Peds
A 6-week-old female is brought to your office by her parents to establish care after the family recently moved from out of state. The infant was born at term after an uncomplicated normal spontaneous vaginal delivery but failed her initial newborn hearing screen in the right ear only. Both parents are confident that she is able to hear out of both ears because she turns her head toward their voices regardless of where they are standing. A physical examination is within normal limits.
Which one of the following would be the most appropriate next step in response to this patient’s
abnormal hearing screen?
No further testing
A bilateral audiology evaluation before 3 months of age
A bilateral audiology evaluation at 6 months of age
A bilateral audiology evaluation at 12 months of age
A bilateral audiology evaluation immediately before entering kindergarten
B. A bilateral audiology evaluation before 3 months of age
All newborns should have a bilateral hearing screen completed before hospital discharge. For infants that fail the initial hearing screen in one or both ears, a repeat bilateral audiology evaluation should be performed before 3 months of age to ensure early identification of hearing loss and therefore maximize
speech perception and development.
A 42-year-old female who owns a bakery presents with a several-month history of gradually worsening pain, swelling, and paresthesia affecting her entire right arm whenever she has to blend ingredients by hand. She says that her “arm veins pop out” and her arm develops a deep aching pain if she has to stir mixes for very long. The pain and swelling have become so severe that she is no longer able to make wedding cakes and is concerned she will be unable to continue running her business. She does not recall any trauma and has no swelling in her left arm. She has a history of essential hypertension that is treated with losartan (Cozaar). On examination the patient has full active range of motion and the Neer and Hawkins impingement tests of the shoulder are negative.
Based on this patient’s history and the physical examination findings, which one of the following is the most likely diagnosis?
ANSWER: 4
Thoracic outlet syndrome can be differentiated into neurogenic, venous, or arterial, with neurogenic being the most common, constituting more than 95% of cases. This patient has venous thoracic outlet syndrome, which is the second most common, occurring in about 3% of cases. Swelling of the arm with associated pain strongly suggests obstruction of the subclavian vein. Paresthesias in the fingers and hand are common, likely due to swelling rather than nerve compression at the thoracic outlet. Venous thoracic outlet syndrome is easily identified by swelling, cyanosis, and distention of superficial veins in the arm. Due to the exceptionally high risk of developing a venous thrombosis, patients should undergo diagnostic evaluation with upper extremity venous duplex ultrasonography. False negatives are common in patients without a thrombus and in such cases the patient may benefit from evaluation with either contrast-enhanced upper extremity CT or magnetic resonance venography. If a thrombosis is present anticoagulation should be started immediately and catheterization of the vein should be performed with thrombolysis with or without
balloon angioplasty. Ultimately the patient will require surgical decompression.
You admit a 68-year-old female with an acute stroke to the hospital. She has no other acute cardiovascular conditions. CT rules out a hemorrhagic event. You have determined that the patient is not a candidate for reperfusion therapy with alteplase or thrombectomy.
You advise the nursing staff that you will be initiating antihypertensive therapy if the patient’s blood pressure rises above a threshold of
ANSWER: 4
Because patients with an acute ischemic stroke may require the increased perfusion pressure to limit ischemia, antihypertensive therapy should not be given during the first 48–72 hours as long as they are not candidates for, or recipients of, reperfusion therapy with alteplase or thrombectomy; do not have a comorbid condition requiring acute blood pressure lowering; and do not have a blood pressure >220/120
mm Hg.
A patient’s office spirometry results de onstrate an obstructive pattern. This would be seen with
which one of the following?
ANSWER: 2
Office spirometry can be very helpful in the development of a differential diagnosis. The differential can be narrowed with the use of office spirometry, as many conditions create either an obstructive or restrictive pattern. Of the options listed, only cystic fibrosis can cause an obstructive pattern. Other causes of an obstructive pattern include asthma, COPD, 1-antitrypsin deficiency, and bronchiectasis, among others. Common diseases or conditions causing restrictive patterns include adverse reactions to nitrofurantoin, methotrexate, and amiodarone. Chest wall conditions such as kyphosis, scoliosis, and morbid obesity can also cause restrictive patterns. Interstitial lung disease, including idiopathic pulmonary fibrosis,
sarcoidosis, and asbestosis, also causes a restrictive pattern (SOR A).
The mother of a 6-month-old infant is concerned that her child’s feet are “deformed.” On examination the heel bisector line is between the third and fourth digits on the right foot and on the third digit on the left foot. You attempt to flex the feet, and both appear to be rigid.
Which one of the following would you recommend as a corrective intervention?
A) Night splints
E) Surgical correction
B. Adjustable orthotic shoes
Adjustable orthotic shoes in infants who are not yet walking can be effective for the treatment of metatarsus adductus (SOR B). These orthotics can be adjusted to apply an abduction force on the forefoot while maintaining the heel in a neutral position. Night splints, braces, and physical therapy are not indicated or proven to correct this deformity. Surgery has high complication rates and is rarely indicated to treat metatarsus adductus.
According to the Ottawa knee rule, a radiograph would be indicated for a patient presenting with an acute knee injury if the examination reveals tenderness to palpation over the
ANSWER: 1: fibular head
Because of the low prevalence and diagnostic yield for clinically significant fractures in patients with acute knee injuries, radiographs should be limited to patients who meet specific evidence-based criteria. The Ottawa knee rule is a validated tool that decreases unnecessary radiographs in patients with an acutely injured knee. Criteria for imaging according to the Ottawa knee rule include any of the following: age
>55, isolated tenderness of the patella, tenderness of the fibular head, inability to flex the knee to 90°, and inability to bear weight for four steps both immediately after the injury and at the time of the examination. In the absence of these findings patients are highly unlikely to have a clinically significant fracture. Pain over the lateral or medial joint line is more likely to result from meniscal derangements or a sprain or rupture of a collateral ligament. Pain over the tibial tubercle is more typical of Osgood-Schlatter disease (tibial apophysitis). Pain over the upper medial aspect of the tibia suggests pes anserine bursitis.
. A 15-year-old female is brought to your office by her parents for evaluation because they are concerned about her restrictive eating patterns and weight loss. The patient is unconcerned about these issues and says that she feels well and does not need any evaluation. Her parents tell you that for the past 6 months she has had an increasingly restricted diet to the point that she now drinks only water and eats only vegetables and roasted chicken or turkey. They report that she looks much thinner now than she did 6 months ago, but they are uncertain how much weight she has lost. She says that she does not feel depressed or anxious and she is doing well in school.
On examination she has a height of 163 cm (64 in) and a weight of 43 kg (95 lb), with a BMI of 16 kg/m2. She has a pulse rate of 52 beats/min and a blood pressure of 102/68 mm Hg while seated and 84/58 mm Hg while standing. Evaluation of her teeth shows significant erosion of the enamel.
When considering the psychotherapy aspect of care for this patient, which one of the following is preferred for treatment of her condition?
ANSWER: 3
This patient has anorexia nervosa, likely a combination of the restrictive subtype and the binge-eating and purging subtype, given the dental findings on examination. This condition is difficult to treat and carries significant risk of mortality, with an estimated aggregate mortality of 5.6% per decade. Coexisting psychiatric conditions are common, with major depression, anxiety disorders, obsessive-compulsive disorder, and trauma-related disorders predominating. Medical complications include disorders of the esophagus and stomach related to repeated vomiting; cardiovascular conditions associated with bradycardia, orthostatic hypotension, and arrhythmias; renal disease due to chronic dehydration and electrolyte abnormalities; and osteoporosis and bone marrow abnormalities. Treatment may be provided in inpatient or outpatient settings, depending on the severity of disease. Psychotherapy is the foundation of treatment and parental involvement is key for children and adolescents. Parents or guardians typically have a high level of distress around their child’s condition and family therapy helps provide consistent support for treatment goals set by the care team. Other types of one-on-one therapy may be appropriate to augment family therapy and for adolescents with specific comorbidities. Psychotropic drugs have not been consistently and clearly shown to add benefit to psychotherapy, although they are often prescribed.
You diagnose nonvalvular atrial fibrillation in a 54-year-old male. His CHA2DS2-VASc score is 2.
Which one of the following should you recommend as first-line therapy for stroke prevention?
ANSWER: 3
Direct oral anticoagulants such as apixaban, betrixaban, dabigatran, edoxaban, and rivaroxaban are first-line agents for prevention of stroke in patients with nonvalvular atrial fibrillation with a CHA2DS2-VASc score 2 in men or 3 in women. For patients with atrial fibrillation without valvular heart disease, forgoing antithrombotic therapy is only appropriate in patients with a CHA2DS2-VASc score of 0 in men and 1 in women. Aspirin should not be considered a substitute for anticoagulation but may be suggested for patients with an unprovoked deep vein thrombosis or pulmonary embolism who do not wish to receive lifelong anticoagulation. Low molecular weight heparin is recommended as the anticoagulant of choice in patients with cancer and venous thromboembolism, although direct anticoagulants may be appropriate in some situations. If a patient has moderate to severe mitral stenosis or a mechanical valve,
then vitamin K antagonists are the preferred agent.
A 4-year-old male is brought to your office by his mother because of a 2-day history of watery diarrhea and vomiting and you diagnose acute gastroenteritis. On examination his mucous membranes are sticky and he has decreased tear production, but his overall appearance is normal and his eyes are not sunken. Using the Clinical Dehydration Scale, you estimate that he has mild (3%–6%) dehydration.
Which one of the following should you recommend?
ANSWER: 2:
An oral rehydration solution is the treatment of choice for mild dehydration in children with acute gastroenteritis. However, prescribing a formal oral rehydration solution is not necessary. A randomized, controlled trial has shown that initial rehydration with diluted apple juice followed by preferred fluids resulted in fewer treatment failures than use of a formal electrolyte solution. This is likely due to the increased likelihood that children will drink preferred fluids due to better taste, tolerability, and ease of administration. Therefore, in high-income countries, this should be the recommended initial treatment for mild dehydration due to gastroenteritis. Intravenous fluids should be reserved for cases of moderate to
severe dehydration. Metoclopramide is not recommended because of potential adverse effects.
A 55-year-old female presents with swelling and some redness in the area of her right ankle that had a gradual onset over the past week. She has not had any injury, fever, or other signs of systemic illness and has no pain. Her past medical history is significant for type 2 diabetes with polyneuropathy that is moderately well controlled, hypertension, hyperlipidemia, and a BMI of 35 kg/m2.
On examination her right ankle and foot are slightly larger than the left, exhibit faint erythema, and feel slightly warmer than the left. No pain is noted with palpation, and her ankle ligaments appear to be intact. Pedal pulses are 2+ bilaterally and she has no calf pain or swelling.
Which one of the following would be the most appropriate next step?
ANSWER: 5:
Acute Charcot neuropathy is a commonly missed diagnosis, and the diagnosis is delayed in up to 25% of cases. The diagnosis should be considered in patients over age 40 with neuropathy and obesity who present with unilateral foot swelling. There may be associated erythema and warmth, and pain may be absent. In a patient with suspected acute Charcot neuropathy, bilateral weight-bearing radiographs are recommended to detect fractures of the midfoot. Acute Charcot neuropathy is frequently painless, and its consequences can be severe, so it would be inappropriate to counsel a patient that lack of pain means the absence of serious disease. Charcot neuropathy is commonly misdiagnosed as cellulitis. In this patient’s presentation, cellulitis is not a clear diagnosis, and Charcot neuropathy needs to be considered before initiating treatment for cellulitis. Compression stockings and leg elevation are appropriate for peripheral edema when other causes of edema have been evaluated and addressed, but in this case the swelling is lower on the leg than what compression stockings would usually treat, and further evaluation is required prior to treatment. There is no evidence for ankle sprain or instability in this patient, so an ankle brace would not be
appropriate.
An 85-year-old male with hypertension and coronary artery disease comes to your office for a routine wellness visit. He is accompanied by his wife, who notes that the patient’s memory has been worsening over the last few years. His current medications include carvedilol (Coreg), losartan (Cozaar), hydrochlorothiazide, and aspirin.
A brief screening test is positive for cognitive impairment. The Saint Louis University Mental Status (SLUMS) examination places the patient in the dementia category. You order further testing, including a TSH level, a CBC, a comprehensive metabolic panel, and a vitamin B12 level.
Which one of the following should also be included in the workup?
ANSWER: 1
Depression in the elderly can cause symptoms similar to those of dementia. Also, many patients with dementia concurrently have depression. It is recommended that depression be treated first if found (SOR C). If cognitive symptoms improve with depression treatment, pseudodementia is diagnosed.
The recommended workup for dementia includes a TSH level, a CBC, a comprehensive metabolic panel, and a vitamin B12 level; depression screening; and noncontrast MRI of the brain. MRI of the brain is recommended to rule out stroke, mass, or hydrocephalus. If MRI cannot be performed, then CT is indicated.
Testing for the apolipoprotein E epsilon 4 allele is not a diagnostic test for Alzheimer’s dementia. It can be ordered for children of affected individuals to assess risk of developing the disease. An EEG would be useful if the patient also experienced seizures, but it is not routinely indicated. A PET scan is not appropriate in the evaluation for dementia. Cerebrospinal fluid (CSF) testing is indicated for patients with rapidly progressive symptoms of dementia. Testing for infection and prior disease can be accomplished
through CSF analysis.
In patients diagnosed with COPD, testing should be considered for which one of the following
underlying conditions?
ANSWER: 1
Clinicians should consider measuring the 1-antitrypsin level in all symptomatic COPD patients with fixed airflow obstruction, particularly with a COPD onset as early as the fifth decade of life; a family history of 1-antitrypsin deficiency; and emphysema, bronchiectasis, liver disease, or panniculitis in the absence of a recognized risk factor. Identifying this condition is particularly important because current smokers should be urged to quit, given that they are at high risk for accelerated lung function decline, and also to consider intravenous pooled human 1-antitrypsin, which has been shown to reduce declines in lung function and lung density measured on chest CT. In this patient, testing for cystic fibrosis,
hemochromatosis, Williams syndrome, or Wilson’s disease would not be indicated.
An 18-month-old female develops immune thrombocytopenic purpura following MMR administration in your clinic. She requires hospitalization and extensive treatment. The child does not have any health insurance coverage.
The child’s family could be eligible for compensation by the
ANSWER: 4: National vaccine injury compensation program
Common reactions to vaccines are typically mild and include pain or swelling at the injection site, fever, drowsiness, and rash. Serious adverse reactions to vaccines are less common, and in some cases are rare, but can include serious allergic reaction to a vaccine ingredient, febrile seizure, immune thrombocytopenic purpura, and intussusception. The National Childhood Vaccine Injury Act of 1986 established the no-fault National Vaccine Injury Compensation Program for patients and families who were injured by recommended vaccines. This law requires documentation of the manufacturer and lot number of the administered vaccine. Physicians also must document that they have provided their patients with current vaccine information statements. The program is funded by an excise tax on vaccines. Compensation for vaccine injury is not available from the clinic's malpractice insurance or the vaccine manufacturer's
liability coverage.
A 48-year-old runner presents with anterior knee pain. He says that the pain developed insidiously and is worse at the beginning of a run and immediately following a run. There is no history of injury. An examination suggests patellar tendinopathy.
Which one of the following treatment modalities has the best evidence of long-term effectiveness in improving this condition?
ANSWER: 2: Eccentric quad exercises
Patellar tendinopathy may persist for years and may be refractory to treatment. Eccentric quadriceps-strengthening exercises have the best evidence for long-term improvement of the condition. NSAIDs provide only temporary pain relief and do not improve the condition. Corticosteroid injections may predispose tendons in weight-bearing joints such as the patellar tendon to rupturing, so they should be used sparingly for short-term pain relief only. Injection of the tendon with sclerosing agents may also provide pain relief but there is no high-quality evidence of long-term effectiveness in improving this condition. Surgical treatment combined with rehabilitation was found in one study to be inferior to
eccentric exercises alone.
A 29-year-old male tells you that several years ago he was physically assaulted while walking home from work. Since the assault he has experienced insomnia, anhedonia, irritability, and vivid flashbacks and intrusive thoughts about the assault.
Using a screening tool and structured interview you make a diagnosis and discuss treatment. Which one of the following would be the best evidence-based recommendation for initial treatment?
ANSWER:5
Posttraumatic stress disorder (PTSD) is regularly seen in primary care practices, with estimated incidences of 8%–20% in the general population. Expert guidelines recommend screening adults at risk of PTSD, such as this patient who was exposed to a traumatic event, with standardized screening tools and then using a structured interview tool if the screen is positive. Once the diagnosis is established, individual trauma-focused psychotherapy is the intervention that demonstrates the most significant benefit. Pharmacotherapy may be used if psychotherapy is not effective or available. Recommended options include fluoxetine, paroxetine, venlafaxine, or sertraline. Benzodiazepines and escitalopram are not recommended in the treatment of PTSD. Dialectical behavioral therapy is used in the treatment of borderline personality
disorder.
A 66-year-old male presents to your office with a 1-week history of dyspnea with minimal exertion but no chest pain. He has had mild hemoptysis. An examination reveals a pulse rate of 100 beats/min but no other remarkable findings. A chest radiograph, CBC, and metabolic panel are normal, but his D-dimer level is elevated at 750 ng/mL (N <500).
Which one of the following would be the next step in the evaluation?
ANSWER: 2
Pulmonary embolus is reliably diagnosed with CT pulmonary angiography (CTA), but there is now a simple diagnostic algorithm to reduce the reliance on CTA. The simplified recommendations for ordering CTA are a D-dimer 1000 ng/mL, or a D-dimer that is >500 ng/mL and hemoptysis, signs of deep vein thrombosis, or a suspicion that pulmonary embolism is the most likely diagnosis.
A BNP level would be useful in detecting heart failure, and an EKG would be more helpful if ischemic heart disease were suspected. Pulmonary arteriography is invasive and carries a higher risk. A
ventilation-perfusion scan has less risk but is not as accurate.
was born at 35 weeks and 5 days gestation by normal vaginal delivery after induction of labor for maternal preeclampsia with severe features. The infant was discharged with the mother on the third day of life. There were no additional complications noted. Today the parents report exclusive breastfeeding and tell you the infant spits up after longer feedings. Voiding and stooling are as expected and the infant’s development is normal. The weight at birth was at the 20th percentile, and today’s weight is at the 25th percentile.
Which one of the following would be the most appropriate intervention at this time?
ANSWER: 2
In 2018, 1 in 10 infants born in the United States were preterm, with significant racial and ethnic differences noted. Breastfed infants born before 37 weeks gestation should receive iron supplementation at 2 mg/kg/day after 1 month of life. This infant does have some physiologic reflux but since this infant appears asymptomatic, the parents should be counseled on behavioral techniques to reduce spitting up, as there is no clear long-term benefit to antireflux medication. This infant’s growth and development are normal so there is no indication for caloric fortification of breast milk, which is more appropriate for small-for-gestational-age infants or those born below the 10th percentile. There is no specific recommendation for micronutrient supplementation other than iron and vitamin D, so there is no indication to initiate vitamin E supplementation. This child should be screened for developmental delay at each office
visit, but there is currently no evidence of delay so referral to early intervention is not indicated.
. An otherwise healthy 72-year-old male presents with a 4-week history of catching and triggering of his right middle finger. When he awakens in the morning the finger is locked in flexion at the proximal interphalangeal joint and he has to manually extend the finger. He enjoys playing golf and painting, both of which are compromised by the triggering of his finger. He has not had any pain or numbness.
Which one of the following would you tell him regarding his treatment options for this condition?
ANSWER: 2
This patient presents with trigger finger, which has a lifetime prevalence of 2%–3% in the adult population, with higher prevalence rates in patients with diabetes mellitus. There are several options for conservative treatment that are appropriate prior to consideration of surgical release. Splinting, which is a first-line treatment, has been shown to be effective. Single-joint orthoses at either the metacarpophalangeal or the proximal interphalangeal joint can be effective (SOR B). The duration of splinting can range from 6 weeks to 3 months.
A retrospective case series analysis of trigger finger managed by observation only found that trigger finger resolved spontaneously in 52% of patients, with the majority resolving within 1 year.
Corticosteroid injections are generally effective but efficacy depends on the severity of the condition and on the number of fingers involved. They are more effective than NSAID injections (SOR B). Surgical release is considered the most effective treatment but not the most cost-effective. A series of three corticosteroid
injections could result in savings of up to $72,000 in one study.
. Which one of the following psychoactive medications would create the greatest risk of
respiratory depression if used in combination with an opioid?
ANSWER: 4
The FDA has issued a safety communication about combining benzodiazepines with either opioids or cough medications. The FDA expressed its strongest warning due to the risk of central nervous system (CNS) depression and respiratory depression. Also, the 2016 CDC guideline for prescribing opioids for chronic pain recommended specifically that clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible.
While caution should be exercised with all medication combinations, there has not been a specific FDA warning about the risks of combining opioids with amitriptyline, bupropion, escitalopram, or trazodone. Antipsychotics, barbiturates, benzodiazepines, hypnotics, muscle relaxants, and opioid analgesics are
associated with an increased risk of CNS depression.
An 18-year-old female comes to the urgent care clinic because of worsening nausea and vomiting, itching, and a dry cough that began about 30 minutes after she ate lunch at a nearby restaurant. She tells you that she did not experience any choking while eating her lunch, and she has not had any dysphagia, rash, or diarrhea. She takes no medications, and her past medical history is significant only for a severe nut allergy. She says that she was feeling well before today. An examination is notable only for a blood pressure of 88/60 mm Hg, mildly labored breathing, and bilateral expiratory wheezes.
At this point you would administer
ANSWER: 3
Most anaphylactic reactions occur outside of the hospital setting, and early treatment decreases both hospitalizations and mortality. This patient presents with respiratory, dermatologic, cardiovascular, and gastrointestinal symptoms, which are common in anaphylaxis. Tree nut and peanut allergies are risk factors for severe reactions. Early treatment with intramuscular epinephrine and attention to airway, breathing, and circulation are the first steps for treatment. Adjunct medications can be considered after epinephrine, but antihistamines have an onset of action of 1 hour and corticosteroids have an onset of action of 6 hours. Albuterol may be considered as an adjunct but its use does not address the urgent need to resolve
anaphylaxis symptoms first.
A 2-year-old male with a barking cough is brought to the urgent care clinic by his parents. He is noted to have stridor when agitated and mild retractions. He has a normal level of consciousness, good air entry, and no evidence of cyanosis.
Which one of the following treatment modalities would be most appropriate?
ANSWER: 1: Dexamethasone
Based on the Westley Croup Score, this patient has mild croup. Corticosteroids should be used in the treatment of croup regardless of the degree of severity. Dexamethasone is preferred because it can be given in a single dose and administered either orally, parentally, or intravenously. Heliox is a helium and oxygen mixture that theoretically decreases airflow resistance but there is no clear evidence to support its use at this time. Humidified air inhalation has not been shown to have a clinical benefit in terms of croup scores or hospital admissions. Nebulized epinephrine should be reserved for patients with moderate to severe croup. Oxygen should be administered if there are signs of hypoxemia or severe respiratory distress.
A 14-year-old female is brought to your office after a school screening program identified possible scoliosis. She plays basketball at school and has no history of recent injuries. She is feeling well today and a review of systems is negative. A physical examination reveals an elevated right rib on the forward bend test. Radiography demonstrates a Cobb angle of 15°.
Which one of the following would be most appropriate at this point?
ANSWER: A
Despite a lack of consensus between major health care organizations on the benefit of screening for scoliosis, more than half of states require or recommend school-based screening programs. Adolescent idiopathic scoliosis is generally defined as a lateral curvature of the spine or Cobb angle 10°. Cases with a Cobb angle <20° can generally be managed with observation. In this asymptomatic patient there would be no reason to suspend sports participation. Moreover, suspension of sports activity may worsen or contribute to psychologic distress experienced by those with this disorder. In a U.S. Preventive Services Task Force evidence report and systematic review, bracing did decrease progression of the Cobb angle but it did not improve patient-oriented outcomes and did have associated harms. Physical therapy does not have consistent evidence of benefit. Therefore, bracing and physical therapy should be reserved for more
severe cases. Surgical evaluation is reserved for severe cases or those with a Cobb angle 40°.
A 63-year-old male presents for advice on smoking cessation. He was recently hospitalized with acute coronary syndrome and is highly motivated to quit smoking. He says that he has quit several times in the past but never for an extended period of time. He currently smokes 10 cigarettes per day. In addition to behavioral support resources such as 1-800-QUIT-NOW, you decide to prescribe a nicotinic receptor partial agonist.
Which one of the following belongs to this class of medications?
ANSWER: 5
Varenicline, an alpha4-beta2 notine withdrawal by activating the nicotine receptor and producing about 50% of the effect of nicotine. It also prevents tobacco smoke nicotine from binding to the receptor. Acamprosate is a gamma-aminobutyric acid (GABA) agonist and glutamate antagonist that is effective for the treatment of alcohol use disorder. Bupropion is a norepinephrine-dopamine reuptake inhibitor that reduces nicotine withdrawal and the reward from tobacco smoking. Clonidine is an alpha 2-adrenergic agonist, and it has been shown to assist with smoking cessation but is not FDA approved for this purpose. Naltrexone is a pure opioid receptor antagonist that is effective for
the treatment of alcohol use disorder and opioid use disorder.
A 62-year-old male with hypertension and metabolic syndrome sees you for follow-up. A fasting triglyceride level is 300 mg/dL. You address lifestyle and other potential causes of his elevated triglycerides, including his current medications.
If included in his current regimen, which one of the following hypertension medications would be most likely to contribute to his hypertriglyceridemia?
ANSWER: 4
Several medications can be secondary causes of hypertriglyceridemia, including -blockers, with the exception of carvedilol. Others include oral estrogens, glucocorticoids, bile acid sequestrants, protease inhibitors, retinoic acid, anabolic steroids, sirolimus, raloxifene, tamoxifen, and thiazides. Calcium channel blockers, ACE inhibitors, and angiotensin receptor blockers are not associated with
hypertriglyceridemia.
A 15-year-old basketball player presents with a 3-week history of bilateral knee pain that is greater in the left knee. The pain increases with jumping, walking down stairs, and kneeling. He has not had any recent injury. He tells you that he has grown more than 5 inches in the past year. A physical examination is notable for tight quadriceps and hamstrings, and tenderness to palpation over the tibial tuberosity bilaterally.
Which one of the following is the most likely diagnosis?
ANSWER: 3
Apophysitis is a traction injury at the bony site of the tendon attachment. It most often occurs in children or adolescents who are rapidly growing. Rapid growth results in bone lengthening, which occurs more rapidly than lengthening of the associated muscle and tendons. Osgood-Schlatter disease is one type of apophysitis affecting the patellar tendon attachment at the proximal tibia. Anterior cruciate ligament tears will present with joint laxity and meniscal tears with joint line tenderness. Anterior cruciate ligament and medial meniscus tears are usually associated with trauma, especially in younger patients. A patellar sleeve fracture results from a similar type of apophysitis (Larsen-Johansson disease), which affects the patellar tendon attachment at the lower pole of the patella. It most often occurs in athletic children between the ages of 10 and 12. Patellofemoral pain syndrome may present with a similar history, but the pain is generally
felt under the patella and localized tenderness over the tibial tuberosity is not present.
A healthy 50-year-old male with no significant past medical history comes to your office for a health maintenance examination. He does not take any medications and does not smoke cigarettes or drink alcohol. He tells you that a friend who is his age recently had an acute myocardial infarction and he would like testing to help decrease his own risk. On examination he has a BMI of 30 kg/m2.
In addition to checking his lipid profile and hemoglobin A1c, evidence supports which one of the following to assess his risk of cardiovascular disease?
ANSWER: 1
The U.S. Preventive Services Task Force recently concluded that there is insufficient evidence to assess the risk-benefit ratio of screening asymptomatic adults for cardiovascular disease risk by checking an ankle-brachial index, a high-sensitivity C-reactive protein level, or a coronary artery calcium score. The PLAC test is used to measure lipoprotein-associated phospholipase A2 (Lp-PLA2), an enzyme that breaks down oxidized LDL in the vascular wall. High levels of Lp-PLA2 are thought to promote atherosclerotic plaque formation. Analysis of studies concluded that Lp-PLA activity does not add significant information
to the standard evaluation of cardiovascular risk.