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AAFP Family Medicine Board Questions

Terms in this set (533)

midgut volvulus

(Other choices:Infantile colic , Necrotizing enterocolitis, Hypertrophic pyloric stenosis, Intussusception)

Volvulus may present in one of three ways: as a sudden onset of bilious vomiting and abdominal pain in a neonate; as a history of feeding problems with bilious vomiting that appears to be a bowel obstruction; or less commonly, as failure to thrive with severe feeding intolerance. The classic finding on abdominal plain films is the double bubble sign, which shows a paucity of gas (airless abdomen) with two air bubbles, one in the stomach and one in the duodenum. However, the plain film can be entirely normal. The upper gastrointestinal contrast study is considered the gold standard for diagnosing volvulus. Infantile colic usually begins during the second week of life and typically occurs in the evening. It is characterized by screaming episodes and a distended or tight abdomen. Its etiology has yet to be determined. There are no abnormalities on physical examination and ancillary studies, and symptoms usually resolve spontaneously around 12 weeks of age. Necrotizing enterocolitis is typically seen in the distressed neonate in the intensive-care nursery, but it may occasionally be seen in the healthy neonate within the first 2 weeks of life. The child will appear ill, with symptoms including irritability, poor feeding, a distended abdomen, and bloody stools. Abdominal plain films will show pneumatosis intestinalis, caused by gas in the intestinal wall, which is diagnostic of the condition. Hypertrophic pyloric stenosis is a narrowing of the pyloric canal caused by hypertrophy of the musculature. It usually presents during the third to fifth weeks of life. Projectile vomiting after feeding, weight loss, and dehydration are common. The vomitus is always nonbilious, because the obstruction is proximal to the duodenum. If a small olive-size mass cannot be felt in the right upper or middle quadrant, ultrasonography will confirm the diagnosis. Intussusception is seen most frequently between the ages of 3 months and 5 years, with 60% of cases occurring in the first year and a peak incidence at 6-11 months of age. The disorder occurs predominantly in males. The classic triad of intermittent colicky abdominal pain, vomiting, and bloody, mucous stools is encountered in only 20%-40% of cases. At least two of these findings will be present in approximately 60% of patients. The abdomen may be distended and tender, and there may be an elongated mass in the right upper or lower quadrants. Rectal examination may reveal either occult blood or frankly bloody, foul-smelling stool, classically described as currant jelly. An air enema using fluoroscopic guidance is useful for both diagnosis and treatment.
a medication side effect

This patient has galactorrhea, which is defined as a milk-like discharge from the breast in the absence of pregnancy in a non-breastfeeding patient who is more than 6 months post partum. It is more common in women ages 20-35 and in women who are previously parous. It also can occur in men. Medication side effect is the most common etiology. The most common pharmacologic cause of galactorrhea is oral contraceptives. Oral contraceptives that contain estrogen can both suppress prolactin inhibitory factor and stimulate the pituitary directly, both of which can cause galactorrhea. Other medications that can cause galactorrhea include metoclopramide, cimetidine, risperidone, methyldopa, codeine, morphine, verapamil, SSRIs, butyrophenones, dopamine-receptor blockers, tricyclics, phenothiazines, and thioxanthenes. Breast cancer is unlikely to present with a bilateral milky discharge. The nipple discharge associated with cancer is usually unilateral and bloody. Pituitary tumors are a pathologic cause of galactorrhea due to the hyperprolactinemia that is caused by the blockage of dopamine from the hypothalamus, or by the direct production of prolactin. However, patients often have symptoms such as headache, visual disturbances, temperature intolerance, seizures, disordered appetite, polyuria, and polydipsia. Patients with prolactinomas often have associated amenorrhea. These tumors are associated with marked levels of serum prolactin, often >200 ng/mL. Hypothalamic lesions such as craniopharyngioma, primary hypothalamic tumor, metastatic tumor, histiocytosis X, tuberculosis, sarcoidosis, and empty sella syndrome are significant but infrequent causes of galactorrhea, and generally cause symptoms similar to those of pituitary tumors, particularly headache and visual disturbances. It is rare for primary hypothyroidism to cause galactorrhea in adults. Symptoms that would be a clue to this diagnosis include fatigue, constipation, menstrual irregularity, weight changes, and cold intolerance.
video-electroencephalography (vEEG) monitoring

Inpatient video-electroencephalography (vEEG) monitoring is the preferred test for the diagnosis of psychogenic nonepileptic seizures (PNES), and is considered the gold standard (SOR B). Video-EEG monitoring combines extended EEG monitoring with time-locked video acquisition that allows for analysis of clinical and electrographic features during a captured event. Many other types of evidence have been used, including the presence or absence of self-injury and incontinence, the ability to induce seizures by suggestion, psychologic tests, and ambulatory EEG. While useful in some cases, these alternatives have been found to be insufficient for the diagnosis of PNES.

Elevated postictal prolactin levels (at least two times the upper limit of normal) have been used to differentiate generalized and complex partial seizures from PNES, but are not reliable (SOR B). While prolactin levels are often elevated after an epileptic seizure, they do not always rise, and the timing of measurement is crucial, making this a less sensitive test than was previously believed. Other serum markers have also been used to help distinguish PNES from epileptic seizures, including creatine phosphokinase, cortisol, WBC counts, lactate dehydrogenase, pCO2 , and neuron-specific enolase. These also are not reliable, as threshold levels for abnormality, sensitivity, and specificity have not been determined.

MRI is not reliable because abnormal brain MRIs have been documented in as many as one-third of patients with PNES. In addition, patients with epileptic seizures often have normal brain MRIs.
Placental abruption


Late pregnancy bleeding may cause fetal morbidity and/or mortality as a result of uteroplacental insufficiency and/or premature birth. The condition described here is placental abruption (separation of the placenta from the uterine wall before delivery).

There are several causes of vaginal bleeding that can occur in late pregnancy that might have consequences for the mother, but not necessarily for the fetus, such as cervicitis, cervical polyps, or cervical cancer. Even advanced cervical cancer would be unlikely to cause the syndrome described here. The other conditions listed may bring harm to the fetus and/or the mother.

Uterine rupture usually occurs during active labor in women with a history of a previous cesarean section or with other predisposing factors, such as trauma or obstructed labor. Vaginal bleeding is an unreliable sign of uterine rupture and is present in only about 10% of cases. Fetal distress or demise is the most reliable presenting clinical symptom. Vasa previa (the velamentous insertion of the umbilical cord into the membranes in the lower uterine segment) is typically manifested by the onset of hemorrhage at the time of amniotomy or by spontaneous rupture of the membranes. There are no prior maternal symptoms of distress. The hemorrhage is actually fetal blood, and exsanguination can occur rapidly. Placenta previa (placental implantation that overlies or is within 2 cm of the internal cervical os) is clinically manifested as vaginal bleeding in the late second or third trimester, often after sexual intercourse. The bleeding is typically painless, unless labor or placental abruption occurs.
Order CT of the abdomen

Perinephric abscess is an elusive diagnostic problem that is defined as a collection of pus in the tissue surrounding the kidney, generally in the space enclosed by Gerota's fascia. Mortality rates as high as 50% have been reported, usually from failure to diagnose the problem in a timely fashion. The difficulty in making the diagnosis can be attributed to the variable constellation of symptoms and the sometimes indolent course of this disease. The diagnosis should be considered when a patient has fever and persistence of flank pain.

Most perinephric infections occur as an extension of an ascending urinary tract infection, commonly in association with renal calculi or urinary tract obstruction. Patients with anatomic urinary tract abnormalities or diabetes mellitus have an increased risk. Clinical features may be quite variable, and the most useful predictive factor in distinguishing uncomplicated pyelonephritis from perinephric abscess is persistence of fever for more than 4 days after initiation of antibiotic therapy. The radiologic study of choice is CT. This can detect perirenal fluid, enlargement of the psoas muscle (both are highly suggestive of the diagnosis), and perirenal gas (which is diagnostic). The sensitivity and specificity of CT is significantly greater than that of either ultrasonography or intravenous pyelography.

Drainage, either percutaneously or surgically, along with appropriate antibiotic coverage reduces both morbidity and mortality from this condition.
A history of a stress fracture resulting from minimal trauma

The initial definition of the female athlete triad was amenorrhea, osteoporosis, and disordered eating. The American College of Sports Medicine modified this in 2007, emphasizing that the triad components occur on a continuum rather than as individual pathologic conditions. The definitions have therefore expanded. Disordered eating is no longer defined as the formal diagnosis of an eating disorder. Energy availability,defined as dietary energy intake minus exercise energy expenditures, is now considered a risk factor for the triad, as dietary restrictions and substantial energy expenditures disrupt pituitary and ovarian function.

Primary amenorrhea is defined as lack of menstruation by age 15 in females with secondary sex characteristics. Secondary amenorrhea is the absence of three or more menstrual cycles in a young woman previously experiencing menses. For those with secondary amenorrhea, a pregnancy test should be performed. If this is not conclusive, a progesterone challenge test may be performed. If there is withdrawal bleeding, the cause would be anovulation. Those who do not experience withdrawal bleeding have hypothalamic amenorrhea, and fit one criterion for the triad.

Athletes who have amenorrhea for 6 months, disordered eating, and/or a history of a stress fracture resulting from minimal trauma should have a bone density test. Low bone mineral density for age is the term used to describe at-risk female athletes with a Z-score of -1 to -2. Osteoporosis is defined as having clinical risk factors for experiencing a fracture, along with a Z-score <-2.
Lisinopril (Prinivil, Zestril)

ACE inhibitors such as lisinopril are indicated for all patients with heart failure due to systolic dysfunction, regardless of severity. ACE inhibitors have been shown to reduce both morbidity and mortality, in both asymptomatic and symptomatic patients, in randomized, controlled trials. Unless absolutely contraindicated, ACE inhibitors should be used in all heart failure patients. No ACE inhibitor has been shown to be superior to another, and no study has failed to show benefit from an ACE inhibitor (SOR A).

Direct-acting vasodilators such as isosorbide dinitrate also could be used in this patient, but ACE inhibitors have been shown to be superior in randomized, controlled trials (SOR B). β-Blockers are also recommended in heart failure patients with systolic dysfunction (SOR A), except those who have dyspnea at rest or who are hemodynamically unstable. These agents have been shown to reduce mortality from heart failure.

A diuretic such as furosemide may be indicated to relieve congestion in symptomatic patients. Aldosterone antagonists such as spironolactone are also indicated in patients with symptomatic heart failure. In addition, they can be used in patients with a recent myocardial infarction who develop symptomatic systolic dysfunction and in those with diabetes mellitus (SOR B). Digoxin currently is recommended for patients with heart failure and atrial fibrillation, and can be considered in patients who continue to have symptoms despite maximal therapy with other agents.
adult respiratory distress syndrome (ARDS)

Acute respiratory failure following severe injury and critical illness has received increasing attention over the last decade. With advances in the management of hemorrhagic shock and support of circulatory and renal function in injured patients, it has become apparent that 1%-2% of significantly injured patients develop acute respiratory failure in the post-injury period.

Initially this lung injury was thought to be related to a particular clinical situation. This is implied by such names as "shock lung" and "traumatic wet lung," which have been applied to acute respiratory insufficiency. It is now recognized that the pulmonary problems that follow a variety of insults have many similarities in their clinical presentation and physiologic and pathologic findings. This has led to the theory that the lung has a limited number of ways of reacting to injury and that several different types of acute, diffuse lung injury result in a similar pathophysiologic response. The common denominator of this response appears to be injury at the alveolar-capillary interface, with resulting leakage of proteinaceous fluid from the intravascular space into the interstitium and subsequently into alveolar spaces. It has become acceptable to describe this entire spectrum of acute diffuse injury as adult respiratory distress syndrome (ARDS).

The syndrome of ARDS can occur under a variety of circumstances and produces a spectrum of clinical severity from mild dysfunction to progressive, eventually fatal, pulmonary failure. Fortunately, with proper management, pulmonary failure is far less frequent than milder abnormalities.
Evaluation for adrenal hormonal secretion


The incidental discovery of adrenal masses presents a common clinical challenge. Such masses are found on abdominal CT in 4% of cases, and the incidence of adrenal masses increases to 7% in adults over 70 years of age. While the majority of masses are benign, as many as 11% are hypersecreting tumors and approximately 7% are malignant tumors; the size of the mass and its appearance on imaging are major predictors of malignancy. Once an adrenal mass is identified, adrenal function must be assessed with an overnight dexamethasone suppression test. A morning cortisol level >5 μg/dL after a 1-mg dose indicates adrenal hyperfunction. Additional testing should include 24-hour fractionated metanephrines and catecholamines to rule out pheochromocytoma. If the patient has hypertension, morning plasma aldosterone activity and plasma renin activity should be assessed to rule out a primary aldosterone-secreting adenoma.

Nonfunctioning masses require assessment with CT attenuation, chemical shift MRI, and/or scintigraphy to distinguish malignant masses. PET scanning is useful to verify malignant disease. Nonfunctioning benign masses can be monitored for changes in size and for the onset of hypersecretory states, although the appropriate interval and studies are controversial. MRI may be preferred over CT because of concerns about excessive radiation exposure. Fine-needle aspiration of the mass can be performed to differentiate between adrenal and non-adrenal tissue after malignancy and pheochromocytoma have been excluded.
example: A 67-year-old female with hemiparesis, admitted for community-acquired pneumonia

Venous thromboembolism is a frequent cause of preventable death and illness in hospitalized patients. Approximately 10%-15% of high-risk patients who do not receive prophylaxis develop venous thrombosis. Pulmonary embolism is thought to be associated with 5%-10% of deaths in hospitalized patients. Anticoagulant prophylaxis significantly reduces the risk of pulmonary embolism and should be used in all high-risk patients.

Prophylaxis is generally recommended for patients over the age of 40 who have limited mobility for 3 days or more and have at least one of the following risk factors: acute infectious disease, New York Heart Association class III or IV heart failure, acute myocardial infarction, acute respiratory disease, stroke, rheumatic disease, inflammatory bowel disease, previous venous thromboembolism, older age (especially >75 years), recent surgery or trauma, immobility or paresis, obesity (BMI >30 kg/m2), central venouscatheterization, inherited or acquired thrombophilic disorders, varicose veins, or estrogen therapy.

Pharmacologic therapy with an anticoagulant such as enoxaparin is clearly indicated in the 67-year-old who has limited mobility secondary to hemiparesis and is being admitted for an acute infectious disease. The patient on chronic anticoagulation, the patient with severe thrombocytopenia, and the patient with coagulopathy are at high risk for bleeding if given anticoagulants, and are better candidates for nonpharmacologic therapies such as foot extension exercises, graduated compression stockings, or pneumatic compression devices. Although the 22-year-old is obese and recently had surgery, his young age and ambulatory status make anticoagulant prophylaxis less necessary.
Referral for orthopedic consultation

Developmental dysplasia of the hip encompasses both subluxation and dislocation of the newborn hip, as well as anatomic abnormalities. It is more common in firstborns, females, breech presentations, oligohydramnios, and patients with a family history of developmental dysplasia. Experts are divided with regard to whether hip subluxation can be merely observed during the newborn period, but if there is any question of a hip problem on examination by 2 weeks of age, the recommendation is to refer to a specialist for further testing and treatment. Studies show that these problems disappear by 1 week of age in 60% of cases, and by 2 months of age in 90% of cases. Triple diapering should not be used because it puts the hip joint in the wrong position and may aggravate the problem. Plain radiographs may be helpful after 4-6 months of age, but prior to that time the ossification centers are too immature to be seen. Because the condition can be difficult to diagnose, and can result in significant problems, the current recommendation is to treat all children with developmental dysplasia of the hip. Closed reduction and immobilization in a Pavlik harness, with ultrasonography of the hip to ensure proper positioning, is the treatment of choice until 6 months of age. The American Academy of Pediatrics recommends ultrasound screening at 6 weeks for breech girls, breech boys (optional), and girls with a positive family history of developmental dysplasia of the hip. Other countries have recommended universal screening, but a review of the literature has not shown that the benefits of early diagnosis through universal screening outweigh the risks and potential problems of overtreating.
Pseudogout (calcium pyrophosphate disease)

Acute monoarthritis in adults is most commonly caused by infection, trauma, or crystal deposition. Rheumatoid arthritis seldom presents as monoarthritis, and more often has a subacute course with multiple, symmetric joints involved. Although osteoporosis may result in a fracture of the knee joint without trauma at this age, there is no reason to believe that this patient has a torn anterior cruciate ligament. Gonococcal arthritis is one of the most common causes of septic arthritis, but is highly unlikely in this elderly, sexually inactive patient. Nongonococcal septic arthritis (especially due to staphylococcal and streptococcal bacteria) is still a consideration and should be ruled out by aspiration of fluid to be sent for culture. This patient's presentation is most consistent with pseudogout. Having a normal uric acid level suggests against gout, but does not rule it out. Also, gout is seven times more likely to be seen in males, whereas pseudogout is 1.5 times more frequent in females. Pseudogout most often affects the elderly, and usually affects the knee, wrist, and ankle. Gout presents most commonly in the first metatarsophalangeal joint and insteps of the feet, but also can occur in the knee, wrist, finger, and olecranon bursa. Differentiating between gout and pseudogout can be difficult and is best done by analysis of joint fluid. In patients with gout, this fluid contains highly negative birefringent, needle-shaped urate crystals, whereas in pseudogout the fluid contains rhomboid-shaped, weakly positive birefringent calcium pyrophosphate crystals.
Stopping the hydrochlorothiazide may control the hyperuricemia

This is a typical presentation for gout. Elevated uric acid levels are not necessary for the diagnosis, as there are some patients with normal uric acid levels who still have gout. Conversely, hyperuricemia does not establish the diagnosis of gout. Risk factors for the development of gout include several enzyme deficiencies, renal insufficiency, hypertension, obesity, moonshine ingestion (causing lead exposure), and alcohol abuse. There are several medications that elevate uric acid, including diuretics, low-dose salicylates, niacin, cyclosporine, ethambutol, and pyrazinamide. A typical gout attack such as the one described will resolve spontaneously within 2 weeks without treatment. In patients who have an acute monoarticular arthritis in addition to gout, other diagnoses such as osteoarthritis, pseudogout, and infection must be considered. The diagnosis of gout is established by aspiration of synovial fluid or tophi, with characteristic uric acid crystals detected by polarized light microscopy. Treatment can consist of NSAIDs in healthy individuals. Indomethacin is considered the drug of choice. Corticosteroids can also be used, and are particularly helpful when the patient has renal insufficiency. Intra-articular injections of a corticosteroid such as triamcinolone are useful, and intramuscular corticosteroids may be especially useful in patients with polyarticular gout. Colchicine may be used, but may cause diarrhea. Life style changes such as weight loss, discontinuing alcohol use, and changing antihypertensive therapy is often all that is needed to control the hyperuricemia and thus prevent further attacks. Colchicine can be used for prophylaxis as well, although it does not alter hyperuricemia or prevent tophi from forming. If a patient has more than two attacks per year, urate lowering therapy is indicated. A 24-hour urine collection to identify whether the patient is an under-excretor or an overproducer of uric acid would indicate the correct medication. Overproducers are treated with allopurinol, while under-excretors benefit from probenecid if renal function is normal and there is no history of kidney stones.
Early range-of-motion exercises should be initiated to maintain flexibility

This patient has an uncomplicated lateral ankle sprain and requires minimal intervention. The Ottawa ankle rules were developed to determine when radiographs are needed for ankle sprains. In summary, ankle radiographs should be done if the patient has pain at the medial or lateral malleolus and either bone tenderness at the back edge or tip of the lateral or medial malleolus, or an inability to bear weight immediately after the injury or in the emergency department, or both. If the patient complains of midfoot pain and/or bone tenderness at the base of the fifth metatarsal or navicular, or an inability to bear weight, radiographs should be ordered. Sprains can be differentiated from major partial or complete ligamentous tears by anteroposterior, lateral, and 30 degrees internal oblique (mortise view) radiographs. If the joint cleft between either malleolus and the talus is >4 mm, a major ligamentous tear is probable. Stress radiographs in forced inversion are sometimes helpful to demonstrate stability, but ankle instability can be present with a normal stress radiograph. Grade I and II ankle sprains are best treated with RICE (rest, ice, compression, elevation) and an air splint for ambulation. NSAIDs are used for control of pain and inflammation. Heat should not be applied. Early range-of-motion exercises should be initiated to maintain flexibility. Weight bearing is appropriate as tolerated and functional rehabilitation should be started when pain permits. Exercises on a balance board will help develop coordination.
Dexamethasone, 0.6 mg/kg orally or intramuscularly as a single dose

Croup is a syndrome most often caused by viruses, but can occasionally be of bacterial origin as in laryngotracheitis, laryngotracheobronchitis (LTB), laryngotracheobroncheopneumonia (LTBP), or laryngeal diphtheria. Mild croup is manifested by an occasional barking cough with no stridor at rest, and mild or absent intercostal retractions. Moderate croup presents with a more frequent barking cough, stridor with suprasternal and sternal retractions at rest, but no agitation. Severe croup includes more prominent inspiratory and expiratory stridor with agitation and distress. There is good evidence that corticosteroids produce significant improvement. The regimens studied most frequently have consisted of single-dose dexamethasone (0.6 mg/kg orally or intramuscularly), with some studies including up to four more doses over a 2-day period. Longer courses of corticosteroids have not proven to be more effective and may be harmful, leading to secondary infections. Racemic epinephrine by nebulization is indicated in severe croup. Antitussives and decongestants have not been studied and are not recommended. Antibiotics are indicated in LTB and LTBP, which can be diagnosed on the basis of crackles and wheezing on examination, or by an abnormal chest radiograph. Laryngotracheitis can sometimes be associated with a bacterial infection, but should be suspected only after a patient does not improve with corticosteroids and epinephrine.
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