Ortho
Acne appearing at which one of the following ages should prompt detailed endocrine laboratory testing for possible underlying systemic disease?
A) 3 weeks
B) 7 months
C) 5 years
D) 9 years
E) 13 years
ANSWER: C - 5 years
As many as 20% of newborns will be affected by neonatal acne, usually in the form of pustules confined to the cheeks, chin, eyelids, and forehead. This is typically mild, self-limited, and best managed by reassuring the parents. Acne can also appear in infants, typically males 6–12 months of age, and is also usually self-limited and not associated with underlying endocrine pathology in the absence of any other findings suggesting hormonal abnormalities such as clitoromegaly, breast or testicular development, pubic hair growth, hirsutism, or a growth abnormality consistent with increased muscle development. Acne appearing during mid-childhood is rare and, if present, warrants referral for extensive laboratory testing to identify an underlying endocrine abnormality. Preadolescents and adolescents are very likely to develop acne as a result of normal ovarian/testicular development. In the absence of other findings to suggest an endocrine problem, developing an effective treatment regimen is most appropriate for these individuals
A 58-year-old male with a 30-pack-year smoking history comes to your office to discuss screening for COPD. His older brother and sister have both recently been diagnosed with COPD and he wants to be screened for this soon. He continues to smoke and does not express a desire to quit. He does not have shortness of breath, cough, orthopnea, paroxysmal nocturnal dyspnea, or dyspnea on exertion. His only medication is aspirin, 81 mg daily. He has never used inhaled medications such as albuterol (Proventil, Ventolin). His family history is otherwise negative. You counsel him on tobacco cessation today. Which one of the following is recommended with regard to COPD screening for this patient?
A) No screening
B) Spirometry with pre- and postbronchodilator testing
C) Posteroanterior and lateral chest radiographs
D) Noncontrast CT of the chest
E) a1-Antitrypsin deficiency gene testing
ANSWER: A
All patients with a smoking history and symptoms of COPD such as a chronic cough with sputum production and/or chronic and progressive dyspnea should be screened for COPD with spirometry. However, asymptomatic individuals such as this patient should not be screened with spirometry regardless of risk factors. Neither chest radiography nor chest CT has a role in screening for COPD. Screening for a1-antitrypsin deficiency in the absence of a family history is not recommended.
A 15-year-old female presents with a 3-month history of intermittent abdominal pain and headaches. She does not have any associated weight loss, fever, nausea, change in bowel habits, or other worrisome features. An examination is unremarkable. She does report being stressed at school and has a PHQ-2 score of 4. Which one of the following would be most appropriate at this point?
A) Further evaluation for depression
B) Laboratory studies
C) Abdominal imaging
D) Citalopram (Celexa)
E) Fluoxetine (Prozac)
ANSWER: A - Further evaluation for depression
The U.S. Preventive Services Task Force recommends depression screening for all adolescents 12–18 years of age. Although this patient has abdominal pain, the history and physical examination suggest that depression may be playing a role in her somatic complaints. She had a positive initial depression screen on her PHQ-2. This is a brief screening tool, and a positive result merits further evaluation. The evaluation should include a full PHQ-A or a discussion with a qualified clinician. If the patient meets the criteria for major depressive disorder then she should receive treatment for her depression, which could include medication. Both fluoxetine and citalopram have been approved by the FDA to treat depression in this age group. She could also be referred for psychotherapy. Further laboratory studies and imaging may be appropriate at some point, but the most urgent need is to evaluate her positive depression screen.
Which one of the following factors related to pregnancy and delivery increases the risk of developmental dysplasia of the hip in infants?
A) A large-for-gestational age infant
B) Twin birth
C) Breech presentation
D) Cesarean delivery
E) Premature birth
ANSWER: C - Breech presentation
Risk factors for developmental dysplasia of the hip in infants include a breech presentation in the third trimester, regardless of whether the delivery was cesarean or vaginal. Other indications to evaluate an infant for this condition include a positive family history, a history of previous clinical instability, parental concern, a history of improper swaddling, and a suspicious or inconclusive physical examination. Twin birth, a large-for-gestational age infant, and prematurity are not considered risk factors.
A 7-year-old female with asthma is brought to your office because of her fourth episode of wheezing in the last 3 months. She has also had to use her short-acting -agonist rescue inhaler more frequently. Which one of the following should be added to reduce the frequency of asthma exacerbations?
A) A leukotriene receptor antagonist
B) A long-acting -agonist
C) An inhaled corticosteroid
D) Inhaled cromolyn via nebulizer
ANSWER: C - An inhaled corticosteroid
Pediatric asthma is the most commonly encountered chronic illness, occurring in nearly one out of seven individuals. Short-acting -agonists in the form of metered-dose inhalers are clearly favored for acute exacerbations, as well as for intermittent asthma. Treatment for persistent asthma requires the use of inhaled corticosteroids, with short-acting -agonists used for exacerbations. For patients not well controlled with those options, either a long-acting -agonist or a leukotriene receptor antagonist may be added. While both cromolyn and nedocromil are fairly devoid of adverse effects, their use is limited because of a lack of efficacy in the prevention of acute asthma exacerbations.
You are initiating pharmacologic therapy for a 75-year-old patient with depression. Which one of the following would be most appropriate for this patient?
A) Amitriptyline
B) Escitalopram (Lexapro)
C) Imipramine (Tofranil)
D) Paroxetine (Paxil)
ANSWER: B - Escitalopram (Lexapro)
Escitalopram is a preferred antidepressant for older patients (SOR C). Paroxetine should generally be avoided in older patients due to a higher likelihood of adverse effects (SOR C). Amitriptyline, imipramine, and paroxetine are highly anticholinergic and sedating, and according to the Beers Criteria, they can cause orthostatic hypotension. They have an “avoid” recommendation (SOR A).
You see a 3-year-old female with a 2-day history of intermittent abdominal cramps, two episodes of emesis yesterday, and about five watery, nonbloody stools each day. She does not have a fever, her other vital signs are normal, and she has not traveled recently. Today she has tolerated sips of fluid but still has mild fatigue and thirst. An examination is normal except for mildly dry lips. A friend at preschool had a similar illness recently. Which one of the following would be the most appropriate initial management of this patient?
A) A sports drink and food on demand
B) Half-strength apple juice and food on demand
C) Ginger ale and no food yet
D) Water and no food yet
E) A bolus of intravenous normal saline and no food yet
ANSWER: B - Half-strength apple juice and food on demand
Family physicians often see patients with diarrheal illnesses and most of these are viral. Patients sometimes have misconceptions about preferred fluid and feeding recommendations during these illnesses. The World Health Organization recommends oral rehydration with low osmolarity drinks (oral rehydration solution) and early refeeding. Half-strength apple juice has been shown to be effective, and it approximates an oral rehydration solution. Its use prevents patient measurement errors and the purchase of beverages with an inappropriate osmolarity. Low osmolarity solutions contain glucose and water, which decrease stool frequency, emesis, and the need for intravenous fluids compared to higher osmolarity solutions like soda and most sports drinks. Water increases the risk of hyponatremia in children. This patient is not ill enough to need intravenous fluids. Early refeeding has been shown to decrease the duration of illness.
A 60-year-old male presents with a several-month history of a dry cough and progressive shortness of breath with exertion. On examination he has tachypnea and bibasilar end-inspiratory dry crackles, and a chest radiograph reveals interstitial opacities. Which one of the following patient occupations would most likely support a diagnosis of silicosis?
A) Baker
B) Firefighter
C) Stone cutter
D) Goat dairy farmer
E) High-tech electronics fabricator
ANSWER: C - Stone cutter
Family physicians should be aware of the environmental exposures associated with pulmonary disease. Stone cutting, sand blasting, mining, and quarrying expose patients to silica, which is an inorganic dust that causes pulmonary fibrosis (silicosis). Occupational exposure to beryllium, which is also an inorganic dust, occurs in the high-tech electronics manufacturing industry and results in chronic beryllium lung disease. Exposure to organic agricultural dusts (fungal spores, vegetable products, insect fragments, animal dander, animal feces, microorganisms, and pollens) can result in “farmer’s lung,” a hypersensitivity pneumonitis. Other organic dust exposures, such as exposures to grain dust in bakers, can lead to asthma, chronic bronchitis, and COPD. Firefighters are at risk of smoke inhalation and are exposed to toxic chemicals that can cause many acute and chronic respiratory symptoms.
An 85-year-old female with advanced Alzheimer’s disease is brought to your office for treatment of agitation, aggressive behavior, and delusions. Behavioral and psychological interventions have had little success and the family is willing to try medications because they prefer to keep the patient at home. Which one of the following would most likely help control this patient’s symptoms?
A) Alprazolam (Xanax)
B) Aripiprazole (Abilify)
C) Clozapine (Clozaril)
D) Donepezil (Aricept)
E) Haloperidol
ANSWER: B - Aripiprazole (Abilify)
Nonpharmacologic interventions are the first-line treatment for patients with behavioral and psychological symptoms of dementia. Antipsychotic medications can be prescribed for refractory cases but this is an off-label use. Both the patient and family should be aware that the use of atypical antipsychotics for behavioral symptoms of dementia is associated with increased mortality. Patients should be monitored for side effects and the medication should be discontinued if there is no evidence of symptom improvement after a month. Typical antipsychotics such as haloperidol have significant side effects and would not be a good choice. Donepezil is initiated early in the course of Alzheimer’s disease to delay progression of the disease. Benzodiazepines are likely to cause significant side effects including sedation, increased confusion, and falls. Several of the antipsychotics, such as ziprasidone and clozapine, are ineffective. Results with olanzapine, quetiapine, and risperidone are inconsistent. Aripiprazole produces small reductions in behavioral and psychological symptoms of dementia, and it has the least adverse effects of the atypical antipsychotics.
A 45-year-old female who works as a house cleaner presents with left shoulder pain. On examination she has pain and relative weakness when pushing toward the midline against resistance while the shoulder is adducted and the elbow is bent to 90°. With the elbow still at 90° she is unable to keep her left hand away from her body when you position her hand behind her back. This presentation is most consistent with an injury of which one of the following tendons?
A) Deltoid
B) Infraspinatus
C) Subscapularis
D) Supraspinatus
E) Teres minor
ANSWER: C - Subscapularis
This patient’s pain and weakness while pushing against resistance reveals weakness on internal rotation of the shoulder, which suggests a possible tear of the subscapularis tendon. The inability to keep her hand away from her body when it is placed behind her back describes a positive internal lag test, also suggesting involvement of the subscapularis tendon. The infraspinatus and teres minor are involved in external rotation rather than internal rotation. The supraspinatus and deltoid are involved in abduction of the shoulder.
A 5-month-old female is brought to your office for evaluation of a fever to 103.1°F over the past 2 days. Her immunizations are up to date. On examination she does not appear ill. Her vital signs include a rectal temperature of 39.0°C (102.2°F), a heart rate of 90 beats/min, a respiratory rate of 40/min, and an oxygen saturation of 98% on room air. The child is alert and responsive, appears well hydrated, and has no rash or petechiae. The HEENT examination, including fontanelles, is normal, the chest is clear, there are no murmurs, and the abdomen is soft. Which one of the following would be most appropriate at this time?
A) No further testing or treatment at this visit, with close outpatient follow-up
B) A urinalysis and culture, with close outpatient follow-up
C) A CBC with differential, a urinalysis and culture, and close outpatient follow-up
D) A CBC, a urinalysis and culture, a chest radiograph, a lumbar puncture, and consideration of inpatient monitoring
E) A CBC with differential, blood cultures, a urinalysis and culture, a chest radiograph, a lumbar puncture, and empiric inpatient antibiotic treatment
ANSWER: B - A urinalysis and culture, with close outpatient follow-up
For children with a fever without localizing signs, management depends on the child’s age and findings on examination. For children 3–36 months of age with a fever <39°C (102°F), reassurance that this is likely a self-limited viral infection is appropriate, with instructions to return if there are new signs or symptoms. If the temperature is >39° and the child has received appropriate vaccines on schedule, then a urinalysis and culture should be performed for all children <6 months of age and for uncircumcised boys <2 years of age. A more extensive workup would be appropriate for children <3 months of age.
A 62-year-old female has a history of COPD graded as moderate on pulmonary function testing, with an FEV1 of 65% of predicted and a PaO2 of 57 mm Hg. Because her symptoms of dyspnea on exertion and fatigue seem out of proportion to her pulmonary function tests, you order echocardiography, which shows a pulmonary artery systolic pressure of 50 mm Hg, indicating pulmonary hypertension. Which one of the following would be most effective for decreasing mortality in this situation?
A) Supplemental oxygen
B) An endothelin receptor antagonist such as bosentan (Tracleer)
C) A calcium channel blocker such as nifedipine (Procardia)
D) A phosphodiesterase 5 inhibitor such as sildenafil (Revatio)
E) Referral for pulmonary artery endarterectomy
ANSWER: A - Supplemental oxygen
The only proven therapy for pulmonary hypertension related to COPD is supplemental oxygen. Supplemental oxygen should be recommended when the PaO2 is <60 mm Hg, because it has been shown to improve mortality by lowering pulmonary arterial pressures. Treatments effective for pulmonary artery hypertension should not be used. Pulmonary vasodilators such as nifedipine, sildenafil, and bosentan may cause a ventilation-perfusion mismatch. Pulmonary endarterectomy may be indicated for pulmonary hypertension caused by chronic thromboembolic disease.
Intensive behavioral intervention has more benefit than other treatment modalities in treating children who have been diagnosed with
A) attention-deficit/hyperactivity disorder
B) autism
C) depression
D) obsessive-compulsive disorder
E) posttraumatic stress disorder
ANSWER: B - autism
The only evidence-based treatment that confers significant benefits to children with autism is intensive behavioral interventions, which should be initiated before 3 years of age. Attention-deficit/hyperactivity disorder can be treated with cognitive-behavioral therapy (CBT) but medication is often required. CBT is as effective, if not more effective, than medication for treating anxiety, depression, and trauma-related disorders.
A 73-year-old male with advanced degenerative arthritis of the knees asks what you would recommend for relief. He does not wish to have a total knee replacement. He says that NSAIDs have not been effective. Which one of the following would be the best recommendation?
A) Acetaminophen
B) Intra-articular corticosteroids
C) Intra-articular hylan GF 20 (Synvisc)
D) Physical therapy for quadriceps strengthening
E) Tramadol (Ultram)
ANSWER: D - Physical therapy for quadriceps strengthening
Quadriceps-strengthening exercises have been shown in good studies to stabilize the knee and reduce pain for patients with degenerative arthritis. Acetaminophen has not been shown to produce clinically significant improvement from baseline pain. Intra-articular corticosteroids can acutely relieve pain and effusions but do not affect moderate-term outcomes. Hylan GF 20 products are minimally effective. Opiates and other similar drugs are addictive and should be avoided.
In addition to group B Streptococcus (GBS), which one of the following is the most common cause of neonatal sepsis?
A) Escherichia coli
B) Group A Streptococcus
C) Listeria monocytogenes
D) Staphylococcus aureus
E) Streptococcus pneumoniae
ANSWER: A - Escherichia coli
Newborns with sepsis may have focal signs of infection such as pneumonia or respiratory distress syndrome, but they also may have nonfocal signs and symptoms. In the newborn period the two most common causes of neonatal sepsis are group B Streptococcus and Escherichia coli. Listeria monocytogenes was once a more common cause but it is now uncommon. Streptococcal pneumonia is an uncommon cause of sepsis in neonates. Staphylococcus aureus and group A Streptococcus are not as common but should be considered in newborns with cellulitis.
A 45-year-old female has a history of intermittent asthma and her only medication is an albuterol (Proventil, Ventolin) inhaler. Over the past 2 months her asthma has limited her activities. She is using her inhaler daily and waking up at night once or twice a week with a cough. Which one of the following would be the preferred medication to control her asthma?
A) Fluticasone (Flovent)
B) Salmeterol (Serevent Diskus)
C) Fluticasone/salmeterol (Advair)
D) Montelukast (Singulair)
ANSWER: C - Fluticasone/salmeterol (Advair)
This patient has intermittent asthma that has become at least moderate persistent as defined by the frequency of her symptoms. The National Asthma Education and Prevention guidelines recommend a moderate-dose inhaled corticosteroid (ICS) with a long-acting bronchodilator as the preferred treatment in moderate persistent asthma. Fluticasone/salmeterol at a dosage of 250/50 g is the only option that fits this category. Montelukast alone is an alternative treatment for mild persistent asthma (SOR A).
A 30-year-old female who gave birth to a healthy infant 3 months ago has had mildly depressed moods almost daily for the last 7 weeks. She takes very little joy in daily activities and interacting with her baby. She is exclusively breastfeeding and has difficulty sleeping. She says that she felt fine during the first month after the delivery, and has not experienced any homicidal or suicidal ideations. You rule out postpartum psychosis and bipolar disorder. Which one of the following would be most appropriate at this point?
A) Reassurance only
B) A home health visit
C) Oral contraceptives
D) Trazodone (Oleptro)
E) Referral for psychotherapy
ANSWER: E - Referral for psychotherapy
This patient has peripartum depression. All women should be screened for depression during pregnancy and the postpartum period (SOR B). Reassurance may be appropriate for the baby blues, which usually start 2–3 days after birth and last less than 10 days. First-time mothers, adolescent mothers, and mothers who have experienced a traumatic delivery may benefit from home health visits or peer support to prevent but not treat peripartum depression. Mild to moderate peripartum depression can be treated with psychotherapy or SSRIs, with consideration of medications with the lowest serum medication levels in breastfed infants. Tricyclic antidepressants such as trazodone are not considered first-line treatment for peripartum depression.