E. Refer for cardiac resynchronization therapy. This patient is already receiving maximal medical therapy. The 2002 joint guidelines of the American College of Cardiology, the American Heart Association (AHA), and the North American Society of Pacing and Electrophysiology endorse the use of cardiac resynchronization therapy (CRT) in patients with medically refractory, symptomatic, New York Heart Association (NYHA) class III or IV disease with a QRS interval of at least 130 msec, a left ventricular end-diastolic diameter of at least 55 mm, and a left ventricular ejection fraction (LVEF) ≤30%. Using a pacemaker-like device, CRT aims to get both ventricles contracting simultaneously, overcoming the delayed contraction of the left ventricle caused by the left bundle-branch block. These guidelines were refined by an April 2005 AHA Science Advisory, which stated that optimal candidates for CRT have a dilated cardiomyopathy on an ischemic or nonischemic basis, an LVEF ≤0.35, a QRS complex ≥120 msec, and sinus rhythm, and are NYHA functional class III or IV despite maximal medical therapy for heart failure. E. Intravenous labetalol (Normodyne, Trandate). Patients with thoracic aneurysms often present without symptoms. With dissecting aneurysms, however, the presenting symptom depends on the location of the aneurysm. Aneurysms can compress or distort nearby structures, resulting in branch vessel compression or embolization of peripheral arteries from a thrombus within the aneurysm. Leakage of the aneurysm will cause pain, and rupture can occur with catastrophic results, including severe pain, hypotension, shock, and death. Aneurysms in the ascending aorta may present with acute heart failure brought about by aortic regurgitation from aortic root dilatation and distortion of the annulus. Other presenting findings may include hoarseness, myocardial ischemia, paralysis of a hemidiaphragm, wheezing, coughing, hemoptysis, dyspnea, dysphagia, or superior vena cava syndrome. This diagnosis should be suspected in individuals in their sixties and seventies with the same risk factors as those for coronary artery disease, particularly smokers. A chest radiograph may show widening of the mediastinum, enlargement of the aortic knob, or tracheal displacement. Transesophageal echocardiography can be very useful when dissection is suspected. CT with intravenous contrast is very accurate for showing the size, extent of disease, pressure of leakage, and nearby pathology. Angiography is the preferred method for evaluation and is best for evaluation of branch vessel pathology. MR angiography provides noninvasive multiplanar image reconstruction, but does have limited availability and lower resolution than traditional contrast angiography. Acute dissection of the ascending aorta is a surgical emergency, but dissections confined to the descending aorta are managed medically unless the patient demonstrates progression or continued hemorrhage into the retroperitoneal space or pleura. Initial management should reduce the systolic blood pressure to 100-120 mm Hg or to the lowest level tolerated. The use of a β-blocker such as propranolol or labetalol to get the heart rate below 60 beats/min should be first-line therapy. If the systolic blood pressure remains over 100 mm Hg, intravenous nitroprusside should be added. Without prior beta-blocade, vasodilation from the nitroprusside will induce reflex activation of the sympathetic nervous system, causing increased ventricular contraction and increased shear stress on the aorta. For descending dissections, surgery is indicated only for complications such as occlusion of a major aortic branch, continued extension or expansion of the dissection, or rupture (which may be manifested by persistent or recurrent pain). D. Still's murmur. There are several benign murmurs of childhood that have no association with physiologic or anatomic abnormalities. Of these, Still's murmur best fits the murmur described. The cause of Still's murmur is unknown, but it may be due to vibrations in the chordae tendinae, semilunar valves, or ventricular wall. A venous hum consists of a continuous low-pitched murmur caused by the collapse of the jugular veins and their subsequent fluttering, and it worsens with inspiration or diastole. The murmur of physiologic peripheral pulmonic stenosis (PPPS) is caused by physiologic changes in the newborns pulmonary vessels. PPPS is a systolic murmur heard loudest in the axillae bilaterally that usually disappears by 9 months of age. Mitral stenosis causes a diastolic murmur, and Eisenmenger's syndrome involves multiple abnormalities of the heart that cause significant signs and symptoms, including shortness of breath, cyanosis, and organomegaly, which should become apparent from a routine history and examination. A 69-year-old male has a 4-day history of swelling in his left leg. He has no history of trauma, recent surgery, prolonged immobilization, weight loss, or malaise. His examination is unremarkable except for a diffusely swollen left leg. A CBC, chemistry profile, prostate-specific antigen level, chest radiograph, and EKG are all normal; however, compression ultrasonography of the extremity reveals a clot in the proximal femoral vein. He has no past history of venous thromboembolic disease. In addition to initiating therapy with low molecular weight heparin, the American College of Chest Physicians recommends that warfarin (Coumadin) be instituted now and continued for at least (check one)
A. 1 month
B. 3 months
C. 6 months
D. 12 months
E. Total knee replacement. Neurosurgical procedures, particularly those with penetration of the brain or meninges, and orthopedic surgeries, especially those of the hip, have been linked with the highest incidence of venous thromboembolic events. The risk is due to immobilization, venous injury and stasis, and impairment of natural anticoagulants. For total knee replacement, hip fracture surgery, and total hip replacement, the prevalence of DVT is 40%-80%, and the prevalence of pulmonary embolism is 2%-30%. Other orthopedic procedures, such as elective spine procedures, have a much lower rate, approximately 5%. The prevalence of DVT after a coronary artery bypass graft is approximately 5%, after transurethral prostatectomy <5%, and after abdominal hysterectomy approximately 16%. E. Furosemide (Lasix), 40 mg intravenously. B-type natriuretic peptide (BNP) is secreted in the ventricles and is sensitive to changes in left ventricular function. Concentrations correlate with end-diastolic pressure, which in turn correlates with dyspnea and congestive heart failure. BNP levels can be useful when trying to determine whether dyspnea is due to cardiac, pulmonary, or deconditioning etiologies. A value of less than 100 pg/mL excludes congestive heart failure as the cause for dyspnea. If it is greater than 400 pg/mL, the likelihood of congestive heart failure is 95%. Patients with values of 100-400 pg/mL need further investigation. There are some pulmonary problems that may elevate BNP, such as lung cancer, cor pulmonale, and pulmonary embolus. However, these patients do not have the same extent of elevation that those with acute left ventricular dysfunction will have. If these problems can be ruled out, then individuals with levels between 100-400 pg/mL most likely have congestive heart failure. Initial therapy should be a loop diuretic. It should be noted that BNP is partially excreted by the kidneys, so levels are inversely proportional to creatinine clearance. E. Renal insufficiency (creatinine 2.0 mg/dL). Clinical predictors of increased perioperative cardiovascular risk for elderly patients include major risk factors such as unstable coronary syndrome (acute or recent myocardial infarction, unstable angina), decompensated congestive heart failure, significant arrhythmia (high-grade AV block, symptomatic ventricular arrhythmia, supraventricular arrhythmias with uncontrolled ventricular rate), and severe valvular disease. Intermediate predictors are mild angina, previous myocardial infarction, compensated congestive heart failure, diabetes mellitus, and renal insufficiency. Minor predictors are advanced age, an abnormal EKG, left ventricular hypertrophy, left bundle-branch block, ST and T-wave abnormalities, rhythm other than sinus, low functional capacity, history of stroke, and uncontrolled hypertension. E. Midgut volvulus. 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. D. Meckels diverticulum. Meckels diverticulum is the most common congenital abnormality of the small intestine. It is prone to bleeding because it may contain heterotopic gastric mucosa. Abdominal pain, distention, and vomiting may develop if obstruction has occurred, and the presentation may mimic appendicitis. Children with appendicitis have right lower quadrant pain, abdominal tenderness, guarding, and vomiting, but not rectal bleeding. With acute viral gastroenteritis, vomiting usually precedes diarrhea (usually without blood) by several hours, and abdominal pain is typically mild and nonfocal with no localized tenderness. The incidence of midgut volvulus peaks during the first month of life, but it can present anytime in childhood. Volvulus may present in one of three ways: as a sudden onset of bilious vomiting and abdominal pain in the neonate; as a history of feeding problems with bilious vomiting that now appears to be due to bowel obstruction; or, less commonly, as a failure to thrive with severe feeding intolerance. Necrotizing enterocolitis is typically seen in the neonatal intensive-care unit, occurring in premature infants in their first few weeks of life. The infants are ill, and signs and symptoms include lethargy, irritability, decreased oral intake, abdominal distention, and bloody stools. A plain abdominal film showing pneumatosis intestinalis, caused by gas in the intestinal wall, is diagnostic of this disease. B. He should consume a normal age-appropriate diet, and continue breastfeeding. Continued oral feeding in diarrhea aids in recovery, and an age-appropriate diet should be given. Breastfeeding or regular formula should be continued. Foods with complex carbohydrates (e.g., rice, wheat, potatoes, bread, and cereals), lean meats, yogurt, fruits, and vegetables are well tolerated. Foods high in simple sugars (e.g., juices, carbonated sodas) should be avoided because the osmotic load can worsen the diarrhea. Fatty foods should be avoided as well. The BRAT diet has not been shown to be effective. D. Carcinoembryonic antigen (CEA). Prostate-specific antigen (PSA) is a marker that is used to screen for prostate cancer. It is elevated in more than 70% of organ-confined prostate cancers. Alpha-tetoprotein is a marker for hepatocellular carcinoma and nonseminomatous germ cell tumor, and is elevated in 80% of hepatocellular carcinomas. CA-125 is a marker for ovarian cancer. Although it is elevated in 85% of ovarian cancers, it is elevated in only 50% of early-stage ovarian cancers. Carcinoembryonic antigen (CEA) is a marker for colon, esophageal, and hepatic cancers. It is expressed in normal mucosal cells and is overexpressed in adenocarcinoma, especially colon cancer. Though not specific for colon cancer, levels above 10 ng/mL are rarely due to benign disease. CEA levels typically return to normal within 4-6 weeks after successful surgical resection. CEA elevation occurs in nearly half of patients with a normal preoperative CEA level that have cancer recurrence. Cancer antigen 27.29 (CA 27-29) is a tumor marker for breast cancer. It is elevated in about 33% of early-stage breast cancers and about 67% of late-stage breast cancers. Some tumor markers, such as CEA, alpha-fetoprotein, and CA-125, may be more helpful in monitoring response to therapy than in detecting the primary tumor. C. Elliptical excision of the thrombosed hemorrhoid. The appropriate management of a thrombosed hemorrhoid presenting within 48 hours of onset of symptoms is an elliptical excision of the hemorrhoid and overlying skin under local anesthesia (i.e., 0.5% bupivacaine hydrochloride [Marcaine] in 1:200,000 epinephrine) infiltrated slowly with a small (27 gauge) needle for patient comfort. Incision and clot removal may provide inadequate drainage with rehemorrhage and clot reaccumulation. Most thrombosed hemorrhoids contain multilocular clots which may not be accessible through a simple incision. Rubber band ligation is an excellent technique for management of internal hemorrhoids. Banding an external hemorrhoid would cause exquisite pain. When pain is already subsiding or more time has elapsed (in the absence of necrosis or ulceration), measures such as sitz baths, bulk laxatives, stool softeners, and local analgesia may all be helpful. Some local anesthetics carry the risk of sensitization, however counseling to avoid precipitating factors (e.g., prolonged standing/sitting, constipation, delay of defecation) is also appropriate. A 4-year-old white male is brought to your office in late August. His mother tells you that over the past few days he has developed a rash on his hands and sores in his mouth. On examination you note a vesicular exanthem on his hands, with lesions ranging from 3 to 6 mm in diameter. The oral lesions are shallow, whitish, 4- to 8-mm ulcerations distributed randomly over the hard palate, buccal mucosa, gingiva, tongue, lips, and pharynx. Except for a temperature of 37.4°C (99.3°F), the remainder of the examination is normal. The most likely diagnosis is (check one)
B. hand, foot, and mouth disease
C. aphthous stomatitis
D. herpetic gingivostomatitis
E. streptococcal pharyngitis
B. hand, foot, and mouth disease. Hand, foot, and mouth disease is a mild infection occurring in young children, and is caused by coxsackievirus A16, or occasionally by other strains of coxsackie- or enterovirus. In addition to the oral lesions, vesicular lesions may occur on the feet and nonvesicular lesions may occur on the buttocks. A low-grade fever may also develop. Herpangina is also caused by coxsackieviruses, but it is a more severe illness characterized by severe sore throat and vesiculo-ulcerative lesions limited to the tonsillar pillars, soft palate, and uvula, and occasionally the posterior oropharynx. Temperatures can range to as high as 41°C (106°F). The etiology of aphthous stomatitis is multifactorial, and it may be due to a number of conditions. Systemic signs, such as fever, are generally absent. Lesions are randomly distributed. Herpetic gingivostomatitis also causes randomly distributed oral ulcers, but it is a more severe illness, regularly accompanied by a higher fever, and is extremely painful. Streptococcal pharyngitis is rarely accompanied by ulceration except in agranulocytic patients. C. Xerosis. Xerosis is a pathologic dryness of the skin that is especially prominent in the elderly. It is probably caused by minor abnormalities in maturation of the epidermis that lead to decreased hydration of the superficial portion of the stratum corneum. Xerosis often intensifies in winter, because of the lower humidity and cold temperatures. Stasis dermatitis, due to chronic venous insufficiency, appears as a reddish-brown discoloration of the lower leg. Lichen simplex chronicus, the end result of habitual scratching or rubbing, usually presents as isolated hyperpigmented, edematous lesions, which become scaly and thickened in the center. Rosacea is most often seen on the face as an erythematous, acneiform eruption, which flushes easily and is surrounded by telangiectasia. Candidiasis is an opportunistic infection favoring areas that are warm, moist, and macerated, such as the perianal and inguinal folds, inframammary folds, axillae, interdigital areas, and corners of the mouth. A. Dog or cat hookworm (Ancylostoma species). This patient has cutaneous larva migrans, a common condition caused by dog and cat hookworms. Fecal matter deposited on soil or sand may contain hookworm eggs that hatch and release larvae, which are infective if they penetrate the skin. Walking barefoot on contaminated ground can lead to infection. Echinococcosis (hydatid disease) is caused by the cestodes (tapeworms) Echinococcus granulosus and Echinococcus multilocularis, found in dogs and other canids. It infects humans who ingest eggs that are shed in the animals feces and results in slow-growing cysts in the liver or lungs, and occasionally in the brain, bones, or heart. Toxoplasmosis is caused by the protozoa Toxoplasma gondii, found in cat feces. Humans can contract it from litter boxes or feces-contaminated soil, or by consuming infected undercooked meat. It can be asymptomatic, or it may cause cervical lymphadenopathy, a mononucleosis-like illness; it can also lead to a serious congenital infection if the mother is infected during pregnancy, especially during the first trimester. Toxocariasis due to Toxocara canis and Toxocara cati causes visceral or ocular larva migrans in children who ingest soil contaminated with animal feces that contains parasite eggs, often found in areas such as playgrounds and sandboxes. C. Melasma (chloasma). Melasma or chloasma is common in pregnancy, with approximately 70% of pregnant women affected. It is an acquired hypermelanosis of the face, with symmetric distribution usually on the cheeks, nose, eyebrows, chin, and/or upper lip. The pathogenesis is not known. UV sunscreen is important, as sun exposure worsens the condition. Melasma often resolves or improves post partum. Persistent melasma can be treated with hydroquinone cream, retinoic acid, and/or chemical peels performed post partum by a dermatologist. The facial rash of lupus is usually more erythematous, and lupus is relatively rare. Pemphigoid gestationis is a rare autoimmune disease with extremely pruritic, bullous skin lesions that usually spare the face. Prurigo gestationis involves pruritic papules on the extensor surfaces and is usually associated with significant excoriation by the uncomfortable patient. B. A glass splinter. Almost all glass is visible on radiographs if it is 2 mm or larger, and contrary to popular belief, it doesn't have to contain lead to be visible on plain films. Many common or highly reactive materials, such as wood, thorns, cactus spines, some fish bones, other organic matter, and most plastics, are not visible on plain films. Alternative techniques such as ultrasonography or CT scanning may be effective and necessary in those cases. Sea urchin spines, like many animal parts, have not been found to be easily detected by plain radiography. D. celiac sprue. Celiac sprue is an autoimmune disorder characterized by inflammation of the small bowel wall, blunting of the villi, and resultant malabsorption. Symptoms commonly include diarrhea, fatigue, weight loss, abdominal pain, and borborygmus; treatment consists of elimination of gluten proteins from the diet. Extraintestinal manifestations are less common but may include elevated transaminases, osteopenia, and iron deficiency anemia. Serum IgA tissue transglutaminase (TTG) antibodies are highly sensitive and specific for celiac sprue, and a small bowel biopsy showing villous atrophy is the gold standard for diagnosis. This patient's rash is consistent with dermatitis herpetiformis, which is pathognomonic for celiac sprue and responds well to a strict gluten-free diet.
Lactose intolerance, irritable bowel syndrome, collagenous colitis, and Crohn's disease are in the differential diagnosis for celiac sprue. However, significant weight loss is not characteristic of irritable bowel syndrome or lactose intolerance. The diarrhea associated with Crohn's disease is typically bloody. Collagenous colitis does cause symptoms similar to those experienced by this patient, but it is not associated with dermatitis herpetiformis.
B. Over-the-counter heel inserts. Plantar fasciitis is a common cause of heel pain. It may be unilateral or bilateral, and the etiology is unknown, although it is thought to be due to cumulative overload stress. While it may be associated with obesity or overuse, it may also occur in active or inactive patients of all ages. Typically the pain is located in the plantar surface of the heel and is worst when the patient first stands up when getting out of bed in the morning (first step phenomenon) or after prolonged sitting. The pain may then improve after the patient walks around, only to worsen after prolonged walking. The diagnosis is made by history and physical examination. Typical findings include point tenderness to palpation on the plantar surface of the heel at the medial calcaneal tuberosity where the calcaneal aponeurosis inserts. Radiographs are not necessary unless there is a history of trauma or if the diagnosis is unclear.
The condition may last for months or years, and resolves in most patients over time with or without specific therapy. One long-term follow-up study showed that 80% of patients had complete resolution of their pain after 4 years. Treatments with limited (level 2) evidence of effectiveness include off-the-shelf insoles, custom-made insoles, stretching of the plantar fascia, corticosteroid iontophoresis, custom-made night splints, and surgery (for those who have failed conservative therapy). NSAIDs and ice, although not independently studied for plantar fasciitis, are included in most studies of other treatments, and are reasonable adjuncts to first-line therapy. Magnetic insoles and extracorporeal shockwave therapy are ineffective in treating plantar fasciitis.
Due to their expense, custom-made insoles, custom-made night splints, and corticosteroid iontophoresis should be reserved as second-line treatments for patients who fail first-line treatment. Surgery may be offered if more conservative therapies fail. Corticosteroid injection may have a short-term benefit at 1 month, but is no better than other treatments at 6 months and carries a risk of plantar fascia rupture.
D. Acyclovir (Zovirax) suspension. The history and physical findings in this patient are consistent with gingivostomatitis due to a primary or initial infection with herpes simplex virus type 1 (HSV-1). There are no additional findings to suggest other diagnoses such as aphthous ulcers, Behçet's syndrome, or herpangina (coxsackievirus).
After a primary HSV-1 infection with oral involvement, the virus invades the neurons and replicates in the trigeminal sensory ganglion, leading to recurrent herpes labialis and erythema multiforme, among other things. Although some clinicians might choose to use oral anesthetics for symptomatic care, it is not a specific therapy.
Antibiotics are not useful for the treatment of herpetic gingivostomatitis and could confuse the clinical picture should this child develop erythema multiforme, which occurs with HSV-1 infections. An orally applied corticosteroid is not specific treatment, but some might try it for symptomatic relief. An immunosuppressant is sometimes used for the treatment of Behçet's syndrome, but this patient's findings are not consistent with that diagnosis. Therefore, the only specific treatment listed is acyclovir suspension, which has been shown to lead to earlier resolution of fever, oral lesions, and difficulties with eating and drinking. It also reduces viral shedding from 5 days to 1 day (SOR B).
C. frontotemporal dementia. This patient meets the criteria for frontotemporal dementia (FTD), a common cause of dementia in patients younger than 65, with an insidious onset. Unlike with Alzheimer's disease, memory is often relatively preserved, even though insight is commonly impaired.
There are three subtypes of frontotemporal dementia: behavioral variant FTD, semantic dementia, and progressive nonfluent aphasia. This patient would be diagnosed with the behavioral variant due to his loss of executive functioning leading to personality change (apathy) and inappropriate behavior (SOR C). Speech output is often distorted in frontotemporal dementia, although the particular changes differ between the three variants.
Patients with FTD often are mistakenly thought to have major depressive disorder due to their apathy and diminished interest in activities. However, patients with depression do not usually exhibit inappropriate behavior and lack of restraint. Dementia with Lewy bodies and Alzheimer's dementia are both characterized predominantly by memory loss. Alzheimer's dementia is most common after age 65, whereas FTD occurs most often at a younger age. Lewy body dementia is associated with parkinsonian motor features. Patients diagnosed with schizophrenia exhibit apathy and personality changes such as those seen in FTD. However, the age of onset is much earlier, usually in the teens and twenties in men and the twenties and thirties in women.
C. Morphine identified in an employee taking a prescribed cough medicine containing codeine. Results of urine drug test panels obtained in the workplace are reported by a Medical Review Officer (MRO) as positive, negative, dilute, refusal to test, or test canceled; the drug/metabolite for which the test is positive or the reason for refusal (e.g., the presence of an adulterant) or cancellation is also included in the final report. The MRO interpretation is based on consideration of many factors, including the confirmed patient medical history, specimen collection process, acceptability of the specimen submitted, and qualified laboratory measurement of drugs or metabolites in excess of the accepted thresholds. These thresholds are set to preclude the possibility that secondary contact with smoke, ingestion of poppy seeds, or similar exposures will result in an undeserved positive urine drug screen report. Other findings, such as the presence of behavioral or physical evidence of unauthorized use of opiates, may also factor into the final report.
When a properly collected, acceptable specimen is found to contain drugs or metabolites that would be expected based on a review of confirmed prescribed use of medications, the test is reported as negative. Morphine is a metabolite of codeine that may be found in the urine of someone taking a codeine-containing medication; morphine is not a metabolite of methadone. Oxazepam is a metabolite of diazepam but the reverse is not true. Tetrahydrocannabinol would not be found in the urine as a result of tramadol use.
E. Avoidance of contact sports. Infectious mononucleosis presents most commonly with a sore throat, fatigue, myalgias, and lymphadenopathy, and is most prevalent between 10 and 30 years of age. Both an atypical lymphocytosis and a positive heterophil antibody test support the diagnosis, although false-negative heterophil testing is common early in the disease course. The cornerstone of treatment for mononucleosis is supportive, including hydration, NSAIDs, and throat sprays or lozenges.
In general, corticosteroids do not have a significant effect on the clinical course of infectious mononucleosis, and they should not be used routinely unless the patient has evidence of acute airway obstruction. Antihistamines are also not recommended as routine treatment for mononucleosis. The use of acyclovir has shown no consistent or significant benefit, and antiviral drugs are not recommended.
There is also no evidence to support bed rest as an effective management strategy for mononucleosis. Given the evidence from other disease states, bed rest may actually be harmful.
Although most patients will not have a palpably enlarged spleen on examination, it is likely that all, or nearly all, patients with mononucleosis have splenomegaly. This was demonstrated in a small study in which 100% of patients hospitalized for mononucleosis had an enlarged spleen by ultrasound examination, whereas only 17% of patients with splenomegaly have a palpable spleen. Patients should be advised to avoid contact- or collision-type activities for 3-4 weeks because of the increased risk of rupture.
A 64-year-old African-American male presents with persistent pleuritic pain. The patient does not feel well in general and has had a low-grade fever of around 100°F (38°C). His medications include simvastatin (Zocor), lisinopril (Prinivil, Zestril), low-dose aspirin, spironolactone (Aldactone), furosemide (Lasix), isosorbide mononitrate (Imdur), hydralazine, carvedilol (Coreg), and nitroglycerin as needed.
A chest radiograph is normal and does not demonstrate a pneumothorax. Further evaluation rules out pulmonary embolus, pneumonia, and myocardial infarction. A diagnosis of pleurisy is made.
Which one of the patient's medications could be related to this condition? (check one)
E. Ceftazidime, levofloxacin, and vancomycin. Nursing home-acquired pneumonia should be suspected in patients with a new infiltrate on a chest radiograph if it is associated with a fever, leukocytosis, purulent sputum, or hypoxia. Nursing-home patients who are hospitalized for pneumonia should be started on intravenous antimicrobial therapy, with empiric coverage for methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa. The 2005 American Thoracic Society/Infectious Diseases Society of America guideline recommends combination therapy consisting of an antipseudomonal cephalosporin such as cefepime or ceftazidime, an antipseudomonal carbapenem such as imipenem or meropenem, or an extended-spectrum β-lactam/β-lactamase inhibitor such as piperacillin/tazobactam, PLUS an antipseudomonal fluoroquinolone such as levofloxacin or ciprofloxacin, or an aminoglycoside such as gentamicin, tobramycin, or amikacin, PLUS an anti-MRSA agent (vancomycin or linezolid). Ceftriaxone and azithromycin or levofloxacin alone would be reasonable treatment options for a patient with nursing home-acquired pneumonia who does not require hospitalization. B. Chlamydia trachomatis. Women who present with symptoms of acute dysuria, frequency, and pyuria do not always have bacterial cystitis. In fact, up to 30% will show either no growth or insignificant bacterial growth on a midstream urine culture. Most commonly these patients represent cases of sexually transmitted urethritis caused by Chlamydia trachomatis, Neisseria gonorrhoeae, or herpes simplex virus.
In this case, the gradual onset, absence of hematuria, and week-long duration of symptoms suggest a sexually transmitted disease. A history of a new sexual partner or a finding of mucopurulent cervicitis would confirm the diagnosis. Empiric treatment with a tetracycline and a search for other sexually transmitted diseases would then be indicated.
Another possible diagnosis is urinary tract infection with Escherichia coli or Staphylococcus species; however, the onset of these infections is usually abrupt and accompanied by other signs, such as suprapubic pain or hematuria. Candida is unlikely because there is no accompanying discharge or itching, and the patient's symptoms predate the use of antibiotics.
A. Visual impairment. Gait and balance disorders are one of the most common causes of falls in older adults. Correctly identifying gait and balance disorders helps guide management and may prevent consequences such as injury, disability, loss of independence, or decreased quality of life. The "Timed Up and Go" test is a reliable diagnostic tool for gait and balance disorders and is quick to administer. A time of <10 seconds is considered normal, a time of >14 seconds is associated with an increased risk of falls, and a time of >20 seconds usually suggests severe gait impairment.
This patient has the cautious gait associated with visual impairment. It is characterized by abducted arms and legs; slow, careful, "walking on ice" movements; a wide-based stance; and "en bloc" turns. Patients with cerebellar degeneration have an ataxic gait that is wide-based and staggering. Frontal lobe degeneration is associated with gait apraxia that is described as "magnetic," with start and turn hesitation and freezing. Parkinson's disease patients have a typical gait that is short-stepped and shuffling, with hips, knees, and spine flexed, and may also exhibit festination and "en bloc" turns. Motor neuropathy causes a "steppage" gait resulting from foot drop with excessive flexion of the hips and knees when walking, short strides, a slapping quality, and frequent tripping.
A. on the basis of clinical symptoms alone. Influenza is a highly contagious viral illness spread by airborne droplets. This patient's symptoms are highly suggestive of typical influenza: a sudden onset of malaise, myalgia, headache, fever, rhinitis, sore throat, and cough. While influenza is typically uncomplicated and self-limited, it can result in severe complications, including encephalitis, pneumonia, respiratory failure, and death.
The effectiveness of treatment for influenza is dependent on how early in the course of the illness it is given. Because of the recent global H1N1 influenza outbreak that resulted in demand potentially outstripping the supply of antiviral medication, the Centers for Disease Control and Prevention has modified its recommendation as follows:
Antiviral treatment is recommended as soon as possible for patients with confirmed or suspected influenza who have severe, complicated, or progressive illness or who require hospitalization.
Antiviral treatment is recommended as soon as possible for outpatients with confirmed or suspected influenza who are at higher risk for influenza complications based on their age or underlying medical conditions. Clinical judgment should be an important component of outpatient treatment decisions.
Antiviral treatment also may be considered on the basis of clinical judgment for any outpatient with confirmed or suspected influenza who does not have known risk factors for severe illness, if treatment can be initiated within 48 hours of illness onset.
Many rapid influenza tests produce false-negative results, and more accurate assays can take more than 24 hours. Thus, treatment of patients with a clinical picture suggesting influenza is recommended, even if a rapid test is negative. Delaying treatment until further test results are available is not recommended.
E. A CBC, serum chemistry panel, and erythrocyte sedimentation rate. The diagnosis of inflammatory bowel disease (IBD) can be elusive but relies primarily on the patient history, laboratory findings, and endoscopy (or double-contrast radiographs if endoscopy is not available). Endoscopy is usually reserved for patients with more severe symptoms or in whom preliminary testing shows the potential for significant inflammation. It is recommended that this preliminary evaluation include a WBC count, platelet count, potassium level, and erythrocyte sedimentation rate.
Patients who have minimal symptoms and normal preliminary testing likely do not have a significant case of IBD. Plain radiographs and CT of the abdomen may help rule out other etiologies but are not considered adequate to diagnose or exclude IBD. Panels of serologic blood tests have recently been developed and are being assessed as to their place in evaluating patients who may have IBD. However, this testing is expensive, lacks sufficient predictive value, and has yet to prove its utility compared to standard testing.
D. Prescribe dexamethasone. Altitude illness is common, affecting 25%-85% of travelers to high altitudes. The most common manifestation is acute mountain sickness, heralded by malaise and headache. Risk factors include young age, residence at a low altitude, rapid ascent, strenuous physical exertion, and a previous history of altitude illness. However, activity restriction is not necessary for patients with coronary artery disease who are traveling to high altitudes (SOR C).
Ginkgo biloba has been evaluated for both prevention and treatment of acute mountain sickness and high-altitude cerebral edema, and it is not recommended. Acetazolamide is an effective prophylactic agent (SOR B), but is contraindicated in patients with a sulfa allergy. If used, it should be started a minimum of one day before ascent and continued until the patient acclimatizes at the highest planned elevation. Dexamethasone is an effective prophylactic and treatment agent (SOR B), and it is not contraindicated for those with a sulfa allergy. It would be the best option for this patient.
D. Herpes simplex viral lesions on the breasts. Breastfeeding provides such optimal nutrition for an infant that the benefits still far outweigh the risks even when the mother smokes tobacco, tests positive for hepatitis B or C virus, or develops a simple undifferentiated fever. Maternal seropositivity to cytomegalovirus (CMV) is not considered a contraindication except when it has a recent onset or in mothers of low birthweight infants. When present, the CMV load can be substantially reduced by freezing and pasteurization of the milk. All patients who smoke should be strongly encouraged to discontinue use of tobacco, particularly in the presence of infants, but smoking is not a contraindication to breastfeeding.
Mothers with active herpes simplex lesions on a breast should not feed their infant from the infected breast, but may do so from the other breast if it is not infected. Breastfeeding is also contraindicated in the presence of active maternal tuberculosis, and following administration or use of radioactive isotopes, chemotherapeutic agents, "recreational" drugs, or certain prescription drugs.
D. Scombroid fish. Only symptomatic treatment is indicated for ciguatera poisoning, as there is no specific treatment. The same is true for shellfish poisoning, although potential respiratory distress or failure must be kept in mind.
Scombroid poisoning is a pseudoallergic condition resulting from consumption of improperly stored scombroid fish such as tuna, mackerel, wahoo, and bonito. Nonscombroid varieties such as mahi-mahi, amberjack, sardines, and herring can also cause this problem. The poisoning is due to high levels of histamine and saurine resulting from bacterial catabolism of histidine. Symptoms occur within minutes to hours, and include flushing of the skin, oral paresthesias, pruritus, urticaria, nausea, vomiting, diarrhea, vertigo, headache, bronchospasm, dysphagia, tachycardia, and hypotension. Therapy should be the same as for allergic reactions and anaphylaxis, and will usually lead to resolution of symptoms within several hours.
C. Postural orthostatic tachycardia syndrome (POTS). Postural orthostatic tachycardia syndrome (POTS) is manifested by a rise in heart rate >30 beats/min or by a heart rate >120 beats/min within 10 minutes of being in the upright position. Symptoms usually include position-dependent headaches, abdominal pain, lightheadedness, palpitations, sweating, and nausea. Most patients will not actually pass out, but some will if they are unable to lie down quickly enough. This condition is most prevalent in white females between the ages of 15 and 50 years old. Often these patients are hardworking, athletic, and otherwise in good health.
There is a high clinical correlation between POTS and chronic fatigue syndrome. Although no single etiology for POTS has been found, the condition is thought to have a genetic predisposition, is often incited after a prolonged viral illness, and has a component of deconditioning. The recommended initial management is encouraging adequate fluid and salt intake, followed by the initiation of regular aerobic exercise combined with lower-extremity strength training, and then the use of β-blockers.
D. A dipyridamole-thallium scan. Family physicians are often asked to perform a preoperative evaluation prior to noncardiac surgery. This requires an assessment of the perioperative cardiovascular risk of the procedure involved, the functional status of the patient, and clinical factors that can increase the risk, such as diabetes mellitus, stroke, renal insufficiency, compensated or prior heart failure, mild angina, or previous myocardial infarction.
This patient is not undergoing emergency surgery, nor does she have an active cardiac condition; however, she is undergoing a high-risk procedure (>5% risk of perioperative myocardial infarction) with vascular surgery. As she cannot climb a flight of stairs or do heavy housework, her functional status is <4 METs, and she should be considered for further evaluation. The patient's diabetes is an additional clinical risk factor.
With vascular surgery being planned, appropriate recommendations include proceeding with the surgery with heart rate control, or performing noninvasive testing if it will change the management of the patient. Coronary angiography is indicated if the noninvasive testing is abnormal. Pulmonary function studies are most useful in patients with underlying lung disease or those undergoing pulmonary resection. Hemoglobin A1c is a measure of long-term diabetic control and is not particularly useful perioperatively. Carotid angiography is not indicated in asymptomatic patients being considered for lower-extremity vascular procedures.
C. Awaiting spontaneous labor. This estimated fetal weight is at the 90th percentile for a term fetus. Unfortunately, the accuracy of fetal weight estimates declines as pregnancy proceeds, and the actual size may be as much as 15% different from the estimate. Delivery of a large infant results in shoulder dystocia more often than delivery of a smaller infant, but most large infants are delivered without complications. Intuitively, it would seem logical to induce labor when the fetus seems to be getting large, but this intervention has been studied in controlled trials and the only difference in outcome was an increase in the cesarean rate for women who underwent elective induction for this indication.
Recently, there has been an increase in requests from patients to have an elective cesarean section near term to avoid the risks of labor, including pain, shoulder dystocia, and pelvic relaxation. The American Congress of Obstetricians and Gynecologists (ACOG) recommends consideration of cesarean delivery without a trial of labor if the estimated fetal weight is 4500 g in a mother with diabetes mellitus, or 5000 g in the absence of diabetes. Even at that size, there is not adequate data to show that cesarean section is preferable to a trial of labor. Frequent ultrasonography is often performed to reduce anxiety for both patient and physician, but the problem of accuracy of weight estimates remains an issue even with repeated scans at term.
C. a topical corticosteroid cream. This patient has symptoms and signs consistent with chronic paronychia. This condition is often associated with chronic immersion in water, contact with soaps or detergents, use of certain systemic drugs (antiretrovirals, retinoids) and, as is most likely in a 6-year-old child, finger sucking.
Findings on examination are similar to those of acute paronychia, with tenderness, erythema, swelling, and retraction of the proximal nail fold. Often the adjacent cuticle is absent. Chronic paronychia has usually been persistent for at least 6 weeks by the time of diagnosis.
In addition to medication, basic treatment principles for the condition include avoidance of contact irritants, avoiding immersion of the hands in water, and use of an emollient. Topical corticosteroids have higher efficacy for treating chronic paronychia compared to oral antifungals (SOR B), particularly given the young age of the patient. A topical antifungal can also be tried in conjunction with the corticosteroid.
B. Start levothyroxine (Synthroid). Autoimmune hypothyroidism is common in elderly women. Symptoms often include fatigue, bradycardia, dry skin, brittle hair, and a prolonged relaxation phase of the deep tendon reflexes. While replacement therapy with levothyroxine is indicated, care must be taken in the elderly, particularly in those with coronary artery disease, to replace the deficit slowly. Levothyroxine replacement should begin at 25μg daily for 6 weeks, with the dosage increased in 25-μg increments as needed, based on TSH levels.
Rapid replacement of thyroid hormone can increase the metabolic rate, and therefore myocardial oxygen demand, too quickly. This can precipitate complications of coronary artery disease such as atrial fibrillation, angina, and myocardial infarction. Stopping a β-blocker in this setting is likely to increase the risk. Radioactive iodine ablation is indicated for some cases of hyperthyroidism.
C. LMWH subcutaneously for at least 5 days, followed by oral warfarin for 3 months. Upper extremity deep-vein thrombosis (UE-DVT) accounts for 4% of all cases of DVT. Catheter-related thromboses make up the majority of these cases. Occult cancer, use of oral contraceptives, and inheritable thrombophilia are other common explanations. Another proposed risk factor is the repetitive compression of the axillary-subclavian vein in athletes or laborers, which is the most likely cause of this patient's UE-DVT.
Taken as a whole, UE-DVT is generally associated with fewer venous complications, including less chance for thromboembolism, postphlebitic syndrome, and recurrence compared to lower-extremity deep-vein thrombosis (LE-DVT). However, the rates of these complications are still high enough that most experts recommend treatment identical to that of LE-DVT. Specifically, heparin should be given for 5 days, and an oral vitamin-K antagonist for at least 3 months.
B. vocal cord dysfunction. Vocal cord dysfunction is an idiopathic disorder commonly seen in patients in their twenties and thirties in which the vocal cords partially collapse or close on inspiration. It mimics, and is commonly mistaken for, asthma. Symptoms include episodic tightness of the throat, a choking sensation, shortness of breath, and coughing. A careful history and examination reveal that the symptoms are worse with inspiration than with exhalation, and inspiratory stridor during the episode may be mistaken for the wheezing of asthma. The sensation of throat tightening or choking also helps to differentiate it from asthma.
Pulmonary function tests (PFTs) are normal, with the exception of flattening of the inspiratory loop, which is diagnostic of extra-thoracic airway compression. Fiberoptic laryngoscopy shows paradoxical inspiratory and/or expiratory partial closure of the vocal cords. Vocal cord dysfunction is treated with speech therapy, breathing techniques, reassurance, and breathing a helium-oxygen mixture (heliox).
PFTs in patients with asthma are normal between exacerbations, but when symptoms are present the FEV1 /FVC ratio is reduced, as with COPD. With anaphylaxis, there will typically be itching or urticaria and signs of angioedema, such as lip or tongue swelling, in response to a trigger such as food or medication; PFTs are normal when anaphylaxis symptoms are absent. Globus hystericus is a type of conversion disorder in which emotional stress causes a subjective sensation of pain or tightness in the throat, and/or dysphagia; diagnostic tests such as spirometry and laryngoscopy are normal.
B. An age of 9 months. Sudden infant death syndrome (SIDS) is the most common cause of death during the first 6 months of life in the United States, with a peak incidence at 2-4 months of age and a quick dropoff by the age of 6 months. The cause of death is a retrospective diagnosis of exclusion, and is supported by a history of quiet death during sleep in a previously healthy infant younger than 6 months of age. Evidence of terminal activity may be present, such as clenched fists or a serosanguineous, blood-tinged, or mucoid discharge from the mouth or nose. Lividity and mottling are frequently present in dependent areas.
The reported history and autopsy findings of deliberate suffocation may mirror the findings of SIDS, but suffocation should be considered when there is documentation of any of the following: infant age older than 6 months, previous similar sibling deaths, simultaneous twin deaths, or evidence of pulmonary hemorrhage. A history of recurrent apnea or cyanosis has not been causally linked to SIDS; when such reported events have only been witnessed by one caretaker, deliberate suffocation should be suspected.
D. Fomepizole (Antizol). Ethylene glycol poisoning should be suspected in patients with metabolic acidosis of unknown cause and subsequent renal failure, as rapid diagnosis and treatment will limit the toxicity and decrease both morbidity and mortality. This diagnosis should be considered in a patient who appears intoxicated but does not have an odor of alcohol, and has anion gap acidosis, hypocalcemia, urinary crystals, and nontoxic blood alcohol levels. Ethylene glycol is found in products such as engine coolant, de-icing solution, and carpet and fabric cleaners. Ingestion of 100 mL of ethylene glycol by an adult can result in toxicity.
The American Academy of Clinical Toxicology criteria for treatment of ethylene glycol poisoning with an antidote include a plasma ethylene glycol concentration >20 mg/dL, a history of ingesting toxic amounts of ethylene glycol in the past few hours with an osmolal gap >10 mOsm/kg H O2 (N 5-10), and strong clinical suspicion of ethylene glycol poisoning, plus at least two of the following: arterial pH <7.3, serum bicarbonate <20 mmol/L, or urinary oxalate crystals.
Until recently, ethylene glycol poisoning was treated with sodium bicarbonate, ethanol, and hemodialysis. Treatment with fomepizole (Antizol) has this specific indication, however, and should be initiated immediately when ethylene glycol poisoning is suspected. If ethylene glycol poisoning is treated early, hemodialysis may be avoided, but once severe acidosis and renal failure have occurred hemodialysis is necessary. Ethylene glycol is rapidly absorbed, and use of ipecac or gastric lavage is therefore not effective. Large amounts of activated charcoal will only bind to relatively small amounts of ethylene glycol, and the therapeutic window for accomplishing this is less than 1 hour.
D. Pasteurella multocida. Pasteurella species are isolated from up to 50% of dog bite wounds and up to 75% of cat bite wounds, and the hand is considered a high-risk area for infection (SOR A). Although much more rare, Capnocytophaga canimorsus, a fastidious gram-negative rod, can cause bacteremia and fatal sepsis after animal bites, especially in asplenic patients or those with underlying hepatic disease. Anaerobes isolated from dog and cat bite wounds include Bacteroides, Fusobacterium, Porphyromonas, Prevotella, Propionibacterium and Peptostreptococcus.
In addition to animal oral flora, human skin flora are also important pathogens, but are less commonly isolated. These can include streptococci and staphylococci, including methicillin-resistant Staphylococcus aureus (MRSA). Coverage for MRSA may be especially important if the patient has risk factors for colonization with community-acquired MRSA. Pets can also become colonized with MRSA and transmit it via bites and scratches.
Cat bites that become infected with Pasteurella multocida can be complicated by cellulitis, which may form around the wound within 24 hours and is often accompanied by redness, tenderness, and warmth. The use of prophylactic antibiotics is associated with a statistically significant reduction in the rate of infection in hand bites (SOR A). If infection develops and is left untreated, the most common complications are tenosynovitis and abscess formation; however, local complications can include septic arthritis and osteomyelitis. Fever, regional adenopathy, and lymphangitis are also seen.
A. Aspirin, 325 mg daily. Atrial fibrillation is the most common arrhythmia, and its prevalence increases with age. The major risk with atrial fibrillation is stroke, and a patient's risk can be determined by the CHADS 2 score. CHADS stands for Congestive heart failure, Hypertension, Age >75, Diabetes mellitus, and previous Stroke or transient ischemic attack. Each of these is worth 1 point except for stroke, which is worth 2 points. A patient with 4 or more points is at high risk, and 2-3 points indicates moderate risk. Having ≤1 point indicates low risk, and this patient has 0 points.
Low-risk patients should be treated with aspirin, 81-325 mg daily (SOR B). Moderate-or high-risk patients should be treated with warfarin. Amiodarone is used for rate control, and clopidogrel is used for vascular events not related to atrial fibrillation.
A 28-year-old male presents with the recent onset of intermittent urethral discharge accompanied by dysuria. He is heterosexual, has no prior history of a sexually transmitted infection, and acquired a new sexual partner a month ago. He has no regional lymphadenopathy or ulcers, and gentle milking of the urethra produces no discharge. Evaluation of a first-void urine specimen, however, reveals 15 WBCs/hpf. You treat him with oral azithromycin (Zithromax), 1 g in a single dose, and ceftriaxone (Rocephin), 125 mg intramuscularly. Test results for gonorrhea, Chlamydia, syphilis, HIV, and hepatitis B are negative.
He returns 2 months later because his urethral discharge has persisted. He reports no relationships with a different sexual partner, and is confident that his current partner has only had sexual contact with him. You repeat the previous tests and again treat him with oral azithromycin.
According to CDC testing and treatment guidelines, which one of the following drugs should be added to his treatment regimen? (check one)
A. Metronidazole (Flagyl)
B. Amoxicillin/clavulanate (Augmentin)
C. Ciprofloxacin (Cipro)
D. Trimethoprim/sulfamethoxazole (Bactrim, Septra)
E. Cefixime (Suprax)
A. Metronidazole (Flagyl). According to CDC guidelines, the initial workup for urethritis in men includes gonorrhea and Chlamydia testing of the penile discharge or urine, urinalysis with microscopy if no discharge is present, VDRL or RPR testing for syphilis, and HIV and hepatitis B testing. Empiric treatment for men with a purulent urethral discharge or a positive urine test (positive leukocyte esterase or ≥10 WBCs/hpf in the first-void urine sediment) includes azithromycin, 1 g orally as a single dose, OR doxycycline, 100 mg orally twice a day for 7 days, PLUS ceftriaxone, 125 mg intramuscularly, OR cefixime, 400 mg orally as a single dose.
If the patient presents with the same complaint within 3 months, and does not have a new sexual partner, the tests obtained at his first visit should be repeated, and consideration should be given to obtaining cultures for Mycoplasma or Ureaplasma and Trichomonas from the urethra or urine. Treatment should include azithromycin, 500 mg orally once daily for 5 days, or doxycycline, 100 mg orally twice daily for 7 days, plus metronidazole, 2 g orally as a single dose.
C. Oral fluoride supplementation is recommended if the primary drinking water source is low in fluoride. The current (2004) recommendation of the U.S. Preventive Services Task Force (USPSTF) is that children over the age of 6 months receive oral fluoride supplementation if the primary drinking water source is deficient in fluoride. The USPSTF cites "fair" evidence (B recommendation) that such supplementation reduces the incidence of dental caries and concludes that the overall benefit outweighs the potential harm from dental fluorosis.
Dental fluorosis is chiefly a cosmetic staining of the teeth, is uncommon with currently recommended fluoride intake, and has no other functional or physiologic consequences. Fluoridated toothpaste can cause fluorosis in children younger than 2 years of age, and is therefore not recommended in this age group. Fluoridated toothpaste by itself does not reliably prevent tooth decay.
Fluoride varnish, applied by a dental or medical professional, is another treatment option to prevent caries. It provides longer-lasting protection than fluoride rinses, but since it is less concentrated, it may carry a lower risk of fluorosis than other forms of supplementation.
Oral fluoride supplementation for children over the age of 6 months is based not only on age but on the concentration of fluoride in the primary source of drinking water, whether it be tap water or bottled water. Most municipal water supplies in the United States are adequately fluoridated, but concentrations vary. Fluoride concentrations in bottled water vary widely. If the concentration is >0.6 ppm no supplementation is needed, and may result in fluorosis if given. Lower concentrations of fluoride may indicate the need for partial or full-dose supplementation.
A 67-year-old Hispanic male comes to your office with severe periumbilical abdominal pain, vomiting, and diarrhea, which began suddenly several hours ago. His temperature is 37.0°C (98.6°F), blood pressure 110/76 mm Hg, and respirations 28/min. His abdomen is slightly distended, soft, and diffusely tender; bowel sounds are normal. Other findings include clear lungs, a rapid and irregularly irregular heartbeat, and a pale left forearm and hand with no palpable left brachial pulse. Right arm and lower extremity pulses are normal. Testing reveals the presence of blood in both his stool and his urine. His hemoglobin level is 16.4 g/dL (N 13.0-18.0) and his WBC count is 25,300/mm3 (N 4300-10,800).
The diagnostic imaging procedure most likely to produce a specific diagnosis of the abdominal pain is: (check one)
A. intravenous pyelography (IVP)
B. sonography of the abdominal aorta
C. a barium enema
D. celiac and mesenteric arteriography
E. contrast venography
B. Blood pressure screening at a local church. Prevention traditionally has been divided into three categories: primary, secondary, and tertiary. Primary prevention targets individuals who may be at risk to develop a medical condition and intervenes to prevent the onset of that condition (e.g., childhood vaccination programs, water fluoridation, antismoking programs, and education about safe sex). Secondary prevention targets individuals who have developed an asymptomatic disease and institutes treatment to prevent complications (e.g., routine Papanicolaou tests; screening for hypertension, diabetes, or hyperlipidemia). Tertiary prevention targets individuals with a known disease, with the goal of limiting or preventing future complications (e.g., screening diabetics for microalbuminuria, rigorous treatment of diabetes mellitus, and post-myocardial infarction prophylaxis with β-blockers and aspirin). B. color duplex Doppler ultrasonography. The history and physical examination are critical for making a diagnosis in patients with scrotal pain. Transillumination may also be performed as part of the clinical assessment. If the diagnosis is uncertain, ultrasonography with color Doppler imaging has become the accepted standard for evaluation of the acutely swollen scrotum (SOR B). Ultrasonography alone can confirm the diagnosis in a number of conditions, such as hydrocele, spermatocele, and varicocele. For other conditions such as orchitis, carcinoma, or torsion, color Doppler ultrasonography is essential because it will show increased flow in orchitis, normal or increased flow in carcinoma, and decreased blood flow in testicular torsion.
For testicular torsion, color Doppler ultrasonography has a sensitivity of 86%-88% and a specificity of 90%-100%. When testicular torsion is strongly suspected, emergent surgical consultation should be obtained before ultrasonography is performed, because surgical exploration as soon as possible is critical to salvaging the testis and should not be delayed for imaging unless the diagnosis is in doubt.
While radionuclide imaging would be accurate for diagnosing testicular torsion, it is not used for this purpose because of time limits and lack of easy availability. CT or MRI may be appropriate if ultrasonography indicates a possibility of carcinoma. Plain films are not useful in assessing scrotal swelling or masses.
E. After 5 days, if the INR has been ≥2.0 for 24 hours. For patients with a pulmonary embolus, American College of Chest Physicians guidelines recommend initial treatment with low molecular weight heparin (LMWH), unfractionated heparin, or fondaparinux for at least 5 days, and then can be stopped if the INR has been ≥2.0 for at least 24 hours (SOR C). Warfarin reduces the activity of coagulation factors II, VII, IX, and X produced in the liver. Coagulation factors produced prior to initiating warfarin remain active for their usual several-day lifespan, which is why LMWH and warfarin must be given concomitantly for at least 5 days. The INR may reach levels >2.0 before coagulation factors II and X have reached their new plateau levels, accounting for the need for an additional 24 hours of combined therapy before stopping LMWH. A. cardiac output. Cardiovascular changes associated with aging include decreased cardiac output, maximum heart rate, and stroke volume, as well as increased systolic and diastolic blood pressure. Respiratory changes include an increase in residual lung volume and a decrease in vital capacity. Other changes include decreases in nerve conduction, proprioception and balance, maximum O2 uptake, bone mass, muscle strength, and flexibility. Most of these changes, however, can be reduced in degree by a regular aerobic and resistance training program. A. Exclusive breastfeeding until the infant is 4 months of age. Atopic dermatitis is a pruritic, inflammatory skin disorder affecting nearly 1 in 5 children residing in developed countries. The vast majority of those eventually afflicted experience the onset of symptoms by the age of 5 years, and more than half will present before the age of 1 year. The etiology is not fully understood, but it seems clear that environmental, immune, genetic, metabolic, infectious, and neuroendocrine factors all play a role. Environmental factors that may be involved include harsh detergents, abrasive clothing, Staphylococcus aureus skin infection, food allergens (cow's milk, eggs, peanuts, tree nuts, etc.), overheating, and psychological stress. Aeroallergens that are problematic for asthmatics, such as animal dander, dust mites, and pollen, have not been clearly linked to atopic dermatitis.
Large, well-designed studies have found no evidence that delaying the introduction of solid foods until after 6 months of age reduces the likelihood of atopic dermatitis. Ingestion of probiotic agents during pregnancy has also not been shown to have any effect, and studies of probiotic use in breastfeeding mothers and their infants have yielded conflicting results. Exclusive breastfeeding for the first 4 months of life has been shown to reduce the cumulative incidence of atopic dermatitis in the first 2 years of life for infants at high risk of developing atopic disease; doing so beyond 4 months does not appear to provide additional benefit. Maternal dietary restriction during pregnancy and lactation has not been associated with significant benefit. Limited studies have demonstrated that emollients and moisturizers can reduce associated xerosis and are thought to be helpful treatments, but the data is not convincing.
A. separation anxiety disorder. This patient suffers from separation anxiety disorder, which is unique to pediatric patients and is characterized by excessive anxiety regarding separation from the home or from people the child is attached to, such as family members or other caregivers. The anxiety is beyond what is developmentally appropriate for the child's age. Patients may even suffer distress from anticipation of the separation. Other characteristics include persistent worry about harm occurring to major attachment figures, worry about an event that may separate the patient from caregivers, reluctance to attend school due to the separation it implies, fear of being alone, recurring nightmares with themes of separation, and physical complaints when faced with separation. Children diagnosed with separation anxiety disorder must be under 18 years of age and have had symptoms for at least 4 weeks.
Social phobia is a persistent fear of a specific object or situation. Exposure to the object provokes an immediate anxiety response such as a panic attack. To meet the criteria for social phobia, patients must suffer symptoms for at least 6 months. Generalized anxiety disorder is characterized as excessive anxiety and worry regarding a number of events or activities. Physical symptoms include restlessness, irritability, or sleep disturbance. Symptoms must be present for at least 6 months.
Acute stress disorder occurs after a traumatic event that the individual considers life threatening. Patients experience dissociative symptoms, flashbacks, and increased arousal. Symptoms are present for at least 2 days, with a maximum of 4 weeks. Beyond 4 weeks, a diagnosis of posttraumatic stress disorder is made. Panic disorder with agoraphobia is characterized by recurrent panic attacks with a fear of being in situations in which the patient cannot escape or may be embarrassed by doing so. Symptoms must be present for 1 month for the diagnosis to be made (SOR C).
D. are homebound. Factors associated with a higher risk of heat-related death include being confined to bed, not leaving home daily, and being unable to care for oneself. Living alone during a heat wave is associated with an increased risk of death, but this increase is not statistically significant. Among medical conditions, the highest risk is associated with preexisting psychiatric illnesses, followed by cardiovascular disease, use of psychotropic medications, and pulmonary disease.
A lower risk of heat-related death has been noted in those who have working air conditioning, visit air-conditioned sites, or participate in social activities. Those who take extra showers or baths and who use fans have a lower risk, but this difference is not statistically significant.
E. Doxylamine (Unisom) and vitamin B6. Approximately 10% of women with nausea and vomiting during pregnancy require medication. Pharmacologic therapies that have been used include vitamin B6 , antihistamines, and prokinetic agents, as well as other medications. Randomized, placebo-controlled trials have shown that vitamin B6 is effective for this problem. The combination of vitamin B 6 and doxylamine was studied in more than 6000 patients and was associated with a 70% reduction in nausea and vomiting, with no evidence of teratogenicity. It is recommended by the American Congress of Obstetricians and Gynecologists as first-line therapy for nausea and vomiting in pregnancy. A combination pill was removed from the U.S. market in 1983 because of unjustified concerns about teratogenicity, but the medications can be bought separately over the counter.
In rare cases, metoclopramide has been associated with tardive dyskinesia, and the FDA has issued a black-box warning concerning the use of this drug in general. The 5-HT3 -receptor antagonists, such as ondansetron, are being used for hyperemesis in pregnancy, but information is limited. Droperidol has been used for this problem in the past, but it is now used infrequently because of its risks, particularly heart arrhythmias.
C. Laboratory testing. Testing for androgen excess is indicated in the young woman with an acute onset of hirsutism or when it is associated with menstrual irregularity, infertility, central obesity, acanthosis nigricans, or clitoromegaly. It should be kept in mind that excess hair has a male pattern in women with hirsutism, whereas hypertrichosis is characterized by excessive hair growth all over the body.
Elevated early morning total testosterone is most often associated with polycystic ovary syndrome, but other causes of hyperandrogenism and other endocrinopathies should be eliminated. These studies should include pregnancy testing if the patient has amenorrhea, as well as a serum prolactin level to exclude hyperprolactinemia. DHEA-S and early morning 17-hydroxyprogesterone can detect adrenal hyperandrogenism and congenital adrenal hyperplasia. Assessment for Cushing syndrome, thyroid disease, or acromegaly is appropriate if associated signs or symptoms are present. Pelvic ultrasonography can be performed to evaluate for ovarian neoplasm or polycystic ovaries, although PCOS is a clinical diagnosis and ultrasonography has a low sensitivity.
D. Men over age 70. All women ≥65 (SOR A) and all men ≥70 (SOR C) should be screened for osteoporosis. For men and women age 50-69, the presence of factors associated with low bone density would merit screening. Risk factors include low body weight, previous fracture, a family history of osteoporosis with fracture, a history of falls, physical inactivity, low vitamin D or calcium intake, and the use of certain medications or the presence of certain medical conditions.
Chronic systemic diseases that increase risk include COPD, HIV, severe liver disease, renal failure, systemic lupus erythematosus, and rheumatoid arthritis. Endocrine disorders that increase risk include type 1 diabetes mellitus, hyperparathyroidism, hyperthyroidism, Cushing's syndrome, and others. Medications that increase risk include anticonvulsants, corticosteroids, and immunosuppressants. Nutritional risks include celiac disease, vitamin D deficiency, anorexia nervosa, gastric bypass, and increased alcohol or caffeine intake.
C. hookworm. When third-stage hookworm larvae, most commonly of the species infecting dogs and cats, penetrate the skin and migrate through the dermis, they create the serpiginous, erythematous tracks characteristic of cutaneous larva migrans. Although this dermatosis can occur in northern areas when conditions are ideal, it is most often encountered in tropical and semitropical regions such as the Caribbean, Africa, Asia, and South America.
Travelers to beach environments where pet feces have been previously deposited are most at risk because of the direct contact of bare skin with the sand. As in this case, a stinging or itching sensation may be noted upon penetration; this is followed by the development of the creeping eruption, which usually appears 1-5 days later, although the onset may be delayed for up to a month. The larvae will not develop in the human host, so the infection is self-limited, usually resolving within weeks to months. Treatment with antihelminthic drugs can greatly reduce the clinical course. Preventive measures include treatment of infected dogs and cats and limiting exposure to contaminated soil by wearing shoes and protective clothing.
D. torsades de pointes. The EKG shown represents torsades de pointes. This special form of ventricular tachyarrhythmia is often regarded as an intermediary between ventricular tachycardia and ventricular fibrillation. Morphologically it is characterized by wide QRS complexes with apices that are sometimes positive and sometimes negative. It is generally restricted to polymorphous tachycardias associated with QT prolongation.
Anything that produces or is associated with a prolonged QT interval can cause torsades de pointes, including drugs (quinidine, procainamide, disopyramide, phenothiazines), electrolyte disturbances, insecticide poisoning, subarachnoid hemorrhage, and congenital QT prolongation. Its great clinical importance lies in the fact that the usual anti-arrhythmic drugs are not only useless but contraindicated, because they can make matters worse.
Ventricular flutter is the term used by some authorities to describe a rapid ventricular tachycardia producing a regular zigzag on EKG, without clearly formed QRS complexes. Ventricular tachycardia consists of at least three consecutive ectopic QRS complexes recurring at a rapid rate. They are usually regular. Ventricular fibrillation is characterized by the complete absence of properly formed ventricular complexes; the baseline wavers unevenly, with no clear-cut QRS deflections.
D. central retinal artery occlusion. The retinal findings shown are consistent with central retinal artery occlusion. The painless, unilateral, sudden loss of vision over a period of seconds may be caused by thrombosis, embolism, or vasculitis. Acute narrow-angle glaucoma is an abrupt, painful, monocular loss of vision often associated with a red eye, which will lead to blindness if not treated. In persons with optic neuritis, funduscopy reveals a blurred disc and no cherry-red spot. Occlusion of the central retinal vein causes unilateral, painless loss of vision, but the retina will show engorged vessels and hemorrhages. E. Pityriasis rosea. This presentation is typical of pityriasis rosea. There was a mild prodrome, thought to be jet lag by this patient, followed by the development of an ovoid salmon-colored, slightly raised herald patch, most commonly seen on the trunk. This was followed by an outbreak of multiple smaller, similar lesions that trend along Langer's lines. In this case, clear evidence of the herald patch remains visible in the left interscapular region, which is helpful in confirming the diagnosis.
Guttate psoriasis shares some features with pityriasis rosea in that it can appear suddenly and often follows a triggering incident such as a streptococcal infection, which could be confused with a prodromal phase; however, the absence of a herald patch and the smaller but thicker erythematous lesions differentiate psoriasis from pityriasis rosea. Tinea versicolor often involves the upper trunk and may appear as a lightly erythematous, scaling rash, but the onset is more gradual than in this case. Although this patient may be exposed to low levels of radiation in her job, radiation dermatitis requires doses such as those administered in cancer treatment protocols and would generally be limited to the field of exposure. Cutaneous T-cell lymphoma usually presents as a nonspecific dermatitis, most commonly in men over the age of 50.
An infectious etiology for pityriasis rosea is strongly suspected, although none has been identified. There is some evidence that the agent may be human herpesvirus 6. The illness generally resolves within 2 months, leaving no residual signs other than postinflammatory hyperpigmentation.
E. Slower gastrointestinal transit times in women. There are key physiologic differences between women and men that can have important implications for drug activity. Gastrointestinal transit times are slower in women than in men, which can diminish the absorption of medications such as metoprolol, theophylline, and verapamil. In addition, women should wait longer after eating before taking medications that should be administered on an empty stomach, such as ampicillin, captopril, levothyroxine, loratadine, and tetracycline.
Women also secrete less gastric acid than men, so they may need to drink an acidic beverage to aid in absorption of medications that require an acidic environment, such as ketoconazole. Women usually have lower BMIs than men, and may need smaller loading or bolus dosages of medications to avoid unnecessary adverse reactions. Women typically have higher fat stores than men, so lipophilic drugs such as benzodiazepines and neuromuscular blockers have a longer duration of action. Women also have lower glomerular filtration rates than men, resulting in slower clearance of medications that are eliminated renally, such as digoxin and methotrexate.
D. Screening mammography. Medicare pays for some preventive measures, including pneumococcal vaccine, influenza vaccine, annual mammography, and a Papanicolaou test every 3 years. Medicare does not pay for custodial care, nursing-home care (except limited skilled nursing care), dentures, routine dental care, eyeglasses, hearing aids, routine physical checkups and related tests, or prescription drugs. D. Viral infection. The conditions that result in an absolute increase in lymphocytes are divided into primary causes (usually neoplastic hyperproliferation) and secondary or reactive causes. The presence of reactive lymphocytes will often be reported on a manual differential, since they have a distinctive appearance. The most common conditions that produce a reactive lymphocytosis are viral infections. Most notable are Epstein-Barr virus, infectious mononucleosis, and cytomegalovirus. Other viral infections known to cause this finding include herpes simplex, herpes zoster, HIV, hepatitis, and adenovirus.
Connective tissue disease can infrequently cause a reactive lymphocytosis, but other signs or symptoms are usually present. Bacterial infections more commonly result in an increase in neutrophils. One exception to this is Bordetella pertussis, which has been known to cause absolute lymphocyte counts of up to 70,000/μL. This infection is associated with classic symptoms that this patient does not have.
B. They should be avoided in persons with cirrhotic liver disease. NSAIDs are prescribed commonly and many are available over the counter. It is important for clinicians to understand when they are not appropriate for clinical use. They should be avoided, if possible, in persons with hepatic cirrhosis (SOR C). While hepatotoxicity with NSAIDs is rare, they can increase the risk of bleeding in cirrhotic patients, as they further impair platelet function. In addition, NSAIDs decrease blood flow to the kidneys and can increase the risk of renal failure in patients with cirrhosis.
NSAIDs differ from aspirin in terms of their cardiovascular effects. They have the potential to increase cardiovascular morbidity, worsen heart failure, increase blood pressure, and increase events such as ischemia and acute myocardial infarction.
There are no known teratogenic effects of NSAIDs in humans. This drug class is considered to be safe in pregnancy in low, intermittent doses, although discontinuation of NSAID use within 6-8 weeks of term is recommended. Ibuprofen, indomethacin, and naproxen are considered safe for lactating women, according to the American Academy of Pediatrics.
D. 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.
E. Metronidazole gel (MetroGel). Rosacea is a relatively common condition seen most often in women between the ages of 30 and 60. Central facial erythema and telangiectasias are prominent early features that may progress to a chronic infiltrate with papules and sometimes sterile pustules. Facial edema also may occur. Some patients develop rhinophyma due to hypertrophy of the subcutaneous glands of the nose. The usual presenting symptoms are central facial erythema and flushing that many patients find socially embarrassing. Flushing can be triggered by food, environmental, chemical, or emotional triggers. Ocular problems occur in half of patients with rosacea, often in the form of an intermittent inflammatory conjunctivitis with or without blepharitis.
Management includes avoidance of precipitating factors and use of sunscreen. Oral metronidazole, doxycycline, or tetracycline also can be used, especially if there are ocular symptoms. These are often ineffective for the flushing, so low-dose clonidine or a nonselective β-blocker may be added.
Topical treatments such as metronidazole and benzoyl peroxide may also be effective, particularly for mild cases. Other illnesses to consider include acne, photodermatitis, systemic lupus erythematosus, seborrheic dermatitis, carcinoid syndrome, and mastocytosis.
C. Gonorrhea. The diagnosis of any sexually transmitted or associated infection in a postnatal prepubescent child should raise immediate suspicion of sexual abuse and prompt a thorough physical evaluation, detailed historical inquiry, and testing for other common sexually transmitted diseases. Gonorrhea, syphilis, and postnatally acquired Chlamydia or HIV are virtually diagnostic of sexual abuse, although it is possible for perinatal transmission of Chlamydia to result in infection that can go unnoticed for as long as 2-3 years. Although a diagnosis of genital herpes, genital warts, or hepatitis B should raise a strong suspicion of possible inappropriate contact and should be reported to the appropriate authorities, other forms of transmission are common. Genital warts or herpes may result from autoinoculation, and most cases of hepatitis B appear to be contracted from nonsexual household contact. Bacterial vaginosis provides only inconclusive evidence for sexual contact, and is the only one of the options listed for which reporting is neither required nor strongly recommended. E. Conversion aphonia. This patient has conversion aphonia. In this condition, the patient loses his or her spoken voice, but the whispered voice is maintained. The vocal cords appear normal, but if observed closely by an otolaryngologist, there is a loss of vocal cord adduction during phonation, but normal adduction with coughing or throat clearing. This often occurs after a traumatic event (in this case a divorce) (SOR C).
Muscle tension aphonia presents with strained, effortful phonation, vocal fatigue, and normal vocal cords. It is caused by excessive laryngeal or extralaryngeal tension associated with a variety of factors, including poor breath control and stress, for example. The patient with laryngopharyngeal reflux presents with a raspy or harsh voice. The hoarseness is usually worse early in the day and improves as the day goes by. There is usually associated heartburn, dysphagia, and/or throat clearing.
The patient with spasmodic dysphonia (also known as laryngeal dystonia) has a halting, strangled vocal quality. It is a distinct neuromuscular disorder of unknown cause. Uncontrolled contractions of the laryngeal muscles cause focal laryngeal spasm. The hoarseness of vocal abuse is usually worse later in the day after effortful singing or talking. The history usually reveals vocal cord abuse, such as with an untrained singer or some other situation that increases demands on the voice. Nodules or cysts may be seen on the vocal cords with this condition.
E. Immobilization in a cast boot for 3 weeks is indicated. The diagnosis of tendinopathy of the posterior tibial tendon is important, in that the tendon's function is to perform plantar flexion of the foot, invert the foot, and stabilize the medial longitudinal arch. An injury can, over time, elongate the midfoot and hindfoot ligaments, causing a painful flatfoot deformity.
The patient usually recalls no trauma, although the injury may occur from twisting the foot by stepping in a hole. This is most commonly seen in women over the age of 40. Without proper treatment, progressive degeneration of the tendon can occur, ultimately leading to tendon rupture.
Pain and swelling of the tendon is often noted, and is misdiagnosed as a medial ankle sprain. With the patient standing on tiptoe, the heel should deviate in a varus alignment, but this does not occur on the involved side. A single-leg toe raise should reproduce the pain, and if the process has progressed, this maneuver indicates progression of the problem.
While treatment with acetaminophen or NSAIDs provides short-term pain relief, neither affects long-term outcome. Corticosteroid injection into the synovial sheath of the posterior tibial tendon is associated with a high rate of tendon rupture and is not recommended. The best initial treatment is immobilization in a cast boot or short leg cast for 2-3 weeks.
E. 9 mm induration on a hospital-based nurse who had a test with 2 mm induration 1 year ago. Three different cutoff levels defining a positive reaction on a tuberculin skin test are recommended by the CDC, each based on the level of risk and consideration of immunocompetence. For those who are at highest risk and/or immunocompromised, including HIV-positive patients, transplant patients, and household contacts of a tuberculosis patient, an induration ≥5 mm is considered positive. For those at low risk of exposure, a screening test is not recommended, but if one is performed, induration ≥15 mm is considered positive.
For those who have an increased probability of exposure or risk, an induration ≥10 mm should be read as positive. This group includes children; employees or residents of nursing homes, correctional facilities, or homeless shelters; recent immigrants; intravenous drug users; hospital workers; and those with chronic illnesses. For individuals who are subject to repeated testing, such as health-care workers, an increase in induration of 10 mm or more within a 2-year period would be considered positive and an indication of a recent infection with Mycobacterium tuberculosis. A nurse with a 9-mm induration would be considered to have a negative PPD.
C. 130/80 mm Hg. Hypertension and diabetes mellitus are very common, both separately and in combination. End-organ damage to the heart, brain, and kidneys is more common in patients with both diabetes mellitus and hypertension, occurring at lower blood pressure levels than in patients with only hypertension. JNC 7, an evidence-based consensus report, recommends that patients with diabetes and hypertension be treated to reduce blood pressure to below 130/80 mm Hg, as opposed to 140/90 mm Hg for other adults.
It should be noted, however, that the recently published ACCORD blood pressure trial found no significant cardiovascular benefit from targeting systolic blood pressure at <120 mm Hg rather than <140 mm Hg in patients with type 2 diabetes. This finding may affect the JNC 8 guidelines, which are currently being developed.
E. Taking patient compliance into account when performing the evaluation. Pay-for-performance programs are becoming a critical part of the health care reform debate, and when the discussion began in 2005, over 100 such programs were in existence. The objective is to reward physicians for achieving goals that should lead to improved patient outcomes. In addition to evaluating clinical performance, many programs now also evaluate efficiency and information technology. However, many programs are not based on outcomes data, and have less desirable aspects such as inadequate incentive levels, withholding of payment, limited clinical focus, or unequal or unfair distribution of incentives. Plans that exclude patient compliance as a factor can lead to withholding of physician incentives because of patient nonadherence, or to physicians selectively removing such patients from their panels.
As the exact process is still being defined, all family physicians should be actively engaged in learning more about these programs, and in negotiating for appropriate measures to be included. The AAFP has seven main principles in its support for pay-for-performance programs: (1) the focus should be on improved quality of care; (2) physician-patient relationships should be supported; (3) evidence-based clinical guidelines should be utilized; (4) practicing physicians should be involved with the program design; (5) reliable, accurate, and scientifically valid data should be used; (6) physicians should be provided with positive incentives; and (7) physician participation should be voluntary. Ensuring that patient adherence is included helps prevent conflicts between patients and their physicians.
A pay-for-performance program should not result in a reduction of fees paid to the physician as a result of implementing a program. Negative results should not penalize the physician with regard to health plan credentialing, verification, or licensure.
E. Acupuncture. Most chronic back pain (up to 70%) is nonspecific or idiopathic in origin. Treatment options that have the best evidence for effectiveness include analgesics (acetaminophen, tramadol, NSAIDs), multidisciplinary rehabilitation, and acupuncture (all SOR A).
Other treatments likely to be beneficial include herbal medications, tricyclics, antidepressants, exercise therapy, behavior therapy, massage, spinal therapy, opioids, and short-term muscle relaxants (all SOR B). There is conflicting data regarding the effectiveness of back school, low-level laser therapy, lumbar supports, viniyoga, antiepileptic medications, prolotherapy, short-wave diathermy, traction, transcutaneous electrical nerve stimulation, ultrasound, and epidural corticosteroid injections (all SOR C).
A. A. When possible, it is important for the family physician to base clinical decisions on the best evidence. Strength-of-Recommendation Taxonomy (SORT) grades in medical literature are intended to help physicians practice evidence-based medicine. SORT grades are only A, B, and C. These should not be confused with the U.S. Food and Drug Administration labeling categories for the potential teratogenic effects of medications on a fetus: pregnancy categories A, B, C, D, and X.
Strength of Recommendation (SOR) A is a recommendation that is based on consistent, good-quality, patient-oriented evidence. SOR B is a recommendation that is based on limited-quality patient-oriented evidence. SOR C is a recommendation that is based on consensus, disease-oriented evidence, usual practice, expert opinion, or case series for studies of diagnosis, treatment, prevention, or screening.
D. Elevated levels of ALT. Chronic hepatitis B develops in a small percentage of adults who fail to recover from an acute infection, in almost all infants infected at birth, and in up to 50% of children infected between the ages of 1 and 5 years. Chronic hepatitis B has three major phases: immune-tolerant, immune-active, and inactive-carrier.There usually is a linear transition from one phase to the next, but reactivation from immune-carrier phase to immune-active phase also can be seen.
Active viral replication occurs during the immune-tolerant phase when there is little or no evidence of disease activity, and this can last for many years before progressing to the immune-active phase (evidenced by elevated liver enzymes, indicating liver inflammation, and the presence of HBeAg, indicating high levels of HBV DNA). Most patients with chronic hepatitis B eventually transition to the inactive-carrier phase, which is characterized by the clearance of HBeAg and the development of anti-HBeAg, accompanied by normalization of liver enzymes and greatly reduced levels of hepatitis B virus in the bloodstream.
Random Board Review Questions 33
A 48-year-old female with type 2 diabetes has been hospitalized for 4 days with persistent fever. Her diabetes has been controlled with diet and glyburide (Micronase, DiaBeta). You saw her 2 weeks ago in the office with urinary frequency, urgency, and dysuria. At that time a urinalysis showed 25 WBCs/hpf, and a urine culture subsequently grew Escherichia coli sensitive to all antibiotics. She was placed on trimethoprim/sulfamethoxazole (Bactrim, Septra) empirically, and this was continued after the culture results were reported.
She improved over the next week, but then developed flank pain, fever to 39.5°C (103.1°F), and nausea and vomiting. She was hospitalized and intravenous cefazolin (Kefzol) and gentamicin were started while blood and urine cultures were performed. This urine culture also grew E. coli sensitive to the current antibiotics. Her temperature has continued to spike to 39.5°C since admission, without any change in her symptoms.
Which one of the following would be most appropriate at this time? (check one)
A. Add vancomycin (Vancocin) to the regimen
B. Order a radionuclide renal scan
C. Order intravenous pyelography
D. Order a urine culture for tuberculosis
E. Order CT of the abdomen
A. A fasting plasma glucose level ≥126 mg/dL on two separate occasions. The American Diabetes Association (ADA) first published guidelines for the diagnosis of diabetes mellitus in 1997 and updated its diagnostic criteria in 2010. With the increasing incidence of obesity, it is estimated that over 5 million Americans have undiagnosed type 2 diabetes mellitus. Given the long-term risks of microvascular (renal, ocular) and macrovascular (cardiac) complications, clear guidelines for screening are critical. The ADA recommends screening for all asymptomatic adults with a BMI >25.0 kg/m whohave one or more additional risk factors for diabetes mellitus, and screening for all adults with no risk factors every 3 years beginning at age 45.
Current criteria for the diagnosis of diabetes mellitus include a hemoglobin A1c≥6.5%, a fasting plasma glucose level ≥126 mg/dL, a 2-hour plasma glucose leve l≥200 mg/dL, or, in a symptomatic patient, a random blood glucose level ³200 mg/dL. In the absence of unequivocal hyperglycemia, results require confirmation by repeat testing.
D. Ultrasonography. This child meets the criteria for possible septic arthritis. In this case ultrasonography is recommended over other imaging procedures. It is highly sensitive for detecting effusion of the hip joint. If an effusion is present, urgent ultrasound-guided aspiration should be performed. Bone scintigraphy is excellent for evaluating a limping child when the history, physical examination, and radiographic and sonographic findings fail to localize the pathology. CT is indicated when cortical bone must be visualized. MRI provides excellent visualization of joints, soft tissues, cartilage, and medullary bone. It is especially useful for confirming osteomyelitis, delineating the extent of malignancies, identifying stress fractures, and diagnosing early Legg-Calvé-Perthes disease. Plain film radiography is often obtained as an initial imaging modality in any child with a limp. However, films may be normal in patients with septic arthritis, providing a false-negative result. E. 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.
A. The absence of calcification. Pulmonary nodules are a common finding on routine studies, including plain chest radiographs, and require evaluation. Radiographic features of benign nodules include a diameter <5 mm, a smooth border, a solid appearance, concentric calcification, and a doubling time of less than 1 month or more than 1 year. Features of malignant nodules include a size >10 mm, an irregular border, a "ground glass" appearance, either no calcification or an eccentric calcification, and a doubling time of 1 month to 1 year (SOR B). A. Likelihood ratio. There has been a large increase in the number of diagnostic tests available over the past 20 years. Although tests may aid in supporting or excluding a diagnosis, they are associated with expense and the potential for harm. In addition, the characteristics of a particular test and how the results will affect management and outcomes must be considered. The statistics that are clinically useful for evaluating diagnostic tests include the positive predictive value, negative predictive value, and likelihood ratios.
Likelihood ratios indicate how a positive or negative test correlates with the likelihood of disease. Ratios greater than 5-10 greatly increase the likelihood of disease, and those less than 0.1-0.2 greatly decrease it. In the example given, if the patient's endometrial stripe is >25 mm, the likelihood ratio is 15.2 and her post-test probability of endometrial cancer is 63%. However, if it is ≤ 4 mm, the likelihood ratio is 0.02 and her post-test probability of endometrial cancer is 0.2%.
The number needed to treat is useful for evaluating data regarding treatments, not diagnosis. Prevalence is the existence of a disease in the current population, and incidence describes the occurrence of new cases of disease in a population over a defined time period. The relative risk is the risk of an event in the experimental group versus the control group in a clinical trial.
E. 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.
A. 12 months of age AND weighs 20 lb. If a child faces forward in a crash, the force is distributed via the harness system across the shoulders, torso, and hips, but the head and neck have no support. Without support, the infant's head moves rapidly forward in flexion while the body stays restrained, causing potential injury to the neck, spinal cord, and brain. In a rear-facing position, the force of the crash is distributed evenly across the baby's torso, and the back of the child safety seat supports and protects the head and neck. For these reasons, the rear-facing position should be used until the child is at least 12 months old and weighs at least 20 lb (9 kg). For example, a 13-month-old child who weighs 19 lb should face rearward, and a 6-month-old child who
weighs 21 lb should also face rearward.
A. ACE inhibitors. Secondary prevention of cardiac events consists of long-term treatment to prevent recurrent cardiac morbidity and mortality in patients who have either already had an acute myocardial infarction or are at high risk because of severe coronary artery stenosis, angina, or prior coronary surgical procedures. Effective treatments include aspirin, β-blockers after myocardial infarction, ACE inhibitors in patients at high risk after myocardial infarction, angiotensin II receptor blockers in those with coronary artery disease, and amiodarone in patients who have had a myocardial infarction and have a high risk of death from cardiac arrhythmias.
Oral glycoprotein IIb/IIIa receptor inhibitors appear to increase the risk of mortality when compared with aspirin. Calcium channel blockers, class I anti-arrhythmic agents, and sotalol all appear to increase mortality compared with placebo in patients who have had a myocardial infarction. Contrary to decades of large observational studies, multiple randomized, controlled trials show no cardiac benefit from hormone therapy in postmenopausal women.
E. cyclic administration of progesterone for 3 months. Abnormal uterine bleeding is a relatively common disorder that may be due to functional disorders of the hypothalamus, pituitary, or ovary, as well as uterine lesions. However, the patient who is younger than 30 years of age will rarely be found to have a structural uterine defect. Once pregnancy, hematologic disease, and renal impairment are excluded, administration of intramuscular or oral progesterone will usually produce definitive flow and control the bleeding. No further evaluation should be necessary unless the bleeding recurs.
Endometrial aspiration, dilatation and curettage, and other diagnostic procedures are appropriate for recurrent problems or for older women. Estrogen would only increase the problem, which is usually due to anovulation with prolonged estrogen secretion, producing a hypertrophic endometrium.
C. Pelvic inflammatory disease. The promise of a reduction in the incidence and prevalence of sexually transmitted diseases through partner notification and treatment programs remains elusive, as evidence supporting this effect is scarce and inconclusive. What is clear is that treating sexual partners does reduce reinfection of the index patient. Programs such as contact notification, counseling and scheduling of appointments for evaluation of the partner, and expedited partner therapy (EPT), in which sexual contacts of infected patients are provided antibiotics delivered by the index patient without evaluation or counseling, have demonstrated only limited effectiveness; in the case of EPT this limited benefit has been shown only with trichomoniasis. Because currently available evidence fails to demonstrate benefit from treating the male sexual contacts of women with vaginal candidiasis, vaginal warts, or bacterial vaginosis, the Centers for Disease Control and Prevention (CDC) states that treating the male partner is not indicated with these infections.
In the case of pelvic inflammatory disease (PID), evaluation and treatment of males with a history of sexual contact with the patient during the 60 days preceding the onset of symptoms is imperative because of the high risk of reinfection. Current CDC guidelines recommend empiric treatment of these male contacts with antibiotic regimens effective against both chlamydial and gonococcal infection, regardless of the presumed etiology of the PID.
B. anxiety disorder with hyperventilation. The elevated pH, normal oxygen saturation, and low pCO2 are characteristic of acute respiratory alkalosis, as seen with acute hyperventilation states. In patients with a pulmonary embolism, pO2 and pCO2 are decreased, while the pH is elevated, indicating the acute nature of the disorder. With the other diagnoses, findings on the physical examination would be different than those seen in this patient. Vital signs would be normal with carbon monoxide poisoning, and patients with an asthma exacerbation have a prominent cough and wheezing, and possibly other abnormalities. Tension pneumothorax causes severe cardiac and respiratory distress, with significant physical findings including tachycardia, hypotension, and decreased mental activity. D. Frontotemporal dementia. Frontotemporal dementia is the second most common cause of early-onset dementia. It often presents with behavioral and personality changes. Examples include disinhibition, impairment of personal conduct, loss of emotional sensitivity, loss of insight, and executive dysfunctions. Alzheimer's disease presents with memory loss and visuospatial problems. Vascular dementia is associated with risk factors for stroke, or occurs in relation to a stroke, with a stepwise progression. Alzheimer's disease and vascular dementia can occur together, with features of both. Progressive supranuclear palsy is characterized by early falls, vertical (especially downward) gaze, axial rigidity greater than appendicular rigidity, and levodopa resistance. D. Acute angle-closure glaucoma. This patient presents with acute angle-closure glaucoma, manifested by an acute onset of severe pain, blurred vision, halos around lights, increased intraocular pressure, red conjunctiva, a mid-dilated and sluggish pupil, and a normal or hazy cornea. Findings with retinal detachment include either normal vision or peripheral or central vision loss; absence of pain; increasing floaters; and a normal conjunctiva, cornea, and pupil. Central retinal artery occlusion findings include amaurosis fugax, a red conjunctiva, a pale fundus, a cherry-red spot at the fovea, and "boxcarring" of the retinal vessels. In patients with mechanical injury to the globe, findings include moderate to severe pain, normal or decreased vision, subconjunctival hemorrhage completely surrounding the cornea, and a pupil that is irregular or deviated toward the injury (SOR B). A 51-year-old immigrant from Vietnam presents with a 3-week history of nocturnal fever, sweats, cough, and weight loss. A chest radiograph reveals a right upper lobe cavitary infiltrate. A PPD produces 17 mm of induration, and acid-fast bacilli are present on a smear of induced sputum.
While awaiting formal laboratory identification of the bacterium, which one of the following would be most appropriate? (check one)
A. Observation only
B. INH only
C. INH and ethambutol (Myambutol)
D. INH, ethambutol, and pyrazinamide
E. INH, ethambutol, rifampin (Rifadin), and pyrazinamide
E. INH, ethambutol, rifampin (Rifadin), and pyrazinamide. Leading authorities, including experts from the American Thoracic Society, CDC, and Infectious Diseases Society of America, mandate aggressive initial four-drug treatment when tuberculosis is suspected. Delays in diagnosis and treatment not only increase the possibility of disease transmission, but also lead to higher morbidity and mortality. Standard regimens including INH, ethambutol, rifampin, and pyrazinamide are recommended, although one regimen does not include pyrazinamide but extends coverage with the other antibiotics. Treatment regimens can be modified once culture results are available.