Questions
Each of the following questions or incomplete statements is followed by suggested answers or completions. Select the ONE BEST ANSWER in each case.
1. A 21 year old is brought to your clinic in status epilepticus. What drug should be administered initially?
A) Lorazepam
B) Phenytoin
C) Phenobarbital
D) Pentobarbital
E) Fosphenytoin
View Answer
Answer and Discussion
The answer is A. Lorazepam should be administered intravenously and approximately 1 minute allowed to assess its effect. Diazepam or midazolam may be substituted if lorazepam is not available. If seizures continue at this point, additional doses of lorazepam should be infused and a second intravenous catheter placed in order to begin a concomitant phenytoin (or fosphenytoin) loading infusion. Even if seizures terminate after the initial lorazepam dose, therapy with phenytoin or fosphenytoin is generally indicated to prevent the recurrence of seizures.
MM Stecker. Status epilepticus in adults. Up to Date, version 14.1. Accessed 3/18/2006.
2. A 42-year-old carpenter presents with wrist pain and grip weakness. On exam he is found to have pain over the radial aspect of the wrist that is aggravated by flexing the thumb and applying ulner flexion. The most likely diagnosis is
A) carpal tunnel syndrome
B) scaphoid fracture
C) de Quervain's tenosynovitis
D) boxer's fracture
E) hamate fracture
View Answer
Answer and Discussion
The answer is C. The combination of wrist pain and grip weakness is characteristic of de Quervain's tenosynovitis. The pain is generally located on the radial aspect of the wrist and reproduced with direct palpation of the involved tendons. Pain is aggravated by passively stretching the thumb tendons over the radial styloid in thumb flexion (the Finkelstein maneuver).
Sheon RP, Anderson BC. de Quervain's tenosynovitis. Up to Date, version 14.1. Accessed 3/18/2006.
The combination of wrist pain and grip weakness is characteristic of de Quervain's tenosynovitis.
3. Which of the following statements is true regarding corneal injuries?
A) Patients should have the affected eye patched for 24 hours.
B) Topical antibiotics are recommended to prevent superinfection.
C) Foreign bodies should not be removed because of potential further injury to the cornea.
D) Topical anesthetics should be given to treat the discomfort.
E) None of the above.
View Answer
Answer and Discussion
The answer is B. Controlled studies have not found patching to improve the rate of healing or comfort in patients with traumatic or foreign body abrasions. Patients should be treated with topical antibiotics to prevent superinfection. If a corneal foreign body is detected, an attempt can be made to remove it by irrigation. Topical anesthetics should never be administered or prescribed for pain relief because they delay corneal epithelial healing.
Jacobs DS. Corneal abrasions and corneal foreign bodies. Up to Date, version 14.1. Accessed 3/18/2006.
4. Which finger is most likely to be affected with disruption of the flexor digitorum profundus tendon (also known as a jersey finger)?
A) Thumb
B) Index finger
C) Third finger
D) Ring finger
E) Fifth finger (“pinky”)
View Answer
Answer and Discussion
The answer is D. Disruption of the flexor digitorum profundus tendon, also known as jersey finger, commonly occurs when an athlete's finger catches on another player's clothing, usually while playing a tackling sport such as football or rugby. The injury causes forced extension of the DIP joint during active flexion. The ring finger is the weakest finger and accounts for 75% of jersey finger cases.
Leggit JC, Meko CJ. Acute finger injuries: Part I. Tendons and ligaments. Am Fam Physician. 2006;73:810–816, 823.
5. Injury to the extensor tendon at the DIP joint is also known as
A) boutonnière deformity
B) jersey finger
C) mallet finger
D) swan necking
E) “jammed” finger
View Answer
Answer and Discussion
The answer is C. Injury to the extensor tendon at the DIP joint is also known as mallet finger. The condition is the most common closed tendon injury of the finger. Mallet finger usually is caused by an object (e.g., a ball) striking the finger, creating a forced flexion of an extended DIP. The extensor tendon may be strained, partially torn, or completely ruptured or separated by a distal phalanx avulsion fracture. Those affected with mallet finger complain of pain at the dorsal DIP joint; inability to actively extend the joint; and, often, with a characteristic flexion deformity. It is critical to isolate the DIP joint during the evaluation to ensure extension is from the extensor tendon and not the central slip. The absence of full passive extension may indicate bony or soft tissue entrapment requiring surgical intervention.
Marx JA, Hockberger RS, Walls RM, et al., eds. Rosen's emergency medicine: concepts and clinical practice, 6th ed. Philadelphia: Elsevier/Mosby; 2006:604–608, 2002.
6. Which of the following would indicate the patient must be monitored in an intensive care unit setting following an overdose?
A) PaCO2 >45 mmHg
B) Seizures
C) QRS duration ≥ 0.12 seconds
D) Second- or third-degree atrioventricular block
E) All of the above
View Answer
Answer and Discussion
The answer is E. The presence of any of eight clinical criteria predict a complicated hospital course that could be best managed in an ICU:
· PaCO2 >45 mmHg
· A need for emergency intubation
· The presence of postingestion seizures
· Unresponsiveness to verbal stimuli
· A non-sinus cardiac rhythm
· Second- or third-degree atrioventricular block
· Systolic blood pressure <80 mmHg
· QRS duration ≥ 0.12 seconds
Brett AS, Rothschild N, Gray R, et al. Predicting the clinical course in intentional drug overdose: Implications for use of the intensive care unit. Arch Intern Med. 1987;147:133.
7. Where are most Morton's neuromas found?
A) In the tarsal tunnel
B) At the first metatarsal phalangeal joint
C) The second and third interdigital space
D) At the attachment of the plantar fascia
E) At the head of the fifth metatarsal
View Answer
Answer and Discussion
The answer is C. The interdigital spaces of the foot are common sites for painful neuromas, a condition termed Morton's neuroma. The second and third common digital branches of the medial plantar nerve are the most frequent sites for development of interdigital neuromas. Morton's neuromas develop as a result of chronic trauma and repetitive stress, as occurs in persons wearing tight-fitting or high-heeled shoes. Pain and paresthesias are usually mild at onset and are located in the interdigital space of the affected nerve. In some cases, the interdigital space between the affected toes may be widened as a result of an associated ganglion or synovial cyst. Pain is noted in the affected interdigital space when the metatarsal heads of the foot are squeezed together. Injection with 1% lidocaine (Xylocaine) can assist in confirming the diagnosis.
Wu KK. Morton's interdigital neuroma: a clinical review of its etiology, treatment, and results. J Foot Ankle Surg. 1996;35:112–119.
8. Which of the following tests is the most sensitive and specific for the detection of renal stones?
A) KUB plain film
B) Ultrasound
C) Intravenous pyelography
D) Noncontrast helical CT
View Answer
Answer and Discussion
The answer is D. Compared with abdominal ultrasonography and KUB radiography, intravenous pyelography has greater sensitivity (64% to 87%) and specificity (92% to 94%) for the detection of renal calculi. Noncontrast helical CT is being used increasingly in the initial assessment of renal colic. This imaging modality is fast and accurate, and it readily identifies all stone types in all locations. Its sensitivity (95% to 100%) and specificity (94% to 96%) suggest that it may definitively exclude stones in patients with abdominal pain.
Chen MY, Zagoria RJ. Can noncontrast helical computed tomography replace intravenous urography for evaluation of patients with acute urinary tract colic? J Emerg Med. 1999;17:299–303.
Vieweg J, Teh C, Freed K, et al. Unenhanced helical computerized tomography for the evaluation of patients with acute flank pain. J Urol. 1998;160:679–684.
9. Which of the following statements regarding cholecystectomy is false?
A) Between 5% and 26% of patients undergoing elective laparoscopic cholecystectomy require conversion to an open procedure.
B) A common reason for conversion to an open procedure is failure to identify the anatomy.
C) Laparoscopic cholecystectomy is safer than an open procedure.
D) Laparoscopic cholecystectomy has a lower rate of common bile duct injury.
E) Common bile duct injuries are extremely difficult to repair.
View Answer
Answer and Discussion
The answer is D. Between 5% and 26% of patients undergoing elective laparoscopic cholecystectomy require conversion to an open procedure. A common reason for conversion is the inability to clearly identify the biliary anatomy. In a recent meta-analysis, researchers compared the outcomes of laparoscopic cholecystectomy for more than 78,000 patients in 98 studies with the outcomes of open cholecystectomy for more than 12,000 patients in 28 studies. The researchers found a decreased mortality rate in patients undergoing laparoscopic cholecystectomy compared with those undergoing open cholecystectomy (8.6 to 16 deaths/10,000 patients versus 66 to 74 deaths/10,000 patients, respectively), but also noted a higher rate of common bile duct injury (36 to 47 injuries/10,000 patients versus 19 to 29 injuries/10,000 patients, respectively). Common bile duct injuries associated with cholecystectomy can be extremely difficult to repair, and management at a tertiary care center with surgeons experienced in biliary injuries should be strongly considered.
Shea JA, Healey MJ, Berlin JA, et al. Mortality and complications associated with laparoscopic cholecystectomy. A meta-analysis. Ann Surg. 1996;224:609–620.
10. Which of the following medications is associated with a reduction of cardiac-related mortality in perioperative patients with known or suspected coronary heart disease?
A) Lisinopril
B) Metoprolol
C) Aspirin
D) Simvastatin
E) Warfarin
View Answer
Answer and Discussion
The answer is B. Use of perioperative beta blockers reduces cardiac-related mortality in patients with known or suspected coronary heart disease.
Mangano DT, Layug EL, Wallace A, et al. Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. Multicenter Study of Perioperative Ischemia Research Group. N Engl J Med. 1996;335:1713–1720.
Poldermans D, Boersma E, Bax JJ, et al. The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group. N Engl J Med. 1999;341:1789–1794.
11. When vancomycin is used as a preoperative prophylactic antibiotic, it should be administered within ______ minutes of the start of surgery.
A) 15
B) 30
C) 60
D) 120
E) At the time of incision
View Answer
Answer and Discussion
The answer is D. Ideally, a preoperative dose of antibiotic should provide a sufficient antibiotic serum level throughout the surgery to combat organisms most likely to cause a site infection. It is recommended that the first dose be timed to occur within 60 minutes before the surgical incision is made. If a fluoroquinolone or vancomycin is chosen for prophylaxis, the first dose should be administered within 120 minutes of the start of surgery. If the surgery involves the use of a tourniquet (e.g., hip or knee arthroplasty), the antibiotic infusion should be completed before inflation of the tourniquet. For most surgeries, it is recommended that use of prophylactic antibiotics end within 24 hours after surgery.
Bratzler DW, Houck PM. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis. 2004;38:1706–1715.
Ideally, a preoperative dose of antibiotic should provide a sufficient antibiotic serum level throughout the surgery to combat organisms most likely to cause a site infection.
12. Which of the following is not an absolute contraindication for breast conservative therapy?
A) Estrogen/progesterone receptor positive tumor
B) Two tumors are located in different quadrants
C) Diffuse micocalcifications that appear malignant
D) Prior breast radiation
E) Positive surgical margins
View Answer
Answer and Discussion
The answer is A. When there are two or more primary tumors located in different quadrants of the breast or there are associated diffuse microcalcifications that appear malignant, breast-conserving therapy is not considered appropriate. Additionally, a woman with previous breast irradiation is also not a candidate for breast conservation treatment. Breast irradiation cannot be given during pregnancy, but it may be possible to perform breast-conserving surgery in the third trimester and administer irradiation after delivery. Positive surgical margins are also an absolute contraindication.
Winchester DP, Cox JD. Standards for breast-conservation treatment. CA Cancer J Clin. 1992;42:134–162.
Apantaku LM. Breast-conserving surgery for breast cancer. Am Fam Physician. 2002;66:2271–2278, 2281.
13. Which of the following antibiotics given alone is adequate for prophylaxis when performing an appendectomy?
A) Cephalexin
B) Ceftriaxone
C) Cefotaxime
D) Metronidazole
E) Ampicillin
View Answer
Answer and Discussion
The answer is B. Ceftriaxone and cefotaxime provide effective prophylaxis for abdominal surgeries, but cefotaxime does not provide adequate coverage for appendectomy without the addition of metronidazole. Overall, ceftriaxone is more effective, particularly against Staphylococcus aureus, and has a longer half-life and no active metabolites. Despite being more expensive, this agent is a more versatile choice for antibiotic prophylaxis in abdominal surgery.
Woodfield JC, Van Rij AM, Pettigrew RA. A comparison of the prophylactic efficacy of ceftriaxone and cefotaxime in abdominal surgery. Am J Surg. 2002;185:45–459.
14. Which of the following may have an antiplatelet activity and should be stopped before surgery?
A) Ephedra
B) Ginseng
P.260
C) Valerian
D) St. John's wort
E) Kava
View Answer
Answer and Discussion
The answer is B. Ginseng is touted to protect the body against stress. Pharmacologically, ginseng lowers blood glucose levels (even in patients without diabetes mellitus) and, therefore, may cause intraoperative complications, especially in patients who fasted before surgery. Ginseng may also have a platelet inhibitory effect, and this effect may be irreversible. It should be discontinued at least 7 days before surgery.
Ang-Lee MK, Moss T, Yuan CS. Herbal medicines and perioperative care. JAMA. 2001;286:208–216.
15. After hip surgery, DVT prophylaxis should be maintained for at least
A) 24 hours
B) 3 days
C) 1 week
D) 1 month
E) indefinitely
View Answer
Answer and Discussion
The answer is C. In patients not receiving DVT prophylaxis who are having elective hip or knee replacement or hip fracture surgery, the risk of postoperative DVT is at least 40%, and the risk of pulmonary embolus can be as high as 30%. Low-molecular-weight heparin is considered safe and effective following surgery for hip replacement. It has been shown in a recent study to be superior to low-dose subcutaneous heparin, and its use resulted in significantly fewer hemorrhagic complications. Studies comparing low-molecular-weight heparin with low-dose warfarin (Coumadin) therapy [maintaining an International Normalized Ratio (INR) between 2.0 and 3.0] showed that low-molecular-weight heparin is slightly more effective, although the difference is small. As a result the decision to use low-molecular-weight heparin or warfarin should be based on convenience and cost. Low-molecular-weight heparin is given subcutaneously twice daily, and laboratory monitoring is not required. Treatment with either warfarin or low-molecular-weight heparin should be continued for a minimum of 7 days postoperatively.
Imperiale TF, Speroff T. A meta-analysis of methods to prevent venous thromboembolism following total hip replacement. JAMA. 1994;271:1780–1785.
16. A general surgeon contacts you regarding preoperative clearance for an otherwise healthy 42 year old scheduled for an appendectomy. The patient has no history of excessive bleeding, no family history of bleeding disorders, and is on no medications. He inquires about the need for coagulation studies, which have not been performed. A correct response is
A) a PT/PTT must be performed before surgery
B) a bleeding time is sufficient for assessing the risk of bleeding
C) a prior normal PT/PTT test performed within the last year is sufficient to clear this patient for surgery
D) no further testing is necessary to clear this patient for surgery
E) none of the above
View Answer
Answer and Discussion
The answer is D. Coagulation times are not routinely indicated in patients undergoing surgery. Studies have shown that the yield is very low and that abnormal results are expected or do not significantly affect management. Coagulation studies would be indicated if the patient is receiving anticoagulant therapy, has a family or personal history that suggests a bleeding disorder, or has evidence of liver disease.
King MS. Preoperative evaluation. Am Fam Physician. 2000;62:387–396.
17. A 56-year-old female is found to have biliary colic. You explain to her that the risk of developing acute cholecystitis is
A) 10%
B) 25%
C) 50%
D) 75%
E) 90%
View Answer
Answer and Discussion
The answer is A. Acute cholecystitis develops in up to 10% of patients with symptomatic gallstones and is caused by the complete obstruction of the cystic duct.
Friedman GD. Natural history of asymptomatic and symptomatic gallstones. Am J Surg. 1993;165:399–404.
Bellows CF, Berger DH, Crass RA. Management of gallstones. Am Fam Physician. 2005;72:637–642.
18. You receive a call from the newborn nursery and are told that there is a breast-fed newborn who is vomiting bile-stained emesis. The most appropriate management is
A) decrease feeding frequency
B) switch to formula feedings
C) administration of rectal promethazine (Phenergan)
D) barium enema
E) nasogastric feedings
View Answer
Answer and Discussion
The answer is D. Intestinal malrotation is a condition that results during development of the fetus. As the bowel develops outside the abdomen, it returns to the body cavity with a counterclockwise rotation. When malrotation occurs, the bowel returns in a clockwise rotation, and intestinal obstruction can result. Presenting symptoms include vomiting of bile-stained material, abdominal distention, and dehydration soon after birth. Diagnosis is usually accomplished by a barium enema revealing an abnormal cecal position. An upper gastrointestinal barium series of a patient with volvulus typically shows twisting of the bowel (i.e., the site of obstruction) at the level of Treitz's ligament. Treatment is usually surgical.
Beers MH, Berkow R, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 17th ed. Whitehouse Station, NJ: Merck & Co.; 1999:2215.
19. Which of the following statements about lumbar disc disease is true?
A) It usually involves the L5–S1 interspace.
B) It typically involves anterior herniation of the nucleus pulposus.
C) It usually requires surgical intervention.
D) Treatment involves strict bed rest for 1 to 2 weeks.
E) Forward flexion of the trunk often helps relieve symptoms.
View Answer
Answer and Discussion
The answer is A. Lumbar disc disease usually results from posterior herniation of the nucleus pulposus that impinges on the spinal cord. The most common site is the L5–S1 interspace, which affects the first sacral nerve root. Patients typically recall a precipitating event such as lifting a heavy object. Symptoms include severe back pain that radiates to the legs and is aggravated by coughing, sneezing, or forward flexion of the trunk. The condition is the most common cause of sciatica. Examination may show decreased sensation in a dermatome pattern, weakness, decreased reflexes, and a positive straight leg–raising test. In severe cases, patients may experience bowel or bladder incontinence. Radiographs and laboratory tests are generally unnecessary, except in the few patients in whom a serious cause is suspected based on a comprehensive history and physical examination. Surgical evaluation is indicated in patients with worsening neurologic deficits or intractable pain that is resistant to conservative treatment. The current recommendation is 2 or 3 days of bed rest for patients with acute radiculopathy. The treatment plan should be reassessed in patients who do not return to normal activity within 4 to 6 weeks. Most mild cases can be treated with the limitation of aggravating activity, anti-inflammatory agents, and muscle relaxants.
Patel AT, Ogle AA. Diagnosis and management of acute low back pain. Am Fam Physician. 2000;61:1779–1786,1789–1790.
20. Which of the following is not an indication for referral for Mohs’ micrographic surgery?
A) Lesion in close proximity to nose
B) Lesion size >2 cm
C) Lesion with indistinct margin
D) Recurrent lesions
E) Lesion is identified as an actinic keratosis
View Answer
Answer and Discussion
The answer is E. Patients with nonmelanoma skin cancer measuring >2 cm, lesions with indistinct margins, recurrent lesions, and those close to important structures, including the eyes, nose, and mouth, should be considered for referral for complete excision via Mohs’ micrographic surgery. The Mohs’ surgeon can confirm the complete removal of the lesion by immediately reviewing the pathology during a staged excision, which, in these high-risk settings, can require removal of much more tissue than might have been clinically apparent initially. If a complicated repair is anticipated or a poor cosmetic result is expected, referral is appropriate.
Stulberg DC, Crandell B, Fawcett RS. Diagnosis and treatment of basal cell and squamous cell carcinomas. Am Fam Physician. 2004;70:1481–1488.
Patients with non-melanoma skin cancer measuring >2 cm; lesions with indistinct margins, recurrent lesions; and those close to important structures, including the eyes, nose, and mouth, should be considered for referral for complete excision via Mohs’ micrographic surgery.
21. A newborn who develops aspiration pneumonia should be evaluated for
A) tracheoesophageal fistula
B) hypothyroidism
C) cystic fibrosis
D) human immunodeficiency virus
E) tetralogy of Fallot
View Answer
Answer and Discussion
The answer is A. Tracheoesophageal fistula is a congenital defect seen in newborns. The incidence is 1 in 1,500 to 3,000 live births. Boys and girls are equally affected. The condition is commonly associated with esophageal atresia. Cases have been associated with Down syndrome and trisomy 18. Symptoms include excessive secretions with coughing and aspiration after feedings. Complications include the development of cyanosis and aspiration pneumonia. Diagnosis can be established by the inability to pass a red-rubber catheter or nasogastric tube into the stomach. Frontal and lateral radiographs confirm the level of obstruction. If gas is noted below the diaphragm, then an associated fistula is present. If not, the patient most likely is affected with esophageal atresia alone. Care must be taken to avoid aspiration of dye during diagnostic tests. Treatment involves withholding oral feedings and providing surgical correction. Prognosis is generally good; however, some patients may develop incompetence of the lower esophageal sphincter with chronic reflux symptoms.
Townsend CM, ed. Sabiston textbook of surgery, 16th ed. Philadelphia: WB Saunders; 2001:1467.
22. Extracorporeal shock wave therapy for renal stones
A) requires stones to be present in the renal pelvis
B) rarely requires repeated treatment regardless of stone size
C) is more effective for stones <2 cm in diameter
D) requires less energy for calcium oxalate and cystine stones
E) rarely achieves optimal results
View Answer
Answer and Discussion
The answer is C. Lithotripsy has been used to fragment and remove kidney stones. The procedure involves placing the patient on a lithotripsy gantry so the calculus overlies a circular window in the table containing the water bath and is focused on the calculus. The procedure is more effective for stones <2 cm in diameter. Calcium oxalate and cystine stones are usually dense and require increased energy. Large stones may require repeated treatments. Previously, extracorporeal shock wave therapy was reserved primarily for renal calculi, but now it may be used for calculi within the kidney, ureter, or bladder with a 90% chance of rendering the patient stone free within 3 months.
Taylor R, David AK, Johnson TA Jr, et al., eds. Family medicine: principles and practice, 5th ed. New York: Springer-Verlag; 1998:878.
23. Topical lidocaine is used with ______________ to treat chronic anal fissures
A) nifedipine
B) cocaine
C) nitroglycerin
D) nystatin
E) mupirocin
View Answer
Answer and Discussion
The answer is A. Topical nifedipine in addition to lidocaine gel is effective and well tolerated in the treatment of chronic anal fissures.
Perrotti P, Bove A, Antropoli C. Topical nifedipine with lidocaine ointment vs. active control for treatment of chronic anal fissure: results of a prospective, randomized, double-blind study. Dis Colon Rectum. 2002;45:1468–1475.
24. A 24-year-old woman presents to your office. She is quite concerned that she is bleeding internally, because her stools have been dark, tarry black. Further questioning reveals that she has been having episodes of diarrhea, which have resolved with the use of Pepto-Bismol. She denies abdominal pain, light-headedness, nausea, vomiting, or fevers. The most likely cause of her dark stools is
A) upper gastrointestinal bleeding source
B) lower gastrointestinal bleeding source
C) rectal outlet bleeding
D) bismuth ingestion
E) None of the above
View Answer
Answer and Discussion
The answer is D. Melena is the passage of black tarry stools, which is secondary to gastrointestinal bleeding. In most cases, the source is located in the upper gastrointestinal tract; however, a source in the distal right colon or small intestine can also cause melena. Approximately 100 to 200 mL of blood loss is needed to cause melena. Other causes for black stools that are often confused with melena include iron, bismuth, licorice, and a variety of other food ingestions.
Beers MH, Berkow R, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 17th ed. Whitehouse Station, NJ: Merck & Co.; 1999:241.
25. Which of the following local anesthetics has the longest duration of action?
A) Procaine (Novocaine)
B) Bupivacaine (Marcaine)
C) Mepivacaine (Carbocaine)
D) Lidocaine (Xylocaine)
E) All are about the same
View Answer
Answer and Discussion
The answer is B. The following local anesthetics have the following durations of action:
· Procaine (Novocaine): <30 minutes
· Bupivacaine (Marcaine): 180 to 360 minutes, the longest-acting anesthetic; good for nerve blocks
· Mepivacaine (Carbocaine): 45 to 75 minutes
· Lidocaine (Xylocaine): 60 to 180 minutes
The use of epinephrine should be avoided in areas such as the fingers, nose, penis, and toes or other distal appendages. The vasoconstrictive effect can lead to ischemic necrosis. The most common reason for inadequate anesthesia is not allowing enough time for the anesthetic to take effect. In most cases, the surgeon should wait at least 5 minutes after injection before starting a procedure.
Townsend CM, ed. Sabiston textbook of surgery, 16th ed. Philadelphia: WB Saunders; 2001:286.
26. Blunt objects in the esophagus (with the exception of button batteries) may be observed for _____________ before performing endoscopy for removal.
A) 4 hours
B) 24 hours
C) 3 days
D) 1 week
E) 10 days
View Answer
Answer and Discussion
The answer is B. Most blunt objects (with the exception of button batteries) in the esophagus may be observed for up to 24 hours. If the object fails to pass into the stomach, it should be removed or possibly pushed into the stomach. Objects that have been lodged in the esophagus for >24 hours or for an unknown duration should be removed endoscopically. If the object has been lodged in the esophagus for >2 weeks, there is significant risk of erosion into surrounding structures, and surgical consultation should be obtained before attempting removal. Early intervention is indicated for patients who have swallowed button or disc batteries because of the potential for voltage burns and direct corrosive effects. Burns can occur as early as 4 hours after ingestion.
Eisen GM, Baron TH, Dominitz JA, et al. Guideline for the management of ingested foreign bodies. Gastrointest Endosc. 2002;55:802–806.
27. Which of the following statements regarding preoperative evaluations is correct?
A) A patient with a previous coronary bypass graph 2 years earlier should undergo cardiac stress testing before clearance, regardless of the presence of cardiac symptoms
B) Urine pregnancy testing should be considered for women of childbearing age
C) Coagulation studies should be included in your laboratory assessment of all surgical candidates
D) Patients who have had angioplasty within 6 months are not required to have further cardiology assessment
E) A baseline renal function study should be assessed for all surgical candidates
View Answer
Answer and Discussion
The answer is B. Before elective surgery, a preoperative examination should be performed to review a patient's history. Preoperative laboratory studies once routinely included a complete blood count, extensive blood chemistry profile, urinalysis, prothrombin time, partial thromboplastin time, electrocardiogram (ECG), and chest radiographs. Current recommendations allow for fewer routine tests and for selective ordering of laboratory tests based on the specific indications in a given patient. In addition, the availability of previous laboratory testing can obviate the need for additional preoperative tests. A hemoglobin measurement is useful in detecting unsuspected anemia and providing a baseline level, which can be helpful information postoperatively, particularly for surgeries with potential bleeding complications. Renal and liver function studies are not routinely needed but may be indicated for patients who have a medical condition or medication use that would serve as indications for these tests. Preoperative glucose determination should be obtained in patients 45 years or older, as there are currently recommendations to screen everyone older than 45 years for diabetes mellitus and the presence of diabetes increases perioperative risks. A urine pregnancy test should be considered for women of childbearing age. Coagulation times are not routinely indicated, as studies have shown that the yield is very low and that abnormal results are expected or do not significantly affect management. Coagulation studies would be indicated if the patient is receiving anticoagulant therapy, has a family or personal history that suggests a bleeding disorder, or has evidence of liver disease. An ECG is also not routinely indicated in patients 40 years or younger, but it should be obtained in patients older than 40 years or in patients with cardiac indications based on the medical history. Chest radiographs should be obtained on the basis of findings from the medical history or physical examination. Assessing risk for cardiac patients is important. In general, patients in whom cardiac stress testing was normal within the previous 2 years or who have had coronary bypass surgery within the previous 5 years and are without symptoms require no further assessment. Clinically stable patients who have undergone angioplasty between 6 months and 5 years previously require no further assessment. However, patients who have had angioplasty within the previous 6 months may require cardiac reevaluation and/or consultation with a cardiologist before surgery. Patients at high risk for complications usually warrant cardiology consultation and possibly angiography. Cardiac stress testing should be performed in patients at intermediate risk and with poor functional capacity or who are undergoing high-risk procedures such as vascular surgery. For patients with minor clinical predictors, only patients who have poor functional capacity and are undergoing a high-risk procedure require stress testing. Patients with positive stress test results warrant cardiology consultation before proceeding with surgery. Assessment of left ventricular function is not routinely indicated for preoperative evaluation whether or not the patient has cardiac disease. The preoperative assessment guideline from the American College of Physicians notes that radionuclide or echocardiographic assessment of left ventricular function does not appear to improve the risk prediction provided by the clinical examination alone. In summary, recommendations do not call for preoperative cardiac testing in all patients. The need for further cardiac evaluation before surgery is determined by the clinical risk predictors identified from the patient's history, physical examination, ECG, and functional status, along with the risk associated with the operation itself. Pulmonary function testing may be helpful in diagnosing and assessing disease severity. Baseline chest radiographs may be helpful in at-risk patients. Preoperative guidelines do not define the degree of pulmonary function impairment that would prohibit surgery other than that for lung resection. With lung resection surgery, patients with a forced expiratory volume in 1 second of <2L require preoperative ventilation/perfusion studies to determine the predicted postoperative forced expiratory volume in 1 second. An estimated postoperative forced expiratory volume in 1 second of 800 mL or more is required before lung resection is performed. Patients who smoke cigarettes should be advised to quit smoking for 8 weeks before surgery. Asthma should be under control before surgery, if possible. Steroid therapy for asthma can be continued throughout the perioperative period without excess surgical morbidity. Patients with asthma or chronic obstructive pulmonary disease can be given pre- and postoperative bronchodilators to increase pulmonary function.
King MS. Preoperative evaluation. Am Fam Physician. 2000;62:387–396.
28. A 65-year-old retired secretary presents with a painful bump that is associated with the medial first metatarsal joint. She reports that the bump has developed over the past 10 to 20 years. The most likely diagnosis is
A) hallux valgus
B) Morton's neuroma
C) chronic gout
D) metatarsalgia
E) bunionette
View Answer
Answer and Discussion
The answer is A. Hallux valgus (bunions) is more common in women than in men. Symptoms include a painless or painful bump (exostosis) that forms on the medial aspect of the first metatarsal joint. Contributing physical factors include hyperelasticity syndromes, metatarsus varus, short first metatarsal joint, and pes valgus. Other factors include a family history of bunions and the prolonged use of narrow high-heeled shoes. Conservative treatment is usually all that is needed and includes wide shoes, the use of bunion pads, ice, rest, and anti-inflammatory agents for acute pain. Most cases referred for surgery have intermetatarsal angles greater than 10 degrees or fail to improve with conservative measures. Absolute contraindications for surgery include peripheral vascular disease and local tissue infections, whereas relative contraindications include narcissistic personality disorders, painless cosmetic bunions, and age 65 years or older. A bunionette is a bony prominence on the lateral aspect of the fifth metatarsal head.
Taylor R, David AK, Johnson TA Jr, et al., eds. Family medicine: principles and practice, 5th ed. New York: Springer-Verlag; 1998:985.
29. When injecting a local anesthetic with epinephrine, which of the following locations should be avoided?
A) Lip
B) Distal finger
C) Forehead
D) Back
E) Scalp
View Answer
Answer and Discussion
The answer is B. Epinephrine administration should be avoided near the terminal arterial branches in the digits, tip of the nose, ear lobes, or tip of the penis.
Avina R. Primary care local and regional anesthesia in the management of trauma. Clin Fam Pract. 2000;2:533–550.
30. Which of the following is the standard treatment for subacute bacterial endocarditis (SBE) prophylaxis for minor procedures in low-risk adult patients?
A) Amoxicillin: 1 g given intravenously at the time of the procedure
B) Amoxicillin: 2 g given orally 1 hour before the procedure
C) Ampicillin: 2 g given intravenously plus gentamicin (1.5 mg / kg intravenously) 30 minutes before the procedure; dose repeated 8 hours after the procedure
D) Ampicillin: 500 mg given orally 1 hour before the procedure and 250 mg given 6 hours after the procedure
E) Amoxicillin 3 g orally 1 hour before the procedure and 1.5 g given 6 hours after
View Answer
Answer and Discussion
The answer is B. Standard regimens for SBE prophylaxis involve the following:
· Minor or repetitive procedures in low-risk patients (dental procedures, oral, respiratory tract procedures, or esophageal procedures): amoxicillin, 2 g orally given 1 hour before procedure; the follow-up dose is no longer recommended; those unable to take oral medication are given ampicillin, 2 g intravenously or intramuscularly
· Gastrointestinal and genitourinary surgery and instrumentation or those at high risk for other procedures (prosthetic heart valves), excluding esophageal procedures: ampicillin, 2 g intravenously or intramuscularly plus gentamicin (1.5 mg / kg intravenously or intramuscularly—not to exceed 120 mg) 30 minutes before procedure and ampicillin (1 g) intramuscularly or intravenously or amoxicillin (1 g) orally 6 hours later
If the patient is allergic to penicillin, then cephalexin, cefadroxil, azithromycin, clarithromycin, or clindamycin may be given orally (for low risk), and vancomycin may be substituted for ampicillin intravenously (for high risk).
Gilbert DN, Moellering RC, Sande MA. The Sanford guide to antimicrobial therapy, 2000. Hyde Park, VT: Antimicrobial Therapy, Inc. 2000:118–119.
When administering subacute bacterial endocarditis (SBE) prophylaxis, if the patient is allergic to penicillin, then cephalexin, cefadroxil, azithromycin, clarithromycin, or clindamycin may be given orally (for low-risk procedures), and vancomycin may be substituted for ampicillin intravenously (for high-risk procedures).
31. Diverticulosis is a condition associated with
A) increased risk of colon cancer
B) herniations of the bowel mucosa and submucosa through the muscular layers of the bowel wall
C) inflammatory bowel disease
D) a 90% risk of developing diverticulitis
E) predominantly the proximal colon
View Answer
Answer and Discussion
The answer is B. Diverticulosis, an outpouching of the bowel wall, increases in frequency after 40 years of age. Acquired diverticular disease affects approximately 5% to 10% of the Western population older than 45 years and approximately 80% of persons older than 85 years. It is more common in the sigmoid and distal colon. Colonic diverticula are related primarily to two factors: increased intraluminal pressure and a weakening of the bowel wall. Patients with known diverticula have been found to have elevated resting colonic pressures. The Western diet, which tends to be low in dietary fiber and high in refined carbohydrates, is also believed to be a contributing factor. The condition occurs when there is herniation of bowel mucosa and submucosa through muscular layers of the colon. Inflammation of the small herniations, referred to as diverticulitis, occurs in approximately 10% to 20% of patients with diverticulosis and more commonly in men. Most patients with diverticulosis remain asymptomatic. Symptoms of diverticulitis include lower abdominal pain usually located on the left that may be steady or cramping and is sometimes relieved with a bowel movement, anorexia, nausea, vomiting, and constipation. Physical examination usually shows abdominal tenderness and guarding and, occasionally, a palpable abdominal or rectal mass with abscess formation. Occult blood is present in approximately 20% of patients. Fever and an increased white blood cell count may also be present. Previously, diverticular disease was diagnosed using a contrast barium enema. However, because of the possibility of an obstructing fecalith being dislodged by insufflation and causing bowel perforation, CT scanning is now the diagnostic procedure of choice. 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 severe illness, or those who cannot tolerate oral hydration or who have pain severe enough to require narcotic analgesia, should be hospitalized. Because feeding increases intracolonic pressure, 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 causes colonic spasm. If the pain, fever, and leukocytosis do not resolve within 3 days, further imaging studies are indicated. If an abscess is uncovered and is >5 cm in size, CT-guided drainage and adequate antibiotic coverage should be considered. Approximately 20% of patients with diverticulitis require surgery. Bowel resection is usually recommended for recurrent episodes of diverticulitis or if fistulas are present.
Ferzoco LB, Raptopoulos V, Silen W. Acute diverticulitis. N Engl J Med. 1998;338:1521–1526.
32. Of the following, which local anesthetic has the fastest onset of action?
A) Lidocaine
B) Mepivicaine
C) Bupivicaine
D) Procaine
E) Tetracaine
View Answer
Answer and Discussion
The answer is A. Lidocaine has the fastest onset of action.
Salam GA. Regional anesthesia for office procedures: Part I. Head and neck surgeries. Am Fam Physician. 2004;69:585–590.
33. Which of the following sutures is not absorbable?
A) Catgut
B) Vicryl
C) Polypropylene
D) Dexon
E) Chromic catgut
View Answer
Answer and Discussion
The answer is C. The goal of suturing is to approximate the skin and eliminate unnecessary dead space. Tension at the wound site should be minimized. To achieve maximal cosmetic result, a suture is chosen based on the clinical situation. Monofilament sutures have significantly lowered the incidence of infection compared with multifilament sutures that can harbor bacteria. Nonabsorbable sutures (i.e., nylon, silk, polypropylene, braided polyester, and polybutester) are usually used to close the superficial layer of skin; absorbable sutures (i.e., catgut, chromic catgut, Dexon, Maxon, and Vicryl) are used to close deep layers of skin. Silk is often used on oral lacerations because of its tolerability in the mouth.
Graber MA, Toth PP, Herting RL Jr. University of Iowa: The Family Practice Handbook, 3rd ed. St. Louis: Mosby; 1997:385.
34. Which of the following statements regarding cervical cancer screening is true?
A) The death rate from cervical cancer continues to increase despite Pap smear screening.
B) Immunosuppression has not been identified as a risk factor for cervical cancer.
C) Human papillomavirus (HPV) types 1 and 3 are most closely linked to cervical cancer.
D) Smoking has been linked to the development of cervical cancer.
E) Most cases of cervical cancer occur between the ages of 20 and 30 years.
View Answer
Answer and Discussion
The answer is D. Cervical cancer before 20 years of age is rare. Most cases occur between the ages of 45 and 55 years. Since the mid-1970s, the death rate has decreased significantly as the result of Pap smear screening. Women who are at risk for developing cellular abnormalities include those who smoke and those with a history of sexually transmitted diseases, HPV infection, low socioeconomic status, two or more lifetime sexual partners, or immunosuppression. The latter factors cause frequent exposure to potential carcinogens, and their requisite presence supports the hypothesis that cervical cancer is a sexually transmitted disease. Smoking also contributes to the development of cervical cancer. Although nicotine is not considered a causative agent, smoking may predispose a woman to the development of cervical cancer by lowering her immune surveillance at the cellular level. Smokers also may engage in behaviors that increase their susceptibility to malignant change. A preponderance of evidence suggests a causal link between HPV infection and cervical neoplasia. This link is strongest for certain HPV types, particularly types 16 and 18. The American College of Obstetricians and Gynecologists, the American Academy of Family Physicians, and the U.S. Preventive Services Task Force recommend that all women receive screening Pap smears at the onset of sexual activity or at 18 years of age. Once three normal annual Pap smears are documented, the interval for continued surveillance with screening Pap smears may be lengthened at the discretion of the physician and the patient.
Canavan TP, Doshi NR. Cervical cancer. Am Fam Physician. 2000;61:1369–1376.
35. Of the following, which local anesthetic has the longest duration of action?
A) Lidocaine
B) Mepivicaine
C) Bupivicaine
D) Procaine
E) Tetracaine
View Answer
Answer and Discussion
The answer is C. Bupivicaine has the longest duration of action (2 to 4 hours).
Salam GA. Regional anesthesia for office procedures: Part I. Head and neck surgeries. Am Fam Physician. 2004;69:585–590.
36. A 32-year-old woman is brought to the emergency room by ambulance. She was involved in a motor vehicle accident. Close observation shows that her chest expands with expiration and contracts with inspiration. The most likely diagnosis is
A) ruptured thoracic aorta
B) pneumothorax
C) ruptured esophagus
D) flail chest
E) cardiac contusion
View Answer
Answer and Discussion
The answer is D. In cases of severe blunt trauma to the chest, multiple rib fractures may lead to flail chest. By definition, a flail chest occurs in the presence of two or more fractures in three or more consecutive ribs, causing instability of the chest wall; however, the condition can also occur after costochondral separation. The diagnosis is made by noting paradoxical chest wall motion in which the chest wall depresses with inspiration and expands with expiration. There may be coexisting intrathoracic or intraabdominal injuries. Patients report dyspnea, and respiratory failure occurs in severe cases. Treatment is accomplished in most cases by intubation and mechanical ventilation with peak-end expiratory pressure as long as pain control is adequate. Further evaluation of underlying cardiac and pulmonary injury should be initiated once the patient's respiratory status has stabilized.
Townsend CM, ed. Sabiston textbook of surgery, 16th ed. Philadelphia: WB Saunders; 2001:327.
37. Which of the following can be added to lidocaine to reduce the burning sensation when it is administered?
A) Sodium bicarbonate
B) Epinephrine
C) Normal saline
D) Lactated Ringer's solution
E) Aluminum hydroxide
View Answer
Answer and Discussion
The answer is A. Sodium bicarbonate may be added to neutralize the acidic local anesthetic and to reduce the burning sensation associated with anesthetic administration.
Salam GA. Regional anesthesia for office procedures: Part I. Head and neck surgeries. Am Fam Physician. 2004;69:585–590.
38. Which of the following statements about total parenteral nutrition (TPN) is true?
A) Lipid emulsions can lead to fatty emboli and are not added to TPN solutions.
B) Electrolytes should be monitored closely until stable.
C) In most cases, TPN is administered through peripheral access.
D) Equivalent amounts of calories can be delivered via a central or peripheral access.
E) Because glucose is delivered in standard amounts at predetermined rates, there is little need to follow glucose on a regular basis.
View Answer
Answer and Discussion
The answer is B. TPN is nutritional support given intravenously to patients who suffer from malnutrition. TPN supplies all of the patient's daily nutritional requirements. A peripheral vein may be used for short periods, but longer periods of use with concentrated solutions can readily lead to thrombosis. Therefore, central venous access is usually required. For shorter periods requiring TPN, peripheral access may be used; however, fewer calories can be given via this route. TPN requires water (30 to 40 mL/kg/day) and energy (30 to 60 kcal/kg/day) depending on energy expenditure and amino acids (1 to 3 g/kg/day) depending on the degree of catabolism. Lipid emulsions supplying essential fatty acids and triglycerides may be used in addition to a basic solution. Indications include malnourished patients scheduled for surgery, chemotherapy, or radiation. Patients with severe burns, anorexia, coma, Crohn's disease, ulcerative colitis, or pancreatitis may benefit from TPN. The following should be monitored daily: weight, plasma urea and glucose (several times daily until stable), complete blood cell count, blood gases, accurate fluid balance, 24-hour urine, and electrolytes. When the patient becomes stable, the frequency of these tests can be reduced considerably. Liver function tests should be performed, and plasma proteins; prothrombin time; plasma and urine osmolality; and calcium, magnesium, and phosphate (not during glucose infusion) should be measured twice weekly. Progress should be followed on a flowchart. Nutritional assessment and C3 complement should be repeated at 2-week intervals.
Beers MH, Berkow R, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 17th ed. Whitehouse Station, NJ: Merck & Co.; 1999:17–21.
39. Patients with gallbladder carcinoma
A) typically have a life expectancy of more than 5 years
B) may have a history of chronic cholecystitis
C) rarely develop jaundice
D) rarely have metastasis at the time of diagnosis
E) are typically of middle age (35 to 65 years of age)
View Answer
Answer and Discussion
The answer is B. Cancer of the gallbladder is rare, affects predominantly the elderly, and is very difficult to detect clinically. In most cases, it is found during surgery and has metastasized at the time of diagnosis. Ninety percent are adenocarcinomas. Symptoms, when they are present, include right-upper quadrant pain that radiates to the back, jaundice, weight loss, and anorexia. A palpable gallbladder with obstructive jaundice usually signifies cancer of the gallbladder. Treatment is limited, and surgery is used only in certain situations to relieve biliary obstruction. The prognosis is poor; few patients survive longer than 6 months. Chronic calculus cholecystitis increases the risk for cancer of the gallbladder, and cholecystectomy is recommended. Elective cholecystectomy with no indication to prevent carcinoma of the gallbladder carries a significant surgical risk and is not recommended.
Townsend CM, ed. Sabiston textbook of surgery, 16th ed. Philadelphia: WB Saunders; 2001:331.
Chronic calculus cholecystitis increases the risk for cancer of the gallbladder, and cholecystectomy is recommended.
40. When diagnosing an acute appendicitis, which of the following tests has the highest accuracy rate?
A) Plain films of the abdomen
B) Barium enema
C) CT of the abdomen
D) HIDA scan
E) Abdominal ultrasound
View Answer
Answer and Discussion
The answer is C. Acute appendicitis is the most common reason leading to emergent abdominal surgery. The overall diagnostic accuracy achieved by traditional history, physical examination, and laboratory tests has been approximately 80%. The accuracy of diagnosis varies and is more difficult in women of childbearing age, children, and elderly persons. If the diagnosis of acute appendicitis is clear from the history and physical examination, prompt surgical referral is warranted. In atypical presentations, ultrasonography and computed tomography (CT) may help lower the rate of false-negative appendicitis diagnoses, reduce morbidity from perforation, and lower medical expenses. Ultrasonography is safe and readily available, with accuracy rates between 71% and 97%, although it is highly operator dependent and difficult in patients with a large body habitus. Although there is controversy regarding the use of contrast media and which CT technique is best, the accuracy rate of CT scanning is between 93% and 98%. Disadvantages of CT include radiation exposure, cost, and possible complications from contrast media.
Old JL, Dusing RW, Yap W, et al. Imaging for suspected appendicitis. Am Fam Physician. 2005;71:71–78.
41. Pain over the anatomic “snuff box” may indicate
A) Colles’ fracture
B) cuboid fracture
C) scaphoid fracture
D) hook of the hamate fracture
E) boxer's fracture
View Answer
Answer and Discussion
The answer is C. Scaphoid fractures account for approximately 60% of carpal bone fractures and are often missed on the initial radiograph. Symptoms include pain over the anatomic “snuff box” (area between the extensor pollicis brevis and the extensor pollicis longus tendons) and pain with radial deviation of the wrist. Reduction is seldom necessary; however, the arm, wrist, and thumb should be immobilized with a thumb spica cast for at least 6 weeks. If pain persists for longer than 4 months, there is an increased risk of nonunion or avascular necrosis with development of arthritis. Surgery may be indicated for this condition. If clinically suspected, radiographs (including scaphoid views) should be performed initially. Plain wrist films usually do not detect these fractures. In some cases, a bone scan or tomograms may be necessary to confirm the diagnosis. Bony electrical stimulation has also been shown to be effective in the healing of scaphoid fractures. Displaced fractures require open reduction with screw fixation.
Townsend CM, ed. Sabiston textbook of surgery, 16th ed. Philadelphia: WB Saunders; 2001:1576–1577.
42. Relief of hip pain after hip replacement occurs
A) almost immediately
B) after 3 months
C) after 6 months
D) usually after 1 year
E) rarely; hip replacement mostly improves functionality
View Answer
Answer and Discussion
The answer is A. Hip arthroplasty is usually reserved for elderly patients with severe degenerative or rheumatoid arthritis. Indications include intractable pain or severe limitation of motion that interferes with the patient's activity level. Those patients with rheumatoid arthritis have longer and more lasting improvement than those with osteoarthritis. Complications include bleeding, infection, and the major immediate complication of thromboembolism. Bone resorption is a major complication that may affect the life of the prosthesis. Long-term complications include loosening of the prosthesis, which may require further surgery. In most cases, relief is immediate after hip replacement, and 90% of hip replacements are never revised.
NIH Consensus Development Panel on Total Hip Replacement. NIH consensus conference: Total hip replacement. JAMA. 1995;273:1950–1956.
43. A felon is a/an
A) prominence of the distal fifth toe
B) form of a cleft lip
C) neuroma associated with the flexor tendon
D) asymmetric nevus
E) abscess of the distal fingertip
View Answer
Answer and Discussion
The answer is E. A felon is an abscess of the distal pulp or phalanx pad of the fingertip.
Harrison BP, Hilliard MW. Emergency department evaluation and treatment of hand injuries. Emerg Med Clin North Am. 1999;17:793–822.
44. Which of the following conditions is an indication for SBE prophylaxis?
A) Previous pacemaker placement
B) Previous coronary artery bypass graft
C) Previous episode of bacterial endocarditis
D) Mitral valve prolapse without regurgitation
E) History of ventricular septal defect successfully repaired 10 years ago
View Answer
Answer and Discussion
The answer is C. Indications for SBE prophylaxis include the following:
· Previous episode of endocarditis
· Mitral valve prolapse with regurgitation (or thickened or redundant valve)
· Prosthetic cardiac valves
· Congenital cardiac defects (except for those specified)
· Hypertrophic cardiomyopathy
· Previous valvular surgery
· Rheumatic valvular dysfunction
· Surgically constructed systemic pulmonic shunts or conduits
· Dental or surgical indications for SBE prophylaxis
· Dental or surgical procedures likely to cause mucosal bleeding
· Tonsillectomy/adenoidectomy
· Surgery involving the respiratory or gastrointestinal mucosa
· Rigid bronchoscopy
· Sclerotherapy of esophageal varices
· Esophageal dilation
· Gallbladder surgery
· Urinary tract surgery if infection is present
· Prostatic surgery
· Cystoscopy
· Ureteral dilation
· Incision and drainage of infected tissue
· Vaginal delivery in the presence of infection
SBE prophylaxis is not necessary for ventricular septal defects, patent ductus arteriosus, and isolated secundum atrial septal defects if they have been repaired for at least 6 months without complications, physiologic murmurs, previous rheumatic fever without valve dysfunction, history of coronary artery bypass surgery, coronary stent placement, transesophageal echocardiogram, previous pacemaker or defibrillator placement, or history of Kawasaki disease without valve dysfunction. Also, SBE prophylaxis is not necessary for dental procedures not likely to cause gingival bleeding (fillings above the gum line, adjustment of orthodontic equipment, etc.), injection of intraoral anesthetics, shedding of primary teeth, tympanostomy tube placement, skin biopsy, cesarean section, endotracheal intubation, flexible bronchoscopy with or without biopsy, cardiac catheterization, endoscopy with or without biopsy, routine urinary catheterization (no infection present), dilation and curettage, uncomplicated vaginal delivery, abortion, insertion and removal of intrauterine devices, sterilization procedures, or laparoscopy.
Gilbert DN, Moellering RC, Sande MA. The Sanford Guide to Antimicrobial Therapy, 2000. Hyde Park, VT: Antimicrobial Therapy, Inc.; 2000:118–119.
45. A pipe smoker is found to have a white elevated plaque on his buccal mucosa during a general medical examination. The area cannot be wiped away with sterile gauze. The most likely diagnosis is
A) squamous cell carcinoma
B) thrush
C) gingivitis
D) leukoplakia
E) periodontitis
View Answer
Answer and Discussion
The answer is D. Leukoplakia is a precancerous lesion that appears as a white, elevated, plaque-like growth that usually has asymmetric borders and usually affects the oral mucosa. It cannot be wiped off. The lesions tend to occur on the lip, mouth, buccal mucosa, or vaginal mucosa. Those at risk are cigarette smokers, pipe smokers, smokeless tobacco users, and heavy alcohol users. Others at risk include those with chronic oral infections, chronic malocclusion, or chronic ultraviolet light exposure. If suspected, these lesions should be biopsied to rule out malignancy. Approximately 10% may show malignant transformation. Candida infections can resemble leukoplakia, but Candida can be removed using a cotton swab.
Taylor R, David AK, Johnson TA Jr, et al., eds. Family medicine: principles and practice, 5th ed. New York: Springer-Verlag; 1998:1043.
46. Which of the following statements is true regarding screening for abdominal aortic aneurysms?
A) Screening is not beneficial for any subgroups of the populations.
B) Both women and men over the age of 50 should be screened.
C) Only men older than 75 should be screened.
D) Only men ages 65 to 75 with prior history of smoking should be screened.
E) Abdominal CT scanning is recommended for screening.
View Answer
Answer and Discussion
The answer is D. The U.S. Preventive Services Task Force (USPSTF) recommends a single screening for abdominal aortic aneurysm (AAA) by ultrasonography in men ages 65 to 75 years who have previously smoked (defined as 100 or more cigarettes in a person's lifetime). The USPSTF found adequate evidence from large population-based studies in the United Kingdom that screening for AAA and surgical repair of large AAAs lead to decreased AAA-specific mortality. Almost all deaths from ruptured AAAs occur in men older than 65 years; most AAA-related deaths occur in men younger than 80 years. For most men, 75 years may be considered an upper age limit for screening, because increased comorbidities in patients 75 years and older decrease the likelihood that they will benefit from screening. Because few AAA-related deaths occur in women, and those AAAs that do rupture
P.268
occur after 80 years of age when there are competing causes of mortality, the potential benefit of screening for AAA among women is low. Physicians must individualize recommendations for men and women depending on a patient's risk and likelihood of benefit. One-time screening to detect an AAA using ultrasonography is sufficient. Death from AAA rupture after negative results on a single ultrasound scan at age 65 is rare.
U.S. Preventive Services Task Force. Screening for abdominal aortic aneurysm: recommendation statement. Ann Intern Med. 2005;142:198–202.
47. A 65-year-old man presents to your office complaining of abdominal pain. His vital signs are stable. Examination reveals a pulsatile mass in the mid-abdomen. The most appropriate test is
A) magnetic resonance imaging (MRI) of the abdomen
B) laboratory tests, including complete blood count, electrolytes, and erythrocyte sedimentation rate
C) ultrasound examination of the abdomen
D) upper gastrointestinal series
E) barium enema
View Answer
Answer and Discussion
The answer is C. Abdominal aortic aneurysms result from a weakening in the wall of the aorta. Most cases occur inferior to the renal arteries and are asymptomatic; however, back pain or abdominal pain may precede rupture. Most aneurysms are the result of atherosclerotic disease that results in weakening of the vessel. Strong evidence suggests a genetic susceptibility to abdominal aortic aneurysms. Patients with these aneurysms have a 20% chance of having a first-degree relative with the same condition. Male siblings are at particular risk. Approximately 75% of abdominal aortic aneurysms are asymptomatic and are detected during routine physical examination or during an unrelated radiologic or surgical procedure. Symptoms of an abdominal aortic aneurysm may result from expansion or rupture of the aneurysm, pressure on adjacent structures, embolization, or thrombosis. The most commonly reported symptom is any type of abdominal, flank, or back pain. Pressure on adjacent viscera may result in compression of the bowel. Patients may present with early satiety and, occasionally, nausea and vomiting. Rarely, ureteral compression may result in a partial ureteral obstruction. Thrombus and atheromatous material, which line nearly all abdominal aortic aneurysms, may occasionally result in distal arterial embolization and, rarely, aneurysm thrombosis. The abrupt onset of severe, constant pain in the abdomen, flank, or back, unrelieved by positional changes, is characteristic of expansion or rupture of the aneurysm. Physical examination often reveals a pulsating abdominal mass. Obesity, uncooperativeness, ascites, tortuosity of the aorta, and excessive lumbar lordosis are conditions that may make diagnosis by palpation difficult. Examination of the abdominal aorta is facilitated by having the patient lie on the examination table with the knees slightly flexed. The aorta is palpated during exhalation. A pulsatile abdominal mass left of midline—between the xiphoid process and the umbilicus—is highly suggestive of an abdominal aortic aneurysm. Diagnosis is made with ultrasound or CT examination. B-mode ultrasound is the screening method of choice for asymptomatic abdominal aortic aneurysms. It is available in most hospitals, is relatively inexpensive (approximately $150/examination), does not require ionizing radiation, reveals details of the vessel wall and associated atherosclerotic plaques, and allows accurate measurement of the aneurysm in longitudinal and transverse dimensions. Typically, aneurysms >5 cm are treated surgically, whereas smaller aneurysms are observed for any changes. Endovascular repair is safer, results in shorter hospital stays and quicker recovery, and translates into significant cost savings when compared with conventional surgery. The operative mortality rate is usually <5%. The mortality rate of patients with aneurysms >6 cm is approximately 50% in 1 year; patients with aneurysms between 4 and 6 cm have a mortality rate of 25% in 1 year.
Santilli JD, Santilli SM. Diagnosis and treatment of abdominal aortic aneurysms. Am Fam Physician. 1997;56(4):1081.
48. Which of the following can impede the healing of decubitus ulcers?
A) Wet-to-dry dressing changes
B) Doughnut cushions
C) Frequent position changes
D) Air-fluidized mattresses
E) Débridement of nonviable tissue
View Answer
Answer and Discussion
The answer is B. Decubitus ulcers occur when there is prolonged pressure of skin against an external object such as a bed or a wheelchair. It occurs most often in patients who are debilitated and have impaired sensory function. The sacrum, ischia, greater trochanters, external malleoli, and heels are at particular risk for tissue breakdown. There are four stages in the development of a decubitus ulcer:
· Stage 1—nonblanchable erythema of intact skin
· Stage 2—partial thickness dermal or epidermal loss causing a blister, shallow crater, or abrasion
· Stage 3—full thickness necrosis causing a deep crater down to fascia
· Stage 4—full thickness destruction of muscle, bone, or supporting structures
Intrinsic and extrinsic factors play a role in the development of pressure ulcers. Intrinsic factors include loss of pain and pressure sensations (which ordinarily prompt the patient to shift position and relieve the pressure) and minimal fat and muscle padding between bony weight-bearing prominences and skin. Disuse atrophy, malnutrition, anemia, and infection also contribute. In a paralyzed patient, loss of vasomotor control leads to lowered tone in the vascular bed and lowered circulatory rate. Spasticity, especially in patients with spinal cord injuries, can place a shearing force on the blood vessels to further compromise circulation. Extrinsic factors include pressure due to infrequent shifting of the patient's position; friction, irritation, and pulling of the skin from ill-adjusted supports or wrinkled bedding or clothing also contribute. In an immobilized patient, severe pressure can impair local circulation in less than 3 hours, causing local tissue anoxia that, if unrelieved, progresses to necrosis of the skin and subcutaneous tissues. Moisture (e.g., from perspiration or incontinence) leads to tissue maceration and predisposes to pressure sores. The treatment of decubitus ulcers includes wet-to-dry dressing changes and the use of air-fluidized beds, particularly for large ulcers. 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 may be débrided by cleansing them with hydrogen peroxide. Whirlpool baths may also assist débridement. The use of egg-crate mattresses, sheepskins, and doughnut cushions are not adequate to prevent ulcers; doughnut cushions can actually decrease the blood flow to the area of the body in the center of the cushion, thereby impeding the healing process. The use of antibiotics is unnecessary unless cellulitis, osteomyelitis, or sepsis is present. The use of topical antiseptics and antibiotics may also impede the healing process by damaging fibroblasts, which are needed for healing.
Beers MH, Berkow R, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 17th ed. Whitehouse Station, NJ: Merck & Co.; 1999:834–835.
49. Which of the following measurements is considered a threshold for surgical intervention in treating a man with an abdominal aortic aneurysm?
A) 4.0 cm
B) 5.0 cm
C) 6.0 cm
D) 7.0 cm
E) 8.0 cm
View Answer
Answer and Discussion
The answer is B. In patients with abdominal aortic aneurysms with a diameter >6 cm, the risk of rupture is increased markedly and surgical repair is indicated if the patient can tolerate the intervention. A recent study recommends delaying surgical repair of abdominal aortic aneurysms 5.5 cm in diameter. The risk of aneurysm rupture is four times as high in women. Although there should be a lower threshold for surgical repair in women, the authors of the study did not think that a specific numeric cutoff could be recommended, based on the data.
Powell JT, Greenhalgh RM. Small abdominal aortic aneurysms. N Engl J Med. 2003;348:1895–1901.
In patients with abdominal aortic aneurysms with a diameter >6 cm, the risk of rupture is increased markedly, and surgical repair is indicated if the patient can tolerate the intervention.
50. A 51-year-old woman presents to the office with a 2-day history of right-upper quadrant, colicky abdominal pain, as well as nausea and vomiting. Examination shows significant pain with palpation in the right-upper quadrant. Laboratory findings include an elevated white blood cell count, alkaline phosphatase, and bilirubin level. The most likely diagnosis is
A) viral gastroenteritis
B) dissecting abdominal aneurysm
C) acute pancreatitis
D) acute cholecystitis
E) perforated duodenal ulcer
View Answer
Answer and Discussion
The answer is D. Cholecystitis is an acute inflammation of the gallbladder wall. The condition usually results from an obstruction of the bile ducts as a result of biliary stones (most commonly cholesterol). Risk factors for cholesterol gallstone formation include age, obesity, rapid weight loss, pregnancy, female gender, use of exogenous estrogens, diabetes, certain gastrointestinal conditions, and certain medications. Symptoms include colicky right-upper quadrant abdominal pain that starts out mild and crescendos into more severe pain that may last several hours before resolving spontaneously. Patients may also report nausea and vomiting and low-grade fevers. Physical examination usually shows marked right-upper quadrant tenderness with a positive Murphy's sign (marked abdominal pain and inspiratory arrest with palpation of the right-upper quadrant). A palpable gallbladder is present in as many as 30% to 40% of patients. Jaundice is present in 15% of patients. Laboratory findings include an elevated white blood cell count, increased serum transaminases, alkaline phosphatase, bilirubin levels, and, in some cases, amylase levels. The diagnosis is usually made with ultrasound; however, cholescintigraphy (HIDA scan) is the most sensitive test to document obstruction in the biliary system. Oral cholecystograms are rarely used for diagnosing acute cholecystitis. CT scans are not superior to ultrasound and are more expensive. Up to one-half of stones in the common bile duct are not detected on ultrasonography. In the gallbladder, stones <2 mm in diameter may be missed or misdiagnosed as sludge. Endoscopic retrograde cholangiopancreatography is the test of choice to detect stones in the common bile duct. If infection is suspected, antibiotics—including ampicillin plus sulbactam (Unasyn), or a third-generation cephalosporin plus metronidazole—are indicated. Pain can be managed with ketorolac or meperidine. Morphine should be avoided, because it may cause spasm of the sphincter of Oddi and increase pain. Treatment usually involves surgical excision.
Ahmad M, Cheung RC, Keeffe EB, et al. Differential diagnosis of gallstone-induced complications. South Med J. 2000;93:261–264.
51. Which of the following cardiac arrhythmias is associated with lightning strikes?
A) Asystole
B) Ventricular fibrillation
C) Atrial fibrillation
D) Atrioventricular dissociation
E) Third-degree heart block
View Answer
Answer and Discussion
The answer is A. More people are killed each year in the United States by lightning than by any other natural disaster. Lightning injuries are direct current injuries. They differ from alternating current injuries, because victims can suffer from a shock-wave phenomenon that may violently throw them and cause multiple trauma. Therefore, the cervical spine must be protected after a lightning strike. The major cardiac effect is asystole, whereas a high-voltage alternating current injury usually causes ventricular fibrillation. A flashover effect in which the main current travels peripherally over the victim's body may also occur. Leaf-like patterns of burned skin result. Wet clothing can cause excessive skin injury. Treatment should follow advanced cardiac life-support protocol and can be successful if initiated immediately after the injury. Other complications include vitreous hemorrhage, retinal detachment, and ruptured tympanic membranes. Lightning rarely, if ever, produces entry and exit wounds and seldom causes muscle damage or myoglobulinuria, because the duration of current is too short to break down the skin and tissues. Lightning flashes over the person, producing little internal damage other than electrical short-circuiting of systems (e.g., heart asystole, brain confusion, loss of consciousness, neuropsychologic sequelae). Some form of amnesia generally results. Neuropsychologic damage, pain syndromes, and sympathetic nervous system damage are the most common long-term sequelae. Cardiopulmonary arrest is the most common cause of death.
Beers MH, Berkow R, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 17th ed. Whitehouse Station, NJ: Merck & Co.; 1999:2442.
52. Which of the following factors would be favorable in deciding if a patient would benefit from a carotid endarterectomy?
A) Female sex
B) Patient is older than 75 years
C) Surgery to be performed 4 weeks after their ischemic event
D) Patient has diabetes
E) Bilateral carotid stenosis is present
View Answer
Answer and Discussion
The answer is B. The European Carotid Surgery Trial and the North American Symptomatic Carotid Endarterectomy Trial included 95% of patients in trials of carotid endarterectomy surgery. The participants had experienced recent clinical events in the distribution of the carotid artery, and the symptomatic vessel was visualized by angiography. Participants were randomized to medical or surgical treatment, and follow-up was conducted by neurologists or by subspecialists in stroke. Follow-up data were obtained for 5,893 patients over an average of 66 months. Of the 3,157 patients treated with endarterectomy, 222 (7%) had operative deaths or strokes. The perioperative risk of death or stroke was increased in women, patients with diabetes, patients with occlusion of the other carotid artery, patients with ulcerated or irregular plaques, and patients who had hemispheric (rather than retinal) events preceding clinical events. Age, sex, and time since last symptomatic event greatly modified the outcome of surgery. When all variables were included in the analysis, the benefits from surgery were greatest in men, patients older than 75 years, and those who had surgery within 2 weeks of their last ischemic event.
Rothwell PM, Eliasziw M, Gutnikov SA. Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery. Lancet. 2004;363:915–924.
53. A 25-year-old patient arrives in the emergency room after being involved in a high-speed motor vehicle accident. The patient is conscious, hypotensive, and complains of abdominal pain. The most appropriate management includes
A) flat and upright abdominal series
B) diagnostic peritoneal lavage
C) abdominal ultrasound
D) emergent abdominal computed tomography (CT) scan
E) exploratory laparotomy
View Answer
Answer and Discussion
The answer is B. Patients who have experienced significant abdominal trauma, have abdominal pain, or are unstable and the diagnosis remains unclear should undergo diagnostic peritoneal lavage once they arrive in the emergency room. The procedure involves making a small incision between the umbilicus and pubis after local anesthesia is administered. A small 1-cm incision is then made in the peritoneal fascia, and a peritoneal dialysis catheter is placed. The catheter is directed to the posterior sacral area and 1,000 mL of normal saline is infused into the peritoneal cavity and allowed to return by gravity. A return of at least 10 mL of gross blood; a bloody lavage effluent; an RBC count greater than 100,000/mm3; a white blood cell count greater than 500/mm3; an amylase greater than 175 IU/dL; or the detection of bile, bacteria, or food fibers in the aspirated fluid is considered a positive response and requires immediate laparotomy to look for an internal bleeding site. Patients who are clinically stable may undergo CT or ultrasound to further evaluate the abdomen when blunt trauma has occurred. Diagnostic peritoneal lavage is highly sensitive for the presence of intraperitoneal blood; however, specificity is low.
Townsend CM, ed. Sabiston textbook of surgery, 16th ed. Philadelphia: WB Saunders; 2001:331.
54. A 33-year-old street person presents to the emergency room. While scavenging in garbage cans, the patient cut his left hand. He does not recall if he has ever had immunization for tetanus before. The most appropriate immunization is
A) adult diphtheria tetanus toxoid (dT)
B) diphtheria-pertussis-tetanus vaccine (DPT)
C) dT and tetanus immunoglobulin (TIG)
D) observation
View Answer
Answer and Discussion
The answer is C. Tetanus immunization for adults is recommended every 10 years with an adult dT. If the patient has not received adequate immunization before injury and the wound is dirty and tetanus-prone, they should receive tetanus and diptheria toxiod and tetanus immune globulin.
|
Inadequate or unknown immunization (<3 doses) |
Adequate immunization (at least 3 doses and a booster within 10 years) |
|
|
Wound |
||
|
Clean |
Adult dT |
— |
|
Dirty |
dT, TIG |
dTa |
|
a If immunization occurred >5 years ago. |
Gilbert DN, Moellering RC, Sande MA. The Sanford Guide to Antimicrobial Therapy, 2000. Hyde Park, VT: Antimicrobial Therapy, Inc.; 2000:128.
55. Which of the following statements is true regarding hip fractures?
A) Most hip fractures do not require surgery for repair.
B) Avascular necrosis of the femoral head is a serious complication.
C) Nonunion or malunion does not occur with hip fractures.
D) Location of the fracture has no bearing on the outcome.
E) None of the above.
View Answer
Answer and Discussion
The answer is B. The distinction between intracapsular and extracapsular hip fracture has prognostic value for the patient's outcome. Early detection of intracapsular fractures is especially important, because these fractures are prone to complications for two primary reasons. First, interuption of the blood supply to the femoral head frequently occurs and can lead to avascular necrosis. Second, the head fragment of the fracture is often a shell containing fragile cancellous bone that provides poor attachment for a fixation device, a situation that often increases the possibility of nonunion or malunion.
Caviglia HA, Osorro PQ, Comando D. Classification and diagnosis of intracapsular fractures of the proximal femur. Clin Orthop. 2002;(399):17–27.
56. Which of the following types of polyps is associated with the greatest risk of malignant transformation?
A) Hyperplastic polyp
B) Tubular adenoma
C) Villous adenoma
D) Mixed tubulovillous adenoma
E) All have equal risk.
View Answer
Answer and Discussion
The answer is C. The development of colon polyps has been associated with a high-fat, low-fiber diet. They also occur more frequently in patients with a positive family history (two to four times more common than in the healthy population). Polyps are divided into differing histologic types, including the following:
· Tubular adenoma: 5% chance of cancer development
· Villous adenoma: 40% chance of cancer development
· Mixed tubulovillous adenoma: 22% chance of cancer development
Although controversial, the U.S. Agency for Health Care Policy and Research has recommended screening for average-risk persons older than 50 years using one of the following techniques: fecal occult blood testing each year, flexible sigmoidoscopy every 5 years, fecal occult blood testing every year combined with flexible sigmoidoscopy every 5 years, double-contrast barium enema every 5 to 10 years, or colonoscopy every 10 years. Screening of persons with risk factors should begin at an earlier age, depending on the situation. The detection of adenomatous polyps should prompt thorough evaluation and removal using colonoscopy. The risk of synchronous polyps affecting the proximal colon is as high as 35%. For those with a positive family history of colon cancer, more frequent and earlier periodic colonoscopy should be considered.
Read TE, Kodner IJ. Colorectal cancer: risk factors and recommendations for early detection. Am Fam Physician. 1999;59:2975.
57. A 40-year-old woman is found to have chronic cholestasis. The most serious complication is the development of
A) intractable hiccups
B) primary biliary cirrhosis
C) cholelithiasis
D) hypercholesterolemia
E) chronic urticaria
View Answer
Answer and Discussion
The answer is B. Primary biliary cirrhosis is a condition that is characterized by chronic cholestasis, which can damage the liver and ultimately result in the development of cirrhosis. The cause is unknown but may be associated with an underlying autoimmune disorder. The condition typically affects women between 35 and 70 years of age; the condition can occur in men. The disease usually involves four stages:
· Bile duct inflammation
· Periportal fibrosis
· Progressive scarring
· Cirrhosis
Symptoms include itching secondary to elevations of bilirubin, fatigue, and jaundice. Physical findings include hepatosplenomegaly, skin xanthomas (especially around the eyelids and involving the tendons), clubbing, and jaundice. Laboratory tests show elevated alkaline phosphatase, bilirubin, γ-glutamyl transferase, aspartate aminotransferase, and alanine aminotransferase. Serum cholesterol is also usually elevated. Diagnostic procedures include ultrasound, endoscopic retrograde cholangiopancreatography, and liver biopsy. Unfortunately, no specific treatment is available; however, those affected may be candidates for liver transplantation if they develop cirrhosis with hepatic failure. Cholestyramine may be beneficial for the pruritus. Those affected have a variable prognosis, depending on the severity of the disease. Those with slow progression may be minimally affected. Chronic urticaria may be associated with underlying urticarial vasculitis and is diagnosed by skin biopsy.
Beers MH, Berkow R, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 17th ed. Whitehouse Station, NJ: Merck & Co.; 1999:375.
58. A 54-year-old male with no prior history of DVT presents with unilateral swelling of the right lower extremity after a recent prolonged plane flight. The patient is found to have a below-the-knee DVT associated with the calf. He has no contraindication for anticoagulation therapy. What is the appropriate therapy?
A) Heparin therapy followed by oral anticoagulation for 6 to 12 weeks.
B) No anticoagulation and monitor for proximal for proximal extension with duplex ultrasound two times per week for 2 weeks.
C) No anticoagulation and monitor for proximal for proximal extension with duplex ultrasound once a week for 4 weeks.
D) No anticoagulation and application of compressive stockings.
E) No anticoagulation and elevation of the extremity and early mobilization.
View Answer
Answer and Discussion
The answer is A. Patients with a first episode of calf DVT with a transient risk factor should receive heparin therapy followed by oral anticoagulation for 6 to 12 weeks. If anticoagulation is contraindicated, physicians should monitor for proximal thrombus extension with duplex ultrasound twice weekly for 2 weeks. The use of low-molecular-weight heparin (LMWH), outpatient therapy, compression stockings, elevation of the extremity, and early mobilization may be beneficial based on extrapolation from studies of proximal DVT.
Diagnosis and treatment of deep venous thrombosis and pulmonary embolism. Evidence Report/Technology Assessment No. 68. AHRQ Publication No. 03-E012. Rockville, MD: Agency for Healthcare Research and Quality, January 2003. Accessed online March 19, 2006, at: http://www.ahrq.gov/clinic/epcsums/dvtsum.htm.
Lagerstedt CI, Olsson CG, Fagher BO, et al. Need for long-term anticoagulant treatment in symptomatic calf-vein thrombosis. Lancet. 1985;2:515–518.
59. A 45-year-old woman complains of rectal discomfort and bleeding aggravated by bowel movements. The patient reports a long history of constipation. On examination, there is a small fissure at the lateral 9 o'clock position. Which of the following statements is true?
A) Rectal spasms increase blood flow and accelerate healing.
B) A cause other than trauma should be considered.
C) Bowel movements help relieve symptoms.
D) Exercise often leads to development of fissures.
E) Corticosteroid creams should be avoided because of the risk of bacterial overgrowth.
View Answer
Answer and Discussion
The answer is B. Anal fissures are small tears in the mucosa of the anal canal. They often produce pain disproportionate to the size of the lesion. The cause is thought to be secondary to traumatic tearing of the mucosa with the passage of large, hard stools. Other causes include proctitis as a result of previous rectal surgery, hemorrhoids, or rectal cancer. Because of its location in the area of the rectal sphincter, spasms may keep the area from healing. Fissures are most commonly located anterior or posterior to the anus. When fissures are found laterally, syphilis, tuberculosis, occult abscesses, leukemic infiltrates, carcinoma, herpes, acquired immunodeficiency syndrome, or inflammatory bowel disease should be considered as causes. Symptoms include rectal pain and bleeding, which is aggravated with bowel movements. Treatment involves the use of stool softeners and laxatives, hydrocortisone creams, benzocaine ointments, and sitz baths, as well as increased oral fluids and adequate exercise. Another nonsurgical treatment for anal fissure is nitroglycerin ointment. Surgery may be indicated for severe cases that are refractive to these measures.
Pfenninger JL, Zainea GG. Common anorectal conditions: Part II. Lesions. Am Fam Physician. 2001;64:77–88.
60. How long should an isolated calf DVT be treated with anticoagulation?
A) 1 month
B) 3 months
C) 6 months
D) 9 months
E) 12 months
View Answer
Answer and Discussion
The answer is B. In the Seventh Conference on Antithrombotic and Thrombolytic Therapy, the American College of Chest Physicians (ACCP) recommends treating symptomatic isolated calf DVT with anticoagulation for 3 months (INR 2 to 3).
Buller HR, Agnelli G, Hull RD, et al. Antithrombotic therapy for venous thromboembolic disease: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy [published correction appears in Chest. 2005;127:416]. Chest. 2004;126(3 suppl):S401–S428.
61. The best test for the diagnosis of acute obstructive cholecystitis is
A) ultrasound examination
B) radionuclide excretion test (HIDA scan)
C) CT examination
D) oral cholecystography
E) MRI
View Answer
Answer and Discussion
The answer is B. Cholecystitis (inflammation of the gallbladder) usually results as a complication of cholelithiasis (gallstones) and obstruction of the biliary duct by gallstones. The condition is seen more commonly in women than in men. The incidence increases with age. Symptoms include rapid onset of intermittent cramping abdominal pain in the upper-right quadrant, which gradually becomes worse and lasts for several hours; fever, nausea, and vomiting may be present in some cases. Physical findings include right-upper quadrant pain, guarding, and a positive Murphy's sign (significant tenderness with palpation in the right-upper quadrant with inspiration). Chronic cholelithiasis follows a more indolent course with less severe symptoms that are shorter in duration and are recurrent. Diagnosis of acute and chronic cholelithiasis is commonly made with ultrasound examination; however, the best test for detection of acute obstructive cholelithiasis is the radionuclide excretion test (HIDA scan), particularly if the ultrasound is normal or nondiagnostic. Laboratory tests usually show elevations in white blood cell count, liver function tests, amylase, alkaline, phosphatase, and bilirubin during attacks of biliary colic. Patients with chronic cholecystitis rarely have abnormal laboratory studies. Laparoscopic cholecystectomy is the procedure of choice for uncomplicated acute and chronic cholecystitis. Stones can be composed of cholesterol (most common), pigment, and mixed stones. Oral cholecystography is no longer commonly used in the diagnosis of cholecystitis. Prophylactic cholecystectomy for asymptomatic cholelithiasis is generally not recommended.
Taylor R, David AK, Johnson TA Jr, et al., eds. Family medicine: principles and practice, 5th ed. New York: Springer-Verlag; 1998:805–806.
Prophylactic cholecystectomy for asymptomatic cholelithiasis is generally not recommended.
62. What is the annual risk of major hemorrhage when treating a DVT?
A) 2%
B) 25%
C) 50%
D) 75%
E) 98%
View Answer
Answer and Discussion
The answer is A. Oral anticoagulation for DVT carries a steady 2% annual risk of major hemorrhage plus risk of minor hemorrhage.
Diagnosis and treatment of deep venous thrombosis and pulmonary embolism. Evidence Report/Technology Assessment No. 68. AHRQ Publication No. 03-E012. Rockville, MD: Agency for Healthcare Research and Quality, January 2003. Accessed online March 19, 2006, at: http://www.ahrq.gov/clinic/epcsums/dvtsum.html.
63. Which of the following statements about an abnormal breast lesion is true?
A) Cystic lesions are usually benign.
B) A risk factor for breast cancer is early menopause.
C) Mammograms can be used to determine whether the lesion is cystic or solid.
D) Baseline mammogram screening should begin at 50 years of age.
E) Mammograms have less than a 5% false-negative rate.
View Answer
Answer and Discussion
The answer is A. The development of a breast mass requires a thorough evaluation to rule out a possible malignancy. Risk factors for breast cancer include increased age, early menarche, late menopause, BRCA gene mutation, being nulliparous, having a first-degree relative with breast cancer, or having cancer in the contralateral breast. A palpable mass can be evaluated with fine-needle or excisional biopsy. It is important to remember that mammograms have a 10% to 15% false-negative rate; therefore, a palpable solid mass should, in most cases, be biopsied despite a negative mammogram. In addition, a solid lesion is more worrisome for malignancy than a cystic lesion, and ultrasound may be used to differentiate between the two. If the mass is cystic, it can be watched closely with serial ultrasounds or aspirated. The screening guidelines for the diagnosis of breast cancer are continually changing. Because of increased awareness of the signs and symptoms of breast cancer and the use of screening mammograms, breast cancers are increasingly being diagnosed at earlier stages. Annual mammograms and clinical breast examinations are recommended for women older than 40 years. Women older than 20 years should be encouraged to do monthly breast self-examinations, and women between 20 and 39 years of age should have a clinical breast examination every 3 years. These guidelines are modified for women with risk factors, particularly those with a strong family history of breast cancer.
Beers MH, Berkow R, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 17th ed. Whitehouse Station, NJ: Merck & Co.; 1999:1974–1976.
64. A 71-year-old hospitalized patient who previously underwent bowel resection and is now receiving TPN is noted to have a mild elevation in his liver function test. The most appropriate action is
A) observation
B) ultrasound examination of the liver, pancreas, and gallbladder
C) exploratory laparoscopy
D) discontinuation of parenteral nutrition
E) liver biopsy
View Answer
Answer and Discussion
The answer is A. TPN is the intravenous administration of a patient's daily nutritional requirements. Generally, the concentrated solution is given through central vein access, although peripheral access can be used for short durations. Patients who may be candidates for TPN include burn victims, malnourished patients in the perioperative period, or patients who have severe trauma or are in a comatose state. Formulations include daily nutritional requirements, including vitamin supplementation. Patients should be monitored closely with laboratory tests, daily weights, and accurate intakes and outputs. Complications involve nutritional deficiencies and administration complications (e.g., infection of intravenous sites). Laboratory abnormalities may include elevated liver function tests, hepatosplenomegaly, thrombocytopenia, or hyperlipidemia. Peripheral TPN typically provides less calories than centrally administered TPN.
Beers MH, Berkow R, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 17th ed. Whitehouse Station, NJ: Merck & Co.; 1999:17–21.
65. Which of the following statements regarding dipstick urinalysis is false?
A) In women with classic UTI symptoms, in the absence of vaginal symptoms, empiric treatment may be considered without dipstick testing.
B) In low-risk patients with a low pretest probability of UTI, the dipstick adequately rules out infection when both leukocyte esterase and nitrites are negative.
C) Given the more serious consequences of a missed diagnosis of UTI in children, a backup urine culture is recommended.
D) Even in women with classic UTI symptoms, treatment over the telephone should not be performed.
E) Dipstick urinalysis are not sufficiently accurate to make a diagnosis.
View Answer
Answer and Discussion
The answer is D. In women with classic UTI symptoms, particularly in the absence of vaginal symptoms, the probability of a UTI is so high that empiric treatment may be considered without dipstick testing. This might allow treatment by telephone, without necessitating a patient visit resulting in improved cost savings and patient convenience. In a patient with nonspecific complaints such as dysuria and vaginal discharge, a dipstick might be useful. In low-risk patients with a low pretest probability of UTI, the dipstick adequately rules out infection when both leukocyte esterase and nitrites are negative. This also has the benefit of cost containment because fewer urine cultures are needed in low-risk patients. Given the more serious consequences of a missed diagnosis of UTI in children, a backup urine culture is recommended.
Wright OR, Safranek S. FPIN's clinical inquiries: urine dipstick for diagnosing urinary tract infection. Am Fam Physician. 2006;73:129.
66. Which of the following statements is true regarding vasectomies?
A) Early failure rate is approximately 1 in 300.
B) Development of sperm antibodies occurs in <1%.
C) Sperm antibodies are related to the future development of coronary artery disease.
D) The incidence of testicular cancer increases after vasectomy.
E) Patients may resume unprotected intercourse after one sperm-free semen analysis.
View Answer
Answer and Discussion
The answer is A. Vasectomies are performed to provide sterilization for men. Before the procedure, the possibility of complications should be discussed with the patient. The most important complication to discuss is the failure rate of vasectomy as a contraceptive method. Pregnancy occurs after a vasectomy in most cases because the couple had sexual intercourse before azoospermia was documented by two separate semen samples. Early failure occurs in approximately 1 out of 300 vasectomies. Late recanalization is thought to be rare after vasectomy. As many as 50% to 66% of patients develop sperm antibodies after vasectomy. Previous concern about the damage of coronary vessels by these antibodies has not been substantiated. Except for the development of epididymitis, orchitis, and sperm granulomas, those with vasectomies have no higher incidence of disease (including testicular cancer) than control groups. Patients who develop sperm granulomas are at increased risk for recannulation of the vas deferens and should have periodic sperm samples checked. After vasectomy, approximately 15 to 20 ejaculations are required to clear the sperm. The patient should not be considered sterile until two sperm-free specimens are obtained. Contraindications for vasectomy include bleeding disorders, current infection, coercion by family or friends, or anatomic abnormalities.
Clenney TL, Higgins JC. Vasectomy techniques. Am Fam Physician. 1999;60:137–152.
67. Which of the following deters healing of anal fissures?
A) Sitz baths
B) Internal sphincter spasms
C) Poor blood supply to the dentate line
D) External hemorrhoids
E) Rectal rugae
View Answer
Answer and Discussion
The answer is B. Fissures of the anal canal are usually due to traumatic lacerations as a result of chronic constipation with perhaps an underlying infection of the lesion. Other associated conditions include chronic proctitis, rectal carcinoma, hemorrhoids, or previous rectal surgery. The lesion is often associated with the internal sphincter and can cause spasms that can deter healing. Symptoms include pain and bleeding during and after defecation. Physical examination usually shows evidence of a linear fissure located in the midline. Treatment involves the use of stool softeners, fiber supplements, sitz baths, and hydrocortisone- or benzocaine-containing cream, which may aid in decreasing any associated pain or inflammation and promote healing. Surgery is reserved for cases that fail to respond to medical therapy.
Pfenninger JL, Zainea GG. Common anorectal conditions: Part II. Lesions. Am Fam Physician. 2001;64:77–88.
68. A 16-year-old gymnast suffers a fall onto an outstretched hand. On exam she appears to have an unstable distal radioulnar joint. Which of the following injuries is most likely?
A) Greenstick fracture of the radius
B) de Quervain's tenosynovitis
C) Colles’ fracture
D) Injury to the triangular fibrocartilage complex (TFCC)
E) Scaphoid fracture
View Answer
Answer and Discussion
The answer is D. Ulnar wrist pain and weakness caused by a fall onto an outstretched hand may suggest injury to the TFCC, which is the primary stabilizer of the distal radioulnar joint. TFCC injury is common in gymnasts and in racquetball, tennis, and hockey players.
Rettig AC. Athletic injuries of the wrist and hand. Part I: traumatic injuries of the wrist. Am J Sports Med. 2003;31:1038–1048.
69. Which of the following blood types is considered the universal donor?
A) AB positive
B) O positive
C) AB negative
D) O negative
E) B negative
View Answer
Answer and Discussion
The answer is D. In trauma settings, the use of intravenous fluid is important to maintain adequate perfusion to vital tissues and organs. The use of blood for fluid replacement requires typing and proper storing, making it impractical to use in emergent settings in which time is extremely valuable. Because of this, a trauma patient should receive two large-bore (16-gauge or larger) intravenous lines and normal saline or lactated Ringer's solution until proper blood can be given in a controlled setting. For adults, 1,000 mL of crystalloid solution should be given as an initial bolus—children should receive 20 mL/kg. In some emergent situations, O-negative blood, the universal donor blood, can be given until appropriately typed blood arrives.
Ritchie WP, Steele G, Dean RH. General Surgery. Philadelphia: JB Lippincott Co.; 1995:923.
In some emergent situations, O-negative blood (the universal donor blood) can be given until appropriately typed blood arrives.
70. The most common form of malignant melanoma is
A) lentigo maligna melanoma
B) superficial spreading melanoma
C) nodular melanoma
D) acrolentiginous melanoma
View Answer
Answer and Discussion
The answer is B. Malignant melanoma is not as common as squamous cell carcinoma and basal cell carcinoma but is more serious and life threatening because of the potential for distant metastasis. It is the leading cause of death as a result of a skin disease, and the incidence is increasing. Studies have shown that the prevalence of melanoma increases with proximity to the equator. Persons with skin types that are sensitive to the effects of ultraviolet radiation—red or blond hair, freckles, and fair skin that burns easily and tans with difficulty—are at higher risk. Although cumulative sun exposure is linked to nonmelanoma skin cancer, intermittent intense sun exposure seems to be more related to melanoma risk. Other risk factors for melanoma include melanocytic precursor lesions (atypical moles), increased numbers of acquired nevi (>50), a family history of melanoma, a personal history of nonmelanoma skin cancer, giant congenital nevi (>20 cm), and immunosuppression. Melanomas are classified into the following:
· Lentigo maligna melanoma. This usually affects older patients in their 60s and 70s. These lesions usually show variegation of color including black, brown, reddish lesions and are rather large (measuring 2 to 6 cm).
· Superficial spreading melanoma. This is the most common type. These lesions are usually smaller (2 to 3 cm in diameter) and tend to affect patients in their 50s and 60s.
· Nodular melanoma. These patients are usually younger (average, 30 to 50 years of age). These lesions are usually smaller than the other two types and are slightly raised and uniform in color. Unfortunately, these lesions tend to spread deeply into the underlying tissue and have the worst prognosis.
· Acrolentiginous melanoma. This condition is rare and is associated with lesions affecting the palmar and plantar surface of the extremities as well as the subungual skin. It is similar to lentigo maligna melanoma.
Rare before puberty, malignant melanoma may tend to bleed or ulcerate. Early metastasis occurs through the lymph nodes; late metastasis occurs through a hematogenous route and may affect the skin, liver, or lungs. A properly performed biopsy is essential for the diagnosis. If melanoma is diagnosed, the histologic interpretation of the biopsy determines the prognosis and treatment plan. General recommendations include performing an excisional biopsy whenever possible. Accepted techniques for excisional biopsy include punch, saucerization, and elliptic excision. Shave biopsy is not recommended. A shave biopsy will not miss a diagnosis of melanoma, but may interfere with the staging process of determining the depth of invasion. Treatment involves a full-thickness wide excision of the lesion and node dissection for advanced tumors. Prognosis depends on the depth of invasion.
Edman RL, Wolfe JT. Prevention and early detection of malignant melanoma. Am Fam Physician. 2000;62:2277–2285.
71. When treating anaphylaxis, which of the following, in addition to intravenous fluid, is considered the mainstay of treatment?
A) Diphenhydramine
B) Prednisone
C) Propanolol
D) Epinephrine
E) Naproxen
View Answer
Answer and Discussion
The answer is D. Anaphylaxis is a life-threatening reaction with respiratory, cardiovascular, cutaneous, or gastrointestinal manifestations that results from an exposure to a precipitating agent, usually a food, insect sting, medication, or physical factor. It causes approximately 1,500 deaths in the United States annually. The differential includes septic or other forms of shock, asthma, airway foreign body, panic attack, or other entities. Urinary and serum histamine levels and plasma tryptase levels drawn after onset of symptoms may help in the diagnosis. Prompt treatment of anaphylaxis is crucial, with subcutaneous or intramuscular epinephrine and intravenous fluids remaining the mainstay of management. Adjunctive measures include airway protection, antihistamines, steroids, and beta agonists. Patients taking β-blockers may require additional treatment. Patients should be observed for delayed or protracted anaphylaxis and instructed how to initiate urgent treatment for future episodes.
Tang AW. A practical guide to anaphylaxis. Am Fam Physician. 2003;68:1325–1332, 1339–1340.
72. The first step in the management of a lower gastrointestinal hemorrhage is to
A) obtain a CT scan of the abdomen
B) perform a bleeding scan
C) resuscitate the unstable patient
D) perform a colonoscopy
E) obtain a surgical consult
View Answer
Answer and Discussion
The answer is C. Gastrointestinal bleeding suspected from a lower source may be secondary to diverticular disease, angiodysplasia, ulcerative colitis, ischemic colitis, neoplasm, or hemorrhoids. The immediate response to significant bleeding is to resuscitate the patient if they are unstable. Further evaluation includes bowel studies, including flexible sigmoidoscopy or colonoscopy. Radioisotope bleeding scans may be helpful in identifying the site of bleeding if the volume is >0.1 to 0.4 mL/minute. However, positive findings in this type of testing must be verified with an alternative test because of a relatively high number of false-positive results. Angiography may be useful in patients with active bleeding >0.5 mL/minute and can identify highly vascular nonbleeding lesions such as angiodysplasia and neoplasms.
Clinical Practice and Practice Economics committee, American Gastroenterological Association. AGA technical review on the evaluation and management of occult and obscure gastrointestinal bleeding. Gastroenterology. 2000;118:201–221.
73. Which of the following patients affected with chronic knee pain is best suited for joint replacement?
A) 45-year-old mailman
B) 52-year-old weekend golfer
C) 70-year-old retired banker
D) 20-year-old college athlete with hopes of a professional career
E) 42-year-old business executive
View Answer
Answer and Discussion
The answer is C. Joint replacement is reserved for patients with intractable pain that does not respond to other medical regimens (i.e., nonsteroidal anti-inflammatory agents, gold or antimalarials, exercise and physical therapy, corticosteroids, and immunosuppressants). Surgery is usually reserved for patients older than 65 years who have severe arthritis. Osteoarthritis of the knee that is complicated by internal derangement may be treated with arthroscopic débridement or joint lavage. Osteotomy may be performed if significant malalignment of the knee or hip joints is present. Total joint arthroplasty usually has an excellent outcome and markedly improves quality of life. The life expectancy of the replaced joint varies, but is usually between 15 and 20 years.
Manek NJ, Lane NE. Osteoarthritis: current concepts in diagnosis and management. Am Fam Physician. 2000;61:1795–1804.
74. Which of the following is false regarding latex allergies?
A) Approximately 10% of health-care workers experience some form of allergic reaction to latex.
B) Latex is not found in catheters.
C) Persons allergic to latex also may be sensitive to fruits such as bananas, kiwis, pears, pineapples, grapes, and papayas.
D) Latex allergies became an important problem with the institution of universal precautions.
E) Many consumer products contain latex.
View Answer
Answer and Discussion
The answer is B. Latex allergy has become a significant problem since the widespread adoption of universal precautions against infection. As many as 17% of health-care workers experience some form of allergic reaction to latex, although not all are anaphylaxis. Recognizing latex allergy is crucial, because physicians may inadvertently expose the patient to more latex during treatment. Latex is in gloves, catheters, and numerous other medical supplies, as well as consumer products. Persons allergic to latex also may be sensitive to fruits such as bananas, kiwis, pears, pineapples, grapes, and papayas.
Latex Hypersensitivity Committee of the American College of Allergy, Asthma, and Immunology. Latex allergy—an emerging healthcare problem. Ann Allergy Asthma Immunol. 1995;75:19–21.
Tang AW. A practical guide to anaphylaxis. Am Fam Physician. 2003;68:1325–1332, 1339–1340.
75. Risk factors for colon cancer include all of the following except
A) history of breast cancer
B) Asian descent
C) inflammatory bowel disease
D) Peutz-Jeghers syndrome
E) prior hyperplastic polyps
View Answer
Answer and Discussion
The answer is E. Colorectal cancer is the leading cause of death due to cancer in the United States. Risk factors for colon cancer include the following:
· Personal or family history of colon cancer (two to four times risk when a first-degree relative is affected)
· Women with histories of breast or genital cancer
· Asian descent
· High-fat, low-fiber diet (although this is a controversial factor)
· Inflammatory bowel disease (greater risk with ulcerative colitis than with Crohn's disease)
· Gardner's syndrome
· Peutz-Jeghers syndrome
· Prior uterosigmoidostomy
· Advanced age (older than 50 years)
· History of colorectal polyps (adenomas)
The majority of cancers arise from preexisting adenomas and rarely do they form de novo. Warning signals for colorectal cancer include changes in bowel movements, abdominal pain, blood in the stool, fever, malaise, fatigue, or weight loss. A col-laborative group of experts convened by the U.S. Agency for Health Care Policy and Research has recommended screening for average-risk persons older than 50 years using one of the following techniques:
· fecal occult blood testing each year
· flexible sigmoidoscopy every 5 years
· fecal occult blood testing every year combined with flexible sigmoidoscopy every 5 years
· double-contrast barium enema every 5 to 10 years or colonoscopy every 10 years
Screening of persons with risk factors should begin at an earlier age, depending on the family history of colorectal cancer or polyps. Medicare has recently agreed to provide reimburse-ment for screening colonoscopy. The U.S. Agency for Health Care Policy and Research panel recommended that persons who have first-degree relatives with colorectal cancer or adenomatous polyps undergo screening for colorectal neoplasia beginning at 40 years of age or 10 years before the age at which the diagnosis was made in the affected relative, whichever is earlier. Because patients whose first-degree relatives developed colorectal cancer before the age of 50 years may be at higher risk, complete colonic evaluation with colonoscopy should be strongly considered. Persons with a family history of familial adenomatous polyposis should undergo flexible sigmoidoscopy or colonoscopy at puberty. Lower endoscopy should be repeated every 1 to 2 years, because adenomatous polyps throughout the bowel generally precede cancer. Genetic testing should be considered, especially in large families with many at-risk members; in such situations, genotyping may be more cost-effective than repeated endoscopy. Expert panels convened by the U.S. Agency for Health Care Policy and Research and the Cancer Genetics Studies Consor-tium recommend that persons who are members of a family that fits the clinical criteria for hereditary nonpolyposis colorectal cancer undergo colonoscopy at 20 to 25 years of age and every 1 to 3 years thereafter. In addition, these patients and their family members should be referred for genetic counseling. Patients with ulcerative colitis (or Crohn's disease) are commonly screened every 1 to 2 years by colonoscopy with multiple random biopsy samples to look for dysplasia. This screening is initiated 7 to 8 years after the diagnosis of pancolitis and 12 to 15 years after the diagnosis of left-sided colitis.
Read TE, Kodner IJ. Colorectal cancer: risk factors and recommendations for early detection. Am Fam Physician. 1999;59:2975.
76. A 56-year-old man presents to your office. He reports persistent, severe chest pain after repeated bouts of vomiting over the past 24 hours. The most appropriate management involves
A) chest x-ray
B) administration of H2 antagonists
C) treadmill exercise testing
D) administration of proton pump inhibitor
E) observation with antiemetics
View Answer
Answer and Discussion
The answer is A. Esophageal rupture, also known as Boerhaave's syndrome, is a rare, life-threatening condition that can lead to mediastinitis and pleural effusions. A delay in the diagnosis can lead to a poor prognosis. Symptoms include midsternal chest pain after a severe episode of vomiting. Associated conditions include peptic ulcer disease, alcoholism, and other neurologic disorders. The differential diagnosis includes myocardial infarction, pulmonary embolism, pancreatitis, peptic ulcer disease with rupture, or a dissecting aortic aneurysm. Chest radiographs and CT scans of the chest usually show pneumomediastinum, and a barium swallow showing communication between the esophagus and pleural space can be used to confirm the diagnosis. Treatment involves immediate surgery and drainage of any associated fluid collection.
Townsend CM, ed. Sabiston textbook of surgery, 16th ed. Philadelphia: WB Saunders; 2001:724–726.
77. Facial sutures should be removed at
A) 24 hours
B) 3 to 5 days
C) 7 to 10 days
D) 14 days
E) Only absorbable sutures should be used on the face.
View Answer
Answer and Discussion
The answer is B. Postoperative care for lacerations does not include routine use of prophylactic antibiotics unless there is evidence of bacterial contamination or a risk factor is evident. Sutured or stapled lacerations should be covered with a pro-tective, nonadherent dressing for at least 24 to 48 hours to avoid 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 subject to high tension should be left in place for 10 to 14 days.
Hollander JE, Singer AJ. Laceration management. Ann Emerg Med. 1999;34:356–367.
78. The most appropriate treatment for cholesteatoma is
A) oral antibiotics
B) antibiotic otic drops
C) oral steroids
D) tympanostomy tube placement
E) surgical removal
View Answer
Answer and Discussion
The answer is E. A cholesteatoma results from a chronic otitis media and perforation of the tympanic membrane. Prolonged dysfunction of the eustachian tube with the development of chronic negative pressure results in the formation of a squamous epithelial lined sac, which remains chronically infected. Cholesteatomas may be recognized during otoscopic examination by the white debris in the middle ear and the destruction of the ear canal bone adjacent to the perforation. Bone destruction due to an otherwise unsuspected cholesteatoma may be demonstrated on a CT scan. Aural polyps are usually associated with cholesteatomas. A cholesteatoma, particularly with an attic perforation, greatly increases the probability of a serious complication (e.g., purulent labyrinthitis, facial paralysis, intracranial suppuration). A cholesteatoma typically erodes the temporal bone and may destroy the small ossicle bones. With time, they can erode into the facial nerve or into the brain. Treatment involves surgical removal.
Beers MH, Berkow R, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 17th ed. Whitehouse Station, NJ: Merck & Co.; 1999:677.
A cholesteatoma typically erodes the temporal bone and may destroy the small ossicle bones.
79. A 27-year-old woman presents to the emergency room complaining of periumbilical pain, anorexia, and vomiting. Physical findings show a fever of 101.5º F, rebound tenderness, and extreme pain with rectal examination. The patient is also found to have positive psoas and obturator signs. The most likely diagnosis is
A) bowel infarction
B) acute appendicitis
C) acute cholecystitis
D) torsion of the ovary
E) ectopic pregnancy
View Answer
Answer and Discussion
The answer is B. Appendicitis is the most common acute surgical condition of the abdomen. Approximately 7% of the population will have appendicitis in their lifetime, with the peak incidence occurring between the ages of 10 and 30 years. Despite technologic advances, the diagnosis of appendicitis is still based primarily on the patient's history and the physical examination. Prompt diagnosis and surgical referral may reduce the risk of perforation and prevent complications. The mortality rate in nonperforated appendicitis is less than 1%, but it may be as high as 5% or more in young and elderly patients in whom diagnosis may often be delayed, thus making perforation more likely. Appendicitis occurs when there is an obstruction in the appendiceal lumen. Although the symptoms are not always consistent, the typical presentation involves dull periumbilical pain that migrates to the right-lower abdomen. Anorexia, nausea, and vomiting usually accompany the onset of the abdominal pain. It is more common in adolescents; diagnosis in infants, the elderly, and obese and pregnant patients is often more difficult. Physical findings often include a low-grade fever, right-lower quadrant pain, rebound tenderness, and spasms of the overlying abdominal muscles with guarding. A positive psoas sign (i.e., pain with passive extension of the right hip) and obturator sign (i.e., pain with internal and external rotation of the flexed right hip) are strongly supportive of the diagnosis. Rectal examination may reveal localized tenderness. Laboratory results usually show a moderate leukocytosis (10,000 to 20,000 white blood cells/mm3) with a left shift; however, this finding neither confirms nor excludes the diagnosis. Hematuria, proteinuria, and pyuria may be present. Visualization of the appendiceal lumen with a barium enema rules out the diagnosis. Ultrasound and CT examination may be helpful in determining the diagnosis in complicated cases. CT, specifically the technique of appendiceal CT, is more accurate than ultrasonography. Appendiceal CT consists of a focused, helical, appendiceal CT after a gastrografin saline enema (with or without oral contrast) and can be performed and interpreted within 1 hour. Intravenous contrast is unnecessary. The accuracy of CT is due in part to its ability to identify a normal appendix better than ultrasonography. An inflamed appendix is more than 6 mm in diameter, but the CT also demonstrates periappendiceal inflammatory changes. If appendiceal CT is not available, then a standard abdominal/pelvic CT with contrast remains highly useful and may be more accurate than ultrasonography. In most cases, diagnostic testing is unnecessary for the typical presentation of appendicitis. If the patient is suspected of having appendicitis, he or she should be given nothing by mouth, and surgical consultation should be pursued.
Hardin DM. Acute appendicitis: review and update. Am Fam Physician. 1999;60:2027–2034.
80. Application of tissue adhesives is useful in repairing lacerations; which of the following statements regarding adhesives is not true?
A) They are resistant to bacterial growth.
B) They have lower tensile strength when compared to sutures.
C) They are not useful on the hand.
D) Exposure to water has little effect on adhesives.
E) Adhesives are not recommended over high-tension areas.
View Answer
Answer and Discussion
The answer is D. Tissue adhesives are used to close lacerations and have some advantages and disadvantages when compared to traditional suturing. Adhesives are resistant to bacterial growth and they have lower tensile strength when compared to sutures. They are not useful on the hand, and exposure to water is contraindicated. Adhesives are not recommended over high-tension areas.
Hollander JE, Singer AJ. Laceration management. Ann Emerg Med. 1999;34:356–367.
81. Diagnosis of corneal abrasions can best be accomplished in a family physician's office with
A) fluorescein dye examination
B) slit-lamp examination
C) hand-held ophthalmoscope
D) visual field testing
E) Schiøtz's tonometer
View Answer
Answer and Discussion
The answer is A. Eye injuries are frequently encountered in the family physician's office. The following are some of the most common:
· Corneal abrasions. Corneal abrasions occur when there is localized loss of epithelium from the cornea typically caused by trauma. Symptoms include pain, foreign body sensation, tearing, and injection. A fluorescein dye examination is used to diagnose corneal abrasions. Treatment involves instilling a topical anesthetic before an examination is performed, followed by administering the fluorescein dye. A Wood's light is then used to examine all four quadrants of the globe. If an abrasion is detected, antibiotic drops are applied and the eye is covered for 24 hours (some recent evidence shows that patching may not always be necessary and may delay healing). The patient should be reexamined in 24 hours when the patch is removed. Visual acuity should be tested at the time of presentation and again the day after. Repeated patching with reexamination every 24 hours may be necessary until the abrasion heals. Antibiotic drops are usually continued for an additional 5 days.
· Foreign bodies. Inspection of the entire cornea is necessary to identify foreign bodies. The upper and lower eyelid should also be inspected. Foreign bodies should be removed by flushing with normal saline, cotton swab, eye spud, or 25-gauge needle. Fluorescein dye examination should be performed to rule out an abrasion. Rust rings should be examined for and removed as much as possible by an ophthalmologist; however, complete removal is unnecessary.
· Blunt trauma. Blunt trauma can cause orbital wall fractures. Signs and symptoms include diplopia, epistaxis, ecchymosis, crepitus, hypesthesia in the infraorbital nerve distribution, and restricted upward gaze secondary to inferior rectus entrapment. CT of the orbits is necessary for diagnosis. Surgical referral is indicated.
· Subconjunctival hemorrhage. This condition is present when there is a well-demarcated area of injection from the rupture of small subconjunctival vessels. Causes include trauma, coughing, vomiting, straining, or viral hemorrhagic conjunctivitis. Blood in the anterior chamber indicates a hyphema and requires immediate ophthalmologic referral.
Graber MA, Toth PP, Herting RL Jr. University of Iowa: The Family Practice Handbook, 3rd ed. St. Louis: Mosby; 1997:525.
82. Which of the following statements about epistaxis is true?
A) Unless there are previous symptoms of infection, the use of antibiotics while nasal packs are in place is unwarranted.
B) Nasal packs should be left in place for at least 72 hours.
C) In most cases, anterior bleeding originates from Kiesselbach's area.
D) The use of silver nitrate or electric cautery is contraindicated in the nose.
E) Patients with chronic obstructive pulmonary disease are not affected by nasal packing, because the majority are mouth breathers.
View Answer
Answer and Discussion
The answer is C. Nosebleeds can be caused by a number of different mechanisms including trauma, nose picking, infection, foreign bodies, excessive drying of the nasal mucosa, and bleeding disorders. Most bleeding originates from a plexus of vessels in the anteroinferior septum called Kiesselbach's plexus. In most cases, pinching the nasal ala together for 10 to 15 minutes stops the bleeding. If nasal bleeding continues, identifying the source is the goal. Once the source is located, nasal packing or cauterization with silver nitrate or electric cautery may be necessary. If the nose is packed, antibiotics such as trimethoprim-sulfamethoxazole should be started while the packing is in place. Packs should not be left in place more than 48 hours. If bleeding continues, a posterior source is most likely the cause, and a posterior pack should be placed by an otolaryngologist. Hospitalization for observation is indicated with serial blood counts in posterior bleeds. For severe nosebleeds, a bleeding time and von Willebrand's factor should be checked to rule out bleeding disorders. Caution should be used when placing nasal packs in patients with chronic obstructive pulmonary disease, because the nasopulmonary reflex can produce a 15 mm Hg drop in PO2.
Graber MA, Toth PP, Herting RL Jr. University of Iowa: The Family Practice Handbook, 3rd ed. St. Louis: Mosby; 1997:699–700.
83. A patient collapses in your office. A cardiac monitor is placed and the rhythm is determined to be ventricular fibrillation. Despite three defibrillation shocks, intravenous epinephrine, and a further attempt at defibrillation there is no change. The patient is unconscious. What is the most appropriate next step?
A) Another attempt at defibrillation
B) Administer lidocaine
C) Administer amiodarone
D) Administer procainamide
E) Administer magnesium sulfate
View Answer
Answer and Discussion
The answer is C. Intravenous amiodarone appears to be more effective than lidocaine, as demonstrated in the ALIVE trial of 347 patients with persistent or recurrent VF despite three defibrillation shocks, intravenous epinephrine, and a further attempt at defibrillation.
Dorian P, Cass D, Schwartz B, et al. Amiodarone as compared with lidocaine for shock-resistant ventricular fibrillation. N Engl J Med. 2002;346:884.
84. A 60-year-old man presents with pain in the upper legs that is exacerbated with walking. Symptoms are relieved with sitting. Peripheral pulses are intact. The most likely diagnosis is
A) spinal stenosis
B) claudication
C) dissecting aortic aneurysm
D) incarcerated inguinal hernia
E) myasthenia gravis
View Answer
Answer and Discussion
The answer is A. Spinal stenosis is a condition characterized by pain in the legs, calves, thighs, and buttocks that occurs with walking, running, or climbing stairs. Symptoms are often relieved by flexing at the spine or sitting. Conversely, lying prone or in any position that extends the lumbar spine exacerbates the symptoms, presumably because of ventral infolding of the ligamentum flavum in a canal already significantly narrowed by degenerative osseus changes. Middle-age patients and the elderly are most commonly affected. Typically, the earliest complaint is back pain, which is relatively nonspecific and may result in delayed diagnosis. Patients then often experience leg fatigue, pain, numbness, and weakness, sometimes several months to years after the back pain was first noticed. Patients may undergo minor trauma that can exacerbate symptoms, which may lead to a more rapid diagnosis. Once the leg pain begins, it is most commonly bilateral, involving the buttocks and thighs and spreading distally toward the feet, typically with the onset and progression of leg exercise. In some patients, the pain, paresthesias, and/or weakness are limited to the lower legs and feet, remaining present until movement ceases. The lower extremity symptoms are almost always described as burning, cramping, numbness, tingling, or dull fatigue in the thighs and legs. Disease onset is usually insidious; early symptoms may be mild and progress to become extremely disabling. Symptom severity does not always correlate with the degree of lumbar canal narrowing. Causes include osteoarthritis, spondylolisthesis with associated edema in the area of the cauda equina, and Paget's disease affecting the lower spine. Spinal stenosis may be difficult to distinguish from claudication; however, with spinal stenosis, there are usually neurologic deficits present and peripheral pulses are normal. MRI scanning, with its multiplanar-imaging capability, is currently the preferred modality for establishing a diagnosis and excluding other conditions. The MRI depicts soft tissues, including the cauda equina, spinal cord, ligaments, epidural fat, subarachnoid space, and intervertebral discs, with exquisite detail in most instances. Loss of epidural fat on T1-weighted images, loss of cerebrospinal fluid signal around the dural sac on T2-weighted images, and degenerative disc disease are common features of lumbar stenosis on MRI. Treatment for symptomatic lumbar stenosis is usually surgical decompression. Medical treatment alternatives such as bed rest, pain management, and physical therapy should be reserved for use in debilitated patients or patients whose surgical risk is prohibitive as a result of concomitant medical conditions.
Alvarez JA, Hardy RH Jr. Lumbar spine stenosis: a common cause of back and leg pain. Am Fam Physician. 1998;57:1825.
85. A 31-year-old man is brought to the emergency room after suffering severe injuries in a motorcycle accident. A dipstick urinalysis shows hemoglobin. However, the microscopic examination fails to show red blood cells (RBCs). The most likely diagnosis is
A) renal trauma
B) urethral rupture
C) laboratory error
D) myoglobinuria
E) underlying urinary tract infection
View Answer
Answer and Discussion
The answer is D. Myoglobinuria is a condition that results when there is massive muscle destruction known as rhabdomyolysis. The condition occurs as a result of severe infection, toxic insult, inflammation, or metabolic or traumatic damage to the muscles. Laboratory findings include elevated creatinine kinase, lactate dehydrogenase, aspartate aminotransferase, alanine aminotransferase, and a positive urine test for blood with the absence of RBCs. Specific tests for the detection of myoglobinuria are done with immunoassay. Treatment involves correcting the underlying causative factor and administering fluids. Renal failure may require further treatment.
Beers MH, Berkow R, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 17th ed. Whitehouse Station, NJ: Merck & Co.; 1999:1808.
86. At what age do children develop anticipatory pain when faced with a potentially painful situation?
A) 3 months
B) 6 months
C) 12 months
D) 24 months
E) 36 months
View Answer
Answer and Discussion
The answer is B. Children's perception of pain is influenced by age, cognitive level, and past experiences of painful experiences. Other factors affecting pain perception include the perceived cause and expected duration of the pain, extent of control over the situation, and parental response. The response to pain differs with the level of development and age of the child. Treatment approaches should account for these differences. Following are some characteristics:
· Younger than 6 months: Infants do not express anticipatory fear. Their level of anxiety reflects that of the parent. Typical responses are facial grimacing, thrashing of extremities, withdrawal from the painful stimulus, and crying a few seconds after the event.
· 6 to 18 months: Infants begin to develop fear of painful experiences and withdraw when pain is anticipated (e.g., when they see a needle).
· 18 to 24 months: Children express pain with words such as “hurt” or “boo boo.”
· 3 years: Children more reliably assess the pain they feel. They begin to localize pain and identify external causes. However, they depend on a visual injury or cause for adequate localization and are unable to understand a reason for pain. Control over certain aspects of a procedure (e.g., when and where it is performed) improves their tolerance.
· 5 to 7 years: Children in this age group have improvements in understanding of pain, the ability to localize internal pain, and cooperation.
Comprehension continues to grow as the child becomes older. By adolescence, patients become more adept at qualifying and quantifying pain, and they develop cognitive coping strategies that help to diminish physical pain.
Joseph MH, Brill J, Zeltzer LK. Pediatric pain relief in trauma. Pediatr Rev. 1999;20:75.
87. Duodenal obstruction is associated with which of the following radiographic signs?
A) Bird's beak sign
B) Hampton's hump
C) Double bubble sign
D) Kerley B lines
E) Scalloping of the diaphragm
View Answer
Answer and Discussion
The answer is C. Duodenal obstruction is a congenital abnormality that can be caused by several different abnormalities, including duodenal atresia, duodenal stenosis, and malrotation of the intestine. Infants with Down syndrome are at increased risk. Symptoms include projectile vomiting after the first few feedings. Polyhydramnios may also be present during pregnancy and is caused by a failure of absorption of amniotic fluid in the distal intestine. Diagnosis is usually made radiographically. Plain radiographs show the characteristic “double bubble” sign—one large bubble in the stomach with a smaller adjacent bubble that represents the duodenum. If atresia is present, no abdominal gas is seen in the distal bowel; however, if stenosis is present, a small amount of gas may be present. A barium swallow helps localize the site of obstruction. Treatment involves nasogastric suction to decompress the stomach and surgery to correct the obstruction.
Townsend CM, ed. Sabiston textbook of surgery, 16th ed. Philadelphia: WB Saunders; 2001:1469.
Duodenal obstruction is associated with a “double bubble” radiographic sign.
88. When repairing a facial laceration, it is important to test all aspects of the facial nerve. Which of the following tasks tests the zygomatic branch?
A) Contract the forehead and elevate the eyebrow
B) Open and shut the eyes
C) Smile
D) Frown
E) Contract the platysma muscle
View Answer
Answer and Discussion
The answer is B. When repairing a facial laceration the facial nerve function should be tested in all five branches as follows:
· Temporal: Contract the forehead and elevate the eyebrow
· Zygomatic: Open and shut eyes
· Buccal: Smile
· Mandibular: Frown
· Cervical: Contract the platysma muscle
Trott AT. Wounds and Lacerations. St. Louis: Mosby-Year Book, 1991.
89. A 42-year-old woman following the American Cancer Society guidelines should have a mammogram
A) beginning at 50 years of age
B) every 2 years
C) every year
D) every 3 years
E) every 5 years
View Answer
Answer and Discussion
The answer is C. Breast cancer is the most common cancer that affects women. Approximately 1 in 9 to 10 women will have breast cancer during her life. Unfortunately, it is the second leading cause of cancer death. The screening guidelines for the diagnosis of breast cancer are continually changing. Because of increased awareness of the signs and symptoms of breast cancer and the use of screening mammograms, breast cancers are increasingly being diagnosed at earlier stages. The American Cancer Society recommends annual mammograms and clinical breast examinations for women older than 40 years. Women older than 20 years should be encouraged to do monthly breast self-examinations, and women between 20 and 39 years of age should have a clinical breast examination every 3 years. These guidelines are modified for women with risk factors, particularly those with a strong family history of breast cancer. Risk factors for breast cancer include the following:
· First-degree relative with breast cancer (especially premenopausal)
· Prior breast cancer in the patient
· Nulliparity
· First pregnancy after the age of 35 years
· Early menarche (before age 12 years)
· Late menopause (older than 50 years)
· BRCA gene mutation
· Age older than 50 years
· Age older than 30 at first birth
· Obesity
· High socioeconomic status
· Atypical hyperplasia on biopsy
· Ionizing radiation exposure
Apantaku LM. Breast cancer diagnosis and screening. Am Fam Physician. 2000;62:596–602, 605–606.
90. Which of the following foreign bodies should not be removed with irrigation from the ear?
A) Plastic bead
B) Small pebble
C) BB
D) Alkaline button battery
E) Metal part from a matchbox car
View Answer
Answer and Discussion
The answer is D. Small, inorganic objects can be removed from the external auditory canal by irrigation. The irrigation solution should be at body temperature, and the stream of water should be directed along the superior margin of the external ear canal and should deliver an adequate volume of water with brisk flow. This volume can be achieved using a 20 to 50 mL syringe attached to a flexible catheter or plastic tubing from a butterfly needle. This technique is contraindicated if the tympanic membrane is perforated or the foreign body is vegetable matter or an alkaline button battery. Organic matter swells as it absorbs water, leading to further obstruction. Irrigation of the button battery enhances leakage and potential for liquefaction necrosis.
Kavanagh KT, Litovitz T. Miniature battery foreign bodies in auditory and nasal cavities. JAMA. 1986;255:1470.
91. Which of the following is the best time for a woman to perform breast self-examination?
A) During mid-cycle
B) One week before menses
C) During the first week after menses
D) During menstruation
View Answer
Answer and Discussion
The answer is C. Breast self-examination should begin at 20 years of age and be repeated each month during the first week following menses, which is when fibrocystic changes are less prominent. The technique involves examining all quadrants of the breast in a systematic, circular motion. The tips of the middle three fingers should be used, and patients should examine themselves sitting up and in the supine position. The recommendations for mammographic screening include screening every 1 to 2 years after age 40.
If a woman has a strong family history for breast cancer, BRCA gene mutation, or a previous abnormal mammogram, more frequent screening may be necessary. Medicare pays for biannual screening for women older than 65 years. The false-negative rate for mammography is approximately 10% to 15%. Elderly women whose life expectancy is 5 to 10 years should continue to undergo mammographic and clinical breast examination screening.
Apantaku LM. Breast cancer diagnosis and screening. Am Fam Physician. 2000;62:596–602, 605–606.
92. Which of the following is associated with a positive Tinel's sign?
A) Carpal tunnel syndrome
B) Scaphoid fracture
C) de Quervain's tenosynovitis
D) Raynaud's phenomenon
E) Gamekeeper's thumb
View Answer
Answer and Discussion
The answer is A. Carpal tunnel syndrome occurs when there is an entrapment of the median nerve at the level of the wrist. Symptoms include pain, numbness, and paresthesia in the distribution of the median nerve, including the palmar surface of the first three fingers. Symptoms characteristically occur at night and may awaken the patient. Symptoms may also involve the forearm or shoulder. Women are more frequently affected than men, and the condition can involve one or both hands. Percussion of the median nerve at the area of the carpal tunnel (Tinel's sign), sustained flexion of the wrist (Phalen's sign), or extension of the wrist (reverse Phalen's sign) reproduce symptoms. Other clinical findings include weakness of the thumb and thenar atrophy. Carpal tunnel syndrome is associated with continuous repetitive flexion of the wrist, pregnancy (most cases resolve after delivery), acromegaly, rheumatoid arthritis, and myxedema. Nerve conduction tests are used to help make the diagnosis but are not always necessary. Treatment includes anti-inflammatory agents, wrist braces, and steroid injections; surgery is indicated in severe cases that are unresponsive to conservative therapy.
Taylor R, David AK, Johnson TA Jr, et al., eds. Family medicine: principles and practice, 5th ed. New York: Springer-Verlag; 1998:576–577.
93. Which of the following is indicated immediately after a minor burn?
A) Application of butter
B) Rapid cooling with ice
C) Extensive debridement of non viable skin
D) Application of room temperature water
E) Firm washing to remove particulate matter
View Answer
Answer and Discussion
The answer is D. Initial treatment of minor thermal injuries consists mainly of cooling (with room temperature water, not with ice), simple gentle cleansing with mild soap and water, and appropriate dressing. Pain management and tetanus prophylaxis are important. Extensive debridement is generally not immediately necessary and may be deferred until the initial follow-up visit.
Morgan ED, Miser WF. Treatment of minor thermal burns. Up to Date, version 14.1. Accessed 3/20/2006.
94. A 17-year-old high school football player is knocked unconscious for a brief period during a game for which you provide medical coverage. He now is doing well, and the results of his examination are normal. The most appropriate action is
A) transfer the athlete to a local emergency room
B) keep the athlete out of the game for a full quarter; if he remains normal, he may return to play
C) prohibit the athlete from returning to play for 5 to 7 days
D) allow the athlete to return to competition after 10 additional minutes of normal observation
E) prohibit the athlete from returning to play for the rest of the season
View Answer
Answer and Discussion
The answer is C. If the cervical spine is not injured and the level of consciousness is not significantly altered, the athlete can be allowed to sit up and, if stable, walk off the field with support. A review of symptoms and a complete neurologic and head and neck evaluation are performed on the bench. If the examination is negative, the athlete should be observed for 15 minutes (typically one quarter of play) unless there is a history of loss of consciousness. If no loss of consciousness and no return of symptoms occur during the 15 minutes, the next step is a provocative test such as a 40-yard dash. If no symptoms return, the athlete may be returned to the game, but repeated observations must be performed. If any symptoms return, the athlete must be removed from the game. If the athlete has documented loss of consciousness or signs and symptoms that did not clear in 15 minutes or that returned with the provocative test, the athlete should not be allowed to return to competition. Any new or unusual headaches within the first 48 to 72 hours after the injury should be treated as a medical emergency. In addition, any deterioration in mental status or deterioration in physical condition is a medical emergency. When to return the athlete to play after the first concussion that resulted in loss of consciousness is controversial. Most recommend that the athlete not compete for 5 to 7 days. Before any return to competition, the athlete must be evaluated by the same clinician who performed the initial evaluation.
Wojtys EM, Hovda D, Landry G, et al. Concussion in sports. Am J Sports Med. 1999;27:676–687.
95. A 21 year old is brought to the emergency room by ambulance after developing sudden shortness of breath. A chest radiograph shows a 10% pneumothorax. The patient remains stable. Appropriate management includes
A) immediate chest tube placement
B) intubation and mechanical ventilation
C) pulmonary function testing
D) large-bore needle placed in the second intercostal space
E) observation
View Answer
Answer and Discussion
The answer is E. Pneumothorax is the accumulation of air within the pleural space. The usual cause of pneumothorax is a penetrating wound such as a stabbing, gunshot wound, or deceleration-type injury (e.g., as seen in motor vehicle accidents). Spontaneous pneumothorax can also occur and typically affects tall, thin men or smokers (as a result of a ruptured bleb). Clinical findings include decreased breath sounds on the side affected, shortness of breath, chest pain (most common symptom), cough, distended neck veins, and hypotension. A chest radiograph is usually diagnostic. Treatment may require immediate intervention but in many cases depends on the extent of pneumothorax. If pneumothorax involves up to 15% to 20% of lung volume, observation is the only treatment necessary. Supplemental oxygen is usually administered, and most cases resolve in 10 days. For larger pneumothoraces, chest tube placement is necessary. Tension pneumothoraces require emergent decompression with a large-bore needle placed in the second intercostal space followed by chest tube placement.
Townsend CM, ed. Sabiston textbook of surgery, 16th ed. Philadelphia: WB Saunders; 2001:1180–1182.
96. If an unprotected individual develops minimal erythema after 20 minutes of sun exposure, after use of an SPF-8 sunscreen, minimal erythema would be expected after how many minutes exposure?
A) 60 minutes
B) 100 minutes
C) 160 minutes
D) 200 minutes
E) 300 minutes
View Answer
Answer and Discussion
The answer is C. Sun protection factor (SPF) is a measure of the ability of a blocking agent (typically clothing or sunscreen) to prevent erythema in response to sun exposure. The SPF can be multiplied by the time of exposure necessary to produce minimal erythema in an unprotected individual to get the expected time until minimal erythema using that protection. As an example, if an unprotected individual develops minimal erythema after 20 minutes of sun exposure, after use of an SPF-8 sunscreen, minimal erythema would be expected after 160 minutes of exposure. However, the duration of protection with sunscreen may be shorter in many circumstances than the SPF would indicate.
Johnson KR. Sunburn. Up to Date, version 14.1. Accessed 3/20/2006.
97. The most appropriate test for the detection of a subdural hematoma is
A) skull radiographs
B) CT of the head with and without contrast
C) CT of the head without contrast
D) MRI of the head
E) lumbar puncture
View Answer
Answer and Discussion
The answer is C. CT scans can be used to look for numerous intracranial processes. Intravenous contrast should be given when looking for intracranial tumors; however, the use of contrast is not necessary when looking for subdural, epidural, or intracranial hemorrhages. Blood is denser than brain tissue; thus, the color differential makes the diagnosis of intracranial blood accumulation relatively simple without contrast. Cerebral vascular accidents may not be immediately visible on CT scanning until several days after the event. Serial scans may show progressive involvement over several days if the stroke is severe. Contrast is not necessary for the detection of strokes.
Graber MA, Toth PP, Herting RL Jr. University of Iowa: The Family Practice Handbook, 3rd ed. St. Louis: Mosby; 1997:583.
When performing computed tomography (CT), intravenous contrast should be given when looking for intracranial tumors; however, the use of contrast is not necessary when looking for subdural, epidural, or intracranial hemorrhages.
98. For individuals with average risk factors, screening flexible sigmoidoscopy should begin at age
A) 40 years
B) 50 years
C) 65 years
D) 70 years
View Answer
Answer and Discussion
The answer is B. The U.S. Agency for Health Care Policy and Research has recommended screening for average-risk persons older than 50 years using one of the following techniques:
· fecal occult blood testing each year
· flexible sigmoidoscopy every 5 years
· fecal occult blood testing every year combined with flexible sigmoidoscopy every 5 years
· double-contrast barium enema every 5 to 10 years
· colonoscopy every 10 years
Screening of persons with risk factors should begin at an earlier age, depending on the situation. Digital rectal examinations should begin at 40 years of age. The major complication associated with flexible sigmoidoscopy is intestinal perforation, which occurs in <0.05% of cases. Polyps are usually described as sessile, broad based, or pedunculated. Polyps are usually classified histologically into hyperplastic and adenomatous types. If adenomatous polyps are noted, the patient should undergo colonoscopy to rule out synchronous polyps located more proximally in the colon. Tubular adenomas are the most common type of adenomatous polyp and have a 5% chance of malignant growth. Less commonly seen are villous-type polyps, which possess malignant cells in up to 40%. Size is also used to predict malignant potential. If the polyp is <1 cm, only 1% of polyps contain malignant growth. If the polyp is 1 to 2 cm, 10% contain malignant growth. If the polyp is >2 cm, 35% to 45% have malignant growth. Hyperplastic polyps have no malignancy potential.
Townsend CM, ed. Sabiston textbook of surgery, 16th ed. Philadelphia: WB Saunders; 2001:957.
99. Which of the following statements is false regarding the treatment of high-voltage lightning injuries?
A) Cervical spine immobilization and clearance should be performed.
B) Airway burns should be administered.
C) Tetanus immunization should be administered.
D) Serum CK-MB measurements should be measured to assess myocardial injury.
E) Cardiac monitoring should be maintained after the injury.
View Answer
Answer and Discussion
The answer is D. A patient exposed to a serious electrical burn or lightning strike should be treated as a trauma patient. Resuscitation should begin with a rapid assessment of airway and cardiopulmonary status. Cervical spine immobilization and clearance should be maintained, and tetanus vaccination should be administered. Coexisting smoke inhalation or airway burns should be excluded. Patients can have spontaneous cardiac activity but paralysis of the respiratory muscles. Prompt restoration of a secure airway may prevent secondary cardiac and neurologic dysfunction or death. Coma or neurologic deficit should include brain and/or spine imaging. An extensive head-to-toe and neurologic examination should be performed. The survivor of high-energy injury should have cardiac and hemodynamic monitoring due to the high incidence of arrhythmia and autonomic dysfunction, especially if there have been arrhythmias in the field or emergency department, loss of consciousness, or if the initial ECG is abnormal. Serum CK-MB measurements and ECG changes are poor measures of myocardial injury. The diagnostic and prognostic value of cardiac troponin levels has not been evaluated in this setting.
Xenopoulos N, Movahed A, Hudson P, et al. Myocardial injury in electrocution. Am Heart J. 1991;122:1481.
McBride JW, Labrosse KR, McCoy HG, et al. Is serum creatine kinase-MB in electrically injured patients predictive of myocardial injury? JAMA. 1986;255:764.
100. An 18 year old with a history of von Willebrand's deficiency is involved in a motor vehicle accident and presents to the emergency room. There is concern about bleeding; however, the patient is stable. You want to minimize the amount of fluid the patient receives. Which of the following would be indicated to help correct the coagulation disorder?
A) Platelets
B) Cryoprecipitate
C) Whole blood
D) Fresh frozen plasma (FFP)
E) Packed RBCs
View Answer
Answer and Discussion
The answer is B. The following are blood products available to treat various bleeding disorders and hemorrhagic conditions:
· Whole blood: Typically, whole blood is used to treat patients in an emergent setting who have lost more than 15% of their blood volume. Whole blood is less expensive than packed RBCs and plasma and has a lower infectious risk. The oxygen-carrying capacity and replacement of volume can be replaced as effectively with packed RBCs and crystalloid. However, the storage of whole blood is very inefficient, and most blood banks do not routinely store this product.
· Packed RBCs: Packed RBCs can be stored in cooled storage for up to 35 days; however, refrigerated temperatures cause platelets to degenerate, so banked, packed RBCs contain essentially no functioning platelets. Also, factors V and VII decrease with refrigeration; however, other factors remain unchanged. Packed RBC transfusion should be used only when time or the clinical situation precludes other therapy. Each unit of packed RBCs usually raises the hematocrit 2% to 3% in a 70-kg adult, although this varies depending on the donor, the recipient's fluid status, the method of storage, and its duration. Leukocyte-poor RBCs may be given to help reduce transfusion reactions in those who have experienced reactions with previous transfusions.
· Platelets: Platelet transfusions are indicated if patients have thrombocytopenia or platelet dysfunction, or both. Patients are usually administered 6 or 10 units at one time (6-pack or 10-pack). Multiple-unit, single-donor platelets are harvested from one donor using apheresis. After platelet transfusion in the adult, the platelet count obtained at 1 hour should rise at least 5,000 platelets/mm3 for each unit of platelets transfused. Patients may experience a smaller response after multiple transfusions. Platelets should not be routinely given for bleeding prophylaxis unless there is evidence of microvascular bleeding or planned surgery and the platelet count is <50,000/mm3 or the platelet count is <10,000/mm3 (for prophylaxis against bleeding). Previous guidelines of 20,000/mm3 are no longer used. Patients receiving massive transfusion should not automatically receive platelets in the absence of microvascular bleeding. Additionally, body temperature can affect platelets’ ability to function, and, ideally, body temperature should be restored before consideration of platelet transfusion.
· FFP: FFP is used to replace labile clotting factors. A unit of FFP contains near normal levels of all clotting factors, including approximately 400 mg of fibrinogen. A unit of FFP increases clotting factors by approximately 3%. Adequate clotting is usually obtained with factor levels >30% (however, higher levels are recommended before surgery). FFP is used to correct prothrombin time and activated partial thromboplastin time. FFP should not be used routinely after RBC transfusion without evidence of coagulopathy, as a volume expander, nutritional supplement, or for hypoalbuminemia. A new FFP called solvent detergent plasma is treated to inactivate enveloped viruses (human immunodeficiency virus; hepatitis B, C) and has virtually no risk in transmitting these viruses.
· Cryoprecipitate: Cryoprecipitate is useful in treating factor deficiencies such as hemophilia A, von Willebrand's disease, and hypofibrinogenemia. Because proteins are in high concentrations, a smaller volume can be used than with FFP. Cryoprecipitate is usually administered as a transfusion of 10 single units.
Townsend CM, ed. Sabiston textbook of surgery, 16th ed. Philadelphia: WB Saunders; 2001:70–73.
101. Which of the following medications could make the pain of acute cholecystitis worse?
A) Acetaminophen
B) Propoxyphene
C) Meperidine
D) Morphine
E) Naproxen
View Answer
Answer and Discussion
The answer is D. The administration of morphine during attacks of pancreatitis can lead to spasm of the sphincter of Oddi and exacerbate pain symptoms; therefore, meperidine is typically used for the treatment of pain associated with cholecystitis. It is important to remember that meperidine (Demerol) has several disadvantages when compared with other narcotic preparations. In particular, there is potential for a neurotoxic metabolite, normeperidine, to accumulate and cause seizures, myoclonus, and tremors. This may be of specific concern for alcoholic patients who are already at risk for developing neurologic complications of ethanol withdrawal. Furthermore, meperidine has a shorter duration of action than morphine or hydromorphone and is, therefore, less effective for sustained analgesia and more likely to result in a potentially avoidable “rebound” effect. Finally, meperidine is more likely to cause muscle fibrosis than competing narcotics when administered intramuscularly.
Munoz A, Katerndahl DA. Diagnosis and management of acute pancreatitis. Am Fam Physician. 2000;62:164–174.
102. Which of the following is a risk factor for a near-drowning or drowning event?
A) Resident of Northeast coastal states
B) Age between 6 to 10 years
C) Low socioeconomic status
D) White/Caucasian race
E) Female sex
View Answer
Answer and Discussion
The answer is C. The highest incidence of near-drowning occurs among males, African Americans, children between the ages of 1 and 5 years, persons with low socioeconomic status, and among residents of southern states. Drowning is much more common during the summer months.
Quan L, Cummings P. Characteristics of drowning by different age groups. Inj Prev. 2003;9:163.
Ellis AA, Trent RB. Hospitalizations for near drowning in California: incidence and costs. Am J Public Health. 1995;85:1115.
103. Which of the following statements regarding acute pancreatitis is true?
A) All patients should receive nasogastric suction to maintain strict bowel rest.
B) Anticholinergics are useful in the treatment of acute pancreatitis.
C) Amylase is the most sensitive and specific test for the detection of acute pancreatitis.
D) Enteral feedings (distal to the ligament of Treitz) can be beneficial after 48 hours for severe cases.
E) Nausea and vomiting are rarely present.
View Answer
Answer and Discussion
The answer is D. Acute pancreatitis usually results from alcohol abuse or bile duct obstruction. Patients with acute pancreatitis present with mild to severe epigastric pain with radiation to the flank, back, or both. Classically, the pain is characterized as constant, dull, and boring, and is worse when the patient is supine. The discomfort may lessen when the patient assumes a sitting or fetal position. A heavy meal or drinking binge often triggers the pain. Nausea and nonfeculent vomiting are present in the vast majority of patients. Serum amylase and lipase (more sensitive and specific) levels are still used to confirm the diagnosis of acute pancreatitis. Although not routinely available, the serum trypsin level is the most accurate laboratory indicator for pancreatitis. Ultrasonography, CT, and endoscopic retrograde cholangiopancreatography are used in some cases for confirming the diagnosis. Prompt identification of patients who need intensive care referral or subspecialty consultation is crucial. Intravenous rehydration should usually be aggressive, with close attention to blood pressure and cardiac and pulmonary status. Therapies such as nasogastric suctioning, anticholinergics, and histamine H2-receptor blockers have not been shown to decrease symptoms or hospital stays in patients with acute pancreatitis. In the past, patients were routinely treated by withholding food and placing a nasogastric tube with suction for 2 to 10 days. This was done in an attempt to reduce pancreatic stimulation by food, hydrochloric acid, cholecystokinin, and secretin. Withholding food by mouth does reduce pain, but the use of a nasogastric tube with suction is no longer advocated as a routine therapeutic measure in acute pancreatitis, because it has not been shown to decrease symptoms, mortality, or hospital stay. However, a nasogastric tube may be used when the patient has protracted vomiting or if obstruction is seen on the abdominal radiograph. Anticholinergics have been used in an attempt to decrease gastric secretions and increase pH. As with the use of nasogastric tubes, anticholinergics do not decrease hospital stay or pain. In mild pancreatitis, oral intake should be withheld until the nausea and vomiting subside. Total enteral feeding beyond the ligament of Treitz administered within 48 hours of onset of severe acute pancreatitis may reduce the incidence of total and infectious complications. Systemic antibiotics (although controversial) have been found to improve outcome in patients with severe disease. With supportive care, most patients have a good clinical outcome.
Munoz A, Katerndahl DA. Diagnosis and management of acute pancreatitis. Am Fam Physician. 2000;62:164–174.
104. A 75 year old presents to your office complaining of anorexia, nausea, abdominal pain, and muscle weakness. Laboratory tests show an elevated calcium level. The most likely diagnosis is
A) osteoporosis
B) Paget's disease
C) hyperparathyroidism
D) myasthenia gravis
E) chronic fatigue syndrome
View Answer
Answer and Discussion
The answer is C. Hyperparathyroidism is a common cause of hypercalcemia. The incidence of hyperparathyroidism increases with age. Women are more commonly affected. The hypercalcemia usually is discovered during a routine serum chemistry profile. Often, there has been no previous suspicion of this disorder. In most patients initially believed to be asymptomatic, previously unrecognized symptoms resolve with surgical correction of the disorder. In the majority of the persons affected, primary hyperparathyroidism is the result of an adenoma in a single parathyroid gland. Hypertrophy of all four parathyroid glands causes hyperparathyroidism in a smaller percentage of patients. A very small number of cases of hyperparathyroidism result from parathyroid malignancies. In addition, the incidence of hyperparathyroidism is higher in patients with type I and type II multiple endocrine neoplasia syndromes, in patients with familial hyperparathyroidism, and in patients who received radiation therapy to the head and neck area for benign diseases during childhood. Chronic renal failure, rickets, and malabsorption syndromes are the most frequent conditions leading to secondary hyperparathyroidism. The symptoms of hyperparathyroidism are vague and often similar to symptoms of depression, irritable bowel syndrome, fibromyalgia, or stress reaction. Some combination of headaches, fatigue, anorexia, nausea, paresthesias, muscular weakness, pain in the extremities, pain in the abdomen, and other such nonspecific symptoms appears to be the most common presentation of primary hyperparathyroidism. Complications of primary hyperparathyroidism include peptic ulcers, nephrolithiasis, pancreatitis, and dehydration. Intravenous hydration is the most critical treatment for a patient with an acute presentation of hyperparathyroidism and hypercalcemia. The addition of furosemide (Lasix) increases urinary calcium loss. Administration of pamidronate (Aredia) inhibits bone resorption and lowers serum calcium levels. Other drugs that have been used in the management of acute hyperparathyroidism include calcitonin (Calcimar, Miacalcin), glucocorticoids, and mithramycin (Mithracin), although use of the latter agent is limited by its toxicity. When medical management is used, routine monitoring for clinical deterioration is recommended. Surgical management is usually indicated in most cases. Preoperative localization of adenomas with technetium Tc 99m sestamibi scan is possible but may be unnecessary. An experienced surgeon should perform the parathyroidectomy.
Allerheiligen DA, Schoeber J, Houston RE, et al. Hyperparathyroidism. Am Fam Physician. 1998:1795.
105. Patients who have been scuba diving should wait at least _____ before flying because of the risk of decompression illness.
A) 4 hours
B) 12 hours
C) 24 hours
D) 72 hours
E) 1 week
View Answer
Answer and Discussion
The answer is B. Patients who travel by air soon after scuba diving are at increased risk for developing decompression sickness (DCS) inflight. Such a passenger should be advised to wait 12 hours before flying, if he or she has been making only 1 dive/day. Individuals who have participated in multiple dives or those requiring decompression stops should consider waiting up to 48 hours before flying.
Sheffield PJ. Flying after diving guidelines: a review. Aviat Space Environ Med. 1990;61:1130.
Freiberger JJ, Denoble PJ, Pieper CF, et al. The relative risk of decompression sickness during and after air travel following diving. Aviat Space Environ Med. 2002;73:980.
106. Which of the following statements is true regarding breast implants?
A) There is a higher incidence of connective tissue disease in patients who received silicone breast implants.
B) There is a higher incidence of breast cancer in women who have had breast augmentation.
C) Mammography (with Eklund views) can be helpful in assessing breast lumps after augmentation.
D) MRI is not helpful in detecting rupture of breast implants.
E) According to the U.S. Food and Drug Administration, all women with silicone breast implants should have them removed.
View Answer
Answer and Discussion
The answer is C. Women who have undergone augmentation mammoplasty with silicone gel implants may present for routine breast cancer screening or with palpable breast lumps. Conventional mammography supplemented by additional displaced or Eklund view is usually sufficient to detect most abnormalities. Ultrasonographic evaluation may be performed as an ancillary technique to characterize palpable lumps or nonpalpable lesions detected on mammography. In patients suspected of having implant rupture, conventional mammography and displaced views are performed. If clinical findings warrant, an MRI may be performed to detect intracapsular and extracapsular rupture and migration of silicone globules to the axilla, branchial plexus, and adjacent structures. A relationship between connective-tissue diseases and silicone breast implants has been the focus of controversy since the early 1990s. All studies investigated support that there is no evidence of an increased risk of any specific connective-tissue disease, all definite connective-tissue diseases combined, or other autoimmune conditions associated with the use of breast implants, including nonsilicone and silicone implants.
Janowsky EC, Kupper LL, Hulka BS, et al. Meta-analyses of the relation between silicone breast implants and the risk of connective-tissue diseases. N Engl J Med. 2000;342:781–790.
107. Weight-loss surgery (vertical-banded gastroplasty and gastric bypass) can be considered in individuals who have a body mass index that exceeds
A) 10 kg/mm2
B) 20 kg/mm2
C) 30 kg/mm2
D) 40 kg/mm2
E) 50 kg/mm2
View Answer
Answer and Discussion
The answer is D. For persons with very severe obesity (body mass index >40 kg/mm2) and those with less severe obesity and serious or life-threatening complications, surgical procedures may represent an option for treatment. The procedures can result in large weight losses that are usually well maintained for more than 5 years. The most common operations—vertical banded gastroplasty and gastric bypass—radically reduce stomach volume by creating a gastric pouch of no more than 25 mL in volume. Weight loss after surgery is rapid at first, slowing gradually over a period of 2 years. It is directly proportional to the extent of obesity and usually varies between 40 and 60 kg. The weight loss is accompanied by marked improvement in medical complications as well as in mood, self-esteem, body image, activity levels, and interpersonal and vocational effectiveness. In experienced hands, preoperative and operative mortality is usually less than 1%, and operative complications are <10%. Medication can be used when the body mass index reaches 30 kg/mm2 without comorbidities or 27 kg/mm2 when other risk factors are present.
Beers MH, Berkow R, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 17th ed. Whitehouse Station, NJ: Merck & Co.; 1999:62.
108. How long should air travel be postponed after a patient experiences an uncomplicated myocardial infarction?
A) 1 week
B) 2 weeks
C) 1 month
D) 6 months
E) 1 year
View Answer
Answer and Discussion
The answer is B. Based on consensus opinion of the ASMA, the American College of Cardiology (ACC), and the American Heart Association (AHA), patients with uncomplicated myocardial infarctions (MI) or those who have undergone uncomplicated percutaneous coronary interventions should not fly until at least 2 to 3 weeks have passed and they are tolerating their usual daily activities. The week immediately after coronary stent placement carries the highest risk for stent thrombosis, and patients should not travel by air during this period. Following an MI, a stress test is recommended in all low-risk patients. Results gained from testing help determine the patient's ability to tolerate flight. Patients with an MI complicated by severely depressed cardiac function or an untoward event during treatment should not fly until 2 weeks after they are deemed medically stable. Unstable angina is a contraindication to air travel; stable angina is generally well tolerated during flight. Severe decompensated congestive heart failure (CHF) is a contraindication to flight. Patients with class III or IV New York Heart Association CHF should be carefully assessed to determine whether they require inflight oxygen. Symptomatic valvular heart disease is a relative contraindication to airline travel.
Possick SE, Barry M. Evaluation and management of the cardiovascular patient embarking on air travel. Ann Intern Med. 2004;141:148.
Prout M, Pine JR. Preflight patient assessment. Up to Date, version 14.1. Accessed 3/20/2006.
Based on consensus opinion of the ASMA, the American College of Cardiology (ACC), and the American Heart Association (AHA), patients with uncomplicated myocardial infarctions (MI) or those who have undergone uncomplicated percutaneous coronary interventions should not fly until at least 2 to 3 weeks have passed and they are tolerating their usual daily activities.
109. Which of the following is true regarding patient-controlled anesthesia (PCA)?
A) The administration is labor intensive.
B) Oversedation can usually be avoided.
C) The delivery system can usually increase the time interval between patient demand and delivery of the medication.
D) Basal infusion rates should be routinely delivered.
E) Patient response is not a good indicator of PCA effectiveness.
View Answer
Answer and Discussion
The answer is B. Opioid analgesics are used in managing severe acute postoperative pain. Injectable nonsteroidal anti-inflammatory drugs (e.g., ketorolac) are also useful, and regional anesthetic techniques (e.g., local spinal anesthetic) are used in some cases. An opioid may be administered epidurally, typically administered during surgery and continued 2 to 3 days postoperatively. In the recovery room, morphine sulfate or meperidine are medication options. The dose of narcotics may have to be repeated at short intervals (e.g., every 15 to 30 minutes) until pain relief is established. On the hospital floor, parenteral morphine sulfate usually provides pain relief. Higher doses provide greater analgesia and a longer duration of effect. PCA allows self-administration of small opioid doses as needed. It has become the standard of care for the administration of postoperative narcotic analgesics for pain control. Dosage (frequency and amount) should be modified according to the patient's response. By limiting the number of doses of medication per hour, the physician can avoid oversedation of the patient. PCA pumps avoid the lag period between when the patient senses pain and initiates the call for medication and actual delivery by the nurse. It can also reduce the amount of work of drawing up and delivering multiple doses of medication by the nursing staff. PCA pumps can also deliver a constant rate of medication per hour whether or not the patient hits the demand button. Studies have shown that most patients don't benefit from the additional basal infusion rate, and oversedation may occur with it. Only patients with a high narcotic tolerance may be good candidates for basal infusion rates.
Townsend CM, ed. Sabiston textbook of surgery, 16th ed. Philadelphia: WB Saunders; 2001:287.
Beers MH, Berkow R, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 17th ed. Whitehouse Station, NJ: Merck & Co.; 1999:1370–1371.
110. A 31 year old is seen in the emergency room for lateral foot pain that occurred when he fell playing basketball. X-rays of the foot confirm a displaced fracture of the proximal fifth metatarsal. Appropriate management consists of
A) nonsteroidal anti-inflammatory drugs and limited weight bearing with a gradual return to usual activities in 2 to 4 weeks
B) crutches with no weight bearing for 4 to 6 weeks
C) short leg walking cast for 6 to 8 weeks
D) external reduction followed by casting for 6 to 8 weeks with limited weight bearing
E) orthopedic referral
View Answer
Answer and Discussion
The answer is E. Fractures of the proximal portion of the fifth metatarsal may be classified as avulsions of the tuberosity or fractures of the shaft within 1.5 cm of the tuberosity. Tuberosity avulsion fractures cause pain and tenderness at the base of the fifth metatarsal. Bruising, swelling, and other injuries may be present. Nondisplaced tuberosity fractures are usually treated conservatively, but orthopedic referral is indicated for (a) fractures that are comminuted or displaced, (b) fractures that involve more than 30% of the cubometatarsal articulation surface, and (c) fractures with delayed union. Management and prognosis of acute (Jones fracture) and stress fracture of the fifth metatarsal within 1.5 cm of the tuberosity depend on the type of fracture, based on classification. Simple fractures are generally treated conservatively with a non-weight-bearing short leg cast for 6 to 8 weeks. Fractures with delayed union may also be treated conservatively or may be managed surgically, depending on patient preference and other factors. All displaced fractures and nonunion fractures should be managed surgically. Although most fractures of the proximal portion of the fifth metatarsal respond well to appropriate management, delayed union, muscle atrophy, and chronic pain may be long-term complications.
Strayer SM, Reece SG, Petrizzi MJ. Fractures of the proximal fifth metatarsal. Am Fam Physician. 1999:2516.