therapeutic doses. Therefore, laboratory monitoring is not required.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:675, 688–689, 1564.
255. A 36-year-old runner presents with pain associated with the anterior heel. The patient reports his symptoms are worse on awakening and improve as the day progresses. The most likely diagnosis is
A) Achilles tendonitis
B) plantar fasciitis
C) calcaneal fracture
D) calcaneal bone spur
E) anterior talotibial impingement syndrome
Answer and Discussion
The answer is B. Plantar fasciitis is caused by inflammation or tearing (microtears) of the plantar fascia at the attachment site to the os calcis. It is a common complaint in runners. Symptoms include pain at the attachment of the plantar fascia at the calcaneus. The pain is usually worse in the morning on standing or standing after prolonged sitting. The pain may improve early in the day but usually worsens toward the end of the day and is relieved when the patient lies or sits down. Calcaneal spurs, visible on radiographs, may occur in chronic cases but are not responsible for evoking pain and discomfort. Treatment involves NSAIDs, stretching exercises (e.g., rolling a tennis ball under the foot), heel pads (Viscoheel), orthotics, rest, and ice therapy. In more severe cases that are refractory to these measures, iontophoresis, night splints, or steroid injection (0.5 mL of steroid and 1.0 mL of 1% lidocaine) can be used. In addition, surgery may be indicated for severe cases that are unresponsive to conservative therapy.
Young CC, Rutherford DS, Niedfeldt MW. Treatment of plantar fasciitis. Am Fam Physician. 2001;63:467–474, 477–478.
256. A 52-year-old man is seen for fevers and weight loss. A chest radiograph shows mediastinal lymphadenopathy. Laboratory findings show hypercalcemia, elevated alkaline phosphatase, and an elevated level of ACE. The most likely diagnosis is
A) small cell carcinoma of the lung
B) pulmonary tuberculosis
C) sarcoidosis
D) histoplasmosis
E) asbestosis
Answer and Discussion
The answer is C. Sarcoidosis is a systemic granulomatous disease that is characterized by noncaseating granulomas that may affect multiple organ systems. The condition occurs mainly in persons ages 20 to 40 years and is most common in Northern Europeans and African-Americans. Symptoms are variable and the etiology is unknown. Fever, weight loss, arthralgias, and erythema nodosum (more commonly seen in Europeans) are the usual initial presenting symptoms. Cough and dyspnea may be minimal or absent. Other manifestations include mediastinal lymphadenopathy seen on chest radiograph (hallmark finding in 90% of cases), hepatic granulomas, granulomatous uveitis, polyarthritis, cardiac symptoms (including angina, CHF, and conduction abnormalities), cranial-nerve palsies, and diabetes insipidus. Laboratory findings include leukopenia, hypercalcemia, hypercalciuria, and hypergammaglobulinemia (particularly in African-American patients). Other abnormalities include elevated uric acid (not usually associated with gout), elevated alkaline phosphatase, elevated gamma glutamyl transpeptidase, elevated levels of ACE, and pulmonary function tests showing restriction and impaired diffusing capacity. Diagnosis can be made with biopsy of peripheral lesions or fiberoptic bronchoscopy for central pulmonary lesions. Whole-body gallium scans can be used to show useful sites for biopsy and, in some cases, to follow disease progression. Serial pulmonary function tests are important for assessing disease progression and guiding treatment. The prognosis depends on the severity of the disease. Spontaneous improvement is common; however, significant disability can occur with multiorgan involvement. Pulmonary fibrosis is the leading cause of death. Treatment for symptomatic patients consists of corticosteroids, methotrexate, and other immunosuppressive medications if steroid therapy is not helpful.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:462–469.
257. A cytomegalovirus infection has developed in a patient with AIDS. The most appropriate treatment is
A) ganciclovir
B) amphotericin B
C) amantadine
D) metronidazole
E) ciprofloxacin
Answer and Discussion
The answer is A. Cytomegalovirus is a viral infection that may occur congenitally or at any age. The severity of the infection varies. The virus is a variant of the herpes virus and is ubiquitous. Manifestations of the illness include fever, hepatitis, pneumonitis, and neurologic damage to brain tissue in the newborn (hearing losses or perinatal death in severe cases). The infection may be acquired in utero from an infected mother or by contact with infected secretions, including urine, saliva, breast milk, feces, blood, and semen. Patients with AIDS or immunocompromised conditions such as transplant patients and those living in institutions (such as nursing homes) or attending daycare centers are at increased risk. The infection is very common (as much as 90% of the population is affected) and in most cases is represented by mild symptoms. More severe cases can produce a mononucleosis-type illness, retinitis, or pneumonitis in adults. Congenital cytomegalovirus may include jaundice, hepatosplenomegaly, petechial rash, microcephaly, and cerebral calcifications. Diagnosis is achieved with the detection of the virus by immunofluorescence with monoclonal antibodies. Treatment is usually supportive; however, ganciclovir can be used in more severe cases and particularly in AIDS patients. Foscarnet sodium (Foscavir) is also effective, especially in ganciclovir-resistant cases.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1605–1606.
258. Which of the following ECG findings is associated with hypothermia?
A) J (Osborne) wave
B) Tachycardia
C) Atrioventricular dissociation
D) Atrial fibrillation
E) First-degree AV block
Answer and Discussion
The answer is A. Hypothermia is caused by prolonged exposure to a cold environment, causing the body's core temperature to fall below 35°C (or 95°F). Infants, the elderly, and those with altered mental status or debilitating illnesses are at increased risk. Others at increased risk include trauma and burn victims and those with malnutrition. Symptoms include shivering, decreased mental status with confusion, impaired coordination, drowsiness, bradycardia, and, in more severe cases, loss of the shivering reflex and coma. ECG tracings may show a characteristic J (Osborne) wave, a positive deflection after the QRS complex in the lateral leads. Death usually results from the progression of severe bradycardia to ventricular fibrillation. Treatment involves slow central body warming (over 2 to 3 hours to prevent shock) with warmed intravenous fluids, warmed oxygen, and warming blankets or warm baths. Life-sustaining measures should always be continued until the normal core body temperature is achieved.
Ferri F. Ferri's Clinical Advisor, Instant Diagnosis and Treatment. Philadelphia: Elsevier/Mosby; 2006:440.
259. Which of the following toxin–antidote associations is correct?
A) Organophosphates–atropine and pralidoxime
B) Carbon monoxide–nitrous oxide
C) Opioids–benzodiazepines
D) Methanol–isopropyl alcohol
E) Arsenic–flumazenil
Answer and Discussion
The answer is A. One of the common smells associated with poisonings is a garlic smell that may represent arsenic, dimethyl sulfoxide, organophosphates, and selenium toxicities. There is a cluster of symptoms that is associated with organophosphates represented by the acronym SLUDGE:
· Salivation
· Lacrimation
· Urinary frequency
· Defecation
· Gastric hypersecretion
· Emesis
The treatment for organophosphate poisoning is the concomitant use of atropine and pralidoxime. The treatment of choice for arsenic poisoning is penicillamine or dimercaprol. Sodium nitrite and sodium thiosulfate are antidotes for poisoning with cyanide amyl nitrate. Oxygen is used for carbon monoxide poisoning. Anticholinergic overdoses with medication such as atropine, scopolamine, and antihistamines are usually associated with symptoms in which the patient is described as “Dry as a bone, red as a beet, and mad as a hatter.” Treatment involves the use of physostigmine as an antidote. Methanol overdoses are treated with ethanol, and opioid overdoses are treated with naloxone. Flumazenil (Romazicon) is used to treat benzodiazepine overdoses. Acetylcysteine is the treatment of choice for acetaminophen overdose.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2651–2695.
The treatment for organophosphate poisoning is the concomitant use of atropine and pralidoxime.
260. A blood urea nitrogen (BUN):creatinine level greater than 20 is associated with
A) dehydration
B) renal stones
C) bladder outlet obstruction
D) hypercalcemia
E) renal artery stenosis
Answer and Discussion
The answer is A. Acute renal failure is divided into the following categories:
· Prerenal. This is due to inadequate renal perfusion. It can be caused by volume depletion (dehydration), cardiac or hepatic failure, and sepsis. Laboratory tests reveal a low urinary sodium (<20 mEq/L) and a high urine-to-plasma creatinine ratio (>20:1). The BUN to serum creatinine ratio is higher than 20.
· Intrarenal. This was previously known as acute tubular necrosis. Causes include ischemia, hypertension, vasculitis, metabolic disorders (e.g., hypercalcemia, hyperuricemia), toxins, x-ray dyes, myoglobinuria, and medications (e.g., aminoglycosides, penicillins, anesthetic agents). Laboratory tests show results similar to postrenal azotemia.
· Postrenal. This is usually caused by obstruction by renal calculi or bladder outlet obstruction (prostate enlargement). Laboratory tests show a high-urinary sodium (>40 mEq/L) and a low urine-to-plasma creatinine ratio (<20:1). The BUN to serum creatinine ratio is lower than 20.
Prerenal and postrenal causes for acute renal failure are potentially reversible. If caught early, some forms of intrarenal azotemia (e.g., drug effects, infections, hypertension) can be reversed.
Agrawal M, Swartz R. Acute renal failure. Am Fam Physician. 2000; 61:2077–2088.
261. Which of the following tests is used in the initial evaluation of persistent hemoptysis?
A) Fiberoptic bronchoscopy
B) Chest radiograph
C) Upper gastrointestinal (GI)
D) MRI of chest
E) CT scan of chest
Answer and Discussion
The answer is B. Hemoptysis is the presence of blood in the expectorate. Intrapulmonary causes include infections (e.g., bronchitis, pneumonia, tuberculous, fungal infections), neoplasm, bronchiectasis, pulmonary embolus, AV malformations, Goodpasture's disease, vasculitis, trauma, or the presence of a foreign body. Extrapulmonary causes include GI bleeding, CHF with pulmonary edema, severe mitral stenosis, epistaxis, or other conditions (including disseminated intravascular coagulation). Most cases are self-limited and require no additional workup; however, persistent or severe hemoptysis should be evaluated with sputum collection for Gram's stain and culture, cytology, acid-fast bacillus stains, CBC, PT, PTT, chest radiograph, and flexible bronchoscopy. If a lower respiratory tract source is suspected, the patient should undergo a chest x-ray first, and if a mass is noted, bronchoscopy should be performed. A high-resolution CT may be helpful in the diagnosis. It is important to distinguish between GI blood loss (which has a dark red color and acidic pH) and true hemoptysis, which is typically bright red in color and alkaline.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:207–209.
262. Thyroid replacement therapy can be assessed by measuring the patient's
A) T3 level
B) T4 level
C) TSH level
D) thyroid-releasing hormone level
E) none of the above
Answer and Discussion
The answer is C. Patients diagnosed with hypothyroidism should receive replacement therapy with levothyroxine. These patients can be monitored for effective replacement by evaluating their serum sTSH levels. A low-level TSH usually results from over-replacement, and adjustments should be made in the dose of medication; monitoring is repeated in 6 to 8 weeks. Underreplacement is represented by an increased TSH level and can be corrected by increasing the dose of thyroxine; monitoring is repeated in 6 to 8 weeks. Checking TSH levels earlier usually does not provide enough time for the levels to stabilize.
Rakel RE, Bope ET. Conn's Current Therapy 2005. Philadelphia: Elsevier/Saunders; 2005:761–762.
263. Which of the following statements is true regarding breast self-examination?
A) Multiple studies have shown benefit in breast self evaluation in the prevention of breast cancer.
B) The mortality risk of breast cancer is reduced by the practice of breast self-examination.
C) Breast self-examination may decrease overall mortality.
D) No benefit has been found with the use of breast self-examination.
Answer and Discussion
The answer is C. A large study conducted over 10 years demonstrates that a formal program of teaching breast self-examination has no effect on breast cancer mortality but may produce a small reduction in overall mortality.
Thomas DB, Gao DL, Ray RM. Randomized trial of breast self-examination in Shanghai: final results. J Natl Cancer Inst. 2002; 94:1445–1457.
264. Which of the following statements about ALS, or Lou Gehrig's disease, is true?
A) It is a progressive motor neuron disease that affects the corticospinal tracts.
B) The onset is usually before 20 years of age.
C) It typically destroys sensory function.
D) It may respond to high-dose steroid administration.
E) Dementia is common.
Answer and Discussion
The answer is A. ALS, or Lou Gehrig's disease, is a progressive motor neuron disease that affects the corticospinal tracts and/or the anterior horn cells and/or bulbar motor nuclei. Onset of the disease is usually after 40 years of age, and the disease is more common in men. Approximately 5% to 10% of cases are familial and are associated with an autosomal-dominant mode of transmission. The hands are usually affected first with cramps, followed by weakness. Other manifestations include atrophy, muscle fasciculations, spasticity, and increased reflex response. There is usually a combination of upper and lower motor neuron signs. Dysarthria and dysphagia may occur; however, extraocular muscles, sensory function, sexual function, and urinary continence are usually not affected. Dementia is usually not present. Late in the illness inappropriate, involuntary, and uncontrollable laughter or crying may occur. Diagnosis is usually made with EMG findings that correlate with the clinical presentation. Unfortunately, there is no treatment other than supportive care. Baclofen has been used to treat muscular spasticity and cramping. Death as a result of respiratory failure usually occurs within 5 years.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1897, 1899.
265. A 32-year-old man presents with recurrent oral and genital ulcers. He also has had arthralgias. Recently he was administered a tetanus vaccination and developed a sterile abscess at the site of the injection. The most likely diagnosis is
A) Behçet's disease
B) systemic herpes
C) syphilis
D) gonorrhea
E) Lyme disease
Answer and Discussion
The answer is A. Named after a famous Turkish dermatologist, Behçet's syndrome is an inflammatory disorder that may involve ocular, genital, articular, mucocutaneous, vascular, and CNS structures. Symptoms usually develop when patients are in their 30s. Men are more severely affected than women. Symptoms include episodic and recurrent oral and genital apthous type ulcers, uveitis, arthritis (usually affecting the knees and ankles), skin lesions, thrombophlebitis, and vasculitis. Signs include cranial-nerve palsies, seizures, mental disturbances, and spinal cord lesions. The disease is usually chronic and is characterized by remissions and exacerbations. The syndrome is usually benign; however, severe ocular involvement can lead to blindness. Steroids and immunosuppressive medication (interferon, azathioprine, cyclosporine) have been used for treatment, especially in cases of severe uveitis and CNS involvement. Other medications used in treatment include thalidomide, chlorambucil, and colchicine. The disease is more commonly seen in Japan and Korea, as well as the eastern Mediterranean countries. Sterile abscesses or pustules at the site of an injection are hallmark findings for the disease.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:2014.
266. The pneumococcal vaccine should be administered to healthy individuals at age
A) 50 years
B) 55 years
C) 60 years
D) 65 years
E) 70 years
Answer and Discussion
The answer is D. Adult immunizations include tetanus immunization, which should be given every 10 years. Pneumococcal immunization should be administered to those who are healthy and older than 65 years and those with other chronic or debilitating illnesses. The pneumococcal vaccine is typically a single, lifetime immunization; however, if the patient received their first dose before age 65 years and it has been more than 5 years they should receive a one-time booster. In addition, immunocompromised individuals or those with chronic underlying conditions should be considered for booster vaccination after 5 years. Influenza vaccination should be given yearly to those older than 50 years and those with underlying chronic illnesses. Patients born after 1956 should receive a booster measles vaccination, and those who have not had chickenpox (varicella) should receive the varicella vaccine. Adults who work in the health-care field or around body secretions or blood should receive the hepatitis B vaccination, which consists of three doses: one given at the initial visit, one 1 month later, and a booster 6 months later. In some cases, additional boosters may be necessary.
Centers for Disease Control and Prevention website. Summary of adolescent/adult immunization recommendations. Available at: http://www.cdc.gov/nip/recs/adult-schedule.pdf. Accessed 6/2/06.
267. A boy who plays Little League baseball presents with swelling over the lateral elbow and pain with valgus and varus stress while flexing and extending the elbow. The patient reports locking of the elbow. In addition, radiographs show the presence of loose bodies. The most likely diagnosis is
A) osteochondritis dissecans
B) chondromalacia
C) nursemaid's elbow
D) lateral epicondylitis
Answer and Discussion
The answer is A. Little leaguer's elbow is an overuse injury caused by compressive forces at the radiocapitellar joint and opposite pulling forces at the medial aspect of the elbow. These injuries usually occur in adolescents who use motions such as overhand pitching in sports such as baseball. The repetitive forces may lead to damage of the articular surface of the capitellum, ligamentous injury of the medial elbow, and ulnar nerve dysfunction. In severe cases, osteochondritis dissecans of the capitellum with the formation of loose bodies can occur and result in locking of the elbow joint. Other symptoms include pain and swelling over the lateral elbow and pain with valgus and varus stress while flexing and extending the elbow. For mild cases, treatment involves rest, ice, elevation, and NSAIDs. However, if there are signs of osteochondritis dissecans, orthopedic referral for possible surgical intervention is necessary.
Ferri F. Ferri's Clinical Advisor, Instant Diagnosis and Treatment. Philadelphia: Elsevier/Mosby; 2006:595.
268. Mitral valve prolapse (MVP) is associated with
A) elderly, obese men
B) diastolic click that disappears with Valsalva's maneuver
C) chest pain, dyspnea, and syncope
D) rheumatic heart disease
E) myxomatous transformation of the valve leaflet
Answer and Discussion
The answer is E. Mitral valve prolapse (MVP) (systolic-click syndrome, Barlow's syndrome, and floppy valve syndrome) is usually asymptomatic but may cause chest pain, palpitations, anxiety, dyspnea, or fatigue. The condition is common and associated with myxomatous transformation of the valve leaflet. MVP usually affects healthy, young (15 to 30 years of age), thin women. MVP is determined by the detection of a midsystolic click that is followed by a late systolic murmur and becomes louder with Valsalva's maneuver. A high-pitched late systolic crescendo–decrescendo murmur heard best at the apex may also be present. Presence of both murmur and click are not necessary for the diagnosis. In patients with MVP, cardiac arrhythmias, including PVCs, paroxysmal supraventricular tachycardia, and ventricular tachycardia, may cause palpitations and may need treatment (usually with β blockers). Patients with MVP with mitral regurgitation, those with a systolic murmur, or those with thickened leaflets need subacute bacterial endocarditis prophylaxis. Antibiotic prophylaxis for prevention of infective endocarditis during procedures that carry risk for bacteremia is recommended in most patients. Rarely, MVP may progress to mitral insufficiency because of rupture of the chordae tendineae and may require valve replacement.
Ferri F. Ferri's Clinical Advisor, Instant Diagnosis and Treatment. Philadelphia: Elsevier/Mosby; 2006:533, 1353.
Mitral valve prolapse (MVP) is determined by the detection of a midsystolic click that is followed by a late systolic murmur and becomes louder with Valsalva's maneuver.
269. Which of the following statements about Peutz-Jeghers syndrome is true?
A) The condition is sex linked and usually skips a generation.
B) The condition involves the development of multiple polyps in the stomach and the small and large intestine that commonly show malignant change.
C) There is associated hyperpigmentation around the oral cavity, lips, soles of the feet, and dorsum of the hands.
D) The condition is associated with inflammatory bowel disease.
E) The condition is identified by elevation in carcinoembryonic antigen levels.
Answer and Discussion
The answer is C. Peutz-Jeghers syndrome is a familial autosomal-dominant condition that involves the development of multiple, benign, hamartomatous polyps in the stomach and in the small and large intestine. Malignant change has occurred but is rare. Those affected also have melanin-associated brownish-black hyperpigmentation around the oral cavity, lips, soles of the feet, and dorsum of the hands. The condition usually causes no problems except in severe cases in which abdominal pain, intestinal obstruction, or bleeding can occur. In these severe cases, surgery may be considered.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:173, 1004, 1208.
270. Which of the following statements about angina pectoris is true?
A) It typically lasts 1 to 2 hours.
B) It may be associated with epigastric pain.
C) It causes predictable ECG changes.
D) It is typically associated with chest wall tenderness.
E) It rarely radiates to the neck, jaw, or left arm.
Answer and Discussion
The answer is B. Angina pectoris is typically described as substernal chest pain or pressure that may radiate to the neck, jaw, or left arm. Patients usually also experience shortness of breath, dizziness, nausea, and vomiting with diaphoresis. Symptoms are usually precipitated by physical exertion or stress and are relieved with rest. Episodes usually last 2 to 10 minutes and rarely last longer than 30 minutes. Atypical presentations include epigastric pain, indigestion, right-arm pain, light-headedness, nausea, or shortness of breath. These occurring alone are referred to as anginal equivalents. There are several types of angina:
· Stable: Intensity, character, and frequency of episodes are predictable; angina occurs in response to a known amount of exercise or stress.
· Unstable: Intensity, frequency, and duration are different and unpredictable; pain is precipitated by a lesser amount of exercise or the angina is longer in duration. Angina at rest or new-onset angina is unstable.
· Variant: Pain that may occur at rest and is secondary to spasm of the coronary arteries is variant angina.
Typically, the pain is relieved with the administration of sublingual nitroglycerin. ECG may show T-wave inversion or ST-segment depression, but in many cases is normal and should not be discounted if normal. Exercise stress testing can be used to determine coronary insufficiency. Treatment of angina is accomplished with the use of nitrates, β-blockers, and calcium-channel blockers.
Ferri F. Ferri's Clinical Advisor, Instant Diagnosis and Treatment. Philadelphia: Elsevier/Mosby; 2006:61–64.
271. Which of the following best describes Ludwig's angina?
A) Substernal chest pain that radiates to the right arm.
B) An infection involving the sublingual and submaxillary space.
C) Abdominal pain secondary to an enlarging abdominal aortic aneurysm.
D) A tonsillar infection that leads to chronic abscess formation.
E) Ischemic pain related to insufficient blood flow to an extremity.
Answer and Discussion
The answer is B. Ludwig's angina usually develops from a periodontal or dental infection and is one of the most common neck space infections. The condition is usually a rapidly developing, bilateral cellulitis that affects the sublingual and submaxillary space, without involvement of the lymph nodes or formation of abscesses. The infection usually rapidly arises from the second and third mandibular molars as a result of poor dental hygiene, tooth extraction, or trauma. Symptoms include edema and erythema of the upper neck (under the chin) and floor of the mouth, trismus, drooling, dysphonia, dysphagia, and dyspnea. Fever, chills, and tachycardia are usually present. Tongue displacement upward may also occur and threaten the airway. In severe cases, the condition may be fatal. Treatment includes protection of the airway in severe cases and intravenous antibiotics (e.g., penicillin, wide-spectrum cephalosporins) in high doses to cover anaerobic organisms (Bacteroides). Incision and drainage may be required.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:824–825.
272. Vitamin A toxicity is associated with
A) peripheral neuropathy
B) renal stones
C) increased intracranial pressure and vomiting
D) night blindness
E) pulmonary fibrosis
Answer and Discussion
The answer is C. Excessive ingestion of vitamin A may cause acute or chronic toxicity. Acute toxicity especially in children may result from taking large doses (>100,000 µg or 300,000 IU). The condition is associated with increased intracranial pressure and vomiting, which may lead to death. After discontinuation, recovery is usually spontaneous, with no residual damage. Infants who are given 6,000 to 20,000 µg (20,000 to 60,000 IU)/day of water-soluble vitamin A may show evidence of toxicity within a few weeks. Birth defects have been reported in the children of women receiving 13-cis-retinoic acid (isotretinoin) for skin conditions during pregnancy. Megavitamin tablets containing vitamin A have occasionally induced acute toxicity when taken long term. Chronic toxicity usually affects older children and adults after doses of >33,000 µg (100,000 IU)/day have been taken for an extended course (i.e., months).
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2684.
273. A 65-year-old female is undergoing a general examination. On your exam you note a fullness in the left adnexa. Which of the following conditions would be reassuring that the finding is benign?
A) A multi-loculated cyst noted on ultrasound
B) Elevated CA 125 level
C) Simple cyst measured at 2.5 cm
D) Elevated CEA level
E) All cysts in a postmenopausal female require surgical removal
Answer and Discussion
The answer is C. Adnexal masses are commonly encountered in women. In premenopausal women, physiologic follicular cysts and corpus luteum cysts are the most common adnexal masses. Ectopic pregnancy can occur and should be considered. Other causes for masses in this age group include endometriomas, polycystic ovaries, tubo-ovarian abscesses, and benign neoplasms. Malignant neoplasms become more frequent with increasing age. In postmenopausal women with adnexal masses, neoplasms must be considered, along with leiomyomas, ovarian fibromas and other lesions such as diverticular abscesses. Measurement of serum CA-125 is an appropriate test for assessing postmenopausal women with pelvic masses. Asymptomatic premenopausal patients with simple ovarian cysts <10 cm in diameter can be observed or placed on suppressive therapy with oral contraceptives. Postmenopausal women with simple cysts <3 cm in diameter may also be followed, provided the serum CA 125 level is not elevated and the patient has no signs or symptoms suggestive of malignancy. If the cyst is >3 cm or the CA 125 is elevated, further evaluation is necessary.
Drake J. Diagnosis and management of the adnexal mass. Am Fam Physician. 1998;57:2471.
274. Which of the following factors is associated with a cause of impotence?
A) Masturbation
B) Alcohol dependence
C) Nocturnal tumescence
D) Vacuum erection devices
E) Excessive testosterone levels
Answer and Discussion
The answer is B. Impotence (often referred to as erectile dysfunction) was for the most part attributed to psychogenic factors such as life stressors and performance anxiety. However, current studies show that up to 90% of men with erectile dysfunction have underlying organic pathology. Organic causes of impotence include diabetes, drug or alcohol dependency, vascular and neurogenic compromise, and medications (e.g., hypertension medications). Most causes are multifactorial in nature. Nocturnal tumescence studies have been advocated as a method to distinguish psychogenic versus organic impotence; however, there is no consensus on the use and validity of these studies. Most urologists now initiate diagnostic testing by injecting alprostadil (Caverject), with resultant increase in penile flow. The ability to obtain an erection with pharmacologic injection, for the most part, rules out significant vascular causes of impotence. Initial laboratory testing should include only basic tests (however, this is controversial); hormonal testing should be based on clinical suspicion. Many experts feel serum testosterone determination should only be obtained in cases of low sexual desire or abnormal physical findings. Serum prolactin measurements should be obtained only in patients with low sexual desire, gynecomastia, visual symptoms, and/or testosterone levels <4 ng/mL. Others advocate serum testosterone and prolactin levels for all those affected. If pituitary abnormalities are suspected, brain imaging to rule out pituitary tumors should be performed. Treatment may involve the use of phospodiesterase 5 inhibitors (PDE5) including oral sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis), testosterone patches or injections, penile injections (phentolamine, alprostadil), vacuum devices, or penile implants.
Rakel RE, Bope ET. Conn's Current Therapy 2005. Philadelphia: Elsevier/Saunders; 2005:818–822.
Miller TA. Diagnostic evaluation of erectile dysfunction. Am Fam Physician. 2000;61:95–104, 109–110.
275. Cephalosporins are contraindicated for which of the following groups?
A) Patients allergic to eggs
B) Patients who have had a mild rash as a result of penicillin administration
C) Patients with G6PD deficiency
D) Patients suspected of bacterial meningitis
E) None of the above
Answer and Discussion
The answer is E. Hypersensitivity reactions to cephalosporins may occur and include rash, urticaria, and, in severe cases, anaphylaxis. Because of the similar chemical structure, there is a small proportion (<2%) of patients with penicillin allergy who cross-react with cephalosporins. Therefore, cephalosporins should be avoided in patients with a history of an immediate reaction to penicillin. Cephalosporins are used in patients with a history of mild reactions to penicillins.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:801.
276. A 21-year-old man presents to your office complaining that his left testicle feels abnormal. On examination, the area adjacent to the left testicle feels like a “bag of worms” that gets larger with a Valsalva maneuver. The most likely diagnosis is
A) hydrocele
B) varicocele
C) left inguinal hernia
D) spermatocele
E) testicular cancer
Answer and Discussion
The answer is B. Varicoceles are a collection of veins (pampiniform plexus) usually associated with the left scrotum, which are separate from the testicle. They are found in up to 15% of adult men. On clinical examination, a varicocele feels like a bag of worms that becomes larger with a Valsalva maneuver. Some cases may be associated with decreased sperm counts and infertility. In these cases or if the patient has testicular pain or discomfort, surgical correction should be considered; otherwise, no further therapy is needed. Varicoceles are found most commonly on the left side, but up to 20% may be bilateral. Diagnosis should be made in a warm room by palpation of the spermatic cord with the patient in the standing position. Varicoceles are graded 1+ (palpable with Valsalva's maneuver only), 2+ (palpable), and 3+ (visible through the scrotal skin). An isolated right-sided varicocele or a lesion on either side that does not disappear when the patient assumes the supine position should prompt imaging of the retroperitoneum to evaluate for inferior vena caval or renal vein obstruction.
Kolettis PN. Evaluation of the subfertile man. Am Fam Physician. 2003;67:2165–2173.
An isolated right-sided varicocele or a lesion on either side that does not disappear when the patient assumes the supine position should prompt imaging of the retroperitoneum to evaluate for inferior vena caval or renal vein obstruction.
277. Exposure to radon gas has been associated with the development of
A) renal cell carcinoma
B) pancreatic cancer
C) lung cancer
D) bladder cancer
E) esophageal cancer
Answer and Discussion
The answer is C. Radon gas exposure may be linked to the development of lung cancer. The highest amounts of radon exposure are associated with people who mine uranium. Radon found in the soil and in the water supply around homes represents a theoretic risk to inhabitants. Levels associated with excess lung cancer risk may be present in as many as 10% of houses in the United States. Concrete block foundations provide a better barrier against radon than do cinder block foundations. Adequate ventilation of the home is also important to minimize radon levels. According to the Environmental Protection Agency, the maximum limit for radon in homes is 4 pCi/L. Radon levels tend to be higher in the winter months when houses are more poorly ventilated. Radon levels <1.5 pCi/L are considered safe. When smokers reside in the affected household, the problem is potentially greater, because the molecular size of radon particles allows them to readily attach to smoke particles that are inhaled.
Viera AJ. Radon and lung cancer. Am Fam Physician. 2000;62;950–951.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:1528.
278. A 28-year-old homosexual man presents to your office complaining of a nonproductive cough, shortness of breath, fever, and chills. A chest radiograph shows bilateral interstitial infiltrates. The best treatment is
A) oral azithromycin
B) intravenous penicillin
C) intravenous TMP-SMX
D) intravenous amphotericin
E) observation only
Answer and Discussion
The answer is C. Pneumocystis jiroveci (formerly P. carinii) is an opportunistic pulmonary infection that often affects patients with AIDS. As many as 30% of patients with AIDS present with this initial infection. Symptoms include a fever; dry, nonproductive cough; tachypnea; and hypoxia. Chest radiograph usually shows bilateral perihilar infiltrates; however, 20% to 30% may have a normal chest x-ray. ABGs show hypoxemia with an increase in the alveolar-arterial oxygen gradient. Diagnosis involves sputum collection followed by immunofluorescent tests. If the diagnosis is suspected and the sputum samples are negative, bronchoscopy may be necessary to collect adequate samples. Treatment involves TMP-SMX if the patient's PO2 is <70 mm Hg for 21 days. Prednisone may also be added once tuberculosis is ruled out if the PaO2 is <70 mm Hg. Prophylactic therapy should be initiated for all patients with a CD4+ count <200 or a previous infection with P. jiroveci. Medications for patients with CD4+ counts <200 include TMP/SMX, dapsone, or aerosolized pentamidine.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:435–436.
279. Which of the following terms is used to describe a peripheral neuropathy with simultaneous or sequential involvement of individual, noncontiguous nerve trunks?
A) Polyneuropathy
B) Mononeuropathy
C) Mononeuropathy multiplex
D) Polyneuropathy simplex
Answer and Discussion
The answer is C. Peripheral neuropathies are classified into the following categories:
· Polyneuropathy, which affects peripheral nerves in a symmetrical bilateral distribution
· Mononeuropathy, which involves a single nerve
· Mononeuropathy multiplex, which is simultaneous or sequential involvement of individual noncontiguous nerve trunks
Symptoms include pain, paresthesias, numbness, burning, weakness, muscle atrophy, and loss of reflexes. Motor and sensory deficits may occur. Causes include diabetes and alcoholism, which usually lead to deficits in the distal extremities in a stocking-glove distribution; hereditary diseases (e.g., Charcot-Marie-Tooth syndrome); metabolic conditions (e.g., hypothyroidism, vitamin B12 deficiency); toxic disorders (e.g., INH administration, heavy metal ingestion, dapsone administration); inflammatory conditions (e.g., Guillain-Barré syndrome, diphtheria, sarcoidosis); and idiopathic disorders. Electromyographic studies are helpful in determining the extent of the deficit and for documenting progression or regression of the deficit. Treatment involves correction of the underlying cause. In severe cases, the use of tricyclic antidepressants can be used for chronic pain.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:2500–2508.
280. People who follow vegetarian diets should be counseled to
A) avoid the use of iron utensils
B) take a daily multivitamin
C) avoid the use of vitamin D
D) avoid calcium supplementation
E) none of the above
Answer and Discussion
The answer is B. The most common form of vegetarianism is ovolactovegetarianism, in which meat and fish are avoided, but eggs and dairy products are eaten. Vegetarian diets usually provide enough nutrition to satisfy most daily nutritional requirements. However, these diets are usually low in animal protein, iron, zinc, calcium, vitamin D, and vitamin B12. In most cases, vegetarians should be counseled to take a multivitamin, which may help to satisfy the daily requirements that they may not achieve with their diets. The use of iron utensils when cooking can also help to maintain their iron requirements.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:11.
281. Which of the following treatments should be used for a patient suspected of having Wernicke-Korsakoff syndrome?
A) Intravenous administration of glucose followed by administration of thiamine
B) Administration of folic acid followed by intravenous administration of dextrose
C) Administration of haloperidol with psychotherapy
D) Administration of thiamine followed by intravenous administration of dextrose
E) Lactated Ringer's solution with naloxone
Answer and Discussion
The answer is D. Wernicke-Korsakoff syndrome refers to the coexistence of Wernicke's encephalopathy and Korsakoff's psychosis. Wernicke's encephalopathy is characterized by gait ataxia, mental confusion, nystagmus, vomiting, fever, and ophthalmoplegia. The disease is primarily seen in alcoholics but can also occur in hyperemesis gravidarum or the use of vitamin-free nutrition (e.g., fad diets). The cause is thiamine deficiency (also known as beriberi). Wernicke's encephalopathy is a medical emergency and deserves prompt attention; otherwise, permanent brain damage or even death may occur. If Wernicke's encephalopathy is suspected, thiamine should always be administered before dextrose. Administration of glucose solution before thiamine administration may exhaust a patient's reserve of B vitamins and worsen his or her condition. Korsakoff's psychosis is also related to thiamine deficiency and may follow Wernicke's disease. Symptoms include retrograde amnesia, impaired learning ability, and confabulation. Treatment also involves the administration of thiamine.
Ferri F. Ferri's Clinical Advisor, Instant Diagnosis and Treatment. Philadelphia: Elsevier/Mosby; 2006:48, 468, 913.
282. Which of the following laboratory findings is not associated with Graves' disease?
A) Thyroid-stimulating antibodies
B) Increased TSH
C) Increased T4 level
D) Increased T3 level
Answer and Discussion
The answer is B. The following are thyroid conditions and their associated laboratory findings:
· Euthyroid sick syndrome: decreased serum T3, increased reverse T3, decreased total T4, and normal serum TSH
· Primary thyroid gland failure (hypothyroidism): marked elevation of serum TSH with decreased serum T3 and T4 levels
· Thyrotoxicosis: increased T4 and T3
· T3 toxicosis: increased T3 and normal T4
· Graves' disease: increased T4 and T3, decreased TSH, and thyroid-stimulating antibodies present
· Plummer's disease (toxic multinodular goiter): increased T3 and T4, decreased TSH, thyroid-stimulating antibodies absent, and increased radioimmunoassay uptake in the hyperfunctioning nodule
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1192–1206.
283. Benign positional vertigo is most easily confirmed by
A) orthostatic blood pressures
B) Dix-Hallpike maneuvers
C) cover–uncover test
D) MRI
E) cold–warm water calorics
Answer and Discussion
The answer is B. Benign positional vertigo is a condition characterized by severe episodes of vertigo that usually last less than 1 minute and are precipitated by certain head positions. The vertiginous symptoms are accompanied by nystagmus, and there is no tinnitus or hearing loss (as is seen in Meniere's disease). The diagnosis is usually based on the history and reproduction of symptoms by the Dix-Hallpike maneuver: The patient's head is turned to the side and the patient goes from a sitting to a lying position with the head positioned beneath the level of the bed. A positive response is noted when the patient reports vertigo and there is evidence of nystagmus. Most cases are self-limited, and repeating the position that causes the vertigo usually fatigues the vertiginous response. Vestibular-type exercises performed several times daily may help eliminate the symptoms, especially for younger patients. Labyrinthine sedatives are of little help for this condition. Canalith repositioning can also be attempted and is beneficial for select patients. If fatigability of symptoms does not occur, further workup may be indicated to rule out a central cause for the vertigo.
Froehling DA, Bowen JM, Mohr DN, et al. The canalith repositioning procedure for the treatment of benign paroxysmal positional vertigo: a randomized controlled trial. Mayo Clin Proc. 2000;75:695–700.
Kroenke K, Hoffman RM, Einstadter D. How common are various causes of dizziness? A critical review. South Med J. 2000;93:160–167.
Benign positional vertigo is a condition characterized by severe episodes of vertigo that usually last less than 1 minute and are precipitated by certain head positions. The vertiginous symptoms are accompanied by nystagmus, and there is no tinnitus or hearing loss (as is seen in Meniere's disease). The diagnosis is usually based on the history and reproduction of symptoms by the Dix-Hallpike maneuver.
284. A 72-year-old woman presents to your office with left-sided headaches, visual disturbances, low-grade fevers, generalized malaise, anorexia, and weight loss. Laboratory testing reveals a mild normocytic anemia, ESR of 120 mm/hour, and a mild leukocytosis. Appropriate management at this time consists of
A) MRI of the brain
B) colonoscopy
C) neurology referral
D) visual field testing
E) high-dose steroid therapy
Answer and Discussion
The answer is E. Temporal arteritis is an inflammatory disease that predominantly affects the temporal and occipital arteries, although other arteries of the aortic arch may be involved. Systemic symptoms include low-grade fever, malaise, weakness, anorexia, weight loss, painful joints, headaches in the temporal distribution, and visual disturbances. Most cases occur in patients older than 50 years, and women are more commonly affected than men. Although the cause is unknown, it is believed to be autoimmune in origin. Granulomatous inflammatory lesions involving the arteries are seen. The diagnosis is made by the clinical history and an elevated ESR (usually greater than 100 mm/hour). Leukocytosis and mild normochromic normocytic anemia are also usually seen. A biopsy of the temporal artery showing inflammation provides the definitive diagnosis. If left untreated, the major and most serious complication of temporal arteritis is blindness. If temporal arteritis is suspected, high doses of corticosteroids (at least 40 mg/day) should be initiated immediately to prevent blindness. Monitoring the patient's ESR can determine dose reduction of steroid therapy. Significant improvement is usually seen within 4 weeks of therapy. Extended therapy (up to 2 years) may be necessary to control the disease. Polymyalgia rheumatica occurs in 40% to 60% of patients with temporal arteritis.
Rakel RE, Bope ET. Conn's Current Therapy 2005. Philadelphia: Elsevier/Saunders; 2005:1144–1145.
285. Which of the following individuals is not a candidate for 23-valent pneumococcal vaccination (Pneumovax)?
A) A 48-year-old smoker with COPD
B) A 37-year-old African-American woman with sickle cell anemia
C) A healthy 75-year-old individual
D) A 15 month old with asthma
E) A 28-year-old man with cystic fibrosis
Answer and Discussion
The answer is D. The pneumococcal vaccination (Pneumovax) contains the purified polysaccharide antigens from 23 of the most common strains of S. pneumoniae. These serotypes consist of approximately 90% of the different subtypes that cause pneumococcal pneumonia. In most individuals, it takes approximately 2 weeks before antibodies are formed. Those recommended to receive the vaccination include the following:
Adults
· Immunocompetent adults who are at increased risk of pneumococcal disease or its complications because of chronic illnesses (e.g., cardiovascular disease, pulmonary disease, diabetes mellitus, alcoholism, cirrhosis, or CSF leaks) or who are 65 years old or older.
· Immunocompromised adults at increased risk of pneumococcal disease or its complications (e.g., persons with splenic dysfunction or anatomic asplenia, Hodgkin's disease, lymphoma, multiple myeloma, chronic renal failure, nephrotic syndrome, or conditions such as organ transplantation associated with immunosuppression).
· Adults with asymptomatic or symptomatic HIV infection.
Children
· Children 2 years of age or older with chronic illnesses specifically associated with increased risk of pneumococcal disease or its complications [e.g., anatomic or functional asplenia (including sickle cell disease), nephrotic syndrome, CSF leaks, and conditions associated with immunosuppression].
· Children 2 years of age or older with asymptomatic or symptomatic HIV infection.
· The currently available 23-valent vaccine is not indicated for patients having only recurrent upper respiratory tract disease, including otitis media and sinusitis.
Special Groups
· Persons living in special environments or social settings with an identified increased risk of pneumococcal disease or its complications (e.g., certain Native American populations).
The vaccine is routinely given as a one-time dose; administer if previous vaccination history is unknown. A one-time revaccination is recommended 5 years later for persons at highest risk of fatal pneumococcal infection or rapid antibody loss (e.g., renal disease) and for persons age 65 years and older if the first dose was given prior to age 65 and 5 years or more have elapsed since the prior dose.
Side effects of the vaccination include erythema and pain at the site of injection (50% of patients), fever, and myalgia; rare cases of anaphylaxis (5:1,000,000) have been reported. Safety and effectiveness in children younger than 2 years have not been established.
In 2000, a 7-valent pneumococcal conjugate vaccine (Prevnar) was approved for young children. When initiated during infancy, the four-dose vaccination schedule is set at 2, 4, 6, and 12 to 15 months of age. Adverse reactions are minimal. Efficacy is reported to be 94%.
Centers for Disease Control and Prevention website. Recommendations of the Immunization Practices Advisory Committee Pneumococcal Polysaccharide Vaccine. Available at: http://cdc. gov, accessed 6/2/06.
Zimmerman RK. Pneumococcal conjugate vaccine for young children. Am Fam Physician. 2001;63:2003–2004.
286. Which of the following statements regarding enoxaparin (Lovenox) is true?
A) It use has not been shown to be cost effective in an outpatient setting.
B) The medication does not require laboratory monitoring.
C) The incidence of thrombocytopenia is the same as with heparin.
D) It must be given through an intravenous route.
E) It is safe to use in renal failure patients.
Answer and Discussion
The answer is B. Enoxaparin (Lovenox) was the first LMW heparin approved by the U.S. FDA for the treatment of DVT in a dosage of 1 mg/kg twice daily or 1.5 mg once daily. Low-molecular-weight (LMW) heparin offers distinct advantages over unfractionated heparin: It can be administered subcutaneously once or twice daily, it has a longer biologic half-life, dosing is fixed, and laboratory monitoring is not required. In addition, thrombocytopenia appears to be less likely. In patients with DVT, subcutaneous administration of heparin is as effective as continuous infusion of unfractionated heparin in preventing complications and reducing the risk of recurrence. Outpatient management of DVT using LMW heparin for short-term anticoagulation until warfarin is at a therapeutic level is considered safe and cost-effective. Candidates for outpatient therapy must be hemodynamically stable, without renal failure, and not at high risk for bleeding. Additionally, they must have an appropriate supportive home environment, and be capable of daily monitoring until the INR is therapeutic. LMW heparin is typically given in combination with warfarin for 4 to 5 days. Simultaneous initiation of warfarin and unfractionated heparin or LMW heparin has not been associated with adverse outcomes. Dalteparin (Fragmin), another LMW heparin, is approved only for prophylaxis of DVT. The FDA has also approved the use of tinzaparin (Innohep) for the treatment of DVT.
Ramzi DW, Leeper KV. DVT and pulmonary embolism: part II. diagnosis. Am Fam Physician. 2004;69:2841–2848.
287. A 59-year-old man presents to your office with complaints of vasomotor rhinitis with only symptoms of rhinorrhea. Appropriate treatment would be
A) topical corticosteroid
B) topical anticholinergic
C) topical antihistamine
D) oral antihistamine
E) topical decongestant
Answer and Discussion
The answer is B. Vasomotor rhinitis is manifested by a combination of symptoms that includes nasal obstruction and rhinorrhea.
Vasomotor rhinitis is a usually a diagnosis of exclusion. According to a 2002 evidence-based report published by the Agency for Healthcare Research and Quality (AHRQ), treatment involves avoiding known environmental triggers such as odors (e.g., cigarette smoke, perfumes, bleach, formaldehyde, newspaper or other inks); auto emission fumes; light stimuli; temperature changes; and hot or spicy foods. A stepwise pharmacologic approach includes an initial treatment based on the patient's major symptom. If the presenting symptom is solely rhinorrhea, a topical anticholinergic [ipratropium (Atrovent)] is considered the initial step. If nasal congestion and obstruction are present, a topical corticosteroids is recommended. If the patient presents with the full spectrum of symptoms including rhinorrhea with sneezing, postnasal drip, and congestion, a topical antihistamine [azelastine (Astelin)] may be utilized. After an adequate trial period, changes and additions should be made if the response is inadequate. Exercise is beneficial for overall health and may be a useful treatment addition because it produces decreased airway resistance and assists natural nasal decongestion. The effect of exercise on nasal decongestion is short-lived, but it has numerous other benefits and can be repeated. Traditional oral antihistamines have no established beneficial effect in patients with vasomotor rhinitis and may be associated with sedation. Newer, less-sedating antihistamines also have no proven effectiveness for vasomotor rhinitis, and their use may delay proper treatment while incurring significant cost. The empiric use of the topical decongestant ephedrine on a chronic basis can result in tolerance and development of rhinitis medicamentosa.
Wheeler PW, Wheeler SF. Vasomotor rhinitis. Am Fam Physician. 2005;72:1057–1062.
288. Postpolio syndrome typically occurs
A) immediately after the primary infection
B) 3 to 6 months after the initial infection
C) 2 to 3 years after the initial infection
D) 5 to 10 years after the initial infection
E) 15 to 30 years after the initial infection
Answer and Discussion
The answer is E. Postpolio syndrome is a constellation of symptoms that affects patients previously infected with the poliovirus. Typically, symptoms occur 15 to 30 years after the initial infection and include progressive generalized weakness, muscle pain, cramps, fasciculations, and atrophy. Other findings include cold, cyanotic extremities that have adequate pulses, and diffuse joint pain. Typically, the areas that were affected during the original infection are the same areas affected with the postpolio syndrome. In most, new symptoms are not due to progression of remote polio but to a superimposed second condition such as diabetes, disk herniation, or degenerative joint disease. Treatment is supportive and involves rest.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:1144.
289. Clubbing is thought to be a result of
A) chronic hypercarbia
B) chronic hypoxemia
C) excess nitrogen production
D) malignancy
E) protein storage disease
Answer and Discussion
The answer is B. Clubbing has interested physicians for years. The cause is thought to be related to chronic hypoxemia. The condition is evident when the patient has an enlargement and softness of the nail beds and a reduction in the angle between the nail and the distal phalanx. The ratio of the anteroposterior diameter of the finger at the nail bed to that at the distal interphalangeal joint is a simple measurement of finger clubbing. If the ratio is more than 1, clubbing is present. Causes include pulmonary processes such as bronchogenic carcinoma, chronic pulmonary tuberculosis, COPD, and bronchiectasis; cyanotic congenital heart disease; subacute bacterial endocarditis; inflammatory bowel disease; and biliary cirrhosis. Clinical evidence of clubbing should be further evaluated with a chest radiograph because of the possibility of underlying lung disease.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:259, 354.
290. Which of the following statements about myasthenia gravis is true?
A) Symptoms usually improve with administration of norepinephrine-inhibiting medications.
B) Symptoms include ptosis, diplopia, dysarthria, dysphagia, and proximal muscle weakness of the limbs.
C) Symptoms are aggravated by the administration of edrophonium.
D) Symptoms rarely fluctuate and usually spare the facial nerves.
Answer and Discussion
The answer is B. Myasthenia gravis is a neuromuscular transmission disorder. It may occur at any age and may be associated with thymic tumors, thyrotoxicosis, lupus, or rheumatoid arthritis. It is more commonly seen in young women and appears to be linked to the HLA-DR3 genetic focus. If the patient is an elderly man, there is often an associated thymoma. Episodic muscle weakness is a symptom that often fluctuates in intensity, particularly in muscles associated with the cranial nerves; this includes ptosis, diplopia, dysarthria, dysphagia, and proximal muscle weakness in the limbs. These symptoms improve when cholinesterase-inhibiting medication is administered. Sensory function and deep tendon reflexes are unaffected. The disease is thought to be associated with an autoimmune-mediated attack on the postsynaptic acetylcholine-receptor sites, which prevents neurosynaptic transmission.
Diagnosis is usually confirmed by the edrophonium (Tensilon) test, which involves administration of an anticholinesterase medication. This test can help distinguish between a myasthenic and a cholinergic crisis. The patient is given 2 mg of edrophonium intravenously. If the patient's symptoms improve, the diagnosis of myasthenia gravis is confirmed. If symptoms become worse, a cholinergic crisis should be suspected. Because of the potential for respiratory arrest, atropine must be available as an antidote. Other findings that support the diagnosis of myasthenia gravis include the detection of acetylcholine-receptor antibodies in the patient's serum and the detection of thymomas by chest CT scans. Treatment is accomplished with the use of anticholinesterase medications (e.g., pyridostigmine, neostigmine), thymectomy, corticosteroids, immunosuppressive agents, and plasmapheresis.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:2518.
291. Coenzyme Q10 appears to be most promising in the treatment of
A) Parkinson's disease
B) diabetes mellitus
C) congestive heart failure
D) hyperthyroidism
Answer and Discussion
The answer is A. Coenzyme Q10 is a supplement used in the treatment of a variety of medical conditions primarily related to low cellular energy metabolism and oxidative injury. Coenzyme Q10 appears most promising for neurodegenerative disorders such as Parkinson's disease and certain encephalomyopathies for which coenzyme Q10 has been used. Results in other areas of research, including treatment of congestive heart failure and diabetes, appear to be contradictory or need further clarification before proceeding with recommendations. Coenzyme Q10 appears to be a safe supplement with minimal side effects (e.g., gastrointestinal) and low drug interaction potential.
Shults CW, Oakes D, Kieburtz K, et al. Effects of coenzyme Q10 in early Parkinson disease: evidence of slowing of the functional decline. Arch Neurol. 2002;59:1541–1550.
292. A 60-year-old woman presents with complaints of diffuse proximal muscle pain, low-grade fevers, and generalized fatigue. Laboratory findings include an elevated ESR and mild anemia. The most likely diagnosis is
A) influenza
B) dermatomyositis
C) polymyalgia rheumatica
D) systemic lupus erythematosis
E) rheumatoid arthritis
Answer and Discussion
The answer is C. Polymyalgia rheumatica is an inflammatory disease characterized by pain and stiffness associated with the proximal muscle groups. The condition is more common in women and usually occurs in patients older than 50 years. As many as 25% of patients may have associated giant cell arteritis, which can lead to blindness if not treated immediately with steroids. Symptoms include symmetric pain and morning stiffness associated with the proximal muscles such as the neck, shoulders, and hips. Patients may also report fever, generalized fatigue, anorexia, and weight loss. Laboratory findings include an elevated ESR (usually >50 mm / hour and often >100 mm/hour) and anemia of chronic disease. The physical examination is unremarkable with no evidence of synovitis or true muscle weakness. Diagnosis is made based on the clinical findings and confirmed with response to therapy. Treatment involves the use of orally administered corticosteroids (prednisone 10 to 20 mg/day); usually the patient responds immediately. Once the ESR returns to normal and the patient's symptoms are improved, the steroids may be slowly tapered. In some cases, it may take months to years to completely taper the medication.
Ferri F. Ferri's Clinical Advisor, Instant Diagnosis and Treatment. Philadelphia: Elsevier/Mosby; 2006:668.
293. Which of the following statements best describes the rash associated with Rocky Mountain spotted fever?
A) It usually develops first on the extremities and spreads centrally.
B) It usually develops first on the trunk and spreads to the extremities.
C) It typically affects only the face.
D) It appears as bull's-eye lesions with central clearing.
E) The lesions are erythematous, raised papules that are intensely pruritic.
Answer and Discussion
The answer is A. The causative agent of Rocky Mountain spotted fever is Rickettsia rickettsii, which is transmitted by the bite of the wood tick. The disease is usually found in the southern United States and is more commonly seen during the summer months. Symptoms include a flu-like prodrome that is followed by fevers, headaches, generalized myalgias, and, occasionally, delirium, seizures, and coma. In most cases, a rash develops on the wrist and ankles, sparing the face, and spreads centrally after the first few days of the fever. The rash, initially erythematous and macular, often becomes petechial. Laboratory findings include anemia, thrombocytopenia, leukocytopenia, proteinuria, and hematuria. Treatment involves the use of doxycycline, tetracycline, chloramphenicol, or rifampin. Mortality rates for the elderly can approach 70%, whereas mortality rates for children are less than 20%.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:999.
In most cases of Rocky Mountain Spotted Fever, a rash develops on the wrist and ankles, sparing the face, and spreads centrally after the first few days of the fever. The rash, initially erythematous and macular, often becomes petechial.
294. Which of the following is associated with pseudogout?
A) Calcium pyrophosphate crystal deposition in the large joints
B) Lack of response with the use of colchicine
C) High uric acid levels
D) Lack of response with the use of anti-inflammatory medication
E) Negative birefringence seen with polarized microscopy
Answer and Discussion
The answer is A. Pseudogout is a condition that results from the deposition of calcium pyrophosphate crystals in the large joints (principally the knees) and leads to a reactive synovitis. Affected patients are usually older than 60 years. Men and women are affected equally, except in some studies that show women are more affected than men. Pseudogout is associated with trauma, surgery, amyloidosis, hemochromatosis, and hyperparathyroidism. Diagnosis is made by joint aspiration and examination of the fluid under a polarized microscope. Calcium pyrophosphate exhibits a positive birefringence in contrast to a negative birefringence seen with urate crystals in gout. Laboratory tests do not show elevated uric acid levels. Radiographs of the affected joints usually show degenerative changes and calcification of the surrounding cartilaginous structures. Treatment involves the use of anti-inflammatory agents and colchicine. Intra-articular steroid injection is occasionally helpful in resistant cases.
Chokkalingam S, Velazquez C, Mody A, et al. Diagnosing acute monoarthritis in adults: a practical approach for the family physician. Am Fam Physician. 2003;68:83–90.
295. Diabetic foot ulcers
A) are typically polymicrobial
B) rarely become infected
C) require topical antibiotics
D) should not be débrided because of the risk of bacteremia
Answer and Discussion
The answer is A. Foot ulcers in diabetic patients result from a diminished sensation associated with peripheral neuropathy and peripheral vascular disease (which is also usually present). Persistent pressure from ill-fitting shoes or skin cracking secondary to tinea pedis may predispose the patient's feet to infection. Diabetics who smoke should be encouraged to stop, and alcohol use should be discouraged. Infections associated with the feet are usually caused by Staphylococcus, Streptococcus, anaerobes, and gram-negative organisms. Aerobic and anaerobic cultures should be taken when signs of infection, such as purulence or inflammation, are present. Cultures are best taken from purulent drainage or curetted material from the ulcer base. Because all ulcers are contaminated, culture of noninfected wounds is generally not recommended. Polymicrobial infections predominate in severe diabetic foot infections and include a variety of aerobic gram-positive cocci, gram-negative rods, and anaerobes. Treatment involves débridement of nonvital and necrotic tissue, as well as oral or intravenous antibiotics. In severe cases, amputation may be necessary. Topical antibiotics are of little help and may delay healing. Osteomyelitis should always be considered in severe and persistent cases. Periodic examinations and treatment by a podiatrist are recommended.
Frykberg RG. Diabetic foot ulcers: pathogenesis and management. Am Fam Physician. 2002;66:1655–1662.
296. A 16-year-old girl presents to the office complaining of throat pain, difficulty swallowing, and trismus. Physical examination shows erythema and enlargement of the left tonsillar pillar. In addition, the patient holds her head to the left side and has muffled speech. The most likely diagnosis is
A) peritonsillar abscess
B) streptococcal pharyngitis
C) tonsillar cancer
D) epiglottitis
E) retropharyngeal abscess
Answer and Discussion
The answer is A. Peritonsillar abscess (also known as quinsy) is the most common ear, nose, and throat abscess. It is seen most commonly in teenagers and young adults and is rare in children under the age of 5 years. The condition occurs when an abscess develops between the tonsil and the superior constrictor muscle. Symptoms include worsening throat pain, muffled speech (hot-potato voice), trismus, and difficulty swallowing. The patient often holds his or her head toward the side that the abscess affects. If the abscess is large, airway compromise may occur. Ultrasound or CT scanning can help distinguish between cellulitis and abscess formation. Treatment of peritonsillar abscess is accomplished by lancing a fluctuant area, if present, with an 18-gauge needle (making certain not to go deeper than 1 cm where the internal carotid artery passes) and prescribing penicillin-containing antibiotics. The fluid should be cultured before initiation of antibiotics. Common infecting organisms include group A Streptococcus and anaerobes. Recurrent episodes necessitate tonsillectomy.
Ferri F. Ferri's Clinical Advisor, Instant Diagnosis and Treatment. Philadelphia: Elsevier/Mosby; 2006:978.
297. What is the threshold body mass index (BMI) for obesity?
A) 25
B) 27
C) 30
D) 35
E) 40
Answer and Discussion
The answer is C. The BMI is an approximate measure of body fat. It is based on height and weight. A BMI between 19 and 25 is considered normal. If a patient's BMI is 25 to 29.9, that individual is considered to be overweight. A person is categorized as obese if his or her BMI is 30 or higher.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:402, 422.
298. The mother of a 4-year-old calls to report that her child was bitten by a pet hamster. Which of the following is the appropriate management?
A) Human diploid cell vaccine
B) Rabies immune globulin
C) Reassurance to the mother with no further treatment
D) Immediate sacrifice of the hamster for pathologic evaluation
E) Hospitalization and close observation of the child for abnormal behavior
Answer and Discussion
The answer is C. Rabies is an infectious viral infection that is often transmitted by the bite of an infected animal or, rarely, by exposure of mucous membranes and saliva with a skin abrasion. The rabies virus affects the CNS, and the presence of intracytoplasmic Negri bodies seen microscopically is pathognomonic for the infection. Symptoms affecting humans include depression, difficulty with concentration, malaise, fever, extreme restlessness with excessive salivation, painful laryngeal and pharyngeal muscle spasms, and convulsions. Although patients often experience extreme thirst, they are hydrophobic, because drinking can often precipitate pharyngeal spasms. Death usually occurs secondary to exhaustion and asphyxia with generalized paralysis. The disease is usually found in wild animals such as skunks, foxes, coyotes, raccoons, bobcats, and bats, but is also seen in domestic dogs and cats. Other animals affected include livestock. Treatment of those bitten includes confining the animal that bit the patient for at least 10 days to look for abnormal behavior. If no changes are seen, the patient usually does not need treatment. Animals with abnormal behavior should be sacrificed and examined pathologically for rabies infection. If the animal cannot be caught or if the animal exhibits abnormal behavior and has evidence of rabies infection, the patient should be treated with human diploid cell vaccine or rabies vaccine, adsorbed: 1 mL administered intramuscularly at the time of presentation and then at days 3, 7, 14, and 28 for a total of five doses. Rabies vaccine (adsorbed) should not be given intradermally. Also, to bridge the gap of time it takes for the patient to develop antibodies to the rabies vaccine, 20 IU/kg of rabies immune globulin is given, with much of the dose administered at the site of the bite and the rest administered at a distant site from vaccine inoculation intramuscularly. In most cases, the wound should not be sutured. If rabies does develop, aggressive symptomatic treatment is required. The prognosis is not universally fatal, but there is significant mortality associated with rabies. Prophylaxis for rabies should be considered for high-risk populations such as veterinarians, animal handlers, technicians in laboratories in which rabies is present, and travelers spending a month or more in countries in which rabies is common. Bites of rodents such as squirrels, opossums, rats, mice, guinea pigs, gerbils, hamsters, rabbits, and hares rarely, if ever, require rabies prophylaxis.
Ferri F. Ferri's Clinical Advisor, Instant Diagnosis and Treatment. Philadelphia: Elsevier/Mosby; 2006:713.
299. A 65-year-old man complains of gynecomastia and galactorrhea with erectile dysfunction. The most likely diagnosis is
A) breast cancer
B) testicular cancer
C) prolactinoma
D) adrenal adenoma
E) diabetes mellitus
Answer and Discussion
The answer is C. Prolactinomas are the most common functioning, secreting pituitary tumors. Galactorrhea, oligomenorrhea, primary and secondary amenorrhea, and infertility are seen in women with prolactinomas. Men may experience impotence, infertility, and, less commonly, gynecomastia and/or galactorrhea. Prolactin levels >300 µg/L usually indicate a pituitary adenoma. Patients with hypogonadism, impotence, or galactorrhea may have abnormal prolactin levels associated with prolactinomas. Some medications, including oral contraceptives, phenothiazines, tricyclic antidepressants, antihypertensives (e.g., α-methyldopa), and opioid-type medications, may increase prolactin levels. Other causes for hyperprolactinemia include nipple stimulation, pregnancy, stress, sexual intercourse, sleep, hypoglycemia, hypothyroidism, sarcoidosis, paraneoplastic syndromes (bronchogenic carcinoma and hypernephroma), and chronic renal failure. Treatment (controversial) for larger tumors involves the use of bromocriptine (dopamine agonist), which lowers the serum prolactin level. If residual tumor remains, surgery or radiotherapy may be necessary. With small tumors, close observation may be instituted if the patient is asymptomatic.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1187–1189.
300. Which of the following statements about clonidine is true?
A) Rapid withdrawal may precipitate a hypertensive crisis.
B) It is classified as an ACE inhibitor.
C) Concomitant use with β-blockers decreases the risk of hypertensive crisis when both medications are discontinued.
D) The mechanism of action involves the increased release of renin and α-receptor activation.
E) Use of the drug can exacerbate restless legs syndrome.
Answer and Discussion
The answer is A. Clonidine is a second-line drug used in the treatment of hypertension, restless legs syndrome, nicotine withdrawal, prophylaxis for vascular headaches, and opiate withdrawal. Clonidine works by decreasing vascular resistance through α-receptor blockade and inhibiting renin release. Rapid withdrawal of the medication may precipitate a hypertensive crisis, which can be life threatening. Symptoms of hypertensive crisis include tachycardia, diaphoresis, headache, nervousness, and abdominal pain. Concomitant use with β-blockers may also increase the risk of hypertensive crisis when both medications are discontinued.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:614, 1699.
301. A 62-year-old woman presents complaining of joint pain, polyuria, polydipsia, and generalized fatigue. The woman reports a history of recurrent kidney stones and depression. Radiographs show osteopenia and subperiosteal resorption on the phalanges. Which of the following blood tests may best help determine the cause of her symptoms?
A) ACE level
B) Parathyroid hormone level
C) Antinuclear antibody (ANA) test
D) Sedimentation rate (ESR)
E) Bone densitometry
Answer and Discussion
The answer is B. Primary hyperparathyroidism is a disorder caused by excessive secretion of parathyroid hormone. Findings include hypercalcemia (ionized), hypophosphatemia (hyperphosphatemia suggests secondary hyperparathyroidism), an excessive bone loss leading to cystic bone lesions, and osteitis fibrosa cystica. Most patients are asymptomatic; however, some may present with renal lithiasis, joint or back pain, polyuria and polydipsia, constipation, and fatigue. It is the most common cause of hypercalcemia in the general population. Familial cases are often related to endocrine tumors. The condition is more common in women and in patients older than 50 years. It also occurs in high frequency three or more decades after neck irradiation. It is usually caused by an adenoma of the parathyroid (90% of cases); carcinoma is rare (3% of cases). Radiographs may show subperiosteal resorption of the phalanges and osteopenia. Treatment usually involves surgical exploration and removal of parathyroid adenoma. For patients with mild, asymptomatic primary hyperparathyroidism the recommendations for surgery are controversial.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1254–1255.
302. The most common cause of chronic cough is
A) postnasal drip
B) bronchiectasis
C) gastroesophageal reflux
D) asthma
E) ACE inhibitors
Answer and Discussion
The answer is A. Coughing is part of the body's infection protective system and helps remove particles and material from the airway. In some cases, the patient may experience a chronic cough that can be attributed to a number of different problems, including postnasal drip (most common cause), gastroesophageal reflux, and bronchoconstriction as seen in cough-variant asthma patients. Other common associated conditions include the use of ACE inhibitors, chronic bronchitis seen in smokers, and bronchiectasis. Treatment involves eliminating the underlying cause. Treatment of conditions, such as asthma and COPD, may involve the use of bronchodilators (β agonist or theophylline), cromolyn sodium, and inhaled steroids; the treatment of postnasal drip may involve the use of antihistamines and topical nasal steroids. Patients should be informed that it may take 8 to 12 weeks before their cough improves when using inhaled steroids. Treatment of gastroesophageal reflux involves the use of antacids, H2-receptor blockers, and proton pump inhibitors. Eliminating a cough caused by ACE inhibitors usually takes several days before improvement is seen. Unfortunately, it is more difficult to treat patients with chronic bronchitis. The use of antibiotics with the absence of supporting symptoms suggestive of infection is not useful and should be avoided. Mucolytics have not been shown to be beneficial.
Holmes RL, Fadden CT. Evaluation of the patient with chronic cough. Am Fam Physician. 2004;69:2159–2166, 2169.
303. A 26-year-old single man presents to your office complaining of a painless ulcer that formed on his penis approximately 3 months ago. The ulcer healed, but an erythematous rash on the palms and soles of his feet has recently developed. He also reports generalized fatigue, malaise, fever, headache, and arthralgias. The most likely diagnosis is
A) gonorrhea
B) chancroid
C) syphilis
D) Reiter's syndrome
E) Lyme disease
Answer and Discussion
The answer is C. Syphilis, also known as lues, is a disease caused by the spirochete Treponema pallidum. The disease is characterized by differing clinical stages that may affect multiple organ systems and is transmitted primarily by sexual contact. The usual incubation period is approximately 4 to 5 weeks. The following are the different stages associated with the disease:
· Primary syphilis is the initial stage of syphilis and is marked by the appearance of a chancre, which is a papule that ruptures and develops into a painless ulcer. In most cases, the ulcer heals in 4 to 6 weeks. Chancres occur on the penis; vulva; cervix; anus; and also the lips, tongue, oral mucosa, fingers, and other body parts. In addition to the ulcer, there may be associated lymphadenopathy but usually no other symptoms.
· Secondary syphilis is the second stage of syphilis and is characterized by cutaneous rashes that usually affect the volar surfaces of extremities, such as the palms of the hands and soles of the feet. They appear 6 to 12 weeks after the initial infection and are usually circular macules, papules, or pustules that are not pruritic. Other areas can be affected, and uveitis, periostitis, hepatitis, meningitis, and glomerulitis can occur. Additional symptoms include flu-like symptoms such as generalized fatigue, anorexia, malaise, fever, headache, anemia, lymphadenopathy, and arthralgias. Mucous membranes often become ulcerated and form circular ulcerated lesions. The secondary stage may last up to 1 year.
· Latent syphilis is characterized by the resolution of the rashes seen during the secondary stage and may last for many years after the initial infection. During this period, the patient is usually completely asymptomatic but has a positive treponemal antibody test.
· Late or tertiary syphilis occurs 10 or more years after the initial infection and is characterized by benign tertiary syphilis involving the skin and giving rise to gummas (granulomatous lesions that lead to fibrosis, necrosis, and scarring), cardiovascular syphilis (giving rise to thoracic aortic aneurysms and aortic insufficiency), and neurosyphilis (causing a multitude of neurologic disorders including headaches, insomnia, blurred vision, confusion, seizures, and decreased motor function with paralysis). Tabes dorsalis presents as symptoms and signs of demyelination of the posterior columns, dorsal roots, and dorsal root ganglia. Symptoms include an ataxic wide-based gait, paresthesias, bladder dysfunction, impotence, areflexia, and loss of pain, temperature, and position sensation.
Screening tests for syphilis include a VDRL test and the rapid plasma reagin test. If positive, a confirming fluorescent treponemal antibody–absorption test should be performed. In addition, microscopic examination of fluid taken from lesions can be examined with darkfield microscopy to look for spirochetes. The treatment of choice is penicillin given in the long-acting benzathine form intramuscularly. In many cases, there is a reaction to treatment after 6 to 12 hours called the Jarisch-Herxheimer reaction; symptoms include fatigue, headaches, low-grade fever, sweating, and more severe reactions, including seizures in patients with neurologic involvement. It is important to distinguish these reactions from allergic reactions to penicillin. A repeated VDRL or rapid plasma reagin can be assessed to ensure adequate treatment. In most cases, they become negative 1 year after treatment. Sexual contacts should also be treated appropriately. Any patient suspected of having syphilis more than 1 year should have a CSF examination.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:977.
Screening tests for syphilis include a VDRL test and the rapid plasma reagin test. If positive, a confirming fluorescent treponemal antibody–absorption test should be performed.
304. An 18-year-old hiker presents with an erythematous, maculopapular rash that began on the palms and feet and now has spread to involve the trunk area. He complains of low back pain, fever, and headaches. Laboratory evaluation shows hyponatremia and thrombocytopenia. The most likely diagnosis is
A) Lyme disease
B) Rocky Mountain spotted fever
C) infectious mononucleosis
D) poison ivy
E) tularemia
Answer and Discussion
The answer is B. Rocky Mountain spotted fever is caused by Rickettsia rickettsii and is the most common rickettsial disease in the United States. The wood tick (Dermacentor andersoni) is the principal vector in the western United States, whereas the dog tick (Dermacentor variabilis) is the most common vector in the eastern and southern United States. Transmission from person to person is not thought to occur. The incidence of Rocky Mountain spotted fever is highest in children 5 to 9 years of age. A tick bite is recalled by only 50% to 70% of patients. The onset of symptoms of Rocky Mountain spotted fever usually begins 5 to 7 days after inoculation. Common symptoms include generalized malaise, myalgias (especially in the back and leg muscles), fever, frontal headaches, nausea, and vomiting. Other symptoms may include nonproductive cough, sore throat, pleuritic chest pain, and abdominal pain. The classic presenting symptoms include sudden onset of headache, fever, and chills accompanied by an exanthem appearing within the first few days of symptoms. Initially, lesions appear on the palms, soles, wrists, ankles, and forearms. The lesions are pink and macular and fade with applied pressure. The rash then extends to the axilla, buttocks, trunk, neck, and face, becoming maculopapular and then petechial. The lesions may then coalesce to form large areas of ecchymosis and ulceration. Respiratory and circulatory failure, as well as neurologic compromise, may occur. Patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency are at especially high risk for complications and poor outcomes. Diagnosis is based primarily on clinical signs and symptoms. If a rash is present, the use of skin biopsy and immunofluorescent staining for Rickettsia is highly specific, although with only slightly more than 60% sensitivity. Laboratory testing is of limited usefulness but may include thrombocytopenia and hyponatremia. Elevation of specific enzyme-linked immunosorbent assay (ELISA) and latex agglutination titers usually is delayed until the convalescence period. Fever and headache during peak months of tick exposure in endemic areas should suggest Rocky Mountain spotted fever. Rash, thrombocytopenia, and hyponatremia make immediate treatment imperative. Antimicrobial agents for the treatment of Rocky Mountain spotted fever include tetracycline, doxycycline (Vibramycin), and chloramphenicol (Chloromycetin) for a minimum of 7 days. Fluoroquinolones also may be effective, but are not recommended for routine use in patients with Rocky Mountain spotted fever because of a lack of evidence. For optimal effect, it is critical to treat patients early in the course of their illness. Treatment should not be delayed until laboratory confirmation is obtained.
Bratton RL, Corey GR. Tick-borne disease. Am Fam Physician. 2005;72:1057–1062.
305. A 16-year-old surfer presents with an erythematous, maculopapular rash that was noted in the area of his bathing suit. Initial treatment includes
A) cryotherapy
B) clotrimazole cream
C) ice packs
D) application of vinegar
E) zinc oxide
Answer and Discussion
The answer is D. Swimmers or surfers with seabather's eruption present with an urticarial maculopapular rash on areas of the body that were covered by the swimsuit. The rash may appear while the bather is in the water or up to 1.5 days later. The rash may last for 2 to 28 days; most reactions resolve within 1 to 2 weeks. Systemic symptoms include fever, nausea, vomiting, and headache and are more likely to affect children. Initial treatment involves the topical application of heat or vinegar. Further treatment is symptomatic and may include topical corticosteroids, oral antihistamines, and oral steroids. Twice-daily application of thiabendazole (Mintezol) can be beneficial. The swimsuit should be cleaned thoroughly because larvae can persist and re-envenomate.
Zoltan TB, Taylor KS, Achar SA. Health issues for surfers. Am Fam Physician. 2005;71:2313–2317.
306. Which of the following medications should generally be avoided in diabetic nephropathy?
A) Lisinopril
B) Nifedipine
C) Losartan
D) Terazocin
E) Hydrochlorothiazide
Answer and Discussion
The answer is B. Diabetic nephropathy is a complication of long-standing, poorly controlled diabetes. It is more commonly seen in patients with insulin-dependent diabetes or coexisting, poorly controlled hypertension. Almost all diabetic patients develop glomerulosclerosis, but only approximately 35% develop nephropathy. In most cases, these findings develop 15 to 20 years after the diagnosis of diabetes. Diabetic nephropathy is the most common cause of end-stage renal disease in the United States. Diagnosis is made by the detection of proteinuria, decreased creatinine clearance, and, in some cases, the development of hypertension. ACE inhibitors (e.g., lisinopril, enalapril) and angiotensinreceptor blockers (ARBs) such as losartan and candesartan have been shown to be beneficial (renoprotective) for patients with diabetes. Dietary measures, including the restriction of protein, sodium, phosphorous, and potassium, may be necessary if the creatinine clearance is <20 mL/minute. In severe cases, dialysis may be instituted.
American Diabetes Association. Standards of medical care in diabetes. Diabetes Care. 2004;27(suppl 1): S15–S35.
307. Which of the following conditions is NOT associated with smoking?
A) Peptic ulcer disease
B) Depression
C) Children of smokers are at increased risk for otitis media
D) Osteoporosis
E) Cervical cancer
Answer and Discussion
The answer is B. Smoking is the largest single health risk in the United States and other developed countries. Smokers are at significant risk for multiple lung diseases, particularly lung cancer. Other cancers that occur more frequently in smokers include laryngeal cancer, pancreatic cancer, cervical cancer, bladder cancer, and leukemia. Other diseases linked with smoking include coronary atherosclerosis, peptic ulcer disease, and osteoporosis. In addition, smoking increases free fatty acids, very-low-density lipoprotein cholesterol, and serum glucose. Smoking decreases HDL cholesterol. Children of parents who smoke tend to have more respiratory illnesses, including otitis media, and are more likely to smoke than children of nonsmoking parents. Secondhand smoke has been declared harmful and can increase the risk of lung cancer. Therefore, at each office visit, physicians should strongly encourage patients who smoke to stop.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2733–2736.
308. Which of the following infections causes tabes dorsalis?
A) Gonorrhea
B) Tuberculosis
C) Syphilis
D) Bacterial meningitis
E) ALS
Answer and Discussion
The answer is C. Tabes dorsalis is the result of syphilitic lesions that affect the posterior columns of the spinal cord. Symptoms include the insidious onset of pain, loss of sensation, proprioception and vibratory sense, loss of reflexes, and ataxia. The main symptom is an insidious, sharp, stabbing pain that is periodic and recurrent and affects the lower extremities. Over time, the patient may experience increasing difficulty with gait, particularly in poorly illuminated areas. Paresthesias and loss of sensation are commonly associated with the soles of the feet. Other findings include a thin appearance with sad- or depressed-appearing facies, Argyll Robertson pupils (react poorly to light but well to accommodation), positive Romberg's sign, loss of reflexes in the lower extremities, bladder disturbances, and visible ataxia. Acute abdominal pain with vomiting (visceral crisis) can occur in 15% to 30%. In tabes dorsalis, the rapid plasma reagin and VDRL tests may not be positive; however, the fluorescent treponemal antibody absorption test is usually positive. Treatment involves the administration of a prolonged course of high-dose penicillin to treat syphilis. Pain medications along with chlorpromazine and carbamazepine may be helpful for the control of pain. Unfortunately, tabes dorsalis often progresses despite treatment.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:83, 980, 2446.
309. A 21-year-old otherwise healthy woman is seen in your office with a recent purified protein derivative tuberculin skin test that is positive. The woman has never had a positive test before. A chest radiograph is negative, and there are no signs of disease. The most appropriate treatment is
A) reassurance
B) isoniazid (INH) and rifampin for 6 months
C) INH for 6 months
D) INH, rifampin, and streptomycin (or ethambutol) for 12 months
E) streptomycin for 6 months
Answer and Discussion
The answer is C. Tuberculosis is caused by Mycobacterium tuberculosis, a nonmotile acid-fast rod that is spread primarily by inhalation. The organism can affect many different systems but usually affects the lungs. There has been a recent increase in incidence, particularly in the immunocompromised and elderly populations. Symptoms include fever, fatigue, weight loss, a productive cough, dyspnea, and, occasionally, hemoptysis. Diagnosis is usually accomplished with a chest radiograph, which shows apical infiltrates and mediastinal lymphadenopathy, and microscopic examination of sputum, which shows acid-fast rods. A definitive diagnosis is achieved with a culture of early morning sputum growing M. tuberculosis. A Mantoux tuberculin skin test using purified protein derivative injected intradermally is also used to support the diagnosis. In most cases, an area of induration >10 mm (with risk factors), 15 mm (without risk factors), or 5 mm (in HIV patients) 48 hours after administration is a positive response. A negative response does not exclude the diagnosis. A calcified focus of infection seen on chest radiograph is referred to as a Ghon complex.
Treatment for active disease is accomplished with INH, rifampin, and pyrazinamide. In some cases, a fourth drug (e.g., streptomycin or ethambutol) is necessary. Most treatment regimens require extended courses lasting at least 6 to 9 months. Patients younger than 35 years who have a positive skin test but no evidence of disease (including a negative chest radiograph) are usually treated with INH for 6 to 9 months. Immunocompromised patients may require longer treatment times. Older patients are at risk for INH's side effects, including liver toxicity, and are generally not given prophylactic therapy. In addition, compliance is a critical factor in ensuring adequate treatment, particularly for the elderly. Other sites affected by tuberculosis include the kidneys, pericardium, and spine. All patients with a new diagnosis of tuberculosis should be tested for HIV (and vice versa).
Jerant AF, Bannon M, Rittenhouse S. Identification and management of tuberculosis. Am Fam Physician. 2000;61:2667–2678, 2681–2682.
310. A 32-year-old woman reports frequent bouts of constipation alternating with diarrhea. She frequently experiences abdominal discomfort, which is relieved with bowel movements. Stress tends to aggravate her symptoms. The most appropriate treatment includes
A) steroid enemas
B) mesalamine enemas
C) fiber supplement
D) metoclopramide
E) none of the above
Answer and Discussion
The answer is C. Irritable bowel syndrome is characterized by bouts of recurrent and intermittent diarrhea and constipation that tend to be aggravated by stress or anxiety. It begins before 50 years of age (median age is 35 years) and affects women more frequently than men. Symptoms include abdominal pain and distention that are relieved with bowel movements, which are often mixed with mucus, bloating, nausea, flatulence, the sensation of incomplete voiding, and, occasionally, pelvic or back pain. The diagnosis is made by excluding organic causes for the symptoms. The workup includes stool cultures, examination of stool for occult blood, CBC, flexible sigmoidoscopy, and barium enema, all of which are found to be normal. Colonoscopy is usually unnecessary, unless other studies are abnormal. Treatment involves stress reduction, reassurance to the patient, and maintenance of a high-fiber diet that avoids triggering foods. Fiber supplements, such as psyllium (Metamucil), are often helpful. Antidiarrheal medication and antispasmodics may be necessary in some patients. Irritable bowel syndrome is a benign disease that has no anatomic abnormality or inflammatory component. Symptoms associated with organic disease that are not associated with irritable bowel syndrome include abdominal pain that interrupts sleep, nocturnal diarrhea, visible or occult blood found in the stool, fever, and weight loss.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:1789.
311. Which of the following statements about treadmill exercise testing is true?
A) Women have a low incidence of false-positive results.
B) It is recommended for patients who experience angina at rest to document ECG changes.
C) It is contraindicated in patients with moderate to severe aortic stenosis.
D) The appearance of a bundle branch block on ECG represents no concern.
E) A positive result requires >3 mm of ST-segment depression.
Answer and Discussion
The answer is C. Exercise stress testing is used to evaluate chest pain in patients with suspected cardiovascular disease. The sensitivity ranges from 56% to 81%, and the specificity ranges from 72% to 96%. With this in mind, the exercise stress test has relatively low sensitivity and specificity. Because of this, a patient with a high pretest likelihood of ischemic heart disease still has a high probability of developing significant disease even in the face of a normal (negative test). Furthermore, a patient with a low probability of ischemic heart disease still has a low chance of significant disease even if the test is positive. The optimal use of diagnostic testing is for those patients with moderate pretest probabilities. Women tend to have a higher incidence of false-positive results. There are two basic protocols: the Bruce protocol and the Ellestad protocol. In the standard exercise stress test (Bruce protocol), the patient is asked to exercise for 3-minute intervals on a motorized treadmill device while being monitored for the following: heart rate and blood pressure response to exercise, symptoms during the test, ECG response (specifically ST segment displacement), dysrhythmias, and exercise capacity. A positive test is defined as a ST segment depression of at least 1 mm below baseline. Contraindications to exercise stress testing include the following:
· Recent myocardial infarction within the preceding 4 to 6 weeks [except for a submaximal exercise stress test (65% of predicted maximum heart rate) that is often performed before hospital discharge for patients with a recent myocardial infarction]
· Angina at rest
· Rapid ventricular or atrial arrhythmias
· High-grade AV block or bradyarrhythmias
· Uncompensated CHF
· Recent acute illness (noncardiac in origin)
· Moderate to severe aortic stenosis
· Uncontrolled blood pressure (systolic >200 or diastolic >110 mm Hg before onset of exercise)
· Active myocarditis/pericarditis
· Acute pulmonary embolism
· Systemic illness
· Noncompliant patient
Criteria for stopping an exercise stress test include:
· Predicted heart rate is achieved
· Patient complains of excessive fatigue, claudication, or dyspnea
· PVCs that increase in frequency or ventricular tachycardia
· High-grade AV block appears on ECG
· Significant ST changes seen on ECG (>3 mm depression)
· Severe angina
· Systolic blood pressure >220 or diastolic blood pressure >120 during exercise or a decrease in systolic blood pressure with exercise
· Appearance of a bundle branch block
· Equipment malfunction or technical failure
The following are considered to be parameters associated with poor prognosis or increased disease severity: failure to complete stage 2 of a Bruce protocol, failure to achieve a heart rate >120 bpm (off β-blockers), onset of ST-segment depression at a heart rate of <120 bpm, ST-segment depression more than 2 mm, ST-segment depression lasting >6 minutes into recovery, ST-segment depression in multiple leads, poor systolic blood pressure response to exercise, ST-segment elevation, angina with exercise, and exercise-induced ventricular tachycardia.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:602.
Lee TH, Boucher CA, Noninvasive tests in patients with stable coronary artery disease. N Engl J Med. 2001;344:1840–1845.
312. Anemia of chronic disease is associated with which of the following?
A) Macrocytic, normochromic anemia
B) Increased serum ferritin
C) Increased TIBC
D) High serum iron level
E) Hemoglobin of 5 to 8 mg/dL
Answer and Discussion
The answer is B. Anemia of chronic disease can be caused by
· Chronic infections, such as osteomyelitis and subacute bacterial endocarditis
· Chronic disorders, including rheumatoid arthritis, lupus, renal failure, sarcoidosis, and polymyalgia rheumatica
· Other disorders, including neoplasm, liver disorders, and hypothyroidism
Symptoms include typical complaints associated with anemia such as generalized fatigue, malaise, decreased mentation, and those symptoms associated with the primary disorder. Laboratory tests show a mild, normocytic normochromic anemia with an Hb at approximately 10 mg/dL. Microcytic indices are also possible. Serum ferritin is also usually increased, with a low TIBC and low serum-iron level. The only therapy is treatment of the underlying disorder. The administration of iron, folic acid, or vitamin B12 is ineffective. Transfusion should only be considered in advanced cases in patients with severe symptoms.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:334.
313. Which of the following would be best in the short- and long-term treatment of back pain?
A) Regular physical activity
B) Back supports
C) Work site modification
D) Back education school
Answer and Discussion
The answer is A. U.S. Preventive Services Task Force (USPSTF) recommendations on low back pain include the following: Although exercise has not been shown to prevent low back pain, regular physical activity has other proven health benefits, including prevention of cardiovascular disease, hypertension, type 2 diabetes, obesity, and osteoporosis. Neither lumbar supports nor back belts appear to be effective in reducing the incidence of low back pain. Work site modifications, including educational interventions, have some short-term benefit in reducing the incidence of low back pain. However, their applicability to the primary care setting is unknown. Back (educational) schools may prevent further back injury for persons with recurrent or chronic low back pain, but their long-term effectiveness has not been well studied.
Krishnaraj R. Primary care interventions to prevent low back pain: a brief evidence update for the U.S. Preventive Services Task Force. Agency for Healthcare Research and Quality, 2003. Accessed online September 17, 2005, at: http://www.ahrq.gov/clinic/uspstf/uspsback.htm.
Neither lumbar supports nor back belts appear to be effective in reducing the incidence of low back pain.
314. A 75-year-old presents with a painful erythematous and vesicular rash that is developing on the forehead in the periorbital area. The rash began yesterday. The patient has had some generalized myalgias and low-grade fevers. Appropriate management at this time includes
A) antiviral medication and follow up in 3 to 5 days
B) antibiotics plus antiviral medications and follow up in 3 to 5 days
C) reassurance
D) hospitalization with IV antibiotics
E) antiviral medication and ophthalmology referral
Answer and Discussion
The answer is E. The most common complication of herpes zoster is postherpetic neuralgia (i.e., pain along cutaneous, dermatomal nerves persisting >30 days after the lesions have healed). The incidence of postherpetic neuralgia increases with age and is not commonly seen in patients younger than 60 years. Herpes zoster lesions can become secondarily infected with staphylococci or streptococci, and cellulitis may develop. Herpes zoster involving the ophthalmic division of the trigeminal nerve can lead to ocular complications and visual loss. In these cases immediate referral to an ophthalmologist is recommended. Other less common complications include motor paresis and encephalitis.
Mouncey AL, Matthew LG, Slawson DC. Herpes zoster and postherpetic neuralgia: prevention and management. Am Fam Physician. 2005;72:1075–1080.
315. Addison's disease (primary adrenal insufficiency) is associated with
A) increased adrenocorticotropic hormone (ACTH) production
B) decreased ACTH production
C) increased urine 17-hydroxysteroids and 17-ketosteroids
D) hypernatremia
E) hypothalamic dysfunction
Answer and Discussion
The answer is A. Primary adrenal insufficiency (Addison's disease) is a condition resulting from adrenocortical insufficiency. Secondary adrenal insufficiency is secondary to a lack of ACTH production from the pituitary gland. The primary disease results in electrolyte disturbances, such as hyponatremia, hyperkalemia, low bicarbonate, and elevated BUN. The plasma renin and ACTH are increased with primary adrenal insufficiency. Other laboratory findings include moderate neutropenia, lymphocytosis, eosinophilia, low plasma cortisol, decreased urine 17-hydroxysteroids, and decreased 17-ketosteroids. There is also a failure of plasma cortisol to rise after administration of ACTH (corticotropin). Symptoms include weakness, fatigue, anorexia with nausea, vomiting, and diarrhea. Physical findings include hypoglycemia; sparse axillary hair; and increased pigmentation of the gingival mucosa, nipples, labia, and linea alba. Treatment involves the replacement of glucocorticoids and mineralocorticoids. Symptoms of adrenal crisis include severe abdominal pain, generalized muscle weakness, hypotension, and shock. Severe cases may result in death.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1207–1210.
316. Which of the following tests is the most appropriate to diagnose carbon monoxide poisoning?
A) Arterial blood gas
B) Chest radiograph
C) Carboxyhemoglobin levels
D) CBC
E) Lactic acid levels
Answer and Discussion
The answer is C. Carbon monoxide poisoning is a dangerous but relatively common occurrence. It usually occurs during the winter months in cold regions of the United States. The affinity of CO for hemoglobin is 240 times greater than that of oxygen; it shifts the oxygen dissociation curve to the left, which impairs hemoglobin release of oxygen to tissues and inhibits the cytochrome oxidase system. Symptoms include headache, confusion, fatigue, and nausea; in more severe cases, seizures, rhabdomyolysis, Parkinsonian-type symptoms, coma, and death may occur. In many cases, the initial symptoms are attributed to a flu-like illness, and CO poisoning is overlooked. The diagnosis is usually made by obtaining a history of exposure (usually a fuel oil furnace or exhaust fumes in a poorly ventilated enclosure) and laboratory testing, which shows elevated carboxyhemoglobin levels. Treatment involves the use of 100% oxygen and, in severe cases, hyperbaric oxygen. Prolonged exposures usually have a worse prognosis. Patients with CO poisoning necessitating treatment need follow-up neuropsychiatric examinations.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:1634–1635.
317. Barrett's esophagus is associated with
A) overuse of proton pump inhibitors
B) tracheoesophageal fistula
C) trauma associated with prior esophagogastroduodenoscopy
D) transformation of columnar epithelium to squamous epithelium
E) adenocarcinoma of the esophagus
Answer and Discussion
The answer is E. Barrett's esophagus is the result of chronic gastroesophageal reflux. The condition causes metaplasia and transformation of squamous to columnar epithelium in the areas affected. Patients usually report symptoms of pyrosis and, occasionally, dysphagia if strictures develop. Men are more commonly affected than women. The diagnosis is made with esophagoscopy and biopsy of suspected areas. Treatment is accomplished with H2-blockers and proton pump inhibitors. Proton pump inhibitors strongly inhibit gastric acid secretion. They act by irreversibly inhibiting the H+–K+ adenosine triphosphatase pump of the parietal cell. By blocking the final common pathway of gastric acid secretion, the proton pump inhibitors provide a greater degree and duration of gastric acid suppression compared with H2-receptor blockers. Clinical trials have clearly shown that the proton pump inhibitors provide better symptom control, esophageal healing, and maintenance of remission than H2-receptor blockers or prokinetic agents. Long-term use of proton pump inhibitors in humans has not been associated with an increased risk of gastric carcinoma, although this was initially a concern. Prolonged use of the drugs has been associated with gastric atrophy; however, atrophy is more likely to be a problem in patients infected with H. pylori. The proton pump inhibitors are fairly well tolerated. The most common side effects are nausea, diarrhea, constipation, headache, and skin rash. Proton pump inhibitors are more expensive than standard-dose H2-receptor blockers or prokinetic agents. However, when prescribed appropriately to patients with severe symptoms or refractory disease, the proton pump inhibitors are more cost-effective because of their higher healing and remission rates and the consequent prevention of complications. Occasionally, severe cases of Barrett's esophagitis are treated with surgery. Because of a 10% increased risk for the development of adenocarcinoma in the affected areas, follow-up with endoscopy every 3 to 5 years is indicated, although screening endoscopy time frames are controversial. Treatment of gastroesophageal reflux disease associated with Barrett's esophagus has not been shown to eliminate the metaplasia of that condition or the risk of malignancy. Consequently, patients with Barrett's esophagus require periodic endoscopic biopsy to assess esophageal tissue for malignant changes.
Shalauta MD, Saad R. Barrett's esophagus. Am Fam Physician. 2004;69:2113–2118, 2120.
318. Type I diabetes mellitus is associated with
A) hypersensitivity to glucose
B) overproduction of glucagon
C) lack of insulin production by the pancreas
D) tissue resistance to insulin
E) excessive growth hormone secretion
Answer and Discussion
The answer is C. Diabetes mellitus type I (juvenile diabetes) tends to occur in individuals younger than 30 years. The cause is complete failure of the beta islet cells in the pancreas to produce insulin. A genetic predisposition and perhaps a viral or autoimmune reaction that destroys the insulin-producing beta cells are believed to be the cause. The incidence among school children is reported to be 1 in 500. Symptoms include polydipsia, polyphagia, polyuria, dry mouth, nausea, vomiting and abdominal pain, weight loss, and fatigue. In severe cases, the patient may present in diabetic ketoacidosis with stupor, coma, dehydration, labored Kussmaul-type respirations, abdominal distention, and pain. The treatment is aggressive fluid and electrolyte replacement along with exogenous insulin administration. Diabetic complications include retinopathy, nephropathy, macrovascular disease, and diabetic foot ulcers. Judicious control of glucose may help to prevent these complications. Typically, patients require 0.5 to 1.0 U/kg/day of insulin. This daily dose is divided as follows:
· Morning dose. Two-thirds of the total daily dose is administered in the morning. The morning dose is composed of two-thirds intermediate-acting insulin and one-third short-acting regular insulin.
· Evening dose. One-third of the total daily dose is administered in the evening; 50% is short-acting regular insulin, which the patient takes before the evening meal, and 50% is intermediate-acting insulin, which the patient takes at bedtime.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:2174.
319. Which of the following is a common ophthalmologic finding in patients with HIV infection?
A) Retinal tears
B) Cataracts
C) Retinitis
D) Glaucoma
E) Conjunctivitis
Answer and Discussion
The answer is C. HIV syndrome can affect many different organ systems. Ophthalmologic findings include toxoplasmic and cytomegalovirus retinitis, herpes infections, syphilis, and pneumocystic infections of the eye. The most common ophthalmologic finding is cotton-wool spots caused by retinal ischemia secondary to microvascular disease. All patients with HIV should undergo complete eye examinations to rule out associated conditions.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:1119.
320. Which of the following statements is true regarding insulin injections?
A) Absorption from the buttock is rapid and can be used as a site just before eating.
B) Rotation of injections to different zones of the body can cause wide variations in serum glucose levels.
C) Injection in the arm often leads to exercise-induced hypoglycemia.
D) The thigh is the best site for reliable and predictable absorption.
Answer and Discussion
The answer is B. The abdomen is the best site for insulin administration, because the insulin is more reliably and predictably absorbed. Injection in exercised areas (e.g., the thigh) may lead to development of exercise-induced hypoglycemia. However, insulin injection at the arm does not cause as much exercise-induced hypoglycemia and thus can be used as an alternative injection site. Absorption from the buttocks is the slowest and is a good site to use at bedtime to avoid nocturnal hypoglycemia. Rotation of injection sites can lead to erratic absorption of insulin with wide variations in serum glucose levels. Thus, injection sites should remain within the same zone (abdomen, arm, or buttock) but rotated at different sites within the zones to prevent lipohypertrophy.
Green GB, Harris IS, et al. The Washington Manual of Medical Therapeutics, 31st ed. Lippincott Williams & Wilkins; 2004:474.
321. The treatment of choice for adult respiratory distress syndrome (ARDS) is
A) loop diuretics
B) corticosteroids
C) positive end-expiratory pressure
D) β2 agonist
E) high-dose immunosuppressive drugs
Answer and Discussion
The answer is C. Acute Respiratory Distress Syndrome (ARDS) is characterized by respiratory distress that may be caused by different insults, including trauma, near-drowning, aspiration, pneumonia, sepsis, and multiple blood transfusions. The predominate medical risk factor for ARDS is sepsis, particularly from an abdominal source. The mechanism of injury involves damage of capillary endothelial cells and alveolar epithelial cells, which leads to pulmonary edema with decreased pulmonary compliance and decreased functional residual capacity. Symptoms include rapid onset of dyspnea usually 12 to 48 hours after the insult, with wheezing and intercostal retractions. Laboratory tests show hypoxemia that responds poorly to oxygen administration, requiring frequent monitoring of arterial blood gases. Radiographs show diffuse or patchy alveolar and interstitial infiltrates without cardiomegaly or pulmonary vascular redistribution. Treatment involves mechanical ventilation with the use of low volume ventilation with positive end-expiratory pressure (PEEP). Fluids should be minimized. Patients are usually paralyzed with pancuronium. Antibiotics are unnecessary, but nosocomial infections may develop. Most patients with the development of ARDS also have multiple organ failure, which is the major cause of death. Mortality rates approach 50%.
Mortelliti MP, Manning HL. Acute respiratory distress syndrome. Am Fam Physician. 2002;65:1823–1830.
The predominate medical risk factor for ARDS is sepsis, particularly from an abdominal source.
322. Which of the following is associated with rebound hypertension?
A) Oral contraceptives
B) Hyperthyroidism
C) Excessive alcohol consumption
D) Abrupt withdrawal of β-blockers
E) Pheochromocytoma
Answer and Discussion
The answer is D. Causes for secondary hypertension are numerous and include the use of oral contraceptives, excessive alcohol consumption, disorders of the renal parenchyma associated with malfunction of the renin-aldosterone system, Cushing's syndrome, pheochromocytoma, primary aldosteronism, hyperthyroidism, myxedema, renal vascular disease, and coarctation of the aorta. In many cases, blood pressure may be difficult to control. Physical examination may reveal abdominal bruits, suggestive of renovascular hypertension, or other findings suggestive of contributing disease. Adequate treatment is necessary to prevent the long-term detrimental effects of hypertension. Abrupt discontinuation of βblockers is associated with rebound hypertension.
Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7) Express. National Heart, Lung, and Blood Institute. Bethesda, Md. 2003. JAMA. 2003;289:2560–2571.
323. A 27-year-old patient with asthma presents to your office complaining of shortness of breath with wheezing. Which of the following medications is indicated in the initial treatment of this patient?
A) Salmeterol
B) Albuterol
C) Cromolyn sodium
D) Ipratropium bromide
E) Theophylline
Answer and Discussion
The answer is B. Asthma is a reversible obstructive lung disorder that is characterized by reactive airways. The condition is thought to be inherited; however, some individuals may be affected without a family history. Many factors may precipitate an attack, including infections, smoke, cold weather, exercise, toxic fumes, and stress. Symptoms include wheezing, shortness of breath, tachypnea, cough (particularly in children), and tightness or pressure in the chest. The mainstay of acute treatment (rescue therapy) is an inhalant form of a β2-adrenergic agonist, such as albuterol. Inhaled corticosteroids and salmeterol (a long-acting β2-adrenergic agonist) are used in chronic therapy. For patients who have more severe asthmatic attacks, short courses of oral corticosteroids may be necessary, particularly with upper respiratory infections. Theophylline, once readily prescribed, is used less frequently, and its benefits are controversial. Cromolyn sodium, a mast cell stabilizer, and ipratropium bromide, an anticholinergic medication, and the leukotriene modifiers can be used for chronic asthmatic conditions. Pulmonary function tests in patients affected with asthma usually show a normal or decreased vital capacity, decreased forced expiratory volume in 1 second, increased residual volume, increased total lung capacity, and a positive response to inhaled bronchodilators. In children, rescue β2-adrenergic agonists are the treatment of choice for mild intermittent asthma.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:381–398.
324. A 22-year-old sexually active female presents with a 24-hour history of dysuria. She is otherwise healthy and has no other symptoms. Appropriate management includes
A) urine culture followed by antibiotics until culture result is determined
B) dipstick urinalysis followed by antibiotic coverage if positive
C) continued observation
D) midstream urinalysis followed by microscopic evaluation and treatment if positive
Answer and Discussion
The answer is B. Sexually active young women are at an increased risk to develop urinary tract infections. Their likelihood to develop UTIs is related to their anatomy (short urethra) and certain behavioral factors, including delays in micturition, sexual activity, and the use of diaphragms and spermicides (both of which increase the colonization of the periurethral area with coliform bacteria). Most UTIs in this group are uncomplicated and are rarely associated with functional or anatomic abnormalities. Extensive diagnostic work-ups are not necessary in young women presenting with an uncomplicated episode of cystitis. The diagnosis of UTI was once based on a quantitative urine culture yielding >100,000 colony-forming units (CFU) of bacteria per milliliter of urine. However, CFU counts below this level (low-coliform-count infections) have been associated with cystitis in symptomatic women. Therefore, urine cultures are no longer recommended as part of the routine work-up of these patients. Instead, patients should undergo an abbreviated laboratory work-up in which the presence of pyuria is confirmed by traditional urinalysis or a dipstick test for leukocyte esterase. A positive leukocyte esterase test has a reported sensitivity of 75% to 90% in detecting pyuria associated with a UTI. The dipstick test for nitrite is used as a surrogate marker for bacteriuria. It should be noted that not all uropathogens reduce nitrates to nitrite; Enterococcus, S. saprophyticus, and Acinetobacter species do not, and therefore give false-negative results. Treatment options for uncomplicated cystitis include 3- or 7-day courses of antibiotics. Three-day regimens offer the optimal combination of convenience, low cost, and efficacy comparable to that of 7-day or longer regimens but with fewer side effects. When considering cost and efficacy, trimethoprim–sulfamethoxazole remains the antibiotic of choice in the treatment of uncomplicated UTIs in young women. The use of fluoroquinolones as first-line therapy for uncomplicated UTIs should be avoided, except in patients who cannot tolerate sulfonamides or trimethoprim, who have a high frequency of antibiotic resistance because of recent antibiotic treatment, or who reside in an area in which significant resistance to trimethoprim–sulfamethoxazole has been noted. A 7-day antibiotic course should be considered in pregnant women, diabetic women, and women who have had symptoms for more than 1 week and thus are at higher risk for pyelonephritis because of the delay in treatment.
Orenstein R, Wong ES. Urinary tract infections in adults. Am Fam Physician. 1999;59:1225.
325. Shy-Drager syndrome is associated with
A) peripheral neuropathies
B) autonomic instability
C) bilateral foot drop
D) tearing and excessive salivation
E) emotional lability
Answer and Discussion
The answer is B. Patients with Shy-Drager syndrome have plasma norepinephrine levels that do not increase on standing. In this condition there is widespread autonomic dysfunction in addition to failure of arteriolar and venous vasoconstriction; loss of sweating; bowel, bladder, and stomach atony; impotence; decreased salivation and tearing; mydriasis; and impaired visual accommodation. Paradoxically, blood pressure may be elevated in the supine position, even when severe postural hypotension is present, because of loss of parasympathetic, as well as sympathetic, regulation of the cardiovascular system. Orthostatic hypotension is accentuated in the early morning due to overnight natriuresis and may also be more prominent postprandially and after exercise. In Shy-Drager syndrome, bulbar dysfunction and laryngeal stridor may be fatal. Occasionally, the physical and pathologic findings are those of Parkinson's disease plus involvement of the intermediolateral cell columns of the spinal cord. Treatment includes intravascular volume expansion with fludrocortisone, salt supplementation, application of constrictive garments to the lower body (including the abdomen), and α adrenoreceptor stimulation with ephedrine. Keeping the head raised during sleep may reduce morning orthostatic hypotension. Metoclopramide, parenteral dihydroergotamine, and indomethacin are effective in some patients. Metoclopramide may exacerbate parkinsonian symptoms in some, and long-term use may lead to tardive dyskinesia, dystonia, or akathisia.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1768–1769.
326. Which of the following statements about use of ticlopidine is true?
A) The drug inhibits von Willebrand factor.
B) Side effects include peripheral neuropathy and tremor.
C) Liver function tests and blood counts should be monitored initially.
D) The drug is associated with gastric ulceration.
E) The drug inhibits vitamin K–dependent clotting factors.
Answer and Discussion
The answer is C. Ticlopidine (Ticlid) and clopidogrel (Plavix) are used as an alternative to aspirin when selecting an anticoagulant for stroke prophylaxis. Ticlopidine works by inhibiting platelet aggregation by blocking adenosine diphosphate–induced aggregation. Major side effects include diarrhea, nausea, dyspepsia, rash, an abnormal liver function test, and severe neutropenia and thrombocytopenia. Most side effects, including blood dyscrasias, occur within the first 3 months. Blood tests, including CBCs and liver function tests, should be monitored every 2 weeks for the first 3 months of drug therapy. Abnormalities may necessitate the discontinuation of the medication. Unlike aspirin, ticlopidine is not associated with gastric ulceration. Because of safety and tolerance issues associated with ticlopidine, clopidogrel is the more widely used second-line antiplatelet agent. Neutropenia, rash, diarrhea, and thrombotic thrombocytopenic purpura (TTP) occur less frequently with clopidogrel than with ticlopidine. The incidence of ticlopidine-related TTP is estimated to be 1 case per 1,600 to 5,000 patients treated. Although clopidogrel and aspirin have similar safety profiles, there have been rare reports of clopidogrel-related TTP, with the majority of cases occurring within 2 weeks of initiation of the drug.
Solenski NJ. Transient ischemic attacks. Am Fam Physician. 2004;69:1681–1688.
327. Which of the following positive test results supports the diagnosis of Raynaud's phenomenon?
A) Allen's test
B) Finkelstein's test
C) Phalen's test
D) Reverse Phalen's test
Answer and Discussion
The answer is A. Raynaud's phenomenon is secondary to spasm of the arterioles that usually supply the hands but can also affect the nose and other appendages. It is usually idiopathic (termed Raynaud's disease), but has been associated with emotional stress, connective tissue diseases (e.g., lupus, rheumatoid arthritis, scleroderma), arterial obstructive diseases, medications (e.g., ergots, β-blockers, clonidine, methysergide), and endocrine disorders. Idiopathic Raynaud's phenomenon occurs more frequently in women and frequently occurs in patients with migraines or variant angina. Symptoms include blanching, cyanosis, and paresthesias that affect the distal extremities. Diagnosis can be determined by performing Allen's test. The radial and ulnar arteries are occluded by the examiner while the patient makes a fist. The hand is then opened, and one side of the wrist is released. Blood flow to the hand should be detected by color, which is restored to the hand. If the hand remains pale and cyanotic with either of the two sides, Raynaud's phenomenon should be suspected. During asymptomatic periods the examination is entirely normal. Treatment for mild to moderate cases should only involve avoiding triggering factors (e.g., cold, stress, nicotine, previously listed medications). The medication of choice for the treatment of severe Raynaud's phenomenon includes the calcium channel blockers nifedipine and diltiazem. Other medications include reserpine, phenoxybenzamine, methyldopa, terazosin, doxazosin, and prazosin. Surgical treatment for resistant, severe cases involves sympathectomy.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:1489–1490.
328. Which of the following statements about the diagnosis of systemic lupus erythematosis (SLE) is true?
A) The ANA test is specific.
B) The LE prep test is a confirmatory test.
C) The LE prep test should be used as a screening test.
D) The anti-double-stranded DNA test is a confirmatory test.
Answer and Discussion
The answer is D. Systemic lupus erythematosis (SLE) is an autoimmune disorder affecting all major organ systems. Symptoms wax and wane and include diffuse joint pain, facial rashes (butterfly distribution), cardiac involvement (including pericarditis, myocarditis, and endocarditis), renal involvement (proteinuria, hypertension, and uremia), pulmonary involvement (pleuritis, pleural effusions), CNS findings (depression, transient ischemic attacks, strokes, chorea, and psychosis), and vasculitis. GI involvement is less common. Women are more commonly affected than men. Laboratory findings include a positive fluorescent ANA screening test, which is sensitive but not specific. The anti-double-stranded DNA is a confirmatory test that is specific but not sensitive. Because of the high rate of false-positive ANA titers, testing for SLE with an ANA titer or other autoantibody test is not recommended in patients with isolated myalgias or arthralgias in the absence of these specific clinical signs. Under most circumstances, a persistently negative ANA titer (<1:40) can be assumed to rule out SLE. A normal-range ANA titer in the setting of organ system involvement that suggests SLE should prompt an evaluation for alternative diagnoses. If no other cause is identified, the diagnosis of ANA-negative SLE and consultation with a rheumatologist should be considered. If patients with a normal ANA titer develop new clinical features that are consistent with SLE, ANA testing should be repeated. According to a guideline from the College of American Pathologists (CAP), no further laboratory tests are necessary in patients who meet diagnostic criteria for SLE and also have a positive ANA test result. Testing for antibody to double-stranded DNA antigen (anti-dsDNA) and antibody to Sm nuclear antigen (anti-Sm) may be helpful in patients who have a positive ANA test but do not meet full criteria for the diagnosis of SLE. Anti-dsDNA and anti-Sm, particularly in high titers, have high specificity for SLE, although their sensitivity is low. Therefore, a positive result helps to establish the diagnosis of the disease, but a negative result does not rule it out. The CAP guideline recommends against testing for other autoantibodies in ANA-positive patients, because there is little evidence that these tests are of benefit. Treatment involves the use of local or systemic steroids, antimalarials, and other immunosuppressive agents. The major challenge for physicians managing patients with SLE is to treat the active phase without allowing the treatment itself to cause long-term damage. This intent has led to a major change in treatment approach, with the goal of limiting corticosteroid exposure, if possible. As a result, physicians are now less reluctant to turn to immunosuppressive drugs such as azathioprine (Imuran) or cyclophosphamide (Cytoxan). Treatment for active SLE differs depending on the organ systems involved and disease severity. Current treatment often includes a combination of drugs.
Gill JM, Quisel AM, Rocca PV, et al. Diagnosis of systemic lupus erythematosis. Am Fam Physician. 2003;68:2179–2186.
329. Recurrent vertigo, tinnitus, and hearing loss are hallmark findings of
A) Meniere's disease
B) cholesteatoma
C) vestibular neuronitis
D) benign positional vertigo
E) acoustic neuroma
Answer and Discussion
The answer is A. Meniere's disease is a peripheral cause of vertigo. Symptoms include the hallmark findings of recurrent vertigo, tinnitus, and hearing loss. The cause is thought to arise from endolymphatic hydrops. In most cases, the vertigo lasts for several hours, up to an entire day. Although at first hearing may be little affected, over time it deteriorates. Tinnitus is usually constant and may become worse during the acute attacks. Vertigo may be severe and accompanied by nausea and vomiting. Treatment consists of salt restriction (i.e., no more than 2 g/day) and the use of hydrochlorothiazide, anticholinergics, antihistamines, and antiemetics. Resistant cases may require referral to an ear-nose-throat specialist.
Labuguen RH. Initial evaluation of vertigo. Am Fam Physician. 2006;73:244–251, 254
330. Primary hypothyroidism is associated with a deficiency of
A) T4
B) TSH
C) thyroid-releasing hormone
D) thyroid-stimulating antibodies
E) none of the above
Answer and Discussion
The answer is A. There are basically two types of hypothyroidism:
· Primary hypothyroidism (most common form), which is a deficiency of T4 that is caused by thyroid gland disease.
· Secondary hypothyroidism, which is associated with a deficiency in TSH from the pituitary gland or deficient thyroid-releasing hormone by the hypothalamus.
Hypothyroidism is seen more commonly in patients older than 55 years and in women. The most common form occurs as a result of Hashimoto's thyroiditis followed by post-therapeutic hypothyroidism, especially after radioactive iodine therapy or surgery for hyperthyroidism. Symptoms include fatigue, weakness, cold intolerance, constipation, hair loss, menorrhagia, carpal tunnel syndrome, dry skin, nonpitting edema (also referred to as myxedema) caused by deposition of mucopolysaccharides, weight gain, memory impairment, depression, hoarseness, delayed relaxation of reflexes, altered mental status, and bradycardia. A low free T4 with a high TSH is seen in primary hypothyroidism, whereas a low free T4 with a low TSH is indicative of secondary or tertiary hypothyroidism. In congenital hypothyroidism, the deficiency of thyroid hormone is severe and symptoms usually develop in the early weeks of life. Affected infants may show hypotonia and developmental delay. In the United States, mandatory newborn routine testing includes tests to rule out hypothyroidism, which has made the complications of neonatal hypothyroidism rare. Mental retardation may occur if infants are not identified and treated.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1200–1203.
331. Which of the following statements about Osler-Weber-Rendu disease is true?
A) The condition is not associated with hereditary transmission.
B) It is associated with telangiectasia lesions of the face, lips, nasal and oral mucosa, and GI mucosa.
C) The pulmonary system is unaffected.
D) Treatment involves high-dose prednisone.
E) Laboratory studies show pernicious anemia.
Answer and Discussion
The answer is B. Osler-Weber-Rendu disease (also known as hereditary hemorrhagic telangiectasia) is a hereditary disorder that is associated with telangiectasia lesions on the face, lips, nasal and oral mucosa, and GI mucosa. The mode of transmission is autosomal dominant. The condition can lead to significant GI hemorrhage or epistaxis. Some patients may have pulmonary arteriovenous malformations and may experience hemoptysis or dyspnea. Cerebral or spinal arteriovenous malformations may cause subarachnoid hemorrhage, seizures, or paraplegia. Laboratory findings may indicate an iron deficiency anemia. Treatment is nonspecific and involves topical hemostatics and laser ablation of accessible lesions. In severe cases, blood transfusions may be necessary. Iron supplementation is also recommended.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1089.
Osler-Weber-Rendu (also known as hereditary hemorrhagic telangiectasia) is a hereditary disorder that is associated with telangiectasia lesions on the face, lips, nasal and oral mucosa, and GI mucosa.
332. B-type natriuretic peptide (BNP) is used in the diagnosis of
A) pulmonary embolism
B) congestive heart failure
C) type 1 diabetes mellitus
D) asthma
E) amyloidosis
Answer and Discussion
The answer is B. B-type natriuretic peptide (BNP) has shown sensitivity and specificity in the diagnosis of heart failure. This peptide is released by ventricular myocytes when heart failure causes increased wall stretch. It is a simple and rapid test that reliably predicts the presence or absence of left ventricular dysfunction on an echocardiogram. A BNP level of 100 pg/mL or below is unlikely to support the diagnosis of congestive heart failure, and an elevation >400 to 500 pg/mL is indication that heart failure is likely present. Intermediate values require physicians to rely on other standard evaluation measures to decide whether heart failure was present.
Mueller C, Scholer A, Laule-Kilian K. Use of B-type natriuretic peptide in the evaluation and management of acute dyspnea. N Engl J Med. 2004;350:647–654.
333. Which of the following are rich in omega-3 fatty acids?
A) Legumes
B) Vegetable oils
C) Fish
D) Meats
E) Tomatoes
Answer and Discussion
The answer is C. Omega-3 fatty acids have been shown to reduce the risk of mortality in patients with known coronary heart disease. Fish, including salmon and tuna, and fish oil are rich sources of the omega-3 fatty acids eicosapentaenoic acid and docosahexaenoic acid. Flaxseed, canola oil, and walnuts are also good dietary sources of omega-3 fatty acids. The omega-3 fatty acids are antithrombotic and anti-inflammatory. In contrast, omega-6 fatty acids, which are present in most seeds, vegetable oils, and meat, are prothrombotic and proinflammatory. Omega-3 fatty acids also are used to treat hyperlipidemia, hypertension, and rheumatoid arthritis. There appears to be no significant drug interactions with omega-3 fatty acids. The American Heart Association recommends consumption of two servings of fish per week for persons with no history of coronary heart disease and at least one serving of fish daily for those with known coronary heart disease. Approximately 1 g/day of omega-3 fatty acid is recommended for cardioprotection. Higher dosages of omega-3 fatty acids are required to reduce elevated triglyceride levels (2 g to 4 g per day) and to reduce morning stiffness and the number of tender joints in patients with rheumatoid arthritis (at least 3 g/day). Modest decreases in blood pressure occur with significantly higher dosages of omega-3 fatty acids.
Covington MG. Omega-3 fatty acids. Am Fam Physician. 2004;70:133–140.
334. Which of the following conditions is often the first sign of amyloidosis?
A) Proteinuria
B) CHF
C) Cardiac arrhythmias
D) Rheumatoid arthritis
E) Night blindness
Answer and Discussion
The answer is A. Amyloidosis is a condition characterized by excessive protein deposition in tissues, which interferes with normal organ functioning. Common forms include the following:
· Primary idiopathic amyloidosis, or that associated with multiple myeloma. This condition is also referred to with the designation AL, which denotes amyloidosis involving Ig light chains. Fewer than 20% of patients with AL have myeloma. Approximately 15% to 20% of patients with myeloma have amyloidosis. AL is a systemic disease that has the capability of affecting multiple organ systems.
· Secondary amyloidosis (designated AA, reactive or acquired amyloidosis) is associated with chronic inflammatory diseases such as tuberculosis, osteomyelitis, and leprosy. It more commonly affects the liver, spleen, kidneys, adrenal glands, and lymph nodes. Vascular involvement may be widespread. Effective treatment of the underlying chronic inflammatory disease has reduced the incidence in developed countries.
Diagnosis is usually accomplished after the point of irreversible organ damage and involves biopsy of the abdominal fat or rectal mucosa. Tissue is then examined under a polarizing microscope using Congo red stain to look for a characteristic green birefringence of amyloid. Proteinuria is often the first symptom associated with systemic amyloidosis, particularly the AA and AL types. Nephrotic syndrome may be severe and lead to renal failure. Myocardial amyloidosis–causing arrhythmias and CHF are two common forms of death in those affected with amyloidosis. Generalized amyloidosis is usually a slowly progressive disease that leads to death in several years, but, in some instances, prognosis is improving. The most effective form of treatment (for the AL form) is stem-cell transplantation and immunosuppressive drugs (melphalan). Cardiac transplantation has also been used.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:2024.
335. Which of the following statements is true regarding acyclovir?
A) The medication is not effective for the treatment of herpes zoster.
B) The drug effectively prevents the transmission of herpes from those affected.
C) Topical acyclovir is less effective than oral acyclovir.
D) The medication is most effective after the onset of vesicles.
E) Seizures are not associated with the use of acyclovir.
Answer and Discussion
The answer is C. Acyclovir is a purine compound used as an antiviral agent against the herpes virus. The medication is incorporated into the viral DNA and inhibits DNA polymerase, thus preventing replication of the virus. The medication is used for genital and oral herpes, as well as the herpes zoster infection. Immunocompromised patients infected with the varicella virus may also benefit from acyclovir. The medication should be used with caution in patients with underlying renal disease or dehydration. Adverse reactions include headache, encephalopathic signs (e.g., lethargy, obtundation, hallucinations, seizures), hypotension, rash, pruritus, nausea, vomiting, diarrhea, renal dysfunction, and arthralgias. The patient must be informed that the medication helps decrease the number and severity of occurrences but does not cure the virus. The best response is achieved when the medication is taken at the first symptoms of an outbreak of the virus. Patients should also be counseled that there is risk of herpes transmission even when there is no visible evidence of the virus. Topical use of acyclovir may help but is less effective than oral medication.
Emmert DH. Treatment of common cutaneous herpes simplex viral infections. Am Fam Physician. 2000;61:1697–1704, 1705–1706, 1708.
336. Which of the following tests is used to detect hepatitis B infection during the “window period”?
A) Hepatitis B surface antigen
B) Hepatitis B surface antibody
C) Hepatitis B core antibody (IgM)
D) Hepatitis B e antigen
E) Hepatitis B antibody to the delta agent
Answer and Discussion
The answer is C. The following are specific tests used when assessing a patient infected with hepatitis B virus:
· Hepatitis B surface antigen (Australian antigen). This test detects the surface antigen of the hepatitis B virus. It is usually detected 1 to 4 months after exposure to the virus. Its presence represents infection with the virus. In approximately 10% of cases, this test remains positive and no antibodies are formed. This state denotes the chronic carrier state.
· Hepatitis B antibody. This test detects the presence of antibodies to the hepatitis B surface antigens. It usually occurs 5 months after exposure to the virus and persists for life. Its presence represents past infection and relative immunity to hepatitis B. It can also be used to check for antibodies after immunization for the hepatitis B virus.
· Hepatitis B core antibody IgM and IgG. Anti–hepatitis B core antibody IgM is useful when trying to determine infection with the virus during the “window period” (i.e., the time between the disappearance of the surface antigen and the development of the antibody). Its presence indicates a current infection with hepatitis B. Anti–hepatitis B core antibody IgG indicates a previous hepatitis B infection, and its presence remains indefinitely.
· Hepatitis B e antigen. The presence of the e antigen indicates that the blood is highly infectious. It is associated with more severe cases and the development of the chronic carrier state. Its persistence for longer than 8 weeks indicates that a chronic carrier state has developed. In 90% of cases, hepatitis B e antigen–positive mothers infect their fetuses.
· Hepatitis B antibody to the delta agent. Conversion from the hepatitis B e antigen to the anti–hepatitis B e indicates a lower infectivity rate and improvement in the patient's liver function status. It usually reflects a benign outcome.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:219–230.
337. In which of the following clinical situations is digoxin best used?
A) CHF in the setting of diastolic dysfunction
B) Idiopathic hypertrophic subaortic stenosis
C) Recent myocardial infarction with CHF
D) Supraventricular arrhythmia with the development of CHF
E) Emergent treatment of ventricular fibrillation
Answer and Discussion
The answer is D. The use of cardiac glycosides, such as digoxin, is not disputed and is generally recommended if there is a supraventricular arrhythmia present, such as atrial fibrillation in the presence of CHF. Digoxin is also used in cases of CHF in which the heart is dilated and the systolic function is significantly impaired. In patients with normal systolic function but with decreased ventricular compliance (diastolic dysfunction) that gives rise to CHF, the use of digoxin is not recommended. Digoxin should also not be used in patients with idiopathic, hypertrophic, subaortic stenosis; the medication is also usually withheld in patients with an acute myocardial infarction and CHF, unless diuretics and vasodilators fail to improve cardiac failure. Other agents, including ACE inhibitors, β blockers, and spironolactone, are being used increasingly to prolong life in patients with heart failure. Although digoxin has been used to treat heart failure for >200 years, its role in patients with CHF and sinus rhythm is still debatable. Since the mid-1990s, digoxin has received renewed attention because of recognition of its neurohormonal effect and the successful use of lower dosages. In recent trials, digoxin has been shown to reduce morbidity associated with CHF but to have no demonstrable effect on survival. The goal of digoxin therapy in patients with CHF is to improve quality of life by reducing symptoms and preventing hospitalizations.
Haji SA, Movahed A. Update on digoxin therapy in congestive heart failure. Am Fam Physician. 2000;62:409–416.
338. Which of the following conditions is a cardiovascular contraindication to vigorous exercise?
A) Myocardial infarction that occurred 1 year ago
B) Compensated CHF
C) Myocarditis occurring 1 month ago
D) Mild aortic stenosis
E) Pulmonary embolism that occurred 6 months ago
Answer and Discussion
The answer is C. Cardiovascular contraindications to vigorous exercise include the following:
· Recent (within 6 to 8 weeks) acute myocardial infarction
· Cardiac arrhythmia that compromises cardiac function
· Uncompensated CHF
· Severe aortic stenosis
· Unpaced third-degree heart block
· Severe idiopathic hypertrophic subaortic stenosis
· Episode of myocarditis within the past year
· Cardiomyopathy
· Aortic dissection
· Recent (within 6 to 8 weeks) pulmonary embolism or thrombophlebitis
An exercise program should be a gradual increase of activity that keeps the heart rate in the desired range (220 bpm—patient's age × 75% to 90%) for 30 minutes performed at least 5 times weekly. Select patients may benefit from cardiac stress testing before the onset of vigorous exercise.
Murphy JG. Mayo Clinic Cardiology Review, 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2000:244.
339. The treatment of choice for cryptococcal meningeal infection is
A) amphotericin B and flucytosine
B) metronidazole
C) acyclovir
D) amantadine
E) penicillin G
Answer and Discussion
The answer is A. Cryptococcus is an infection caused by the fungus Cryptococcus neoformans that usually involves the lungs with spread to the meninges and occasionally to other sites, including the kidneys, bones, and skin. The disease is found worldwide and tends to affect immunodeficient patients with lymphoma and AIDS or those chronically taking steroids. Symptoms include headaches (usually the first symptom), blurred vision, and mental status changes seen with meningeal involvement. In addition, the patient usually reports a persistent cough, which reflects pulmonary involvement. The disease is acquired by respiratory transmission. Skin lesions and the development of osteomyelitis are infrequent; however, as many as 33% of patients with meningeal involvement also have renal involvement. Laboratory tests show CSF with an increased protein, a white cell count that is mostly lymphocytes, and a decreased glucose level with meningeal involvement. Culture of sputum, blood, urine, or other areas of involvement is diagnostic. The diagnosis is also supported with the evidence of budding yeast seen with India ink preparation. The treatment of choice for cryptococcal meningitis is the administration of intravenous amphotericin B and oral flucytosine until lumbar cultures are clear, followed by lifelong prophylaxis with amphotericin, fluconazole, or ketoconazole. Nonprogressive pulmonary cryptococcus may not require treatment in patients who are not immunocompromised.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1566–1567.
340. A 28-year-old active runner presents to your office complaining of lateral knee and hip pain. The patient reports she has been training intensely for an upcoming marathon. On physical examination, tenderness of the lateral portion of the thigh and a prominent lateral epicondyle are noted. The most likely diagnosis is
A) patellofemoral syndrome
B) ITB syndrome
C) tibial plateau fracture
D) pes anserine bursitis
E) stress fracture
Answer and Discussion
The answer is B. Iliotibial band (ITB) syndrome is characterized by lateral knee pain and, occasionally, lateral hip pain. The pain is caused by inflammation of the distal portion of the ITB band or at the point in which the ITB crosses the lateral femoral epicondyle. Runners, hammer throwers, and racket sport enthusiasts are those usually affected. The condition usually affects runners when there is an increase in the running distance, increased speed or hill running, change in running surface, or consistent running on a banked surface. These activities lead to increased friction of the ITB and cause inflammation. Associated conditions include genu valgum, prominent lateral epicondyle, trochanteric bursitis, leg-length discrepancy, excessive foot pronation, and quadriceps weakness. Testing may show an excessively tight ITB or gluteus maximus. Treatment involves relative rest, anti-inflammatory medication, ice massage, and electronic galvanic stimulation. Prevention is aimed at proper stretching techniques (e.g., quadriceps strengthening) and measures to correct underlying abnormalities (e.g., excessive pronation).
Sullivan JA, Anderson SJ, eds. Care of the young athlete. American Academy of Pediatrics. Rosemont, Il: American Academy of Orthopaedic Surgeons; 2000:374.
341. Which of the following statements about the use of digoxin is true?
A) It is contraindicated in the treatment of CHF and supraventricular tachyarrhythmias.
B) It decreases conduction through the AV node.
C) It can be associated with hepatic failure.
D) Hyponatremia can increase the heart's sensitivity to the medication, leading to cardiac arrhythmias.
E) Patients with a history of Cushing's disease are more sensitive to the effects of digoxin.
Answer and Discussion
The answer is B. Digoxin is classified as a cardiac glycoside. It is used in the treatment of CHF and in supraventricular tachyarrhythmias. In previous trials, digoxin has been shown to reduce morbidity associated with congestive heart failure but to have no demonstrable effect on survival. The goal of digoxin therapy in patients with congestive heart failure is to improve quality of life by reducing symptoms and preventing hospitalizations. The mechanism of action involves positive inotropic activity, which increases the contractility of the cardiac muscle. It also has a negative chronotropic effect, which depresses the sinoatrial node and decreases conduction through the AV node. The drug is distributed widely throughout the body, and approximately 20% to 30% is bound to plasma proteins. The drug is excreted by the kidneys; therefore, drug levels of patients who are elderly or who have renal insufficiency must be monitored closely and the dosage adjusted. Patients with a history of hypothyroidism are also more sensitive to digoxin's effects. Hepatic failure is not associated with digoxin toxicity, because only approximately 10% of the drug goes through enterohepatic recirculation. Potassium levels should also be monitored carefully when administering digoxin. Hypokalemia can increase the heart's sensitivity to the medication and lead to toxicity. Digoxin toxicity is manifested by cardiac arrhythmias, nausea, vomiting, and yellow-green halos around visual images or lights. In severe cases of toxicity, the drug should be withheld and digoxin-specific antibody fragments (Digibind) can be given. Digoxin (Digibind) binds the digoxin and allows rapid excretion.
Haji SA, Movahed A. Update on digoxin therapy in congestive heart failure. Am Fam Physician. 2000;62:409–416.
Digoxin toxicity is manifested by cardiac arrhythmias, nausea, vomiting, and yellow-green halos around visual images or lights.
342. Which of the following statements about rapid streptococcal screening tests (enzyme immunoassays) is true?
A) Their accuracy is generally unreliable.
B) They are less accurate than latex agglutination tests.
C) They are expensive and difficult to perform.
D) They are rarely used when compared to cultures.
E) They may be avoided if the criteria for strep pharyngitis is met.
Answer and Discussion
The answer is E. Rapid Streptococcus screen tests are quick, easy to perform, and approximately as accurate as the latex agglutination tests. Their sensitivity approaches 80%, whereas their specificity is 85% to 100%; thus, a positive test is fairly predictive of a streptococcal infection and a culture is unnecessary. If negative, cultures can be performed to confirm the results. In adults, many experts are recommending that treatment can be started or avoided without a strep test. The criteria include: history of fever, tonsillar exudates, absence of cough, and tender anterior cervical lymphadenopathy. Patients who have 0 or only 1 criterion are unlikely to have strep pharyngitis and do not need to be tested. Patients who have 2 criteria can be tested. Those with 3 or 4 criteria can be tested or treated empirically.
Sheeler RD, Houston MS, Radke S. Accuracy of rapid strep testing in patients who have had recent streptococcal pharyngitis. J Am Board Fam Pract. 2002;15:261–265.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:826.
343. The treatment of choice for mucormycosis is
A) amphotericin
B) ketoconazole
C) clotrimazole
D) miconazole
Answer and Discussion
The answer is A. Mucormycosis infections are usually fulminant and can be fatal. Necrotic lesions usually appear on the nasal mucosa or sometimes the palate. Vascular invasion by hyphae leads to progressive tissue necrosis that may involve the nasal septum, palate, and bones surrounding the orbit or sinuses. Findings include pain, fever, orbital cellulitis, proptosis, purulent nasal discharge, and mucosal necrosis. Extension of the infection to involve the brain can cause cavernous sinus thrombosis, convulsions, aphasia, or hemiplegia. Patients with diabetic ketoacidosis are most commonly affected, but opportunistic infections may also develop in chronic renal disease or with immunosuppression, particularly with neutropenia or high-dose corticosteroid therapy. Pulmonary infections resemble invasive aspergillosis. Diagnosis requires a high index of suspicion and careful examination of tissue samples for large nonseptate hyphae with irregular diameters and branching patterns, because much of the necrotic debris contains no organisms. Cultures usually are negative, even when hyphae are clearly visible in tissues. CT scans and x-rays often underestimate or miss significant bone destruction. Effective antifungal therapy requires that diabetes be controlled or, if at all possible, immunosuppression reversed. IV amphotericin B must be used, because azoles are ineffective. Surgical debridement of necrotic tissue may be indicated, because amphotericin B cannot penetrate into these avascular areas to clear remaining organisms.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1534.
344. Cardiac troponins may remain elevated up to
A) 24 hours
B) 48 hours
C) 72 hours
D) 1 week
E) 2 weeks
Answer and Discussion
The answer is E. The term acute coronary syndrome refers to a range of thrombotic coronary artery diseases, including unstable angina and both ST-segment elevation and non-ST-segment elevation myocardial infarction. Symptoms of acute coronary syndrome include chest pain, referred pain, nausea, vomiting, dyspnea, diaphoresis, and lightheadedness. Pain may be referred to the arms, the jaw, the neck, the back, or even the abdomen. Pain radiating to the shoulder, left arm, or both arms increases the likelihood of acute coronary syndrome. Typical angina is described as pain that is substernal, occurs on exertion, and is relieved with rest. Diagnosis utilizes an electrocardiogram and a review for signs and symptoms of cardiac ischemia. In acute coronary syndrome, common electrocardiographic abnormalities include T-wave tenting or inversion, ST-segment elevation or depression (including J-point elevation in multiple leads), and pathologic Q waves. Most high-risk patients should be hospitalized. Intermediate-risk patients should undergo further evaluation, often in a chest pain unit. Many low-risk patients can be discharged with appropriate follow-up. Troponin T or I generally is the most sensitive determinant of acute coronary syndrome, although the MB isoenzyme of creatine kinase also is used. Troponins (T, I, C) are found in striated and cardiac muscle. They are the preferred markers for the diagnosis of myocardial injury. Troponin T and I have similar sensitivity and specificity for the detection of myocardial injury. Unlike troponin I levels, troponin T levels may be elevated in patients with renal disease, polymyositis, or dermatomyositis. The cardiac troponins typically are measured at emergency department admission and repeated in 6 to 12 hours. Patients with a normal CK-MB level but elevated troponin levels are considered to have sustained minor myocardial damage or microinfarction or cardiac strain, whereas patients with elevations of both CK-MB and troponins are considered to have had acute myocardial infarction. The cardiac troponins may remain elevated up to 2 weeks after symptom onset, which makes them useful as late markers of recent acute myocardial infarction. An elevated troponin T or I level is helpful in identifying patients at increased risk for death or the development of acute myocardial infarction. Increased risk is related quantitatively to the serum troponin level.
Achar SA, Kundu S, Norcross WA. Diagnosis of acute coronary syndrome. Am Fam Physician. 2005;72:119–126.
345. A 45-year-old carpenter has a history of hepatitis C. He is returning for a check up and is doing well without complaints. You should make the following recommendation:
A) Ibuprofen is considered safe.
B) Even low-dose acetaminophen should be avoided.
C) Vaccination for hepatitis A and B is recommended.
D) Milk thistle should be avoided.
E) Mild to moderate alcohol use has little detrimental effect.
Answer and Discussion
The answer is C. Hepatitis C virus infection is the most frequent cause of chronic liver disease and the most common reason for liver transplantation. Chronic liver disease is the tenth leading cause of death in the United States. Preventive care can significantly reduce the progression of liver disease. Because alcohol in the setting of hepatitis C can increase the development of cirrhosis, patients with hepatitis C infection should abstain from alcohol use. Because associated infections with hepatitis A or B virus can lead to liver failure, vaccination of both is recommended. Medications that are potentially hepatotoxic should be avoided or used with caution in patients with chronic liver disease. In general, NSAIDs should be avoided; acetaminophen in a dosage below 2 g/day is a safer alternative. Many herbal remedies are potentially hepatotoxic and should also be avoided. Milk thistle can be used safely in patients who have chronic liver disease and may be beneficial. Weight reduction and exercise can improve liver function in patients with fatty infiltration of the liver.
Riley TR III, Bhatti AM. Preventive strategies in chronic liver disease: Part I. Alcohol, vaccines, toxic medications and supplements, diet and exercise. Am Fam Physician. 2001;64:1555–1560.
346. Which of the following statements concerning the use of metformin is true?
A) The drug is an oral sulfonylurea.
B) Weight gain is common with its use.
C) The most common side effect is headache.
D) Patients using metformin must have periodic liver function tests.
E) The most severe side effect is ketoacidosis.
Answer and Discussion
The answer is B. Metformin belongs to the class of drugs referred to as biguanides. Metformin decreases hepatic glucose production by inhibiting gluconeogenesis. The drug also decreases insulin production as a result of decreasing insulin resistance. Metformin decreases plasma triglycerides and LDL cholesterol and increases HDL cholesterol. Hypoglycemia does not occur with metformin monotherapy, and, in contrast to other hypoglycemic agents, weight is not gained and even may be lost with its use. The most common side effects are GI irritation, abdominal cramps, and diarrhea. Patients with inflammatory bowel disease and peptic ulcer disease are not good candidates for metformin therapy. The most severe side effect is lactic acidosis, which can be fatal. Metformin is contraindicated in men with a serum creatine greater than 1.5 mg/dL, or greater than 1.4 mg/dL in women, in patients receiving intravenous radiographic iodinated contrast media, acute myocardial infarction, CHF, and any ischemic condition.
Rakel RE, Bope ET. Conn's Current Therapy 2005. Philadelphia: Elsevier/Saunders; 2005:665, 666.
347. A 28-year-old man presents to your office complaining of pain in the perirectal area for the last week. Examination shows an area of tenderness, redness, and induration just lateral to the anus. The area is warm and fluctuant. The area is otherwise unremarkable. The most appropriate management is
A) warm sitz baths
B) oral antibiotics and warm sitz baths as an outpatient
C) high-dose, intravenous antibiotics as an inpatient
D) topical steroids applied to the rectal area
E) surgical incision and drainage
Answer and Discussion
The answer is E. Pilonidal disease often affects young, white, hirsute males. The disease is related to acute abscesses or chronic draining sinuses that form in the sacrococcygeal region. These sinuses or pits may form a cavity often containing hair. The lesion is often painless unless it becomes infected. Treatment involves incision and drainage and removal of communicating sinus tracts. In many cases, antibiotics are not necessary.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:166.
348. The drug of choice for treatment of severe coccidiomycosis (“valley fever”) is
A) ceftriaxone
B) tetracyline
C) ciprofloxacin
D) mefloquin
E) amphotericin
Answer and Discussion
The answer is E. Coccidioidomycosis (“valley fever”) is an infection that is usually asymptomatic. In some cases, nonspecific respiratory symptoms resembling influenza or acute bronchitis occur. Less frequently, acute pneumonia or pleural effusion can develop. Symptoms include fever, cough, chest pain, chills, sputum production, sore throat, and hemoptysis. Physical signs may be absent or limited to scattered rales with or without areas of dullness to percussion over lung fields. Leukocytosis and, in some cases, eosinophilia is seen. Other symptoms include arthritis, conjunctivitis, erythema nodosum, or erythema multiforme. Primary pulmonary lesions sometimes resolve, leaving nodular coin lesions that may be confused with neoplasms and tuberculosis or other granulomatous infections. In some cases, cavitary lesions develop that may vary in size over time and often appear thin-walled. Although dissemination does not occur from these residual areas, a small percentage of these cavities fail to heal. Hemoptysis or the threat of rupture into the pleural space may occasionally require surgery. Treatment for mild primary coccidioidomycosis is unnecessary in low-risk patients. Mild to moderate nonmeningeal extrapulmonary involvement should be treated with fluconazole or itraconazole. IV amphotericin B or fluconazole is preferable for severely ill patients. As with histoplasmosis, patients with AIDS-associated coccidioidomycosis require maintenance therapy to prevent relapse. Treatment for meningeal coccidioidomycosis must be continued for many months, probably lifelong. Surgical removal of involved bone may be necessary to cure osteomyelitis.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1530–1531.
349. A 65-year-old woman with a seizure disorder controlled with phenytoin presents to your office complaining of muscle cramps, dry skin, and depression. Examination shows carpal pedal spasms after application of a blood pressure cuff. The most likely diagnosis is
A) hypothyroidism
B) hyperventilation with panic attacks
C) hyperkalemia
D) hypocalcemia
E) hyponatremia
Answer and Discussion
The answer is D. Hypocalcemia is defined as a decrease in total plasma calcium concentration <8.8 mg/dL in the presence of normal plasma protein concentration. Causes include hypoparathyroidism; vitamin D deficiency; renal tubular disease; magnesium depletion; acute pancreatitis; hypoproteinemia; septic shock; hyperphosphatemia; and drugs, including phenytoin, phenobarbital, and rifampin. Most patients are asymptomatic. Symptoms, when present, include muscle cramps involving the legs and back, mental status changes, dry skin, depression, and psychosis. Papilledema may occasionally occur, and cataracts may develop after prolonged hypocalcemia. Severe hypocalcemia (<7 mg/dL) may cause tetany, laryngospasm, or generalized seizures. With hypocalcemia giving rise to latent tetany, the patient may exhibit a positive Chvostek's sign (involuntary twitching of the facial muscles caused by a light tapping of the facial nerve just anterior to the exterior auditory meatus) or a positive Trousseau's sign (carpopedal spasm caused by reduction of the blood supply to the hand with a blood pressure cuff inflated to 20 mm Hg above the systolic BP applied to the forearm after 3 minutes). Hypocalcemia can cause heart block and arrhythmias. ECG changes show prolongation of the QTc and ST intervals. T-wave peaking or inversion can also occur. Severe hypocalcemic tetany is treated initially with intravenous infusion of calcium salts (calcium gluconate). In chronic hypocalcemia, oral calcium and vitamin D supplements are usually sufficient. Treatment of hypocalcemia in patients with renal failure must be combined with dietary phosphate restriction and phosphate-binding agents such as calcium carbonate to prevent hyperphosphatemia and metastatic calcification.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1250–1254.
350. Shy-Drager syndrome is best characterized by
A) autonomic dysfunction
B) unilateral foot drop
C) peripheral neuropathy
D) proximal muscle weakness
E) muscle atrophy
Answer and Discussion
The answer is A. Shy-Drager syndrome affects multiple organ systems and causes neurologic damage, including autonomic dysfunction with cerebellar ataxia, Parkinsonism, corticospinal, and corticobulbar tract dysfunction. Patients may experience orthostatic hypotension, impotence, urinary retention, fecal incontinence, decreased sweating, iris atrophy, and decreased tearing and salivation. Treatment consists of intravascular volume expansion with the administration of fludrocortisone, application of constrictive garments to the lower extremities, and the administration of an α-adrenoreceptor stimulator midodrine. Bulbar dysfunction and laryngeal stridor can be fatal if not treated.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1768.
Treatment of Shy-Drager syndrome consists of intravascular volume expansion with the administration of fludrocortisone, application of constrictive garments to the lower extremities, and the administration of an alpha-adrenoreceptor stimulator midodrine.
351. A 24-year-old yard maintenance worker is bitten by a venomous snake. Which of the following is considered acceptable treatment?
A) Arterial tourniquet
B) Application of ice
C) Wound incision and forced bleeding
D) Lymphatic tourniquet
E) None of the above
Answer and Discussion
The answer is D. Poisonous snakebites, although rare, are a potentially life-threatening emergency in the United States. Rattlesnakes are responsible for most snakebites and related fatalities. Venomous snakes in the United States can be classified as having hemotoxic or neurotoxic venom. Associated signs and symptoms ranging from fang marks, with or without local pain and swelling, to life-threatening coagulopathy, renal failure, and shock are seen. First-aid techniques such as arterial tourniquets, application of ice, and wound incisions are ineffective and can be harmful; however, suction with a venom extractor within the first 5 minutes after the bite may be useful. Conservative measures, such as immobilization and lymphatic constriction bands, are now advocated until emergency care can be administered. Equine-derived antivenin is considered the standard of care; however, a promising new treatment is sheep-derived antigen binding fragment ovine (CroFab), which is much less allergenic. Surgical intervention with fasciotomy is now reserved for rare cases. Snakebite prevention should be taught to patients.
Juckett G, Hancox JG. Venomous snakebites in the United States: management review and update. Am Fam Physician. 2002;65:1367–1374.
352. Which of the following statements is true regarding low-carbohydrate diets?
A) They may be more effective than low-fat diets in helping patients lose weight in the short term.
B) They cause adverse changes in lipid values.
C) They are often effective years after initiation.
D) They invariably lead to longer healthier lives.
Answer and Discussion
The answer is A. A low-carbohydrate diet can help patients lose more weight in the short term than a conventional low-fat diet. Although a low-carbohydrate diet does not cause adverse changes in lipid levels, it may not help patients live longer, better lives, which is the goal of diet therapy. There appears to be a diminishing benefit after 12 months.
Samaha FF, Iqbal N, Seshadri R. A low-carbohydrate as compared with a low-fat diet in severe obesity. N Engl J Med. 2003;348:2074–2081.
Foster GD, Wyatt HR, Hill J. A randomized trial of a low-carbohydrate diet for obesity. N Engl J Med. 2003;348:2082–2090.
353. A 42-year-old indigent patient is found to have secondary syphilis and treatment is started. Two hours after his first dose of antibiotics, the patient is noted to have low-grade fever, chills, myalgias, headache, tachypnea, and tachycardia. Appropriate management at this point consists of
A) stopping all antibiotics
B) ordering ECG, chest x-ray, blood cultures, and urinalysis
C) starting intravenous dexamethasone
D) administering acetaminophen for symptomatic treatment
E) administering diphenhydramine and epinephrine
Answer and Discussion
The answer is D. The Jarisch-Herxheimer reaction is usually a mild reaction consisting of acute, transient fever (low grade), chills, myalgias, headache, tachycardia, increased respiratory rate, increased circulating neutrophil count (average total white blood cell count, 12,500/µL), and vasodilation with mild hypotension that may follow the initiation of treatment for syphilis or other spirochete-related illness. This reaction occurs in approximately 50% of patients with primary syphilis, 90% of those with secondary syphilis, and 25% of those with early latent syphilis. The onset comes within 2 hours of treatment, the temperature peaks at approximately 6 to 8 hours, and defervescence takes place within 12 to 24 hours. The reaction is more delayed in neurosyphilis, with fever peaking after 12 to 14 hours. In patients with secondary syphilis, erythema and edema of the mucocutaneous lesions increase; occasionally, subclinical or early mucocutaneous lesions may first become apparent during the reaction. The pathogenesis of this reaction is undefined, although recent studies have demonstrated the induction of inflammatory mediators such as tumor necrosis factors by treponemal lipoproteins. Patients should be warned to expect such symptoms, which can be managed by symptomatic treatment. Adjunctive steroid and anti-inflammatory therapy has not been shown to prevent the Jarisch-Herxheimer reaction in syphilis and is not recommended for this transient reaction.
Lukehart SA. Chapter 153: Syphilis. Available at Harrison's Online website (http://www.harrisonsonline.com). Accessed 6/1/06.
The Jarisch-Herxheimer reaction is usually a mild reaction consisting of acute, transient fever (low grade), chills, myalgias, headache, tachycardia, increased respiratory rate, increased circulating neutrophil count (average total white blood cell count, 12,500/µL), and vasodilation with mild hypotension that may follow the initiation of treatment for syphilis or other spirochete-related illness.
354. You are covering the local high school football game on Friday night. An 18-year-old star running back goes down on the field after a hard tackle. When you arrive at his side, he is holding his knee. He describes a “pop” followed by severe pain. Which of the following would be most helpful in the initial diagnosis?
A) Ability to walk
B) Lachman's test
C) Anterior drawer test
D) CT of the knee
E) Arthrogram of the knee
Answer and Discussion
The answer is B. ACL injuries typically present after a noncontact deceleration, a “cutting” movement or hyperextension, often accompanied by a “pop,” with the inability to continue sports participation and associated knee instability. In all cases of knee injury it should be determined how quickly swelling occurred after the injury. If an effusion evolved within 4 hours of injury, there is a high likelihood of major osseous, ligamentous, or meniscal injury. The ACL is particularly prone to injury. Physical findings include effusion, positive ACL tests, and chronic quadriceps atrophy. The Lachman's test is performed with the knee in 20 degrees of flexion. The tibia is pulled anteriorly on a secured femur. A positive test result is indicated by increased tibial movement compared with the unaffected knee. The quality of the end point should also be noted; a soft end point indicates an ACL tear. The anterior drawer test (although much less specific) is performed with the knee in 90 degrees of flexion. Similar to the Lachman's test, the tibia is drawn anteriorly, and asymmetric movement is an indicator of ACL injury. The most specific test for ACL disruption is the pivot shift test, but this test is often difficult to perform because of patient guarding and apprehension. Radiographs should be obtained in patients with suspected ACL injuries to rule out associated intra-articular fractures and possibly determine the presence of a marginal avulsion fracture off the lateral tibial plateau (Segond fracture), which helps confirm the diagnosis. MRI is not necessary to diagnose ACL disruption but is often used and may be helpful in diagnosing associated meniscal pathology. Treatment involves rehabilitation with physical therapy and, in some cases, surgical repair.
Johnson MW. Acute knee effusion: a systematic approach to diagnosis. Am Fam Physician. 2000;61:2391–2400.
355. A 78-year-old retired carpenter presents to your office complaining of gradually increasing right-sided shoulder pain. The patient reports he is unable to sleep on his right side and has a difficult time raising the right arm. Physical examination shows his shoulder's range of motion is significantly restricted. X-rays of the shoulder show osteopenia of the humeral head. The most likely diagnosis is
A) biceps muscle tear
B) adhesive capsulitis
C) multiple myeloma
D) subacromial bursitis
E) osteoporosis
Answer and Discussion
The answer is B. Adhesive capsulitis, or frozen shoulder, results from thickening and contraction of the capsule around the glenohumeral joint and causes loss of motion and pain. Frozen shoulder classically consists of shoulder pain that is slow in onset and presents without any radiographic abnormalities. Usually the discomfort is localized near the deltoid insertion, the patient is unable to sleep on the affected side, and glenohumeral elevation and external rotation are restricted. Frozen shoulder most often occurs as a result of immobility after a shoulder injury. An autoimmune cause of frozen shoulder has been proposed. The diagnosis is usually made clinically, and physicians should always be concerned about a possible underlying rotator cuff tear. Radiographs often appear normal, although osteopenia of the humeral head may be noted as a result of disuse. Arthrography demonstrates generalized constriction of the joint capsule, with loss of the normal axillary and subscapularis spaces. The capsule can be dilated during arthrography, converting the procedure from a diagnostic to a therapeutic one. A carefully designed treatment plan for patients with frozen shoulder may include physical therapy, pain medication such as NSAIDs, and, occasionally, intra-articular corticosteroid injection. Surgical referral may be indicated after conservative treatment has failed, although the exact timing of surgery should be decided on an individual basis.
Woodward TW, Best TM. The painful shoulder: Part II. Acute and chronic disorders. Am Fam Physician. 2000;61:3291–3300.
356. During one rescuer CPR the ventilation/compression ratio should be
A) 1:1
B) 1:5
C) 1:10
D) 2:10
E) 2:30
Answer and Discussion
The answer is E. The new algorithm for adult basic life support recommends the following sequence when a rescuer finds an unresponsive person:
· Call for help and an AED (if available).
· Open the adult's airway, check for breathing, and give two breaths if he or she is not breathing.
· Start cycles of 30 compressions and two breaths (100 compressions/minute).
· On arrival of a defibrillator or AED, check for a shockable rhythm (ventricular fibrillation or tachycardia).
· Give one shock (if indicated), then resume CPR for another five cycles; if no shock is indicated, continue another five cycles of CPR before rechecking the rhythm.
Health-care professionals are to check for a pulse after the initial breaths (step 2) and continue with one rescue breath every 5 or 6 seconds if there is a pulse, but this step is not recommended for lay rescuers.
American Heart Association. 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2005;112(24 suppl):IV1–203.
357. Of the following supplements, which has been associated with an increased risk of lung cancer in smokers?
A) Folic acid
B) β Carotene
C) Ginseng
D) Vitamin E
E) Saw palmetto
Answer and Discussion
The answer is B. Many carotenoids are known, but their functions are not yet understood. β Carotene is a vitamin A precursor carried in plasma and LDL. It reduces oxidized LDL uptake but does not prevent LDL oxidation. Sources of dietary carotenoids include fruits, yellow-orange vegetables (e.g., carrots, squash, and sweet potatoes), and deep-green vegetables (e.g., spinach and broccoli). No recommended daily allowance has been established for carotenoids. Research supports the benefit of a carotenoid-rich diet, but not β carotene supplementation. The Beta-Carotene and Retinol Efficacy Trial combined β carotene and retinol supplementation in 18,314 smokers and patients with asbestos exposure. However, the study was terminated prematurely because of a significant increase in lung cancer mortality and a nonsignificant increase in CHD mortality. In 12 years of β carotene supplementation in 22,071 male physicians, no significant beneficial effects on CHD mortality, nonfatal myocardial infarction, or stroke were found. In addition, no interactive effect with cigarette smoking (i.e., no harm or benefit) was demonstrated. A nonsignificant reduction in CHD events occurred in the groups who had clinical evidence of atherosclerosis.
Forman D, Altman D. Vitamins to prevent cancer: supplementary problems [Editorial]. Lancet. 2004;364:1193–1194.
358. A urine culture grows more than 100,000 colony-forming units. The patient is asymptomatic. For which of the following patients is treatment indicated?
A) 94-year-old nursing home resident
B) 72-year-old business executive
C) 68-year-old with a history of breast cancer
D) 78-year-old scheduled for cataract surgery
E) 28-year-old pregnant woman at 38 weeks' gestation
Answer and Discussion
The answer is E. Asymptomatic bacteriuria is defined as the presence of >100,000 colony-forming units / mL of voided urine in persons with no symptoms of urinary tract infection. The largest patient population at risk for asymptomatic bacteriuria is the elderly (particularly women). Up to 40% of elderly men and women may have bacteriuria without symptoms. Although early studies noted an association between bacteriuria and excess mortality, more recent studies have failed to demonstrate any such link. Aggressively screening elderly persons for asymptomatic bacteriuria and subsequent treatment of the infection has not been found to reduce infectious complications or mortality. Consequently, this approach is currently not recommended. Three groups of patients with asymptomatic bacteriuria have been shown to benefit from treatment: (1) pregnant women, (2) patients with renal transplants, and (3) patients who are about to undergo genitourinary tract procedures. Between 2% and 10% of pregnancies are complicated by urinary tract infections; if left untreated, 25% to 30% of these women develop pyelonephritis. Pregnancies that are complicated by pyelonephritis have been associated with low-birth-weight infants and prematurity. Thus, pregnant women should be screened for bacteriuria by urine culture at 12 to 16 weeks of gestation. The presence of 100,000 colony-forming units of bacteria per milliliter of urine is considered significant. Pregnant women with asymptomatic bacteriuria should be treated with a 3- to 7-day course of antibiotics, and the urine should subsequently be cultured to ensure cure and the avoidance of relapse.
Orenstein R, Wong ES. Urinary tract infections in adults. Am Fam Physician. 1999;59(5):1235.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:317–318.
359. Which of the following statements is true regarding orolabial herpes?
A) Highest rate of infection occurs in adolescent children.
B) Lesions are usually painless vesicles that form on the tongue, palate, and gingival area.
C) Topical acyclovir is the drug of choice.
D) Recurrent infections are less severe and shorter in duration.
E) Pain associated with lesions typically lasts 2 to 3 weeks.
Answer and Discussion
The answer is D. Orolabial herpes (gingivostomatitis) is the most prevalent form of mucocutaneous herpes infection; 35% to 60% of White persons in the United States show serologic evidence of having been infected by herpes simplex virus (HSV)-1. African-American persons and persons from low-economic populations are infected earlier in life. Overall, the highest rate of infection occurs during the preschool years. Female gender, history of sexually transmitted diseases, and multiple sexual partners have also been identified as risk factors for HSV-1 infection. Primary herpetic gingivostomatitis usually affects children under the age of 5 years. It typically takes the form of painful vesicles and ulcerative erosions on the tongue, palate, gingiva, buccal mucosa, and lips. Edema, halitosis, and drooling may be present, and tender submandibular or cervical lymphadenopathy is not uncommon. Hospitalization may be necessary when pain prevents eating or fluid intake. Systemic symptoms are often present, including fever [38.4° to 40°C (101° to 104°F)], malaise, and myalgia. The pharyngitis and flu-like symptoms are difficult to distinguish from mononucleosis in older patients. The duration of the illness is 2 to 3 weeks, and oral shedding of the virus may continue for as long as 23 days. Recurrences typically occur 2 or 3 times per year. The duration is shorter and the discomfort less severe than in primary infections; the lesions are often single and more localized, and the vesicles heal completely by 8 to 10 days. Pain diminishes quickly in 4 to 5 days. UV radiation predictably triggers recurrence of orolabial HSV-1, an effect that, for unknown reasons, is not fully suppressed by acyclovir. Pharmacologic intervention is therefore more difficult in patients with orolabial infection.
Topical medication for HSV infection is generally not highly effective. In the treatment of primary orolabial herpes, oral acyclovir or valcyclovir can reduce the severity and duration of the outbreak. Standard analgesic therapy with acetaminophen or ibuprofen, careful monitoring of hydration status, and aggressive early rehydration therapy are usually sufficient to avoid hospitalization. Although long-term suppression of orolabial herpes has not been addressed by clinical trials, episodic prophylaxis has been studied because of the predictable trigger effect of UV radiation. Short-term prophylactic therapy with acyclovir may be desirable in some patients who anticipate intense exposure to UV light (e.g., skiers or those who work outdoors), although the clinical effect may vary. Early treatment of recurrent orolabial HSV infection with high doses of antiviral medication has been found to markedly decrease the size and duration of lesions.
Emmert EH. Treatment of common cutaneous herpes simplex infections. Am Fam Physician. 2000;61:1697–1704, 1705–1706, 1708.
360. Vegan diets differ from vegetarian diets in that
A) vegetarian diets can lead to iron deficiency
B) vegans avoid all animal products in their diets
C) vegan diets allow for consumption of eggs and their products
D) vegetarians rarely satisfy nutritional needs
Answer and Discussion
The answer is B. Vegetarian diets differ according to the degree of avoidance of foods of animal origin. According to the traditional definition, a vegetarian diet consists primarily of cereals, fruits, vegetables, legumes, and nuts; animal foods, including milk, dairy products, and eggs are generally excluded. Several less restrictive vegetarian diets may include animal flesh, eggs, or milk and dairy products. Vegan diets are more rigid in that all animal products, including eggs, milk, and milk products, are excluded from the diet. Some vegans do not use honey and may refrain from using animal products such as leather or wool. They also may avoid foods that are processed or not organically grown. Vegetarian diets usually satisfy nutritional needs for growth and development if they are carefully planned with attention to the following possible limiting nutrients: energy, protein, iron, zinc, calcium, vitamin D, vitamin B12 (cyanocobalamin), and dietary fiber.
Johnston PK. Vegetarians among us: Implications for health professionals. Top Clin Nutr. 1995;10:1.
Vegan diets are more rigid than vegetarian diets in that all animal products, including eggs, milk, and milk products, are excluded from the diet.
361. In assessing the risk of coronary artery disease (CAD), a diet with high levels of __________ would increase the patient's risk.
A) trans-fatty acids
B) polyunsaturated fatty acids
C) monounsaturated fatty acids
D) polysaccharides
Answer and Discussion
The answer is A. Diet plays an important role in the risk of coronary heart disease (CHD). Higher cholesterol levels show a consistent relationship with the incidence of CHD. The type of fat consumed appears to be more important than the amount of total fat. Based on current knowledge, trans-fatty acids increase risk of CHD, while polyunsaturated fat and monounsaturated fat decrease risk. Additionally, an increase in carbohydrates tends to reduce the serum level of high-density lipoprotein (HDL) cholesterol in addition to total and low-density lipoprotein (LDL) cholesterol. Thus, the reduction in CHD risk may be less than predicted by the effect of saturated fat alone on cholesterol levels. Diets with a high glycemic load also decrease the serum HDL concentration. The major sources of trans-fats include margarines and partially hydrogenated vegetable fats. These fats are present in many manufactured foods (e.g., store-bought bread and cookies). Another major source is oils that are maintained at high temperatures for a sustained period of time, such as in fast food restaurants where oils are used to fry meat and potatoes.
Trans fatty acids and coronary heart disease risk. Report of the expert panel on trans fatty acids and coronary heart disease. Am J Clin Nutr. 1995;62:655S.
Hooper L, Summerbell CD, Higgins JP, et al. Reduced or modified dietary fat for preventing cardiovascular disease (Cochrane Review). Cochrane Database Syst Rev. 2001;3:CD002137.
362. A 40-year-old woman who is otherwise healthy presents to your office complaining of a lump in her neck. On examination, she is found to have a firm 2-cm nodule associated with the left lobe of the thyroid gland. Appropriate management at this time includes
A) ultrasound of the thyroid
B) thyroid uptake scan
C) fine-needle aspiration
D) radiation ablation
E) surgical excision
Answer and Discussion
The answer is C. Thyroid nodules are frequently encountered by family physicians. The majority of these are benign; however, children and the elderly have a higher incidence of malignancy. Previous studies have found that the prevalence of thyroid carcinoma was similar (i.e., approximately 5%) in palpable and nonpalpable nodules. Nearly all single thyroid nodules should be evaluated with needle aspiration biopsy. Ultrasonographically guided fine-needle aspiration biopsy of thyroid nodules should be performed if the patient has a history of radiation to the head, neck, or upper chest or a family history of thyroid carcinoma; the diameter of the nodule is 1.0 cm or greater; or suspicious ultrasonographic characteristics are present. In the absence of these findings, follow-up every 6 to 12 months is appropriate, because most occult carcinomas are papillary and rarely aggressive. Calcifications associated with thyroid nodules suggest the presence of psammoma bodies, which are associated with papillary carcinoma. TSH-suppressive therapy for benign solitary thyroid nodules is controversial. The effectiveness of such therapy in reducing nodule size is uncertain. Suppressive therapy is more appropriate for younger patients. Older patients may experience a decrease in bone mineral density or increase the risk of atrial fibrillation and cardiac hypertrophy.
Welker MJ, Orlov D. Thyroid nodules. Am Fam Physician. 2003;67:559–566, 573–574.
363. Which of the following effects is associated with selective estrogen receptor modulators?
A) Estrogen-like effects on endometrium
B) Estrogen-like effects on lipids
C) Estrogen antagonistic effects on bone
D) Estrogen-like effects on the breast
E) Decreased risk of thromboembolic events
Answer and Discussion
The answer is B. Raloxifene (Evista) is a selective estrogen receptor modulator that produces estrogen-agonistic effects on bone and lipid metabolism and estrogen-antagonistic effects on uterine endometrium and breast tissue. Because of its tissue selectivity, raloxifene may have fewer side effects than are typically observed with estrogen therapy. The most common adverse effects of raloxifene are hot flushes and leg cramps. The drug is also associated with an increased risk of thromboembolic events. The beneficial estrogenic activities of raloxifene include a lowering of total and LDL cholesterol levels and an augmentation of bone mineral density. Raloxifene has been labeled by the U.S. FDA for the prevention of osteoporosis. Studies are also being conducted to determine its impact on breast and endometrial cancer reduction.
Selective estrogen receptor modulators. Washington, D.C.: American College of Obstetricians and Gynecologists, 2002. Accessed online May 27, 2005, at: http://www.ngc.gov/summary/ summary.aspx?ss=15&doc_id=3987.
364. A 68-year-old retired fisherman presents to your office complaining of a lesion that developed on the dorsal aspect of his hand over the last few months. Inspection of the lesion shows a dome-shaped lesion measuring 2 cm in diameter. The volcano-shaped lesion has a protruding mass of keratin. The most likely diagnosis is
A) basal cell carcinoma
B) keratoacanthoma
C) sebaceous cyst
D) malignant melanoma
E) dermatofibroma
Answer and Discussion
The answer is B. Keratoacanthoma appears as a skin-colored or pink smooth lesion that becomes dome-shaped during a period of very rapid growth. Onset is rapid; usually within 1 to 2 months the lesion reaches its full size. Common sites include the face, dorsum of the hands, and forearms. When mature, it is volcano-shaped, with protruding masses of keratin resembling lava. Classic keratoacanthoma is not malignant and regresses spontaneously, but atypical lesions may actually be squamous cell carcinoma. Many dermatopathologists include keratoacanthoma in the spectrum of squamous cell carcinoma. Total excision is the preferred treatment for most solitary keratoacanthomas. For smaller lesions, electrodesiccation and curettage or blunt dissection is sufficient. Mohs' surgery can be used in difficult areas, especially around the nose and ears. Alternative therapies include oral isotretinoin, topical (Effudex) and intralesional (Adrucil) fluorouracil, intralesional methotrexate (Rheumatrex), and intralesional 5-interferon alfa-2a (Roferon-A). Radiotherapy is an option for patients with recurrence or larger lesions.
Luba MC, Bangs SA, Mohler AM, et al. Common benign skin tumors. Am Fam Physician. 2003;67:729–738.
365. In a placebo-controlled trial involving 100 patients, 30 died during the study period (10 receiving active drug and 20 receiving placebo), giving a mortality of 20% with active drug versus 40% with placebo. The number needed to treat (NNT) is
A) 5
B) 10
C) 25
D) 50
E) 100
Answer and Discussion
The answer is A. The benefit of an intervention can be expressed by the “number needed to treat” (NNT). NNT is the reciprocal of the absolute risk reduction (the absolute adverse event rate for placebo minus the absolute adverse event rate for treated patients). From a practical standpoint, an NNT interpretation can be shown by the following statement: “This study suggests that I would have to treat five patients with a drug to prevent one death.” As an example, consider a placebo-controlled trial involving 100 patients. Thirty patients died during the study period (10 receiving active drug and 20 receiving placebo), giving a mortality rate of 20% with active drug [10 divided by (10 + 40)], versus 40% [20 divided by (20 + 30)] with placebo. The difference between these two rates, the “risk difference,” is used to calculate NNT.
40% minus 20% = 20% = 0.2
1 divided by 0.2 = 5
Thus, this study suggests that only five patients need to be treated with the drug (compared with placebo) to prevent one death.
Bonis PAL. Glossary of common biostatistical and epidemiological terms. Accessed from Up to Date 9/19/2005 at http://uptodateonline.com.
366. The test of choice for screening for hereditary hemochromatosis is
A) aspartate aminotransferase (AST)
B) serum ferritin
C) transferrin saturation
D) total iron
E) total iron binding capacity
Answer and Discussion
The answer is C. Initial screening of individuals with suspected iron overload and those over the age of 20 years who are first-degree relatives of known cases of hereditary hemochromatosis should be done by measurement of transferrin saturation after an overnight fast. Simultaneous serum ferritin determination increases the predictive accuracy for diagnosis of iron overload. Transferrin saturation is also the test of choice for screening the general adult population for iron overload states.
Tavill AS. AASLD guideline: diagnosis and management of hemochromatosis. Hepatology. 2001;33:1321.
367. Mad cow disease (bovine spongiform encephalopathy [BSE]) has symptoms similar to which of the following conditions?
A) Lyme disease
B) Syphilis
C) Chronic fatigue syndrome
D) Malaria
E) Creutzfeldt-Jakob disease
Answer and Discussion
The answer is E. The FDA Center for Veterinary Medicine is responsible for protection against animal feed that can affect the safety of derived human food. In recent years, the spread of BSE, the so-called mad cow disease, in foreign countries has prompted the Center for Veterinary Medicine to place restrictions on the production of several types of feed. The action was based on research indicating that BSE is transferred among cows through feed made from the rendered carcasses of cattle that contain a prion that has been linked to BSE. The seriousness of the problem was magnified by the emergence in the United Kingdom of the human illness “new-variant Creutzfeldt-Jakob disease,” which gave rise to a theory that BSE can be transferred to humans. Because of the potential risk of transmission, the Center for Veterinary Medicine has banned the use of mammalian tissues such as meat, bone meal, meat byproducts, and cooked bone marrow in feed for cattle and other ruminant animals. The implementation of the ban is verified through intensive inspection of rendering plants and feed manufacturers.
U.S. Food and Drug Administration. A proposed framework for evaluating and assuring the human safety of the microbial effects of antimicrobial new animal drugs intended for use in food-producing animals. Center for Veterinary Medicine. Available at: http://www.fda.gov/cvm. Accessed June 22, 2000.
368. Charcot foot is most commonly seen in patients with
A) gonorrhea
B) primary syphilis
C) rheumatoid arthritis
D) diabetes mellitus
E) neurofibromatosis
Answer and Discussion
The answer is D. First described in patients with tertiary syphilis, Charcot foot is now seen mostly in patients with diabetes mellitus. It is a condition of acute or gradual onset and, in its most severe form, causes significant disruption of the bony architecture of the foot. It often results in foot deformities and causes abnormal pressure distribution on the plantar surface, foot ulcers, and, in some cases, requires amputation. The exact pathogenesis is unknown, but underlying sensory neuropathy is nearly universal. Arteriovenous shunting due to autonomic neuropathy is also thought to play a role. Repeated unrecognized microtrauma or an identifiable injury may be the inciting factors of Charcot foot. Approximately 50% of patients with Charcot foot remember a precipitating event such as a slip or a trip, or they may have had unrelated surgery on the foot as an antecedent event. In approximately 25% of patients, a similar problem ultimately develops on the other foot. Clinical findings in patients with an acute Charcot process include warmth, erythema, and swelling, and the disease is often thought to be cellulitis. Pain and tenderness are usually absent because of sensory neuropathy, which is universal and is probably a component of the basic pathogenesis of the Charcot foot. However, because patients with Charcot foot may have some pain if the sensory loss is not complete, the presence of pain does not totally exclude the diagnosis. Such pain is always much less than would be expected for the severity of the clinical and /or radiographic findings. Although cellulitis should be considered in any patient with diabetes, missing the diagnosis of Charcot foot can be serious, because failure to initiate proper treatment of the Charcot foot can lead to total loss of function. Inappropriate treatment with antimicrobial therapy and even incision and drainage can lead to unnecessary complications. Minimal pain or the absence of pain (characteristic of a Charcot fracture) can lead patients and physicians to ignore this serious disease. The initial radiographic findings can be normal, making the diagnosis difficult, but if a Charcot foot is strongly suspected from the clinical presentation, treatment should be initiated and serial radiographs should be taken. The proper treatment for a hot, swollen foot in a patient with sensory neuropathy is immobilization. Most cases of Charcot foot can be treated nonsurgically with pressure-relieving methods such as total contact casting (TCC), which is considered to be the gold standard of treatment.
Sommer TC, Lee TH. Charcot foot: the diagnostic dilemma. Am Fam Physician. 2001;64:1591–1598.
While cellulitis should be considered in any patient with diabetes, missing the diagnosis of Charcot foot can be serious, because failure to initiate proper treatment of the Charcot foot can lead to total loss of function.
369. A 38-year-old describes severe rectal pain associated with pallor, diaphoresis, and tachycardia that lasts for only a few minutes. The pains occur mostly at night and are described as spasms. The most likely diagnosis is
A) thrombosed hemorrhoids
B) irritable bowel syndrome
C) ulcerative colitis
D) gay bowel syndrome
E) proctalgia fugax
Answer and Discussion
The answer is E. Proctalgia fugax is a unique anal pain. Patients with proctalgia fugax experience severe episodes of spasm-like pain that often occur at night. Proctalgia fugax may only occur once a year, or may be sporadic in waves of three or four times per week. Each episode lasts only minutes, but the pain is severe and may be accompanied by sweating, pallor, and tachycardia. Patients experience urgency to defecate, yet pass no stool. No specific etiology has been found, but proctalgia fugax may be associated with spastic contractions of the rectum or the muscular pelvic floor in irritable bowel syndrome. Other unproven associations are food allergies, especially to artificial sweeteners or caffeine. Reassurance that the condition is benign may be helpful, but little can be done to treat proctalgia fugax. Medications are not helpful, because the episode is likely to be over before the drugs become active. Sitting in a tub of hot water or, alternatively, applying ice may provide symptomatic relief. A low dose of diazepam (Valium) at bedtime may be beneficial in cases of frequent and disabling proctalgia fugax.
Pfenninger JL, Zainea GG. Common anorectal conditions: Part I. Symptoms and complaints. Am Fam Physician. 2001;63:2391–2398.
370. The procedure of choice for detecting osteomyelitis in diabetic foot ulcers is
A) plain films
B) CT scan
C) MRI
D) technetium bone scan
E) indium scan
Answer and Discussion
The answer is C. Although plain films of the feet are usually ordered initially, magnetic resonance imaging (MRI) is the imaging procedure of choice for osteomyelitis in diabetic foot ulcers. The following values for sensitivity and specificity were obtained in a study in which 19 patients with diabetic foot infection underwent all four of the following imaging studies; 9 had osteomyelitis on bone biopsy: MRI (88% and 100%), plain radiography (22% and 94%), technetium bone scan (50% and 50%), and indium scan (33% and 69%). MRI can show abnormal bone marrow signal, soft tissue masses, and cortical destruction characteristic of osteomyelitis. Unlike plain films, MRI can detect these changes early (within days) in infection. MRI also provides the anatomic detail, necessary when surgical debridement is required.
Croll SD, Nicholas GG, Osborne MA, et al. Role of magnetic resonance imaging in the diagnosis of osteomyelitis in diabetic foot infections. J Vasc Surg. 1996;24:266.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:317–318.
371. The BRCA genetic locus has been linked with all of following cancers except
A) breast cancer
B) ovarian cancer
C) prostate cancer
D) colon cancer
E) gastric cancer
Answer and Discussion
The answer is E. Discovered in the 1980s, BRCA1 is a gene on chromosome 17 that is known to be involved in tumor suppression. A woman with certain known mutations in BRCA1 has an increased risk for breast cancer and ovarian cancer. There is a higher risk in Ashkenazi Jewish women (most Jewish people in the United States are of this Eastern European origin). BRCA2 is another susceptibility gene for breast cancer and is found on chromosome 13. Mutations in BRCA2 confer an elevated breast cancer risk similar to that occurring with BRCA1 mutations. As with BRCA1, BRCA2 mutations are also found in a higher percentage of Ashkenazi Jewish women. Mutations in BRCA1 and BRCA2 are associated with early-onset breast cancer. As many as one-third of women under age 29 years with breast cancer carry a BRCA1 or -2 mutation, but only 2% of women ages 70 to 79 years with breast cancer carry such a mutation. Genetic studies in high-risk families suggest that BRCA1 and -2 mutations may account for 50% of inherited breast and ovarian cancers and are also associated with an increase in prostate and colon cancers. A task force organized by the National Institutes of Health and the National Human Genome Research Institute proposed recommendations for monitoring known carriers of BRCA1and -2 mutations. The consensus panel acknowledged the lack of proven benefit for early screening, but suggested that known carriers should begin performing monthly breast self-examinations at age 18 years and should begin having annual clinical examinations at age 25 years. Annual mammography was also recommended beginning at age 25 years. The panel noted that “insufficient evidence [exists] to recommend for or against prophylactic mastectomy.” Even this invasive procedure does not appear to provide definitive treatment, as cases have been reported of breast cancer occurring after bilateral mastectomies. Women who have a family history of breast cancer under age 50 years, two first-degree relatives with the disease, a male relative with breast cancer, or ovarian cancer in relatives under age 50 years are at increased risk for carrying a BRCA1 or -2 mutation. These women should be offered genetic counseling. Currently, the U.S. Preventive Services Task Force (USPSTF) recommends against routine referral for genetic counseling or routine breast cancer susceptibility gene (BRCA) testing for women whose family history is not associated with an increased risk for deleterious mutations in breast cancer susceptibility gene 1 (BRCA1) or breast cancer susceptibility gene 2 (BRCA2). Additionally, the USPSTF recommends that women whose family history is associated with an increased risk for deleterious mutations in BRCA1 or BRCA2 genes be referred for genetic counseling and evaluation for BRCA testing.
Burke W, Daly M, Garber J, et al. Recommendations for follow-up care of individuals with an inherited predisposition to cancer. II. BRCA1 and BRCA2. Cancer Genetics Studies Consortium. JAMA. 1997;277:997–1003.
U.S. Preventive Services Task Force (USPSTF). Genetic risk assessment and BRCA mutation testing for breast and ovarian cancer susceptibility. Ann Intern Med. 2005;143:355–361.
372. Which of the following statements regarding hepatitis C is correct?
A) Most patients are symptomatic with development of the disease.
B) The course of the disease shows no variability and is progressive.
C) Most patients develop chronic hepatitis.
D) The disease is not transferred through sexual contact.
E) Immune globulin is effective for post-exposure prophylaxis.
Answer and Discussion
The answer is C. Hepatitis C virus is the most common chronic blood-borne infection in the United States. The hepatitis C virus (HCV), identified in 1988 through molecular biologic techniques, is an enveloped RNA virus that is classified as a separate genus in the Flaviviridae family. The incubation period for newly acquired (acute) HCV infection ranges from 2 weeks to 6 months, with an average incubation period of 6 to 7 weeks. However, viral replication can be detected as early as 1 week after exposure. Of patients with acute HCV infection, 60% to 70% are asymptomatic; 20% to 30% have jaundice; and 10% to 20% have nonspecific symptoms such as loss of appetite, fatigue, and abdominal pain. The course of acute hepatitis C is variable, although its most characteristic feature is fluctuating, polyphasic ALT patterns. Normalization of ALT levels, which may occur, suggests full recovery, but is frequently followed by ALT elevations, indicating chronic liver disease. Most patients with acute HCV infection develop persistent infection; chronic hepatitis develops in an average of 70% of infected patients. No clinical features of the acute disease or risk factors for infection, including a history of percutaneous exposures, have been found to be predictive of chronicity. HCV is a blood-borne virus that is most efficiently transmitted through large or repeated percutaneous exposures to blood, such as transfusions or transplants from infected donors, inadvertent contamination of supplies shared among patients undergoing chronic hemodialysis, or sharing of equipment among injection drug users. Transmission of HCV may also occur through high-risk sex, perinatal exposure, percutaneous exposures in the health-care setting, or exposure to an infected household contact. The diagnosis of HCV infection can also be made through detection of HCV RNA using reverse transcriptase-polymerase chain reaction techniques. HCV RNA can be detected within 1 to 2 weeks after exposure to the virus, weeks before the onset of ALT elevations or the appearance of anti-HCV. In some patients, the detection of HCV RNA may be the only evidence of HCV infection. No tests are available to differentiate acute, chronic, and resolved infections, and the diagnosis of chronic hepatitis C is usually based on the presence of elevated ALT values in patients who are positive for anti-HCV. For anti-HCV-positive patients with a normal ALT value, the presence of ongoing liver inflammation should be assessed by monitoring serum ALT values several times over 6 to 12 months because abnormalities may be present only intermittently in patients with chronic hepatitis C. There is no vaccine to prevent HCV infection, and immune globulin is not effective for postexposure prophylaxis. A recent National Institutes of Health consensus conference recommended that all patients who have bridging hepatic fibrosis and moderate inflammation together with detectable viremia should receive treatment with pegylated interferon and ribavirin. These medications are very expensive and have significant side effects. Hematologic toxicities include anemia and leukopenia. These can be managed with close monitoring, use of growth factors, or dose reductions. Depression also can be caused or exacerbated by these medicines and may require treatment with a selective serotonin reuptake inhibitor, co-management with psychiatry, or cessation of pegylated interferon and ribavirin treatment. Contraception is imperative because ribavirin is highly teratogenic. Influenza-like symptoms of fatigue, nausea, and mild fevers can be helped by patient education and support including frequent office visits.
Moyer LA, Mast EE, Alter MJ. Hepatitis C: Parts I and II. Routine serologic testing and diagnosis, prevention counseling, and medical evaluation. Am Fam Physician. 1998;59:79–92.
Ward RP, Kugelmas M. Using pegylated interferon and ribavirin to treat patients with chronic hepatitis C. Am Fam Physician. 2005;72:655–662.
373. The most common cause of bacterial conjunctivitis in American adults is
A) Streptococcus pneumoniae
B) Haemophilus influenzae
C) Chlamydia trachomatis
D) Staphylococcus aureus
E) Klebsiella
Answer and Discussion
The answer is D. The conjunctiva is a thin, translucent, relatively elastic tissue layer with bulbar (outer aspect of the globe) and palpebral (inside of the eyelid) portions. Underneath the conjunctiva lie the episclera, sclera, and uveal tissue layers. Conjunctivitis is the most common cause of red eye. Most frequently, acute conjunctivitis is caused by a bacterial or viral infection. Sexually transmitted diseases such as chlamydia and gonorrhea are less common causes of conjunctivitis. Ocular allergy is one of the major causes of chronic conjunctivitis. Blepharitis (inflammation of the eyelid margin), dry eye, and the prolonged use of ophthalmic medications, contact lenses, and ophthalmic solutions are also frequent causes of chronic conjunctival inflammation. Adenovirus is by far the most common cause of viral conjunctivitis, although other viruses can also cause the condition. Viral conjunctivitis often occurs in community epidemics, with the virus transmitted in schools, workplaces, and physicians' offices. The usual modes of transmission are contaminated fingers, medical instruments, and swimming pool water. Patients with viral conjunctivitis typically present with an acutely red eye, watery discharge, conjunctival swelling, a tender preauricular node, and, in some cases, photophobia and a foreign-body sensation. Both eyes may be affected simultaneously, or the second eye may become involved a few days after the first eye. Some patients have an associated upper respiratory tract infection. Patients should be instructed to avoid direct contact with other persons for at least 1 week after the onset of symptoms. Treatment is supportive. Cold compresses and topical vasoconstrictors may provide symptomatic relief. Topical antibiotics are rarely necessary, because secondary bacterial infection is uncommon. The three most common pathogens in bacterial conjunctivitis are S. pneumoniae, H. influenzae, and S. aureus. Infections with S. pneumoniae and H. influenzae are more common in children, whereas S. aureus most frequently affects adults. Newer childhood immunizations for H. influenzae and S. pneumoniae further decrease the incidence of these causative organisms. Treatment requires good eyelid hygiene and the application of topical antibiotics. Empiric treatment with a topical medication is a safe and cost-effective approach in most patients with clinically mild acute bacterial conjunctivitis. Allergic conjunctivitis is distinguished by severe itching and allergen exposure. This condition is generally treated with topical antihistamines, mast-cell stabilizers, or anti-inflammatory agents. Pain and photophobia are not typical features of a primary conjunctival inflammatory process. If these features are present, the physician should consider more serious underlying ocular or orbital disease processes, including uveitis, keratitis, acute glaucoma, and orbital cellulitis. Similarly, blurred vision that fails to clear with a blink is rarely associated with conjunctivitis. Patients with pain, photophobia, or blurred vision should be referred to an ophthalmologist.
Morrow GL, Abbott RL. Conjunctivitis. Am Fam Physician. 1998; 57:735.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:889–894.
374. β- Blockers
A) are not associated with depression
B) are not associated with fatigue
C) do not produce sexual related side effects
D) have been found to have significant side effects that limit their use
Answer and Discussion
The answer is A. Depression, fatigue, and sexual dysfunction are commonly cited side effects of β-blockers, and may represent reasons why use of β-blockers is lower than expected for some approved indications. However, these associations are primarily based on flawed studies. Thus, although beta blockers appear to cause small increases in the risk of fatigue and sexual dysfunction, the risk is much lower than previously thought, and beta blockers should not be withheld based on concerns about developing these adverse effects. Additionally, there was no significant increased risk of reported depressive symptoms when taking β-blockers.
Ko DT, Hebert PR, Coffey CS, et al. Beta-blocker therapy and symptoms of depression, fatigue, and sexual dysfunction. JAMA. 2002;288:351.
375. Which of the following drugs is a leukotriene antagonist/inhibitor?
A) Theophylline
B) Prednisone
C) Salmeterol
D) Terbutaline
E) Zafirlukast
Answer and Discussion
The answer is E. Medications used in the treatment of asthma are divided into long-term control medications that are taken regularly and quick-relief (rescue) medications that are taken as needed to relieve bronchoconstriction rapidly. Long-term control medications include anti-inflammatory agents [i.e., corticosteroids, cromolyn sodium (Intal), nedocromil (Tilade), and leukotriene modifiers] and long-acting bronchodilators. Quick-relief medications include short-acting β2 agonists, anticholinergics, and systemic corticosteroids. Patients with persistent asthma require treatment with long-term control and quick-relief medications. Corticosteroids remain the most potent and effective anti-inflammatory agents available for the management of asthma. They are useful in treating all types of persistent asthma in patients of all ages. For long-term use, inhaled steroids are preferred over oral steroids, because the inhaled agents have fewer systemic side effects. Oral steroid therapy for long-term control is usually used only to treat refractory, severe, persistent asthma. Cromolyn and nedocromil are very safe agents with a mild to moderate anti-inflammatory effect. Both drugs inhibit the early- and late-phase asthmatic response to allergens and exercise. Nedocromil appears to be more effective than cromolyn in inhibiting bronchospasm induced by exercise, cold air, and provocative testing. Because of their excellent safety profiles, cromolyn and nedocromil are good initial long-term control medications in children and pregnant women with mild persistent asthma. Salmeterol (Serevent) is a long-acting β2 agonist. Its mechanism of action and side effect profile are similar to those of other β2 agonists. Unlike the short-acting agents, salmeterol is not intended for use as a quick-relief agent. It should not be used as a single agent for long-term control but instead should be used in combination with inhaled corticosteroids or other anti-inflammatory agents. Newer recommendations suggest limitation of its use in favor of inhaled corticosteroids. Albuterol (Proventil Repetabs, Volmax) is available as an oral, extended-release tablet for the long-term control of asthma. Like salmeterol, this long-acting β2 agonist is not intended to be used as a rescue medication. It is an alternative to sustained-release theophylline or inhaled salmeterol, especially in patients who have nocturnal asthma despite treatment with high-dose anti-inflammatory agents. Theophylline, once the mainstay of asthma treatment, is now considered a second- or third-line agent because of its adverse effect profile and potential interactions with many drugs. Furthermore, serum theophylline levels have to be monitored during treatment. In addition to its well-known bronchodilator effects, theophylline has anti-inflammatory activity. Currently, theophylline therapy is generally reserved for use in patients who exhibit nocturnal asthma symptoms that are not controlled with high-dose anti-inflammatory medications. Zafirlukast (Accolate) and zileuton (Zyflo) are two new drugs that antagonize the action of leukotrienes at their receptor (zafirlukast) or inhibit the lipoxygenase pathway (zileuton). Both drugs are approved for the management of chronic asthma in adults and in children older than 12 years. Zafirlukast and zileuton have numerous drug interactions. Short-acting inhaled β2 agonists are the agents of choice for relieving bronchospasms and preventing exercise-induced bronchospasms. Selective β2 agonists, including albuterol, bitolterol (Tornalate), metaproterenol (Alupent), pirbuterol (Maxair), and terbutaline (Brethaire), are preferred to nonselective β agonists such as epinephrine, ephedrine, and isoproterenol (Isuprel), because the selective agents have fewer cardiovascular side effects and a longer duration of action. Inhaled β2 agonists have a rapid onset of action. Short-term systemic corticosteroid therapy is useful for gaining initial control of asthma and for treating moderate to severe asthma exacerbations. The intravenous administration of systemic corticosteroids offers no advantage over oral administration when GI absorption is not impaired. Ipratropium (Atrovent) is a quaternary atropine derivative that inhibits vagal-mediated bronchoconstriction. It may be useful as an adjunct to inhaled β2 agonists in patients who have severe asthma exacerbations or who cannot tolerate β2 agonists.
Gross KM, Ponte CD. New strategies in the medical management of asthma. Am Fam Physician. 1998;58:89.
376. The most common primary cancer of the bone in adults is
A) multiple myeloma
B) osteosarcoma
C) osteoid osteoma
D) osteitis fibrosa cystica
E) metastatic prostate cancer
Answer and Discussion
The answer is A. Multiple myeloma is the malignant proliferation of plasma cells involving more than 10% of the bone marrow. Multiple myeloma is the most common primary cancer of the bones in adults. The median age at diagnosis of multiple myeloma is 62 years. Only 2% to 3% of cases are reported in patients younger than 30 years. African Americans in the United States are twice as likely to develop multiple myeloma as Whites.
The multiple myeloma cell produces monoclonal immunoglobulins that may be identified on serum or urine protein electrophoresis. Bone pain related to multiple lytic lesions is the most common clinical presentation. However, up to 30% of patients are diagnosed incidentally while being evaluated for unrelated problems, and one-third of patients are diagnosed after a pathologic fracture, commonly of the axial skeleton. Multiple myeloma must be differentiated from other causes of monoclonal gammopathy, including monoclonal gammopathy of undetermined significance, heavy chain disease, plasmacytoma, and Waldenstrom macroglobulinemia. Routine laboratory workup may show pancytopenia, abnormal coagulation, hypercalcemia, azotemia, elevated alkaline phosphatase and ESR, and hypoalbuminemia. Examination may reveal proteinuria, hypercalciuria, or both. Urine dipstick tests may not indicate the presence of Bence Jones proteinuria. All patients with suspected multiple myeloma require a 24-hour urinalysis by protein electrophoresis to determine the presence of Bence Jones proteinuria and kappa or lambda light chains. Serum protein electrophoresis identifies an M protein as a narrow peak or “spike” in the γ, β, or α2 regions of the densitometer tracing. Chemotherapy with melphalan and prednisone is the standard treatment for multiple myeloma. Other treatment modalities include polychemotherapy (thalidomide, immunomodulatory drugs, proteasome inhibitors) and bone marrow transplantation. Only 50% to 60% of patients respond to therapy. The aggregate median survival for all stages of multiple myeloma is 3 to 5 years.
George ED, Sadovsky R. Multiple myeloma: recognition and management. Am Fam Physician. 1999;59:1890.
377. A 21-year-old returns from a camping trip early complaining of a dull numbness affecting his upper left extremity. He recalls a sharp pinprick sensation before the development of symptoms. The patient now describes a cramping pain and muscle rigidity of the back and chest area. A red, indurated area is found on the distal left arm. The patient has profuse sweating, nausea, vomiting, and shortness of breath. The likely diagnosis is
A) Lyme disease
B) tick paralysis
C) malaria
D) black widow spider envenomation
E) Rocky Mountain spotted fever
Answer and Discussion
The answer is D. Black widow spider bites are associated with a sharp, pinprick-like pain, followed by a dull, sometimes numbing pain in the affected extremity and by cramping pain and muscular rigidity in the abdomen or the shoulders, back, and chest. Associated manifestations may include severe abdominal pain, restlessness, anxiety, sweating, headache, dizziness, ptosis, eyelid edema, rash and pruritus, respiratory distress, nausea, vomiting, salivation, weakness, and increased skin temperature over the affected area. Blood pressure and CSF pressure are usually elevated in more severe cases in adults. An ice cube may be placed over a black widow spider bite to reduce pain. Patients younger than 16 years or older than 60 years, those with hypertensive cardiovascular disease, or those with symptoms and signs of severe envenomation should be hospitalized and, when symptomatic treatment is unsuccessful, should be given antivenin. Antivenin must be given within 30 minutes and the manufacturer recommends skin testing prior to administration (however, skin testing does not always predict anaphylaxis). Children may require respiratory assistance. Vital signs should be checked frequently during the 12 hours after the bite. In the elderly, acute hypertension may require treatment. For muscle pain and spasms, intravenous calcium gluconate may be given slowly and requires cardiac monitoring. Several doses at 4-hour intervals may be necessary.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2649.
378. A 75-year-old man presents to your office complaining of flashes of light and blurred vision. He reports no pain. In-office examination reveals no findings other than decreased visual acuity. Appropriate management consists of
A) patching of the affected eye
B) course of oral steroids
C) ultrasound of the carotids
D) initiation of aspirin therapy
E) immediate ophthalmology referral
Answer and Discussion
The answer is E. Retinal detachment can occur as the result of a retinal tear (occurs more frequently in myopia, after cataract surgery, or after ocular trauma), by detachment without a tear as a result of vitreal traction (seen in proliferative retinopathy of diabetes or sickle cell disease), or by transudation of fluid into the subretinal space (e.g., severe uveitis or primary or metastatic choroidal tumors). Retinal detachment is painless. Early symptoms may include dark or irregular vitreous floaters, flashes of light, or blurred vision. As the detachment progresses, the patient notices a curtain or veil in the field of vision. If the macula is involved, central visual acuity is significantly affected. Direct ophthalmoscopy may show retinal irregularities and a retinal elevation with darkened blood vessels. Indirect ophthalmoscopy, including scleral depression, is necessary for detecting peripheral breaks and detachment. If a vitreous hemorrhage obscures the retina, especially in myopia, postcataract extraction, or eye injury, retinal detachment should be suspected and B-scan ultrasonography performed. Although often localized, retinal detachments due to retinal tears can expand to involve the entire retina if not treated promptly. Any patient with a suspected or established retinal detachment should be seen urgently by an ophthalmologist.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy. Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:919–920.
Retinal detachment is painless. Early symptoms may include dark or irregular vitreous floaters, flashes of light, or blurred vision. As the detachment progresses, the patient notices a curtain or veil in the field of vision.
379. Which of the following statements concerning diarrhea in the United States is true?
A) Diarrhea is defined as frequent stools with >30% of stool mass in liquid.
B) Traveler's diarrhea is caused by a virus in most cases.
C) Pathogens are not identifiable in 80% of cases of diarrhea.
D) The goal of treatment is eradication of the causative agent.
E) Resistance to antimicrobial agents is not a concern with treatment of diarrhea.
Answer and Discussion
The answer is C. Diarrhea is defined as watery or liquid stools, usually with increases in daily frequency and in total stool weight (e.g., >300 g/day). In Western countries, stool amounts are typically 100 to 300 g/day in healthy adults. Infants typically produce 10g/kg/day. The pathogens that commonly cause sporadic diarrhea in adults in developed countries are Campylobacter, Salmonella, and Shigella species; E. coli; Yersinia species; protozoa; and viruses. However, pathogens are not identifiable in more than one-half of cases. Traveler's diarrhea is caused by bacteria in approximately 80% of patients. Common pathogens are enterogenic E. coli, Salmonella, Shigella, Campylobacter, Vibrio, Yersinia, and Aeromonas species. Death from diarrhea is rare, but infants, elderly patients, and those in long-term care facilities are at greater risk. The goals of treatment include reducing the infectious period, length of illness, risk of transmission to others, risk of dehydration, and rates of severe illness. Empiric treatment of traveler's diarrhea shortened the length of illness, although it was occasionally associated with prolonged presence of the causative pathogen in the stool and the development of resistant strains. Empiric treatment of community-acquired diarrhea with ciprofloxacin shortened the length of illness by 1 to 2 days. Development of resistant strains occurred with the use of some antibiotics but not with others. Adverse effects were similar to those noted for traveler's diarrhea.
de Bruyn G. Infectious disease: diarrhea. West J Med. 2000;172:409–412.
Herbert ME. Medical myths. Measuring white blood cells in the stools is useful in the management of acute diarrhea. West J Med. 2000;172:414.
380. A 25-year-old HIV patient presents with pain associated with his gums. He has also noted bleeding of his gums when he brushes his teeth. The most likely severe complication of this condition is
A) necrotizing ulcerative gingivitis
B) plaque deposition
C) dental caries
D) glossitis
E) bacterial endocarditis
Answer and Discussion
The answer is A. HIV-infected persons may present with various periodontal diseases, from mild inflammation (HIV gingivitis) to localized acute necrotizing ulcerative gingivitis and from localized periodontitis to necrotizing stomatitis. Patients with HIV gingivitis present with a bright erythematous line along the gingival margin and complain of spontaneous bleeding. In acute necrotizing ulcerative gingivitis, the gingiva appears erythematous, with ulcerations of the papillae that become tender and bleed when teeth are brushed. Rapid bone and soft tissue loss and loosening teeth are characteristic of HIV periodontitis. Patients complain of “deep” pain, and the condition can rapidly progress to large areas of necrotizing stomatitis. Patients affected with HIV gingivitis should be referred to an oral surgeon for débridement, scaling, and curettage of the involved areas. This treatment is followed by administration of metronidazole (Flagyl), irrigation with povidone iodine, and daily mouth rinsing with chlorhexidine gluconate (Peridex). Because it may potentiate peripheral neuropathy, metronidazole should not be given to patients taking didanosine (Videx) or zalcitabine (Hivid). In these patients clindamycin (Cleocin) or amoxicillin may be used.
Moazzez AH, Alvi A. Head and neck manifestations of AIDS in adults. Am Fam Physician. 1998;57:1813.
381. Which of the following medications would be most effective to treat postmenopausal flushing?
A) Venlafaxine
B) Amitryptyline
C) Green tea
P.117
D) Trazadone
E) Propanolol
Answer and Discussion
The answer is A. The selective serotonin reuptake inhibitors (SSRIs) including paroxetine (Paxil) and venlafaxine (Effexor) have been used to relieve the symptoms of vasomotor instability (hot flushes) associated with menopause and are considered first line therapy in women who are not taking estrogen. Their efficacy has been demonstrated in a number of randomized trials.
Loprinzi CL, Kugler JW, Sloan JA, et al. Venlafaxine in management of hot flashes in survivors of breast cancer: a randomised controlled trial. Lancet. 2000;356:2059.
Stearns V, Beebe KL, Iyengar M, et al. E. Paroxetine controlled release in the treatment of menopausal hot flashes: a randomized controlled trial. JAMA. 2003;289:2827.
382. Patients with antithrombin deficiency are at increased risk for
A) myelodysplasia
B) thrombosis
C) multiple myeloma
D) vitamin K deficiency
E) bleeding complications while taking warfarin
Answer and Discussion
The answer is B. Antithrombin is a protein that inhibits thrombin and factors Xa, IXa, and XIa. Deficiency of plasma antithrombin is inherited in an autosomal-dominant fashion with a prevalence of approximately 0.2% to 0.4%; approximately one-half of these persons experience venous thrombotic episodes. Acquired deficiencies in antithrombin levels are observed in patients with acute thrombosis, disseminated intravascular coagulation, liver disease, or nephrotic syndrome and during heparin therapy, estrogen therapy (including contraceptive use), or L-asparaginase therapy. Homozygous deficiency is usually lethal to the fetus in utero. Laboratory screening involves quantification of plasma inhibition of thrombin in the presence of heparin. Oral anticoagulation with warfarin is highly effective prophylaxis for patients who have experienced or are at risk of thrombosis.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1082.
383. An essential tremor most commonly affects the
A) head
B) voice
C) tongue
D) legs
E) hands
Answer and Discussion
The answer is E. Tremor is a symptom of many disorders, including Parkinson's disease, essential tremor, orthostatic tremor, cerebellar disease, peripheral neuropathy, and alcohol withdrawal. Tremors may be classified as postural, rest, or action tremors. Symptomatic treatment is directed to the tremor type:
· Parkinson's tremor. The tremor in Parkinson's disease occurs at rest and is characterized by a frequency of 4 to 6 Hz and medium amplitude. It is classically referred to as a pill rolling tremor of the hands, but can also affect the head, trunk, jaw, and lips. Combination therapy with carbidopa and levodopa is commonly used for Parkinsonian tremor.
· Essential tremor. Essential tremor is the most common movement disorder. Its onset occurs anywhere between the second and sixth decades of life and its prevalence increases with age. The tremor is usually bilateral. The tremor is minimal or absent at rest. The tremor is slowly progressive over a period of years, and the specific pathophysiology of essential tremor remains unknown. Essential tremor occurs sporadically or can be inherited (in 50% of patients, inheritance is autosomal dominant). It most commonly affects the hands, but can also affect the head, voice, tongue, and legs. In many cases, essential tremor is alleviated by small amounts of alcohol, an effect not found in Parkinson's disease. Essential tremor may be amenable to propranolol or primidone.
· Other tremors. Propranolol may be useful in treating alcohol withdrawal tremor, and INH may control the cerebellar tremor associated with multiple sclerosis. Clonazepam may relieve orthostatic tremor. Other agents are also available for the treatment of tremor. When medical therapy fails to control the tremor, surgical options such as thalamotomy, pallidotomy, and thalamic stimulation should be considered in severe cases. Thalamic stimulation, the most recent of these surgical approaches, offers the advantage over ablative procedures of alleviating tremor without the creation of a permanent lesion.
Charles PD, Esper GJ, Davis TL, et al. Classification of tremor and update on treatment. Am Fam Physician. 1999;59:1565–1572.
384. Which of the following statements is true regarding firearm-related injuries?
A) The incidence has risen significantly over the last few years.
B) Most of the nonfatal injuries occurring in adult men ages 15 to 44 years were inflicted by others.
C) The rates for African-American and Hispanic individuals have decreased.
D) Law enforcement practices have not affected the incidence.
E) Increases in the cocaine market have attributed to increases in firearm injuries.
Answer and Discussion
The answer is C. The overall annual rates of nonfatal and fatal firearm-related injuries in the United States declined consistently from 1993 to 1997. The annual nonfatal rate decreased by 40.8%. The annual mortality rate also declined by 21.1%. The declines in the rates of nonfatal and fatal firearm-related injury were generally consistent across all population subgroups. The decreases in the rates of nonfatal and fatal injuries were similar in men and women. Declines in fatality rates in African Americans and Hispanics were similar and were both greater than the decline in non-Hispanic Whites. In the rates of nonfatal injury, no consistent pattern was seen in the estimated decline across age groups, but, in the rates of fatal injury, age and percentage change were inversely related. Most of the nonfatal injuries occurred among men 15 to 44 years of age; were self-inflicted; and were associated with hunting, target shooting, and routine gun handling.
Numerous factors may have contributed to the decline in the rates of nonfatal and fatal assaultive firearm-related injury. These factors include: improvements in economic conditions; the aging of the population; the decline in the “crack” cocaine market; changes in legislation, sentencing guidelines, and law-enforcement practices; and improvements associated with violence prevention programs.
American Academy of Family Physicians website. Morbidity and mortality related to firearm injuries. Available at: http://www.aafp.org/afp/20000401/clinical.html#5.Accessed 11/28/06.
Morbidity and Mortality Weekly Report website. Available at http://www.cdc.gov/mmwr/mmwr_wk.html.Accessed 11/28/06.
385. The Health Insurance Portability and Accountability Act (HIPAA) has recently been updated and calls for
A) mandatory health insurance for all people who earn less than $12,000/year
B) stringent codes for the uniform transfer of medically related data
C) health maintenance organizations to allow more diagnostic testing of patients and less scrutiny of physicians
D) all Americans to invest in a medical savings account
E) improved access of third parties to patients' medical records
Answer and Discussion
The answer is B. The HIPAA of 1996 (also known as the Kassenbaum-Kennedy legislation) has recently been implemented. HIPAA was signed into law in 1996, and includes the “portability” aspect of the law (which protects the ability of people with current or preexisting medical conditions to get health insurance) and the “accountability” aspects of the law (which include enforcement). Its multiple provisions include strict codes for the uniform transfer of electronic data, including billing and other routine exchanges, and new patient rights regarding personal health information, including the right to access this information and to limit its disclosure. Also outlined are specific physical, procedural, and technological security protections all health-care organizations must take to ensure the confidentiality of patients' medical information. The purpose of HIPAA is to improve the portability of health insurance coverage in the group and individual markets, focus on health-care fraud and abuse, promote the use of medical savings accounts, improve access to long-term care services and coverage, and simplify the administration of health insurance. The U.S. Department of Health and Human Services is developing new standards for the electronic transmission of health records and financial transactions, identifiers for individuals, health plans, employers and providers, code sets and classification systems, and security standards and safeguards. Once the standards are developed and implemented, failure to comply will result in fines and/or imprisonment. Every medical practice in the United States must comply with these regulations, including transaction standards (i.e., the rules standardizing electronic data exchange of health-related information).
Kibbe DC. What you need to know about HIPAA now. Fam Pract Manag. 2001;8(3):43.
The purpose of HIPAA is to improve the portability of health insurance coverage in the group and individual markets, focus on health care fraud and abuse, promote the use of medical savings accounts, improve access to long-term care services and coverage, and simplify the administration of health insurance.
386. The drug of choice for the treatment of chronic opioid dependence is
A) naloxone
B) bupropion
C) disulfiram (Antabuse)
D) methadone
E) diazepam
Answer and Discussion
The answer is D. Opioid dependence is a chronic, often relapsing, disorder that can be very challenging to treat. Between 500,000 and 1,000,000 Americans are believed to be opioid dependent at any point in time. Opioid-related disorders are more prevalent in men than in women by a ratio of up to 4:1. Opioid dependency is often linked to a history of drug-related criminal activity, antisocial personality disorder, and coexisting mood disorders, especially depression. Methadone is effective in reducing illicit narcotic use, retaining patients in treatment, and decreasing illegal drug use. Ongoing methadone maintenance decreases the risk of contracting and transmitting HIV, hepatitis B virus, and HCV and is considered a cost-effective intervention. Long-term methadone maintenance is more successful in averting relapse than shorter-term treatment. The goals of early treatment with methadone are to decrease withdrawal symptoms, diminish opioid craving, and arrive at a tolerance threshold, while preventing euphoria and sedation from overmedication. Detoxification is indicated when a patient demonstrates consistent, long-term abstinence and possesses adequate supportive resources (e.g., productive use of time, a stable home life). Patient acceptance of community resources for opiate addicts such as Narcotics Anonymous is a good prognostic sign. Narcotics Anonymous is also a useful tool in relapse prevention.
Krambeer LL, McNelly WV, Gabrielli WF, et al. Methadone therapy for opioid dependence. Am Fam Physician. 2001;63:2404–2410.
387. The use of anti-obesity medication is acceptable when the body mass index (BMI) is
A) >10 kg/m2
B) >20 kg/m2
C) >30 kg/m2
D) greater than the normal weight of the individual
E) more than the calculated fat percentage of the patient
Answer and Discussion
The answer is C. Obesity is epidemic in the United States and other industrialized nations. Obesity is defined as a BMI (BMI = weight in kg divided by height in m2) of 30 kg/m2 or more. There are three classes of severity:
· Class I (BMI of 30.0 to 34.9 kg/m2)
· Class II (BMI of 35.0 to 39.9 kg/m2)
· Class III (BMI of 40.0 kg/m2 or higher).
The age-adjusted prevalence rates of classes I, II, and III obesity in American adults are estimated to be 14.4%, 5.2%, and 2.9%, respectively. These estimates represent a substantial increase in the prevalence of all three obesity classes since the mid-1990s. Although behavior modification strategies are helpful for most obese patients, they do not guarantee long-term weight-loss maintenance. Without ongoing management, most or all of the weight patients lose can be regained within 3 to 5 years. This limitation contributes to the active development of pharmacologic approaches to obesity. Current guidelines consider pharmacotherapy to be an adjunct to lifestyle modification programs and are targeted toward at-risk patients (patients with a BMI of 30 or greater or a BMI of 27 or greater combined with medical comorbidities such as hypertension or insulin resistance).
· Noradrenergic drugs. One class of weight-loss medications is the noradrenergic drugs that affect weight loss by suppressing one's appetite. Some noradrenergic agents include phentermine resin (Ionamin), mazindol (Sanorex), phenylpropanolamine (Dexatrim, recently removed from the market), phendimetrazine (Plegine), and diethylpropion (Tenuate). When combined with dietary programs, these drugs produced modest short-term net weight losses compared with dietary changes and placebo. The FDA has not labeled any of these drugs for long-term treatment of obesity.
· Orlistat. Orlistat (Xenical) is an intestinal lipase inhibitor that has been approved by the FDA for long-term use. After 12 weeks of treatment with orlistat (360 mg/day), patients showed weight losses of up to 5 kg (11 lb), compared with 2- to 3-kg losses (4.4 to 6.6 lb) among patients in the placebo group. Weight losses appear to be dosage dependent, with lower dosages producing smaller weight losses. Flatus, oily stools, and diarrhea are common but usually resolve during the second year of treatment. Vitamin deficiencies can occur with its use, and a vitamin supplement is recommended.
· Sibutramine. Sibutramine (Meridia), which has been approved by the FDA for long-term treatment of obesity, is a centrally acting, specific reuptake inhibitor of norepinephrine and serotonin, thus having satiating and potential thermogenic effects. Several clinical studies of 12 to 52 weeks' duration showed weight losses of 4.7 to 7.6 kg (10.3 to 16.7 lb) in patients receiving sibutramine. Weight losses were dosage dependent and tended to plateau by the twenty-fourth week. Efficacy of sibutramine at 1 year has also been established. Patients taking 5-, 10-, and 15-mg daily dosages experienced dosage-related weight loss for up to 12 weeks, and all dosages were well tolerated. Common adverse effects are headache, dry mouth, insomnia, and constipation. The most common serious side effect is hypertension. Sibutramine should not be used with SSRIs and in patients with cardiovascular disorders, particularly poorly controlled hypertension.
Because of the inherent difficulties in treating obesity, physicians should attempt to develop continuous care programs emphasizing lifestyle modifications such as enduring changes in dietary and activity habits. Patients using behavior modification strategies to make these changes are more likely to succeed in long-term weight maintenance. Weight loss related to drug treatment is modest (5% to 10%) and occurs in the first 6 months. Medication appears to be more effective at maintaining weight loss.
Poston WSC, Foreyt JP. Successful management of the obese patient. Am Fam Physician. 2000;61:3615–3622.
388. Which of the following statements regarding onychomycosis is true?
A) The infection is caused by Trichophyton rubrum.
B) Fungi are responsible for 90% of nail dystrophies.
C) Ciclopirox (Penlac) is very effective for the treatment of onychomycosis.
D) Griseofulvin and ketoconazole are first-line medications for the treatment of onychomycosis.
E) Periodic testing of renal function is indicated with the use of antifungal medication.
Answer and Discussion
The answer is A. Onychomycosis (tinea unguium) is a fungal infection of the nail bed, matrix, or plate. Toenails are affected more often than fingernails. The infection is usually caused by T. rubrum, which invades the nail bed and the underside of the nail plate beginning at the hyponychium and then migrating proximally through the underlying nail matrix. Because fungi are responsible for only approximately one-half of nail dystrophies, the diagnosis of onychomycosis may need to be confirmed by potassium hydroxide preparation, culture, or histology. Psoriasis, lichen planus, contact dermatitis, trauma, nail-bed tumor, and yellow nail syndrome may be mistakenly diagnosed as onychomycosis. The FDA has approved ciclopirox (Penlac) nail lacquer for the treatment of mild to moderate onychomycosis caused by T. rubrum without involvement of the lunula. Although safe and relatively inexpensive, ciclopirox therapy is seldom effective. Triazole and allylamine antifungal drugs have largely replaced griseofulvin and ketoconazole as first-line medications in the treatment of onychomycosis. These agents offer shorter treatment courses, higher cure rates, and fewer relapses. Of the newer drugs, terbinafine (Lamisil), itraconazole (Sporanox), and fluconazole (Diflucan) are the most widely used. Liver enzyme monitoring is recommended before continuous medication therapy is initiated and every 4 to 6 weeks during treatment. Onychomycosis is expensive to treat. Costs include medications, procedures, laboratory tests, and health-care providers' time, as well as expenses associated with the management of adverse drug effects and treatment failures.
Rodgers P, Bassler M. Treating onychomycosis. Am Fam Physician. 2001;63:663–672, 677–678.
389. A 31-year-old man who enjoys scuba diving presents to your office after a dive complaining of severe back pain, loss of sensation around the trunk, and numbness of the legs. Appropriate management consists of
A) administration of acetazolamide
B) furosemide (Lasix) and fluid restriction
C) NSAIDs and narcotic pain medication
D) intravenous steroids
E) transfer to a facility with a recompression chamber
Answer and Discussion
The answer is E. Recreational scuba diving, which is defined as pleasure diving without mandatory decompression to a maximum depth of 130 feet, has become a popular activity since the mid-1980s. Although divers are concentrated along coastal regions, many others dive in inland lakes, streams, quarries and reservoirs, or fly to distant dive sites. Physicians practicing almost anywhere in the United States may see a patient with a dive-related injury or complaint. Injuries related to diving are usually mild and include ear-related complaints. Barotrauma to the middle or inner ear can occur during the descent or ascent phases of the dive and may cause vertigo and other neurologic symptoms. Middle-ear barotrauma of descent is the most common type of diving injury and may involve hemorrhage and rupture of the tympanic membrane. Symptoms include the acute onset of pain, vertigo, and conductive hearing loss. In severe cases (usually during ascent), increased pressure in the middle ear can cause reversible weakness of the facial nerve and Bell's palsy (facial baroparesis). The most severe illness related to diving is decompression illness (the “bends”). Neurologic decompression sickness can present with a wide spectrum of symptoms. A prodrome of malaise, fatigue, anorexia, and headache is common. The most severe presentation is partial myelopathy referable to the thoracic spinal cord. Patients complain of paresthesias and sensory loss in the trunk and extremities, a tingling or constricting sensation around the thorax, ascending leg weakness ranging from mild to severe, pain in the lower back or pelvis, and loss of bowel and/or bladder control. The neurologic examination often reveals monoparesis or paraparesis, a sensory level, and sphincter disturbances. However, neurologic examination also may be normal. The diagnosis of neurologic decompression sickness is clinical and should be suspected in any patient with a recent history of diving who has a consistent presentation. Flying shortly after a dive can precipitate symptoms. The initial management of neurologic decompression sickness requires transport to a recompression facility. The majority of recreational divers with neurologic decompression sickness have an excellent recovery after prompt recompression therapy.
Newton HB. Neurologic complications of scuba diving. Am Fam Physician. 2001;63:2211–2218, 2225–2226.
390. Which of the following may increase the risk of lung cancer in smokers?
A) Vitamin C
B) Vitamin E
C) Folate
D) β-Carotene
E) Vitamin D
Answer and Discussion
The answer is D. Research studies suggest that, although once thought to be protective against the development of malignancy, β-carotene actually increased the risk of lung cancer in smokers. The ATBC (Alpha-Tocopherol, Beta-Carotene) cancer prevention trial involved almost 30,000 male cigarette smokers in Finland; the patients given supplemental β-carotene for 5 to 8 years had an 18% increase in the incidence of lung cancer. The excess risk appeared to decline once supplements were discontinued.
The Alpha-Tocopherol Beta Carotene Cancer Prevention Study Group. The effect of vitamin E and beta carotene on the incidence of lung cancer and other cancers in male smokers. N Engl J Med. 1994;330:1029.
Research studies suggest that, although once thought to be protective against the development of malignancy, beta-carotene actually increased the risk of lung cancer in smokers.