Pediatrics
A 16-year-old female presents for a routine checkup. During the visit, she discloses that she is sexually active and wants to discuss contraceptive options. However, she is hesitant to inform her parents, fearing their disapproval. Which one of the following is the most ethical course of action?
A) Providing the patient with contraception without informing her parents, and respecting her confidentiality by not noting this discussion in her medical record
B) Offering confidential counseling and contraceptive options while encouraging open communication with her parents
C) Insisting on parental involvement in the decision-making process, emphasizing the importance of open communication
D) Referring the patient to a mental health professional to address her concerns about parental disapproval before discussing contraception
E) Refusing to discuss contraception without parental consent, citing the patient’s age
ANSWER: B - Offering confidential counseling and contraceptive options while encouraging open communication with her parents
While respecting the patient’s autonomy and confidentiality is important, ethical obligations also extend to ensuring her well-being and safety, and accurately maintaining the medical record. Encouraging open communication with parents can foster trust and support, but forcing it might create a harmful environment. Offering counseling and contraceptive options while advocating for open communication allows the physician to foster patient autonomy as well as uphold responsible guidance. This approach aligns with ethical guidelines from the American Academy of Pediatrics that emphasize respect for minors’ confidentiality while considering parental involvement in sensitive situations.
A 30-year-old female with a medical history of anxiety and seasonal allergies presents for evaluation of palpitations and a racing heartbeat that has worsened over the last 3–4 days. Recently, her escitalopram (Lexapro) dosage was increased to 20 mg daily and she started using fluticasone propionate nasal spray (Flonase) and oral cetirizine (Zyrtec), 10 mg daily. A CBC, comprehensive metabolic panel, and TSH level are normal. A urine pregnancy test is negative. An EKG today shows a heart rate of 85 beats/min and a QTc interval of 500 milliseconds. Which one of the following would be the most appropriate next step?
A) Reassurance only
B) Discontinuing cetirizine
C) Discontinuing escitalopram
D) Discontinuing fluticasone
E) Echocardiography
ANSWER: C
This patient’s EKG shows a prolonged QTc interval (>460 milliseconds for women). QT prolongation can indicate polymorphic ventricular tachycardia characterized by palpitations. QT prolongation can be congenital or acquired. Escitalopram and other antidepressants are associated with QT prolongation. Any QT-prolonging medications should be discontinued, and a subsequent EKG should be obtained once the drug levels are expected to be minimal. Reassurance only would not be the most appropriate next step as QT prolongation can lead to torsades de pointes, a potentially fatal arrhythmia (SOR C). Cetirizine and fluticasone are not known to prolong the QT interval. Echocardiography would not be the next step in management. References Kandiah JW, Blumberger DM, Rabkin SW. The fundamental basis of palpitations: a neurocardiology approach. Curr Cardiol Rev. 2022;18(3):e090921196306.
A 32-year-old female presents to your office because of a 2-month history of fatigue and myalgias. She reports a 5-lb weight loss and bilateral joint pain in her hands and knees. She has had intermittent fevers to 101 °F with no cough, dyspnea, or abnormal urinary symptoms. Examination findings are normal. An erythrocyte sedimentation rate is elevated at 35 mm/hr (N <20), and a CBC reveals leukocytosis and a hemoglobin level of 10.4 g/dL (N 12.0–15.0). An antinuclear antibody titer is positive at 1:80, and anti–double-stranded DNA and anti-Smith antibodies are elevated. Which one of the following is the most likely diagnosis?
A) Polymyalgia rheumatica
B) Psoriatic arthritis
C) Rheumatoid arthritis
D) Septic arthritis
E) Systemic lupus erythematosus
ANSWER: E - SLE
This patient’s presentation is suggestive of systemic lupus erythematosus, in which the diagnosis is confirmed by a positive antinuclear antibody (ANA) test and positive anti– double-stranded DNA and anti-Smith antibodies. Polymyalgia rheumatica usually occurs in older patients with bilateral joint pain and weakness in the shoulder joint who also have elevated erythrocyte sedimentation rates but do not have a positive ANA test or other positive autoantibodies. Psoriatic arthritis usually presents as a polyarthritis and is not associated with a positive ANA test. Rheumatoid arthritis typically presents with morning stiffness and symmetrical polyarthritis in small joints. Septic arthritis typically has an acute presentation involving a single joint with findings of erythema, warmth, and leukocytosis. References Foster ZJ, Day AL, Miller J. Polyarticular joint pain in adults: evaluation and differential diagnosis. Am Fam Physician. 2023;107(1):42-51.
A 40-year-old with type 1 diabetes and poor glycemic control is started on an SGLT2 inhibitor. Two weeks later, she presents with nausea, tachypnea, and a normal glucose due to this diagnosis
-What is euglycemic DKA
The U.S. Preventive Services Task Force recommends screening which one of the following groups for obstructive sleep apnea (OSA)?
A) All adults >50 years of age
B) All adults who have ≥1 first-degree relative with documented OSA
C) All adults who have a BMI ≥35 kg/m2
D) All adults who have hypertension
E) No groups should be routinely screened
ANSWER: E - No groups should be routinely screened
In November 2022, the U.S. Preventive Services Task Force concluded that the current evidence was insufficient to assess the balance of benefits and harms of screening for obstructive sleep apnea (OSA) in the general adult population (I recommendation). This applies to all adults ≥18 years of age without signs of OSA or with unrecognized symptoms of OSA. This recommendation also includes persons who are unaware of or are unconcerned by their symptoms. Reference US Preventive Services Task Force. Final recommendation statement: obstructive sleep apnea in adults: screening. Updated November 15, 2022.
A 2-month-old infant has noisy, high-pitched breathing that worsens when lying flat and improves when prone. The child is feeding and gaining weight appropriately. Symptoms are likely attributed to this diagnosis
-What is laryngomalacia?
Clinical Pearl: Most cases resolve by 12–18 months; surgery (supraglottoplasty) is rare but needed in severe cases.
Explanation: Laryngomalacia is the most common cause of stridor in infants. It results from floppy supraglottic tissue collapsing during inspiration.
A 15-year-old female is brought to your office in May with a 3-week history of nasal congestion, sneezing, and itchy eyes. She reports that these episodes occur every spring and last about 6 weeks. She has been taking oral cetirizine (Zyrtec) with no improvement. You initiate an intranasal corticosteroid. The patient returns for follow-up 4 weeks later and says that she has seen some improvement but is dissatisfied with her progress. The patient and her parent ask about further steps in diagnosis. Which one of the following would be the most appropriate next step in diagnosis?
A) A CBC
B) Skin allergen testing
C) Serum allergy testing
D) Chest radiography
E) Sinus CT
ANSWER: B - Skin allergen testing
This patient most likely has seasonal allergic rhinitis that has not responded to empiric treatment. The most appropriate next step in diagnosis is skin allergen testing. Serum allergy testing is more expensive and less specific than skin allergen testing. It also does not provide the immediate results of skin allergen testing. A CBC will likely show eosinophilia, given the patient’s likely diagnosis of allergic rhinitis. However, this is a nonspecific finding. This patient likely does not have a true respiratory illness such as pneumonia, so a chest x-ray would not be appropriate. Sinus CT likely will not lead to actionable management. It is also expensive and carries the risk for radiation exposure, which needs to be weighed carefully in a pediatric patient. References Savard DJ, Ursua FG, Gaddey HL. Smell and taste disorders in primary care. Am Fam Physician. 2023;108(3):240-248.
A 44-year-old male presents for evaluation of left shoulder pain and stiffness that has developed gradually over the past few months after a fall while skiing. He describes a dull, deep, poorly localized ache. On examination he has impaired active and passive range of motion in all planes. Radiography of the shoulder is unremarkable. Which one of the following is most likely to lead to symptom resolution?
A) Wearing a sling on the left arm for 4–6 weeks
B) Extracorporeal shock wave therapy
C) Biceps tendon sheath injection and physical therapy
D) Glenohumeral corticosteroid injection and physical therapy
E) Surgical repair
ANSWER: D - Glenohumeral corticosteroid injection and physical therapy
This patient presents with adhesive capsulitis, manifested as the typical cardinal symptoms of pain, stiffness, and dysfunction of the affected shoulder. A combination of glenohumeral or subacromial corticosteroid injection and physical therapy is most likely to produce early and sustained improvement in symptoms and joint functioning. Prolonged use of a sling would worsen the condition. Referral for surgery may be indicated after a 3-month trial of conservative treatment fails. While extracorporeal shock wave therapy has shown benefit for frozen shoulder, its current role is as an adjunct to other primary therapies. References Ramirez J. Adhesive capsulitis: diagnosis and management. Am Fam Physician. 2019;99(5):297-300.
A 69-year-old male with a history of coronary artery disease sees you for follow-up after hospitalization for new-onset atrial fibrillation. After some difficulty with low blood pressure with other rate control agents, he was discharged on amiodarone. Name 3 things to monitor while on this medication
Pulmonary Function Test
Thyroid function tests
LFTs
Vision
A 26-year-old nulliparous female presents for an evaluation after she discovered a breast mass while showering. An examination confirms a 4 × 3-cm nonpainful mass in the upper outer quadrant of the right breast. Which one of the following should you recommend?
A) Screening mammography of the breast
B) Diagnostic mammography of the breast
C) Ultrasonography of the breast
D) MRI of the breast
E) Surgical referral for excision and biopsy
ANSWER: C - Ultrasonography of the breast
Diagnostic mammography is typically the preferred imaging modality for a palpable breast mass. However, ultrasonography is more sensitive in women younger than 30 years of age and is preferred. Screening mammography should be performed biennially for asymptomatic women ages 40−74. MRI is not appropriate for this patient at this time. Surgical excision and biopsy would be necessary if abnormalities are found on imaging. References Salzman B, Collins E, Hersh L. Common breast problems. Am Fam Physician. 2019;99(8):505-514.
The mother of a newborn infant is concerned because her baby’s eyes are sometimes crossed. Assuming the intermittent eye crossing persists, when is the most appropriate age for ophthalmologic referral?
6-months
In many normally developing infants there may be imperfect coordination of eye movements and alignment during the early days and weeks of life, but proper coordination should be achieved by age 4–6 months. Persistent deviation of an eye in an infant requires evaluation.
Ref: Bell AL, Rodes ME, Collier Kellar L: Childhood eye examination. Am Fam Physician 2013;88(4):241-248. 2) Kliegman RM, Stanton BF, Geme JW III, et al (eds): Nelson Textbook of Pediatrics, ed 20. Elsevier Saunders, 2016, pp 3026-3031.
A 62-year-old male who currently receives chemotherapy for colon cancer presents to the emergency department with a 1-week history of worsening nausea and vomiting. He has been vomiting all oral intake for the past day, and he has not had a bowel movement in the past week. He reports severe, diffuse, crampy, intermittent abdominal pain that improves after vomiting. He has not had any fevers or chills. The physical examination is significant for abdominal distention, minimal bowel sounds, and diffuse tenderness. Which one of the following studies would be the most appropriate next step in evaluation?
A) Ultrasonography of the right upper quadrant
B) CT of the abdomen and pelvis with contrast
C) A PET/CT scan D) A HIDA scan
E) Magnetic resonance cholangiopancreatography (MRCP) of the abdomen
ANSWER: B - CT of the abdomen and pelvis with contrast
This patient’s presentation is consistent with a malignant bowel obstruction, and CT of the abdomen and pelvis with contrast is useful for determining if any surgical interventions are warranted. Ultrasonography typically does not yield useful information due to the amount of bowel gas present during an obstruction. A PET/CT scan would not be indicated to evaluate for the etiology of a bowel obstruction in an acute situation. A HIDA scan or magnetic resonance cholangiopancreatography (MRCP) would be useful if biliary obstruction or gallbladder disease were suspected, but these are not helpful in the evaluation of a malignant bowel obstruction. References Jackson P, Vigiola Cruz M. Intestinal obstruction: evaluation and management. Am Fam Physician. 2018;98(6):362-367. Yew KS, George MK, Allred HB. Acute abdominal pain in adults: evaluation and diagnosis. Am Fam Physician. 2023;107(6):585-596.
A 62-year-old female sees you for evaluation of pain and stiffness in her neck. For several years she has attributed these symptoms to the aging process, but she has recently developed a loss of dexterity in her hands that makes typing and knitting difficult. She does not have any loss of sensation or weakness in her extremities but has noticed some difficulties with balance in recent weeks. The pain does not radiate, and she does not have any history of recent trauma. She feels well otherwise and has not had any fevers, chills, bowel incontinence, or bladder incontinence. On examination you note mild tenderness of the spinous processes and paraspinous muscles of the cervical spine without focal tenderness. Her range of motion at the neck is limited due to pain. There are brisk reflexes in the bilateral upper and lower extremities and a positive Hoffman sign bilaterally with 4 beats of clonus on the right and 5 on the left. Her strength and sensation to light touch are intact in the bilateral upper extremities. Which one of the following cervical spine conditions is the most likely diagnosis?
A) Facet joint arthropathy
B) Myelopathy
C) Radiculopathy
D) Vertebral compression fracture
E) Vertebral osteomyelitis
ANSWER: B - Myelopathy
The patient history and physical examination findings are most consistent with degenerative cervical myelopathy, a condition in which spinal cord dysfunction develops due to compression in the neck. Spinal cord compression can be due to disk herniation, ligament hypertrophy, or osteophyte formation, sometimes collectively called spondylosis. Symptoms can initially be nonspecific and subtle, and they can overlap with less serious conditions. Loss of hand dexterity, ataxia, and urinary urgency can be signs of spinal cord compression and warrant a comprehensive neurologic examination. The development of upper motor neuron signs including hyperreflexia, a positive Hoffmann sign (digital reflex of the fingers), and clonus are key findings that warrant urgent evaluation with MRI. Facet joint arthropathy causes more focal pain and is not associated with neurologic symptoms. Cervical radiculopathy involves compression of the nerve root rather than the spinal cord. Symptoms include shooting pain with sensory changes and weakness in a dermatomal distribution. A vertebral compression fracture leads to focal pain in the neck at the site of the fracture without neurologic symptoms. Osteomyelitis also causes more focal pain in the setting of systemic symptoms such as malaise and fever. References Childress MA, Stuek SJ. Neck pain: initial evaluation and management. Am Fam Physician. 2020;102(3):150-156.
A 77-year-old female with a medical history of atrial fibrillation, COPD, depression, and hypothyroidism presents for follow-up of a recent visit to the emergency department (ED) for a fall in which she hit her head on the edge of a dresser. CT of the head in the ED was negative for intracranial bleeding and she received staples for a scalp laceration. Which one of the following medications in this patient's current regimen is most likely to increase her fall risk?
A) Apixaban (Eliquis)
B) A budesonide/formoterol inhaler (Symbicort)
C) Fluoxetine (Prozac)
D) Levothyroxine (Synthroid)
E) Prednisone
ANSWER: C - Fluoxetine
Use of an SSRI has been found to increase fall risk in older persons. While anticoagulants such as apixaban increase the risk for bleeding from fall-related injuries, they are recommended to prevent stroke in patients with atrial fibrillation regardless of fall risk and have not been noted to increase the risk of falling. Budesonide/formoterol, levothyroxine, and prednisone have not been associated with an increased fall risk. References Marcum ZA, Perera S, Thorpe JM, et al. Antidepressant use and recurrent falls in community-dwelling older adults: findings from the Health ABC Study. Ann Pharmacother. 2016;50(7):525-533.
Hypocalcemia can cause which one of the following?
A) Constipation
B) Hypertension
C) Paresthesias
D) Respiratory suppression
E) Tachycardia
ANSWER: C - Paresthesias
Hypocalcemia causes generalized neuromuscular irritability, leading to peripheral symmetric paresthesias and muscle spasms that can cause tetany, extrapyramidal symptoms, and seizures. Hypocalcemia can cause QTc prolongation, heart block, and bronchospasm. It can also lead to complications of hypercalciuria such as nephrolithiasis and can trigger psychiatric conditions including anxiety and mania. Hypocalcemia does not cause hypertension, respiratory suppression, or tachycardia. Constipation is more associated with hypercalcemia.
An 18-year-old male with no significant past medical history presents for a sports preparticipation evaluation prior to his high school senior football season. On cardiac auscultation, you detect a previously undocumented systolic murmur. Which one of the following additional characteristics of this murmur, if present, would raise concern for hypertrophic cardiomyopathy and necessitate additional testing prior to clearing this patient for sports participation?
A) Decreased intensity with an isometric handgrip
B) Decreased intensity with the Valsalva maneuver
C) Increased intensity with moving from squatting to standing
D) Increased intensity with passive leg raiseA) Reassurance that the condition will resolve spontaneously
ANSWER: C - Increased intensity with moving from squatting to standing
One of the most important purposes of the sports preparticipation evaluation is to screen for potentially life-threatening cardiovascular conditions. Hypertrophic cardiomyopathy is a leading cause of sudden cardiac death in younger athletes, and recognition of the typical pathologic murmur that occurs with this condition can identify people who are at risk. The characteristic harsh midsystolic ejection murmur results from a dynamic left ventricular outflow tract obstruction. The murmur intensifies with maneuvers that reduce preload or afterload, which increase the relative obstruction. Moving from squatting to standing, the Valsalva maneuver, and dehydration states all reduce preload and therefore cause the murmur to increase. In contrast, maneuvers that increase preload or afterload cause the murmur to soften due to decrease in the relative obstruction. This includes moving from standing to squatting and passive leg raise, which increase preload, and isometric handgrip, which increases afterload. References Authors/Task Force members; Elliott PM, Anastasakis A, et al. 2014 ESC guidelines on diagnosis and management of hypertrophic cardiomyopathy: the Task Force for the Diagnosis and Management of Hypertrophic Cardiomyopathy of the European Society of Cardiology (ESC). Eur Heart J. 2014;35(39):2733-2779.
A 40-year-old female presents with symptoms of heartburn and regurgitation of sour-tasting fluid into her throat after meals. She experiences these symptoms at least twice per week and says that they have been significantly affecting her quality of life. She has tried lifestyle modifications, including elevating the head of her bed and avoiding trigger foods, without significant relief. Which one of the following would be the most appropriate initial management of this patient's condition?
A) An antacid as needed
B) An H2-receptor antagonist as needed
C) A proton pump inhibitor (PPI) as needed
D) A PPI daily for 4–8 weeks
E) Esophageal pH monitoring
ANSWER: D - A PPI daily for 4-8 weeks
This patient's symptoms of heartburn and regurgitation that occur at least twice per week and significantly affect her quality of life are suggestive of GERD. The most appropriate initial management for this patient would be a proton pump inhibitor (PPI) daily for 4–8 weeks. PPIs are more effective than antacids and H₂-receptor antagonists in providing sustained symptomatic relief and resolution of esophagitis. Antacids provide short-term relief of symptoms by neutralizing gastric acid but do not provide sustained relief or resolve esophagitis, making them inadequate as the initial management strategy for this patient. Similarly, H₂-receptor antagonists reduce the secretion of gastric acid but are less effective than PPIs in providing symptom relief and healing esophagitis. They are typically used as an alternative treatment or for milder cases of GERD. As-needed PPIs are not the preferred initial management strategy for this patient. Esophageal pH monitoring is indicated in cases in which there is diagnostic uncertainty or when evaluating the effectiveness of acid suppression therapy in refractory GERD, but it is not necessary for the initial management of uncomplicated GERD.
A 29-year-old female presents with low back pain that began after giving birth 3 months ago. She reports pain on her right side when climbing and descending stairs and when lying on her right side. On examination she has mild lumbar paraspinal muscle tightness on the left and moderate tenderness inferomedial to the posterior superior iliac spine on the right. Muscle strength testing and lower extremity reflexes are normal. Which one of the following conditions is the most likely cause of this patient’s pain?
A) Lumbar strain
B) Piriformis syndrome
C) Pudendal nerve entrapment
D) Sacroiliac joint dysfunction
E) Spondyloarthropathy
ANSWER: D - Sacroiliac joint dysfunction
Sacroiliac joint dysfunction is commonly seen in primary care and is an important consideration in the evaluation of low back pain. It often occurs during pregnancy and post partum. Other inciting incidents include a motor vehicle accident or a mechanical fall onto the buttocks. It can be associated with ankylosing spondylitis and other spondyloarthropathies; however, the etiology in this case is more likely to be childbirth. Symptoms often include pain at the sacroiliac joint that worsens with climbing stairs, lying on the affected side, prolonged standing and sitting, and weight-bearing on the leg of the affected side. Examination findings include tenderness that is inferomedial to the posterior superior iliac spine. A number of provocation tests for sacroiliac joint dysfunction can help to confirm the diagnosis. NSAIDs, physical therapy, and joint manipulation are first-line treatments. Pelvic belts, corticosteroid injections, and sacroiliac joint fusion are used for refractory cases. Lumbar strain is in the differential diagnosis, but sacroiliac joint dysfunction is more likely given this patient’s history and the duration and location of tenderness. Piriformis syndrome is usually unilateral and causes sciatic-like symptoms. Pudendal nerve entrapment would cause perineal pain or labial numbness. Spondyloarthropathies are associated with sacroiliac joint inflammation but are not as likely in this postpartum patient. References Nejati P, Safarcherati A, Karimi F. Effectiveness of exercise therapy and manipulation on sacroiliac joint dysfunction: a randomized controlled trial. Pain Physician. 2019;22(1):53-61.
An 82-year-old woman with a history of atrial fibrillation, congestive heart failure, and chronic kidney disease (eGFR 48 mL/min/1.73 m²) presents for follow-up after completing a 7-day course of erythromycin prescribed for presumed bacterial bronchitis. She now reports fatigue, nausea, and blurred vision. On exam, her heart rate is 48 bpm and irregular, and she appears mildly confused. Labs show potassium 4.1 mmol/L and creatinine 1.5 mg/dL. Her medications include digoxin, furosemide, lisinopril, and warfarin. Her symptoms are likely explained by this
-What is digoxin toxicity?
This patient has multiple risk factors for digoxin toxicity: age, renal impairment, and polypharmacy. The recent addition of erythromycin, a P-glycoprotein inhibitor, reduces digoxin elimination and increases its bioavailability. Classic signs of toxicity include GI symptoms (nausea), visual disturbances ("yellow vision" or blurring), confusion, and bradyarrhythmia.
In patients with posttraumatic stress disorder, this medications is most effective for the treatment of midsleep awakening due to hyperarousal or nightmares?
ANSWER:What is Prazosin
The α-blocker prazosin can be effective in the treatment of midsleep awakening due to hyperarousal or nightmares by decreasing sympathetic nervous tone. Due to their toxicity profiles, tricyclic antidepressants such as amitriptyline are usually not initiated in patients with posttraumatic stress disorder (PTSD) until multiple first-line treatments have failed. Benzodiazepines such as clonazepam are generally avoided in patients with PTSD due to potential misuse and chronic long-term effects. SSRIs such as fluoxetine and SNRIs such as venlafaxine are the most effective pharmacologic treatments for overall reduction of PTSD symptoms. However, they are not used specifically for nighttime trauma-related nightmares.
A 15-year-old male is brought to your office for a sports preparticipation evaluation. You obtain a medical history and perform a physical examination, including elements from the American Heart Association's (AHA) 14-point screening evaluation. According to the AHA 14-point screening evaluation, which one of the following findings would warrant an EKG prior to clearing this patient for participation in sports?
A) Elevated systemic blood pressure
B) Complete recovery from mild COVID-19 diagnosed 14 days ago
C) A family history of coronary artery bypass surgery in a 65-year-old grandfather
D) A family history of mitral stenosis due to rheumatic heart disease in a 45-year-old aunt
E) A coach’s request for an EKG
ANSWER: A - Elevated systemic blood pressure
The American College of Cardiology/American Heart Association (ACC/AHA) recommend obtaining an EKG prior to clearance for sports participation only in a patient who has a positive result, such as elevated systemic blood pressure, on the AHA 14-point screening evaluation. An athlete with COVID-19 and mild symptoms should rest and avoid exercise for 14 days after diagnosis and may then return to sports if asymptomatic. A family history of cardiac problems or sudden death prior to age 50 is a qualifying element; however, a history of rheumatic heart disease in a relative would not be relevant. A coach’s preference is not a qualifying element. References ACC/AHA release recommendations for congenital and genetic heart disease screenings in youth. American College of Cardiology. September 15, 2014. Schefft M, Wolf ER, Quinonez R, Haskell H, James J. Appropriate use of electrocardiography in preparticipation physical evaluations. Am Fam Physician. 2022;105(3):302-306.
A 35-year-old female presents for evaluation of bilateral breast pain that varies in intensity with her menstrual cycle. She drinks 2 cups of caffeinated coffee per day and does not take any regular medications. Her past medical history is unremarkable and she does not have any family history of breast cancer. A physical examination, including a clinical breast examination, is normal. A urine hCG test is negative. Which one of the following would be the most appropriate next step? A) A trial of dietary caffeine elimination
B) A trial of topical diclofenac
C) Prolactin and TSH levels
D) Ultrasonography
E) Diagnostic mammography
ANSWER: B - A trial of topical diclofenac
Evidence supports the use of topical NSAIDs such as diclofenac for first-line pharmacologic treatment of both cyclic and noncyclic mastalgia (SOR B). Topical NSAIDs are preferred over oral NSAIDs due to lower risk for adverse effects. Although caffeine is commonly cited as a contributing cause of breast pain, randomized, controlled trials have not demonstrated clear evidence that caffeine avoidance reduces pain. Patients with galactorrhea should undergo hormone evaluation with measurement of prolactin and TSH levels, although hormone evaluation is not indicated for patients with breast pain who present without associated nipple discharge. Patients without a palpable mass who present with cyclic breast pain, such as the patient in this scenario, are at low risk for breast cancer and do not require imaging. Reference Salzman B, Collins E, Hersh L. Common breast problems. Am Fam Physician. 2019;99(8):505-514.
A 70-year-old male with well-controlled hypertension reports that he slipped and fell in his bedroom 2 weeks ago. The fall did not result in any injuries. He has heard that tai chi is effective at reducing fall risk in older adults, but no classes are offered locally. He asks about other options to prevent future falls. You should tell this patient that in older adults, evidence shows that any type of exercise
A) decreases fall risk for women but not men
B) decreases health-related quality of life
C) reduces the rate of falls
D) reduces the rate of falls requiring hospital admission
ANSWER: C - reduces the rate of falls
Evidence shows that in older, community-dwelling adults, all types of exercise reduce the rate of falls by 23% (rate ratio 0.77, 95% confidence interval [CI] 0.71 to 0.83) and the number of persons experiencing ≥1 falls in 1 year by 15% (risk ratio 0.85, 95% CI 0.81 to 0.89). More women than men have been studied in exercise research, but exercise appears to show similar reductions in falls for men. Exercise has not been found to make a significant difference in quality of life in older adults. The evidence is insufficient to determine if exercise programs decrease fall-related hospital admissions. References Lee PG, Jackson EA, Richardson CR. Exercise prescriptions in older adults. Am Fam Physician. 2017;95(7):425-432.
A 68-year-old man on warfarin begins taking an over-the-counter herbal supplement for memory. He presents with epistaxis and an elevated INR. This interaction was likely caused by this supplement
What is ginkgo biloba?
Clinical Pearl: Ginkgo biloba can increase bleeding risk by inhibiting platelet aggregation.
Explanation: Many supplements, including ginkgo, garlic, and ginseng, can interact with anticoagulants like warfarin, leading to increased bleeding risk.
A 44-year-old male with a history of hypertension presents to the urgent care clinic after he was noted to have a blood pressure of 175/105 mm Hg at a workplace screening event. He has not established medical care since relocating last year and has not been taking his previously prescribed medications. His blood pressure in the clinic is 189/119 mm Hg after sitting for 10 minutes and being positioned appropriately. He does not have chest pain, shortness of breath, headache, or vision changes. Physical examination findings are unremarkable. Which one of the following would be the most appropriate next step in management?
A) A urine drug screen
B) A stat troponin level
C) Reinitiation of his antihypertensive medication
D) Clonidine, 0.3 mg orally
E) Transfer to the emergency department
ANSWER: C - reinitiation of his antihypertensive regimen
This patient has severe asymptomatic hypertension, also known as hypertensive urgency. This condition is characterized by a systolic blood pressure of >180 mm Hg and a diastolic blood pressure of >110 mm Hg, with no evidence of end-organ damage. Patients with this condition are often nonadherent to their routine blood pressure medications, and resuming the regimen with close follow-up is the best treatment. While alcohol, amphetamines, and cocaine can elevate blood pressure, ruling out substance abuse is not the first step in management. It is extremely rare to find abnormalities on an EKG, a chest x-ray, or cardiac markers in asymptomatic patients and these diagnostic tests are not recommended. Acute treatment with clonidine or other oral agents to lower blood pressure prior to discharge does not improve outcomes. Hypertensive urgency does not require the intensive monitoring, intravenous therapy, or advanced testing available at an emergency department.