Questions/Answers and Explanations
The following questions are designed to assess clinical problem-solving skills. For each option, select either “T” for true or “F” for false. All options are related to the specific clinical case provided. There is no penalty for guessing; however, if “T” and “F” are both marked, the response will be scored as incorrect.
Patient A
Options 1–11
A 55-year-old female has recently been divorced and has moved to the West Coast to assume a sales position after losing her job with another company. Her children are in college and the rest of her family is located on the East Coast. She is under considerable financial strain after her divorce and her supervisor has been inquiring about her multiple days of unexplained absenteeism. She is having difficulty sleeping and trouble concentrating and often feels anxious. Other than some chronic constipation she is otherwise healthy.
Which of the following disorders may be present?
1. Depression
2. Panic disorder
3. Schizophrenia
4. Substance abuse
5. Generalized anxiety
Which of the following would be indicated for treating this patient?
6. SSRI antidepressant
7. Exercise
8. Tricyclic antidepressant
9. Short-term hypnotic [e.g., zolpidem (Ambien)]
10. Counseling
11. A long-acting benzodiazepine
View Answer
Options 1–11
Answers: 1. T2. T3. F4. T5. T6. T7. T8. F9. T10. T11. F
This patient has undergone life events associated with major psychological stress including divorce, loss of job, relocation, and loss of support from friends and family. Based on her reported symptoms it is likely this patient may have depression, generalized anxiety with possible panic disorder, or substance abuse. Psychotic illness such as schizophrenia is unlikely. Appropriate treatment for this individual would include SSRI antidepressants. Because of her constipation a tricyclic antidepressant should be avoided. Other treatments may include regular exercise, a short term hypnotic to help establish a sleeping pattern, and counseling. Long acting benzodiazepines would not be appropriate at this time for this patient.
Moore DP, Jefferson JW. Handbook of Medical Psychiatry, 2nd ed. St. Loius: Mosby; 2004:176–177.
Tricyclic antidepressants can cause significant constipation.
Patient B
Options 12–26
A 6-month-old male infant is brought to your office by the parents for his 6-month well-child visit. The birth was a vacuum-assisted vaginal delivery. The child weighed 8 lb, 5 oz; Apgar scores were 8 and 9. The child has done well since delivery, and the parents have no concerns.
Which of the following developmental milestones are considered appropriate for this child's age?
12. Reaches and grasps objects
13. Sits alone without support
14. Crawls
15. Poor neck tone when pulled to a sitting position
16. Says “mama” and “dada”
Important anticipatory guidance recommendations at this age should include
17. advising the use of shoes
18. advising the use of an infant car seat
19. advising parents to keep a supply of ipecac syrup at home
20. advising parents to supplement feedings with whole milk
21. discussing the use of fluoride supplementation if indicated
Appropriate immunizations for the child would include
22. diphtheria-tetanus-acellular pertussis
23. polio immunization
24. measles-mumps-rubella
25. varicella
26. Pneumovax
View Answer
Options 12–26
Answers: 12. T13. T14. F15. F16. F17. F18. T19. T20. F21. T22. T23. T24. F25. F26. F
A 6-month well-child visit should consist of evaluation of developmental milestones. Appropriate development in the child would include reaching to grasp objects, rolling over, showing no head lag when pulled to a sitting position, sitting without support, bearing some weight on the lower extremities, playing with feet, and laughing, squealing, or babbling. Crawling is usually not accomplished until 9 months of age. Saying “mama” and “dada” discriminately occurs at approximately 10 months of age. Appropriate anticipatory guidance counseling should consist of the use of infant car seats, the availability of ipecac syrup at home, and the use of fluoride supplement if indicated. The use of shoes is not necessary, and whole milk should be added to the infant's diet after 1 year of age. Appropriate immunizations for this child should include diphtheria-tetanus-acellular pertussis, inactivated polio immunization,Haemophilus influenzae, hepatitis B vaccination, and pneumococcal 7–valent conjugate vaccine (Prevnar). Measles-mumps-rubella (MMR) immunization is given at 12 to 15 months, and varicella is given after 1 year of age. Pneumococcal (Pneumovax 23) polysaccharide isolate vaccination is not given to children who are younger than 2 years old.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: Saunders; 2004:1174–1184.
Saying “mama” and “dada” discriminately occurs at approximately 10 months of age.
Patient C
Options 27–41
A 3-year-old girl is brought to your office by her parents. They report that the patient has been complaining of left-sided ear pain over the last 24 hours. She has had a nonproductive cough and runny nose over the last week but has had no diarrhea or vomiting. Physical examination includes the following:
· General: Child is clinging to mother but appears alert.
· Ears: Erythematous, bulging tympanic membrane is noted on left with decreased mobility; right tympanic membrane appears unremarkable.
· Nose: Dry, crusted yellow mucus is present.
· Mouth: Membranes are moist; tonsils and pharynx are mildly erythematous; there are no exudates.
· Neck: Supple bilateral lymphadenopathy is present.
· Heart: Regular rate and rhythm.
· Lungs: Scattered rhonchi, no wheezing.
· Abdomen: Soft, nontender; no organomegaly.
Appropriate management of this child consists of
27. reassuring parents and continuing observation without further medical therapy
28. oral antibiotics for 10 days
29. analgesic ear drops
30. lumbar puncture with examination of cerebrospinal fluid
31. immediate hospitalization
After treatment, the child returns to the physician on three occasions in the next 6 months with similar symptoms.
Appropriate management at this time includes
32. antibiotic prophylaxis continued through the respiratory illness season
33. tympanocentesis
34. referral to an allergy specialist
35. hospitalization for intravenous antibiotic treatment
36. referral to ear-nose-throat specialist for tympanostomy tube placement
Complications of otitis media include
37. perforation of the tympanic membrane
38. hearing loss
39. mastoiditis
40. cholesteatoma formation
41. facial nerve paralysis
View Answer
Options 27–41
Answers: 27. F28. T29. T30. F31. F32. T33. F34. F35. F36. F37. T38. T39. T40. T41. T
Acute otitis media is a problem that is commonly encountered in a family physician's office. Symptoms include ear pain, fever, hearing loss, vomiting, and diarrhea and are commonly preceded by upper respiratory symptoms. The classic findings of acute otitis media, such as fever and earache, are sometimes absent even in cases confirmed by tympanocentesis. A bulging, red, immobile tympanic membrane is highly associated with acute otitis media. However, many physicians rely on redness of the eardrum as the main diagnostic clue. Crying (most young children cry when their ears are examined), removal of cerumen with associated irritation of the auditory canal, and fever can all cause redness of the eardrum in the absence of middle ear infection. Common bacterial organisms that are responsible for otitis media in this age group are Streptococcus pneumoniae (40% to 50%), H. influenzae (20% to 25%), Moraxella catarrhalis (10% to 15%), group A Streptococcus (2%), and enteric gram-negative bacteria (1%). Mycoplasma pneumoniae and various viruses are other causative agents. Acute otitis media is defined by the presence of symptoms of acute illness and signs (full or bulging) of a tympanic membrane under positive pressure. Otitis media with effusion is defined by the absence of symptoms and signs of acute infection (other than reduced hearing) and the presence of signs (retracted or neutral position) of a tympanic membrane under negative pressure or no pressure and fluid in the middle ear space. Antibiotics are traditionally indicated for acute otitis media but can often be appropriately deferred if otitis media with effusion is present. Treatment consists of antibiotic coverage (amoxicillin, trimethoprim-sulfamethoxazole, erythromycin-sulfisoxazole) given orally for 5 to 10 days (10 days being standard). Amoxicillin remains the antibiotic of first choice, although a higher dosage (80 mg/kg/day) may be indicated to ensure eradication of resistant S. pneumoniae. Oral cefuroxime or amoxicillin-clavulanate and intramuscular ceftriaxone are suggested second-line choices for treatment failure. Risk factors for resistant pathogens include recent antibiotic treatment of acute otitis media, children in daycare facilities, wintertime infections, and acute otitis media in children who are younger than 2 years of age. Compliance with antibiotic regimens is enhanced by selecting agents that require less frequent dosing (such as 1 or 2 times a day) and by prescribing shorter (5 days) treatment courses. Selective use of tympanocentesis if the patient does not respond to empiric therapy can help to confirm the diagnosis and guide effective therapy. Analgesic eardrops or oral analgesics may help to alleviate the patient's discomfort. Recurrent otitis media (three or more episodes in 6 months or four episodes in 1 year) can be treated with prophylactic antibiotics (amoxicillin, sulfisoxazole) and continued through the respiratory illness season. Recurrent otitis media despite prophylactic therapy requires evaluation by an ear-nose-throat specialist; tympanostomy tube placement may be needed. Complications of otitis media include perforation of the tympanic membrane, hearing loss, mastoiditis, meningitis, epidural abscess formation, cholesteatoma formation, facial nerve paralysis, language delay, labyrinthitis, lateral sinus thrombosis, and otic hydrocephalus.
Pichichero ME. Acute otitis media (Pt I). Improving diagnostic accuracy. Am Fam Physician. 2000;61:2051–2056.
Pichichero ME. Acute otitis media (Pt II). Treatment in an era of increasing antibiotic resistance. Am Fam Physician. 2000;61:2410–2416.
Risk factors for resistant pathogens in otitis media include recent antibiotic treatment, children in daycare facilities, wintertime infections, and acute otitis media in children who are younger than 2 years of age.
Patient D
Options 42–51
A 72-year-old previously healthy man presents to the emergency room with sudden onset of left-sided paralysis. The patient's wife reports that he was watching television when his symptoms began. The patient is confused, with a facial droop and increased reflexes on the left. Blood pressure is 190/108 mm Hg.
Appropriate initial management of this patient includes
42. laboratory tests, including complete blood cell count (CBC) with differential, electrolytes, and coagulation studies (prothrombin time: international normalized ratio and partial thromboplastin time)
43. immediate treatment with sublingual nifedipine to lower blood pressure to <140/90 mm Hg
44. initiation of intravenous heparin
45. emergent computed tomography (CT) scan of the head
46. electrocardiogram
Further studies confirm the presence of an evolving nonhemorrhagic cerebrovascular accident.
Appropriate treatment at this point consists of
47. hospitalization with telemetry monitoring
48. initiation of intravenous heparin
49. transesophageal echocardiogram
50. carotid ultrasound
51. neurologic consultation
View Answer
Options 42–51
Answers: 42. T43. F44. F45. T46. T47. T48. T49. T50. T51. T
The initial management of a cerebrovascular accident consists of ordering laboratory studies: CBC with differential, electrolytes, pulse oximetry or arterial blood gas, glucose, prothrombin time/international normalized ratio, partial thromboplastin time, chest radiograph, and electrocardiogram. Before consideration of anticoagulation, an emergent CT of the head (magnetic resonance imaging is more sensitive for detecting infarction or masses, but CT is preferred because of the difficulty of obtaining a magnetic resonance image emergently) is necessary to rule out hemorrhage. It is important to correct hypertension slowly and gently after a cerebrovascular accident to avoid extending the infarcted area as a result of decreased perfusion pressure. Sublingual nifedipine should not be used. Once the stroke is determined to be nonhemorrhagic, intravenous heparin can be initiated if the patient is a candidate for anticoagulation and has a low risk for development of a hemorrhage. In some cases, patients may be candidates for thrombolytic therapy. The patient should be hospitalized and monitored for arrhythmias on a telemetry bed. Also, a transesophageal echocardiogram can determine if cardiac thrombi have developed; a carotid ultrasound can determine if carotid occlusive disease is present. Angiography may be necessary to confirm a carotid lesion. A neurology consultation is appropriate, and a physical therapist can be involved to help with the patient's rehabilitation.
Papadakis MA, McPhee SJ. 2006 Current Consult Medicine. New York: Lange/McGraw-Hill; 2006:212–213.
It is important to correct hypertension slowly and gently after a cerebrovascular accident to avoid extending the infarcted area as a result of decreased perfusion pressure.
Patient E
Options 52–62
A 42-year-old police officer presents to the emergency room complaining of left calf pain that has been present over the last 3 days.
Which of the following would be appropriate questions to be asked at the time of his evaluation?
52. Recent long flights?
53. Prolonged sitting?
54. Chest pain?
55. Shortness of breath?
56. Trauma associated with the leg?
57. Visual changes?
He is treated with anti-inflammatories and sent home. Ten days later he presents to your office complaining of shortness of breath. His vital signs include a respiratory rate of 26/min and a pulse of 115 bpm. Although he is having some respiratory distress, on examination you find his lungs are clear.
Appropriate tests at this time include
58. spiral CT of the lungs
59. sedimentation test
60. Factor 8 level
61. pulmonary function tests
62. pulmonary angiogram
View Answer
Options 52–62
Answers: 52. T53. T54. T55. T56. T57. F58. T59. F60. F61. F62. F
Risk factors for deep venous thrombosis (DVT) include prolonged sitting such as during long car rides or flights, surgery (especially orthopedic), family or personal history of coagulopathy, and malignancy. Symptoms often present with unilateral swelling usually of the lower extremity with or without discomfort. The major life threatening complication of DVT is pulmonary embolism. If a pulmonary embolus occurs patients may present with shortness of breath, tachypnea, chest pain, and tachycardia. The appropriate testing to order in this individual is a spiral CT of the lungs. Non-diagnostic pulmonary angiography can assist in confirming or alleviating the diagnosis but should be reserved until after a spiral CT is obtained.
Papadakis MA, McPhee SJ. 2006 Current Consult Medicine. New York: Lange/McGraw-Hill; 2006:280–281.
Risk factors for deep venous thrombosis (DVT) include prolonged sitting, such as during long car rides or flights; surgery (especially orthopedic); and family or personal history of coagulopathy and malignancy.
Patient F
Options 63–79
A 17-year-old girl (gravida 1, para 0) presents to your office for an initial obstetric visit. The patient is at 8 weeks' gestation and unmarried. She admits to multiple sexual partners over the last 6 months and does not know who is the father of the child; she has decided to give the baby up for adoption.
Appropriate laboratory tests include
63. CBC
64. urinalysis
65. ABO blood type
66. serum α-fetoprotein
67. hepatitis B surface antigen
68. human immunodeficiency virus (HIV) antibody testing
69. cytomegalovirus titers
Tests show that the mother is Rh negative. Appropriate management includes
70. repeat antibody screen at 26 weeks' gestation
71. administration of 300 mg Rho (D) immune globulin (RhoGAM) intramuscularly if no antibody is present
72. administration of 600 mg Rho (D) immune globulin intramuscularly if antibody is present
73. after delivery, check the fetal ABO/Rh type, and if the infant is Rh positive, the mother receives 300 mg Rho (D) immune globulin intramuscularly within 72 hours
74. a Kleihauer-Betke test if fetal-maternal hemorrhage occurs during pregnancy
You remain concerned that gestational diabetes may develop.
Which of the following are risk factors for the development of gestational diabetes?
75. Maternal age younger than 20 years
76. Obesity
77. Family history of diabetes mellitus
78. First pregnancy
79. Smoking
View Answer
Options 63–79
Answers: 63. T64. T65. T66. F67. T68. T69. F70. T71. T72. F73. T74. T75. F76. T77. T78. F79. F
Laboratory tests to be ordered with the first prenatal visit include a Papanicolaou smear, CBC, urinalysis and screen for bacteriuria, ABO blood type, antibody screen (indirect Coombs' test), Venereal Disease Research Laboratory (VDRL), rubella antibody titer, HIV testing, and hepatitis B surface antigen. When indicated, cervical cultures for gonorrhea and chlamydia should be ordered; in this case, because of the patient's multiple sexual partners, they should be included. The patient does not have risk factors for cytomegalovirus; thus, testing is unnecessary. A serum triple screen (α-fetoprotein, β–human chorionic gonadotropin, and estradiol) is measured at 15 to 20 weeks' gestation. Because of the patient's Rh-negative status, she needs repeat antibody screening at 26 weeks' gestation. If the test is negative, she should receive 300 mg Rho (D) immune globulin intramuscularly. If the test is positive for antibodies, she should be referred to a specialist. After delivery, it is important to check the fetal ABO/Rh type. If the infant is Rh positive, the mother should receive 300 mg Rho (D) immune globulin intramuscularly within 72 hours of delivery. If an Rh-negative mother has evidence of fetal maternal hemorrhage, a Kleihauer-Betke test should be obtained; this test measures the amount of fetal blood that has entered the maternal circulation. The dose of Rho (D) immune globulin that is required can then be calculated from this value. Risk factors for the development of gestational diabetes include maternal age older than 25 years, obesity, positive family history of diabetes, previous history of gestational diabetes, macrosomic infant or stillborn, and signs or symptoms of diabetes with glycosuria.
Cunningham FG, Gant NF, et al. Williams Obstetrics, 21st ed. New York: McGraw-Hill; 2001:1056, 984.
A serum triple screen (α-fetoprotein, β-human chorionic gonadotropin, and estradiol) is measured at 15 to 20 weeks' gestation.
Patient G
Options 80–89
A 62-year-old housewife with a history of depression and known diverticulosis presents to the emergency room complaining of vomiting, fevers, and left lower abdominal pain. Her last bowel movement was 4 days ago. Physical examination includes the following:
· Head, ears, eyes, nose, and throat: Oral mucosa dry, otherwise unremarkable
· Heart: Tachycardic
· Lungs: Clear to auscultation
· Abdomen: Soft, mildly distended; decreased, high-pitched bowel sounds; diffuse tenderness localized to the left lower abdomen with slight fullness noted
· Pelvis: Normal-appearing external genitalia, no cervical motion tenderness, no adnexal masses or tenderness
· Rectum: Positive hemorrhoids, stool guaiac positive
· Extremities: Unremarkable
· Neurologic: Nonfocal
Initial treatment of this patient should consist of
80. clear liquid diet only
81. morphine sulfate for pain control
82. contrast barium enema
83. administration of broad-spectrum intravenous antibiotics
84. colonoscopy
Three days after admission, the patient's condition has not improved, and she continues to have high fevers, left lower abdominal pain, and no bowel movements.
Appropriate management at this time includes
85. ultrasound of the liver, gallbladder, and pancreas
86. colonoscopy
87. CT scan of the abdomen
88. upper gastrointestinal series with small bowel follow-through
89. surgical consultation
View Answer
Options 80–89
Answers: 80. F81. F82. F83. T84. F85. F86. F87. T88. F89. T
The diagnosis of diverticulitis is suggested by abdominal pain that is initially hypogastric but then localizes to the left lower quadrant. Urinary symptoms may occur if the affected colonic segment is close to the bladder. A lower quadrant abdominal or rectal mass may be palpated, but associated rectal bleeding is uncommon and suggests an alternative diagnosis. Other symptoms include fever, constipation, or frequent defecation. Approximately 85% of cases of acute diverticulitis involve the descending or sigmoid colon; however, right-sided disease may also occur and is reported more frequently in persons of Asian descent. Abscess formation can occur and lead to bowel obstruction, which is characterized by vomiting, decreased or high-pitched bowel sounds, inadequate response to broad-spectrum antibiotic administration, and lack of bowel movements or flatulence. Previously, diverticular disease was diagnosed using a contrast barium enema. However, because of the possibility of an obstructing fecolith being dislodged by insufflation and causing bowel perforation, CT scanning is now the diagnostic procedure of choice. Besides being safe and cost effective, CT can also be used to assist percutaneous drainage of an abscess. Treatment of diverticulitis can take place on an outpatient basis for a patient with a mild first attack who is able to tolerate oral hydration and an antibiotic. Treatment consists of a liquid diet and 7 to 10 days of therapy with broad-spectrum antimicrobials such as metronidazole and ciprofloxacin. Patients with more severe illness (as seen in the example), those who cannot tolerate oral hydration, or those who have pain that is severe enough to require narcotic analgesia should be hospitalized. Patients should receive nothing by mouth and should be treated with intravenous triple therapy consisting of ampicillin, gentamicin, and metronidazole. Alternative monotherapy includes piperacillin or tazobactam. If narcotics are required for pain control, meperidine is recommended because morphine sulfate can lead to colonic spasm. If pain, fever, and leukocytosis do not resolve within 3 days, further imaging studies are indicated. If an abscess is present and is >5 cm in size, CT-guided drainage and adequate antibiotic coverage should be considered. Colonoscopy is generally not indicated in the initial treatment of diverticulitis. Complications of diverticular disease include bowel perforation and fistula formation. Bowel resection is usually recommended for recurrent episodes of diverticulitis or if fistulas are present. Resection with primary anastomosis is now the procedure of choice unless generalized peritonitis has occurred, in which case a two-stage procedure is usually necessary. Rarely is the older three-stage Hartmann's procedure required.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:1795–1796.
The diagnosis of diverticulitis is suggested by abdominal pain that is initially hypogastric, but then localizes to the left lower quadrant.
Patient H
Options 90–104
A 17-year-old woman is brought to the emergency room after taking an overdose of acetaminophen. The patient's family reports that she has been distraught over the recent breakup with her boyfriend. On arrival, her vital signs are stable, and she is alert and oriented. Physical examination is unremarkable. Laboratory tests, including liver function tests and serum creatinine, are normal.
Initial management of this patient in the emergency room should consist of
90. gastric lavage
91. administration of sodium bicarbonate
92. administration of charcoal
93. administration of ipecac syrup
94. reassurance to the patient and family, with discharge home and close follow-up
95. hospitalization in a monitored bed
Four hours after ingestion a plasma acetaminophen assay is drawn. A significantly high value of 250 µg/mL is obtained.
Appropriate treatment should consist of
96. administration of intravenous deferoxamine
97. oral administration of acetylcysteine
98. intravenous steroids
99. hemodialysis
100. forced diuresis
The most common complications that are associated with acetaminophen toxicity include
101. renal failure
102. hepatic failure
103. tinnitus
104. peripheral neuropathy
View Answer
Options 90–104
Answers: 90. T91. F92. T93. F94. F95. T96. F97. T98. F99. F100. F101. F102. T103. F104. F
Acetaminophen toxicity is a potentially life-threatening condition. An oral dose of acetaminophen of ≥150 mg/kg in a child is considered toxic. In adults, ≥150 mg/kg acetaminophen or a total dose of 7.5 g, regardless of the mg/kg amount, is considered toxic. Symptoms are usually mild until 48 hours or more after ingestion and include abdominal symptoms as well as nausea and vomiting. Treatment at home can be initiated with ipecac syrup to induce vomiting. Once patients reach the emergency room, they should undergo gastric lavage with administration of activated charcoal. They should be hospitalized in a monitored setting and observed closely. Acetaminophen levels should be measured 3 to 4 hours after ingestion and plotted on the Rumack-Matthew nomogram. If the plasma level is within the high-risk zone (≥150 µg/mL), the patient should receive acetylcysteine (Mucomyst) orally or by gastric tube. Intravenous administration has also been used, but the U.S. Food and Drug Administration has not approved this route, and it is not commercially available. Repeated doses should be given every 4 hours. Forced diuresis may be harmful and is not helpful. Hemodialysis is ineffective. The use of steroids, deferoxamine, and sodium bicarbonate is not included in the treatment of acetaminophen toxicity. The most common complication of acetaminophen toxicity is hepatic failure. Patients with fulminant hepatic failure are often candidates for liver transplantation.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2658–2660.
When treating an overdose acetaminophen levels should be measured 3 to 4 hours after ingestion and plotted on the Rumack-Matthew nomogram. If the plasma level is within the high-risk zone (≥150 µg/mL), the patient should receive acetylcysteine (Mucomyst).
Patient I
Options 105–121
An otherwise healthy 59-year-old factory worker presents with complaints of erectile dysfunction. His past medical history is significant for a prior appendectomy, mild hypertension, and benign prostatic hypertrophy. He denies any cardiac disease. He smokes 1 pack of cigarettes per day and drinks an occasional beer. His medications consist of terazosin (Hytrin) once daily. Occasionally, he has noted some low blood pressures but reports no syncopal or near-syncopal episodes.
An appropriate problem-focused exam should include
105. opthalmology evaluation
106. abdominal evaluation
107. evaluation of peripheral pulses
108. evaluation of pinprick sensation in the peripheral extremities
109. evaluation of deep tendon reflexes
Your findings are normal. Appropriate laboratory tests include:
110. fasting glucose level
111. lipid profile
112. erythrocyte sedimentation rate (ESR)
113. serum cortisol level
114. serum testosterone level
115. urinalysis
The laboratory tests come back normal. Which of the following may be indicated?
116. Sildenafil (Viagra)
117. Tadalafil (Cialis)
118. Vardenafil (Levitra)
119. Alprostadil (Muse)
120. Vacuum erection device (VED)
121. Monthly testosterone injections
View Answer
Options 105–121
Answers: 105. F106. T107. T108. F109. T110. T 111. T112. F113. F114. T115. T116. F117. F118. F119. F120. T121. F
The evaluation of erectile dysfunction can be conducted with a problem-focused examination that includes examination of the breast, penis, testes, hair distribution, palpation of the peripheral pulses, and testing of the genital and perineal sensation. Laboratory tests that should be conducted in a fasting state include a urinalysis, CBC, serum glucose, creatinine, lipid profile, and testosterone level. In this scenario the patient is taking an α-blocker for his hypertension and prostate related symptoms and because of his borderline low blood pressure would not be a good candidate for treatment with phosphodiesterase type 5 inhibitors (sildenafil, tadalafil, vardenafil) because of the potential to cause hypotension. Additionally, alprostadil can also cause hypotension and would not be a good selection. Monthly testosterone injections would not be indicated in this patient because there is no evidence of testosterone deficiency. Of the following choices listed, a vacuum erection device is the only suitable option.
Lue TF. Erectile dysfunction. N Engl J Med. 2000;342(24):1802–1813.
Kasper DL, Braunwald E, Fauci AS, et. al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:273, 2188.
The evaluation of erectile dysfunction can be conducted with a problem-focused examination that includes examination of the breast, penis, testes, hair distribution, palpation of the peripheral pulses, and testing of the genital and perineal sensation.
Patient J
Options 122–135
A 47-year-old woman presents to your office complaining of generalized fatigue, insomnia, the inability to concentrate, and a 10-lb weight gain over the last 6 months. Her husband, a local politician, recently told her that he has been having sexual relations with a young intern at his office. The wife reports that she is not suicidal but is under a great deal of stress. She has had frequent crying episodes and mood swings.
Appropriate initial evaluation for this patient includes
122. CT scan of the head
123. CBC
124. thyroid-stimulating hormone (TSH)
125. sleep study
126. neuropsychometric testing
Further testing is unremarkable. Appropriate treatment at this point includes
127. inpatient observation
128. psychiatric counseling
129. electroconvulsive shock treatment
130. initiation of diet and exercise program
131. initiation of antidepressant medication
Four weeks after a selective serotonin reuptake inhibitor (SSRI) is initiated, the patient presents to the emergency room with agitation, anxiety, confusion, tremors, tachycardia, hypertension, excessive salivation, and hyperthermia.
Appropriate treatment consists of
132. increasing the dose of antidepressant
133. applying cooling blankets
134. administering diazepam (Valium)
135. stabilizing the patient, lowering the dose of the SSRI, and adding a nonselective monoamine oxidase inhibitor
View Answer
Options 122–135
Answers: 122. F123. T124. T125. F126. F127. F128. T129. F130. T131. T132. F133. T134. T135. F
Depression is often manifested by symptoms such as depressed mood, loss of interest or pleasure in all or almost all activities, significant weight loss or gain, decreased appetite, insomnia or hypersomnia, fatigue, diminished ability to concentrate, or feelings of worthlessness. Appropriate initial evaluation of the patient would include a CBC to rule out anemia (which can cause fatigue) and a measure of TSH to rule out thyroid dysfunction (which could cause similar symptoms). A CT of the head, a sleep study, and neuropsychometric testing are not indicated. Appropriate treatment for this patient would include psychiatric counseling, regular exercise, diet modification, and initiation of an antidepressant medication. Serotonin syndrome is a condition that is associated with the use of selective SSRIs. Symptoms include altered mental status, anxiety, agitation, confusion, hyperreflexia, myoclonus, diaphoresis, hyperthermia, abnormal neuromuscular activity, salivation, diarrhea, tachycardia, and hypertension. Seizures and death may occur. Treatment consists of managing adequate airway, breathing, and circulation. The patient should be rapidly cooled in the setting of hyperthermia, and serotonin antagonists (e.g., benzodiazepines, cyproheptadine, propranolol, methysergide) should be administered. The concomitant use of fluoxetine and nonselective monoamine oxidase inhibitors has resulted in the serotonin syndrome. Because of the long half-life of fluoxetine (2 to 3 days) and its active metabolite norfluoxetine (half-life of 7 to 9 days), fluoxetine interactions theoretically can occur weeks after the drug is discontinued. It is generally accepted that all combinations of nonselective monoamine oxidase inhibitors and SSRIs are contraindicated.
Ament PW, Bertolino JG, Liszewski JL. Clinically significant drug interactions. Am Fam Physician. 2000;61:1745–1754.
Symptoms of serotonin syndrome include altered mental status, anxiety, agitation, confusion, hyperreflexia, myoclonus, diaphoresis, hyperthermia, abnormal neuromuscular activity, salivation, diarrhea, tachycardia, and hypertension. Seizures and death may occur.
Patient K
Options 136–145
You have been asked to perform sports physicals for the local high school football team. During these examinations, you discover a systolic murmur in a 16-year-old boy. The murmur becomes louder with Valsalva maneuver. The boy has neither cardiac symptoms nor a history of cardiac problems. He denies any family history of cardiac problems before the age of 50.
Appropriate management of this patient includes
136. reassurance to patient and parents with approval to play
137. recommendation of subacute bacterial endocarditis prophylaxis and limitation of the patient's playing time to one quarter per game
138. ordering a cardiolyte (sestamibi radionuclide) stress test
139. ordering an echocardiogram
140. allowing the patient to participate in noncontact sports only
Additional laboratory tests that should be checked include
141. electrolyte panel
142. fasting serum glucose
143. CBC
144. urinalysis
145. thyroid-stimulating hormone
View Answer
Options 136–145
Answers: 136. F137. F138. F139. T140. F141. F142. F143. F144. F145. F
Each autumn, family physicians perform sports examinations for athletic teams. In evaluating athletes, it is important to obtain an accurate history and to perform an adequate physical examination to determine if the patient is at risk during sports participation. The presence of a systolic murmur that becomes louder with Valsalva maneuver is a hallmark warning sign for hypertrophic obstructive cardiomyopathy, a potentially fatal condition that may affect young, seemingly healthy athletes. Evaluation of this finding should consist of an echocardiogram; if the condition is present, refer the patient to a cardiologist before allowing the athlete to participate in sports. Further laboratory testing is not recommended for sports examinations unless the history and physical examination suggest abnormalities; it is cost prohibitive, and there is a high rate of false-positive results.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2631, 2669.
The presence of a systolic murmur that becomes louder with Valsalva maneuver is a hallmark warning sign for hypertrophic obstructive cardiomyopathy, a potentially fatal condition that may affect young, seemingly healthy athletes.
Patient L
Options 146–155
A 65-year-old woman presents with a 20-lb weight gain over the last year, generalized fatigue, cold intolerance, dry skin, constipation, and problems with concentration. She denies being depressed but is concerned about her health.
Physical examination includes the following:
· Head, ears, eyes, nose, and throat: Unremarkable except for periorbital swelling
· Neck: Supple; thyroid unremarkable; no carotid bruits
· Heart: Regular rate and rhythm
· Lungs: Clear to auscultation
· Abdomen: Soft, nontender; no organomegaly
· Pelvis: Atrophic external genitalia; no adnexal masses or tenderness
· Rectum: Stool guaiac positive
· Extremities: Unremarkable
· Neurologic: Prolonged relaxation of deep tendon reflexes, otherwise nonfocal
· Skin: Hair is sparse; skin is coarse, dry, scaly, and thick
Appropriate laboratory tests include the following:
146. CBC
147. thyroid function tests
148. serum follicle-stimulating hormone level
149. serum estrogen level
150. antinuclear antibody
Laboratory tests confirm your suspicions. Further treatment of this patient may include
151. colonoscopy
152. initiation of levothyroxine
153. administration of propylthiouracil
154. administration of potassium iodide
155. administration of propranolol
View Answer
Options 146–155
Answers: 146. T147. T148. F149. F150. F151. T 152. T153. F154. F155. F
Hypothyroidism is manifested by lethargy, constipation, cold intolerance, stiffness and cramping of muscles, carpal tunnel syndrome, menorrhagia, weight gain, dry skin, and decreased concentration. Prolonged relaxation of deep tendon reflexes may also be seen. Although unrelated to the patient's hypothyroidism, the patient also has an occult source for gastrointestinal blood loss indicated by the guaiac-positive stool. Appropriate laboratory tests include a CBC and thyroid function tests. Although the patient is postmenopausal and has evidence of lack of estrogen (i.e., vaginal atrophy), measurement of hormone levels is unnecessary. In addition, an antinuclear antibody test is unnecessary. Treatment consists of colonoscopy to evaluate further for a gastrointestinal bleeding source and the administration of levothyroxine to treat hypothyroidism. Propylthiouracil, potassium iodide, and propranolol are used to treat thyroid storm.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:2109.
Hypothyroidism is manifested by lethargy, constipation, cold intolerance, stiffness and cramping of muscles, carpal tunnel syndrome, menorrhagia, weight gain, dry skin, and decreased concentration. Prolonged relaxation of deep tendon reflexes may also be seen.
Patient M
Options 156–165
A 93-year-old debilitated and bedridden nursing home patient is noted to have a sacral decubitus ulcer.
Contributing factors for the development of decubitus ulcers include
156. fecal incontinence
157. skin colonization by Staphylococcus aureus
158. inability to reposition oneself
159. poor nutrition
160. recent antibiotic use
Further care of this patient should include
161. use of a doughnut cushion
162. frequent repositioning
163. nutrition evaluation
164. débridement of necrotic tissue
165. application of topical antibiotic
View Answer
Options 156–165
Answers: 156. T157. F158. T159. T160. F161. F 162. T163. T164. T165. F
Decubitus ulcers may affect elderly, bedridden nursing home patients who are in a poor nutritional state. Risk factors include fecal incontinence, lack of ability to reposition oneself, and malnutrition. The classification of decubitus ulcers consists of four stages:
· Stage 1: Nonblanchable erythema
· Stage 2: Partial-thickness skin loss
· Stage 3: Full-thickness skin loss
· Stage 4: Full-thickness skin loss with extensive destruction
Treatment consists of frequent repositioning of the patient, nutrition assessment, use of pressure-relieving devices (e.g., foam- or air-fluidized mattresses), débridement of necrotic tissue, and close follow-up. Doughnut cushions are not recommended because they decrease blood flow to the ulcer and prevent the healing process. The application of a topical antibiotic may interfere with granulation tissue formation and has no significant benefit to healing. Mild pressure sores (stages 1 and 2) require all the prophylactic measures above to prevent necrosis. The area should be kept exposed, free from pressure, and dry. Stimulating the circulation by gentle massage can accelerate healing. Ulcers that have not advanced beyond stage 3 may heal spontaneously if the pressure is removed and the area is small. New hydrophilic gels and hydrocolloid dressings speed healing. Stage 4 ulcers require débridement or more extensive surgery. When the ulcers are filled with pus or necrotic debris, dextranomer beads or newer hydrophilic polymers may hasten débridement without surgery. Conservative débridement of necrotic tissue with forceps and scissors should be instituted. Some ulcers can be débrided by cleansing with hydrogen peroxide 1.5%. Whirlpool baths may assist débridement. More advanced ulcers with fat and muscle involvement require surgical débridement and closure. For cellulitis, an oral or parenteral penicillinase-resistant penicillin or a cephalosporin is necessary.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1011–1017.
Doughnut cushions are not recommended for the prevention of decubitus ulcers because they decrease blood flow to the ulcer and prevent the healing process.
Patient N
Options 166–180
A 31-year-old homosexual man presents to your office complaining of generalized weakness, malaise, anorexia, myalgias, nonproductive cough, and a 15-lb weight loss over the last 2 months. You suspect HIV infection. A chest radiograph obtained by another physician shows bilateral interstitial infiltrates.
Appropriate laboratory tests at this time include
166. CBC
167. CD4+ T-cell count
168. enzyme-linked immunosorbent assay (ELISA) for HIV antibodies
169. TSH
170. Western blot assay
Your suspicion is confirmed with further testing. The patient is HIV positive.
You explain that the following are considered modes of transmission from contamination:
171. blood
172. semen
173. vaginal secretions
174. breast milk
175. sweat
Which of the following can be considered in the treatment of HIV complicated with Pneumocystis infection?
176. Nucleoside derivatives (retroviral agents)
177. Protease inhibitors
178. Combination therapy (retroviral agents and protease inhibitors)
179. Trimethoprim-sulfamethoxazole (Bactrim, Septra)
180. Aerosolized pentamidine (Pentam 300)
View Answer
Options 166–180
Answers: 166. T167. F168. T169. T170. F171. T172. T173. T174. T175. F176. T177. T178. T179. T180. T
HIV and associated acquired immunodeficiency syndrome are the leading cause of death for men ages 25 to 44 years and the eighth leading cause of death for all ages in the United States. The appropriate screening test for HIV antibodies is ELISA. If this test is positive, the results are then confirmed by a Western blot assay. In the initial testing, CD4+ T-cell counts and viral load titers are unnecessary until the presence of HIV is determined. In this patient, because of his symptoms, a CBC and TSH would be acceptable screening tests in addition to the ELISA test for HIV. Infected body fluids that play a role in the transmission of the virus include blood, semen, vaginal secretions, and breast milk. Sweat has not been implicated in the transmission of HIV. Appropriate treatment for this patient who has documented HIV and suspected Pneumocystis jiroveci (formerly known as Pneumocystis carinii) pneumonia based on his symptoms of a dry cough and x-ray findings would include the use of nucleoside derivatives (retroviral agents: zidovudine, abacavir, didanosine, emtricitabine, stavudine, zalcitabine, and lamivudine) and protease inhibitors: saquinavir (Invirase), ritonavir (Novir), indinavir (Crixivan), and others. Other treatment modalities may include combination therapy with antiretroviral therapy and protease inhibitors. Other antiretroviral medications are used as well. Treatment of Pneumocystis jiroveci consists of the use of trimethoprim-sulfamethoxazole (Bactrim, Septra). Trimethoprim-sulfamethoxazole (Bactrim, Septra) is the drug of choice, because it is efficacious and treats systemically, but dapsone, with or without other drugs, and aerosolized pentamidine (NebuPent) are still acceptable treatments in patients who are unable to tolerate trimethoprim-sulfamethoxazole. Non-life-threatening adverse reactions to trimethoprim-sulfamethoxazole, such as maculopapular skin rash, are not contraindications to the medication unless the patient finds the side effect unacceptable even with use of an appropriate antihistamine. Desensitization to trimethoprim-sulfamethoxazole should be considered in patients who have mild or moderate adverse reactions to trimethoprim-sulfamethoxazole.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1625–1642.
The appropriate screening test for HIV antibodies is ELISA. If this test is positive, the results are then confirmed by a Western blot assay.
Patient O
Options 181–194
A 46-year-old rancher presents to the emergency room. The rancher reports that he suffered a laceration to the right leg 1 hour ago while working on the farm. The laceration was caused by rusted barbed-wire fence. He does not recall having had a tetanus immunization within the last 20 years. Physical examination shows a 3-cm laceration that extends into the subcutaneous fat layer. Examination of the distal extremity reveals that tendons are intact and there are no neurovascular deficits.
Appropriate treatment involves
181. copious irrigation of wound site
182. exploration of wound site for foreign bodies
183. débridement of nonviable tissue
184. suturing of laceration
185. plastic surgery referral
Before treating the laceration, you instill lidocaine 1% with epinephrine to provide anesthesia to the wound site. In which of the following sites would you avoid the use of lidocaine with epinephrine?
186. Fingers
187. Nose
188. Penis
189. Toes
190. Neck
Appropriate immunization for this patient would include
191. tetanus and diphtheria toxoid only
192. tetanus immune globulin only
193. tetanus and diphtheria toxoid plus tetanus immune globulin
194. no further immunization
View Answer
Options 181–194
Answers: 181. T182. T183. T184. T185. F186. T 187. T 188. T189. T190. F191. F192. F193. T194. F
Simple lacerations are often repaired by family physicians in the emergency room or in their office. Repair of lacerations initially involves copious irrigation of the wound site with sterile saline. The wound site should be gently explored after anesthesia is administered to rule out the presence of foreign bodies. Any nonviable tissue should be removed by sharp débridement. Most simple lacerations can be sutured with interrupted nylon sutures, with special care to avoid excess tension when approximating the edges of the wound site. Anesthesia before wound repair can be accomplished with one of the two classes of local anesthetics: esters (e.g., procaine) and amides (e.g., lidocaine). Anesthesia is usually accomplished by local infiltration. Buffering the solution with sodium bicarbonate may help decrease the pain. Warming the anesthetic solution also decreases pain with infiltration. Prior administration of topical anesthetics such as tetracaine 1% can ameliorate injection pain. Alternative methods for local anesthesia include topical and regional applications. A topical combination of tetracaine, adrenaline, and cocaine has been shown to be an effective anesthetic in children and patients with face or scalp lacerations; however, serious adverse events have been reported. Local anesthetic (EMLA) cream has been useful, but the onset of anesthesia is delayed. Local anesthetics can also be administered regionally by infiltrating around a regional sensory nerve. This technique is most useful when dealing with multiple lacerations or when large areas of skin must be débrided or scrubbed. Postoperative care need not include routine use of prophylactic antibiotics unless evidence of bacterial contamination or a risk host factor is evident. Sutured or stapled lacerations should be covered with a protective non-adherent dressing for at least 24 to 48 hours to avoid gross contamination. Patients should be instructed to observe the wound for the presence of warmth, redness, swelling, or drainage. Sutures or staples should be removed after approximately 7 days. Facial sutures should be removed within 3 to 5 days. Sutures in areas that are subject to high tension should be left in place for 10 to 14 days. Lidocaine with epinephrine should be avoided in areas such as the fingers, nose, penis, or toes, or any other distal appendage that may be at risk for ischemia if vasoconstriction occurs. The neck would not be considered at risk for ischemia. A dirty wound caused by an object such as rusted barbed wire should be treated with tetanus and diphtheria toxoid as well as tetanus immune globulin if the patient is unsure of his or her immunization status. Close follow-up to ensure appropriate wound healing and observation for infection are necessary for any laceration repair.
Rakel RE. Textbook of Family Practice, 6th ed. Philadelphia: WB Saunders; 2002:660–661.
Facial sutures should be removed within 3 to 5 days. Sutures in areas that are subject to high tension should be left in place for 10 to 14 days.
Patient P
Options 195–204
A 27-year-old nursing student presents to your employee health clinic after suffering a needle-stick injury. The student reports that she was assisting a laceration repair and was stuck with a solid-bore needle. The patient is reported to be otherwise healthy and has no known history of HIV or hepatitis B. The student is likewise healthy, but has not had hepatitis B immunization.
Which of the following statements is true?
195. The student is at more risk to have contracted HIV than hepatitis B virus.
196. The student is at more risk to have contracted hepatitis B virus than HIV.
197. The student is at equal risk to have contracted HIV as well as hepatitis B.
198. A solid-bore needle-stick is more likely to transmit HIV than a hollow-bore needle-stick.
199. A hollow-bore needle-stick is more likely to transmit HIV than a solid-bore needle-stick.
Appropriate laboratory tests for the student would include
200. ELISA test for HIV
201. Western blot test for HIV
202. antibody to hepatitis B surface antigen
203. hepatitis B surface antigen
204. immunoglobulin M antibodies to hepatitis B core antigen
View Answer
Options 195–204
Answers: 195. F196. T197. F198. F199. T200. T 201. F202. T203. T204. T
Needle-stick injuries are a relatively common occurrence in hospitals and doctors' offices. All health-care providers should receive training on proper disposal of needles and on universal contamination precautions. In addition, all health-care workers should receive hepatitis B immunization. The risk of transmission of HIV by accidental needle-stick is estimated at approximately 1 in 300 accidents. However, the risk for transmission of hepatitis B is higher, presumably because of the relatively low number of HIV virions in blood. In addition, the risk of transmission may be increased by deep injections or injections of blood. With this in mind, the use of hollow-bore needles has an associated higher risk for transmission of disease than solid-bore needles. In this individual, it would be important to document her current HIV status by obtaining an ELISA test for HIV antibodies. The Western blot test is used as a confirmatory test if the initial ELISA test is positive. In addition, documenting her hepatitis status by obtaining tests for hepatitis B surface antigen, antibodies to hepatitis B surface antigen, and immunoglobulin M antibody to hepatitis core antigen is helpful in documenting previous infection. Combinations of a protease inhibitor with two nucleoside reverse transcriptase inhibitors for one month are currently recommended for postexposure prophylaxis of relatively high-risk exposures. Because some women in early pregnancy are offered postexposure prophylaxis before their pregnancy is suspected or confirmed, special caution must be exercised in treating potentially pregnant women. Additional problems arise when the source or HIV status of blood is unknown, but identification of the source and testing of that person for HIV infection should be vigorously pursued.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1639–1640.
In needle-stick injuries, the use of hollow-bore needles has an associated higher risk for transmission of disease than solid-bore needles.