USPSTF recommendations
A 46-year-old male presents to your office and asks you to screen him for pancreatic cancer. He tells you that his best friend was recently diagnosed with pancreatic cancer at age 45. His friend was previously healthy and had no family history of cancer. The patient is doing well and has no symptoms. He does not have a family history of cancer.
Based on U.S. Preventive Services Task Force recommendations, which one of the following would be most appropriate at this time?
A) No screening
B) Ultrasonography of the abdomen
C) CT of the abdomen without contrast
D) CT of the abdomen with contrast
E) MRI of the abdomen
A) NO SCREENING REQUIRED!
Although an uncommon cancer, pancreatic cancer is the third most common cause of cancer death in the United States. The incidence is rising, and it is estimated that it may soon become the second-leading cause of cancer deaths. In an asymptomatic patient with no family history of pancreatic cancer or inherited genetic syndromes, the U.S. Preventive Services Task Force recommends against screening for pancreatic cancer.
A nonverbal 22-year-old male with intellectual disability is brought to your office by the staff of the group home where he lives. They report that the patient has been functioning at his baseline until this morning when he was found to have loud breathing. No other history is available at the time of this visit.
On examination he has a temperature of 37.3°C (99.1°F), a blood pressure of 124/82 mm Hg, a pulse rate of 100 beats/min, and a respiratory rate of 16/min. The patient appears to be in mild distress and a high-pitched whistling, crowing sound on inspiration is heard as you walk in the room.
Which one of the following would be the most appropriate next step for this patient?
A) Oral antibiotics
B) Oral corticosteroids
C) Nebulized albuterol
D) Nebulized epinephrine
E) Urgent evaluation in the emergency department
ANSWER: E
Stridor is a high-pitched whistling, crowing sound on inspiration. It can be caused by obstruction of the larynx or trachea by a foreign body, vocal cord edema, a neoplasm, or a pharyngeal abscess. Acute stridor requires urgent evaluation for obstruction. This patient may have a foreign body or other obstruction in his airway and requires urgent assessment. Oral antibiotics, oral corticosteroids, nebulized albuterol, or nebulized epinephrine would not be appropriate at this time.
A 56-year-old female with a BMI of 37 kg/m2 seeks your advice regarding weight loss. Which one of the following medications in her current regimen is most likely to contribute to weight gain?
A) Bupropion (Wellbutrin)
B) Lisinopril (Prinivil, Zestril)
C) Metformin (Glucophage)
D) Mirtazapine (Remeron)
E) Naproxen
ANSWER: D
Mirtazapine, an antidepressant, is associated with weight gain. Lisinopril and naproxen are weight neutral. Bupropion and metformin may promote weight loss.
A 39-year-old female presents to your office for evaluation of a left-sided headache. She notes pain in the temporal region and inferior to the zygoma. The pain is constant and dull but worsens with chewing. There is no history of recent trauma. Her past medical history includes fibromyalgia and her only medication is amitriptyline, 25 mg at bedtime. Her vital signs are within normal limits and she is afebrile. On examination you note tenderness to palpation over the temporalis region but no mass or cord. There is no swelling or edema of the head, face, or neck.
Which one of the following is the most likely diagnosis?
A) Giant cell arteritis
B) A salivary stone
C) Sinusitis
D) Temporomandibular disorder
E) Trigeminal neuralgia
ANSWER: D
Approximately 10%–15% of adults will experience a temporomandibular disorder (TMD). TMD represents a spectrum of illnesses frequently seen and readily treatable by family physicians. This multifactorial disorder is consistently associated with other pain conditions such as fibromyalgia, as in this case. Patients typically present with facial pain, jaw pain, headache, or ear pain. The symptoms are generally associated with jaw movement such as chewing. Physical examination findings can be broad but often include pain with palpation of the temporomandibular joint, or pain and/or spasm of the muscles of mastication. Giant cell arteritis should be included in the differential diagnosis but is typically seen in patients over age 50 and is often associated with other findings such as jaw claudication, visual symptoms, and palpable abnormalities over the temporal artery. Salivary stones can involve pain in a similar region, such as the parotid gland, but this is often an intermittent pain triggered only by eating. Tenderness or swelling over the gland itself may be seen. Sinusitis would usually present with nasal congestion, maxillary sinus tenderness, mucus, and fever. While trigeminal neuralgia may have a similar distribution of pain, this is typically reported as a brief attack of intense, sharp pain often produced by specific stimuli.
An 18-month-old female is brought to your office by her mother for evaluation of a cough. The patient has had low-grade fevers and a runny nose for 2 days. She now has a cough that is worse at night. On examination she has a temperature of 37.5°C (99.5°F), a pulse rate of 120 beats/min, a respiratory rate of 30/min, and an oxygen saturation of 92% on room air. She is noted to have hoarseness, mild inspiratory stridor, and a barking cough. She does not have drooling or a muffled voice.
Which one of the following should be ordered to confirm the diagnosis?
A) No further testing
B) A CBC
C) A viral culture
D) Rapid antigen testing
E) A radiograph of the neck
ANSWER: A
This patient has croup, which is diagnosed clinically and no further testing is usually indicated. A CBC is nonspecific and is usually only indicated if a bacterial cause of stridor is suspected, such as bacterial tracheitis, epiglottitis, retropharyngeal abscess, or peritonsillar abscess. Viral cultures and rapid antigen testing should be reserved for instances in which the patient fails to respond as expected to initial treatment. A neck radiograph is not indicated in the absence of findings that suggest possible epiglottitis, such as drooling or a muffled voice.
You are asked for your advice as part of a committee formed by your local health system to focus on fall prevention.
Based on U.S. Preventive Services Task Force recommendations, which one of the following interventions has the strongest evidence for preventing falls in community-dwelling older adults at increased risk for falls?
A) Calcium supplementation
B) Vitamin D supplementation
C) Supportive footwear
D) Exercise classes
E) Cognitive-behavioral therapy
ANSWER: D
In the United States falls are the leading cause of injury-related morbidity and mortality among older adults. The U.S. Preventive Services Task Force (USPSTF) concluded with moderate certainty that exercise interventions provide a moderate net benefit in fall prevention in community-dwelling adults 65 years of age or older who are at increased risk for falls (B recommendation). The USPSTF also concluded with moderate certainty that supplementation with calcium and vitamin D has no clear benefit in preventing falls in older adults. Environmental modifications and psychological interventions lack sufficient evidence for fall prevention.
A 76-year-old male sees you for a routine health maintenance examination. He says that he has developed a mild tremor over the past few years, and it has now become bothersome to him because it affects his handwriting and his ability to eat in public. His mother had a similar tremor. He has no tremor at rest. When you ask him to hold out his hands, you note a tremor in both hands and wrists. His voice is also somewhat tremulous. He asks if there are any treatments to reduce the tremor.
Which one of the following would be the most appropriate next step?
A) Observation only
B) A trial of a -blocker
C) A trial of a dopaminergic agent
D) Serum ceruloplasmin and 24-hour urinary copper excretion levels
E) MRI of the brain
ANSWER: B
This patient presents with symptoms of a benign essential tremor. This is a postural symmetric tremor that is most often noted in the hands and wrists. A positive family history is often present. The diagnosis can be made clinically and a trial of -blockers is warranted, especially since this patient is having significant interference in daily and social activities. A resting tremor would suggest parkinsonism, which warrants treatment with a dopaminergic agent. Young patients presenting with a tremor should be evaluated for Wilson’s disease, with ceruloplasmin and urinary copper excretion testing. MRI of the brain would be warranted for a cerebellar tremor, which would manifest as a postural intention tremor.
A 47-year-old male with obesity, hypertension, and type 2 diabetes sees you because of growth of his breasts. An examination confirms gynecomastia.
Stopping which one of the following medications in this patient’s current regimen would most likely result in regression of his gynecomastia?
A) Amlodipine (Norvasc)
B) Hydrochlorothiazide
C) Liraglutide (Victoza)
D) Pioglitazone (Actos)
E) Spironolactone (Aldactone)
ANSWER: E
Spironolactone has antiandrogenic properties and may cause gynecomastia in approximately 9% of male users. Stopping the medication typically leads to regression of the gynecomastia within 3 months.
Amlodipine, hydrochlorothiazide, liraglutide, and pioglitazone do not have antiandrogenic properties and are not associated with gynecomastia.
A 25-year-old male presents with a 4-month history of crampy abdominal pain, diarrhea, and fatigue. His symptoms began gradually but have become more severe and he is now experiencing rectal bleeding. He says that his abdominal pain seems to temporarily improve after eating. He has smoked five cigarettes per day for the past 8 years. He is surprised to learn that he has lost 7 kg (15 lb) when he is weighed today. His vital signs include a blood pressure of 116/70 mm Hg, a heart rate of 76 beats/min, a respiratory rate of 12/min, and a temperature of 37.7°C (99.9°F). A physical examination reveals abdominal tenderness and mild distention. An anorectal examination is significant for a perianal fistula. A laboratory evaluation is notable for mild anemia. His kidney and liver function are normal.
Which one of the following is the most likely diagnosis?
A) Celiac disease
B) Chronic pancreatitis
C) Crohn’s disease
D) Irritable bowel syndrome
E) Ulcerative colitis
ANSWER: C
Crohn’s disease may present insidiously with diarrhea, abdominal pain, rectal bleeding, fever, weight loss, and fatigue. Red-flag symptoms include perianal lesions, a first degree relative with inflammatory bowel disease, weight loss of 5% of the patient’s usual weight, abdominal pain for more than 3 months, nocturnal diarrhea, fever, the absence of abdominal pain for 30–45 minutes after eating, and the absence of rectal urgency. This patient exhibits symptoms consistent with Crohn’s disease. While anemia is also common in celiac disease, rectal bleeding is not. Chronic pancreatitis does not generally present with improved pain after eating. Irritable bowel syndrome is not associated with fever, rectal bleeding, anemia, or perianal fistulas. Ulcerative colitis is not associated with perianal lesions.
A 43-year-old male presents to the emergency department with the acute onset of sharp, stabbing chest pain when inhaling and exhaling. The pain worsens with coughing and deep breathing. He has no significant previous medical history but recently returned from a work trip to Japan and has noted right leg swelling for the past week. He has no other symptoms. He is a smoker and has a family history of coronary artery disease in his paternal grandfather. On examination he appears uncomfortable, and his lungs are clear. A cardiac examination is notable for tachycardia. He has a blood pressure of 110/70 mm Hg, a heart rate of 112 beats/min, a respiratory rate of 18/min, a temperature of 37.7°C (99.9°F), and an oxygen saturation of 89% on room air.
Which one of the following test results is most likely to confirm the diagnosis?
A) Elevated troponin levels
B) Acid-fast bacilli on a Gram stain
C) A filling defect on CT angiography
D) Air in the pleural space on a chest radiograph
E) Diffuse ST elevation on an EKG
ANSWER: C
The differential diagnosis of pleuritic chest pain includes several serious causes that should be considered in the evaluation of a patient with this type of pain. Pulmonary embolism is the most common cause of pleuritic chest pain. This patient presents with the acute onset of pleuritic chest pain associated with travel, a swollen leg, and smoking, which are common risk factors for pulmonary embolism. A filling defect on CT angiography can confirm this diagnosis. Elevated troponin levels would confirm a diagnosis of acute myocardial infarction, which would be more likely if the patient were older, experienced pain with exertion, and had other red-flag symptoms such as diaphoresis, nausea and vomiting, or radiating pain. Acid-fast bacilli on a Gram stain would confirm a diagnosis of tuberculosis (TB), which is associated with travel to or exposure to contacts from high-risk areas. TB would also present with other red-flag symptoms such as hemoptysis, fever, night sweats, and weight loss. A chest radiograph showing air in the pleural space would confirm a diagnosis of pneumothorax, which is usually present with decreased breath sounds on physical examination. An EKG with diffuse ST-segment elevation would confirm a diagnosis of pericarditis, which is usually associated with a recent or current viral infection or prior history of pericarditis.
A 42-year-old male comes to your office for a health maintenance evaluation. He has not been to your office in the past 5 years and has no medical issues. He tells you that his father was diagnosed with hyperlipidemia and hypertension in his sixties. He recently used an online clinic where he could get free medical advice and testosterone testing. He was advised to see you for a stress test. He has recently started an exercise program and is walking 5 days a week for 30 minutes a day with no significant chest pain or shortness of breath. He wants to start running and work up to a 5K race.
Based on U.S. Preventive Services Task Force and other expert guidelines on stress testing, which one of the following would you advise for this patient?
A) No stress testing
B) An exercise EKG
C) Exercise echocardiography
D) An exercise sestamibi stress test
E) Dobutamine stress echocardiography
ANSWER: A
The U.S. Preventive Services Task Force, the American College of Physicians, the American College of Cardiology, and the American Academy of Family Physicians recommend against cardiac screening with stress testing in low-risk asymptomatic individuals, so an exercise EKG, exercise echocardiography, an exercise sestamibi stress test, and dobutamine stress echocardiography would not be recommended for this patient. Cardiovascular screening tests in asymptomatic patients have a low yield and may produce many false positives, leading to costly and potentially harmful invasive procedures. Many patients ask for this type of screening, but explaining current guidelines may help them understand why they should not be screened.
A 32-year-old female comes to your office because of palpitations. She reports a sensation of her heart racing that lasts for several seconds, occurs at rest, and has been occurring daily for the past couple of weeks. She has not had any loss of consciousness or other associated symptoms, has no history of recent stressors or anxiety, and does not drink caffeine or take any illicit drugs. She is otherwise healthy and takes no medications. An examination is unremarkable and an EKG and basic laboratory studies are all normal.
Which one of the following would be the most appropriate next step in your evaluation?
A) Reassurance only
B) A 24-hour Holter monitor
C) A 30-day cardiac event monitor
D) An exercise stress test
E) Transthoracic echocardiography
ANSWER: B
This patient does not have any obvious metabolic or psychiatric explanations for her palpitations, raising the clinical suspicion for an underlying cardiac cause. Reassurance without further investigation of a possible cardiac cause would be inappropriate. Given that her symptoms are occurring daily, a 24-hour Holter monitor would be the most appropriate next step in the evaluation. If her symptoms occurred less frequently, a 30-day cardiac event monitor, which stores data after being activated, could be used. An exercise stress test would be indicated as the next step if her symptoms were exertional. Transthoracic echocardiography would be indicated as the next step if there were a clinical suspicion for structural heart disease based on a previous history of cardiac disease or worrisome signs and symptoms
A 66-year-old female with multiple medical problems has routine laboratory work performed during a regularly scheduled clinic visit. All of the laboratory values are normal except for a serum calcium level of 11.0 mg/dL (N 8.5–10.2).
Which one of the following medications in her current regimen is most likely to cause an elevated calcium level?
A) Alendronate (Fosamax)
B) Lithium
C) Omeprazole (Prilosec)
D) Sertraline (Zoloft)
E) Spironolactone (Aldactone)
ANSWER: B
Hypercalcemia is a commonly encountered laboratory abnormality. It is important for family physicians to be aware of common medications that can cause elevated calcium levels. Of the options listed, lithium is the only medication that can cause high calcium levels. In addition, thiazide diuretics, excluding aldosterone receptor antagonists such as spironolactone, often cause elevated calcium levels. Hypercalcemia is not a side effect of alendronate, omeprazole, sertraline, or spironolactone.
A 52-year-old male sees you for a routine follow-up visit for diabetes mellitus. His hemoglobin A1c is 7.6%. He also notes that he has been having increasing pain in his right shoulder over the past few months but he cannot recall any specific injury. The pain is a dull, poorly localized ache that radiates into the biceps and is aggravated when he reaches overhead. On examination you note decreased range of motion in forward flexion, internal and external rotation, and abduction. There is normal strength with resisted activation of the rotator cuff muscles and there are no impingement symptoms.
Which one of the following is the most likely diagnosis?
A) Osteoarthritis of the shoulder
B) Adhesive capsulitis
C) SLAP lesion
D) Infraspinatus tendinopathy
E) Supraspinatus tendinopathy
ANSWER: B
Increasing shoulder pain that is hard to localize and decreased range of motion are the hallmark findings for adhesive capsulitis, also known as frozen shoulder. The underlying pathology is contraction of the glenohumeral capsule. It is an idiopathic condition but has an increased prevalence in patients with diabetes mellitus and hypothyroidism. Adhesive capsulitis is often self-limited but can persist for years in some patients. Nonsurgical treatment options include physical therapy, oral or intra-articular corticosteroids, acupuncture, and hydrodilatation.
A 36-year-old male sees you for follow-up of progressive fatigue and lightheadedness that has worsened over the past 3 months. He has lost 5 kg (11 lb) during this time. On examination he has a BMI of 21 kg/m2, a blood pressure of 88/48 mm Hg, and a pulse rate of 66 beats/min. A skin examination is notable for patches of nonpigmented skin on the hands. Initial laboratory testing is significant for a sodium level of 132 mEq/L (N 135–145) and a potassium level of 5.3 mEq/L (N 3.5–5.0).
Which one of the following tests would confirm the most likely diagnosis?
A) 17-hydroxyprogesterone
B) ACTH stimulation
C) Dexamethasone suppression
D) Late night salivary cortisol
E) Plasma renin and aldosterone
ANSWER: B
This clinical case is consistent with Addison’s disease, or adrenal insufficiency. This case is most likely the result of autoimmune disease, given the concurrent vitiligo, but it may also be idiopathic or secondary to cancers such as lymphoma or infections such as tuberculosis. Adrenal insufficiency is suggested by a low morning cortisol level, but the test of choice to confirm this diagnosis is the ACTH stimulation test. 17-Hydroxyprogesterone deficiency causes congenital adrenal hyperplasia, which typically presents in childhood. This test is part of newborn screening in the United States. Acquired 17-hydroxyprogesterone deficiency can present in adulthood as adrenal insufficiency but a low 17-hydroxyprogesterone level does not confirm adrenal insufficiency. Late night salivary cortisol is an initial test for corticosteroid excess (Cushing syndrome) and the dexamethasone suppression test is used to confirm that disorder. Renin and aldosterone levels can be helpful to characterize mineralocorticoid deficiency but they are not diagnostic.
A 32-year-old white female presents to your office for a health maintenance visit required by her employer. The patient lives with her husband and two children. Her hobbies include water skiing and traveling. She does not have any significant past medical history. Her last Papanicolaou (Pap) smear was normal 1 year ago, and all of her previous Pap smears have been normal. A review of systems and a physical examination are unremarkable.
Based on U.S. Preventive Services Task Force recommendations, there is good evidence to screen this patient for
A) illicit drug use
B) intimate partner violence
C) skin cancer
D) vitamin D deficiency
ANSWER: B
The U.S. Preventive Services Task Force recommends screening for intimate partner violence for women of reproductive age, with referral to support services for those with a positive screen (B recommendation).
In asymptomatic adults the current evidence is insufficient to recommend screening for illicit drug use, skin cancer, or vitamin D deficiency.
A 50-year-old female sees you for a routine health maintenance visit. On examination you note a thyroid nodule and ultrasonography confirms a solid 1.5-cm nodule. Her TSH level is normal.
Which one of the following would be the most appropriate next step in the management of this patient?
A) Antithyroid antibody titers
B) A thyroid scan
C) A fine-needle aspiration biopsy
D) Surgical excision of the nodule
E) Repeat ultrasonography in 6 months
ANSWER: C
Thyroid nodules >1 cm that are solid or have suspicious features require a fine-needle aspiration biopsy to rule out malignancy. Fine-needle aspiration should not be performed on nodules <1 cm. The evaluation of a single thyroid nodule does not call for testing of antithyroid antibody titers. If the patient had a low TSH level then a radionuclide thyroid uptake scan (nuclear medicine thyroid scan) is indicated to look for a toxic nodule. These hyperfunctioning nodules are seldom malignant. Surgical nodule excision is not indicated since needle aspiration is diagnostic. Repeat ultrasonography in 6 months is not indicated because this would not change management.
A 60-year-old male with a long-standing history of type 2 diabetes is admitted to the hospital. He takes four oral medications for the treatment of diabetes at home. You decide to switch him to insulin instead of continuing oral medications while he is hospitalized. He is eating his meals well.
After calculating the total daily insulin dose, which one of the following would be most appropriate?
A) Administer the total daily dose as long-acting insulin in equal doses every 12 hours
B) Administer half of the total daily dose of insulin as long-acting insulin and the other half as short-acting insulin in three divided doses, given with each meal
C) Administer the total daily dose as short-acting insulin in three divided doses, given with each meal
D) Administer the total daily dose as short-acting insulin in four divided doses, given with each meal and at bedtime
E) Administer the total daily dose as a short-acting sliding scale regimen based on bedside glucose readings, in four divided doses
ANSWER: B
Frequently patients taking oral medications for the treatment of diabetes mellitus need to be switched to insulin while hospitalized. There are formulas to calculate the total daily dose based on weight, renal function, insulin resistance, and other factors. The recommended regimen is half of the calculated total daily dose given as long-acting insulin such as glargine to provide basal insulin and half given as short-acting insulin such as lispro to provide prandial insulin. The short-acting insulin is divided into thirds to be given with each meal.
The American Diabetes Association (ADA) recommends an insulin regimen with a basal and a prandial component for non-critically ill patients in the hospital with good nutritional intake. A correction component can be added to this regimen. The ADA strongly discourages the use of only a sliding scale insulin regimen. The reactive nature of sliding scale does not control glucose levels well and does not address the basal insulin needs of patients.
A 72-year-old female presents with bothersome palpitations. She is otherwise healthy and is not taking any medications. A physical examination is normal, including thyroid and eye examinations. Laboratory studies reveal a serum TSH level of 0.2 U/mL (N 0.4–4.0) and normal T3 and free T4 levels. An EKG reveals frequent premature atrial contractions but is otherwise normal. Ultrasonography of the thyroid does not reveal any nodules, thyroid scintigraphy shows diffuse uptake, and an anti–thyrotropin-receptor (thyroid-stimulating immunoglobulin) antibody level is significantly elevated.
Which one of the following is the most likely diagnosis?
A) Central hypothyroidism
B) Graves disease
C) Iodine deficiency
D) Solitary toxic thyroid nodule
E) Toxic multinodular goiter
ANSWER: B
This patient has subclinical hyperthyroidism caused by Graves disease. A positive anti–thyrotropin-receptor (thyroid-stimulating immunoglobulin) antibody result is virtually diagnostic of Graves disease. Central hypothyroidism is associated with a low TSH level and low T3 and T4 levels. Iodine deficiency is associated with goiter and hypothyroidism. Nodular thyroid disease is unlikely given the imaging results. Treatment of this patient’s mild Graves disease is probably indicated, given her age and cardiac symptoms.
A 35-year-old female comes to your office for follow-up of an emergency department (ED) visit for palpitations. She tells you that she was driving on the highway with her three small children when she suddenly felt her heart racing, along with chest tightness, lightheadedness, and severe anxiety. She pulled over and called 911. While she waited for EMS she took diltiazem (Cardizem), 30 mg orally, which had been prescribed following a similar episode several years ago. Her symptoms lasted about 10 minutes and had improved by the time EMS arrived. An examination, EKG, and chest radiograph in the ED were all normal.
Which one of the following findings in her previous medical record would confirm your diagnosis?
A) A Generalized Anxiety Disorder–7 (GAD-7) score of 6
B) An elevated TSH level
C) P waves hidden within a narrow QRS complex on an event recorder
D) Mitral valve prolapse on an echocardiogram
E) Atherosclerotic plaque seen on carotid ultrasonography
ANSWER: C
This patient presents with a history consistent with typical atrioventricular nodal reentrant tachycardia, which is the most common type of supraventricular tachycardia (SVT). She is also using “pill-in-the-pocket” treatment, which is effective for infrequent SVT. Because the symptoms are episodic and the tachycardia is paroxysmal, patients generally present with normal examination and EKG findings. Further evaluation with event monitoring may identify a narrow-complex tachycardia with P waves hidden within the QRS complex or identified early after it. Most patients with SVT have structurally normal hearts.
An elevated Generalized Anxiety Disorder–7 (GAD-7) score is consistent with a diagnosis of generalized anxiety disorder (GAD). However, GAD is a common misdiagnosis in patients with SVT, particularly females. While hyperthyroidism is associated with tachycardia, hypothyroidism usually is not. Mitral valve prolapse is not specifically associated with SVT. Carotid atherosclerosis is not associated with SVT either, but knowledge of its presence may help determine treatment.
A 72-year-old male comes to your office for an annual health maintenance visit. He mentions that some of his friends recently underwent health screenings and he asks if there are any cardiovascular screening tests recommended for him. His blood pressure is well controlled and he does not have any shortness of breath or chest pain. He exercises regularly. He started smoking cigarettes while he attended college but quit at age 25. He does not have a significant family history of cardiovascular disease.
Which one of the following tests is recommended by the U.S. Preventive Services Task Force for patients such as this?
A) An ankle-brachial index
B) A high-sensitivity C-reactive protein level
C) A coronary artery calcium score
D) Abdominal aortic aneurysm screening with ultrasonography
E) Echocardiography
ANSWER: D
This patient is male, over the age of 65, and smoked in the past, so he meets the criteria for one-time screening for an abdominal aortic aneurysm (AAA) recommended by the U.S. Preventive Services Task Force (USPSTF) (B recommendation). This screening is associated with decreased AAA-related mortality.
The USPSTF found insufficient evidence for screening asymptomatic adults for cardiovascular disease with an ankle-brachial index, high-sensitivity C-reactive protein level, or coronary artery calcium score. Screening asymptomatic individuals with echocardiography is not recommended at this time.
A 3-year-old female is brought to your office by her mother with a 3-day history of a rash. The patient’s mother reports that the child is eating less than usual but tolerating fluids. The mother also reports that other children in the patient’s day care have a similar rash.
On examination the patient’s temperature is 38.2°C (100.8°F). The patient appears alert and active. Examination of the pharynx reveals ulcerations in the posterior oral cavity and soft palate. There is a maculopapular rash on the fingers, soles of the feet, and genitals. The remainder of the examination is normal.
Which one of the following would be the most appropriate next step?
A) Symptomatic treatment only, and increased oral hydration
B) Amoxicillin twice daily for 7 days
C) Valacyclovir (Valtrex) twice daily for 7 days
D) Antinuclear antibody testing
E) Rapid plasma reagin testing
ANSWER: A
This patient has hand-foot-and-mouth disease frequently caused by enterovirus 71 or coxsackievirus A16. It is most common in children under 5 years of age and occurs most often in the fall and spring. It is characterized by painful maculopapular or papulovesicular lesions on the hands and feet, and in the oral cavity. Lesions can also appear on the genitals, trunk, or cheek. Management includes symptomatic treatment of pain and oral hydration. Antibiotics and antiviral treatment are not recommended. Laboratory testing is not appropriate for this condition.
You are working in an urgent care clinic when a 68-year-old male with chronic hypertension sees you for refills of his medications. He has been out of his medication for the past month and could not get an appointment with his primary care physician for refills. His blood pressure is persistently 190/115 mm Hg, even after he has rested in a quiet room for 30 minutes. His blood pressure previously had been well controlled. He has a moderate headache but otherwise feels well. An examination, including a funduscopic examination, is normal.
Which one of the following management options would be most appropriate at this time?
A) Refill his usual medications and arrange for follow-up in 1 week
B) Administer oral labetalol (Trandate) every 30 minutes until his blood pressure is <180/110 mm Hg
C) Administer oral nifedipine (Procardia) every 30 minutes until his blood pressure is <180/110 mm Hg
D) Administer sublingual nifedipine every 30 minutes until his blood pressure is <180/110 mm Hg
E) Refer for immediate hospitalization for intravenous antihypertensive treatment
ANSWER: B
This patient has a hypertensive urgency, defined as symptomatic acute severe hypertension without evidence of acute end-organ injury. Hypertensive urgencies may be managed in the ambulatory setting. Emergent intravenous treatment at the hospital is not indicated. This patient should be treated with an oral agent with a fairly rapid onset of action, such as clonidine, labetalol, captopril, or prazosin. Topical nitroglycerin is also an option. Nifedipine may cause unpredictable blood pressure reduction and should be avoided. The patient may be discharged to resume his usual medications after his symptoms have improved and his blood pressure is below 160–180/110 mm Hg, with follow-up within a week.
A 53-year-old female who typically jogs 8–10 miles per week presents to your office with pain on the anterior part of her left kneecap that increases with running and when she goes up or down stairs. She has been taking ibuprofen, 600 mg three times daily, with partial relief. Plain film radiographs are negative.
Which one of the following is the most likely diagnosis?
A) Iliotibial band syndrome
B) Osgood-Schlatter disease
C) Osteochondritis dissecans
D) Patellofemoral osteoarthritis
E) Patellofemoral pain syndrome
ANSWER: E
This patient presents with the classic symptoms of patellofemoral pain syndrome. The pain is in the anterior knee and increases during weight-bearing activities when the knee is flexed, as well as with prolonged sitting and descending stairs. Iliotibial band syndrome usually involves lateral pain and tenderness over the lateral femoral condyle. Osgood-Schlatter disease occurs in adolescents and is characterized by tenderness and swelling over the patellar tendon insertion at the tibial tubercle. Both osteochondritis dissecans and patellofemoral osteoarthritis would show abnormal findings on plain film radiographs.
A 26-year-old female with a history of bipolar disorder sees you for follow-up of chronic joint pain. The review of systems is positive for intermittent rashes on the dorsal hands and face and left-sided pleuritic chest pain. An examination reveals tender swelling of the hand and wrist joints bilaterally. Examination of the lungs reveals diminished breath sounds at the left base with point-of-care ultrasonography findings consistent with a small pleural effusion. Initial laboratory tests are significant for a platelet count of 96,000/mm3 (N 130,000–450,000), a positive antinuclear antibody test with a 1:80 titer (N <1:40), and negative Lyme disease and HIV tests.
Which one of the following would help confirm your suspected diagnosis?
A) Elevated anticyclic citrullinated peptide antibodies
B) Elevated anti–smooth muscle antibodies
C) Elevated anti-centromere antibodies
D) Low complement levels
E) Positive HLA-B27
ANSWER: D
The clinical findings on examination, including symmetric polyarthritis, thrombocytopenia, positive antinuclear antibodies (ANAs), and pleural effusion, meet the American College of Rheumatology criteria for a diagnosis of systemic lupus erythematosus (SLE). The rash and the patient’s neuropsychiatric history may also factor into the diagnosis, but they are not described specifically in this case. A positive ANA is sensitive but not specific for SLE. Although additional laboratory testing may not be needed to confirm SLE in this case due to classic clinical findings, low complement levels help confirm SLE and may be helpful because the ANA is only mildly elevated.
Elevated anticyclic citrullinated peptide antibodies help confirm a diagnosis of rheumatoid arthritis. Anti–smooth muscle antibodies are used to confirm autoimmune hepatitis, which can also cause an elevated ANA. Anti-centromere antibodies, a subset of ANAs, are more closely associated with systemic sclerosis. A positive HLA-B27 test is associated with the seronegative spondyloarthropathies, such as psoriatic arthritis.