Acute Infections in Kids
Cancer Screening
Preventive Care
CHF Refresher
Mental Health
100
A 2-year-old male is brought to your office in October with a 2-day history of low-grade fever, runny nose, and a barking cough. He has a rectal temperature of 38.9°C (102.0°F) and does not appear toxic. He has a respiratory rate of 35/min and is not wheezing. Oxyhemoglobin saturation (SpO2) is 95% on room air. Which one of the following is indicated? 1. Treatment with humidified air 2. Inhalation of supplemental oxygen 3. Treatment with nebulized racemic epinephrine 4. Oral glucocorticoids 5. Oral amoxicillin
What are oral glucocorticoids? Croup, or inflammation of the larynx and trachea, is common in children. It is caused by a viral infection. It can cause hoarseness, a barking cough, and noisy breathing. Croup is usually self-limited, but children who are hypoxic or have stridor at rest should be hospitalized. Corticosteroids have been shown to accelerate recovery from croup and shorten hospital stays. A Cochrane review of children treated for croup in emergency departments has shown no benefit from inhalation of humidified air (SOR A). This child does not manifest any symptoms or signs of hypoxemia, so oxygen therapy is not indicated. Nebulized epinephrine is not indicated for mild croup, although it may be useful in moderate to severe croup. The effect lasts only 2 hours and the final outcome of disease is not altered. It has many adverse side effects, including tachycardia and restlessness (SOR C). A Cochrane review of randomized, controlled trials has shown that glucocorticoids can improve croup within 6 hours and that the effect lasts for 12 hours, decreasing the need for other interventions and/or hospitalization (SOR A). Croup is a self-limited viral illness and antibiotics are not indicated.
100
The U.S. Preventive Services Task Force has found sufficient evidence to recommend which one of the following for skin cancer screening? 1. No currently available method 2. A periodic questionnaire to identify high-risk patients for referral for total-body skin examinations 3. An annual full-body skin examination by a primary care physician for high-risk patients only 4. An annual full-body skin examination by a dermatologist for all patients after age 65
What is no currently available method? The U.S. Preventive Services Task Force (USPSTF) has determined that the benefits from screening for skin cancer are unproven, even in high-risk patients (USPSTF I recommendation). Patients at increased risk for melanoma include those with atypical moles, fair-skinned individuals over the age of 65, and those with more than 50 moles. Lesions with atypical features, described as the ABCDs of melanoma (Asymmetry, Border irregularity, Color variability, Diameter >6 mm), or rapidly changing lesions, should be biopsied. Study outcomes of patients with familial syndromes have not been evaluated by the USPSTF. The most commonly advocated screening test is the full-body skin examination, although supporting data is limited and has only been collected in volunteer patients. The sensitivity and specificity of examinations performed by dermatologists are quite high. However, those done by other specialists are lower in sensitivity and considerably lower in specificity. Another possible screening tool is the risk-factor questionnaire, but its validity has not been established.
100
True statements regarding tobacco cessation counseling include which of the following? (Choose all that are true.) 1. Tobacco cessation treatment is cost-effective 2. Telephone quit line counseling has been shown to be effective 3. Insurance coverage of tobacco cessation strategies has an effect on tobacco quit rates 4. Multiple first-line pharmacologic agents have been shown to be more effective than placebo in promoting tobacco cessation 5. Use of pharmacologic agents for tobacco cessation will result in long-term abstinence in approximately 50% of patients
What are #1-4? Not only are tobacco cessation treatments effective clinically, they are also cost-effective in comparison to treatments for other medical disorders (SOR A). Several analyses have found that the cost of treatment per patient who quits ranges from several hundred to a few thousand dollars. Insurance coverage of medications and counseling to stop smoking increases quit rates (SOR A). Patients are more likely to receive treatment if their insurance pays for the medication or counseling, and insurance companies are therefore encouraged to cover tobacco cessation. Telephone quit lines are effective in tobacco cessation (SOR A). They reach a diverse population, and family physicians and other practitioners are encouraged to promote their use. Bupropion, varenicline, and five forms of nicotine replacement (gum, inhaler, lozenge, nasal spray, and patch) have all been shown to be effective in helping adults quit smoking (SOR A). However, there is insufficient evidence to recommend their use in adolescents, pregnant women, light smokers, and users of smokeless tobacco. Although medication helps individuals stop smoking, the long-term abstinence rate (12 months) is <30% (SOR A). Further research is needed to identify medications and strategies to extend the period of abstinence.
100
Which one of the following confers the greatest risk for developing heart failure in elderly patients? 1. Low pulse pressure 2. High pulse pressure 3. Low mean arterial pressure 4. High diastolic pressure
What is high pulse pressure? Of the choices listed, high pulse pressure confers the greatest risk for developing heart failure in elderly patients. There is a strong correlation between both increased systolic pressure and increased pulse pressure (pulse pressure = systolic pressure – diastolic pressure) and heart failure risk. High systolic blood pressure is a better predictor of future heart failure than high diastolic blood pressure.
100
Which one of the following would be the most effective treatment for this patient’s PTSD? 1. Sertraline (Zoloft) 2. Topiramate (Topamax) 3. Venlafaxine (Effexor) 4. Cognitive-behavioral therapy 5. Eye-movement desensitization and reprocessing
What is CBT? The most effective therapy for posttraumatic stress disorder (PTSD) is cognitive-behavioral therapy (CBT) (SOR A). SSRIs are the first-line medications for adjunctive therapy (SOR A) and both paroxetine and sertraline have been approved by the FDA for this use. A randomized, controlled trial has shown that extended-release venlafaxine is also effective in the treatment of PTSD (SOR A). Topiramate has been found to be effective as both monotherapy and augmentative therapy (SOR A). Other anticonvulsants, including carbamazepine, valproic acid, and lamotrigine show promise as well. There is some evidence that atypical antipsychotics such as risperidone and olanzapine may also have a role in the treatment of PTSD. CBT can be provided by a qualified psychotherapist or in brief form by a family physician. CBT may include exposure therapy, stress reduction techniques, or cognitive restructuring. Eye-movement desensitization and reprocessing has also been shown to be a useful type of psychotherapy for treating PTSD (SOR A). Other effective treatments include supportive therapy, nondirective counseling, psychodynamic therapy, and hypnotherapy.
200
An 8-year-old female is brought to your office because of an itchy scalp. When you examine her you find head lice. After treatment with permethrin (Nix), what advice do you give to the mother about returning the child to school? 1. Other children in the child’s class should be screened for lice 2. Information about this child’s infestation should be provided to other members of the class 3. The child should be kept out of school as long as there are nits in her hair 4. The child should not be excluded from school because of head lice
What is #4? The problem of head lice causes a lot of anxiety but little morbidity in school-age children and their families (SOR C). Unnecessary treatments are performed, school days are lost, and the economic loss owing to missed workdays by parents who have to stay home with their children is estimated at $4–$8 billion. Screening programs have not been shown to be effective in the management of louse outbreaks (SOR B). This child poses little risk to classmates once effectively treated. Even before treatment, lice are not so easily passed from one child to another in the activities of the classroom (SOR C). After treatment, nits do not necessarily pose a risk to other children, and only a small number of children with nits also have live lice (SOR C).
200
According to the U.S. Preventive Services Task Force, which one of the following screening strategies is likely to result in the fewest colonoscopies? 1. Fecal occult blood testing annually 2. Digital rectal examination annually 3. Fecal occult blood testing every 3 years, with sigmoidoscopy every 5 years 4. Colonoscopy every 10 years
What is #3? According to a modeling study commissioned by the U.S. Preventive Services Task Force (USPSTF), colonoscopy every 10 years will result in 3756 total colonoscopies per 1000 people screened. Annual high-sensitivity fecal occult blood testing will result in 2654 total colonoscopies per 1000 people screened, annual fecal immunochemical testing will result in 2295 colonoscopies per 1000 people screened, and high-sensitivity fecal occult blood testing every 3 years with flexible sigmoidoscopy every 5 years will result in 1655 colonoscopies per 1000 people screened. However, there is a slight tradeoff in terms of effectiveness. Colonoscopy every 10 years will result in 271 life-years gained for every 1000 people screened, while the combination of fecal occult blood testing and sigmoidoscopy will result in 257 life-years gained for every 1000 people screened. The USPSTF and other authorities do not recommend digital rectal examination for routine colorectal cancer screening.
200
Over-the-counter medications considered safe during the entire course of pregnancy include which of the following? (Choose all that are true.) 1. Aspirin 2. Acetaminophen 3. Ibuprofen 4. Pseudoephedrine 5. Chlorpheniramine 6. Guaifenesin
What are 2, 4, and 5? Among over-the-counter pain relievers, only acetaminophen is considered safe throughout pregnancy (category B), and it is considered the analgesic of choice for pregnant patients (SOR C). Aspirin can cause premature closure of the ductus arteriosus, and while ibuprofen is considered a category B drug during the second trimester, it can also cause premature closure of the ductus arteriosus during the third trimester (SOR C). Although pseudoephedrine is a category C drug, it is the decongestant of choice during pregnancy (SOR C). Chlorpheniramine is the antihistamine of choice during pregancy (SOR C), and is rated category B. Diphenhydramine is also rated category B, but has oxytocin-like effects at high doses. Guaifenesin is associated with neural tube defects, and dextromethorphan is preferred for cough during pregnancy (SOR C).
200
In the United States, the most common primary cause of heart failure with systolic dysfunction is 1. hypertension 2. valvular heart disease 3. myocarditis 4. coronary artery disease 5. alcohol abuse
What is CAD? Coronary artery disease (CAD) is the primary cause of left ventricular systolic dysfunction in two-thirds of cases. While hypertension, valvular heart disease, myocarditis, and alcohol abuse can cause heart failure, they are less common than CAD. Hypertension can contribute to CAD, but it is the primary cause of heart failure in a smaller number of patients, and some of these patients have diastolic, rather than systolic, dysfunction.
200
Depression screening instruments that have been validated against a reference standard for accuracy in Spanish-speaking primary care populations include which of the following? (Choose all that are true.) 1. Beck Depression Inventory 2. CES-D 3. Edinburgh Postpartum Depression Scale 4. Geriatric Depression Scale 5. PHQ-9 6. Zung Depression Scale
What are #2, 3, 4, and 5? A 2009 systematic review revealed that the CES-D (Centers for Epidemiologic Studies—Depression), the PHQ-9, the Edinburgh Postpartum Depression Scale, and the Geriatric Depression Scale had been validated against a reference standard in Spanish-speaking primary care populations (SOR A). Sensitivities were generally in the 70%–80% range (as high as 92% for the CES-D in one study) and specificities were generally somewhat higher. No evidence validating the Beck Depression Inventory or the Zung Depression scale was found for Spanish-speaking populations.
300
You see a 3-year-old child in the office with an acute febrile illness. He is uncomfortable because of sores in his mouth, and has not been able to eat or drink comfortably for the past 2 days. His mother says that his energy level is way down. She also says that hand, foot, and mouth disease is going around at his day-care facility. On examination the child appears tired. He has a temperature of 39.3°C (102.8°F) and is mildly tachycardic. He has some vesicular lesions and some ulcerated lesions on his tonsils, buccal mucosa, gingiva, roof of the mouth, and lips. There is no rash on his skin, including his palms and soles. He has bilateral anterior cervical adenopathy. The examination is otherwise normal. What is the most likely diagnosis?
What is herpes simplex stomatitis? Despite the fever and anterior cervical adenopathy, this is not likely to be streptococcal pharyngitis because of the vesicular nature of the rash and the distribution to the anterior parts of the mouth. A bacterial infection may cause this degree of systemic toxicity and adenopathy, but would not cause a vesicular outbreak (level of evidence 3). Herpes simplex is the most common cause of stomatitis in the 1- to 3-year age group. The fever, acute malaise, and cervical adenopathy are characteristic, as is the distribution. While there is a history of recent exposure to hand, foot, and mouth disease (usually caused by a coxsackievirus or echovirus), which is often vesicular, this disease is unlikely to be accompanied by the degree of systemic toxicity seen in this patient. Also, the absence of rash on the extremities makes the diagnosis very unlikely (level of evidence 3). The lesions of herpangina occur in the posterior oral cavity, whereas other vesicular enanthems such as primary herpetic gingivostomatitis and hand, foot, and mouth disease characteristically occur in the anterior oral cavity, especially on the inner aspects of the lips, the buccal mucosa, and the tongue. Gingivitis, prominent systemic toxicity, and cervical lymphadenitis are additional features of primary herpes simplex infection that are not seen in herpangina (level of evidence 3). Recognition of herpes simplex in this setting is important because it can be effectively treated with the acyclovir family of drugs.
300
According to the U.S. Preventive Services Task Force, which of the following women should be offered BRCA mutation genetic counseling, based on the information provided? (Choose all that are true.) 1. An African-American female whose mother was diagnosed with breast cancer at age 70 and whose sister who was diagnosed with breast cancer at age 60, but with no other known family history of cancer 2. A Native American female whose grandfather was diagnosed with breast cancer at age 56 3. An Ashkenazi Jewish female whose sister was diagnosed with breast cancer 2 years ago 4. An Asian female whose mother had breast cancer and whose grandmother had ovarian cancer 5. A Hispanic female whose sister was recently diagnosed with bilateral breast cancer
What 2, 3, 4, and 5? According to the U.S. Preventive Services Task Force (USPSTF), patients should generally not be referred for BRCA counseling or screening because of breast cancer in a female first degree relative unless the diagnosis was made before the age of 55 (USPSTF B recommendation). Ashkenazi Jewish women are at increased risk for BRCA mutations, and thus should be considered for testing if there is a family history of breast cancer in one first degree relative (USPSTF B recommendation). Bilateral breast cancer in a first degree relative also justifies referral for BRCA testing (USPSTF B recommendation). A history of breast cancer in any male relative justifies referral for BRCA testing (USPSTF B recommendation). BRCA mutations increase the risk for both breast and ovarian cancer before age 70 (35%–84% and 10%–50%, respectively). A family history of both types of cancer in first or second degree relatives significantly increases the risk of having a BRCA mutation, and screening is recommended (USPSTF B recommendation). For patients who may have one of these mutations, the physician should have a discussion with the patient about her risk for the mutation and its significance, and then determine her preferences before ordering screening tests.
300
Which one of the following is true regarding screening for drug abuse? 1. All adolescents should be screened for drug abuse 2. Counseling adolescents and young adults about drug abuse has been shown to prevent them from abusing drugs 3. Because of the risks to both mother and fetus, all pregnant women should be screened for drug abuse and counseled about this issue 4. The U.S. Preventive Services Task Force has found insufficient evidence for or against screening and counseling for drug abuse
What is #4? The U.S. Preventive Services Task Force (USPSTF) states that there is currently insufficient evidence to assess the balance of benefits and harms of broad-based screening of adolescents, adults, and pregnant women for illicit drug use (USPSTF I recommendation). They note that there are several validated and reliable instruments available, and that there is evidence that intervention in symptomatic individuals can lead to short-term decreases in drug use. However, they also note the lack of studies to show that use of these instruments in the primary care setting leads to improved social, legal, and health outcomes for patients, especially those who do not have physical, social, school, or occupational problems related to their substance use. The USPSTF review did not identify any studies examining the effectiveness of general counseling to prevent the onset of substance abuse. Experts recommend that physicians explore the possibility of substance abuse in selected patients at high risk (e.g., pregnant adolescents, individuals with changes in school/social/occupational functioning, etc.) (SOR C).
300
There is evidence or general agreement to support the usefulness of treating diastolic heart failure with which of the following? (Choose all that are true.) 1. Diuretics 2. Hypertension control 3. Negative chronotropic agents 4. Digoxin
What are #1, 2, and 3? Methods of treating diastolic heart failure that are supported by evidence or general agreement include controlling hypertension, controlling heart rate and preventing tachycardia, managing vascular volume with diuretics, and treating and preventing myocardial ischemia. In addition, promoting regression of hypertrophy and preventing myocardial fibrosis would be of theoretical benefit. Digoxin is recommended for systolic heart failure but not for diastolic heart failure.
300
A 25-year-old female presents to your clinic with symptoms consistent with bipolar I disorder. You arrange for psychiatric consultation but the patient cannot be seen for 2 months. You decide to start her on a mood stabilizer, and choose valproic acid (Depakote), 250 mg twice daily. You inform the patient about side effects of the medication, which include which of the following? (Choose all that are true.) 1. Weight loss 2. Memory impairment 3. Aplastic anemia 4. Liver toxicity 5. Decreased fertility 6. Teratogenicity
What are #3, 4, 5, and 6? Valproic acid is effective in the treatment of many disorders, including bipolar disorder and seizure disorders, as well as for migraine prophylaxis. There are many well-known side effects, including weight gain, aplastic anemia and coagulopathies, liver toxicities, parkinsonian effects, teratogenesis, and a 25% reduction in fertility (SOR C). It is recommended that hepatic enzyme levels and blood counts be performed to assess toxicity.
400
A 5-year-old African-American male has a kerion on his scalp. True statements about this common dermatophyte infection include which of the following? (Mark all that are true.) 1. Ketoconazole and griseofulvin (Grifulvin) are equally acceptable treatments 2. When griseofulvin is prescribed, a 2-week course is recommended 3. Griseofulvin is best absorbed when taken with food 4. Oral corticosteroids are an acceptable adjunct treatment 5. Treatment with a topical antifungal agent is an acceptable alternative to oral medications
What are #3 and 4. Tinea capitis can either be transmitted by humans (anthropophilic) or acquired from animals (zoophilic). Trichophyton tonsurans and Microsporum audouinii are associated with anthropophilic infections, and Microsporum canis is associated with zoophilic infections (SOR A). Infections caused by Microsporum species fluoresce a typical green color under a Wood’s lamp. However, most cases of tinea capitis in North America are caused by T. tonsurans and unfortunately do not demonstrate fluorescence (SOR A). Griseofulvin is the gold standard for the treatment of tinea capitis, and therapy must be continued long enough for infected keratin to be replaced by resistant keratin, usually 4–6 weeks (SOR A). Absorption of griseofulvin is increased when it is taken with a meal (SOR A). Several newer antifungal agents have been shown to be as effective, but they either have more adverse side effects or have not yet been approved for use in children. Ketoconazole is no more effective than griseofulvin and causes more adverse events and drug interactions (SOR A). Oral corticosteroids may help reduce the risk for, and extent of, permanent alopecia, but topical corticosteroids should be avoided (SOR C). Topical treatment alone is ineffective and is not recommended for the management of tinea capitis (SOR C).
400
List four risk factors for lung cancer, other than tobacco use.
What are established risk factors such as secondhand smoke/passive smoke, a family history of lung cancer, COPD, radon exposure, asbestosis, and idiopathic pulmonary fibrosis? Screening for lung cancer is currently not recommended. A personal smoking history is the most significant risk factor for the development of lung cancer.
400
Which one of the following has the greatest effect on decreasing systolic blood pressure? 1. Reducing dietary sodium intake to 100 mmol/day or less 2. Following the DASH eating plan, which is rich in fruits, vegetables, and low-fat dairy products 3. Moderation of alcohol consumption to 2 drinks or less per day for men or 1 drink or less per day for women 4. Losing 10 kg of body weight in an overweight patient 5. Engaging in 30 minutes of aerobic physical activity on most days of the week
What is weight loss? According to the Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, weight reduction has the potential to reduce systolic blood pressure (SBP) more than other lifestyle modifications (5–20 mm Hg/10 kg weight loss). Adoption of a DASH eating plan, which is rich in fruits, vegetables, and low-fat dairy products, is second in effectiveness, with anticipated SBP reductions of 8–14 mm Hg. Engaging in 30 minutes of aerobic physical activity on most days of the week leads to reductions of 4–9 mm Hg in SBP. Reduction of sodium intake to 100 mmol/day and moderation of alcohol intake to 2 drinks per day or less for men and 1 drink or less per day for women reduces SBP by 2–8 mm Hg and 2–4 mm Hg respectively.
400
A 74-year-old male with New York Heart Association class II heart failure and a left ventricular ejection fraction of 38% is on optimal dosages of an ACE inhibitor, a β-blocker, and pravastatin (Pravachol). His past medical history is notable only for a long history of hypertension. He is a nonsmoker and reports that he has a small glass of red wine with dinner each evening. On examination he has a blood pressure of 128/70 mm Hg and a BMI of 29.1 kg/m2. His chest is clear and his cardiac examination is notable only for an S4. Self-help measures recommended for patients such as this include which of the following? (Choose all that are true.) 1. A sodium intake ≤2300 mg/day 2. Strict avoidance of alcohol consumption 3. Avoiding exercise 4. Avoiding NSAID use 5. A weight-loss program with a goal BMI of 25 kg/m2 or less
What are #1 and 4? Self-care is advocated as a method of improving outcomes in patients with heart failure. The American Heart Association (AHA) currently recommends a sodium intake of no more than 2300 mg daily for heart failure patients, the same amount recommended for healthy adults. Although fluid restriction to <2 L/day may be appropriate for patients with hyponatremia or persistent or recurrent fluid retention, a more liberal intake would be appropriate for stable heart failure patients. Patients with heart failure should be advised to avoid NSAID use, which has been shown to increase the risk for renal insufficiency and hospitalization. Available studies indicate that survival is highest in patients with a BMI of 30–32 kg/m2, and no studies have demonstrated a survival benefit from weight loss in patients with heart failure. Consequently, AHA guidelines currently recommend that weight loss be encouraged only in patients with a BMI >40 kg/m2. Several epidemiologic studies have failed to demonstrate a correlation between alcohol consumption and the development of heart failure. With the exception of patients with alcoholic cardiomyopathy, who should abstain from alcohol use, heart failure patients who choose to drink should be advised to limit their alcohol intake to no more than 1–2 drinks a day. Although avoidance of physical exertion has been advised in the past, it is now thought that a reduction in physical activity leads to physical deconditioning and an unnecessary worsening of symptoms. Exercise training 3–5 days a week should be considered in all stable outpatients with chronic heart failure.
400
A 34-year-old female with major depressive disorder sees you in October because of worsening symptoms. When reviewing her chart, you note that each year her depression worsens during the fall and winter months. After further investigation, you determine that she has seasonal affective disorder, and consider recommending light therapy. True statements regarding this form of therapy include which of the following? (Choose all that are true.) 1. It is a second-line therapy after pharmacotherapy 2. It is most effective when administered in the morning 3. It can precipitate mania 4. Most artificial lights can be used to provide light therapy 5. The effective dose is 5000 lux hours/day
What are #2,3, and 5? Light therapy is a first-line treatment for seasonal affective disorder. It is as effective as pharmacotherapy, with minimal side effects. Light therapy is most effective in the morning; when administered at night, it can alter melatonin production and impair sleep. It works by altering circadian rhythms and affecting serotonin levels, resulting in a reduction in depressive symptoms. Like SSRIs, light therapy can precipitate mania in patients with underlying bipolar disorder, and may not be the treatment of choice for these patients. The most effective dose is 5000 lux hours/day, usually administered for 30 minutes each day (SOR A). Products specifically manufactured for light therapy are recommended. Other light sources may not be appropriately bright and may not provide an appropriate spectrum, including ultraviolet filtration. Tanning beds, for example, are not an appropriate light source.
500
A 2-year-old Mexican-American male is brought to your office with a 5-day history of fever above 102°F (39°C). On examination he has erythema of the palms and soles, a generalized maculopapular rash, bilateral conjunctival injection, a “strawberry” tongue, and firm, nonfluctuant, left-sided lymphadenopathy, with several lymph nodes enlarged to 2 cm in diameter. Appropriate actions at this point include which of the following? (Choose all that are true.) 1. Echocardiography as soon as possible 2. Treatment with high-dose aspirin 3. Treatment with oral prednisolone 4. Treatment with intravenous γ-globulin 5. Echocardiography at monthly intervals for 1 year
What are #1,2, and 4? This patient meets the classic diagnostic criteria for Kawasaki disease. There are a number of epidemiologic, clinical, and laboratory findings that may be present, and the diagnosis can be made if at least four of the five major criteria are found after day 4 of the illness. (See the reference for a list of these criteria.) Echocardiography should be performed as soon as possible to evaluate the coronary arteries for aneurysm, a common complication of Kawasaki disease (SOR C). However, treatment of the disease should not be delayed if this study is not readily available. The initial study is a baseline, and should be repeated at appropriate intervals. Experts recommend echocardiography at the time of diagnosis, 2 weeks into the illness, and at 6–8 weeks into the illness (SOR C). If there are no abnormal findings, then no further testing is helpful. High-dose aspirin is recommended at a dosage of 100 mg/kg/d (SOR C). Some experts recommend this dosage until the child has been afebrile for >48 hrs, then 3–5 mg/kg/d until 8 weeks have passed and the child has shown no evidence of coronary involvement. Others recommend high-dose aspirin for 14 days. Aspirin is useful as both an anti-inflammatory and an antiplatelet agent. Marked thrombocytosis is common in Kawasaki disease, and aspirin is thought to decrease the risk of coronary thrombosis due to generalized thrombocytosis, especially with the increased risk of coronary aneurysms. Other treatments may also be used, depending on the circumstances, although some treatments that have been used are still relatively unproven. Various studies have shown contradictory results with the use of corticosteroids in Kawasaki disease, and they are not currently routinely recommended (SOR C). Treatment with intravenous immune globulin reduces the incidence of coronary aneurysms from 15%–25%, seen without treatment, to <5% (SOR A).
500
Which of the following women would be at increased risk for uterine cancer, based on the information provided? (Choose all that are true.) 1. A 35-year-old with a BMI of 32.4 kg/m2 2. A 39-year-old with polycystic ovary syndrome 3. A 43-year-old who has taken combined oral contraceptive pills for over 25 years 4. A 46-year-old who has had 6 children and breastfed all of them 5. A 47-year-old who experienced menarche at age 10 and has never been pregnant 6. A 59-year-old with hereditary nonpolyposis colon cancer 7. A postmenopausal female with a strong family history of breast cancer who is taking tamoxifen (Soltamox) to prevent breast cancer 8. A postmenopausal female who is taking raloxifene (Evista) to prevent osteoporosis
What are #1, 2, 5, 6, and 7? There is currently no recommended screen for endometrial cancer, but knowing the risk factors is important for counseling patients. Endometrial cancer is associated with obesity, hyperinsulinemia, and chronic anovulation, which are all characteristics of polycystic ovary syndrome (SOR B). Obesity leads to higher estrogen levels, increasing the risk for endometrial cancer; physical activity has been shown to reduce the risk of endometrial cancer (SOR A). Estrogen levels are lower during pregnancy and breastfeeding, and having decreased levels of estrogen for extended periods of time is associated with a lower risk of endometrial cancer (SOR B). As longer exposure to estrogen increases the risk of endometrial cancer, the combination of early menarche and nulliparity increases the risk because of uninterrupted high estrogen levels (SOR B). Oral contraceptives have been found to reduce the risk of endometrial cancer. The protective effect increases with the length of time they are used, and benefits can last years after a woman has stopped taking them (SOR A). Although raloxifene has estrogen-like effects on the uterus, it has not been shown to increase the risk of endometrial cancer (SOR A). Tamoxifen is a selective estrogen receptor modulator that has estrogen-like effects. While it has a protective effect on breast tissue, its effect on the uterus increases the risk of endometrial cancer (SOR A). Hereditary nonpolyposis colon cancer is an inherited disorder linked to certain genes. Women with this cancer have a much higher risk of developing endometrial cancer (SOR B).
500
A 70-year-old female presents to your office after a minor fall in her home and asks you for advice to prevent falls in the future. Interventions that have been shown to prevent falls in the elderly population include which of the following? (Choose all that are true.) 1. Vitamin D supplementation 2. Home safety assessment 3. Strength and balance training 4. Hip protectors 5. Medication reviews
What are #2, 3, and 5? As our population ages, preventing falls is of increasing importance. Approximately 35%–40% of community-dwelling persons age 65 and older fall annually, with 5% of those who fall requiring hospitalization. In addition, it is estimated that up to 40% of nursing-home admissions are fall-related. According to the American Geriatrics Society’s guideline for preventing falls in the elderly, single interventions for fall prevention include home safety assessment and intervention (SOR A), medication reviews (SOR B), and long-term strength and balance training (SOR B). Vitamin D supplementation in deficient patients has been proven to decrease injuries from falls, but not the number of falls (SOR A). Identification of foot problems (SOR B), recommending proper footwear (low heel height and high surface contact) (SOR B), and vision and cardiac evaluations have also been shown to help prevent falls. There is no evidence to support recommending hip protectors (SOR A) or the use of restraints to prevent falls in the elderly.
500
A 69-year-old female with a history of chronic hypertension and a previous myocardial infarction is seen for follow-up 6 weeks after being hospitalized for heart failure. Although she feels comfortable at rest, she reports she is unable to walk up even a single flight of stairs and becomes breathless carrying groceries in from the car. Her current medications include atorvastatin (Lipitor), 40 mg daily; lisinopril (Prinivil, Zestril), 20 mg daily; metoprolol succinate (Toprol-XL), 100 mg daily; furosemide (Lasix), 20 mg daily; and aspirin, 81 mg daily. On examination the patient is not in acute distress. Her blood pressure is 132/78 mm Hg and her pulse rate is 55 beats/min. A lung examination reveals bibasilar rales. Auscultation of the heart reveals a regular rhythm with a soft S3 and S4 and no murmur. She has trace pretibial edema. An EKG reveals sinus bradycardia of 52 beats/min, multifocal PVCs, and a QRS interval of 0.10 sec. Echocardiography shows a left ventricular ejection fraction of 32%. Which of the following interventions has been shown to improve survival in patients such as this? (Choose all that are true.) 1. Amiodarone (Cordarone) 2. Digoxin 3. Eplerenone (Inspra) 4. Amlodipine (Norvasc) 5. Cardiac resynchronization therapy
What is Eplerenone? The addition of an aldosterone antagonist to a β-blocker and an ACE inhibitor was shown in the Randomized Aldactone Evaluation Study (RALES) to reduce rates of death and hospital readmissions in selected patients with moderate to severe symptoms of heart failure and a reduced left ventricular ejection fraction (LVEF) (SOR B). More recently, the Eplerenone in Mild Patients Hospitalization and Survival Study in Heart Failure (EMPHASIS-HF) trial found that the addition of eplerenone in heart failure patients with mild symptoms (NYHA class II) and a mean LVEF of 26% resulted in a reduction in both hospitalizations and deaths. Current AHA guidelines call for the addition of an aldosterone antagonist to an ACE inhibitor and a β-blocker in selected patients with moderately severe to severe symptoms of heart failure and a reduced LVEF. Although the addition of digoxin can be of benefit in selected heart failure patients by reducing the risk for hospitalization, it has not been shown to reduce mortality (SOR B). Amiodarone, which is the preferred antiarrhythmic agent for preventing recurrent atrial fibrillation or symptomatic ventricular arrhythmias in heart failure patients, has been found to have a neutral impact on survival (SOR A). Cardiac resynchronization therapy (CRT) has been shown to improve survival in patients with advanced heart failure (NYHA class III or IV) with a QRS interval >0.12 sec (SOR A), but evidence of benefit in patients with a QRS interval <0.12 sec is lacking. It has been reported that unlike in heart failure patients with a QRS interval exceeding 0.12 sec, CRT does not improve peak oxygen consumption or survival in patients with narrow QRS intervals. Calcium channel blockers can lead to worsening heart failure and an increased risk of cardiovascular events and should be avoided.
500
A 26-year-old female who is one of your patients was admitted to your service last night with jaundice, ascites, and abdominal pain. You last saw her about a year ago, and she has a history of heavy drinking for several years. In addition to treating her liver failure you also attempt to address her alcohol dependence. You tell her that medication might help her stop drinking, and she expresses an interest in trying this. She would also like to try to reconnect with her counselor and her Alcoholics Anonymous group. Which one of the following would be most appropriate for this patient? 1. Acamprosate (Campral) 2. Disulfiram (Antabuse) 3. Lorazepam (Ativan) 4. Naltrexone (ReVia) 5. Sertraline (Zoloft)
What is Acamprosate? Acamprosate has evidence of efficacy for treating alcohol dependence and would be safe in the face of liver failure (SOR A). Naltrexone and disulfiram could be effective, but are metabolized by the liver and are therefore inappropriate in a patient with severe liver failure (SOR B). Lorazepam and sertraline have no evidence of efficacy in treating alcohol dependence.
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