Questions/Answers and Explanations
The following questions are designed to assess clinical problem-solving skills. For each option, select either “T” for true or “F” for false. All options are related to the specific clinical case provided. There is no penalty for guessing; however, if “T” and “F” are both marked, the response will be scored as incorrect.
Patient A
Options 1–9
An 85-year-old nursing home patient resides at a nursing home. You are the medical director for the facility. The facility is about to undergo a state inspection and you have been reviewing guidelines for the care of nursing home patients.
Which of the following is true?
1. Patients who are admitted to a nursing home must undergo a comprehensive evaluation at the time of admission.
2. Patients should be restrained if they are confused or wander to protect their safety.
3. An attempt to taper or discontinue psychiatric medications should not be attempted because of the risk of psychosis.
4. A Minimal Data Set (MDS) typically is filled out by nursing home staff within 14 days of admission and subsequently on a quarterly basis.
Just before Thanksgiving, you are called by the Director of Nursing about an outbreak of influenza A in the facility.
Which of the following is appropriate?
5. Infection can be rapidly detected with a blood test that looks for antibodies to influenza A.
6. Amantadine can be used for prophylaxis in exposed contacts.
7. Rimantadine can be used for prophylaxis and is associated with fewer side effects than amantadine.
8. All nursing home residents should receive prophylaxis with medication regardless if they have been exposed to the virus.
9. A decline in functional status can signal an influenza infection.
View Answer
Options 1–9
Answers: 1. T2. F3. T4. T5. F6. T7. T8. T9. T
In the United States, as a result of the need to provide a systematic assessment for the basis of care planning in nursing homes, the Omnibus Reconciliation Act of 1987 (OBRA 87) mandated that nursing homes complete a comprehensive evaluation of residents at the time of admission.
Physical and chemical restraints are not the solution to wandering. They infringe on patient autonomy and, in the United States, violate OBRA legislation governing skilled nursing facilities. OBRA 87 defines a physical restraint as a device that restricts a resident's freedom of movement or access to his/her body and is intended to restrict movement of the resident. The federal regulations state that restraints (e.g., belts, vests, cuffs, bedrails) cannot be used without a physician's order and that physicians cannot order restraints without clear medical justification. Additionally, psychotropic medications should be reviewed on a regular basis, and an attempt should be made to reduce the dosage or eliminate the medication.
The minimal data set (MDS) typically is filled out by nursing home staff within 14 days of admission and subsequently on a quarterly basis. It can be a useful tool for the physician by providing valuable background information. In addition, if a problem is identified or triggered by the MDS, the companion Resident Assessment Protocols (RAPs) specify how the nursing staff should proceed. In the majority of nursing homes where the physician rounds only once every 30 or 60 days (as required by state law) and is often not available to evaluate an acute problem at its inception, these protocols help ensure good patient care.
Influenza virus is often brought into the nursing home by staff or visitors and spreads quickly among the residents who share rooms and eat in a common dining area. Hospitalization rates rise significantly during epidemics. Many who are frail develop cardiac complications, including myocardial infarction and congestive heart failure, and pulmonary complications, particularly bronchospasm and pneumonia (either due to influenza or from bacterial superinfection with organisms such as Staphylococcus aureus). Additionally, many nursing home residents affected with influenza infection experience a decline in functional status, including a decrease in independent functioning such as bathing, dressing, and ambulation. With this in mind, it is important to vaccinate both residents and staff against influenza in the early fall. If an outbreak of respiratory illness characterized by fever, nonproductive cough, and myalgias occurs, influenza should be suspected. Infection can be confirmed by culture of throat and nose swabs or more rapidly using an enzyme linked immunosorbent assay (ELISA). If influenza A is documented, all exposed residents should be treated with amantadine or rimantadine until the outbreak subsides. Rimantadine, although more expensive, is preferred over amantadine because it is less likely to cause delirium in frail nursing home residents. Neuraminidase inhibitors zanamivir (inhaled) and oseltamivir (oral) have been developed for the treatment and prevention of both influenza A and B with fewer side effects than amantadine and rimantadine. The neuraminidase inhibitors are a useful alternative to amantadine or rimantadine, particularly when influenza B is the source of infection or when there is resistance to these drugs. Additional infection control measures should be instituted in the event of an influenza outbreak and include avoiding new admissions to the affected units and limiting the movement of both residents and staff from affected to unaffected parts of the nursing home.
Gillick MR. Medical care of the nursing home patient. Up to Date, version 14.1. Accessed 5/19/06.
The minimal data set (MDS) typically is filled out by nursing home staff within 14 days of admission and subsequently on a quarterly basis.
Patient B
Options 10–24
A 28-year-old married woman with four children presents to the emergency room with abdominal pain and cramping, which has been present for 3 months. The patient describes episodes of diarrhea alternating with constipation and a 10-lb weight loss over the last 8 weeks. Mild dysuria over the last few days without back pain or fever has been noted. The patient has no new sexual partners or previous surgeries. Her last menstrual period was 6 weeks ago; periods have otherwise been normal. Physical examination, including pelvic examination, is unremarkable except for some mild right upper abdominal pain (without peritoneal signs).
Appropriate diagnostic tests at this point include
10. urinalysis with culture and sensitivity
11. pregnancy test
12. computed tomography (CT) scan of the abdomen
13. ultrasound of the right upper quadrant
14. stool hemoccult testing
15. intravenous pyelography
The initial workup is unremarkable. Further review of her history reveals a fractured wrist 6 months ago from a fall when she tripped on the stairs. The medical assistant also reports that there is mild ecchymosis affecting her left cheek, which she has covered with makeup. When questioned about this finding, the patient reports that her child hit her with a baseball, and she appears uncomfortable when asked the question.
Further questioning of this patient should include
16. a family history of bleeding disorders
17. discussion of possible spousal abuse
18. drug and alcohol history
19. history of child abuse affecting the family
20. discussion of the patient's support system at home
Further management of this patient may involve
21. hospitalization
22. social service consult
23. referral to a gynecologist
24. frequent follow-up visits in your office
View Answer
Options 10–24
Answers: 10. T11. T12. F13. T14. T15. F16. F17. T18. T19. T20. T21. T22. T23. F24. T
Abdominal pain in young, sexually active females has an extensive differential diagnosis. Causes may include bowel-related conditions: infections, including appendicitis and gastroenteritis; irritable bowel syndrome or inflammatory bowel disease; cholecystitis; or peptic ulcer disease. Pelvic pathology may include ectopic pregnancy, torsion of an ovary, ovulation, pelvic inflammatory disease, endometriosis, and menstrual-related problems. Also, urinary causes, such as infection, renal stones, or interstitial cystitis, can be included in the differential. Appropriate initial testing in this patient includes electrolytes because of the diarrhea, a urinalysis with culture and sensitivity, stool for hemoccult blood, CBC with differential, liver function tests, alkaline phosphatase, lipase, amylase, pregnancy test, and abdominal x-ray. Because of the location of the patient's abdominal pain (right upper quadrant), an abdominal ultrasound would be appropriate to rule out cholecystitis. A CT scan of the abdomen and intravenous pyelography are not recommended at this point in the evaluation. The patient's history is also suspicious for spousal abuse. Further questioning of the patient should include a discussion about the possibility of abuse (spousal, sexual, or child), a drug and alcohol history, and a discussion about the patient's living arrangements and support network. The first step in the treatment of a patient who has been abused is to remove her from her dangerous environment and provide safety. Hospitalization is often used to ensure the patient's safety. The physician should make a social service consult to assist in follow-up, and the abuse should always be reported to the proper authorities. Once the patient is released from the hospital, it is important to arrange frequent and close follow-up.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:94–98.
The first step in the treatment of a patient who has been abused is to remove her from her dangerous environment and provide safety.
Patient C
Options 25–34
A 5-year-old girl is brought to your office by her mother. The mother reports that the child has had vulvar itching and irritation for the last 5 days. The patient's mother denies any prior symptoms or vaginal discharge and reports no pain with urination. Bowel movements have been normal. The patient's mother denies any history of child or sexual abuse, and the child's history is otherwise unremarkable. The patient has no history of recent trauma to the pelvic area.
The initial workup of this patient should include
25. Papanicolaou smear
26. vaginal cultures for chlamydia
27. intravenous pyelography
28. digital vaginal examination
29. biopsy of the irritated area
Treatment of this child should include
30. topical estrogen cream application
31. administration of oral sulfa-containing medication
32. a discussion of perineal hygiene
33. a report to child abuse authority
34. referral to a pediatric gynecologist
View Answer
Options 25–34
Answers: 25. F26. F27. F28. F29. F30. F31. F32. T33. F34. F
Nonspecific perineal irritation (vulvovaginitis) in young girls is common and is usually caused by inadequate perineal hygiene. Excessive irritation by urine on the vulvar area or constricting clothing that does not allow proper ventilation usually causes vulvar irritation. The discharge is characteristically brown or green, has a fetid odor, and is associated with a vaginal pH of 4.7 to 6.5. Parents should be instructed to teach young girls to wipe the perineum from front to back after each urination. Children should wear cotton underwear, and underwear should be changed daily (and more often if exposed to moisture). Parents should be instructed to avoid bubble baths and strong soaps or creams that contain irritating perfumes. The child's perineum should be inspected by the physician; however, further evaluation is unnecessary unless initial attempts at treatment fail. Estrogen cream is used as the drug of choice for recurrent vulvovaginitis secondary to labial adhesions.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: Saunders; 2004:1828–1832.
Nonspecific perineal irritation (vulvovaginitis) in young girls is common and is usually caused by inadequate perineal hygiene.
Patient D
Options 35–49
A 63-year-old banker presents to the emergency room with midsternal chest pain that radiates to the neck and left arm, as well as mild shortness of breath. The pain began at 6 a.m. and has been constant for the last 20 minutes. Physical findings include the following:
· Vitals: Temperature, 38°C; blood pressure, 160/92 mm Hg; pulse, 92 bpm; respirations, 20; weight, 245 lb
· General appearance: Nervous, diaphoretic
· Head, ears, eyes, nose, and throat: Negative
· Neck: Supple, faint left carotid bruit, positive jugular venous distention
· Heart: Regular rhythm, positive S3 sound
· Lungs: Crackles in bases bilaterally
· Abdomen: Soft, mild, right upper quadrant tenderness
· Pulses: Intact and equal bilaterally
· Rectum: Hemoccult negative, positive hemorrhoids
· Extremities: 1+ pitting ankle edema
· Neurologic: Nonfocal
Initial assessment for this man should include the following:
35. oxygen saturation
36. chest x-ray
37. partial prothrombin time
38. cardiac enzymes
39. exercise echocardiogram
40. electrocardiogram
Which of the following medications can be used in the initial treatment of this patient?
41. Verapamil
42. Nitroglycerin
43. Aspirin
44. Heparin
45. Captopril
Coronary angiography reveals that the patient has multiple occluded coronary arteries. He subsequently undergoes coronary artery bypass surgery. Six weeks later he returns to your office for follow-up. He is doing well and has no complaints.
Important aspects of this follow-up visit may include
46. consideration of an ultrasound of the gallbladder, pancreas, and liver to rule out cholelithiasis
47. determination of cardiac risk factors and lifestyle modification
48. regular exercise program and diet modification
49. repeat cardiac enzyme tests
View Answer
Options 35–49
Answers: 35. T36. T37. T38. T39. F40. T41. F42. T43. T44. T45. F46. F47. T48. T49. F
Chest pain and associated myocardial infarction is a relatively common problem seen by family physicians. Patients usually present with shortness of breath and substernal pressure or pain that radiates to the neck or upper extremities. In many cases, the patient is anxious and diaphoretic. The physical findings (i.e., jugular venous distention, mild right upper abdominal distention secondary to hepatic congestion, S3 heart sound, crackles in the lungs, and 1+ pitting edema in the lower extremities) in this patient reveal mild congestive heart failure in addition to a likely myocardial infarction. Initial assessment for this patient should include electrolyte panel, CBC, partial thromboplastin time, cardiac enzymes, oxygen saturation, electrocardiogram, and chest x-ray. Data from clinical trials suggest that troponin I and troponin T provide more prognostic information than the patient's demographic characteristics or the electrocardiographic findings at presentation. Myoglobin may be helpful for the early diagnosis of reperfusion. Troponin I and troponin T have been found to be highly cardiac specific and particularly efficient for the diagnosis of myocardial infarction. CK-MB subforms are also efficient for early diagnosis (within 6 hours) of myocardial infarction. An exercise echocardiogram is not indicated.
Medications that are used in the initial treatment of this patient include intravenous nitroglycerin, a vasodilator; aspirin, an antiplatelet agent; and intravenous heparin. A thrombolytic, such as streptokinase or tissue plasminogen activator, may be indicated in select cases. Percutaneous transluminal coronary angioplasty (PTCA) can be considered an alternative to thrombolytic therapy in patients with ST-segment elevation or new (or presumed new) left bundle branch block, provided that angioplasty of the infarct-related artery can be performed within 12 hours of the onset of symptoms or beyond 12 hours if ischemic symptoms persist. In addition, PTCA can be an alternative in patients who are within 36 hours of an acute ST-elevation/Q-wave or new left bundle branch block infarction who develop cardiogenic shock, are younger than 75 years, and in whom revascularization can be performed within 18 hours of shock. PTCA may be appropriate in other situations as well. Glycoprotein IIb/IIIa inhibitors (abciximab [Reopro], eptifibatide [Integrilin], and tirofiban [Aggrastat]) are used in combination with heparin in patients with a myocardial infarction who have some high-risk features or refractory ischemia, or both, provided that they do not have a major contraindication due to a bleeding risk. The drugs are given prior to revascularization. Captopril, an angiotensin-converting enzyme inhibitor that assists in the remodeling process of the myocardium, should be started once the patient's condition has stabilized. β-blockers should also be started if no contraindications (e.g., asthma, congestive heart failure) exist. Verapamil, a calcium-channel blocker, has negative inotropic and chronotropic properties that may exacerbate congestive heart failure, and thus is not indicated for this patient.
Appropriate follow-up management after coronary bypass surgery should include risk factor assessment and lifestyle modification, including establishment of a regular exercise program and diet modification. An ultrasound and cardiac enzyme testing in this patient are not indicated at the time of follow-up.
Morey SS. Practice guidelines: ACC/AHA guidelines on the management of acute myocardial infarction. Am Fam Physician. 2000;61:1901–1902.
Topol EJ, et al. Multi-year follow-up of abciximab therapy in three randomized, placebo-controlled trials of percutaneous coronary revascularization. Am J Med. 2002;113:1–6.
Troponin I and troponin T have been found to be highly cardiac specific and particularly efficient for the diagnosis of myocardial infarction.
Patient E
Options 50–59
A 19-year-old college student presents to your office complaining of profuse vaginal bleeding for the past 7 days. She denies being sexually active. Her periods began at 12 years of age and they have been irregular with intervals ranging from 14 to 28 days. She does have a lot of cramping with her periods and she reports the flow is heavy. She denies any abdominal pain or urinary symptoms. On examination, she appears pale and afebrile, pulse is 118 beats/minute, and her respirations are normal. A pelvic examination reveals clots of dark blood in the vaginal vault and a normal-size uterus with a closed cervical os. There is no adnexal tenderness or masses and the ovaries are not palpated.
Which of the following tests would be appropriate at this time?
50. β-hCG level
51. CBC
52. Blood typing and screening
53. endometrial biopsy
54. coaguluation studies
55. pelvic CT scan
Following your workup, you diagnose the patient with dysfunctional uterine bleeding.
Initial treatment may consist of
56. intramuscular medroxyprogesterone acetate (Depo-Provera)
57. dilation and curettage
58. high dose intravenous estrogen
59. bromocriptine
View Answer
Options 50–59
Answers: 50. T51. T52. T53. F54. T55. F56. F57. T58. T59. F
After the diagnosis of pregnancy has been ruled out, the most common cause of vaginal bleeding in young women is dysfunctional uterine bleeding. Initial evaluation should focus on weather the patient is clinically stable. Some will need to be monitored in a hospital setting. Appropriate laboratory tests include a β-hCG level to rule out pregnancy, CBC, coagulation studies to look for a coagulopathy, and blood typing and screening in case transfusion is necessary. Dysfunctional uterine bleeding results from inadequate estrogen in the setting of a proliferating endometrium. Appropriate treatment in this patient consists of a combination oral hospitalization with administration of high dose intravenous estrogen. If bleeding does not stop, dilation and curettage can be performed. Following the cessation of bleeding, shedding of the endometrium can be triggered by the administration and withdrawal of medroxyprogesterone.
Goldman L, Ausiello D, eds. Cecil textbook of medicine, 22nd ed. Philadelphia: Saunders; 2004:1501.
Dysfunctional uterine bleeding results from inadequate estrogen in the setting of a proliferating endometrium.
Patient F
Options 60–74
An 82-year-old female nursing home patient complains of dysuria and urinary frequency. She has no fevers and no nausea or vomiting. Physical examination shows mild suprapubic tenderness but no costovertebral tenderness. A dipstick urinalysis is positive for leukocyte esterase, nitrite, and white and red blood cells.
Diagnostic tests that are appropriate for this patient include
60. intravenous pyelography
61. renal ultrasound
62. urine culture and sensitivity
63. urine cytology
64. complete blood cell count (CBC) with differential
Appropriate treatment medication for this patient includes
65. amoxicillin (Amoxil)
66. trimethoprim-sulfamethoxazole (Bactrim, Septra)
67. nitrofurantoin (Macrodantin)
68. erythromycin (EES)
69. ciprofloxacin (Cipro)
Six months after treatment, the nursing staff calls once again to report that the patient has cloudy urine. The patient complains of no further symptoms.
Appropriate management at this point includes
70. urologic referral
71. cystoscopy
72. urine culture and sensitivity
73. renal ultrasound
74. observation
View Answer
Options 60–74
Answers: 60. F61. F62. T63. F64. F65. T66. T67. F68. F69. T70. F71. F72. F73. F74. T
Urinary tract infections in elderly women are usually manifested by mild suprapubic discomfort, dysuria, urinary frequency or hesitancy, and incontinence. Initial diagnostic tests should include a urinalysis with culture and sensitivity. Further testing based on these findings is unnecessary. Appropriate treatment may include amoxicillin, trimethoprim-sulfamethoxazole, and fluoroquinolones (e.g., ciprofloxacin). Erythromycin does not provide adequate coverage; nitrofurantoin has a high rate of adverse reactions in elderly patients and should be avoided. Asymptomatic bacteriuria is defined as the presence of more than 100,000 colony-forming units/mL of voided urine in persons with no symptoms of urinary tract infection. The largest patient population at risk for asymptomatic bacteriuria is the elderly. Up to 40% of elderly men and women may have bacteriuria without symptoms. Aggressively screening elderly persons for asymptomatic bacteriuria and subsequent treatment of the infection have not been found to reduce either infectious complications or mortality.
Screening for asymptomatic bacteriuria: a brief evidence update for the U.S. Preventive Services Task Force. Agency for Healthcare Research and Quality, 2004. Accessed online 8/2/2006, at: http://www.preventiveservices.ahrq.gov.
Aggressively screening elderly persons for asymptomatic bacteriuria and subsequent treatment of the infection have not been found to reduce either infectious complications or mortality.
Patient G
Options 75–86
A 60-year-old farmer who has smoked 2 packs of cigarettes/day for 45 years presents to your office complaining of exertional dyspnea that has been gradually worsening over the past year. The patient reports that he can only walk halfway across his cornfield before he gets short of breath. He has also noted a gradually increasing productive cough that is pronounced in the morning and has been present for at least a year.
Physical examination and diagnostic tests reveal the following:
· Temperature: 37.0°C (98.6°F)
· Pulse: 78 bpm, regular
· Blood pressure: 120/86 mm Hg
· Respirations: 20/minute
· Heart: Regular rate and rhythm (heard sounds distant)
· Chest: Barrel shaped, decreased breath sounds
· Extremities: No edema
· Chest x-ray: Normal heart size, flattened diaphragm, prominent pulmonary arteries
· Arterial blood gases on room air: Partial pressure of oxygen (PaO2), 62 mm Hg; partial pressure of carbon dioxide (PaCO2), 44 mm Hg; pH, 7.41; hemoglobin, 14.8 g/dL
· Pulmonary function tests: Vital capacity, 3.16 L (predicted 3.50 L); forced expiratory volume in 1 second (FEV1), 1.78 L (predicted 2.45); FEV1/FVC, 56% (predicted >70%)
Initial treatment would consist of
75. oral furosemide (Lasix)
76. yearly influenza vaccine
77. intravenous antibiotics
78. counseling for smoking cessation
79. prednisone taper
80. pneumovax vaccination
81. ipratroprium bromide (Atrovent) inhaler
Six months after his initial visit, the patient returns, complaining of chills, fever, productive cough with green sputum, dyspnea, and generalized weakness. You decide to admit the patient.
Appropriate medications may include
82. metronidazole
83. nebulized albuterol
84. cefuroxime
85. methylprednisolone
86. erythromycin
View Answer
Options 75–86
Answers: 75. F76. T77. F78. T79. F80. T81. T82. F83. T84. T85. T86. T
Chronic obstructive pulmonary disease (COPD) is a common finding in long-term smokers. Symptoms include dyspnea, increasing cough, and generalized fatigue. The physical examination may reveal an increased anteroposterior chest diameter, decreased breath sounds, and distant heart sounds. Pulmonary function tests often show a normal or decreased FVC, decreased FEV1, and decreased FEV1/FVC ratio. Initial treatment of COPD would include the use of ipratropium bromide, pneumococcal and yearly influenza vaccination, and counseling concerning smoking cessation for those patients who continue to smoke. In this case, antibiotics, prednisone, and the use of furosemide are not warranted. On return, the patient has classic symptoms for a COPD exacerbation.
Initial therapy should focus on maintaining oxygen saturation at 90% or higher. Oxygen status can be monitored clinically as well as by pulse oximetry. Oxygen supplementation by nasal cannula or facemask is frequently required. With more severe exacerbations, intubation or a positive-pressure mask ventilation method (e.g., continuous positive airway pressure) is often necessary to provide adequate oxygenation. Inhaled β2 agonists should be administered as soon as possible during an acute exacerbation of COPD. Use of a nebulizer to provide albuterol (Ventolin) or a similar agent with saline and oxygen enhances delivery of the medication to the airway. Orally administered β2 agonists have more side effects than inhaled forms; therefore, oral agents generally are not used to treat exacerbations of COPD. Compared with β2 agonists, inhaled anticholinergics such as ipratropium provide the same or greater bronchodilation. These agents have been shown to be beneficial in patients with COPD. Anticholinergics can be delivered by nebulizer or metered-dose inhaler. In inhaled forms, anticholinergics have few adverse effects because of minimal systemic absorption. Use of a combination product such as ipratropium-albuterol (Combivent) may simplify the medication regimen, thereby improving compliance. All patients without serious contraindications should receive systemic corticosteroids for severe exacerbations of COPD. The use of methylxanthines such as aminophylline and theophylline is controversial in patients with exacerbations of COPD. Although methylxanthines can be of some help in improving diaphragmatic function, they are potentially toxic and are associated with serious drug effects. With close monitoring and attention to potential adverse effects, methylxanthines may have a place in the treatment of patients who do not respond to other bronchodilators. Antibiotic therapy is directed at the most common pathogens, including Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Mild to moderate exacerbations of COPD are usually treated with broad-spectrum antibiotics such as doxycycline, trimethoprim-sulfamethoxazole, and amoxicillin-clavulanate potassium. Treatment with augmented penicillins, respiratory fluoroquinolones, third-generation cephalosporins, or aminoglycosides can be considered in patients with more severe exacerbations. Newer macrolides offer coverage for atypical organisms. Metronidazole is not indicated in the initial treatment of COPD exacerbation.
Hunter MH, King DE. COPD: management of acute exacerbations and chronic stable disease. Am Fam Physician. 2001;64:603–612, 621–622.
Pulmonary function tests associated with chronic obstructive pulmonary disease often show a normal or decreased FVC, decreased FEV1, and decreased FEV1/FVC ratio.
Patient H
Options 87–96
A 2-year-old boy is brought into your office. The mother reports that the child has a fever to 104.5°F. The child also has been vomiting and has increasing lethargy. Physical examination shows an inactive child with dry mucous membranes and a positive Brudzinski's sign.
Which of the following would be considered a likely diagnosis?
87. streptococcal pharyngitis
88. viral gastroenteritis
89. dehydration
90. bacterial meningitis
91. giardiasis
Appropriate treatment for this child includes
92. oral amoxicillin
93. oral rehydration
94. intravenous rehydration
95. intravenous administration of ceftriaxone (Rocephin)
96. intravenous administration of erythromycin
View Answer
Options 87–96
Answers: 87. F88. F89. T90. T91. F92. F93. F94. T95. T96. F
Bacterial meningitis is a serious and life-threatening problem that affects young children. The most common infecting organisms include H. influenzae, Neisseria meningitidis, and S. pneumoniae. In many cases, children present with signs of dehydration (e.g., dry mucous membranes, sunken fontanels, lethargy, and decreased urine output) secondary to vomiting and fever. Signs of meningitis include nuchal rigidity, headache, lethargy, and decreased feeding. Other signs of meningitis include a positive Brudzinski's sign (neck flexion in a supine patient results in involuntary flexion of the hips and knees) and a positive Kernig's sign (attempts to extend the knees from a flexed-thigh position are met with passive resistance). Because neonates usually do not have meningismus, a change in the child's affect or state of alertness is one of the most important signs. The most sensitive and commonly used test that is currently available is the latex agglutination test, which detects the antigens of the common meningeal pathogens such as H. influenzae type b (Hib), S. pneumoniae, N. meningitidis, Escherichia coli K1, and Streptococcus agalactiae. The emergence of antibiotic-resistant bacterial strains in recent years has necessitated the development of new strategies for empiric antimicrobial therapy for bacterial meningitis. Specifically, the emergence of strains of S. pneumoniae that are resistant to penicillin and the cephalosporins have led to empiric therapy for patients with pneumococcal meningitis consisting of vancomycin with or without rifampin plus a third-generation cephalosporin pending susceptibility testing. Third-generation cephalosporins are also effective as empiric therapy against other pathogens that cause community-acquired bacterial meningitis, with the exception of Listeria monocytogenes, for which ampicillin or penicillin G is the antimicrobial agent of choice. Adjunctive dexamethasone should be administered to infants and children with suspected or proven H. influenzae type b meningitis to reduce audiologic and neurologic sequelae; administration concomitant with or just before the first dose of the antimicrobial agent is optimal for best results. Treatment must be initiated immediately with first suspicion. Oral administration of antibiotics is insufficient for treatment of this child. Erythromycin is not acceptable for the treatment of bacterial meningitis. Institution of recommended immunization has decreased the incidence of meningitis caused by H. influenzae type b, S. pneumoniae, and N. meningitides.
Tunkel AR, Scheld WM. Issues in the management of bacterial meningitis. Am Fam Physician. 1997;56(5):1355–1362.
Signs of meningitis include a positive Brudzinski's sign (neck flexion in a supine patient results in involuntary flexion of the hips and knees) and a positive Kernig's sign (attempts to extend the knees from a flexed-thigh position are met with passive resistance).
Patient I
Options 97–105
A 42-year-old school teacher who presents with a 3-month history of difficulty with sleeping and predominantly early morning awakenings with a loss of appetite and 10-lb weight loss and lack of interest in her usual activities. She is recently divorced. She has had at least two documented episodes of depression in the past requiring medication that she stopped on her own after several months of therapy. She states she does not smoke and consumes one glass of wine nightly. She takes atorvastatin for her cholesterol. Her physical examination is unremarkable. Laboratory tests including thyroid testing are normal.
Prior to starting the patient on an antidepressant, which of the following would be considered appropriate?
97. An MRI of the brain
98. Neuropsychometric testing
99. Discussing with the patient that alcohol may interrupt sleep patterns
100. Discontinuing atovastatin
101. Inquiry about suicidal thoughts or plans
She returns to your office 6 weeks later reporting significant improvement, and she is tolerating the medication without difficulty. Continued management for this patient includes
102. long-term psychoanalytic therapy
103. life-long antidepressant therapy
104. tapering and discontinuing the antidepressant medication
105. consideration of electroconvulsant therapy (ECT)
View Answer
Options 97–105
Answers: 97. F98. F99. T100. F101. T102. F103. T 104. F105. F
This patient has symptoms consistent with a diagnosis of major depression. When evaluating depressed patients it is imperative to ask about and document any suicidal thoughts or plans. Beyond normal screening tests including chemistry panel, complete blood count, and thyroid function tests, further workup is not necessary unless the history physical or baseline laboratory tests show abnormalities that suggest underlying disease. Alcohol may interrupt sleep patterns but atorvastatin should not have deleterious effects on this patient and does not require discontinuation of the medication. Neuropsychiatric testing would not be indicated in this situation. In the situation where the patient has had more than two episodes of major depression, the risk of recurrence is sufficiently high to warrant lifetime medication. Tapering and discontinuation of the medication is not indicated in this scenario. Although short-term psychiatric intervention may be helpful, long-term psychoanalytic therapy and electroconvulsant therapy (ECT) is not indicated.
Rakel RE, Bope ET, eds. Conn's current therapy 2004. 2004:1161–1166.
When evaluating depressed patients, it is imperative to ask about and document any suicidal thoughts or plans.
Patient J
Options 106–115
A 59-year-old secretary with a history of hyperlipidemia presents to your office complaining of severe upper abdominal pain, which has been present for the last 6 months. The patient describes the pain as periodic in nature, worse after meals, and associated with nausea and vomiting. Over the course of the last 4 months she has lost 15 lb. The patient has many responsibilities with work, but denies any excessive stress. The patient's medical history is unremarkable except for two uncomplicated vaginal deliveries and tobacco abuse. The abdomen is soft, with mild, diffuse, upper abdominal discomfort with palpation but no peritoneal signs. No masses are present, and the rest of the examination is unremarkable.
Which of the following initial tests would be appropriate for this patient?
106. Magnetic resonance imaging of the abdomen
107. CT scan of the abdomen
108. Ultrasound of the liver, pancreas, and gallbladder
109. Upper gastrointestinal series
110. Renal ultrasound
After further evaluation, the patient's tests are found to be normal except for mild bowel wall inflammation. Hemoccult stool samples are negative.
Appropriate management at this point would include
111. ultrasound of the abdominal vessels
112. exploratory laparotomy
113. elective cholecystectomy
114. endoscopic retrograde cholangiopancreatography
115. observation
View Answer
Options 106–115
Answers: 106. F107. T108. T109. T110. F111. T 112. F113. F114. F115. F
Acute occlusion of the superior mesenteric artery is usually the result of embolism, acute thrombosis in a narrowed artery, or aortic dissection. Chronic occlusion most often stems from arteriosclerosis and less often from fibromuscular hyperplasia or external compression by mass lesions. Stenosis of the superior mesenteric artery causes postprandial abdominal pain (intestinal angina) that can result in significant weight loss. The pain is usually severe and begins 30 to 60 minutes after eating. Patients become fearful of eating, and weight loss, often severe, is the rule. Intestinal malabsorption may contribute to weight loss. Doppler ultrasonography of the superior mesenteric artery and celiac axis may accurately detect reduced flow through these vessels. Mesenteric arteriography is crucial in demonstrating the presence and severity of the occlusion and the suitability for surgery. Nitroglycerin may provide relief. In severely symptomatic patients, surgical revascularization of the superior mesenteric artery and celiac axis can usually be achieved. The differential diagnosis for this patient may include cholecystitis, pancreatic cancer, peptic ulcer disease, and lymphoma. Appropriate initial diagnostic tests would include CT scan of the abdomen; ultrasound of the liver, pancreas, and gallbladder; and an upper gastrointestinal series. Magnetic resonance imaging is more costly than CT imaging and is not recommended as an initial test. In addition, there is no evidence that this patient has renal dysfunction; therefore, a renal ultrasound would not be appropriate. Based on the patient's presenting symptoms and lack of findings with initial tests, appropriate further workup would include a mesenteric angiogram. Other options listed would not be considered appropriate at this point in the patient's diagnostic evaluation.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:98–100.
Stenosis of the superior mesenteric artery causes postprandial abdominal pain (intestinal angina) that can result in significant weight loss. The pain is usually severe and begins 30 to 60 minutes after eating. Patients become fearful of eating, and weight loss, often severe, is the rule.
Patient K
Options 116–125
A 34-year-old man presents with facial pain, sinus congestion, a productive cough of greenish-yellow sputum, fever to 101°F, and generalized fatigue. Physical findings include the following:
· Appearance: Mildly to moderately ill
· Weight: 185 lb
· Eyes: Pupils equal, round, and reactive; extraocular muscles intact
· Ears: Minimal erythema associated with tympanic membranes
· Nose: Bilateral mucosal thickening with positive maxillary sinus tenderness with palpation
· Throat: Normal tonsils and pharynx; postnasal discharge noted
· Neck: Shoddy anterior cervical nodes palpable
· Heart: Regular rate and rhythm
· Lungs: Clear to auscultation
· Abdomen: Soft, nontender, no hepatosplenomegaly
Further evaluation that is required for this patient would include
116. sinus x-ray
117. CT scan of the sinuses
118. otorhinolaryngology referral
119. sinus lavage
120. chest x-ray
Appropriate first-line treatment regimens for this patient would include
121. 875 mg amoxicillin orally, two times a day for 21 days
122. double-strength trimethoprim-sulfamethoxazole orally, two times a day for 21 days
123. 500 mg levofloxacin orally, once a day for 3 weeks
124. 500 mg cefuroxime axetil orally, two times a day for 3 weeks
125. 400 mg cefixime orally, once a day for 3 weeks
View Answer
Options 116–125
Answers: 116. F117. F118. F119. F120. F121. T122. T123. F124. F125. F
Acute sinusitis is a common problem seen in a family physician's office. Symptoms include facial fullness, purulent nasal discharge, fever, facial headache aggravated by bending forward, and usually a history of a recent upper respiratory illness. The sinuses are normally sterile. This sterility is maintained by factors such as the mucociliary clearance system, endogenous concentrations of nitric oxide, and immunologic defense mechanisms. Inflammatory swelling of the nasal mucosa can constrict the ostia and hamper sinus drainage. Predisposing conditions, such as a viral upper respiratory tract infection and allergic and nonallergic rhinitis, may cause edema that obstructs the ostia. Ostial obstruction often is exacerbated by anatomic defects, such as septal deviation, traumatic fractures, polyps, and concha bullosa (an aerated turbinate) that limit the dimensions of outflow channels. The environment within the enclosed sinus cavities then becomes hypoxic and acidic, providing a stable medium for the growth of bacteria such as S. pneumoniae and H. influenzae. The maxillary and ethmoid sinuses are the most developed in childhood and are the only sinuses that are large enough at birth to be clinically significant in rhinosinusitis. The sphenoidal and frontal sinuses are very small or nonexistent at birth and enlarge with age, becoming well developed by the ages of 7 and 12 years, respectively. Physical findings may include nasal mucosal thickening, sinus tenderness with percussion or palpation, purulent nasal discharge, and postnasal discharge. A reliable history and supporting clinical findings are all that are needed to make the diagnosis of acute sinusitis. First-line treatment is amoxicillin or a double-strength oral dose of trimethoprim-sulfamethoxazole for 14 to 21 days. Second-line treatment may include amoxicillin-clavulanate, cefuroxime axetil, or cefixime. Newer-generation fluoroquinolone antibiotics gatifloxacin (Tequin), levofloxacin (Levaquin), and moxifloxacin (Avelox) are effective against the usual pathogens that are responsible for acute rhinosinusitis but are often more expensive. Expectorants and decongestants have not been proved effective in amelioration of symptoms or in hastening cure of acute bacterial rhinosinusitis.
Semchenko A, Baroody F, Culpepper L. Management of acute sinusitis and acute otitis media. Am Fam Physician. Monograph No. 1, 2001.
The maxillary and ethmoid sinuses are the most developed in childhood and are the only sinuses that are large enough at birth to be clinically significant in rhinosinusitis.
Patient L
Options 126–135
A 52-year-old man is brought to the emergency room after being found staggering and confused in a city park by the police. Vital signs include the following: temperature, 37.0°C (98.6°F); pulse, 96 bpm; respirations, 16/minute; blood pressure, 120/80 mm Hg. The patient has a strong smell of alcohol on his breath. He is disoriented, confused, and drowsy, but is able to be aroused. He is unable to ambulate because of his unsteady gait, and he has vomited three times in the emergency room. Ophthalmology examination shows six-beat nystagmus with lateral gaze bilaterally and bilateral sixth-nerve ophthalmoplegia. The remainder of his examination is unremarkable except for a sensory bilateral lower extremity peripheral neuropathy.
Appropriate initial management of this patient would include
126. drug screen
127. serum alcohol level
128. administration of intravenous glucose
129. arterial blood gas determination
130. administration of intravenous thiamine
After hospitalization, the patient's wife reports that he has recently lost his job, has become despondent, and has been drinking heavily. Two months ago, he attempted suicide with an overdose of over-the-counter medication.
Appropriate treatment of the patient would include
131. alcohol rehabilitation program
132. psychotherapy
133. antidepressant medication
134. major tranquilizers
135. electroconvulsive therapy
View Answer
Options 126–135
Answers: 126. T 127. T 128. F 129. T 130. T 131. T 132. T 133. T 134. F 135. F
Wernicke's syndrome is associated with alcoholism and consists of vomiting, horizontal nystagmus, unilateral or bilateral sixth-nerve ophthalmoplegia, fever, ataxia, and progressive global confusion. Initial evaluation of this patient should include a laboratory workup that includes electrolytes, glucose, arterial blood gases, hemoglobin, and WBC count. In addition, the patient should have a drug screen, serum alcohol level, and CT scan of the head to rule out other precipitating causes of confusion. The cause of Wernicke's encephalopathy is the lack of thiamine, which leads to progressive neurologic deficits. Therefore, before administration of glucose-containing fluids, thiamine should be administered immediately through an intravenous route. The patient should be monitored carefully for the development of delirium tremens and, on discharge, should be enrolled in an alcohol rehabilitation program. The patient also shows signs and symptoms that are consistent with major depression. Treatment should consist of antidepressant medication and psychotherapy. The use of electroconvulsive therapy is reserved for patients who fail medical management. The use of major tranquilizers is not indicated. Korsakoff's syndrome occurs in approximately 80% of patients with Wernicke's encephalopathy. Symptoms and signs include highly characteristic memory defects. Immediate memory is severely affected, but long-term memory is less affected.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1688–1689.
Wernicke's syndrome is associated with alcoholism and consists of vomiting, horizontal nystagmus, unilateral or bilateral sixth-nerve ophthalmoplegia, fever, ataxia, and progressive global confusion.
Patient M
Options 136–149
A 56-year-old state employee with a history of type 2 diabetes mellitus is seen in a follow up to a recent fasting blood test. She is overweight but has no history of cardiovascular disease. Her blood pressure is 138/86. She is on no medications at the present time. She has not seen a doctor recently.
|
Laboratory Findings |
|
|
Hemoglobin A1C |
8.2% |
|
Total cholesterol |
226 mg/dL |
|
HDL cholesterol |
46 mg/dL |
|
LDL cholesterol |
110 mg/dL |
|
Triglycerides |
265 mg/dL |
|
Serum creatinine |
0.6 mg/dL (normal 0.6–1.5) |
Which of the following statements is true regarding this patient's condition?
136. Her diabetic management is under acceptable control.
137. Her blood pressure is acceptable.
138. Her LDL cholesterol is acceptable.
Which of the following medications should be recommended at this time?
139. A statin
140. An ACE inhibitor
141. Glucophage (metformin)
142. Insulin
143. β-Blocker
Other tests that are appropriate in this individual include
144. ultrasound of the kidney
145. urine for microalbumin
146. filament testing for peripheral neuropathy
147. treadmill exercise testing
148. ophthalmology evaluation
149. 24-hour urine for creatinine clearance
View Answer
Options 136–149
Answers: 136. F137. F138. F139. T140. T141. T 142. F143. F144. F145. T146. T147. F148. T149. F
The guidelines for diabetes management recommend a hemoglobin A1C below 7%. Values in the 7% to 8% range are acceptable; however, values >8% require a change in management. Goals for blood pressure in diabetics have also been lowered based on new guidelines. Currently the goal is to maintain levels <130/80 mm Hg. Cholesterol goals include an LDL <100 mg/dL and the target may eventually be even lower. Clearly, this patient's LDL is above goal. Management for this patient would include a statin to lower cholesterol and ACE inhibitor for its reno-protective effect and also blood pressure reduction and the initiation of metformin (Glucophage), which may help the patient to lose weight and will help treat her diabetes. A β-blocker would not be first-line treatment for this individual. Further testing should include a “spot” urine for microalbumin, filament testing for peripheral neuropathy, and ophthalmologic evaluation. Although this patient is at risk for the development of kidney disease and cardiovascular disease the other tests listed would not be indicated.
American Diabetes Association: standards of medical care for patients with diabetes. Diabetes Care. 2005;28 (supplement 1): S4–S36.
The guidelines for diabetes management recommend a hemoglobin A1C below 7%. Values in the 7% to 8% range are acceptable; however, values >8% require a change in management.
Patient N
Options 150–159
A grandmother presents to your office with her 2-year-old grandson. The child has been extremely restless, especially at night, and has been unable to sleep for the last 4 nights. The grandmother also reports that he has been scratching his genitalia and rectal area. Physical examination reveals a well-nourished, well-developed child with no abnormal findings other than excoriations around the genitalia and perianal area.
Workup at this time should include
150. skin biopsy of excoriated areas
151. Scotch-tape test
152. flashlight examination of the child's rectal area at night
153. CBC, including eosinophil count
154. stool cultures for ova and parasites
Appropriate treatment for this child includes
155. topical hydrocortisone cream
156. antifungal topical cream
157. mebendazole (Vermox)
158. pyrantel pamoate (Antiminth)
159. thiabendazole (Mintezol)
View Answer
Options 150–159
Answers: 150. F151. T152. T153. F154. F155. F156. F157. T158. T159. F
Pinworm (Enterobius vermicularis) infections occur worldwide and are especially common in children. Humans are infected by ingesting the eggs, which are carried on the fingernails, clothing, bedding, or house dust. Eggs hatch in the stomach, and larva migrate to the cecum, where they mature into adult worms. Females migrate at night to the anal region, where they deposit eggs. Clinical manifestations include nocturnal anal pruritus and sleeplessness. Diagnosis is made by applying adhesive cellophane tape (Scotch-tape test) to the perianal area early in the morning and microscopic or visual examination for the worm or its eggs. Flashlight examination of the child's perianal area at night may also reveal the presence of a pinworm infection. Because tissue invasion does not occur in most cases of enterobiasis, eosinophilia is not observed. In addition, stool cultures may be difficult to obtain, are expensive, and are generally unnecessary for diagnosis. Treatment consists of mebendazole, albendazole, or pyrantel pamoate. Doses are repeated 2 weeks after initial treatment. In some cases, other family members may require treatment.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: Saunders; 2004:1159.
Because tissue invasion does not occur in most cases of enterobiasis, eosinophilia is not observed.
Patient O
Options 160–168
A 27-year-old woman (gravida 2, para 2) presents to your office with complaints of a 1-week history of vaginal itching and discharge. The discharge is present daily and is minimally foul-smelling. She is married and is using a diaphragm and contraceptive foam for birth control. She denies any extramarital affairs and does not suspect her husband of any. In addition, her husband has not reported any symptoms. Physical findings include the following:
· Labia: Mildly erythematous, no lesions noted
· Vagina: White vaginal discharge present in the posterior vault
· Cervix: Multiparous, nontender, no lesions
· Adnexa: No masses or tenderness
· Rectal and vaginal examination: Unremarkable
A urinalysis was performed showing 0 to 3 white blood cells (WBC) per high-power field, trace ketones, and no bacteria.
The differential diagnosis includes
160. vaginal candidiasisvaginitis secondary to chemical irritation
161. vaginitis secondary to chemical irritation
162. herpes genitalis
163. human papillomavirus
164. bacterial vaginosis
A vaginal smear is obtained and shows the presence of clue cells under the microscope.
Appropriate treatment at this time would include
165. clotrimazole (Gyne-Lotrimin) vaginal suppositories
166. oral metronidazole (Flagyl)
167. intramuscular ceftriaxone (Rocephin)
168. oral trimethoprim-sulfamethoxazole (Bactrim)
View Answer
Options 160–168
Answers: 160. T161. T162. F163. F164. T165. F166. T167. F168. F
Bacterial vaginosis is a common diagnosis for vaginal irritation in women. The cause is usually a Gardnerella or Trichomonas infection. Symptoms include vaginal itching, irritation, and discharge that produces a characteristic fishy odor when mixed with potassium hy-droxide. Microscopic examination of vaginal smears confirms the diagnosis if clue cells are present. The vaginal discharge pH is >4.5. The lack of lesions noted in this patient would exclude the diagnosis of herpes genitalis and human papillomavirus, although vaginal candidiasis and chemical irritation from the diaphragm or contraceptive foam should be considered. Appropriate treatment includes the use of oral or topical metronidazole or clindamycin.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:7767–7768.
When diagnosing bacterial vaginosis, the vaginal discharge pH is >4.5.
Patient P
Options 169–178
A 26-year-old woman (gravida 1, para 0) presents to your office at 34 weeks' gestation after slipping on wet pavement and falling to the ground. On arrival, she reports some vaginal spotting and some lower abdominal cramping, which has been present over the last hour. She has noted fetal movement since her fall but is worried that she has had a miscarriage. Physical findings include the following:
· Blood pressure: 120/80 mm Hg
· Temperature: 37.0°C (98.6°F)
· Pulse: 96 bpm
· Respirations: 16/minute
· Fetal monitor: 150/minute with adequate variability and normal reactivity; two minor contractions in 1 hour
· Heart: Regular rate and rhythm
· Lungs: Clear to auscultation
· Abdomen: Soft, mild diffuse tenderness, no peritoneal signs
Appropriate management at this point would include
169. sterile speculum examination
170. continued external monitoring of uterine contractions and fetal heart rate
171. administration of magnesium sulfate
172. close observation with the patient in a left lateral decubitus position
173. emergent cesarean section
Appropriate laboratory testing may include
174. CBC with differential
175. Rh typing
176. Kleihauer-Betke test
177. amniocentesis for fetal maturity tests
178. obstetric ultrasound
View Answer
Options 169–178
Answers: 169. T 170. T 171. F 172. T 173. F 174. T 175. T 176. F 177. F 178. T
Minor trauma may occur in pregnancy and is usually benign. Complications include maternal anxiety, premature onset of labor, and placental abruption. The workup should consist of external fetal monitoring, sterile speculum examination, and laboratory tests that include CBC with differential, Rh typing, and ultrasound examination (to determine fetal well-being and assess for placental abruption). The Kleihauer-Betke test (to determine fetal-to-maternal hemorrhage) has been shown to have little use in the setting of acute trauma. The mother should be reassured to help relieve anxiety, and she should be monitored in a left lateral position for at least 4 hours. Delivery should not be attempted unless there is a life-threatening situation. Amniocentesis could be performed to confirm hemorrhagic amniotic fluid, but not to assess fetal lung maturity.
Cunningham FG, Gant NF, et al. Williams Obstetrics, 21st ed. New York: McGraw-Hill; 2001:1175.
The Kleihauer-Betke test (to determine fetal-to-maternal hemorrhage) has been shown to have little use in the setting of acute trauma.
Patient Q
Options 179–188
A 78-year-old woman presents to your office complaining of low back pain. She reports that she was planting flowers in her garden last week when the pain began. The pain is aggravated by twisting motions of the back and alleviated by lying still on a flat, firm surface. Physical examination reveals a thin woman who appears her stated age. Back examination reveals point tenderness over L1 vertebrae. Neurologic examination is unremarkable, and she has a negative straight leg–raising test. An x-ray of the spine confirms an L1 compression fracture.
Complications of this condition include
179. nerve root irritation
180. disc herniation
181. back pain for 6 to 8 weeks
182. urinary incontinence
183. peripheral neuropathy
Appropriate treatment for this patient includes
184. strict bed rest for 6 to 8 weeks
185. pain medications
186. gradual increase of activity as tolerated by the patient
187. vertebroplasty
188. laminectomy
View Answer
Options 179–188
Answers: 179. F 180. F 181. T 182. F 183. F 184. F 185. T 186. T 187. T 188. F
Compression fractures of the spine are relatively common in elderly women who have osteoporosis. Vertebral crush fractures may develop with minimal or no trauma, usually in weight-bearing vertebrae (T8 and below); isolated fractures of T4 or above suggest malignancy. When symptomatic, the pain is of acute onset, usually does not radiate, is aggravated by weight bearing, may be associated with local tenderness, and generally begins to subside in 1 week. However, residual pain may last for more than 3 months. Multiple compression fractures eventually may lead to dorsal kyphosis with exaggerated cervical lordosis (“dowager's hump”). Abnormal stress on the spinal muscles and ligaments may cause chronic, dull, aching pain, particularly prominent in the lower thoracic and lumbar area. Fractures at other sites, commonly the hip or distal radius, usually result from a fall. Nerve root irritation and associated disc herniation with possible urinary incontinence are not usually associated with compression fractures. Pain may at times be severe and may require adequate pain medications. Patients should be encouraged to return to normal activities as tolerated once their pain subsides. Strict bed rest is contraindicated and may lead to progressive weakness. Surgery is not indicated, although treatment for osteoporosis should be considered. Vertebroplasty is beneficial in select cases.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:306, 308, 325.
Nerve root irritation and associated disc herniation with possible urinary incontinence are not usually associated with compression fractures.
Patient R
Options 189–198
An 18-year-old college freshman presents to your office complaining of a swollen, erythematous, and painful ankle. He has no history of trauma and states that the condition developed rapidly over the last 48 hours. He has no prior history of joint swelling.
The differential diagnosis may include
189. gonorrhea
190. Lyme disease
191. streptococcal infection
192. Reiter's syndrome
193. rheumatoid arthritis
Appropriate workup for this patient includes
194. CBC with differential
195. monospot
196. erythrocyte sedimentation rate
197. rheumatoid factor
198. joint aspiration with Gram's stain and culture of fluid
View Answer
Options 189–198
Answers: 189. T190. T191. T192. T193. T194. T 195. F196. T197. T198. T
Septic arthritis can result from hematogenous dissemination of bacteria, contiguous spread of an osteomyelitis, or direct inoculation of microorganisms into the joint space as a result of penetrating trauma. Infectious arthritis, if untreated, can lead to irreversible joint damage. Symptoms of septic joint include acute onset of symptoms, history of previously abnormal joint, immunocompromised status, or intravenous drug use. Physical findings such as fever, warmth, and erythema over the involved joint, coupled with the absence of ligamentous or meniscal findings, suggest an infectious etiology. Radiographs are usually normal. The most important test is joint fluid evaluation. Findings that indicate infection include effusion, WBC count >50,000/mm3 (50 ÷ 109/L), organisms present on Gram's stain, and positive cultures. An elevated peripheral WBC and erythrocyte sedimentation rate also support an infectious process. Causative agents may include H. influenzae type b, Staphylococcus aureus, S. pneumoniae, and Neisseria gonorrhoeae (especially in sexually active adolescents). Borrelia burgdorferi, the causative agent of Lyme disease, may also cause septic arthritis. If the joint effusion recurs despite appropriate therapy, evaluation for fungal infection, tuberculosis, and Lyme disease should be undertaken. The differential in this patient should also include other conditions, such as Reiter's syndrome (urethritis, arthritis, and ocular inflammation) and early onset of rheumatoid arthritis. The workup should consist of a CBC with differential, erythrocyte sedimentation rate, rheumatoid factor, and joint aspiration with Gram's stain and culture of fluid.
Johnson MW. Acute knee effusions: a systemic approach to diagnosis. Am Fam Physician. 2000;61:2391–2400.
Septic arthritis can result from hematogenous dissemination of bacteria, contiguous spread of an osteomyelitis, or direct inoculation of microorganisms into the joint space as a result of penetrating trauma.
Patient S
Options 199–212
A 54-year-old obese woman presents with urinary frequency, polyphagia, and blurred vision. Her symptoms have gradually worsened over the last 6 months. Physical examination is unremarkable except for the patient's obesity and decreased pinprick sensation associated with the lower extremities.
Appropriate laboratory testing includes
199. fasting glucose
200. glycosylated hemoglobin
201. thyroid-stimulating hormone
202. urinalysis
203. antinuclear antibody
204. lipid profile
Test results confirm the diagnosis of new-onset type II diabetes mellitus.
Appropriate management of this patient should include
205. regular exercise
206. diet modification to promote weight loss
207. ophthalmologic evaluation
208. audiologic evaluation
After a 3-month trial of diet and exercise, the patient is started on oral medication.
Appropriate management would include
209. weekly monitoring of fasting glucose until the patient's glucose levels are well controlled
210. repeat glycosylated hemoglobin in 8 to 12 weeks
211. continued exercise and diet therapy
212. endocrinology referral
View Answer
Options 199–212
Answers: 199. T 200. F 201. T 202. T 203. F 204. T 205. T 206. T 207. T 208. F 209. T 210. T 211. T 212. F
Type II diabetes mellitus (formerly called non-insulin-dependent diabetes) causes abnormal carbohydrate, lipid, and protein metabolism associated with insulin resistance and impaired insulin secretion. Insulin resistance is a major contributor to progression of the disease and to complications of diabetes. Obesity increases the risk for development of type II diabetes. Symptoms include polyphagia, urinary frequency, and often blurred vision. The diagnosis of diabetes is confirmed by two fasting glucose levels of >126 mg/dL. Initial evaluation usually consists of fasting glucose determination, lipid profile, thyroid function tests, and urinalysis. An antinuclear antibody test is not indicated. Most patients are given a trial of diet and exercise before initiation of medication if the fasting glucose is <200 mg/dL. In addition, the patient should be evaluated for end-organ damage with serum creatinine and ophthalmologic evaluation. Hearing loss is not routinely associated with the development of adult-onset diabetes mellitus; thus, audiology evaluation is unnecessary. Once medication is started, the patient should continue with diet and exercise modification. The patient should also be monitored regularly with fasting glucoses performed at least weekly until glucose levels are controlled and every 8 to 12 weeks with glycosylated hemoglobin determination. Glycosylated hemoglobin levels are not used to diagnose diabetes mellitus. In most cases, the family physician can successfully treat adult-onset diabetes mellitus without an endocrinology referral.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1275, 1279.
Glycosylated hemoglobin levels are not used to diagnose diabetes mellitus.