Note: Just prior to the publication of this study guide, the ABFM eliminated Clinical Problem Set Questions from the examinations. Despite their removal, these additional questions can be used to further your knowledge.
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 1–15
A 65-year-old man presents with complaints of erectile dysfunction. His symptoms began approximately 4 months ago. He reports no new medications and has had no change in his medical condition. His past medical history is significant for coronary artery disease and stable angina and some benign prostatic hypertrophy. He also has a prolonged QT interval on ECG. His medications include metoprolol, nitroglycerin, atorvastatin, aspirin, lisinopril, and saw palmetto.
Appropriate laboratories at this time include
1. complete blood count (CBC)
2. electrolyte panel
3. urinalysis
4. testosterone level
5. prolactin
6. thyroid function tests
7. prostate specific antigen
After you obtain the laboratory results, you note no abnormalities. Which of the following would be appropriate treatment in this gentleman?
8. testosterone patch
9. sildenafil (Viagra)
10. tadalafil (Cialis)
11. vardenafil (Levitra)
12. vacuum erection device
13. prostaglandin injections
14. yohimbine
15. trazadone
View Answer
Options 1–15
Answers: 1. F2. F3. T4. T5. T6. F7. T8. F9. F10. F11. F12. T13. T14. F15. F
A standard evaluation for erectile dysfunction (ED) should include a thorough sexual, medical, and psychosocial history, focusing on conditions such as cardiovascular disease (e.g., hypertension, atherosclerosis, hyperlipidemia), diabetes, depression, alcoholism, premature ejaculation, increased latency associated with age, psychosexual relationships, and other conditions that might be contraindications for certain drug therapies. Other risk factors for ED that may be discovered include smoking; pelvic, perianal, or penile trauma; neurologic disease; endocrinopathy; obesity; pelvic radiation therapy; Peyronie's disease; and prescription or illicit drug use. It is important to distinguish ED from problems with ejaculation or orgasm, as well as to establish the history and severity of symptoms. The physical examination should focus on the abdomen, penis, testicles, secondary sexual characteristics, and lower extremity pulses. A rectal examination, vascular and neurologic assessment, determination of prostate-specific antigen (PSA) and testosterone levels, and monitoring of nocturnal erections would be indicated in this patient. The AUA recommends that PDE5 inhibitors be offered as the first-line therapy for ED unless contraindicated. The three PDE5 inhibitors studied [i.e., sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra)] are metabolized by the liver, and dosage should be adjusted for patients with altered hepatic function. The side effects of all three medications include facial flushing, nasal congestion, headache, and dyspepsia. Sildenafil and vardenafil may cause visual side effects. A limited number a patients taking tadalafil report back pain. Vardenafil may cause mild prolongation of QT interval; caution should be used when prescribing this agent for patients with a history of QT prolongation or those taking medications that prolong the QT interval. Many men being treated for ED also are taking medication for treatment of hypertension or lower urinary tract symptoms. PDE5 inhibitors interact with β-blockers, a class of drugs commonly used to treat hypertension and lower urinary tract symptoms. Vardenafil should not be used by any patient taking any other medication with α-blocker activity. Any dose of tadalafil and 50- and 100-mg doses of sildenafil should be administered with caution to patients taking α-blockers. Patients taking PDE5 inhibitors should not take organic nitrates concomitantly. No safe interval between the use of nitrates and PDE5 has been determined, but it is suggested that a 24-hour interval be used for sildenafil and a 48-hour interval be used for tadalafil. It is important that physicians monitor the effectiveness, side effects, and health changes in patients using PDE5 inhibitors. This can be done at the time of prescription renewal. Patients who do not respond to PDE5 inhibitors may have modifiable risk factors such as hormonal abnormalities, food or drug interactions, incorrect dosing, lack of adequate sexual stimulation, heavy alcohol use, or relationship problems with their partner. Patients who do not respond to PDE5 inhibitors should be informed of the risks and benefits of other therapies. The panel recommends that the first dose of alprostadil intraurethral suppositories be administered under a physician's supervision because hypotension has been reported in approximately 3% of patients. Studies show that alprostadil combined with PDE5 inhibitors or a penile constriction device is more effective than the use of alprostadil alone. Intracavernous injection therapy is invasive, but it is the most effective nonsurgical treatment for ED. The most widely used drugs for this therapy are alprostadil, papaverine (Pavabid), and phentolamine. The initial dose of all intracavernous injection medications should be administered in the presence of a physician to instruct the patient on proper technique, determine the most effective dose, and monitor the patient for side effects. It is important to watch for priapism in patients taking intracavernous injection therapy. Priapism can cause corporal tissue damage but, if caught early, usually can be reversed with nonsurgical measures. Vacuum constriction devices are a low-cost treatment appropriate for some patients with ED. To avoid injury to the penis, only devices that contain a vacuum limiter should be used. Vacuum constriction devices are available with or without a prescription. Trazodone (Desyrel), testosterone (in patients with normal serum testosterone levels), and yohimbine and other herbal therapies are not recommended for treatment of ED.
Montague DK et al. The Management of Erectile Dysfunction: An Update. American Urological Association;2005.
Vardenafil may cause mild prolongation of QT interval; caution should be used when prescribing this agent for patients with a history of QT prolongation or those taking medications that prolong the QT interval.
Patient B
Options 16–25
A 44-year-old African American male physician is noted to be hypertensive, with blood pressure readings in the range of 160/94 mm Hg on three separate occasions. The patient drinks two cups of coffee a day, has an occasional alcoholic drink, and is 30 lb overweight. He does not have a regular exercise program, his family history is negative, and the physical examination is unremarkable.
The minimum baseline testing in the initial evaluation of this patient includes
16. urinalysis
17. 24-hour urine metanephrines
18. serum creatinine
19. electrocardiogram
20. fasting serum glucose
21. intravenous pyelogram
Appropriate management of this patient's condition includes
22. abstinence from alcohol consumption
23. initiation of an exercise program
24. high-dose zinc therapy
25. avoidance of all caffeine-containing products
View Answer
Options 16–25
Answers: 16. T17. F18. T19. T20. T21. F22. F23. T24. F25. F
The initial management of a hypertensive patient includes the following minimal baseline tests: CBC, urinalysis, serum sodium, serum potassium, serum creatinine, fasting glucose determination, total high-density and low-density lipoprotein cholesterol, and an electrocardiogram. Other tests, including chest x-ray, ambulatory blood pressure monitoring, urine studies to rule out pheochromocytoma, and radiographic procedures to study the kidneys, are unnecessary in this patient. The patient should be counseled on weight loss with dietary modification and the institution of a regular exercise program. Sodium restriction to <2 g/day and limitation of alcohol to <1 oz/day in men and <0.5 oz/day in women should be encouraged. Home monitoring of blood pressure may be helpful in management, and the patient should have close outpatient follow-up. If these measures do not improve the patient's condition, medication can be considered. If target organ damage is present or other risk factors (e.g., diabetes) are present, or when the systolic blood pressure is ≥160 mm Hg or diastolic blood pressure is >100 mm Hg, drug therapy should not be deferred while awaiting the results of diet and exercise modification. Minimal amounts of alcohol and caffeine do not significantly alter the treatment of this individual's hypertension. High-dose vitamins and trace mineral supplementation are not recommended in the treatment. The goal is to keep blood pressure at <140/90 mm Hg or as near this level as possible in patients who are younger than 65 years of age. For those with diabetes or kidney disease, the goal should be <130/80 mm Hg. In most cases, drug therapy should be initiated with a β-blocker or diuretic unless they are contraindicated. Diuretics (e.g., hydrochlorothiazide) appear to be more effective in patients older than 60 and in African Americans. Coexisting conditions may help with the initial selection of a hypertensive agent.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:604–620.
For those with diabetes or kidney disease, the blood pressure goal should be less than 130/80.
Patient C
Options 26–33
A 52-year-old professional golfer has noted an irregular-shaped lesion on his left shoulder. He presents to your office for evaluation.
Indications for biopsy include
26. recent increase in size
27. purulent drainage from the lesion
28. variegation in color
29. irregular borders
Pathology results confirm a superficial melanoma (0.6 mm in depth). Initial treatment involves
30. excision with 1-cm borders around the lesion
31. high-dose intravenous chemotherapy
32. 5,000 rads external beam radiation
33. regional lymph node dissection
View Answer
Options 26–33
Answers: 26. T27. F28. T29. T30. F31. F32. F33. T
The incidence of melanoma is rising at an alarming rate. Sun exposure, familial dysplastic nevi syndrome, and a positive family history of melanoma are significant risk factors. The four histologic types are lentigo maligna melanoma, superficial spreading melanoma, nodular melanoma, and acral-lentiginous melanoma. Warning signs include the ABCDE rule: Asymmetric lesions, lesions with irregular Borders, lesions with variegated Color, lesions with Diameter greater than 6 mm, and lesions with an Elevated surface contour. Any suspicious lesion should be biopsied. Initial treatment entails wide excision and regional node dissection. Survival rates are based on the depth of invasion.
Rakel RE, Bope ET. Conn's Current Therapy 2005. Philadelphia: Elsevier/Saunders; 2005:936–941.
Sun exposure, familial dysplastic nevi syndrome, and a positive family history are significant risk factors for melanoma.
Patient D
Options 34–48
A 4-year-old girl is brought in by her mother because of enuresis, abdominal pain, burning with urination, and foul-smelling, cloudy urine. The child has been treated several times previously for documented and culture-proven urinary tract infections. On examination, she appears nontoxic. Mild abdominal tenderness is present with neither rebound tenderness nor costovertebral tenderness. The child does not have a fever, and she has not experienced vomiting. Dipstick urinalysis is positive for 1+ protein, positive leukocyte esterase, and positive bacteria.
Immediate diagnostic tests include
34. urine culture and sensitivity
35. further questioning about the possibility of sexual abuse
36. 24-hour urine protein collection
37. urine cytology
38. cystoscopy
Appropriate treatment for this child may include
39. amoxicillin
40. ciprofloxacin
41. tetracycline
42. nitrofurantoin
43. trimethoprim-sulfamethoxazole
Follow-up after treatment should include
44. repeat urinalysis
45. urethral dilation
46. radionuclide cystogram
47. intravenous pyelogram
48. computed tomographic (CT) scanning of the pelvis
View Answer
Options 34–48
Answers: 34. T35. T36. F37. F38. F39. T40. F41. F42. T43. T44. T45. F46. T47. T48. F
Recurrent urinary tract infections in young girls should always be investigated initially with a urine culture and sensitivity. Because sexual abuse in children can present with symptoms of dysuria, enuresis, and abdominal pain, the physician should always remain alert to the possibility of sexual abuse. The most common infecting organisms include Escherichia coli, Klebsiella, Staphylococcus, and the enteric streptococci. Amoxicillin, nitrofurantoin, and trimethoprim-sulfamethoxazole can be used for urinary tract infections in children. Tetracycline and ciprofloxacin are contraindicated for use in children. After treatment, the child should have a repeat urinalysis. Girls have traditionally been worked up with intravenous pyelography after the second infection; however, recommendations are for further evaluation for all children after the first infection, if the first infection occurs between 2 months and 2 years of age. Renal ultrasound is often used to rule out obstruction and to determine kidney size. After age 2, some advocate further imaging only after the second infection in females. All boys should be evaluated with their first infection. Ultrasound can be done immediately; however, a voiding cystogram (used to detect posterior urethral valves) is usually done after an infection has cleared because an infection can predispose to reflux. Radionuclide cystograms can also be utilized; however, most experts prefer the voiding cystogram and use the radionuclide scan in follow-up to determine if the vesicourethral reflux has resolved. Urethral dilation and CT of the pelvis are not indicated.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2356–2358.
Because sexual abuse in children can present with symptoms of dysuria, enuresis, and abdominal pain, the physician should always remain alert to the possibility of sexual abuse.
Patient E
Options 49–65
A 23-year-old sexually active college student presents with a vaginal itching and discharge that has been present over the last week. She has recently had intercourse with a new partner.
Which of the following tests would be indicated?
49. chlamydia testing
50. saline wet prep test
51. culture for herpes simplex
52. HIV viral load
53. HPV typing
54. gonorrhea testing
Further evaluation shows the presence of trichomonads on microscopic evaluation. Appropriate treatment at this time includes
55. azithromycin
56. metronidazole
57. fluconazole
58. ceftriaxone
Further recommendations concerning treatment include
59. the partner should be treated
60. the patient should abstain from alcohol while taking the medication
61. the medication is considered safe during pregnancy
In women who are pregnant, trichomoniasis is associated with
62. premature rupture of membranes
63. preterm delivery
64. low birth weight
65. twin pregnancy
View Answer
Options 49–65
Answers: 49. T50. T51. F52. F53. F54. T55. F56. T57. F58. F59. T60. T61. T62. T63. T64. T 65. T
Women presenting with vaginal symptoms following intercourse should be evaluated for chlamydia, gonorrhea, bacterial vaginosis, trichomoniasis, and Candida vaginitis. A culture for herpes simplex is not indicated in the absence of suspected lesions. Human papilloma virus (HPV) testing is not clinically useful in this setting, and human immunodeficiency virus (HIV) viral load assessment is not indicated in this situation. If HIV testing is performed, an HIV ELISA antibody test would be the appropriate screening test. Most men who are infected with Trichomonas vaginalis do not have symptoms, but others may have urethritis-type symptoms. Many infected women have a diffuse, malodorous, yellow-green discharge with vulvar irritation; however, some have minimal or no symptoms. Treatment of patients and sex partners results in relief of symptoms, cure of the condition, and reduction of transmission. Patients should be treated with oral metronidazole. The recommended regimens have resulted in cure rates of about 90% to 95%, which might increase if the treatment of sex partners is ensured. Patients should be instructed to avoid sex until they and their sex partners are cured. Follow-up is unnecessary for men and women who are initially asymptomatic or become asymptomatic after treatment. In pregnant women, vaginal trichomoniasis has been associated with premature rupture of the membranes, preterm delivery, and low birth weight. Women who are symptomatic should be treated to relieve symptoms and may be treated with oral metronidazole. Patients who have trichomoniasis and are infected with HIV should receive the same therapy as those who are not infected with HIV.
Ressel GW. CDC releases 2002 guidelines for treating STDs: Part I. Diseases characterized by vaginal discharge and PID. Am Fam Physician. 2002;66(9):1777–1778.
In pregnant women, vaginal trichomoniasis has been associated with premature rupture of the membranes, preterm delivery, and low birth weight.
Patient F
Options 66–75
A 42-year-old woman is the lone survivor of a single-engine plane crash. She is brought to the emergency room by ambulance. Initial examination shows her to be comatose with superficial and deep partial-thickness burns (second-degree) and full-thickness (third-degree) burns over 50% of her body. Vital signs are as follows: blood pressure, 130/70 mm Hg; pulse, 110/minute; respirations, 40/minute; and temperature, 37.5°C. Immunization status is unknown.
Initial management consists of
66. endotracheal intubation
67. 1 mg lorazepam (Ativan) given orally on arrival in the emergency room
68. administration of intravenous antibiotics
69. 2 mg morphine sulfate given every 1 to 2 hours as needed
70. intravenous fluid resuscitation
71. human tetanus immune globulin
72. tetanus toxoid given intramuscularly
After relative stabilization in the first 24 hours, the patient's blood pressure remains low and her urine output is minimal. Further management consists of
73. sufficient fluid to replace evaporated and insensible fluid losses
74. low-dose dopamine
75. transfer to a local burn unit
View Answer
Options 66–75
Answers: 66. T67. F68. T69. T70. F71. T72. T73. T74. T75. T
Burns represent a special challenge to family physicians who work in emergency room settings. They are classified as follows; however, the newer terms (in parentheses) are replacing the old classification:
• First degree (Superficial burns): Superficial burns that affect only the epidermis; usually resulting in mild redness and discomfort, they blanch with pressure; the protective function of the skin is maintained. There is no blister formation. An example is a mild sunburn.
• Second degree (Superficial and Deep Partial-Thickness Burns): Partial-thickness burns that cause pain and blistering of the epidermis and dermis layers, they spare the hair follicles and sebaceous and sweat glands.
• Third degree (Full-Thickness Burns): Involve the epidermis, dermis, and deeper structures; classically anesthetic; they appear white, dry, charred, or inelastic; regeneration of skin tissue is minimal, and skin grafting is required. They are painless and avascular; significant scarring and contractures occur.
• Fourth degree (now included in Full-Thickness Burns): Involve deeper muscles, fascia, or bone. Appearance and healing are similar to that of third-degree burns. Some combine third- and fourth-degree burns together.
Physicians should stabilize all burn victims, secure the airway with endotracheal intubation when airway compromise is a possibility, and perform aggressive fluid resuscitation (including half of fluid deficits administered over the first 8 hours). The victim's clothing and any remaining hot substances should be removed and the victim covered with a sterile sheet. Copious irrigation is indicated for chemical burns. Cool compresses are used for small burns but can cause hypothermia in large burns. Transfer to a major burn center for further care is recommended for extensive burns once the patient's condition is stabilized. Severely burned patients have a generalized increase in capillary permeability throughout the body, which may lead to excessive fluid loss and development of shock. Aggressive fluid resuscitation is imperative.
Narcotic pain medication should be used to manage pain; the use of benzodiazepines for sedation is usually unnecessary. Topical antibiotic (silver sulfadiazine) is generally applied in all but first-degree burns to help prevent infection. Bacitracin ointment is a suitable alternative. If there is an extensive burned area, intravenous antibiotics are necessary to help prevent septicemia. If the patient's immunization status is unknown, tetanus immunization with tetanus toxoid and immune globulin is recommended. Further management includes aggressive management of fluids; administration of dopamine, which can increase urinary output and sustain blood pressure, can be considered. Débridement of necrotic tissue and whirlpool treatments are usually necessary.
Taylor RB, David AK, Fields SA, et al., eds. Family medicine: principles and practice, 6th ed. New York: Springer; 2003:431–434.
Superficial burns affect only the epidermis; usually resulting in mild redness and discomfort, they blanch with pressure; the protective function of the skin is maintained. There is no blister formation.
Patient G
Options 76–87
Before Thanksgiving, a 67-year-old retired female secretary is seen in your office for a general examination. The patient is married, has two daughters, and has enjoyed relatively good health. Her last general examination was 6 years ago, and she has not seen a physician since then. The patient has no overall health complaints, but is interested in updating preventive health issues. Health history includes the following:
• Surgeries: Total abdominal hysterectomy and oophorectomy at age 42 for excessive vaginal bleeding; cholecystectomy at age 45; benign breast biopsy at age 53
• Hospitalizations: Vaginal childbirth at ages 21 and 25; acute pyelonephritis at age 31
• Chronic medical problems: Asthma as a child
• Allergies: Penicillin
• Alcohol: Social only
• Tobacco: None
• Medications: Multivitamin daily
• Immunizations: None over last 20 years
Based on her history, which of the following would be indicated?
76. influenza vaccination
77. pneumococcal (Pneumovax) vaccination
78. tetanus-diphtheria vaccination
79. hepatitis A vaccination
80. hepatitis B vaccination
81. purified protein derivative tuberculosis testing
A physical examination reveals the following:
• General: Thin female in no distress
• Blood pressure: 140/88 mm Hg
• Pulse: 82 bpm and regular
• Respirations: 16/minute
• Temperature: 37.0°C (98.6°F)
• Height: 5 ft, 6 in.
• Weight: 120 lb
• Head, ears, eyes, nose, and throat: Ears clear; pupils equal, round, and reactive; funduscopic examination unremarkable; nose clear; oropharynx clear
• Neck: Supple, no lymphadenopathy, thyroid unremarkable
• Heart: Regular rate and rhythm, no murmurs
• Lungs: Clear to auscultation
• Breast: No distinct masses, fibrocystic changes bilaterally
• Abdomen: Soft and nontender, no masses, no hepatosplenomegaly
• Pelvis: Unremarkable, cervix surgically absent
• Rectum: No stool in the rectal vault
• Extremities: Free range of motion
• Neurologic: Grossly intact
• Skin: No suspicious lesions
Further management of this patient should include
82. mammogram screening
83. chest x-ray
84. pulmonary function tests
85. flexible sigmoidoscopy
86. DEXA screening
87. thyroid function tests
View Answer
Options 76–87
Answers: 76. T77. T78. T79. F80. F81. F82. T83. F84. F85. T86. T87. F
General health maintenance is often provided by family physicians. In this case the patient is relatively healthy, but she needs an update on some preventive health issues. Immunizations for a 67 year old should include a yearly influenza vaccination (beginning at age 50) and Pneumovax if no prior Pneumovax has been given, if the patient had a Pneumovax before age 65 and it has been more than 5 years, and if no contraindications exist (e.g., previous reaction, allergy to eggs with the influenza immunization). Hepatitis A vaccination should be considered for frequent travelers who visit Third-World and underdeveloped countries. Hepatitis B vaccination is now recommended for all schoolchildren, but is not indicated at this age unless the patient is at risk for development of hepatitis B (e.g., those with multiple sexual partners or exposure to blood and body secretions). Purified protein derivative testing for tuberculosis is not generally recommended unless the patient is at risk for tuberculosis exposure, is an immigrant, or is about to enter a nursing home. In these cases, tuberculosis screening should be considered. Further testing for this woman should include a yearly mammogram [which should begin at 50 years of age; some (ACOG/ACS) advocate starting at age 40], monthly breast self-examination, and yearly breast examination by a physician. Chest x-ray screening is not indicated in asymptomatic patients. Although this patient has a history of childhood asthma, pulmonary function testing is not indicated. Colon screening should consist of periodic bowel examination with colonoscopy or flexible sigmoidoscopy combined with yearly hemoccult testing and digital rectal examinations in patients older than 50 years of age. Barium enemas may be an option in certain patients. Unless the patient exhibits symptoms that are consistent with a thyroid disorder, the routine ordering of thyroid function tests is not indicated. DEXA screening is recommended for women over age 65.
Rakel RE. Textbook of Family Practice. Philadelphia: WB Saunders; 2002:170–179.
Hepatitis A vaccination should be considered for frequent travelers who visit Third-World and underdeveloped countries.
Patient H
Options 88–97
A 49-year-old, overweight, sedentary male mortgage banker hired a trainer at a local gym. The patient presents to your office 2 weeks after initiating a vigorous exercise program that consists of weight lifting and aerobic exercise. Recently, the patient added a new exercise machine to his workout routine that allows the user to perform flexion and extension leg exercises against resistance. Twenty-four hours after performing this exercise, he presents to you complaining of anterior knee pain.
Likely causes of the pain include
88. injury of the muscle fibers and surrounding connective tissue
89. stress fracture of the tibial plateau
90. accumulation of lactic acid in the muscle
91. Osgood-Schlatter disease
Appropriate initial treatment for this patient may include
92. ice therapy
93. stretching exercises
94. steroid injection
95. relative rest with limited weight bearing
96. heat wraps
97. ibuprofen administration
View Answer
Options 88–97
Answers: 88. T89. F90. T91. F92. T93. T94. F95. T96. F97. T
Muscle-related injuries are common in poorly conditioned individuals who start a new exercise routine. Typically, muscle fibers and surrounding connective tissue are injured. Accumulation of lactic acid in muscle tissue can also result in pain. Stress fractures occur over a period of time and are associated with chronic use and repeated trauma. Osgood-Schlatter disease is a common cause of anterior knee pain in children but not adults.
Treatment may include relative rest with limited weight bearing, ice therapy, compressive wraps, and elevation (particularly if swelling is present). Nonsteroidal anti-inflammatory agents, such as ibuprofen, should be initiated for their analgesic and anti-inflammatory properties. Stretching exercises can also be instituted. Heat therapy is usually used at least 48 hours after application of ice, and steroid injections are given if necessary for specific conditions, such as severe degenerative joint disease that is unresponsive to anti-inflammatory drugs.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2635–2636.
Osgood-Schlatter disease is a common cause of anterior knee pain in children, but not adults.
Patient I
Options 98–123
You have been asked to participate in a question/answer session about current immunization practices with a local parent group at their November meeting.
The first question a parent asked is, which of the following immunizations is required at the 2-month-old well-child visit?
98. hepatitis B (Hep B)
99. diptheria and tetanus toxoid and acellular pertussis vaccine (DTaP)
100. Haemophilus influenzae type B conjugate vaccine (Hib)
101. inactivated polio (IPV)
102. varicella
103. meningococcal conjugate vaccine (MCV4)
104. influenza
105. hepatitis A (Hep A)
106. heptavalent pneumococcal conjugate vaccine (PCV)
107. measles, mumps, and rubella (MMR)
Another parent states that her daughter has been allergic to eggs and asks what vaccines she will likely react to?
108. hepatitis B (Hep B)
109. diptheria and tetanus toxoid and acellular pertussis vaccine (DTaP)
110. Haemophilus influenzae type B conjugate vaccine (Hib)
111. inactivated polio (IPV)
112. varicella
113. meningococcal conjugate vaccine (MCV4)
114. influenza
115. hepatitis A (Hep A)
116. yellow fever vaccine
The final question has to do with which of the following is a live attenuated virus type vaccine?
117. hepatitis B (Hep B)
118. diptheria and tetanus toxoid and acellular pertussis vaccine (DTaP)
119. Haemophilus influenzae type B conjugate vaccine (Hib)
120. measles, mumps, and rubella (MMR)
121. varicella
122. meningococcal conjugate vaccine (MCV4)
123. influenza
View Answer
Options 98–123
Answers: 98. T99. T100. T101. T102. F103. F104. F 105. F 106. T 107. F 108. F 109. F 110. F 111. F 112. F113. F114. T115. F116. T117. F118. F119. F120. T121. T122. F123. F
At the 2-month-old well-child visit, the following vaccines are indicated in otherwise healthy children: hepatitis B; diphtheria, tetanus, and acellular pertussis (DTaP); Haemophilus influenzae type B (Hib); inactivated poliovirus (IPV); and pneumococcal vaccinations. Various combinations exist for coadministration. Varicella and hepatitis A vaccinations are normally given after 12 months of age. Influenza vaccine is given to children older than 6 months. The measles, mumps, and rubella (MMR) vaccination is given at 12 to 15 months. Egg protein is present in yellow fever and influenza vaccines and may cause reactions in egg-allergic recipients; thus, a history of allergy to the ingestion of egg should be sought prior to the administration of any egg-containing vaccine. Persons with a positive history should be evaluated by an allergist prior to vaccine administration. However, a negative history may not exclude an allergic reaction to egg protein injected with the vaccine, because vaccine recipients can be allergic to heat-labile egg proteins in raw egg, and may not think of themselves as “egg-allergic.” Of the live-attenuated vaccines listed above, only varicella and the MMR vaccine are live-attenuated vaccines.
Advisory Committee on Immunization Practices, Department of Health and Human Services, Centers for Disease Control and Prevention, 2006 Recommended Childhood and Adolescent Immunization Schedule. Accessed at www.aafp.org on 5/18/06.
Kelso, JM. Raw egg allergy—a potential issue in vaccine allergy. J Allergy Clin Immunol. 2000;106:990.
Egg protein is present in yellow fever and influenza vaccines and may cause reactions in egg-allergic recipients.
Patient J
Options 124–134
A 64-year-old wealthy socialite presents to your office for a general examination; the patient has no complaints. Past medical history includes a total abdominal hysterectomy and associated blood transfusion at age 49, mild obesity, hyperlipidemia, and borderline hypertension. The patient has traveled extensively throughout the world without significant medical problems. Medications include atorvastatin taken for cholesterol. The patient is a former smoker and admits to consuming three glasses of wine per night. Family history is noncontributory. Review of systems is unremarkable. Physical examination is normal except for her being overweight and having mild fibrocystic changes in the breasts.
The following laboratory test results were obtained:
|
Electrolyte Panel |
|
|
Sodium (135–145 mEq/L) |
140 mEq/L |
|
Potassium (3.3–5.1 mEq/L) |
4.1 mEq/L |
|
Chloride (100–108 mEq/L) |
102 mEq/L |
|
Creatinine (0.6–0.9 mEq/L) |
0.8 mEq/L |
|
Blood urea nitrogen (6–19 mEq/L) |
10 mEq/L |
|
Liver Function Tests |
|
|
AST (12–31 U/L) |
82 U/L |
|
ALT (10–45 U/L) |
60 U/L |
|
GGT (9–31 U/L) |
102 U/L |
|
Alkaline phosphatase (98–251 U/L) |
232 U/L |
|
Total bilirubin (0.1–1.1 U/L) |
0.8 U/L |
|
Direct bilirubin (0.1–0.3 U/L) |
0.1 U/L |
|
Amylase (35–115 U/L) |
46 U/L |
|
Hepatitis Screen |
|
|
Hepatitis A antibody |
Negative |
|
Hepatitis B surface antigen |
Negative |
|
Hepatitis B surface antibody |
Negative |
|
Hepatitis C antibody |
Negative |
Possible causes of her elevated liver function tests include
124. steatohepatitis
125. cholecystitis
126. acute hepatitis A
127. chronic alcohol use
128. chronic hepatitis B
129. atorvastatin use
Further management at this point may include
130. limitation of alcohol use
131. discontinuation of lovastatin
132. magnetic resonance imaging (MRI) of the abdomen
133. liver biopsy
134. ultrasound of the liver, pancreas, and gallbladder
View Answer
Options 124–134
Answers: 124. T125. F126. F127. T128. F129. T130. T131. T132. F133. F134. T
Elevated liver function tests can result from different causes: inflammation, medications, toxin exposures, infections, tumors, storage diseases, autoimmune diseases, congestive heart failure, muscle disease, and fatty infiltration of the liver as a result of obesity. In this case, causes that could be considered include elevations as a result of alcohol consumption, steatohepatitis, and the patient's atorvastatin use. Cholecystitis is an unlikely cause, because the alkaline phosphatase as well as the total and direct bilirubin tests are normal. If hepatitis screening tests are negative, then acute hepatitis A and chronic hepatitis B are not causes.
Further management of this patient includes weight loss counseling and a recommendation to limit or abstain from alcohol use, discontinue atorvastatin use, and repeat liver function tests. Ultrasound of the liver, pancreas, and gallbladder may be indicated. However, other tests, such as MRI or biopsy of the liver, are not indicated.
Johnston DE. Special considerations in interpreting liver function tests. Am Fam Physician. 1999;59:2223–2230.
Elevated liver function tests can result from different causes: inflammation, medications, toxin exposures, infections, tumors, storage diseases, autoimmune diseases, congestive heart failure, muscle disease, and fatty infiltration of the liver as a result of obesity.
Patient K
Options 135–152
A 21-year-old primagravida is admitted to the labor and delivery ward at 34 weeks' gestation with regular contractions that are 4 minutes apart. Until this presentation, the patient's prenatal history has been unremarkable, with appropriate weight gain and uterus size for dates. The baby has remained active; there have been no problems with blood pressure or proteinuria. Because of nausea, the patient has not been compliant in taking prenatal vitamins on a regular basis. Prenatal laboratory test results were unremarkable.
Risk factors for the development of preterm labor include
135. urinary tract infection
136. septate uterus
137. premature rupture of membranes
138. congenital anomalies
139. polyhydramnios
Physical examination of the patient reveals a blood pressure of 108/72 mm Hg and a pulse of 72 bpm. Heart and lung examinations are unremarkable. The uterus measures 34 cm above the pubic symphysis. Vaginal examination reveals 2-cm dilation and 90% effacement. The station is -2. The cervix is measured at 32 mm in length. Microscopic examination of vaginal secretions shows no evidence of ferning.
Initial testing includes
140. urinalysis with culture and sensitivity
141. vaginal cultures
142. complete blood cell count (CBC) with differential
143. fibronectin assay
Fetal monitoring shows mild to moderate contractions that occur regularly every 4 minutes. Which of the following medications is useful in stopping preterm labor?
144. terbutaline
145. magnesium sulfate
146. nifedipine
147. oxytocin
148. ritodrine
After administration of appropriate medication, preterm labor is successfully arrested. Laboratory findings include a hemoglobin of 8.7 g/dL and a urinalysis that is positive for leukocyte esterase and bacteria.
Appropriate treatment for this patient includes
149. nitrofurantoin
150. ciprofloxacin
151. trimethoprim-sulfamethoxazole
152. iron supplementation
View Answer
Options 135–152
Answers: 135. T136. T137. T138. T139. T140. T 141. T142. T143. T144. T145. T146. T147. F148. T149. T150. F151. F152. T
Preterm labor is defined as labor pains that occur at least every 10 minutes and last for 30 seconds accompanied by cervical dilation between 20 and 37 weeks' gestation. Causes include infections, uterine abnormalities, cervical incompetency, premature rupture of membranes, multiple gestations, and other abnormalities (e.g., polyhydramnios, fetal abnormalities). Initial management of the patient in preterm labor should consist of a sterile speculum examination to determine if there is ferning, which would indicate premature rupture of membranes; vaginal cultures to rule out vaginal infection; urinalysis with culture and sensitivity; CBC with differential; and ultrasound examination of the uterus and fetus. A long cervix (>35 mm by transvaginal ultrasound) and a negative fibronectin assay have an excellent negative predictive value for preterm labor.
Treatment of preterm labor includes appropriate care of any precipitating infections and the use of tocolytics, such as magnesium sulfate, or ritodrine and, in some cases, terbutaline. Calcium-channel blockers, (e.g., nifedipine) and indomethacin can also be used. Oxytocin is used to initiate or augment labor.
Appropriate medication for the treatment of urinary tract infections during pregnancy includes ampicillin, cephalosporins, or nitrofurantoin. Organism susceptibility should be confirmed. Quinolones, sulfonamides, and trimethoprim should be avoided. In addition, this patient should be placed on iron supplementation for anemia.
Cunningham FG, Gant NF, Leveno KJ. Williams Obstetrics, 21st ed. New York: McGraw-Hill; 690–718.
Preterm labor is defined as labor pains that occur at least every 10 minutes and last for 30 seconds accompanied by cervical dilation between 20 and 37 weeks' gestation.
Patient L
Options 153–162
In mid-January, a 24-year-old man who is a painter is brought to the emergency room by ambulance after suffering what coworkers described as seizure-like activity. The patient has been working in an enclosed house, using space heaters to keep him warm. He is drowsy on admission without further seizure-like activity. Further questioning of the family reveals no prior history of seizures in the patient and no family history of seizures.
Initial evaluation should include
153. CT of the head
154. drug screen
155. electroencephalography
156. carboxyhemoglobin level
157. serum electrolytes
158. serum glucose determination
After approximately 15 minutes, the patient becomes more alert, and further evaluation reveals that he has been suffering with nausea and headaches that occur during and immediately after work, but he denies headaches at night or on the weekend when he is not working.
Which of the following can be considered a likely diagnosis?
159. brain tumor
160. new-onset diabetes mellitus
161. migraine headaches
162. carbon monoxide poisoning
View Answer
Options 153–162
Answers: 153. T154. T155. F156. T157. T158. T 159. F160. F161. F162. T
The initial evaluation of seizure-like activity should include baseline laboratory tests: serum electrolytes, calcium, magnesium, phosphorous, CBC, BUN, serum drug screen, glucose determination, and a carboxyhemoglobin level. CT of the brain is indicated to rule out structural abnormalities. A lumbar puncture may be needed after a CT is obtained if infection is suspected. An electroencephalogram may be necessary, but is not indicated in the initial testing.
Carbon monoxide poisoning is manifested by confusion, coma, seizures, headaches, fatigue, and nausea. Diagnosis is usually made by obtaining a careful history of carbon monoxide poisoning (exposure to space heaters, furnaces, or car exhaust) and carboxyhemoglobin determination. Venous carboxyhemoglobin levels are just as good as arterial. Oxygen saturation levels are often normal. Therapy includes the administration of 100% oxygen and the consideration of hyperbaric oxygen therapy.
Brain tumors may present with progressive severe headaches. These headaches often wake the patient from sleep and are accompanied by visual disturbances, neurologic deficits, nausea, and vomiting. Diabetes may present with diabetic ketoacidosis or other symptoms, such as polyphagia, polydipsia, and polyuria. Migraine headaches are usually associated with a previous history or positive family history. Migraines may be associated with nausea, vomiting, and visual disturbances, but they are not generally associated with seizure activity.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1826.
Carbon monoxide poisoning is manifested by confusion, coma, seizures, headaches, fatigue, and nausea. Diagnosis is usually made by obtaining a careful history of carbon monoxide poisoning (exposure to space heaters, furnaces, or car exhaust) and carboxyhemoglobin determination.
Patient M
Options 163–179
A 23-year-old female presents to your office with complaints of vaginal bleeding and left sided lower abdominal pain. She is sexually active. She thinks her last period was approximately 6 weeks ago. She is otherwise healthy but has been experiencing some generalized fatigue. She denies any fevers or any other symptoms.
Which of the following is indicated at this time?
163. dilation and curettage
164. vaginal cultures
165. pregnancy test
166. complete blood count
167. urinalysis
You suspect ectopic pregnancy and order further tests to confirm this. Which of the following would be appropriate at this time?
168. transvaginal ultrasound
169. CT of the abdomen
170. hysterosalpingogram
171. MRI of the fallopian tubes
172. laparoscopic exploration
She is found to have an intrauterine pregnancy and fetal heartbeat is noted. Her bleeding has stopped and she is otherwise stable.
Which of the following is indicated at this time?
173. admission for observation
174. discharge with close follow-up
175. serial quantitative β-hCG levels
176. serial transvaginal ultrasounds
177. serum estrogen levels
178. serum progesterone levels
179. dilation and curettage
View Answer
Options 163–179
Answers: 163. F164. T165. T166. T167. T168. T 169. F170. F171. F172. F173. F174. T175. T176. F177. F178. F179. F
Vaginal bleeding is a common concern in the first trimester of pregnancy, occurring in 20% to 40% of pregnant women. It may be light, heavy, intermittent, or constant, and there may or may not be pain. The four major causes of bleeding in early pregnancy are
1. Ectopic pregnancy
2. Threatened or impending miscarriage
3. Physiologic (i.e., related to implantation of the pregnancy)
4. ervical, vaginal, or uterine pathology
Because the exact cause of uterine bleeding in the first trimester often cannot be determined, the goal of the evaluation is to make a definitive diagnosis when possible and exclude serious pathology in other cases. Ectopic pregnancy is especially important to exclude because it can be life-threatening.
The initial step in the evaluation is to assess the extent of bleeding. If the woman is passing blood clots or the blood is soaking through her clothes, if she feels light-headed, if she has significant pelvic pain or cramping, or if she has passed any tissue, ectopic pregnancy and miscarriage are more likely, and implantation bleeding and cervicovaginal disease (e.g., polyps, infection, cancer) are less likely. However, the presence of only light, intermittent, painless bleeding does not exclude the possibility of a life-threatening underlying disease. A past history of ectopic pregnancy or risk factors for ectopic pregnancy (e.g., pelvic inflammatory disease) increases the probability of this condition. A history of two or more consecutive pregnancy losses or a disorder associated with pregnancy loss (e.g., chromosomal translocation, antiphospholipid antibody syndrome, uterine anomaly) raise the possibility that bleeding may be related to miscarriage. Orthostatic blood pressure changes occur if bleeding has been severe. If the patient has passed tissue, it should be examined for fetal products.
The patient's abdomen should be examined prior to a vaginal examination. Midline pain is more consistent with miscarriage, whereas lateral pain is more consistent with ectopic pregnancy. An attempt should be made to determine uterine size. Typically, the uterus can be palpated abdominally after 12 weeks' gestation. If the pregnancy is at or beyond 10 to 12 weeks' gestation, a Doppler device can be used to check for the fetal heart beat. The fetal heart rate can be easily distinguished from the maternal heart rate, as it is typically in the range of 140 to 160 bpm. The absence of a previously detected fetal heartbeat should raise concern that a missed abortion has occurred. However, vaginal bleeding often occurs well before the fetal heartbeat has been detected with a Doppler device. Doppler confirmation of fetal cardiac activity is reassuring and indicates bleeding is not related to missed abortion (also called delayed miscarriage) or ectopic pregnancy.
After the abdominal examination, the external genitalia are examined to assess the amount and source of bleeding, and then a speculum is inserted into the vagina. If blood clots are present, these can be removed with gauze sponges on a sponge forceps. If products of conception are suspected, the specimen should always be sent for pathologic examination to look for chorionic villi and confirm the diagnosis. Physical examination may reveal a non-pregnancy-related source of bleeding associated with a wound, cervical ectropion, abnormal growth, or purulent discharge. In these cases, further evaluation depends on the nature of the findings. Appropriate testing may include also vaginal cultures and urinalysis with culture to rule out infections.
A speculum-assisted vaginal examination can provide direct visualization of a dilated cervix or the gestational sac may be sufficient to diagnose a miscarriage clinically; however, ultrasound can provide additional information such as the presence of a multiple gestation or retained products of conception.
If uterine bleeding is confirmed but the cervix appears closed and there are no obvious bleeding lesions, a bimanual pelvic examination should be performed. Ectopic pregnancy findings include adnexal, cervical motion, and/or abdominal tenderness; an adnexal mass; and mild uterine enlargement. However, in many cases the physical examination is unremarkable, especially if there is a small, unruptured ectopic pregnancy. Bleeding when the uterine size is larger than expected for dates suggests a multiple gestation with miscarriage of one of the multiples, gestational trophoblastic disease (molar pregnancy), or other uterine pathology (leiomyomas are associated with an irregularly enlarged uterus). Transvaginal ultrasonography is the cornerstone of the evaluation of bleeding in early pregnancy. Ultrasound examination is performed to determine whether the pregnancy is intrauterine or extrauterine (ectopic) and, if intrauterine, whether the pregnancy is viable (fetal cardiac activity present) or nonviable. The ultrasound finding most concerning for a diagnosis of ectopic pregnancy in the setting of first trimester vaginal bleeding is the absence of an intrauterine gestational sac, rather than the presence of an adnexal mass. Rarely, ultrasound examination reveals unusual causes of uterine bleeding, such as gestational trophoblastic disease or partial loss of a multiple gestation. In bleeding patients in whom sonography has previous confirmed a singleton intrauterine pregnancy, another examination is not necessary to confirm fetal viability if fetal heart activity can be detected by a hand-held Doppler device.
Serial measurement of human chorionic gonadotropin (hCG) levels are helpful early in pregnancy if ultrasonography is nondiagnostic (i.e., the site and viability of the pregnancy are not revealed). There is no role for monitoring hCG levels once the presence of an intrauterine pregnancy has been established sonographically. Falling β-hCG concentrations are consistent with a nonviable intrauterine pregnancy or spontaneously resolving ectopic pregnancy, but do not indicate whether the pregnancy is intrauterine or ectopic. Appropriately rising hCG levels (>66% in 48 hours) are most consistent with a viable intrauterine pregnancy. hCG levels that have plateaued or are rising slowly suggest an ectopic pregnancy. Other hormone assays (e.g., progesterone, estrogen, inhibin A, PAPP-A) are less useful.
Norwitz ER, Park JS. Overview of the etiology and evaluation of vaginal bleeding in pregnant women. Up to Date, version 14.1. Accessed 5/19/06.
The four major causes of bleeding in early pregnancy are:
· Ectopic pregnancy
· Threatened or impending miscarriage
· Physiologic (i.e., related to implantation of the pregnancy)
· Cervical, vaginal, or uterine pathology
Patient N
Options 180–194
A 17-year-old sexually active female presents to the emergency room complaining of lower abdominal pain. She is using oral contraceptive pills and denies missing any of her pills. Her last menstrual period was 1 week ago. She denies dysuria, hematuria, or flank pain, but she has had fevers. Although she has had some nausea, she denies any vomiting, diarrhea, or breast tenderness. Her last sexual encounter was 4 days ago, and she complains of dyspareunia. Physical findings include the following:
• Temperature: 38.9°C orally (102°F)
• Pulse: 110 bpm
• Blood pressure: 110/68 mm Hg
• Head, ears, eyes, nose, and throat: Unremarkable
• Heart: Tachycardic, no murmurs
• Lungs: Clear
• Abdomen: Positive bowel sounds, moderate diffuse tenderness in lower quadrants bilaterally, positive guarding with no rebound tenderness
• Extremities: Unremarkable
• Pelvis: Normal external genitalia, positive cervical motion tenderness, positive bilateral adnexal tenderness; fullness of the right adnexa is noted
• Rectum: Normal, stool guaiac negative
Which of the following tests would be indicated in the initial workup?
180. urinalysis with culture and sensitivity
181. CBC with differential
182. electrolyte panel
183. pregnancy test
184. erythrocyte sedimentation rate
185. cervical and vaginal cultures
After initial testing, pelvic inflammatory disease (PID) is diagnosed. Likely infecting organisms include
186. Chlamydia
187. Ureaplasma
188. Neisseria gonorrhoeae
189. Escherichia coli
Which of the following would be considered appropriate outpatient treatment?
190. ceftriaxone given intramuscularly once, followed by oral doxycycline given twice a day for 14 days
191. amoxicillin given orally three times a day for 21 days
192. Cefoxitin given intravenously every 6 hours, plus probenecid followed by doxycycline orally
193. ampicillin intramuscularly once, followed by metronidazole for 14 days
194. ofloxacin orally twice a day for 14 days, plus metronidazole orally daily for 14 days
View Answer
Options 180–194
Answers: 180. T181. T182. F183. T184. T185. T186. T187. T188. T189. T190. T191. F192. T193. F194. T
Pelvic inflammatory disease (PID) should be considered in sexually active females who present with lower abdominal pain. Disease can manifest as any combination of endometritis, salpingitis, tuboovarian abscess, and pelvic peritonitis. Women at increased risk include those who have recently experienced childbirth or abortion, have an intrauterine device, have multiple sexual partners, have had recent menstrual periods, and have recently had pelvic surgery. Symptoms include lower abdominal pain, nausea, vomiting, fevers, vaginal discharge, and dyspareunia. Signs include lower abdominal pain with or without rebound tenderness, cervical motion tenderness, adnexal tenderness, and, in some, adnexal masses or fullness. Fever is usually present, and the white blood cell count is elevated. The differential diagnosis includes appendicitis, ectopic pregnancy, septic abortion, pyelonephritis, inflammatory bowel disease, endometriosis, hemorrhagic corpus luteum, ovarian cysts, and torsion of the ovary. Treatment is usually empiric, and antimicrobial therapy should cover Neisseria gonorrhoeae, Chlamydia trachomatis, anaerobes, gram-negative facultative bacteria, and streptococci. Parenteral therapy is required in several types of patients, including those who are pregnant; those who do not respond to or are unable to tolerate oral antimicrobial therapy; those with severe illness such as nausea, vomiting, or high fever; those with tuboovarian abscess; and patients who are immunodeficient. Sexual partners of patients with PID should be evaluated and treated. The initial workup in a case of suspected PID includes urinalysis with culture and sensitivity, CBC, pregnancy test, erythrocyte sedimentation rate, and cultures of the cervical and vaginal discharge. Likely infecting organisms include N. gonorrhoeae, Chlamydia, Mycoplasma, Ureaplasma, and gram-negative enterics and anaerobes. Outpatient treatment includes ofloxacin or levofloxacin with or without metronidazole. Ceftriaxone, or cefoxitin plus probenecid or another third-generation parenteral cephalosporin (ceftizoxime or cefotaxime), followed by doxycycline with or without metronidazole can also be used. Amoxicillin, ampicillin, and erythromycin are not considered alternatives to outpatient treatment. Complications of PID include peritonitis, increased risk of ectopic pregnancy, infertility, rupture of tuboovarian abscess, adnexal torsion, and bowel obstruction secondary to adhesions and septicemia.
Woodward C, Fisher MA. Drug treatment of common STDs (Part II). Vaginal infections, pelvic inflammatory disease and genital warts. Am Fam Physician. 1999;60:1716–1722.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2088.
Pelvic inflammatory disease (PID) should be considered in sexually active females who present with lower abdominal pain.
Patient O
Options 195–209
An 8-year-old boy presents to your office with his mother. The patient complains of a recurrent cough, shortness of breath, and wheezing that has been present over the last 3 years. He denies any mucus production, fevers, or any other symptoms that are consistent with infection. The patient also has noted that with physical exertion, he has wheezing and shortness of breath.
After a complete history and physical examination, which of the following would be indicated as part of the initial evaluation of this patient?
195. spirometry
196. arterial blood gases
197. CT of the chest
198. chest radiograph
199. echocardiogram
Which of the following would be important information in the diagnosis?
200. severity of symptoms
201. frequency of exacerbations
202. triggering factors
203. family history of reactive airway disease
Once the diagnosis of asthma is made, appropriate initial management of this patient may include
204. use of a β2-agonist inhaler
205. monitoring of peak-flow rate
206. administration of oral theophylline
207. administration of oral steroids
208. environmental control to avoid irritants and allergens
209. immunization for influenza and Pneumococcus
View Answer
Options 195–209
Answers: 195. T196. F197. F198. T199. F200. T201. T202. T203. T204. T205. T206. F207. F208. T209. T
Asthma is a common problem managed by family physicians. Symptoms include cough, dyspnea, and wheezing. Wheezing may be heard with the stethoscope; some may hear it unaided. Patients with severe asthma experience such intense bronchoconstriction that wheezing is inaudible at presentation and noted only after initial treatment. Factors that trigger an asthma attack include environmental allergens (e.g., pollen, molds, pollution), hot and humid or cold conditions, exercise, and barometric changes. Important aspects of the patient's history are triggering factors, severity of symptoms, frequency of attacks, and family history of asthma. Physical findings consist of rhonchi, wheezing, and a reversal of the normal 2:1 inspiratory–expiratory ratio. Other physical findings include nasal flaring (especially in young children), use of accessory muscles for breathing, cyanosis, and altered mental status in severe cases. The initial workup should include CBC determination to rule out infection, chest x-ray, and pulmonary function tests. Initial treatment for mild asthma entails avoidance of triggering factors, proper immunization for influenza and Pneumococcus, monitoring of peak-flow rates, and the use of inhaled β2 agonists. Patients with persistent asthma require medications that provide long-term control of their disease in addition to drugs that give quick relief of symptoms. Medications for long-term control of asthma include inhaled corticosteroids, cromolyn, nedocromil, leukotriene modifiers, and long-acting bronchodilators. Inhaled corticosteroids remain the most effective anti-inflammatory medications in the treatment of asthma. Quick-relief medications include the short-acting β2 agonists. The frequent use of quick-relief medications indicates poor asthma control and the need for larger doses of drugs that provide long-term control of asthma. Guidelines from the National Asthma Education and Prevention Program Expert Panel recommend an aggressive “step-care” approach. In this approach, therapy is instituted at a step higher than the patient's current level of asthma severity, with a gradual “step down” in therapy once control is achieved. Theophylline, oral steroids, and anticholinergics are generally not considered first-line therapy.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:1515–1516.
Inhaled corticosteroids remain the most effective anti-inflammatory medications in the treatment of asthma.
Patient P
Options 210–229
A 33-year-old used-car salesman presents to your office complaining of tightness in his chest, a choking sensation, shortness of breath, paresthesias of his hands, heart palpitations, and light-headedness. The patient denies syncope. Symptoms occur suddenly, often lasting 10 to 15 minutes, and they usually occur at rest. The patient has had six episodes during the last week and describes feeling anxious after the episode of chest discomfort. He was seen by another physician 2 days ago, and a CBC, erythrocyte sedimentation rate, thyroid function tests, electrolyte panel, electrocardiogram, and chest radiograph were all normal. The physician told him that he thought his symptoms were stress-related. The patient is quite concerned, and presents to you for a second opinion. A thorough examination, including cardiac, pulmonary, and neurologic examination, is unremarkable.
A cost-effective workup of this patient may include
210. exercise echocardiogram
211. referral to a cardiologist
212. CT scan of the chest
213. further questioning about the use of diet pills, illicit drugs, or alcohol
214. serum antinuclear antibody test
215. upper extremity electromyography studies
216. lumbar puncture
217. Holter monitoring
Results from further evaluation are normal. Management at this point might include prescribing
218. paroxetine (Paxil)
219. amitriptyline (Elavil)
220. desipramine (Norpramin)
221. verapamil (Calan, Isoptin)
222. sublingual nitroglycerin
223. imipramine (Tofranil)
224. alprazolam (Xanax)
After initiation of treatment, the patient returns for follow-up as symptoms continue. Further treatment may include
225. education concerning manifestations of the illness and ways to control them
226. identification of support systems
227. use of monoamine oxidase inhibitors
228. electroconvulsive therapy
229. psychiatric referral
View Answer
Options 210–229
Answers: 210. F211. F212. F213. T214. F215. F216. F217. T218. T219. T220. T221. F222. F223. T224. T225. T226. T227. T228. F229. T
Panic disorder is a distressing and debilitating condition with a familial tendency; it may be associated with situational (agoraphobic) avoidance. The diagnosis of panic disorder requires recurrent, unexpected panic attacks and at least one of the following characteristics:
• persistent concern about having an additional attack (anticipatory anxiety)
• worry about the implications of an attack or its consequences (e.g., a catastrophic medical or mental consequence)
• making a significant change in behavior as a consequence of the attacks
No organic factor is found to account for the symptoms, which may include dyspnea, dizziness, light-headedness, palpitations, trembling, sweating, choking, nausea or abdominal discomfort, paresthesias, chest discomfort, and fear of uncontrolled behavior. Workup should be focused and must be adequate enough to rule out underlying organic disorders. In this case, a Holter monitor may help to reassure the patient and physician that there are no cardiac arrhythmias contributing to the patient's symptoms. Other testing listed would be considered excessive. Questioning the patient about drug use, alcohol abuse, and the use of diet pills is necessary; many of the symptoms may be similar to those of panic disorder and panic attacks. Extensive and exhaustive workups are unnecessary and should be avoided. Treatment involves the use of tricyclic antidepressants, serotonin reuptake inhibitors, high-potency benzodiazepines, and, for resistant cases, monoamine oxidase inhibitors. The serotonin reuptake inhibitors are an appropriate first consideration. A high-potency benzodiazepine given at the minimum therapeutic dose may be a useful adjunct to antidepressant therapy if prompt relief is indicated. However, the treatment plan should include discontinuing the benzodiazepine when the antidepressant's maximal effects are expected (i.e., approximately 4–6 weeks) to minimize the risks of discontinuation difficulties that are associated with the benzodiazepines. Further treatment should focus on educating the patient about the disorder and the types of symptoms to expect. The physician should also help identify support systems in the patient's life. If further counseling and medication are unsuccessful, psychiatric referral may be necessary.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:2547.
The diagnosis of panic disorder requires recurrent, unexpected panic attacks and at least one of the following characteristics: persistent concern about having an additional attack (anticipatory anxiety), worry about the implications of an attack or its consequences (e.g., a catastrophic medical or mental consequence), and making a significant change in behavior as a consequence of the attacks. No organic factor is found to account for the symptoms.
Patient Q
Options 230–244
A 75-year-old woman presents with a 3-week history of bilateral temporal headaches, diplopia, jaw pain, low-grade fevers, and generalized fatigue with weight loss. The patient's husband recently had a bout with the flu, and she believes she is developing similar symptoms. Physical examination shows the following:
• Weight: 60 kg (132 lb)
• Blood pressure: 120/80 mm Hg
• Temperature: 38°C (100.4°F)
• Scalp: Temporal tenderness
• Eyes: Small retinal hemorrhages
• Nose: Clear
• Oropharynx: Unremarkable
• Neck: Supple
• Heart: Regular rate and rhythm
• Lungs: Clear to auscultation
• Abdomen: Soft, nontender
• Extremities: Unremarkable
• Neurologic: Nonfocal
Appropriate initial testing would include
230. lumbar puncture
231. MRI of the head
232. erythrocyte sedimentation rate
233. CBC
234. urinalysis
235. carotid ultrasound
The diagnosis of temporal arteritis is suspected. Appropriate management at this point would be
236. broad-spectrum oral antibiotics for 10 days
237. high-dose steroid therapy
238. immediate surgical consultation for temporal artery biopsy
239. physical therapy consultation
240. initiation of anticoagulation therapy
Complications of temporal arteritis may include
241. diffuse joint pain
242. amaurosis fugax
243. blindness
244. acute myelocytic anemia
View Answer
Options 230–244
Answers: 230. F231. F232. T233. T234. F235. F 236. F 237. T238. T239. F240. F241. T242. T243. T244. F
Temporal arteritis (also known as giant cell arteritis) is seen predominantly in elderly patients. Women are more commonly affected than men. The condition results from inflammation of the cranial arteries; veins are usually spared. Symptoms include severe headache, temporal tenderness, claudication of the jaw muscles, and visual disturbances, including amaurosis fugax, diplopia, scotomas, ptosis, and visual blurring. Untreated, the condition may lead to blindness. Other symptoms may include generalized arthralgias, low-grade fevers, weight loss, and generalized fatigue. Physical examination usually shows temporal artery tenderness, and the temporal artery may be palpable. Eye examination may show loss of disk margins and hemorrhages. Laboratory testing reveals a normocytic, normochromic anemia and a markedly elevated erythrocyte sedimentation rate (often >100 mm/hour). Definitive diagnosis is made by temporal artery biopsy. Treatment to prevent blindness should begin once the diagnosis is suspected. Treatment consists of high-dose steroid therapy (prednisone, 60 mg/day). This high-dose therapy is usually maintained for 2 to 4 weeks and is then tapered gradually. In many cases, the steroid taper takes months; in some, it may take years. If symptoms flare with reduction of steroid dose, the dose should be increased until symptoms are controlled, followed by continuation of a slow taper.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2547.
Laboratory testing for temporal arteritis reveals a normocytic, normochromic anemia and a markedly elevated erythrocyte sedimentation rate (often >100 mm/hour).
Patient R
Options 245–259
A newlywed couple presents to your office stating that they will be traveling to Central America for their honeymoon. They will be touring urban and rural locations. Both are concerned about the risk of traveler's diarrhea.
Which of the following recommendations should be given?
245. Avoid food from street vendors.
246. Obtain a portable filter for use with drinking water.
247. Peel all fruits before eating.
248. Carbonated beverages are generally considered safe.
249. Fluids should be iced to prevent bacterial growth.
250. Making sure to spit out the water used in brushing your teeth will prevent traveler's diarrhea.
Which of the following statements is true concerning the use of prophylactic antibiotics to prevent traveler's diarrhea?
251. Prophylactic antibiotics should be recommended for most travelers that visit developed countries, including central Europe, England, and Canada.
252. Prophylactic antibiotics are recommended for most travelers who visit third-world countries.
253. Prophylactic antibiotics may be warranted for business executives who are scheduled for important meetings or professional entertainers who are traveling abroad.
254. Prophylactic antibiotics are generally not necessary for travel abroad if hygiene and safety precautions are enforced.
Which of the following medications can be used for the prevention of traveler's diarrhea?
255. penicillin
256. erythromycin
257. bismuth subsalicylate
258. gentamicin
259. ciprofloxacin
View Answer
Options 245–259
Answers: 245. T246. F247.T 248. T249. F250. F251. F252. F253. T254. T255. F256. F257. T258. F259. T
Traveler's diarrhea affects as many as 30% to 50% of travelers who visit Third-World countries. Common pathogens in traveler's diarrhea include enterotoxigenic Escherichia coli, Campylobacter, Shigella, Salmonella, Yersinia, and many other species. Viruses and protozoa are the cause in many cases. Those who travel abroad should avoid drinking water in developing countries. If used, the water must be boiled for at least 10 minutes. Filters are not recommended because small viruses can often pass through the filter pores. In addition, travelers should be advised to avoid street vendors, peel all fruit before eating, and avoid using the water for brushing teeth. Ice cubes can also be contaminated and should be avoided. Carbonated beverages are generally considered safe. The use of prophylactic antibiotics is not recommended for travel abroad except in some circumstances, which may include business executives scheduled for important business meetings that cannot be missed or for professional entertainers performing abroad who also cannot afford to suffer from traveler's diarrhea. Although drug prophylaxis is discouraged, treatment with loperamide (in the absence of dysentery) and a fluoroquinolone, such as ciprofloxacin, is usually safe and effective in adults with traveler's diarrhea. Trimethoprim-sulfamethoxazole and doxycycline are alternatives, but resistance increasingly limits their usefulness. Antibiotic treatment is best reserved for cases that fail to respond to loperamide quickly. Bismuth subsalicylate (Pepto-Bismol), four times a day (taken with meals and in the evening), can prevent traveler's diarrhea.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:758–759.
Filters are not recommended for the prevention of traveler's diarrhea because small viruses can often pass through the filter pores.