Medications
A 44 year old Dr. Degaetano comes to the Emergency Department due to sudden onset dyspnea and palpitations. He does note have chest pain but feels his heart pounding in his chest. He is otherwise healthy and does not have any other medical conditions. Dr. Degaetano’s maternal uncle died suddenly at age 42. Blood Pressure is 110/60 mm Hg and pulse is 170/min. Lungs are clear to auscultation. Cardiac exam is notable for rapid heart rate but is otherwise unremarkable. ECG rhythm strip is shown below:
Which of the following is the best next step in management?
Adenosine
Esmolol
Ibutilide
Lidocaine
Synchronized cardioversion
Answer A
Adenosine
ECG shows narrow QRS Complex one type of AV Nodal reentrant tachycardia. Initial management is focused on slowing conduction through the AV node through vagal maneuvers or adenosine administration.
A 6 month old Marissa is brought to the office for the first time for a well-child visit. The family recently relocated to the area to be close to a sick family member. Review of medical records showed an uncomplicated labor and delivery at 38 weeks gestation. Birth weight was 3.4 kg (7 lb 8 oz) which is at 50th percentile. Head circumference and length were documented at the 45th percentile for weight. SHe was not seen for a 4 month visit. The patient is able to sit with support and roll over. She is babbling consonants and reaching for toys. SHe drinks approximately 30 ounces of formula a day. Her parents started her on solids at 5 months and she eats fruits and vegetables twice a day. Marissa lives at home with her parents and 2 other siblings. Weight today is 6.2 kg (13 lb 11 oz) which is at the 8th percentile, head circumference and length are at the 60th percentile. Physical exam shows an alert and active Marissa. She transfers a toy from her right hand to left hand. The remainder of the physical exam is unremarkable. Her parents seem frustrated as Marissa’ 2 year older brother takes her toy and she screams. What is the most appropriate next step in management?
Administer catch up vaccines and follow up regularly
Explore family hx of celiac disease
Inquire about formula preparation and amount of solid food intake
Involve Child Protective Services for concern of neglect
Obtain CBC and CMP
Answer C
Inquire about formula preparation and amount of solid food intake
A 45 year old Syed comes to the clinic for follow-up of hypertension. Syed has been taking lisinopril since the condition was diagnosed 6 months ago. He has a 10 pack year history. He quit smoking 5 years ago. Medical history includes laparoscopic cholecystectomy 5 years ago after an episode of acute cholecystitis. Syed quit drinking alcohol last year. He has a family history of heart attack and stroke. Blood pressure is 130/80 mm Hg and pulse is 67/min. BMI is 30 kg/m^2. Physical exam is unremarkable. Fasting results are as follows:
Total Cholesterol 250 mg/dL
Triglycerides 340 mg/dL
HDL 35 mg/dL
LDL 147 mg/dL
GLucose 98 mg/dL
Which of the following is the best next step in management of this patient?
Calculate 10 year atherosclerotic cardiovascular disease risk
Initiate fenofibrate therapy to lower triglycerides
Start Aspirin, metformin, and low dose simvastatin
Start Glucagon-like peptide 1 receptor agonist to assist with weight loss
Start high intensity statin therapy with rosuvastatin
Answer: A
Calculate 10 year atherosclerotic cardiovascular disease risk
This patient has osteopenia. Further risk assessment should be performed to determine need for antiresorptive therapy. Antiresorptive therapy is indicated in patients with osteopenia with high 10 year osteoporotic fracture risk.
A 30 year old Nicole comes to your office after finding a thyroid mass. After the appropriate workup, you decide to proceed with a fine-needle aspiration (FNA). Cytology of the aspirate comes back negative for malignancy. However, Nicole is still concerned about the possibility of cancer despite her negative FNA results. Which of the following test parameters would be the most helpful for determining Nicole’s residual risk for thyroid cancer?
Negative predictive value
Positive predictive value
Sensitivity
Specificity
Validity
Answer: A
Negative predictive value
A 38 year old Asif with Type 1 diabetes for the past 24 years comes to your office due to pain in his feet. He describes burning pain in both feet involving the toes and forefoot. On examination, blood pressure is 145/86 mm Hg and pulse is 78/min. His hemoglobin A1c values in the past 2 years have ranged from 9%-10%. Which of the following statements is most accurate regarding Asif’s diabetic neuropathy?
Better control of blood pressure will decrease the risk of progression of peripheral neuropathy
No intervention is required at this time as peripheral neuropathy is usually self limited
Strict glycemic control generally worsens diabetic neuropathy
Strict glycemic control usually reverses preexisting clinical neuropathy
Strict glycemic control will decrease the risk of progression of peripheral neuropathy
Answer E
Strict glycemic control will decrease the risk of progression of peripheral neuropathy
A 54-year-old Seelia is brought to the emergency department due to disorientation. She was recently on vacation and received treatment with high-dose oral prednisone for severe poison ivy dermatitis. In the emergency department, her temperature is 37 C (98.6 F), blood pressure is 138/80 mm Hg, pulse is 102/min, and respirations are 22/min. The mucous membranes are dry. Laboratory results show random blood glucose of 1020 mg/dL with a normal anion gap. Her hemoglobin A1c is 7.6%. The patient is started on intravenous fluids and an intravenous insulin infusion. After a day on intravenous insulin, her mental status is normal and she is transitioned to subcutaneous regular human insulin based on a sliding scale. Her finger stick blood glucose readings are 200-250 mg/dL. Which of the following is the most appropriate next step in management?
Add a long-acting insulin
Add a sulfonylurea
Add metformin
Change to a short-acting insulin analogue
Increase the dose of regular insulin in her sliding scale
Answer: A
Add a long-acting insulin
A 56-year-old Dr. Larsen was found to have a TSH level of 0.2 wU/mL on routine laboratory testing. She has had no symptoms suggestive of thyrotoxicosis. She reports good energy level and no change in body weight. Dr. Larsen has mild hypertension exacerbated every time someone doesn't check their diagnostic imaging jellybeans, for which she is on hydrochlorothiazide. Family history is negative for any thyroid disorder. She does not use tobacco or alcohol. She does not have allergies to any medications. She has never received hormone replacement therapy. She takes adequate amounts of calcium and vitamin D supplementation. Bone mineral density using dual photon absorptiometry was within normal range about 6 months ago. Examination is unremarkable, including examination of the thyroid gland. Free T4 levels and free T3 are well within normal limits.
What is the next best step in this patient's care?
Radioactive iodine uptake
Start methimazole
Start propylthiouracil
Recheck thyroid functions test in 6-8 weeks
Subtotal thyroidectomy
Answer: D
Recheck thyroid functions test in 6-8 weeks
Patients who have mildly suppressed TSH, no symptoms, normal heart rhythm, and normal bone density are not intensively investigated because no treatment is necessary, and there is a high chance of normalization of TSH levels. Repeating TSH after 6-8 weeks is generally performed.
A 76 year old Dominique is brought to the ED due to severe hip pain following a ground-level fall. Medical history is significant for long-standing hypertension for which she takes chlorthalidone. Dominique drinks an alcoholic beverage with dinner on most nights. She smokes 2-3 cigarettes weekly for 30 years until age 65. Blood pressure is 126/76 mm Hg and pulse is 72/min. BMI 34. Serum calcium, phosphorus. And alkaline phosphatase levels are normal. X-ray of the hip reveals osteopenia and a femoral neck fracture. Which of the following is the strongest predisposing factor for Dominique’s condition?
Age
Alcohol Intake
Chlorthalidone use
High BMI
Tobacco use
Answer: A
Age
Fatima’s orthotics and prosthetics company is under hot water and needs a new product soon. She decides to conduct a single-blind, randomized, parallel group trial to investigate the effects of custom foot orthoses with motion control shoes versus the effects of motion control shoes alone in individuals with patellofemoral joint osteoarthritis. Eligible subjects are randomized to receive either custom foot orthoses with motion control shoes or just motion control shoes alone, to be worn for 4 months. A significant number of patients are lost to follow up or are non compliant to the assigned intervention during the study. However, results for the patients who completed the protocol are encouraging. Which of the following techniques is most appropriate to estimate the real effect of fatima’s custom foot orthoses in the population?
As-treated analysis
Intention to treat analysis
Noninferiority analysis
Per protocol analysis
Stratified analysis
Answer: B
Intention to treat analysis
A 16 year old Asif comes to the clinic for a follow up after sustaining a head injury 7 days ago. He was playing cricket and his head collided with Kashif. He was seen in the office that day and diagnosed clinically with a concussion. Asif was instructed to rest for two days before beginning a gradual return to play program. He participated in light aerobic activity yesterday and began moderate aerobic activity exercises today. DUring training today, he developed nausea and felt dizzy. Asif has no chronic medical conditions yet since he's still young. Blood pressure is 112/76 mm Hg, pulse is 90/min and respirations are 16/min. Asif is alert and oriented. Cardiopulmonary examination is normal. Cranial nerves are intact. Strength is normal. Sensation and reflexes are equal bilaterally. Cerebellar exam and gait are normal. Which of the following is the best next step in management for Asif?
Advise him to refrain from contact sports for 6 months
Obtain imaging of the brain
Offer reassurance and allow him to continue moderate aerobic activity
Prescribe physical rest for a week
Prescribe rest for 24 hours followed by return to light aerobic activity
Answer: E
Prescribe rest for 24 hours followed by return to light aerobic activity
A 29 year old Adarsh comes to your office due to 2 days of burning pain during urination after coming back from Japan. He has also had itching of the urethral meatus but no urinary discharge, fever, chills, or rash. Adarash has no chronic medical conditions and takes no medications. He had unprotected intercourse with a new female partner a week ago. Adarash smokes a pack of cigarettes daily since age 14. He drinks alcohol on weekends and does not use illicit drugs for now. Vital signs are within normal limits. There is scant, watery urethral discharge at the urethral meatus. There are no genital ulcers, rashes, erythema, or inguinal lymphadenopathy. Urethral swab is performed and Gram stain of the urethral fluid reveals many neutrophils but no organisms. Nucleic acid amplification tests of the urine are sent for chlamydia trachomatis and Neisseria and gonorrhoeae. Adarsh’s symptoms are most likely to respond to which of the following?
Azithromycin
Ceftriaxone
Metronidazole
Doxycycline
Valacyclovir
Answer: A
Azithromycin
Patients with symptoms of infectious urethritis
who have negative Gram stain for N gonorrhoeae (ie, no visible organisms) and are awaiting NAAT results should receive empiric treatment for NGU with azithromycin or doxycycline. Empiric azithromycin adequately treats most cases of C trachomatis, but treatment failure can occur due to antibiotic resistance or to infection with an alternate organism (eg, M genitalium, Trichomonas vaginalis).
A 25-year-old Aditya comes to see you in the office. His wife, Neha, noticed an area of circular hair loss over the back of his head. He is concerned that he is losing his hair and will be bald soon. He is otherwise in good health and denies any history of smoking, alcohol, or illicit drug use. On examination, there is a 1 cm area of complete, smooth and circular hair loss with distinct margins. There is no scaling or inflammation present in or around the area of hair loss. Which of the following is the most appropriate treatment of his condition?
Topical antifungals
A single intramuscular injection of penicillin G
Intralesional corticosteroids
Oral corticosteroids
Topical tacrolimus
Answer: C
Intralesional corticosteroids
He has Alopecia areata, common disease with discrete smooth and circular areas of hair loss over the scalp. No associated scaling or inflammation. Exact etiology is unknown. Topical or intralesional corticosteroids are treatment of choice.
A 28 year old Aiza at 12 weeks gestation comes to the office for routine prenatal care during the fall season. She has mild nausea, which she controls with vitamin B supplementation but no abdominal pains. Aiza has no chronic medical conditions or previous surgeries. She takes a prenatal vitamin, SHe does not use tobacco, alcohol, or illicit drugs, She did not receive any routine childhood vaccinations but does not object to vaccination. She plans to start working immediately after residency. She has no known allergies. Blood pressure is 120/70 mm Hg and pulse is 65/min. BMI is 23. The fetal heart rate is 150/min by bedside Doppler ultrasound. Initial prenatal lab results are as follows:
Rubella antibody: negative
Varicella antibody: negative
Blood type: O, Rh negative
Which of the following preventive vaccines is most appropriate for this patient at this visit?
Human papillomavirus
Influenza
Measles-mumps-rubella
Tetanus-diphtheria-pertussis
Varicella
Answer: B
Influenza
Inactivated vaccines such as Tetanus-toxoid-reduced diptheria toxoid-acellullar pertusis (Tdap), Injectable influenza virus, and immunoglobulins are safe during pregnancy.
Gurpreet is conducting a cohort study of 1800 infertile women with Polycystic Ovary Syndrome (PCOS).The women who were undergoing their first vitro fertilization cycle were grouped based on whether they would undergo fresh embryo transfer or embryo cryopreservation followed by frozen embryo transfer. WOmen underwent the transfer of up to two fresh or two frozen embryos. The primary outcome was a live birth after the first embryo transfer. An excerpt of her study results is shown below:
There were no significant differences between groups in rates of other pregnancy and neonatal complications. These data best support which of the following conclusions?
Among infertile women with PCOS, frozen embryo transfer is associated with a 17% lower rate of live birth compared to fresh embryo transfer
Frozen embryo transfers cause preeclampsia among women with PCOS who are undergoing vitro fertilization
In vitro fertilization using frozen embryo transfer is associated with significantly lower chance of pregnancy loss compared to fresh embryo transfer among all women with infertility.
The risk of ovarian hyperstimulation syndrome among women with PCOS may be reduced by 80% if they undergo frozen embryo transfer instead of fresh embryo transfer
Answer: D
The risk of ovarian hyperstimulation syndrome among women with PCOS may be reduced by 80% if they undergo frozen embryo transfer instead of fresh embryo transfer
This study specifically involved women with PCOS, a group at increased risk for ovarian hyperstimulation syndrome and pregnancy complications; therefore, these results by themselves do not allow conclusions to be drawn about rates of pregnancy loss among all women with infertility (regardless of etiology) undergoing IVF
A 58 year old homeless Asif is being evaluated for wrist pain after an injury. He was found lying on the sidewalk by a local shopkeeper who then called for an ambulance. He does not remember the details of the injury. Asif reports no other focal pain but says that he hurts all over. On examination in the Emergency department, he appears intoxicated and distractible. He has scattered contusions and abrasion in various stages of healing. There is diffuse swelling at the distal forearm with significant tenderness. Asif is uncooperative with further examination of the upper extremity due to pain. X-ray is shown in the image below.
Which of the following is the most likely mechanism of injury?
Direct blow to the wrist
Hyperflexion of the wrist during a fall
Punching with a clenched fist
Sudden twisting of the hand
Tripping and falling forward
Answer E
Tripping and falling forward
Image shows a distal radius fracture with shortening and dorsal displacement. This is a Colles Fracture and common in older patients following a Fall Onto an Outstretched Hand (FOOSH)
A 34 year old Stephen Walker comes to the Emergency Department due to recurrent fever, chills and excessive sweating. The symptoms began a few days ago and seem to recur every 48 hours. Stephent recently returned from a trip to Latin America after completing missionary work for his church. Temperature is 38.6 C (101.5F). Physical exam is otherwise normal. Lab studies are notable for anemia and thrombocytopenia. A blood smear with Giemsa staining demonstrates red blood cell inclusions. Chloroquine and primaquine are prescribed. The addition of primaquine to the treatment regimen is most likely to have which of the following effects?
Decrease chloroquine adverse effects
Kill erythrocyte trophozoites
Prevent disease relapse
Prevent hemolysis
Treat chloroquine-resistant strains
Answer: C
Prevent disease relapse
Unlike other species, P vivax and P ovale form hypnozoites in the liver that are dormant and reactivate weeks or months later. Therefore, these species must be treated with a medication that targets the intraerythrocytic phase (eg, chloroquine) as well as the dormant hepatic phase (eg, primaquine) to ensure eradication and prevent relapse.
Primaquine has limited therapeutic activity against the intraerythrocytic forms of malaria (eg, trophozoites); it targets the intrahepatic stage of infection (eg, hypnozoites). Primaquine monotherapy is not effective for chloroquine-resistant strains; these strains are usually treated with artemisinin-based combination therapy to halt the erythrocytic asexual reproduction cycle.
An 8 year old Peyton is brought to your office for abnormal behaviour. He has been acting inappropriately, crying and laughing without apparent reason for the past 2 weeks. At school he was restless and easily distracted. Last week his parents noted strange movements of his hands that improved when he slept. On the day before presentation, his parents noticed rapid jerking movements of his face and feet. The only recent history Peyton had was a minor self-resolving URI but has been healthy otherwise. He takes no medications and his vaccinations are up to date. Exam shows an alert and cooperative boy with normal vital signs. Facial grimacing and tongue fasciculations are seen. The lungs are clear to auscultation and a II/VI holosystolic murmur is heard at the apex. When he speaks, distinct changes in the volume and pitch of his voice are noted. Muscular tone is mildly decreased globally. Pronator sign is positive and the relaxation phase of the patellar reflex is delayed. His vital signs are otherwise normal. Which of the following is the most appropriate medication at this time?
Aspirin
Haloperidol
Clonidine
Pimozide
Penicillin
Tetrabenazine
Answer E
penicillin
Streptococcal pharyngitis is the primary risk factor for acute rheumatic fever (ARF), and treatment with oral penicillin is the best method of primary prevention. Sydenham chorea (SC) is a cardinal feature of rheumatic fever, and affected patients should receive long-acting intramuscular penicillin until adulthood for secondary prevention, even if there is no active pharyngitis. The goal of antibiotic therapy is to eradicate group A streptococcus to prevent recurrent ARF and worsening rheumatic heart disease.
A 10-year-old Faridun is brought to the office by his father due to concerns about his behavior and declining school performance over the last 6 months. His teachers have said that he is constantly distracted and does not pay attention in class. Faridun’s grades have dropped significantly and he is failing most of her classes. In addition, he has been irritable and moody with frequent outbursts of crying recently. He takes no daily medications or supplements. Temperature is 36.7 C (98 F), blood pressure is 116/58 mm Hg, and pulse is 114/min. Weight is 27 kg (59.5 lb), decreased by 1 kg (2.2 Ib) from last year. Physical examination reveals a nervous-appearing boy who is fidgeting with his clothes. The pupils are equally reactive to light. The sclera is nonicteric and visible above the iris. Cardiac examination reveals a regular rhythm and normal S1 and S2. The abdomen is soft and nontender without hepatosplenomegaly. Deep tendon reflexes are 3+ and symmetric in the upper and lower extremities. The skin is warm and moist. Without treatment, Faridun is at risk of developing which of the following long-term complications?
Mitral stenosis
Nephropathy
Osteoporosis
Respiratory insufficiency
Stress-induced hypotension
Answer: C
Osteoporosis
In hyperthyroidism, if left untreated, increased adrenergic activity stimulates cardiac contractility which leads to arrhythmias, DCM and osteoporosis due to elevated thyroid hormone stimulating calcium and phosphate release from bone.
Seelia and a group of rheumatologists want to study the association between past use of procainamide for the treatment of arrhythmias and drug-induced lupus. The rheumatologists plan to conduct a case-control study to evaluate the association. Which of the following corresponds with the proposed study design?
Controls without a history of procainamide use should be excluded from the study
Individuals with a history of procainamide use should be identified as cases, and individuals with no history of procainamide use should be identified as controls
Individuals with and without drug-induced lupus should be compared with respect to their frequency of prior procainamide use
The frequency of drug-induced lupus should be compared in individuals with and without a history of procainamide use at the beginning of the study
The study should begin by identifying individuals based on their history of procainamide use and end by comparing the incidence of drug-induced lupus in each group
Answer: C
Individuals with and without drug-induced lupus should be compared with respect to their frequency of prior procainamide use
Case-controlled Study initially identified as cases or controls according to an outcome status (disease or condition of interest). In this case people with Drug induced lupus are cases and without are controls. Once identified, then assess for past exposures to risk factors.
A 40 -year-old Asif comes to the office with his wife for evaluation of abnormal movements for the past 5 months. He has been physically restless and clumsy, dropping objects frequently. Asif was previously traveling across South America with Stephen Walker but had to stop working a month ago due to "shaky hands." Family medical history includes depression in the patient's father, who died in a motor vehicle collision a few years after his birth. Medical history is noncontributory. Vital signs are normal. Asif is alert and fully oriented. Intermittent facial twitching and asymmetric, jerking movements of the upper extremities are noted. He is unable to protrude his tongue for a sustained period of time. Muscle strength and tone are normal. Gait is normal. He recalls 1 of 5 objects after 5 minutes. Which of the following is the most likely clinical course for Asif?
Intermittent, stepwise worsening of cognitive and motor functioning
Progressive neuropsychiatric deterioration over the next 10-20 years
Rapid neurologic decline resulting in death within a year
Relapsing and remitting motor symptoms with mild decline in cognitive functioning
Reversible motor and cognitive changes with no change in life expectancy
Answer: B
Progressive neuropsychiatric deterioration over the next 10-20 years
This is Huntington's disease with chorea (abrupt and involuntary movements of face limbs and trunk). The course is a progressive deterioration in cognitive and motor function over 10-20 years after symptom onset resulting in death. There is no cure or disease-modifying therapy, and treatment is focused on symptom management (eg, pain, constipation, aggression) to improve quality of life.
A 64 year old Kashif is admitted to the rehab facility after right total knee replacement develops sudden onset chest pain and shortness of breath on post op day 5. He has been receiving heparin for prophylaxis of deep vein thrombosis. Two months ago, he was hospitalized for pneumonia and improved with 1 week of antibiotics. Examination shows clear lungs and normal heart sounds. Cardiac enzymes are normal. ECG shows sinus tachycardia. CT angiogram reveals pulmonary embolism. Complete blood count shows platelets of 45.000/mm. Prior to the knee surgery, his platelet count was 170,000/mm. Heparin is discontinued and argatroban is started. Which of the following is the best approach for Asif?
Avoid warfarin therapy
Start warfarin now and continue argatroban for at least 5 days
Start warfarin now and discontinue argatroban the next day
Start warfarin now and stop argatroban
Wait for platelet count recovery before starting warfarin
Answer: E
Wait for platelet count recovery before starting warfarin
Type 2 Heparin Induced Thrombocytopenia (HIT)
First step is stop all heparin products. Alternative agents like argatroban should be given due to high risk of thrombosis in type 2 HIT. Initial treatment with warfarin is contraindicated due to rapidaly dropping protein C levels cause a prothrombotic state. Pt cont on alternative agent until plt count is above 150K.
A 67 year old Steven Jang comes for follow-up for coronary artery disease. He is feeling well. Three months ago he was hospitalized for chest pain, coronary angiography showed 85% narrowing of the mid right coronary artery and a drug eluting stent was placed. In addition TSH was noted to be low. Steven now walks 2-3 miles a day without angina, dyspnea, or lower extremity claudication. He states “I am very happy that I lost 5 lbs since my hospitalization and my stress has decreased since I’m no longer chief resident which also allowed me to give up smoking and drinking. I feel like I got my life back:. Current medications include aspirin, clopidogrel, metoprolol, lisinopril, and atorvastatin. Steven has a family hx of heart attack, osteoporosis, and hypertension. Blood pressure today is 134/76 mm Hg and pulse is 65. Min and BMI is 28. Physical exam, including exam of the thyroid gland, are normal. Repeat thyroid function results are as follows:
During Hospitalization Current
TSH 0.14 uU/mL 0.08 uU/mL
Free T4 1.8 ng/dL 1.74 ng/dL (normal 0.9 - 2.4)
Total T3 88 ng/dL 133 ng/dL
Radioactive iodine uptake is increased, with homogenous distribution on thyroid scan. Which of the following is the most appropriate management for Steven?
Increase the dose of metoprolol
Initiate antithyroid medication
Measure thyrotropin receptor antibodies
No additional treatment, repeat thyroid tests in 6-12 weeks
Obtain thyroid ultrasound
Answer B
Initiate antithyroid medication
Subclinical hyperthyroidism is defined as low TSH with normal thyroid hormone concentrations. Severe TSH suppression (<0.1 uU/mL) is associated with a
higher risk for progression to overt hyperthyroidism and warrants treatment. Patients with mildly suppressed TSH levels (0.1-0.5 uU/mL) often experience spontaneous remission and can usually be monitored with periodic thyroid function tests. However, those with increased risk for complications due to age (>65) or comorbid conditions (eg, heart disease, osteoporosis) warrant consideration for treatment with antithyroid medication or radioactive iodine. In light of this patient's TSH <0.1 uU/mL, age ≥65, and comorbid coronary artery disease, treatment should be offered at this time
A 27-year-old woman, gravida 1 para 0, at 28 weeks gestation comes to the office for a routine prenatal visit. Her initial prenatal laboratory results at 12 weeks gestation were as follows:
Hgb: 11.8 g/dL
MCV: 84 um^3
Platelets 180,000/mm^3
Leukocytes 7,500/mm^3
Urine Culture: Negative
The patient reports no vaginal bleeding, leakage of fluid, or contractions. There is good fetal movement. She has increasing urinary frequency and nocturia but no dysuria or hematuria. The patient has a history of tension headaches, which have become more frequent but resolve with acetaminophen. She has no other chronic medical conditions or previous surgeries. The patient works in a retirement home and reports leg swelling at the end of her shift. She is a vegetarian and takes a daily prenatal vitamin. She does not use tobacco, alcohol, or illicit drugs. Temperature is 37 C (98.6 F), blood pressure is 128/76 mm Hg, and pulse is 86/min. BMI is 30 kg/m?; the patient has been gaining 0.5 kg (1.1 lb) a week during the pregnancy. The fetal heart rate is 152/min. Examination shows a uterus consistent with a 28-week gestation. There is trace lower extremity edema bilaterally. The patient has had no laboratory evaluations since her initial prenatal visit. Which of the following is the most appropriate laboratory evaluation to perform at this visit?
24-hour urine protein collection
Complete blood count
No additional testing needed
Thyroid studies
Urine culture
Answer: B
Complete blood count
At 24-28 weeks gestation at pregnant women should undergo screening for anemia with Hgb/HCt or CBC. Physiological anemia occurs in most pregnancies due to expaning plasma volume. Gestational Diabetes is also screened at this time due to increase in human placental lactogen. In addition Rh(D) negative women should undergo antibody screening and recieve anti-D IG injection
A randomized study assigned patients with sickle cell anemia and silent stroke to either monthly transfusion therapy (transfusion group of 110 patients) or usual care (observation group of 105 patients). An excerpt of the study results is provided below:
Which of the following adverse events is most subject to selection bias?
Acute chest syndrome
Avascular hip necrosis
Headache
Iron overload
Vasoocclusive pain
Answer: D
Iron overload
4 out of 5 adverse events studied (Acute chest Syndrome, Avascular hip, Headache, vasooclusive crisis) data are provided for all 105 participants in the observation group and 110 participants in the transfusion group. However only 35 of 105 participants (33%) in the observation group had their ferritin level measured so the results may be unrepresentative of the entire group. Selection bias occurs when the sample is unrepresentative of the target population which may lead to a different measure of association int he sample than in the target population.
An 86-year-old Asif is evaluated for behavioral changes in the nursing home where he has been a resident for 3 years due to Alzheimer disease. Over the last 2 days, Asif has become more inattentive and withdrawn during the day and has fallen asleep during meals. The staff reports that he typically interacts with other residents but occasionally becomes paranoid about cleanliness and says he hears people singing who are not in the room. For the past 8 months, Asif has needed help putting on his clothes but has been able to eat by himself. He occasionally has transient increased confusion with mild agitation in the early evening but usually sleeps through the night. Medical history includes hypertension and depression. Vital signs are normal. Asif is oriented only to self and nods off during the interview. Then he suddenly becomes agitated and shouts, "You're not going to poison me, and tell that man in the closet to stop singing." Asif is unable to cooperate with neurologic examination, but he moves all extremities and appears to grab involuntarily during attempts to test grip strength. Which of the following findings in Asif is most alarming and requires urgent evaluation?
Change in auditory hallucinations
Existence of apraxia
Fluctuation in consciousness
History of sundowning
Presence of a grasp reflex
Answer: C
Fluctuation in consciousness
this pt suffers from Moderate to Severe forms of Alzheimer disease (AD) has new mental status changes (eg, inattention, altered consciousness, daytime somnolence) concerning for delirium. The ability to recognize delirium in the setting of AD becomes increasingly difficult as dementia progresses because neuropsychiatric symptoms (eg, apathy, agitation, delusions, hallucinations) can be seen with both. However, sudden changes (eg, hours to days) and rapid fluctuations in consciousness (eg, somnolent to agitated over a short time) are not expected with progressive dementia and should raise concern for delirium, which indicates an unstable underlying medical condition that must be urgently identified and treated.