Fitzgerald Rv test 3

Addison's disease (Place holder)
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2 of 75A 66-year-old woman being managed for Addison's disease presents for follow-up evaluation. Findings consistent with an excessive dose of the medication taken for this condition would include:

Diffuse hyperpigmentation.
Blood pressure of 168/98 mm Hg.
Loss of axillary hair.
A white blood cell count of 6,000/mm3.
Blood pressure of 168/98 mm Hg. The first-line medication for Addison's disease is the use of a systemic corticosteroid such as oral prednisone; the goal is to replace endogenous cortisol in a manner that is consistent with the normal, physiologic diurnal variation. A typical starting dose is 15 mg q AM and 10 mg q PM. If the dose of prednisone is too high for this patient, she can demonstrate signs and symptoms of hypercortisolism, such as hypertension. Diffuse hyperpigmentation and loss of axillary hair are consistent with Addison's disease and will improve with medication. With respect to the white blood cell count, excess prednisone use will result in leukocytosis and the count will be >12,000/mm3. Topic:
A 49-year-old female of European ancestry with type 2 diabetes mellitus was started on lisinopril 20 mg tablet daily 6 weeks ago for the management of hypertension. Today her blood pressure is 128/78 mm Hg and the patient is feeling well. The appropriate action at this time would be to:

Order a white blood cell count to assess for neutropenia.
Continue on her current medication regimen.
Add oral HCTZ 12.5 mg to enhance HTN control.
Assess renal function.
Continue on her current medication regimen. Lisinopril, an angiotensin-converting enzyme inhibitor, is the appropriate class of medication in the patient with diabetes and comorbid hypertension according to the Joint National Committee 8 (JNC-8) report. Given her age and DM, her blood pressure goal is <140/90 mm Hg. She also meets the blood pressure goal per ACC/AHA guidelines that recommend <130/80 mm Hg for those with type 2 diabetes mellitus. As she is at goal, the current HTN treatment plan is adequate and can be continued. Her first-line treatment is also consistent with ADA recommendations (i.e., ACE inhibitor, ARB, calcium channel blocker, or thiazide diuretic). If in the future, HTN control is inadequate, her lisinopril dose can be increased and/or a second agent such as HCTZ can be added.
Reduces insulin resistance. Metformin has a multimodal mechanism of action that includes (1) sensitization of peripheral insulin receptors and (2) decreasing the rate of hepatic gluconeogenesis. Metformin does not facilitate renal excretion, nor does it impact the incretin system as do the DPP-4 inhibitors and GLP-1 agonists, two classes of drugs used for the treatment of T2DM.
6. When developing a management plan for a 58-year-old man with a 20-year history of type 2 diabetes mellitus, you recognize which of the following oral medications is less likely to be effective in controlling plasma glucose because of his long-standing condition?
Glipizide. The pathophysiologic trajectory of type 2 diabetes mellitus is that early in the disease the beta cells of the pancreas produce supraphysiologic levels of insulin as a compensatory response to the peripheral insulin resistance and subsequent decrease in effect. However, after several years of supraphysiologic production, the beta cells eventually "burn out" and cannot produce significant amounts of insulin release. An insulin releaser, such as glipizide, will not be effective and exogenous insulin must be added to the regimen. Metformin, pioglitazone, and canagliflozin (an SGLT2 inhibitor) do not stimulate the beta cell, and their mechanisms of action are still likely to be effective.
A1c >6.5%. Diagnostic criteria for diabetes mellitus include (1) fasting plasma glucose >126 mg/dL on two occasions, (2) A1c >6.5%, (3) plasma glucose tolerance >200 mg/dL 2 hours after a 75-g glucose load, or (4) random plasma glucose >200 mg/dL along with classic symptoms of polyuria, polydipsia, or polyphagia along with unexplained weight loss or hyperglycemic crisis.
Glucose-dependent insulin release. Sitagliptin is a dipeptidyl peptidase-4 (DPP-4) inhibitor. DPP-4 inhibitors slow the inactivation of two incretin hormones, glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1). This ultimately increases glucose-dependent insulin release and inhibits hepatic gluconeogenesis.
9. Mrs. Griffin is a 46-year-old woman with type 2 diabetes mellitus who is using metformin and a single 10-unit daily dose of the long-acting insulin glargine. Her fasting blood glucose has been between 120-140 mg/dL (6.7-7.8 mmol/L). Which of the following best describes the next step in her therapy?
Continue on the current glargine dose
Increase her glargine dose by 2 units per day
Increase her glargine dose by 4 units per day
Increase her glargine dose by 6 units per day
The correct answer is: Increase her glargine dose by 2 units per day. The current approach to the management of type 2 diabetes mellitus is that when added, glargine insulin should begin at 10 units daily and then be titrated up or down to reach a target fasting blood glucose of approximately 100 mg/dL. When fasting blood glucose remains 141-180 mg/dL, dose should be increased by 4 units. If the fasting glucose is 120-140 mg/dL, the dose should be increased by 2 units, and when it is >180 mg/dL, the dose should be increased by 6 units. Topic: Common Endocrinopathies? Diabetes Mellitus
Correct answer is: Insulin formulation. Virtually all of the non-insulin agents used in the management of type 2 diabetes mellitus augment, either directly or indirectly, the production or action of insulin. As a result of both pharmacokinetic and pharmacodynamic properties, there is an end point that, in the best-case scenario, is approximately 2% A1c reduction. Conversely insulin, an endogenous compound, can be progressively increased in dose until the desired A1c is achieved, when other agents are noted to be effective
11. A 24-year-old woman who is diagnosed with polycystic ovary syndrome (PCOS) is at greater risk of developing: Rheumatoid arthritis. Type 2 diabetes mellitus. Addison's disease. Hypothyroidism.Type 2 diabetes mellitus. Insulin resistance is now recognized as a root cause (along with genetics and other factors) of polycystic ovary syndrome (PCOS). When patients are insulin resistant, the body perceives this as an insulin deficiency and the pancreas compensates by making more insulin, resulting in hyperinsulinemia. For several years, the elevated insulin levels will compensate for the insulin resistance, and the patient remains normoglycemic. However, the hyperinsulinemia can also trigger increased production and release of androgens, which in turn leads to the development of ovarian cysts and impaired fertility, in part due to anovulation. If hyperinsulinemia and insulin resistance are left untreated for several years, type 2 diabetes mellitus will likely develop. From a clinical perspective, the insulin-resistant patient presents with PCOS years before developing type 2 diabetes mellitus.12. Which of the following characteristics applies to type 2 diabetes mellitus? Inactivity is a potent risk factor for the condition. Genetic influences are associated with type 1 but not type 2 diabetes mellitus risk. Exogenous insulin is consistently needed throughout the course of the disease. "Pear-shaped" body habitus is often noted.Inactivity is a potent risk factor for the condition. Type 2 diabetes mellitus is a complex metabolic disorder characterized by a variety of risk factors including inactivity, obesity, genetics, medication, and aging. Obesity is more often abdominal (rather than pear-shaped body habitus) and hyperinsulinemia is often noted in early disease; thus, exogenous insulin is typically not needed.13. You are teaching a 62-year-old patient with type 2 diabetes mellitus about using mealtime insulin to help with the management of post-prandial hyperglycemia. You describe a situation where blood sugar is between 200 and 250 mg/dL (11.1?13.9 mmol/L) and advise the appropriate dose of rapid-acting insulin to attain a goal of <150 mg/dL (8.3 mmol/L) is: 1 unit. 2 units. 4 units. 8 units.YOU ANSWERED CORRECTLY Correct answer is: 2 units. The American Diabetes Association (ADA) endorses the use of mealtime insulin to achieve glycemic control in patients whose A1c remains >6.5% after 3 months of optimal oral therapy. One unit of rapid-acting insulin will result in a blood sugar decrease of approximately 50 mg/dL (2.78 mmol/L). Therefore, in the example above, 2 units will be needed to attain the goal of <150 mg/dL. Topic: Common Endocrinopathies?14. Which of the following best describes the appropriate use of insulin lispro? In an insulin pump As a mealtime insulin As a basal insulin To prevent the Somogyi effectCorrect answer is: As mealtime insulin. Insulin lispro is ultra-short-acting, with an onset 15-30 minutes after administration and a peak of 30 minutes to 2.5 hours. This insulin is typically used as a mealtime insulin. The American Diabetes Association (ADA) endorses the use of mealtime insulin to achieve glycemic control in patients whose A1c and post-meal blood glucose remains elevated with the use of optimized therapy, particularly with basal insulin.15. Which of the following is a drug class that works predominantly by enhancing insulin release? Sulfonylureas Thiazolidinediones SGLT2 inhibitors MetforminCorrect answer is: Sulfonylureas. The sulfonylureas are pure insulinogenic (of, relating to, or stimulating the production of insulin) drugs. This drug class causes blocking of K+ channels on the membrane of the beta cell of the pancreas, resulting in membrane depolarization and calcium influx. The intracellular rise in calcium leads to insulin release. Sulfonylureas have no impact on insulin receptor activity, hepatic activity, or renal excretion. Metformin and thiazolidinediones are insulin sensitizers while SGLT2 inhibitors increase urinary glucose excretion.16. Delayed gastric emptying is noted with the use of: Exenatide. Pioglitazone. Acarbose. Glyburide.Correct answer is: Exenatide. Exenatide is a GLP-1 agonist, a drug class that is characterized by delayed gastric emptying and also includes liraglutide, lixisenatide and albiglutide. This is normally well-tolerated unless the patient has other risk factors for gastroparesis. GLP-1 agonists are associated with gastrointestinal adverse effects, including nausea, vomiting, and diarrhea, and are not recommended in those with severe gastrointestinal disease, such as gastroparesis. Pioglitazone is an insulin receptor sensitizer. Acarbose blocks gastric absorption of sucrose but does not impact gastric motility. Glyburide is an insulinogenic drug that impacts the beta cell of the pancreas and has no impact on the gut.17. SGLT2 inhibitors work by: Increasing glucose utilization in the muscle. Reducing insulin resistance in the skeletal muscle and adipose tissue. Increasing urinary glucose excretion. Increasing pancreatic insulin release.Correct answer is: Increasing urinary glucose excretion. SGLT2 inhibitors (Sodium-glucose Cotransporter-2) increase urinary glucose excretion and can be used in combination with one or more agents, but not as a first-line choice. These agents do not enhance insulin secretion or sensitivity. Use of these agents is associated with increased risk of genital candidiasis, UTI, and dehydration.18 of 75You see a 24-year-old African American male with a BMI=34 kg/m2 and type 2 diabetes mellitus and extensive acanthosis nigricans. He works on a rotating shift at a factory and eats irregularly. He was initiated on metformin monotherapy 3 months ago and his A1c decreased from 9.8% to 8.7%. Which of the following is the most appropriate next step in the management of this patient? Follow up in 4 weeks as he is at goal Add a sliding scale insulin Add a thiazolidinedione Add a sulfonylureaCorrect answer is: Add a thiazolidinedione. The A1c goal for this patient is generally <7% and thus an additional antihyperglycemic should be used to reduce blood glucose levels. Thiazolidinediones (TZD) are primary insulin receptor sensitizers that can be used as adjunct to metformin to address insulin resistance. Sliding scale insulin is generally not recommended as this is more of a reactive rather than proactive approach to address hyperglycemia. Sulfonylureas act as an insulin secretagogue that promotes constant insulin release. For an individual with an irregular eating schedule, this can increase the risk of hypoglycemia.19 of 75The dyslipidemia pattern most often seen in a person with untreated or poorly-controlled type 2 diabetes mellitus is one of: High TG, normal LDL-C and HDL-C. High TG, high LDL-C, and low HDL-C. Normal TG, high LDL-C and HDL-C. Low TG, low LDL-C, and high HDL-C.Correct answer is: High TG, high LDL-C, and low HDL-C. Type 2 diabetes mellitus (DM) is an endocrine abnormality characterized by decreased storage of the metabolic fuel sources (glucose, amino acids, and triglycerides). As a result of decreased insulin activity, there is an increase in unstored triglycerides, producing the characteristic hypertriglyceridemia of diabetes mellitus. Similarly, there can be decreased hepatic uptake of LDL-C resulting in elevated plasma LDL-C levels. The mechanism of low HDL-C is unclear but has been linked to insulin resistance. Topic: Common Endocrinopathies?20. When prescribing glargine or detemir, the clinician should consider that: Its mechanism of action differs from that of other insulins. It is used as basal insulin. It reaches peak effect at 12 hours after injection. It can be mixed in the same syringe with rapid-acting insulin.Correct answer is: It is used as basal insulin. Insulin glargine and detemir are characterized by a steady-state impact on serum glucose over the entire duration of action. Otherwise, their mechanism of action is like any other insulin; they bind to insulin receptors catalyzing intracellular movement of glucose and amino acids. Like any long-acting insulin, glargine and detemir insulin cannot be mixed in the same syringe with short-acting insulin preparations. Other insulins that are used as basal insulin include ultra-long-acting insulins (e.g., insulin degludec, others). Topic: Common Endocrinopathies?21. Using metformin in a 62-year-old person who has a 20-year history of T2DM and a GFR=28 mL/min/1.73 m2 can potentially increase the risk of: QTc prolongation. Renal failure. Poor glycemic control. Lactic acidosis.Correct answer is: Lactic acidosis. In an otherwise healthy patient, metformin does not typically cause significant adverse effects. However, in cases of impaired renal function, metformin is not readily eliminated and circulating metformin levels can elevate. This elevation in plasma metformin leads to an increase in metformin-mediated lactate production. Like metformin, lactate is not efficiently excreted in cases of decreased renal function. As a result, the elevated lactate production, exacerbated by inefficient excretion, results in elevated circulating lactate and subsequent lactic acidosis. Thus, metformin is contraindicated in individuals with GFR below 30 mL/min/1.73 m2. Other risk factors for lactic acidosis with metformin use include concomitant use of certain medications (e.g., topiramate), age 65 years and older, having a radiological study with contrast, surgery and other procedures, hypoxic states (e.g., acute congestive heart failure), excessive alcohol intake, and hepatic impairment.The correct22. Nancy is a 22-year-old woman who initially presented with significant thyrotoxicosis. She was subsequently diagnosed with Graves' disease. She was then referred to endocrinology and ultimately treated with radioactive iodine. Follow-up laboratory assessment would be expected to reveal: Absence of thyroid-stimulating antibodies. An increase in TSH as compared to pretreatment. An increase in free T3 as compared to pretreatment. Absence of thyroid peroxidase (TPO) antibodies.The correct answer is: An increase in TSH as compared to pretreatment. Graves' disease is characterized by biologically active thyroid-stimulating antibodies that stimulate the thyroid gland and suppress endogenous TSH. As a result, pretreatment TSH is very low and sometimes undetectable. Following radioactive ablation of the gland, thyroxine output falls, circulating levels drop, and the anterior pituitary increases TSH production in an attempt to stimulate thyroxine release. Thyroid-stimulating antibodies can still be present, but the gland can no longer respond to them. T3 will not increase as the ablated gland cannot produce adequate levels of hormone. TPO antibodies are not characteristic of either treated or untreated Graves' disease; they are a marker for Hashimoto's thyroiditis. the23. A 45-year-old woman with hypothyroidism as a result of Hashimoto's thyroiditis was started on an appropriately-calculated dose of levothyroxine. Eight weeks later, the nurse practitioner expects that the patient will report: A modest weight gain. Less fatigue. A decrease in palpitations. Longer sleeping hours.The correct answer is: Less fatigue. Hashimoto's thyroiditis is an autoimmune disorder characterized by the production of thyroid peroxidase (TPO) antibodies that block thyroid-stimulating hormone (TSH) receptors on the thyroid gland and thus block the action of TSH. In the first months of the disease, there will be a fluctuation in symptoms as the body attempts to compensate, but eventually, the patient will become symptomatic of hypothyroidism. Replacing thyroid hormone is expected to improve symptoms of hypothyroidism. As a result, it is expected that the patient will report a decrease in fatigue that is characteristic of thyroid hypofunction. A decrease in palpitations and sleep hours is more consistent with appropriate management of thyrotoxicosis, not hypothyroidism24. The results of a radioactive iodine uptake scan of a 52-year-old woman with a thyroid mass reveal a cold spot. This finding is most consistent with: Amiodarone-induced thyroid disease. Thyroid cyst. Metabolically-active thyroid nodule. Graves' disease.The correct answer is: Thyroid cyst. A thyroid cyst is a nonfunctional collection of tissue on the thyroid gland. Nonfunctional tissue does not uptake iodine, and on a radioactive iodine uptake scan a cyst will appear as nonfunctional or "cold." Amiodarone-induced thyroid disease, active thyroid nodule, and Graves' disease are all conditions of increased gland function, and nodules would scan as hyperfunctioning or "hot."25. A 62-year-old woman who is generally well and now has newly-diagnosed hyperthyroidism complains of periods of tremors and tachycardia. You recommend which of the following as a means to alleviate these symptoms? Clonazepam Propranolol Methyldopa AmlodipineCorrect answer is: Propranolol. Hyperthyroidism results in an increased metabolic rate in virtually all body systems. Tachycardia is a result of excess beta1-receptor stimulation in the heart, and tremor is associated with excess beta2-receptor stimulation in the central nervous system. Propranolol is a non-cardioselective beta-adrenergic antagonist, which blocks both beta1- and beta2-receptors. This nonselective blockade attenuates many symptoms of hyperthyroidism, including tachycardia and tremor. Once the hyperthyroidism is resolved, its associated symptoms should resolve and beta-blocker treatment can be tapered and eventually discontinued.26. Which of the following is most consistent with untreated hypothyroidism? TSH <0.15 mIU/L (0.4-4.0 mIU/L), free T4=79 pmol/L (10-27 pmol/L) TSH=8.9 mIU/L (0.4-4.0 mIU/L), free T4=15 pmol/L (10-27 pmol/L) TSH=1.9 mIU/L (0.4-4.0 mIU/L), free T4=22 pmol/L (10-27 pmol/L) TSH=24 mIU/L (0.4-4.0 mIU/L), free T4=3 pmol/L (10-27 pmol/L)The correct answer is: TSH=24 mIU/L (0.4-4.0 mIU/L), free T4=3 pmol/L (10-27 pmol/L). Hypothyroidism is a condition characterized by decreased circulating thyroid hormone with resultant elevated thyroid stimulating hormone (TSH). When circulating thyroid hormone levels are low, the pituitary gland will respond by releasing TSH. In cases of untreated hypothyroidism, it is expected that the TSH level will be elevated and free T4 level will be low.27. A 27-year-old woman is newly diagnosed with Graves' disease that will be treated with methimazole or propylthiouracil. In counseling the patient, the NP mentions a potential risk for: Renal dysfunction. Weight gain. Liver toxicity. Peripheral neuropathy.The correct answer is: Liver toxicity. Treatment of Grave's disease typically includes the use of antithyroid medications, such as methimazole or propylthiouracil. Both of these drugs are associated with an increased risk of liver toxicity even in the absence of other risk factors for hepatotoxicity. Following treatment, radioactive iodine for thyroid ablation is the usual next step.28. Which of the following is most consistent with findings in thyroid cancer? Hard, fixed thyroid mass of 2 cm in diameter "Hot spot" on thyroid scan Abnormally low TSH Presence of TPO antibodiesCorrect answer is: Hard, fixed thyroid mass of 2 cm in diameter. Cancerous thyroid nodules tend to be nonproductive "dead" tissue that does not produce thyroid hormone. As a result, cancerous nodules do not actively pump iodine from plasma, and an iodine-uptake scan will reveal this absence of activity as a "cold spot" of unproductive tissue. Conversely, toxic nodules that autonomously produce thyroxine will demonstrate hyperactivity or "hot nodules." Because thyroid cancer is a nonfunctioning tissue, thyroid hormone levels can fall, resulting in a compensatory increase in thyroid stimulating hormone (TSH). Presence of TPO antibodies suggests autoimmune thyroid disease but not cancer. A hard, fixed mass larger than 1?1.5 cm should raise suspicion of malignancy and be referred for fine-needle aspiration biopsy.29 of 75Which is most likely to be reported in Graves' disease? QID: 3677795 Mark For Review Free T4=7.2 pmol/L (NL=10-27 pmol/L) TSH=0.09 mIU/L (NL=0.15-4.0 mIU/L) ESR=22 mm/h (NL <15 mm/h) TWBC=4,200/mm3, 0% Neutrophils w/ hypersegmentation (NL=6,000-10,000/mm3, 50%-70% Neutrophils)The correct answer is: TSH=0.09 mIU/L (NL=0.15-4.0 mIU/L). Graves' disease is an autoimmune disorder characterized by the pathologic production of thyroid-stimulating immunoglobulins (TSI) that stimulate the thyroid gland and lead to elevated thyroxine levels. The elevated thyroxine levels suppress pituitary production of thyroid stimulating hormone (TSH). As a result, TSH levels will become very low, often undetectable. According to the American Thyroid Association (ATA), TSH is the most sensitive indicator of thyroid function.30 of 75A 67-year-old woman is diagnosed with hypothyroidism and requires levothyroxine therapy. When considering the initiation of levothyroxine therapy for this patient, the NP realizes that: The therapeutic dose should be lower than what is used in a younger patient. The elderly should have a rapid initiation of thyroxine therapy. The goal of therapy should be a thyroid-stimulating hormone (TSH) of 5?10 mIU/L. TSH levels should be checked 2 weeks after initiation of therapy.Correct answer is: The therapeutic dose should be lower than what is used in a younger patient. Thyroid hormone sets the metabolic rate for virtually all metabolic processes. Thyroxine excess can present as accelerated function in all body systems. As a function of age-related change, the cardiovascular system is particularly sensitive to any deviation from homeostasis, and thyroxine excess will often present as palpitations, dysrhythmia, and angina. In order to avoid symptoms of excess, thyroid hormone replacement should be introduced at a low level and increased gradually, with the ultimate goal of symptom control and a TSH 0.5-2.0 µg/mL. The TSH level should be checked after approximately 8 weeks of treatment. Since the elderly have slower basal metabolism and slower rate of thyroxine elimination, a lower dose will be required as compared to that in young and middle-aged adults. Topic: Common Endocrinopathies?31. A 36-year-old man presents with a 12-h history of anorexia, nausea, and worsening abdominal pain. Physical examination reveals positive obturator and psoas signs. Anticipated WBC with differential results are as follows: TWBC=5,200/mm3, Neutrophils=35%, Bands=1%, Lymphocytes=57% TWBC= 8,300/mm3, Neutrophils= 58%, Bands=2%, Lymphocytes=40% TWBC=6,800/mm3, Neutrophils=28%, Bands=3%, Lymphocytes=45%-55% with reactive forms TWBC=17,600/mm3, Neutrophils=64%, Bands=8%, Lymphocytes=24%Correct answer is: TWBC=17,600/mm3, Neutrophils=64%, Bands=8%, Lymphocytes=24%. The positive obturator and psoas signs are both consistent with pain during a peritoneal stretch in the region of the appendix and are closely associated with appendicitis; the coincident abdominal pain, anorexia, and nausea strengthen the diagnosis. Consequently, the white blood cell (WBC) count will likely demonstrate an increase characterized by elevated neutrophils and bands. A TWBC of 5,200/mm3 and lymphocytes of 57% is more consistent with viral infection. A total WBC of 8,300/mm3 with neutrophils=58%, Bands=2%, Lymphocytes=40% is within normal limits. However, the patient with a TWBC of 17,600/mm3 and neutrophils of 64% has an absolute neutrophil count of 11,264/mm3. This, along with the 8% bands, is highly suggestive of bacterial infection consistent with appendicitis.32. Oral antimicrobials commonly used to treat H. pylori gastrointestinal tract infection include all of the following except: Metronidazole. Vancomycin. Clarithromycin. Amoxicillin.Correct answer: Vancomycin. Helicobacter pylori, a Gram-negative spiral-shaped organism, is found in at least 90% of patients with duodenal ulcer and 40%-70% of individuals with gastric ulcer. Eradication of the organism dramatically reduces the risk of a relapse, and several antimicrobial combinations can be used to effectively treat symptomatic H. pylori infection. Amoxicillin and metronidazole are effective agents, and H. pylori resistance to these agents is uncommon. Clarithromycin can also be used though resistance to this agent is increasing. Vancomycin is used to treat infections caused by Gram-positive organisms and is usually given parenterally (except for the treatment of C. difficile infection).33. Which of the following signs is most consistent with a diagnosis of Crohn's disease involving the small intestine? Diffuse maculopapular rash Vomiting Constipation Blood in the stoolCorrect answer: Blood in the stool. Inflammatory bowel disease (IBD) is a disease of unclear etiology, but likely involves an autoimmune response to the GI tract. The two major types of IBD are ulcerative colitis (UC, characterized by pathological changes limited to the colon) and Crohn's disease (changes can involve any part of the GI tract). The inflammation that occurs in Crohn's disease causes cells in the affected areas of the intestines to secrete large amounts of water and salt, which cannot be completely reabsorbed. The manifestations of IBD generally depend on the area of the intestinal tract involved. Patients with Crohn's disease involving the small intestine frequently have abdominal pain and cramping, reduced appetite and unintended weight loss, blood in the stool, and diarrhea.34. A 37-year-old man presents complaining of recurrent abdominal pain that is relieved with defecation. Symptom onset is often accompanied by bloating and a change in stool frequency and form. He denies seeing blood in the stool, his weight is stable, and his hematocrit is within normal limits. The most likely diagnosis is: Irritable bowel syndrome. Paralytic ileus. Peptic ulcer disease. Ulcerative colitis.Correct answer: Irritable bowel syndrome. Irritable bowel syndrome (IBS) is a functional GI disorder characterized by abdominal pain and altered bowel habits in the absence of specific and unique organic pathology. The Rome IV criteria for the diagnosis of IBS require that patients must have recurrent abdominal pain on average at least 1 day per week during the previous 3 months with two or more of the following: discomfort relieved by defecation, symptom onset associated with a change in stool frequency, or symptom onset associated with a change in stool form or appearance. Additional symptoms usually include altered stool frequency, form, or passage (or a combination of two or all three) usually accompanied by mucorrhea and abdominal bloating or the sensation of distention or both. Ulcerative colitis is typically associated with unintended weight loss, diarrhea, and blood in the stool. Peptic ulcer disease is typically associated with abdominal pain that becomes worse with eating and would not be affected by defecation. Paralytic ileus is a partial or complete blockage of the bowel that will prevent content moving though the gut.35 of 75Clinical presentation of a 38-year-old man with irritable bowel syndrome (IBS) is most likely to reveal: Low hemoglobin level. Elevated ESR. Fecal occult blood. Tenderness in the sigmoid region.Correct answer: Tenderness in the sigmoid region. A person with IBS usually has tenderness in the sigmoid region but the remainder of the examination is usually normal. Laboratory analysis is usually directed at ruling out another cause of the symptoms associated with the condition and will typically reveal a normal hemogram, a normal ESR, and a negative test result for the presence of fecal occult blood. Imaging studies of the GI tract are also usually normal.36. A 52-year-old man presents with 3-day history of intermittent fever, diarrhea with loose, brown-to-yellow stools, up to 5 times a day, and left lower quadrant abdominal pain. Laboratory analysis reveals a WBC=18,000 mm3 with neutrophilia. Which of the following diagnostic procedures would be most useful to confirm a diagnosis of acute colonic diverticulitis? Barium enema Abdominal ultrasound Endoscopic evaluation Abdominal CT scan with contrastCorrect answer: Abdominal CT scan with contrast. In acute colonic diverticulitis, the diverticula are inflamed, causing fever, leukocytosis, diarrhea, and left lower quadrant abdominal pain. Intestinal perforation is the likely origin of the condition. Imaging is often obtained to support the diagnosis and assess disease severity or complications. An abdominal CT scan with contrast is helpful in identifying findings consistent with the condition inducing bowel wall thickening; complications including abscess and fistulas can also be identified. Because of the potential risk of complication, a barium enema should not be obtained during an acute episode of diverticular disease. Abdominal ultrasound is not helpful in this condition. Endoscopic evaluation of the colon is contraindicated in acute diverticulitis, as insufflation of air can result in or exacerbate free perforation and peritonitis.37 of 75You see a 46-year-old woman who states that she "got a stomach flu that has been going around at work." She reports nausea with multiple episodes of vomiting, and diarrhea over the past 18 hours. She is without fever and describes stools as being yellow to brown and watery. You consider all of the following except: Initiating antiemetic therapy. Counseling on staying hydrated. Prescribing antimicrobial therapy prophylactically. Counseling that symptoms should begin to resolve in the next day or two.Correct answer: Prescribing antimicrobial therapy prophylactically. Cases of acute gastroenteritis can be caused by a number of organisms. Most commonly, this is a self-limiting viral infection that can spread quickly through contaminated food, water, or the environment. Less commonly, bacteria or parasites are the causative organisms. Signs of gastroenteritis can include nausea, vomiting, diarrhea, and a low-grade fever. Usually symptoms peak within 24 to 48 hours of infection and resolve after 3 to 5 days. Patients should stay hydrated with clear liquids and an antiemetic can be considered to stop vomiting. Antimicrobial therapy should not be used routinely unless the causative organism is identified and therapy is deemed appropriate.38. Risk factors for nonalcoholic fatty liver disease include all of the following except: Obesity. Hyperthyroidism. Type 2 diabetes mellitus. Hypertriglyceridemia.Correct answer: Hyperthyroidism. Nonalcoholic fatty liver disease (NAFLD) describes the condition of an accumulation of fat in the liver of persons who drink little or no alcohol. For most people, the condition causes no signs or symptoms. Risk factors include high LDL cholesterol, elevated levels of triglycerides, metabolic syndrome, obesity, polycystic ovary syndrome (PCOS), and type 2 diabetes mellitus; these are all conditions associated with increased insulin resistance. Additional NAFLD risk factors include hypothyroidism, and hypopituitarism. NAFLD treatment includes minimizing the contributing risks. Nonalcoholic steatohepatitis (NASH), a progressive form of NAFLD, can be treated with vitamin E or pioglitazone.39. A nurse practitioner is seeing a 37-year-old male in follow-up and wants to evaluate the efficacy of treatment for a patient who was diagnosed with repeat H. pylori infection. Appropriate diagnostic testing includes: Serologic H. pylori antibodies. Biopsy via endoscopy. Serum gastrin level. Urea breath test.Correct answer: Urea breath test. Evaluation for repeat infection cannot include antibody assessment as antibodies will remain indefinitely following initial infection. While biopsy via endoscopy would provide an accurate assessment, it is an invasive and expensive procedure and not necessary solely to diagnose repeat infection. A breath test can be considered as a test for cure. This rapid and noninvasive test is based on the ability of H. pylori to break down urea into ammonia and carbon dioxide. A fecal antigen assay can also be used. This involves the collection of a stool sample and can discriminate recurrent, acute infection by the presence of antigen. Serum gastrin levels are not a marker for bacterial infection.40 of 75One month ago, a 50-year-old man had reported symptoms that were consistent with classic gastroesophageal reflux disease. The patient was started on a proton pump inhibitor and given instructions that this medication needs to be taken at least 30 minutes before the morning meal. The patient appeared to understand and follow instructions. At today's follow-up visit, the expected finding would be: Marked improvement in symptoms. Transient diarrhea. Mild nausea without vomiting. Headache.Correct answer is: Marked improvement in symptoms. Simple gastroesophageal reflux disease (GERD) responds well to proton pump inhibitor (PPI) therapy the large majority of the time; the key is in having the medication used properly. After one month of proper dosing, the patient should report noticeable improvement in GERD symptoms. The medication should be taken at least 30 minutes before eating to allow for proper absorption and distribution just prior to peak proton pump activity. When a patient reports suboptimal response to PPI therapy for GERD, the first step is to ensure that the PPI is being taken at least 30 minutes prior to the morning meal.41 of 75Andrea Wilson is a 62-year-old woman who was seen a few weeks ago for evaluation of ongoing abdominal discomfort and nausea. Laboratory assessment revealed H. pylori, and she was treated for peptic ulcer disease with an appropriate antibiotic/proton-pump inhibitor combination. Today she has completed her course of therapy and admits to no real change in symptoms. This suggests that: Treatment was inadequate and a salvage regimen should be used. It is too soon to expect a response and the patient should be reevaluated in four weeks. The patient could have complicated peptic ulcer disease and should be referred for upper endoscopy. Peptic ulcer disease is likely not the correct diagnosis.Correct answer is: The patient could have complicated peptic ulcer disease and should be referred for endoscopy. Peptic ulcer disease includes both duodenal ulcers and gastric ulcers. Uncomplicated duodenal ulcers are the more common type and usually respond quickly to the appropriate therapeutic regimen. Presuming the diagnosis of peptic ulcer disease was correct, the absence of a response warrants endoscopic evaluation to rule out complicated diseases, such as malignancy.42. Which of the following is most consistent with the hepatic enzyme profile of a person with nonalcoholic fatty liver disease? AST=1208 U/L (0-40 U/L), ALT=560 U/L (0-40 U/L) AST=105 U/L (0-40 U/L), ALT=68 U/L (0-40 U/L) AST=678 U/L (0-40 U/L), ALT=990 U/L (0-40 U/L) AST=98 U/L (0-40 U/L), ALT=149 U/L (0-40 U/L)Correct answer is: AST=98 U/L (0-40 U/L), ALT=149 U/L (0-40 U/L). Nonalcoholic fatty liver disease is the most common cause of transaminase elevation and will produce a mild elevation in transaminases consistent with liver strain or liver cell (hepatocyte) damage anywhere from 1 to 4 times the upper limit of normal (ULN). As in most cases of liver insult, the AST and ALT are both elevated, with the ALT being the higher of the two and the ratio of AST to ALT less than 1. Fatty liver disease does not cause the profound transaminase elevation seen in other types of liver insult.43. A 47-year-old well woman presents with the following laboratory data: HBsAg=present; AST=56 U/L (0-40 U/L); ALT=98 U/L (0-40 U/L). These findings are most consistent with: Acute hepatitis B. Evidence of hepatitis B infection in the past. Immunity against future hepatitis B infection. Chronic hepatitis B.Correct answer is: Chronic hepatitis B. This patient is seropositive for the hepatitis B surface antigen (HBsAg present), which means that she is currently infected with the hepatitis B virus (HBV). Her AST and ALT are minimally elevated, within three times upper limit of normal, and she presents as a well woman. This presentation is inconsistent with acute HBV infection, but rather is consistent with chronic HBV infection. The fact that she is indeed infected with hepatitis B virus precludes evidence of effective immunization. A diagnosis of acute HBV infection would be supported with greatly elevated AST/ALT levels as well as sign of liver disease (e.g., nausea, anorexia, fever, malaise, and jaundice). SEE iPad references44. Megan is a 24-year-old woman diagnosed with ulcerative colitis (UC) 3 years ago. In the past 4 months, she has reported intermittent abdominal pain, diarrhea, weight loss, and fatigue. She now presents after 2 days of worsening symptoms. Which of the following laboratory findings is consistent with an UC flare? A1c >7.5% (NL=4.0?5.6%) Erythrocyte sedimentation rate (ESR)=14 mm/hr (NL=0?29 mm/hr) WBC <10,000/mm3 (NL= 4500?11,000/mm3) C-reactive protein (CRP)=15 mg/L (NL= 0?10 mg/L)Correct answer: C-reactive protein (CRP)=15 mg/L (NL= 0?10 mg/L). During an IBD flare (i.e., Crohn's disease, ulcerative colitis), serological markers of inflammation, including C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are usually elevated. Leukocytosis is also often present. The inflammation induced during an IBD flare should not have a clinically significant impact on blood glucose levels or A1c values in the absence of diabetes mellitus.45. For Megan in the previous question, a first-line treatment option for her UC flare can include: Oral ciprofloxacin. Oral mesalamine. Adalimumab injection. Oral methotrexate.Correct answer is: Oral mesalamine. During a flare of UC or Crohn's disease, oral aminosalicylates, including sulfasalazine (Azulfidine®) and mesalamine (Apriso®) are usually the 1st therapy. In UC, when disease is limited to the distal colon, mesalamine and corticosteroids can be administered rectally to treat a flare. Oral or parenteral corticosteroid use can provide rapid symptom relief because of potent anti-inflammatory effects. In Crohn's disease, metronidazole and ciprofloxacin are used when perineal disease or an inflammatory mass is noted. However, antibiotic use in UC is discouraged because of the increased risk of C. difficile infection. Immune modulators including 6-mercaptopurine and azathioprine are often prescribed to provide long-term disease control. Other immune modulators such as methotrexate and cyclosporine have been used with some success.46. A 28-year-old man presents with a firm, round, painless ulcer in the genital area with localized lymphadenopathy that has been present for 2 weeks. He feels otherwise well. This most likely represents: Genital warts (Condyloma acuminata). Primary syphilis. Secondary syphilis. Genital herpes.Correct answer is: Primary syphilis. Chancre is a key clinical finding in primary syphilis, presenting as a firm, round, painless genital and/or anal ulcer(s) with a clean base and indurated margins. This is usually accompanied by localized lymphadenopathy that lasts about 3 weeks in duration. Secondary syphilis is characterized by nonpruritic skin rash, often involving the palms and soles. Genital warts are characterized by verruca-form lesions, while genital herpes can involve painful ulcerated lesions. A test to detect T. pallidum directly from lesion exudate or tissue is the definitive method to diagnose primary syphilis. A presumptive diagnosis requires the use of two tests: a nontreponemal test (e.g., Rapid Plasma Reagent) and a treponomal test (e.g., fluorescent treponemal antibody absorbed test).47. Which of the following women would least likely be an acceptable candidate for post-menopausal hormone therapy? A 54-year-old with poorly-controlled hypertension and dyslipidemia A 48-year-old with a BMI=28 kg/m2 who is physically inactive A 45-year-old with well-controlled hypertension who is taking an ACE inhibitor with a thiazide diuretic A 47-year-old who is a former smoker, with 10 years since her last cigarette, with a 20 pack-year historyCorrect answer is: A 54-year-old with poorly-controlled hypertension and dyslipidemia. Contraindications on the use of hormone therapy in postmenopausal women include unexplained vaginal bleeding, acute liver disease, chronic impaired liver function, thrombotic disease, neuro-ophthalmologic vascular disease, and endometrial or breast cancer. HT has been linked to cardiovascular disease and should be used with caution in women with dyslipidemia. Thus, the risks/benefits of HT in women with pre-existing risk factors for heart disease (e.g., poorly-controlled hypertension) should be carefully discussed before initiating therapy. Given the risk of cardiovascular disease with HT, it is generally not recommended to initiate HT in healthy older women after menopause.48. Which of the following is the most appropriate first-line treatment for pelvic inflammatory disease in a 28-year-old otherwise well woman? Ceftriaxone IM (one dose) plus doxycycline PO with or without metronidazole PO for 2 weeks Ciprofloxacin PO plus metronidazole PO for 10 days Trimethoprim plus sulfamethoxazole plus doxycycline PO for 2 weeks Ampicillin/sulbactam PO plus ofloxacin PO for 21 daysCorrect answer is: Ceftriaxone IM (one dose) plus doxycycline PO with or without metronidazole PO for 2 weeks. For most cases of PID, outpatient therapy with oral and/or parenteral antibiotics is sufficient. These should include activity against the most common pathogens, including N. gonorrhoeae, chlamydia, bacteroides, and Enterobacteriaceae. Ceftriaxone, 250 mg intramuscularly as a one-time dose, followed by doxycycline 100 mg PO bid for 2 weeks with or without metronidazole 500 mg PO is likely the most commonly-used treatment regimen and is highly effective. The addition of metronidazole is helpful in the treatment of bacterial vaginosis that is often found in the woman with PID as well as provides activity against select anaerobes that are often part of this typically polymicrobial infection. As a result of the emergence of quinolone-resistant N. gonorrhoeae, regimens that include these agents are no longer routinely recommended.49. A 27-year-old woman presents with a 2-day history of fever, pelvic pain, vaginal discharge, and dysuria. Which of the following laboratory findings would support a diagnosis of pelvic inflammatory disease (PID)? Thrombocytopenia Leukocytosis with neutrophilia Elevated procalcitonin level Antinuclear antibody positiveLeukocytosis with neutrophilia. PID (pelvic inflammatory disease) is an infectious disease consisting of endometritis, salpingitis, and oophoritis. Approximately 60% of infections are acquired through sexual transmission. Clinical presentation usually includes lower abdominal pain, abnormal vaginal discharge, dyspareunia, fever, gastrointestinal upset, or abnormal vaginal bleeding. PID should be considered when a woman presents with new-onset lower abdominal or pelvic pain coupled with at least one of the following findings on clinical examination: cervical motion tenderness, uterine tenderness or adnexal tenderness. Supporting laboratory findings in PID include elevated erythrocyte sedimentation rate or C-reactive protein level and leukocytosis with neutrophilia. Testing for serum procalcitonin, a marker for sepsis, should be reserved for severely ill patients as abnormal levels would not be expected in patients who can be treated in the outpatient setting.50. When selecting a treatment for gonococcal cervicitis and vaginitis in an otherwise well 18-year-old woman, the nurse practitioner should consider which of the following? Resistance to fluoroquinolones is uncommon The causative organism frequently produces beta-lactamase Most women resolve the infection without antimicrobial treatment Treatment duration is typically 10-14 daysCorrect answer is: The causative organism frequently produces beta-lactamase. Gonococcal cervicitis is caused by the Gram-negative diplococcus Neisseria gonorrhoeae, which is also a common cause of sexually transmitted disease. Antimicrobial treatment is indicated for this infection and can include one dose of ceftriaxone 250 mg IM and one dose of azithromycin 1 g PO. This regimen will also treat concomitant infection with chlamydia, which is often present in patients with gonococcal cervicitis. The use of fluoroquinolones are no longer recommended due to high levels of resistance to this class of agents, and beta-lactams are not effective due to high rates of beta-lactamase production by his organism.51. Symptoms of gonococcal vaginitis typically include all of the following except: Purulent and/or blood-tinged vaginal discharge. Painful or burning urination. Vaginal bleeding during intercourse. Fever >100.5?F (38.9?C).Correct answer is: Fever >100.5?F (38.9?C). Gonococcal vaginitis is caused by the Gram-negative diplococcus Neisseria gonorrhoeae, which is also a common cause of sexually transmitted disease. This organism is the second most common cause of bacterial STI. Most men with gonococcal infection do not present with any symptoms. For women, common symptoms include a milky to purulent and occasionally blood-tinged vaginal discharge, painful or burning urination, vaginal bleeding during intercourse, and lower abdominal pain during intercourse. When gonococcal infection is limited to the lower reproductive tract, fever is typically not noted.52. You see a 26-year-old woman diagnosed with bacterial vaginosis. She states she does not like to use vaginal products and asks for oral therapy. The appropriate oral treatment option is: Metronidazole. Ciprofloxacin. Cefixime. Fluconazole.Correct answer is: Metronidazole. Bacterial vaginosis occurs when certain species of normal vaginal bacteria undergo abnormal proliferation and cause inflammation. Most likely polymicrobial in nature, causative organisms likely include Gardnerella vaginalis and Mycoplasma hominis. According to the Sanford Guide to Antimicrobial Therapy, treatment of bacterial vaginosis can include oral metronidazole or metronidazole vaginal gel, tinidazole, or clindamycin vaginal gel. Oral clindamycin can be used as an alternative agent. In pregnancy, the preferred treatment is oral metronidazole or oral clindamycin for 7 days.53 of 75Which of the following symptoms is most consistent with a diagnosis of bacterial vaginosis? Fever Pain while urinating Malodorous vaginal discharge Abdominal painCorrect answer is: Malodorous vaginal discharge. Bacterial vaginosis is the most common type of vaginitis in women of reproductive age. The condition occurs when certain species of normal vaginal bacteria undergo abnormal proliferation and cause inflammation. Most likely polymicrobial in nature, causative organisms likely include Gardnerella vaginalis and Mycoplasma hominis. The most common symptom is a malodorous vaginal discharge that can be worse after intercourse. The discharge is occasionally grayish, white, or yellow. However, a large proportion of women with bacterial vaginitis do not notice any symptoms.54. Which of the following is the most likely causative pathogen of bacterial vaginitis with cervicitis in a 22-year-old sexually-active woman? Escherichia coli Klebsiella pneumoniae Staphylococcus epidermidis Chlamydia trachomatis YOU ANSWERED INCORRECTLY Correct answer is: Chlamydia trachomatis. Cervicitis, or inflammation of the cervix, is characterized by vaginal itching or irritation, bleeding between periods, pain or bleeding with sexual intercourse, frequent and painful urination, and unusual grey or white discharge. When associated with bacterial vaginitis, the most likely causes include C. trachomatis, N. gonorrhoeae, or Mycoplasma genitalium. Topic:chlamydia trachomatis. Cervicitis, or inflammation of the cervix, is characterized by vaginal itching or irritation, bleeding between periods, pain or bleeding with sexual intercourse, frequent and painful urination, and unusual grey or white discharge. When associated with bacterial vaginitis, the most likely causes include C. trachomatis, N. gonorrhoeae, or Mycoplasma genitalium.55. A 26-year-old woman presents with uncomplicated UTI. Her last menstrual period ended approximately 5 days ago, and she is taking combined oral contraceptives and denies missed pills. She is otherwise healthy, has not received any systemic antimicrobials in the past year, does not have a sulfa allergy, and is not taking any medications other than combined oral contraceptives for birth control. The local E. coli resistance rate to TMP/SMX is about 25%. The preferred oral therapy for this patient is: Trimethoprim-sulfamethoxazole. Amoxicillin. Nitrofurantoin. Ciprofloxacin.Correct answer is: Nitrofurantoin (Macrodantin, and Macrobid). Escherichia coli is the most common cause of acute, uncomplicated urinary tract infections in women. First-line treatment is oral trimethoprim-sulfamethoxazole when the local E. coli resistance rate is <20% and the patient does not have a sulfa allergy. If the local E. coli resistance rate is greater than 20%, or if the patient has a history of sulfa allergy, then the use of oral nitrofurantoin or fosfomycin is recommended. The use of ciprofloxacin should be limited given trends of increasing resistance by E. coli56 of 75The most likely causative organism in acute, uncomplicated UTI in nearly all patient groups is: Klebsiella species. Proteus mirabilis. Escherichia coli. Staphylococcus saprophyticus.Correct answer is: Escherichia coli. For acute, uncomplicated UTIs, the Gram-negative organism, Escherichia coli, is the predominant pathogen in nearly all patient groups. Other potential pathogens include the Gram-positive organisms Staphylococcus saprophyticus and enterococci. First-line treatment for acute, uncomplicated UTIs in women of reproductive age is oral trimethoprim-sulfamethoxazole when the local E. coli resistance rate is <20% and the patient does not have a sulfa allergy. If the local E. coli resistance rate is greater than 20%, or if the woman has a history of sulfa allergy, then the use of oral nitrofurantoin or fosfomycin is recommended. The use of ciprofloxacin should be limited given trends of increasing resistance by E. coli and a better understanding of fluoroquinolone's adverse effects.57. When evaluating the efficacy of estradiol (Vagifem®) vaginal tablets, the nurse practitioner expects that the patient will say: "I have a bit of vaginal dryness but otherwise I'm OK." "I have a bit of a red vaginal discharge." "Sexual activity is more comfortable." "I'm urinating less frequently."Correct answer is: "Sexual activity is more comfortable." The purpose of vaginal estradiol is to locally replace the estrogen that is lost as a function of menopause. Replacing vaginal estrogen helps to reestablish the lactobacilli population and supports a more lubricated and premenopausal environment. As a result, the clinician expects to hear from the patient that intercourse is more comfortable. Vaginal estradiol should not produce urinary discoloration or impact urination.58. considering the use of the selective estrogen receptor modulator (SERM) raloxifene for a 48-year-old woman, you consider all of the following except: Progestin opposition is not required. Osteoporosis risk is reduced. The frequency and intensity of hot flashes will be reduced. Use is not associated with an increased risk of breast cancer.Correct answer is: The frequency and intensity of hot flashes will be reduced. Selective estrogen receptor modulators (SERMs; e.g., raloxifene [Evista®]) are non-estrogen drugs that target very specific estrogen receptors and help prevent osteoclastic activity. This drug does not contain estrogen and does not produce estrogen-mediated cancer risks; therefore, progestin opposition is not needed, and the use is not contraindicated in patients with a family history of breast cancer. Likewise, SERMs do not attenuate all estrogen-mediated symptoms, so hot flashes are not reduced. Tamoxifen, the most commonly-used SERM for breast cancer, is associated with serious adverse effects, such as blood clots, stroke, and endometrial hyperplasia.59. You see a 62-year-old man with benign prostatic hyperplasia (BPH) and who is being treated for hypertension and chronic low back pain. Which of the following oral medications is most likely to cause acute urinary retention in this patient? Lisinopril Diphenhydramine Acetaminophen ChlorthalidoneCorrect answer is: Diphenhydramine. Diphenhydramine (Benadryl®) is a first-generation antihistamine that is associated with significant anticholinergic properties. Anticholinergic effects include relaxation of smooth muscles, including the smooth muscle of the bladder. In this setting of heightened relaxation, bladder contraction is inhibited. Impaired bladder contraction combined with the mechanical obstruction to urinary outflow that an enlarged prostate can create can produce significant urinary retention. Lisinopril, acetaminophen, and chlorthalidone have little to no anticholinergic effect.60. A 47-year-old man presents with a chief complaint of perineal pain with defecation and is diagnosed with acute bacterial prostatitis. He has had one sexual partner for the past 15 years. Which of the following statements would be most accurate for this patient? Chlamydial infection is likely. An oral macrolide or doxycycline are first-line treatments. A Gram-negative coliform organism is the most likely cause. A 3-day course of antibiotic therapy is preferred.Correct answer is: A Gram-negative coliform organism is the most likely cause. Acute bacterial prostatitis, regardless of causative organism, is frequently characterized by perineal pain with defecation, and this complaint significantly raises the index of suspicion. Causative organisms are generally presumed to be sexually transmitted, e.g., gonorrhea or chlamydia in patients <35 years of age, and Gram-negative intestinal flora (coliforms) in those >35 years of age or in men with low risk for STI. Men who have sex with men are also at higher risk of Gram-negative urinary tract infection, regardless of age. Antibiotic therapy for a minimum of 10 days (and up to 4 weeks) is recommended to ensure adequate penetration in the prostate gland.61. Which of the following would you most likely recommend for follow-up imaging following the resolution of their UTI? A 24-year-old woman who is not pregnant and currently has an acute, uncomplicated UTI A 36-year-old woman who is not pregnant who has a history of 2 acute, uncomplicated UTIs in the past 9 months A 54-year-old man with acute bacterial prostatitis A 42-year-old man with type 2 diabetes mellitus and recurrent pyelonephritisA 42-year-old man with type 2 diabetes mellitus and recurrent pyelonephritis. A complicated UTI has the following four aspects: structural abnormalities, metabolic/hormonal abnormalities (e.g., diabetes or pregnancy), impaired host responses, or unusual pathogens (e.g., yeasts). Patients with a complicated UTI can be considered for abdominal ultrasound to identify abnormalities that can predispose the patient to further infections. Among those listed, the man with type 2 diabetes mellitus and recurrent pyelonephritis would best qualify for diagnostic imaging.62. While evaluating a 27-year-old woman with a 1-day history of dysuria, which of the following findings in urinalysis is most suggestive of urinary tract infection (UTI) caused by a Gram-negative organism? Nitrites 30 mg/dL protein Epithelial cells pH >8Correct answer is: Nitrites. While protein, epithelial cells, and an elevated pH can be present in urinary tract infection, the presence of nitrites is most specific to Gram-negative bacterial infection. In the presence of Gram-negative bacteria, native nitrates are converted to nitrites in urine that has been retained in the bladder for at least 30 minutes.63. Which of the following infections would qualify for 7 days of oral antimicrobial therapy? A 34-year-old nonpregnant woman with an acute UTI receiving TMP-SMX A 42-year-old nonpregnant woman with an acute UTI receiving fosfomycin A 57-year-old man with a UTI receiving ciprofloxacin A 52-year-old man with chronic bacterial prostatitis receiving levofloxacin.Correct answer is: A 57-year-old man with a UTI receiving ciprofloxacin. Absent local geographic resistance, uncomplicated lower urinary tract infection in well women should be treated with a 3-day course of antimicrobial therapy. Alternatively, a 1-day regimen of fosfomycin can be used. Longer regimens are indicated in men, pregnant women, or those patients with other risk for poor outcomes (e.g., diabetes mellitus, age >65 years). A 7-day course with fluoroquinolone is recommended for UTIs in men. Despite concerns of fluoroquinolone resistance, the benefits of ciprofloxacin treatment outweigh the risk for this indication. Chronic bacterial prostatitis is typically treated for 4 weeks with a fluoroquinolone (levofloxacin (Levaquin), ciprofloxacin (Cipro), ciprofloxacin extended-release tablets, moxifloxacin (Avelox), ofloxacin, gemifloxacin (Factive) and delafloxacin (Baxdela).64. The most common cause of cervical squamous intraepithelial neoplasia is: Long-term human papillomavirus infection. Bacterial infection. Herpes simplex virus infection. Parasitic organism infection.Correct answer is: Long-term human papillomavirus infection. Human papillomaviruses are a collection of over 150 viruses, 40 of which are sexually transmitted. Of all of the sexually transmitted types, HPV-16 and HPV-18 have been implicated in approximately 70% of cervical neoplasms. The original FDA-approved quadrivalent HPV vaccine provided protection against HPV types 6, 11, 16 and 18. This has been replaced with a nine-valent HPV vaccine that provides protection against 5 additional types (31, 33, 45, 52, and 58). The 9-valent vaccine has the potential to prevent approximately 90% of cervical, vulvar, vaginal, and anal cancers.65. The loss of the cremasteric reflex in a young man with a chief complaint of sudden-onset scrotal pain most likely represents: Testicular neoplasia. Acute epididymitis. Incarcerated hernia. Testicular torsion.Testicular torsion. Testicular torsion occurs when a testicle rotates, thus twisting the spermatic cord and cutting off the blood supply. The cremasteric reflex is a normal finding during physical examination, and its absence is considered highly sensitive for testicular torsion to a 99% certainty. This superficial reflex, characterized by contraction of the cremaster muscle that pulls up the scrotum and testis on the side in response to light stroking of the ipsilateral inner thigh, remains present in other abnormalities of the testes, including neoplasm, epididymitis, and hernia. A scrotal ultrasound is used to confirm a diagnosis of testicular torsion, which will show reduced blood flow to the testicle. Prompt surgical correction is necessary to prevent testicular loss.66. Match each type of emergency contraception with the FDA-approved maximum amount of time post-coitus that it can be effectively used.A. 24 hoursB. 3 daysC. 5 daysD. 7 days1.Levonorgestrel2.Ulipristal Levonorgestrel-A Ulipristal-B Levonorgestrel-B Ulipristal-C Levonorgestrel-C Ulipristal-A Levonorgestrel-B Ulipristal-DLevonorgestrel? 3 days; Ulipristal? 5 days. When administered properly, emergency hormonal contraception reduces the risk of pregnancy by ≥89%. Levonorgestrel is approved for use up to 3 days (72 hours) following unprotected coitus (though it can still be effective beyond this time frame). Ulipristal is approved for up to 5 days (120 hours) post unprotected coitus. Both options have similar effectiveness when taken within 3 days after unprotected intercourse, but ulipristal has been shown to be more effective than levonorgestrel when taken between 3 and 5 days after unprotected intercourse. Of note, clinical evidence has demonstrated that levonorgestrel has reduced effectiveness in women with higher BMIs, while ulipristal is unaffected by body weight.67. Match each type of emergency contraception with its proposed mechanism of action. A. Copper-IUD B. Ulipristal C. Levonorgestrel 1. Induces a sterile inflammatory response that is toxic to sperm and ova 2. Alterations to the endometrium that could affect implantation 3. Inhibits or delays ovulation 1-B 2-A 3-C 1-C 2-B 3-A 1-A 2-B 3-C 1-A 2-C 3-BCopper-IUD? Induces a sterile inflammatory response that is toxic to sperm and ova; Ulipristal? Alterations to the endometrium that could affect implantation. Levonorgestrel? Inhibits or delays ovulation. Emergency hormonal contraception can have a variety of actions depending upon the contraceptive type and timing of its administration during the ovulation cycle. Levonorgestrel primarily works by inhibiting or delaying ovulation, but can also inhibit tubal transport of the egg or sperm. Ulipristal has a direct inhibitory effect on follicular development and ovum release. When taken early in the cycle, ulipristal can prevent ovulation. Additionally, alterations in the endometrium with ulipristal use can affect implantation. The presence of the copper-IUD in the intrauterine cavity induces a foreign body effect that results in a sterile inflammatory response that is toxic via a number of mechanisms to sperm and ova.68. Louise is a 19-year-old G0P0 female who recently became sexually active with a male partner for the first time. She wants to have a copper IUD placed because her older sister has one and has been very happy with it. Her last menstrual period was 10 days ago, and her urine pregnancy test is negative. She says that her only unprotected sexual episode since her last period was last night. The nurse practitioner: Offers to insert the copper IUD today. Offers oral emergency contraception with IUD insertion to follow. Advises Louise to wait until her next period for copper IUD insertion. Suggests another form of birth control due to her age and nulliparity.Offers to insert the copper IUD today. Since Louise's only episode of unprotected sex was less than 5 days ago, there is no reason to delay insertion of a copper IUD; in fact, the IUD will function as a form of emergency contraception to protect her from an unwanted pregnancy resulting from the unprotected encounter last night. While older forms of intrauterine devices were indicated only in women who have had at least one child, the most recent Practice Bulletin from the American College of Obstetricians and Gynecologists suggests that nulliparous women and adolescents can benefit from copper IUD use.69. patient is currently taking combined oral contraception and now wants a progestin IUD. The first day of her last period was 10 days ago and she denies having heterosexual intercourse since then. What is the best course of action? Insert the progestin IUD within 5 days of the next menstrual period Insert the progestin IUD now but advise a barrier method of contraception for two weeks Insert the progestin IUD now but continue COC for one week Insert the progestin IUD today and advise that no additional contraceptive method is neededInsert the progestin IUD today and advise that no additional contraceptive method is needed. The progestin IUD can be inserted and presumed to confer protection immediately. There is no requirement to wait until the next period and no reason to advise a back-up contraceptive method. A pregnancy test is not needed given her recent sexual history.70. Ana is a 30-year-old woman who had her third child 3 months ago. She has not had what she would call "a normal period" since giving birth. Ana discontinued breastfeeding approximately 8 weeks ago, and she has not had any vaginal bleeding for almost two weeks. She wants to have a progestin implant (Nexplanon) inserted. A urine pregnancy test is negative, but she does report having had unprotected sex approximately two weeks ago. The best action would be to: Insert the implant today but advise Ana to use a backup method for one week. Tell Ana that she is not a candidate for the implant until she has had a normal menstrual cycle. Offer Ana another method of contraception and insert the implant within 5 days of the start of her next menstrual period. Suggest to Ana that a progestin IUD would be more appropriate if she wants insertion today.Offer Ana another method of contraception and insert the implant within 5 days of the start of her next menstrual period. Because Ana's last episode of vaginal bleeding was more than two weeks ago and she has had unprotected sex, she is not a candidate for implant insertion today. While she does not need to go through an entire "normal" cycle, the implant should not be inserted until she begins her next period. Therefore, the best advice is to suggest another method of contraception, such as the pill/patch/ring or barrier, and then schedule her for insertion of the implant within 5 days of the start of her next period. The guidelines for a progestin IUD are the same as those for progestin implants, therefore a progestin IUD is not an appropriate alternative.71. A 26-year-old well woman wants to begin injection contraception (medroxyprogesterone depot {Depo-Provera}) today. Her last menstrual period began 4 days ago. The nurse practitioner informs the patient that: She will have her first injection today and should return in 3 months for the next one. A urine pregnancy test is required and if the result is negative, she is able to have her first injection today. The first injection must be given on the first day of the menstrual period; she will need to use another method this month and return next month. Injection contraception is only appropriate today if she has not had unprotected sex in the last 5 days.She will have her first injection today and should return in 3 months for the next one. Because this patient's last period began less than 5 days ago, it is appropriate to begin hormonal contraception today. A pregnancy test is not required. The injection can be given, and the patient should be instructed to return in 3 months for her next contraceptive injection so as not to experience an interruption in protection72 of 75According to the U.S. Medical Eligibility Criteria for Contraceptive Use, which of the following clinical scenarios describes a Category 3 (theoretical risks usually outweigh the advantages) situation for the use of combined oral contraceptives? Factor V Leiden mutation Age ≥35 years and smokes <15 cigarettes per day Varicose veins BMI ≥30 kg/m2Age ≥35 years and smokes <15 cigarettes per day. Age ≥35 years and smokes <15 cigarettes per day is a Category 3 circumstance, in which theoretical risks generally outweigh the advantages. Factor 5 Leiden mutation, a genetically-based thrombophilia, is a Category 4 condition, in which use represents unacceptable risk. A BMI ≥30 kg/m2 is Category 2, in which advantages outweigh the risk, and varicose veins are Category 1, in which there is no identified risk.73 of 75The use of which of the following antibiotics is most likely to reduce the effectiveness of combined oral contraceptive? Rifampin Amoxicillin Ciprofloxacin DoxycyclineRifampin. The coadministration of combined oral contraceptives and other medications that induce their metabolism can result in a circumstance in which oral contraceptive metabolism is accelerated. Rifampin is a cytochrome 3A4 inducer, and estrogen is a cytochrome 3A4 substrate. Administering these medications concomitantly risks accelerating metabolism of estrogen, and increases the risk of unwanted pregnancy. The use of penicillins, fluoroquinolones, and tetracycline antibiotics can result in increased breakthrough bleeding but without an observed increase in contraceptive failure.74 of 75Which of the following women is the best candidate for progestin-only pill (POP) use? A 26-year-old with multiple sexual partners A 32-year-old who is breastfeeding a 3-week-old infant A 22-year-old who frequently forgets to take prescribed medications A 35-year-old currently taking anticonvulsant therapyA 32-year-old who is breastfeeding a 3-week-old infant. Progestin-only pills (POP) are generally regarded as the better choice in breastfeeding mothers as they do not interfere with the milk supply in the way that estrogen-containing contraceptives can. POPs can safely be used during breastfeeding. However, progestin is metabolized within 20 hours and, therefore, needs to be taken quite consistently. Women who frequently forget to take their pills or tend to take medication at a different time every day are not good candidates. While women with multiple sexual partners can benefit from progestin compounds that thicken the cervical mucus, hormonal contraception is not a primary mechanism of preventing sexually transmitted infections. Though the use of POP with anticonvulsant therapy is not harmful to women, the interaction is likely to reduce the effectiveness of POPs.75 of 75A 26-year-old woman who is taking a combined oral contraceptive (COC) expresses interest in pregnancy. She asks you how long after discontinuing COC use will she be able to conceive. You respond: Immediately. After 1-2 months. After 3-4 months. After 5-6 months.Immediately. Combined oral contraception use, once discontinued, is not a barrier to safe conception. The hormones administered in contraceptives are metabolized and excreted within 24 hours, which is why consistent daily administration is so critical. This also applies for women who discontinue the use of a contraceptive patch or vaginal ring.What are antihypertensive drugs?(SVR) Systemic vascular resistance (SV) Stroke Volume BP = CO x SVR Cardiac output is also equal to heart rate (HR) times stroke volume (SV). CO = HR x SVWhat are to types of medications that facilitate renal excretion and impact the incretin systemDPP-4 inhibitors and GLP-1 agonistsIncretin SystemIncretin Hormones are released from the gut in response to food intake; Incretins are released after eating and augment the secretion of insulin released from pancreatic beta cells of the islets of Langerhans by a blood-glucose-dependent mechanism Potentiate glucose-induced insulin secretion The incretin hormones include glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) Contribute to insulin secretion from the beginning of a meal and their effects are progressively amplified as plasma glucose concentrations riseEndogenous meansEndogenous means caused by factors or produced inside an organism or cell. 1 An endogenous human substance, therefore, is a substance that originates within the human body.What is PCOS?PCOS is one of the most common causes of female infertility, affecting 6% to 12% (as many as 5 million) of US women of reproductive age. But it's a lot more than that. This lifelong health condition continues far beyond the child-bearing years. Women with PCOS are often insulin resistant; their bodies can make insulin but can't use it effectively, increasing their risk for type 2 diabetes. They also have higher levels of androgens (male hormones that females also have), which can stop eggs from being released (ovulation) and cause irregular periods, acne, thinning scalp hair, and excess hair growth on the face and body.Exogenous means what?Health professionals who treat people with diabetes often apply these terms to insulin: Endogenous insulin refers to the insulin the pancreas makes, and exogenous insulin refers to the insulin people inject or infuse via an insulin pumppost prandialfollowing a mealWhat is Prandial insulinsare taken at mealtime and act rapidly in the body, serving to manage the elevation of glucose levels following meals. Prandial insulins can also be used as correction doses - between meals or during the night - if glucose levels are high and out of range on the high sideGraves' disease is an immune system disorder that results?The overproduction of thyroid hormones (hyperthyroidism). Although a number of disorders may result in hyperthyroidism, Graves' disease is a common cause; The thyroid overproduces hormones. The condition is more common in women under age 40. Symptoms include anxiety, hand tremor, heat sensitivity, weight loss, puffy eyes and enlarged thyroid. Treatment includes medications. Sometimes the thyroid is removed.Metronidazole (Flagyl)Antibiotics It can treat various infections, including certain types of vaginal infections. It can also treat skin redness and pimples caused by rosacea. Brands: Metrogel, Nuvessa, MetroCream, Noritate, MetroLotion, Metro I.V., and FlagylWhat is basal insulin?See screen shot BASAl