Medical Jeopardy

USPSTF

100

In which population does the U.S. Preventive Services Task Force support ultrasound screening for abdominal aortic aneurysm?

Men 65-75 years old how have ever smoked (100 cigarettes or more) The U.S. Preventive Services Task Force (USPSTF) recommends one-time screening for abdominal aortic aneurysm (AAA) by ultrasonography in men age 65–75 who have ever smoked (Grade B recommendation). The USPSTF recommends against routine screening for AAA in women (Grade D recommendation).

200

A 58-year-old healthy white female sees you for a routine visit. She is monogamous with her husband, is a nonsmoker, has two alcoholic drinks a week, and has mild GERD. Her BMI is normal. She takes an over-the-counter H2-blocker and a multivitamin with calcium. She had a normal mammogram 1 month ago and a negative colonoscopy at age 53. She has never had a DXA scan or screening for ovarian cancer. Her family history is noncontributory. What should she be screened for?

The U.S. Preventive Services Task Force (USPSTF) and the Centers for Disease Control and Prevention (CDC) recommend that all adults age 65 years and under be screened for HIV regardless of risk factors. The USPSTF does not recommend routine screening for ovarian cancer with a bimanual examination, transvaginal ultrasonography, or CA-125 testing. The USPSTF recommends that women age 65 and older be screened for osteoporosis with a DXA scan. Women younger than age 65 should be screened only if their risk of fracture is equal to or greater than a 65-year-old white female with no additional risk factors. The USPSTF recommends that women age 50–75 be screened for colorectal cancer with colonoscopy every 10 years OR with flexible sigmoidoscopy every 5 years plus fecal occult blood testing (FOBT) every 3 years OR with FOBT annually.

300

A 5 year old female with no known past medical history presents for her WCC. Mother does not have any concerns. What should the patient be screened for if anything?

The USPSTF recommends vision screening for all children at least once between the ages of 3 and 5 years, to detect the presence of amblyopia or its risk factors.

400

A 69-year-old male sees you for a routine evaluation. He has been in good health and takes no medication other than tamsulosin (Flomax) for symptoms of benign prostatic hyperplasia. He has never smoked. His blood pressure is 121/78 mm Hg, pulse rate 72 beats/min, and respiratory rate 18/min. His general physical examination is unremarkable, including cardiac and abdominal examinations. A digital rectal examination reveals mild enlargement of the prostate, without nodules. What should he be screened for?

What is Hep C. The U.S. Preventive Services Task Force recommends one-time screening for hepatitis C for individuals born between the years 1945 and 1965 (USPSTF B recommendation).

500

Define grade C recommendation.

The USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small.

Mama and baby

100

A 2 1⁄2-year-old male is brought to the emergency department with the acute onset of diffuse abdominal pain that began approximately 6 hours ago. He has also had 3 episodes of bilious emesis in the last 2 hours. A review of systems is positive for anorexia today but negative for fever, weight loss, diarrhea, and bloody stools. On examination the patient’s height and weight are in the 50th percentile for age, his blood pressure is normal, his heart rate is 110 beats/min, and his temperature is 36.9°C (98.4°F). Cardiovascular and pulmonary examinations are unremarkable. The abdominal examination is significant for slightly hypoactive bowel sounds and diffuse tenderness to palpation without rebound, guarding, or rigidity. A genitourinary examination is normal. Which one of the following studies is the most appropriate next step to diagnose the cause of abdominal pain in this patient? A) Scrotal ultrasonography B) Abdominal ultrasonography C) Abdominal and pelvic CT D) An upper gastrointestinal series

D. In young children with bilious emesis, anorexia, and lack of fever, the most likely diagnosis is intestinal malrotation with volvulus. Abdominal ultrasonography is less sensitive and specific for malrotation than an upper gastrointestinal series, so an upper GI series should be ordered initially if volvulus is suspected. If appendicitis were suspected, ultrasonography would be preferred. CT is not a good choice because of the amount of radiation it delivers, especially given efforts to decrease the use of CT in children unless absolutely necessary. This patient’s presentation is not typical for testicular torsion, therefore scrotal ultrasonography should not be the initial test of choice.

200

A 31-year-old gravida 1 para 0 presents for a routine visit at 32 weeks gestation. She has gestational diabetes mellitus (GDM) and has been following the dietary guidelines from her dietitian. However, her blood glucose is still elevated and you discuss starting medications for management of her GDM. She is adamant about not starting insulin but is willing to consider taking metformin (Glucophage). Before making a decision she would like to know the specific benefits to her and her baby. You would tell her that one benefit of treatment of GDM is a decreased risk for A) maternal type 2 diabetes mellitus after delivery B) maternal preeclampsia C) perinatal death D) a small-for-gestational-age infant

B. Many outcomes for both the mother and infant are improved with pharmacologic management of GDM. These include a decreased risk for operative delivery, large-for-gestational-age infants, shoulder dystocia, and maternal preeclampsia. Although a significant percentage of women with GDM subsequently develop type 2 diabetes mellitus after delivery, pharmacologic treatment of GDM has not been shown to decrease that risk. In addition, neither perinatal death nor the likelihood of small-for-gestational-age infants is significantly affected. The risk of neonatal hypoglycemia has also not consistently been shown to be affected by treatment.

300

A 35-year-old nulligravida sees you for preconception counseling. She has hypothyroidism treated with levothyroxine (Synthroid), and her most recent TSH level was in the therapeutic range. She has no symptoms of hypothyroidism. Which one of the following is the patient most likely to require if she becomes pregnant? A) A decreased dosage of levothyroxine B) An increased dosage of levothyroxine C) The addition of liothyronine (Cytomel) D) Substitution of desiccated thyroid hormone preparation (Armour Thyroid) for the levothyroxine

B Thyroid hormone requirements increase during pregnancy. Most women with hypothyroidism who become pregnant require an increased levothyroxine dosage (SOR A). A common recommendation is to have women on fixed daily doses of levothyroxine begin taking nine doses weekly (one extra dose on 2 days of the week) as soon as the pregnancy is confirmed (SOR B). Thyroid function tests should be repeated regularly throughout the pregnancy to guide additional dosage adjustments.

400

The mother of a 6-month-old male tells you that he sometimes wheezes while feeding, and this is occasionally associated with a cough. Changing his position does not help. Which one of the following is the most likely diagnosis? A) Tracheoesophageal fistula B) Laryngeal cleft C) Gastroesophageal reflux disease D) Foreign body aspiration E) Tracheomalacia

C. There are many causes of wheezing in infants and children. Wheezing associated with feeding is most commonly due to gastroesophageal reflux disease (level of evidence 3). Tracheoesophageal fistula and laryngeal cleft also cause wheezing associated with feeding, but are rare. Foreign body aspiration is most common between 8 months and 4 years of age and the child is most likely to have a history of the sudden onset of wheezing associated with choking. The wheezing present with tracheomalacia is position related.

500

What are the criteria for kawasaki disease and what is the treatment?

fever be present for 5 days or more with no other explanation. In addition, at least four of the following symptoms must be present: (1) nonexudative conjunctivitis that spares the limbus; (2) changes in the oral membranes such as diffuse erythema, injected or fissured lips, or “strawberry tongue”; (3) erythema of the palms and soles, and/or edema of the hands or feet followed by periungual desquamation; (4) cervical adenopathy in the anterior cervical triangle with at least one node larger than 1.5 cm in diameter; and, (5) an erythematous polymorphous rash, which may be targetoid or purpuric in 20% of cases. Current recommendations are to hospitalize the patient for treatment with intravenous immune globulin. In addition, aspirin is used for both its anti-inflammatory and antithrombotic effects. While prednisone is used to treat other forms of vasculitis, it is considered unsafe in Kawasaki disease, as a study has shown an extraordinarily high rate of coronary artery aneurysm with its use.

Age is in the eye of the beholder

100

An 80-year-old male consults you because he has become constipated. A routine screening evaluation was negative 8 months ago. He admits that he has been less active in the last month because of pain in his knees. He also has been using an over-the-counter antihistamine for “hay fever” symptoms. Appropriate initial measures include which of the following? (Mark all that are true.) A) Increased intake of fluid and dietary fiber B) Increased physical activity C)Bulking agents (e.g., Metamucil) D) Polyethylene glycol (MiraLax) E) Low-dose stimulant laxatives

A and B. Fluid softens stool and counterbalances the effects of many medications that tend to dry the stool. Fiber also softens stool consistency by adding bulk (SOR C). Increased physical activity stimulates bowel motility, decreasing constipation (SOR B). Bulking agents should not be used until nonmedical therapy has been tried (SOR B). Polyethylene glycol may cause electrolyte disturbances and cramping, and should not be used unless dietary changes and increased physical activity fail to resolve the problem (SOR B). Stimulant laxatives may also produce cramping and electrolyte disturbances (SOR B).

200

Indications for checking the TSH level in elderly patients include which of the following? (Mark all that are true.) A) The initial workup for dementia B) The initial workup for depression C) A BMI >28.0 kg/m2 and no recent weight change D) Routine monitoring of patients taking lithium E) Routine monitoring of patients taking amiodarone (Cordarone)

A, B, D, E Hypothyroidism may cause symptoms of dementia or depression (SOR A). Patients on lithium therapy may develop hypothyroidism (SOR A), and patients on amiodarone therapy are at risk for developing hypo- or hyperthyroidism (SOR A). There is no evidence that checking a TSH level is beneficial in patients who are moderately overweight with no recent weight changes (SOR C).

300

An 81-year-old female has recently developed symptoms of mild cognitive impairment. She has multiple chronic medical problems, including depression, hypertension, heart failure, diabetes mellitus, and urinary incontinence. Her medications include amitriptyline, digoxin, oxybutynin (Ditropan), hydrochlorothiazide, and metformin (Glucophage). Which of the patient’s medications could potentially be causing her cognitive problems? (Mark all that are true.) A) Amitriptyline B) Digoxin C) Hydrochlorothiazide D) Metformin E) Oxybutynin

A, B, E. The use of anticholinergic medications is a risk factor for developing mild cognitive impairment (MCI), even in young adults. Even though they belong to different classes of medications, amitriptyline, digoxin, and oxybutynin all have anticholinergic properties and can cause MCI (SOR B). Hydrochlorothiazide and metformin do not have anticholinergic properties, and have not been associated with an increased risk of MCI (SOR B).

400

A 78-year-old male with a previous history of hypertension and chronic atrial fibrillation has a transient ischemic attack (TIA). True statements regarding anticoagulation and antiplatelet therapy in this patient include which of the following? (Mark all that are true.) A) Treatment with warfarin (Coumadin) will reduce his risk of recurrent stroke B) Aspirin will be as effective as warfarin for reducing his risk of stroke C) The combination of aspirin and clopidogrel (Plavix) is better than aspirin alone in reducing the risk of stroke in this patient D) Aspirin should be prescribed if there is a contraindication to anticoagulation E) The target INR in this patient is 2.0–3.0

A, D, E Meta-analyses of randomized, controlled trials (RCTs) have shown that anticoagulants reduce the risk of stroke in patients at high risk of stroke who have atrial fibrillation (SOR A). In persons WITHOUT atrial fibrillation, anticoagulation with warfarin has not been shown to be more effective than aspirin therapy for secondary stroke prevention. Aspirin can be used in patients who have contraindications to anticoagulation, but it is not as effective (SOR A). Aspirin and clopidogrel insignificantly reduces the risk of secondary stroke compared to aspirin alone, but significantly increases the risk of life-threatening bleeding (SOR A). INR below 2.0 is not effective for stroke prevention and that an INR above 3.0 considerably raises the risk of hemorrhage (SOR A).

500

Which one of the following aspects of drug metabolism changes least with age? Distribution Absorption Hepatic clearance Renal elimination

B. Despite age-related changes in small bowel surface area and increases in gastric pH, changes in absorption are trivial or clinically insignificant (SOR A). With aging, the body’s fat compartment increases and the water compartment decreases, increasing the volume of distribution for highly lipophilic drugs, which may in turn increase their elimination half-life. The rapid reductions in serum albumin seen with acute illness or malnutrition may enhance drug effects because serum levels of unbound drug may increase (SOR A). Overall hepatic metabolism of many drugs through the cytochrome P-450 enzyme system decreases with aging, as does elimination of drugs requiring multiple-stage metabolism (SOR A). Creatinine clearance decreases an average of 8 mL/min/1.73 m2/decade, increasing the circulating levels of drugs eliminated by the kidneys. Renal elimination is also dynamic, in that illness, dehydration, or recent recovery from dehydration may require adjustment of maintenance medication dosages (SOR A).

MSK

100

The most common level of lumbar disc herniation occurs at L1-L2 L2-L3 L3-L4 L4-L5 L5-S1

L5-S1

200

A 54-year-old male presents with progressively worsening pain just below his right knee. He describes the pain as deep and aching, and says it is always present throughout the day, even while he is at rest, and worsens at night. Weight bearing intensifies the pain, as does heat. The patient does not recall any injury or other reason for the leg to hurt. He has not had any fever. His family history is positive for osteoarthritis in both parents when they were older, and an uncle has had a knee replacement. A physical examination is negative except for some varus deformity of the right lower extremity just below the knee. There is no redness. Radiographs demonstrate mild to moderate bowing of the proximal tibia. His alkaline phosphatase level is elevated but his glutamyl transaminase level is normal. The remainder of a comprehensive metabolic panel is also normal. A CBC is normal, including the WBC count and differential. Name his condition.

What is Paget’s disease Patients with bone pain caused by Paget’s disease usually describe the pain as continuous. Unlike osteoarthritis, the bone pain of Paget’s disease usually increases with rest, when the limbs are warmed, and at night. A variety of deformities may occur, including bowing of the tibia, and alkaline phosphatase is elevated. The case presented is not typical for osteoarthritis or osteoporosis, and the patient does not have a fever, elevated WBC count, or other findings suggestive of osteomyelitis.

300

An 11-year-old male is brought to your office for evaluation of bilateral posterior heel pain that has occurred for the past few months. He plays basketball and soccer several times a week and the pain begins several minutes into each of these activities. There is no pain at rest or with walking. The patient has not noticed any numbness, tingling, or weakness. On examination you find no swelling or tenderness of the heel or Achilles tendon. Reflexes, strength, and range of motion at the ankle are intact, but he does have bilateral posterior heel pain when you passively dorsiflex the ankles. Which one of the following is the most likely diagnosis? A) Achilles tendinopathy B) Calcaneal apophysitis C) Plantar fasciitis D) Heel pad syndrome E) Tarsal tunnel syndrome

B. Calcaneal apophysitis, also known as Sever disease, is the most common etiology of heel pain in children, usually occurring between 5 and 11 years of age. It is thought that in these children the bones grow faster than the muscles and tendons. A tight Achilles tendon then pulls on its insertion site at the posterior calcaneus with repetitive running or jumping activities, causing microtrauma to the area. There may be swelling and tenderness in this area and passive dorsiflexion may increase the pain. Radiography is usually normal and therefore does not often aid in the diagnosis, but it may reveal a fragmented or sclerotic calcaneal apophysis. Treatment involves decreasing pain-inducing activities, anti-inflammatory or analgesic medication if needed, ice, stretching and strengthening of the gastrocnemius-soleus complex, and the use of orthotic devices.

400

Which one of the following is a risk factor for prolonged recovery from a sports-associated concussion? A) Blurred vision B) Headache lasting longer than 60 hours C) Amnesia for the injury D) Loss of consciousness at the time of injury E) Convulsions following the injury

B The majority of symptoms associated with sports-related concussions resolve within 72 hours of injury. However, some concussions result in prolonged recovery periods. Risk factors associated with a prolonged recovery include headaches lasting 60 hours or more, self-reported fatigue or fogginess, and four or more symptoms at the onset of injury (SOR B). Loss of consciousness and amnesia have NOT been found to be related to recovery time. Convulsions associated with the injury are benign and do not affect prognosis. Nausea is one of the symptoms of concussion, but by itself is not a risk factor for prolonged recovery.

500

What are the ottawa rules for ankle and foot injuries.

FOOT: midfoot pain AND Bone tenderness at the base of the fifth metatarsal (for foot injuries), OR Bone tenderness at the navicular bone (for foot injuries), OR An inability to bear weight both immediately and in the emergency department for four steps. ANKLE: malleolar zone pain AND Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus, OR Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus, OR An inability to bear weight both immediately and in the emergency department for four steps.

Anything

100

Which one of the following accurately describes the classic rash of erythema migrans? A) Scattered individual purple macules on the ankles and wrists B) An annular rash with a bright red outer border and partial central clearing C) A dry, scaling, dark red rash in the groin, with an active border and central clearing D) A diffuse eruption with clear vesicles surrounded by reddish macules E) A migratory pruritic, erythematous, papular eruption

B. An annular rash with a bright red outer border and partial central clearing is characteristic of erythema migrans. It is important to remember that not all lesions associated with Lyme disease look this way, and that some patients with Lyme disease may not have any skin lesions at all. Rocky Mountain spotted fever causes scattered individual purple macules on the ankles and wrists. A dry, scaling, dark red rash in the groin, with an active border and central clearing, is seen with tinea cruris. A diffuse eruption with clear vesicles surrounded by reddish macules is found in chickenpox. A migratory pruritic, erythematous, papular eruption is most consistent with urticaria.

200

A 39-year-old female presents with lower abdominal/pelvic pain. On examination, with the patient in a supine position, you palpate the tender area of her lower abdomen. When you have her raise both legs off the table while you palpate the abdomen, her pain intensifies. Which one of the following is the most likely diagnosis? A) Appendicitis B) A hematoma within the abdominal wall musculature C) Diverticulitis D) Pelvic inflammatory disease E) An ovarian cyst

B. A reduction of the pain caused by abdominal palpation when the abdominal muscles are tightened is known as Carnett’s sign. If the cause of the pain is visceral, the taut abdominal muscles may protect the locus of pain. In contrast, intensification of pain with this maneuver points to a source of pain within the abdominal wall itself.

300

A 44-year-old male with papulopustular rosacea sees you for follow-up. You have been treating his condition with topical azelaic acid (Finacea), and although his condition is improved he is not satisfied with the results. You suggest adding which one of the following oral medications? A) Clarithromycin (Biaxin) B) Clindamycin (Cleocin) C) Doxycycline D) Erythromycin E) Metronidazole (Flagyl)

C The only FDA-approved oral treatment for acne rosacea is doxycycline at a subantimicrobial dosage (40 mg daily). This does not contribute to antibiotic resistance, even when used over several months, and is better tolerated than higher dosages. Other antibiotics have limited and low-quality supporting evidence of efficacy and may lead to antibiotic resistance.

400

A 50-year-old female with a history of refractory hypertension presents with abdominal pain. Her laboratory results are significant for a positive Helicobacter pylori antibody. You decide to initiate treatment for her H. pylori infection with sequential therapy using the following drug regimen: rabeprazole (Aciphex) plus amoxicillin, followed by clarithromycin (Biaxin) plus tinidazole (Tindamax). She is currently on multiple medications for her hypertension. Which one of her antihypertensive agents would be most affected by the treatment regimen described? A) Amlodipine (Norvasc) B) Clonidine transdermal (Catapres-TTS) C) Hydrochlorothiazide D) Metoprolol tartrate (Lopressor) E) Ramipril (Altace)

A Amlodipine is metabolized by the cytochrome P450 3A4 enzyme. Clarithromycin is a strong 3A4 inhibitor that can slow the metabolism of calcium channel blockers metabolized by this enzyme, thus increasing their levels. This can lead to hypotension, edema, and acute kidney injury due to decreased renal perfusion.

500

What are the 5 foundational principles of the patient centered medical home.

Comprehensiveness: Most preventive, acute, and chronic care for individual patients can be performed at the PCMH. Patient Centered: The PCMH provides care that is relationship-based, with an orientation toward the whole person. Coordination: The PCMH coordinates care for patients across all elements of the health care system. Accessibility: The PCMH works to provide patients with timely access to providers. Quality: The PCMH continuously works to improve care quality and safety.