It's All Gen Med to Me
A 54-year-old man is evaluated for a 3-week history of worsening bilateral lower extremity edema. He has no other symptoms. One month ago, he was diagnosed with hypertension. Other medical problems include dyslipidemia and type 2 diabetes mellitus. Current medications are metformin, empagliflozin, atorvastatin, and amlodipine.
On physical examination, vital signs are normal. BMI is 28. Bilateral lower extremity edema with pitting to the mid-tibia is present. Jugular venous pressure and heart sounds are normal.
Urinalysis results are normal.
Which of the following is the most likely cause of the edema?
A) Amlodipine
B) Atorvastatin
C) Empagliflozin
D) Metformin
A) Amlodipine
The drugs most commonly implicated in edema formation are calcium channel blockers, gabapentin, NSAIDs, oral contraceptives, glucocorticoids, and thiazolidinediones.
A 35-year-old woman is evaluated in the emergency department for a 1-week history of fever and chest pain. The pain is sharp and midsternal, worse lying down, and improved leaning forward.
On physical examination, temperature is 38.5 °C (101.3 °F), blood pressure is 120/70 mm Hg with pulsus paradoxus of 10 mm Hg, and pulse rate is 92/min. A three-phase friction rub is heard along the left sternal border and apex.
ECG shows normal sinus rhythm and normal voltage with diffuse ST-segment elevation of 1 to 2 mm. An echocardiogram shows a pericardial effusion without evidence of tamponade.
Which of the following is the most appropriate management?
A) Discharge on ibuprofen and colchicine
B) Discharge on prednisone
C) Hospitalize and begin ibuprofen and colchicine
D) Hospitalize and begin methylprednisolone
C) Hospitalize and begin ibuprofen and colchicine
First-line therapy for acute idiopathic pericarditis is aspirin or NSAIDs and colchicine.
Patients with acute pericarditis and high-risk features, including temperature higher than 38.0 °C (100.4 °F), subacute onset, a large pericardial effusion or tamponade at presentation, oral anticoagulation therapy, or lack of response to treatment, may require hospitalization.
A 53-year-old woman is evaluated in the emergency department for a 2-day history of watery diarrhea occurring 5 times daily. She recently had community-acquired pneumonia treated with levofloxacin 1 week ago. She takes no medications.
On physical examination, temperature is 37.6 °C (99.7 °F); other vital signs are normal. On abdominal examination, bowel sounds are present with diffuse tenderness to palpation but no distension or guarding.
Laboratory studies show a leukocyte count of 12,000/µL (12 × 109/L) and a serum creatinine level of 1.1 mg/dL (97.2 µmol/L). Stool testing for Clostridioides difficile is positive.
Which of the following is the most appropriate treatment?
A) Fecal microbiota transplant
B) Intravenous vancomycin
C) Oral metronidazole
D) Oral vancomycin
E) Oral vancomycin plus intravenous metronidazole
D) Oral vancomycin
Treatment for initial nonsevere or severe Clostridioides difficile infection is either oral fidaxomicin or oral vancomycin.
Oral metronidazole may be used for an initial episode of nonsevere Clostridioides difficileinfection if vancomycin and fidaxomicin are unavailable or intolerable.
A 28-year-old woman is evaluated for sleepiness and difficulty staying awake over the past 6 months. She works as a hospital respiratory therapist. Half of her shifts are from 7:00 PM to 7:00 AM. The sleepiness subsides by the time she drives home, and she then has difficulty falling asleep during the day. Her sleepiness has slowed her cognitive processing during working hours and has resulted in depressed mood.
On physical examination, blood pressure is 118/68 mm Hg and pulse rate is 76/min. BMI is 24.
Which of the following is the most appropriate management?
A) Education and counseling
B) Home sleep apnea testing
C) Modafinil
D) Zolpidem
A) Education and counseling
Conservative strategies for shift work sleep disorder to promote wakefulness include caffeinated beverages, bright-light exposure during the work shift, and short naps during breaks.
Conservative strategies for shift work sleep disorder to promote sleep include avoidance of direct sunlight in the early morning and avoidance of exertion, eating, and alcohol consumption before the morning sleep period.
A 45-year-old woman is evaluated in the emergency department for a 2-day history of right lower extremity swelling. Her only medication is a combination oral contraceptive.
On physical examination, vital signs are normal. Right lower extremity swelling is present to the knee with associated pitting edema.
Duplex ultrasound demonstrates an acute deep venous thrombosis of the right femoral vein.
The combination oral contraceptive is stopped, and alternative means of birth control are discussed. The patient expresses a preference to be treated at home.
Which of the following is the most appropriate treatment?
A) Apixaban
B) Dabigatran
C) Edoxaban
D) Warfarin
A) Apixaban
The direct oral anticoagulants apixaban and rivaroxaban are approved for treatment of acute venous thromboembolism as monotherapy without initial parenteral therapy with heparin.
On physical examination, cardiovascular auscultation and neurologic examination are normal.
An ECG is normal.
Which of the following is the most appropriate diagnostic test to perform next?
A) Cardiac enzyme testing
B) CT of the head
C) Orthostatic blood pressure measurement
D) Transthoracic echocardiography
C) Orthostatic blood pressure measurement
All patients with syncope should be evaluated with orthostatic blood pressure measurement and ECG.
A 69-year-old woman is evaluated during a follow-up visit 7 months after coronary stent placement for non–ST-elevation myocardial infarction. History is also notable for paroxysmal atrial fibrillation, hypertension, and gastrointestinal bleeding due to diverticulosis 5 years ago. Medications are aspirin, clopidogrel, rivaroxaban, metoprolol, lisinopril, and rosuvastatin.
On physical examination, vital signs are normal. The patient weighs 80 kg (176.4 lb). Bruising is present on the arms and legs. The remainder of the examination is unremarkable.
Serum creatinine level is 1.0 mg/dL (88.4 μmol/L).
Which of the following is the most appropriate management?
A) Discontinue aspirin
B) Discontinue rivaroxaban
C) Switch rivaroxaban to reduced-dose apixaban
D) Switch rivaroxaban to warfarin
A) Discontinue aspirin
Among patients with atrial fibrillation who have undergone percutaneous coronary intervention for acute coronary syndrome, double therapy with clopidogrel or ticagrelor plus a direct oral anticoagulant is recommended over triple therapy with an oral anticoagulant, aspirin, and P2Y12 inhibitor to reduce the risk for bleeding.
A 62-year-old man in the ICU is evaluated for fever and chills. He underwent a subtotal colectomy for stage III adenocarcinoma of the descending colon 8 days ago; 6 days ago, hospital-acquired pneumonia was diagnosed and piperacillin-tazobactam was initiated; the patient was moved to the ICU. He was improving but developed increasing fever and hypotension 2 days ago. Repeat blood cultures were obtained, a subclavian catheter was removed, and the tip was cultured.
On physical examination today, temperature is 39.5 °C (103.1 °F), blood pressure is 115/60 mm Hg, pulse rate is 108/min, and respiration rate is 26/min. Crackles are present at the lung bases bilaterally. The surgical wound is healing and nontender, and bowel sounds are present. The remainder of the examination is unremarkable.
Blood culture and catheter tip culture from 48 hours ago show budding yeast.
Which of the following is the most likely cause of the patient's findings?
A) Blastomyces dermatitidis
B) Candida albicans
C) Cryptococcus neoformans
D) Histoplasma capsulatum
B) Candida albicans
Commonly encountered risk factors for candidemia include central venous or hemodialysis-associated catheters, gastrointestinal surgery, and broad-spectrum antimicrobial agents.
The T2 magnetic resonance assay of whole blood and the β-D-glucan assay for invasive candidiasis should be obtained when a patient at high risk receiving antimicrobial agents is not responding to therapy.
A 66-year-old woman is evaluated for stress ulcer prophylaxis. She has been in the ICU on mechanical ventilation for 72 hours for respiratory failure due to community-acquired pneumonia. She has required vasopressors and glucocorticoids to maintain her blood pressure. She has acute kidney injury. Medications are ceftaroline, levofloxacin, norepinephrine, dexamethasone, and low-molecular-weight heparin. She is receiving enteral nutrition through a feeding tube.
The decision is made to initiate stress ulcer prophylaxis with an oral proton pump inhibitor.
A reduction in which of the following outcomes is most likely with this preventive strategy?
A) Gastrointestinal bleeding
B) Hospital stay
C) ICU stay
D) Mortality
A) Gastrointestinal bleeding
Stress ulcer prophylaxis reduces the risk of gastrointestinal bleeding in high-risk critically ill patients but has no discernable impact on mortality or ICU or hospital lengths of stay.
A 45-year-old man is hospitalized for neutropenic fever. He was recently diagnosed with diffuse large B-cell lymphoma, and his last chemotherapy treatment was 10 days ago. His course of chemotherapy consisted of rituximab, cyclophosphamide, doxorubicin, vincristine (day 1), and prednisone (days 1-5). He is treated appropriately with a broad-spectrum antibiotic and is discharged 5 days later feeling improved and with a recovering neutrophil count.
Which of the following is the most appropriate management to reduce the risk of future febrile neutropenia?
A) Reduce cyclophosphamide and doxorubicin doses
B) Start granulocyte colony-stimulating factor (G-CSF) weekly
C) Start G-CSF at the time of chemotherapy
D) Start levofloxacin at the time of chemotherapy
C) Start G-CSF at the time of chemotherapy
Granulocyte colony-stimulating factor can be given prophylactically to patients receiving chemotherapy that carries a high risk of neutropenia and as secondary prophylaxis in patients with a previous episode of febrile neutropenia.
Granulocyte colony-stimulating factor is not indicated for most patients with neutropenia who are afebrile, as a routine adjunct to empiric antibiotics for patients presenting with febrile neutropenia, or for patients undergoing induction chemotherapy for acute leukemia.
An 84-year-old woman is brought to the office by her son for evaluation of dementia. He reports that since the patient's husband died 8 months ago, she has neglected her personal hygiene, naps during the day, has difficulty sleeping at night, and has lost interest in going out. She takes no medications.
On physical examination, vital signs are normal. BMI 1 year ago was 26; today, BMI is 24. She appears sad and has a blunted affect. Neurologic examination is without focal motor deficits. On the Mini-Cog assessment of cognitive function, the patient cannot recall two of three words and did not attempt to draw a clock face due to fatigue.
Which of the following is the most appropriate diagnostic test to perform next?
A) Comprehensive neuropsychological evaluation
B) Depression assessment
C) MRI of the brain
D) Vitamin B12 measurement
B) Depression assessment
A 66-year-old man is seen in the office after hospitalization for an embolic stroke 7 days ago. His initial neurologic findings were minimal and have since resolved. An embolic source has not been identified. He has no other pertinent personal or family history. Medications are aspirin and clopidogrel.
Physical examination, including vital signs and neurologic examination, is normal.
Ambulatory 30-day ECG monitoring showed no arrhythmias.
Which of the following is the most reasonable management?
A) Discontinue aspirin and clopidogrel; begin warfarin
B) Left atrial appendage occlusion
C) Loop recorder implantation
D) Test for thrombophilia
C) Loop recorder implantation
In patients with an ischemic stroke of unknown cause in whom external ambulatory monitoring is inconclusive, implantation of a cardiac monitor (loop recorder) is reasonable to optimize detection of silent atrial fibrillation.
A 76-year-old woman is being evaluated in follow-up for hospital-acquired pneumonia that was diagnosed 48 hours ago. Sputum Gram stain showed gram-positive cocci in clusters. The patient had no risk factors for multidrug-resistant Pseudomonas or methicillin-resistant Staphylococcus aureus; cefepime was started empirically.
On physical examination today, temperature is 38.4 °C (101.2 °F), blood pressure is 122/78 mm Hg, pulse rate is 96/min, and respiration rate is 20/min. Crackles are heard at the left lung base.
Sputum culture is now positive for methicillin-sensitive S. aureus. Blood cultures show no growth.
Which of the following is the most appropriate treatment?
A) Continue cefepime
B) Switch to cefazolin
C) Switch to cephalexin
D) Switch to piperacillin-tazobactam
B) Switch to cefazolin
Broad-spectrum empiric antibiotic therapy should always be narrowed to a specific agent based on culture results.
Most patients with hospital-acquired pneumonia only require treatment for 7 days; exceptions include patients who have bacteremia, have a metastatic infection, show slow response to therapy, are immunocompromised, or have pyogenic complications.
A 66-year-old man who is undergoing annual low-dose CT for lung cancer screening is evaluated following the discovery of a solitary 1.5-cm lung nodule in the right upper lobe. There is no lymphadenopathy or effusion seen on the CT scan. He has a chronic cough and a 90-pack-year smoking history. His medical history is otherwise unremarkable, and he takes no medications.
On physical examination, vital signs and the remainder of the physical examination are normal.
Laboratory studies, including liver chemistry tests and measurement of sodium and calcium levels, are normal.
Which of the following is the most appropriate test to perform next?
A) Endobronchial ultrasonography
B) High-resolution CT
C) Integrated PET/CT
D) Sputum cytology
C) Integrated PET/CT
PET/CT scans are widely used to evaluate risk of malignancy in lung nodules, to stage known thoracic tumors, and to evaluate for metastatic disease from other nonthoracic malignancies.
PET scans are not useful for determining malignancy in lung nodules less than 8 mm in size.
A 75-year-old man is evaluated for an elevated INR found on routine monitoring. He is otherwise well and has no evidence of bleeding. Medical history is significant for atrial fibrillation. His only medication is warfarin.
Laboratory studies show a normal hemoglobin level and INR of 8.5.
The patient is instructed not to take his warfarin until further INR evaluation.
Which of the following is the most appropriate additional management?
A) 4-Factor prothrombin complex concentrate
B) Factor VIIa
C) Fresh frozen plasma
D) Vitamin K
E) Observation
E) Observation
In patients taking warfarin with a supratherapeutic INR less than 10 and no signs of bleeding, warfarin should be withheld until the INR returns to the therapeutic range.
For INR elevation greater than 10 without bleeding, vitamin K is recommended in addition to withholding warfarin; if the INR is elevated and life-threatening bleeding is present, then warfarin is withheld, and vitamin K and a prothrombin complex concentrate should be administered.
A 54-year-old asymptomatic woman is evaluated during a wellness visit. She has a 35–pack-year smoking history but quit smoking 12 years ago. She has no medical problems and takes no medications.
Physical examination, including vital signs, is unremarkable.
Which of the following is the most appropriate lung cancer screening strategy for this patient?
A) Annual chest radiography
B) Annual low-dose CT of the chest
C) One-time low-dose CT of the chest
D) No screening is indicated
B) Annual low-dose CT of the chest
Lung cancer screening with an annual low-dose CT of the chest is indicated for persons aged 50 to 80 years with at least a 20-pack-year smoking history; guidelines differ as to whether patients who stopped smoking greater than 15 years ago should be screened.
A 74-year-old man is evaluated for a 6-month history of progressive bilateral calf pain. The discomfort is worse with walking and improves quickly with rest. Medical history is significant for hypertension and hyperlipidemia. He has a 50-pack-year history of smoking but quit 5 years ago. Medications are rosuvastatin, quinapril, and metoprolol.
On physical examination, vital signs are normal. A right femoral bruit is noted. Bilateral femoral pulses and pedal pulses are faint. Motor and sensory examinations are normal; reflexes are normal.
The ankle-brachial index is 0.92 on the right and 0.94 on the left.
Which of the following is the most appropriate test to perform next?
A) Exercise ankle-brachial index testing
B) Invasive angiography
C) Magnetic resonance angiography
D) Segmental lower extremity blood pressure testing
A) Exercise ankle-brachial index testing
Between 19% and 31% of patients with typical claudication symptoms have a normal or borderline ankle-brachial index.
Exercise ankle-brachial index (ABI) testing is useful to evaluate for peripheral artery disease in patients with normal ABI values (>0.90 and ≤1.40) and high pretest probability.
A 26-year-old woman is evaluated for acute cystitis of 2 days' duration. She is pregnant at 10 weeks' gestation. Medical history is significant for postcoital lower urinary tract infections; her last infection was 6 months ago. Her only medication is a prenatal vitamin.
On physical examination, vital signs and the examination are unremarkable.
Dipstick urinalysis results show a pH of 7.1; positive leukocyte esterase, blood, and nitrites; and negative glucose, protein, and ketones.
Which of the following is the most appropriate management?
A) Nitrofurantoin
B) Trimethoprim-sulfamethoxazole
C) Urine culture; cephalexin
D) Urine culture; ciprofloxacin
C) Urine culture; cephalexin
Cystitis in pregnant individuals is considered a complicated urinary tract infection and requires a urine culture and prompt treatment with antibiotics such as cephalexin, cefpodoxime proxetil, cefdinir, and amoxicillin-clavulanate.
A 77-year-old man is evaluated for acute agitation with worsening of oxygenation, hypotension, and tachycardia over the last 30 minutes. He was hospitalized 2 days ago with pneumonia and hypoxemic respiratory failure requiring mechanical ventilation. Medical history is also significant for COPD and heart failure. Medications are cefotaxime, levofloxacin, propofol, furosemide, albuterol, and low-molecular-weight heparin.
On physical examination, temperature is 37.8 °C (100.0 °F), blood pressure is 102/55 mm Hg, pulse rate is 122/min, and respiration rate is 30/min. Oxygen saturation is 87% with a tidal volume of 420 mL, a positive end-expiratory pressure of 8 cm H2O, and FIO2 of 0.50. Trachea is midline. Pulmonary examination reveals decreased breath sounds bilaterally. The jugular vein is difficult to visualize; an S3 is present.
Which of the following is the most appropriate management?
A) Bedside thoracic ultrasonography
B) CT of the chest
C) Infusion of cisatracurium
D) Needle thoracostomy
A) Bedside thoracic ultrasonography
Point-of-care thoracic ultrasonography can determine the presence or absence of a pneumothorax or pleural effusion and can characterize the lung parenchyma to aid in the detection of heart failure or pneumonia.
Point-of-care thoracic ultrasonography is particularly helpful for critically ill patients when the use of imaging techniques requiring transport would delay diagnosis.
A 62-year-old woman was diagnosed 2.5 years ago with left-sided, stage IIB, estrogen receptor–positive, human epidermal growth factor receptor 2–negative breast cancer treated with mastectomy, postmastectomy irradiation, and letrozole, which was started 2 years ago. Medical history is otherwise unremarkable. Current medications are letrozole, a calcium supplement, and cholecalciferol.
Which of the following is the most appropriate screening or surveillance test to perform at this time?
A) CT of chest, abdomen, and pelvis
B) Dual-energy x-ray absorptiometry
C) Echocardiogram
D) Pelvic ultrasound
B) Dual-energy x-ray absorptiometry
Aromatase inhibitors are associated with bone loss and an elevated risk of fracture; patients on aromatase inhibitors should have bone density studies every 2 years.
A 60-year-old woman is evaluated for bone health during a routine wellness visit. Her mother was treated for a hip fracture after a fall at the age of 65 years. The patient is sedentary and has a 30–pack-year history of cigarette smoking but quit smoking 2 months ago. She has no medical problems and takes no medications.
Physical examination findings, including vital signs, are normal. Her weight is 56 kg (123 lb); BMI is 21.
Which of the following is the most appropriate next step in management?
A) Assess fracture risk with a clinical assessment tool
B) Bone mineral density measurement
C) Initiate alendronate
D) Serum vitamin D measurement
A) Assess fracture risk with a clinical assessment tool
The U.S. Preventive Services Task Force recommends screening for osteoporosis in all women aged 65 years or older and in women younger than 65 years who are at increased risk for osteoporosis, as determined by a formal clinical risk assessment tool.
A 70-year-old man is referred for evaluation after a 6.1-cm abdominal aortic aneurysm was discovered on routine screening ultrasonography. Medical history is significant for hypertension and hyperlipidemia. He has a 50-pack-year history of cigarette smoking, stopping 6 years ago. Medications are rosuvastatin and chlorthalidone.
On physical examination, vital signs are normal. BMI is 28. A bruit is heard over the abdomen, and a pulsatile abdominal mass is present to the left of the midline.
Which of the following is the most appropriate next step in management?
A) Abdominal aortography
B) ACE inhibitor therapy
C) CT angiography
D) Open abdominal aortic aneurysm repair
E) Repeat duplex ultrasonography in 6 months
C) CT angiography
In this patient with an abdominal aortic aneurysm (AAA) greater than 5.5 cm in diameter, the most appropriate next step is CT angiography (CTA)
The U.S. Preventive Services Task Force recommends one-time screening with duplex ultrasonography in all men aged 65 to 75 years who have smoked at least 100 cigarettes in their lifetime and selective screening in men in this age group who have never smoked.
CT angiography or magnetic resonance angiography is the imaging procedure of choice to identify the exact location of an abdominal aneurysm and plan operative repair.
A 46-year-old woman is evaluated for abdominal pain, diarrhea, and low-grade fever of 1 week's duration. She underwent kidney transplantation 4 months ago for end-stage kidney disease resulting from autosomal dominant polycystic kidney disease. She is cytomegalovirus seronegative and received an organ from a cytomegalovirus seropositive donor; she received cytomegalovirus prophylaxis for 3 months after transplantation. Medications are tacrolimus, prednisone, mycophenolate mofetil, and trimethoprim-sulfamethoxazole.
On physical examination, temperature is 37.3 °C (99.1 °F); other vital signs are normal. The abdomen is tender in the lower quadrants, but no guarding is noted. The remainder of the examination is unremarkable.
Colonoscopy biopsy specimens reveal cytopathic “owl's-eye” intracellular inclusions. Tissue culture is pending.
Which of the following is the most appropriate treatment?
A) Cidofovir
B) Foscarnet
C) Letermovir
D) Valganciclovir
D) Valganciclovir
Intravenous ganciclovir is indicated as initial therapy for severe cytomegalovirus infection in immunosuppressed patients; milder disease can be treated with oral valganciclovir.
A 72-year-old woman is evaluated for exacerbation of bronchiectasis symptoms over the past 3 days. Chronic productive cough has worsened in frequency and severity, and her sputum has increased in amount, become thicker, and changed in color from white to dark yellow. She has been using albuterol and hypertonic saline nebulization with a positive expiratory pressure device three times daily since her symptoms increased.
On physical examination, vital signs are normal. Lung examination reveals bibasilar crackles. There is no accessory muscle use.
Prior sputum cultures have grown Pseudomonas aeruginosa and Haemophilus parainfluenzae.
Chest radiograph reveals chronic interstitial markings but no acute change.
Which of the following is the most appropriate treatment?
A) Azithromycin
B) Ciprofloxacin
C) Inhaled dornase alfa
D) Prednisone
In addition to continuing airway clearance, bronchiectasis exacerbations are treated with antibiotics tailored by previous sputum culture results.
If sputum culture results are not available, empiric antibiotic therapy is recommended, often with a fluoroquinolone.
B) Ciprofloxacin
In addition to continuing airway clearance, bronchiectasis exacerbations are treated with antibiotics tailored by previous sputum culture results.
If sputum culture results are not available, empiric antibiotic therapy is recommended, often with a fluoroquinolone.
A 55-year-old woman is admitted to the hospital for chemotherapy following a diagnosis of Burkitt lymphoma. She is considered to be at high risk for tumor lysis syndrome.
On physical examination, blood pressure is 110/60 mm Hg and pulse rate is 110/min; the remainder of her vital signs are normal. The patient has large, palpable, bilateral cervical, supraclavicular, and axillary lymphadenopathy. Cardiopulmonary examination is normal.
CT imaging of the chest, abdomen, and pelvis at the time of diagnosis revealed bulky mediastinal and periaortic lymphadenopathy.
Intravenous isotonic saline is administered at 200 mL/hour.
Which of the following is the most appropriate additional preventive therapy?
A) Acetazolamide
B) Allopurinol
C) Furosemide
D) Rasburicase
D) Rasburicase
Tumor lysis syndrome is seen most often in patients with highly proliferative hematologic malignancies, such as acute leukemia and high-grade lymphomas, such as Burkitt lymphoma.
Patients at high risk for tumor lysis syndrome should receive vigorous intravenous hydration and rasburicase, which reduces existing serum urate levels by metabolizing urate to a more soluble metabolic