"Feeling Blue"
A 26-year-old female presents with symptoms of anhedonia and anxiousness. Your evaluation leads to a diagnosis of major depressive disorder. The patient consents to medical treatment and counseling, but she is engaged to be married in 2 months and is concerned that antidepressants may lower her libido even further.
Which one of the following would be best for reducing the likelihood of sexual dysfunction?
A. Bupropion (Wellbutrin)
B. Paroxetine (Paxil)
C. Fluoxetine (Prozac)
D. Sertraline (Zoloft)
What is Bupropion?
Paroxetine has been found to cause higher rates of sexual dysfunction than bupropion, fluoxetine, and sertraline. Bupropion has been found to have significantly lower rates of adverse effects on sexual function than fluoxetine or sertraline.
The most common identifiable cause of skin and soft-tissue infections presenting to metropolitan emergency departments is:The most common identifiable cause of skin and soft-tissue infections presenting to metropolitan emergency departments is:
A. Staphylococcus epidermidis
B. Streptococcus pneumoniae
C. Pseudomonas aeruginosa
D. methicillin-resistant Staphylococcus aureus (MRSA)
E. Bacillus cereus
What is methicillin-resistant Staphylococcus aureus (MRSA)?
Recent clinical experience has shown that methicillin-resistant Staphylococcus aureus (MRSA) is the most
common identifiable cause of skin and soft-tissue infections among patients presenting to emergency
departments in 11 U.S. cities. The other responses should be considered in evaluating these infections,
but they are not as common as MRSA infections.
An 82-year-old female is hospitalized for pneumonia and sepsis. She has advance directives in place.
Should it become necessary, the patient’s decision-making capacity is determined by:
A. The spouse or next of kin
B. The attending physician
C. A consulting psychiatrist
D. A judge, at the request of hospital social services or the physician
Who is the attending Physician?
The attending physician is responsible for determining capacity and incapacity for decision making. The extent, cause, and probable duration og any incapacity should be documented in the clinical record.
A 25-year-old female presents with a maculopapular rash that has progressed to multiple areas and exhibits target lesions. A cold sore appeared on her upper lip 2 days before the rash appeared. She is not systemically ill and is on no medications.
Which one of the following is true concerning this problem?
A. Herpes simplex virus is a likely cause
B. A skin biopsy will confirm the diagnosis
C. The lesions usually disappear within 24 hours
D. The palms of the hands and soles of the feet are not involved
E. Scarring from the lesions is often seen after resolution
What is Herpes simplex is the most common cause?
Herpes simplex virus is the most common etiologic agent of erythema multiforme. Other infections, particularly Mycoplasma pneumoniae infections and fungal infections, may also be associated with this hypersensitivity reaction. Other causes include medications and vaccines. Skin biopsy findings are not specific for erythema multiforme. As opposed to the lesions of urticaria, the lesions of erythema multiforme usually are present and fixed for at least 1 week and may evolve into target lesions. The palms of the hands and soles of the feet may be involved. The lesions of erythema multiforme usually resolve spontaneously over 3–5 weeks without sequelae. Ref: Lamoreux MR, Sternbach MR, Hsu WT: Erythema multiforme. Am Fam Physician 2006;74(11):1883-1886.
Increasing patient copayments for prescription medications results in:
A. an increase in the number of prescriptions filled by low-income medical-assistance recipients
B. little demonstrable change in purchasing patterns
C. increased hospitalizations for patients with chronic illnesses
D. improved efficiency in the utilization of outpatient medical services
What is increased hospitalizations for patients with chronic illnesses?
Increasing prescription copayments results in a decrease in the number of prescriptions filled and worsening clinical outcomes for patients with heart failure, diabetes mellitus, hyperlipidemia, and schizophrenia. With each 10% increase in copayments, it is estimated that overall prescription spending decreases 2%–6%. The cited study found that up to 25% of Medicaid recipients, faced with a copayment, could not afford to fill at least one prescription in the previous year.
A 27-year-old male with a diagnosis of depression prefers to avoid pharmacologic treatment. You agree to engage in a trial of therapy in your office. During the treatment process, you help the patient realize that some of his perceptions and interpretations of reality may be false and lead to negative thoughts. Next, you help him discover alternative thoughts that reflect reality more closely, and to learn to discard his previous distorted thinking. By learning to substitute healthy thoughts for negative thoughts, he finds his mood, behavior, and physical reaction to different situations are improved.
Which one of the following best categorizes this type of therapy?
A. Psychoanalysis
B. Biofeedback
C. Cognitive therapy
D. Group psychotherapy
E. Hypnosis therapy
What is cognitive therapy?
This patient is engaged in cognitive therapy, which is a treatment process that helps patients correct false self-beliefs that can lead to negative moods and behaviors. Cognitive therapy has been shown to effectively treat patients with unipolar major depression, and is particularly useful in patients who do not respond to medication or who prefer nonpharmacologic therapy.
Psychoanalysis is a process of free association where repressed memories are recovered. Biofeedback involves instrumentation that gives feedback about a patient’s physiologic response to various situations in order to bring the autonomic nervous system under voluntary control. Group psychotherapy is a form of treatment in which people who are emotionally ill meet in a group guided by a trained therapist and help one another effect personality change. Hypnosis involves helping a patient enter a state of heightened focal concentration and receptivity that is typified by a feeling of involuntariness or an altered state of consciousness.
A 45-year-old female presents with a complaint of pain and swelling in her right index finger of 2 days’ duration. She reports that 5 days ago she had artificial nails applied, which she removed yesterday due to the pain. She used hydrogen peroxide on the finger, but it did not help. She denies any systemic symptoms or fever. On examination there is erythema and swelling in the lateral nail fold of the right index finger, with purulent material noted.
Which one of the following would be the most appropriate treatment for this patient? (check one)
A. Removal of the proximal nail fold
B. Topical corticosteroids
C. Topical antibiotics
D. Topical antifungals
What are topical antibiotics?
This is a common presentation for acute paronychia, which typically is caused by local trauma to the nail fold or cuticle, with resulting inoculation and infection. Topical antibiotics, with or without topical corticosteroids, is one treatment option. Other options include warm compresses, oral antibiotics, and incision and drainage; however, incision and drainage is not always necessary. Removal of the proximal nail fold is used to treat chronic paronychia that is not responsive to other treatments. Topical corticosteroids can be used alone for chronic paronychia, but if used for acute paronychia, they should be combined with antibiotics since acute paronychia is typically caused by a bacterial infection. Topical antifungals are a treatment option for chronic paronychia, which can be associated with a fungal infection, but not for acute paronychia.
Which one of the following is appropriate at the routine postpartum visit?
A. A CBC
B. Screening for depression
C. Thyroid function tests
D. Glucose tolerance testing
E. A urine dipstick
What is screening for depression?
Screening for postpartum depression is recommended as part of the routine postpartum visit. The use of a screening tool for depression is recommended, such as the Edinburgh Postnatal Depression Scale. This scale has been shown to increase the identification of women at high risk for depression. A CBC or urine dipstick is recommended only for patients who have an indication for them, and should not be routinely ordered. Thyroid function tests and glucose tolerance testing are recommended for patients who are either symptomatic or at high risk for disease.
The parents of a 2-week-old boy report that his skin turns a blotchy reddish-blue color when he is cold. He is otherwise well. A physical examination in your warm office is unrevealing but the parents have photos on their smartphones that show reticular erythematous patches over the legs and trunk. Which one of the following is the most likely diagnosis?
A. Cutis marmorata.
B. Dermal melanocytosis.
C. Erythema toxicum neonatorum.
D. Neonatal acne.
E. Transient neonatal pustular melanosis.
A. Cutis marmorata is a common vascular phenomenon among neonates. It is characterized by transient, symmetric, erythematous, reticular patches along the trunk and extremities, triggered by exposure to cold and resolved with warming
The 1990 Patient Self-Determination Act requires that:
A. the process for advance directives be standardized for all 50 states
B. a living will be implemented for patients upon admission to the hospital
C. hospitals ask patients about advance directives
D. verbally expressed wishes be honored for individuals who do not have a written advance directive
What is ask patients about advance directives?
The 1990 Patient Self-Determination Act (PSDA) requires hospitals, nursing homes, and health care programs to ask patients about advance directives and then incorporate the information into medical records. The living will, a written advance directive, allows a competent person to indicate his or her health care preferences while cognitively and physically healthy. A living will may list medical interventions the patient wishes to have withheld or withdrawn when he or she becomes unable to communicate. Another type of advance directive, the durable power of attorney for health care, allows persons to designate a proxy (or surrogate) to make decisions for them if they become incapacitated.
Although PSDA mandates that patients be asked about their advance directive status upon admission to the hospital, it does not require hospitals or individual physicians to offer patients an opportunity to complete an advance directive. The acceptance and precision of verbal preferences varies from state to state. Although verbal discussions are binding in many states, five states require “clear and convincing evidence of patient preferences.” In California, Delaware, Michigan, Missouri, and New York, advance directives must include such evidence regarding a specific condition and/or treatment, even if a durable power of attorney states prior general verbal preferences. Therefore, lack of an advance directive may result in continued medical interventions to preserve life even if the patient may not want such treatment.
A 70-year-old female becomes psychotic and risperidone (Risperdal) is prescribed. Which one of the following should be used to monitor the patient for adverse cardiac effects of this drug?
A. Serum sodium levels
B. Echocardiography
C. Nuclear stress testing
D. Lower-extremity venous duplex ultrasonography
E. Electrocardiography
What is EKG?
Both typical and atypical antipsychotics can cause prolongation of the QTc interval, resulting in torsades
de pointes, ventricular tachycardia, and sudden death. The best way of monitoring the QTc interval is
electrocardiography.
A 25-year-old female has an annular rash on the dorsal surface of both hands. The rash does not respond to initial treatment with an antifungal medication, and a biopsy reveals granuloma annulare.
Which one of the following would be the most appropriate advice for this patient?
A. Allow the rash to resolve without further treatment
B. Cover the rash because it is contagious
C. Treat the rash with systemic corticosteroids
D. Treat the rash with a stronger antifungal medication
What is allowing the rash to resolve without further treatment?
Granuloma annulare is a self-limited condition. It is not contagious, and therefore would not need to be covered to prevent transmission. Treatments may include injected or topical corticosteroids, but oral corticosteroids have not been specifically recommended. It may be necessary to refer the patient to a dermatologist because many of the potential treatments can have serious side effects.
Which one of the following statements is true of comparing first-generation and second-generation antipsychotics?
A. First-generation antipsychotics more commonly cause metabolic adverse effects.
B. Second-generation antipsychotics are more likely to improve patient quality of life.
C. Second-generation antipsychotics more commonly cause extrapyramidal symptoms
D. Neither group of antipsychotics is safer than the other
D. Neither group of drugs is safer than the other, although they have different rates of adverse effects
Most cases of congenital dermal melanocytosis resolve without complication. However, extensive skin involvement and persistent or progressive pigmentation over time can be associated with which one of the following conditions?
A. Down syndrome.
B. Huntington disease.
C. Hurler syndrome.
D. Sickle cell disease.
C. Congenital dermal melanocytosis has been observed in neonates with inborn errors of metabolism, most notably mucopolysaccharidosis type I (Hurler syndrome), GM1 gangliosidosis, mucopolysaccharidosis type II (Hunter syndrome), mucolipidosis, Niemann-Pick disease, and mannosidosis. Clinical findings include extensive skin involvement, persistent or progressive pigmentation over time, developmental delay, and failure to thrive
Which one of the following is associated with an increased risk of delirium in hospitalized patients?
A. Not having family members present at the time of admission
B. Vision or hearing impairment
C. Repeated reorientation for patients with cognitive impairment
D. Early mobilization
What are Vision or hearing impairment?
Delirium occurs in 11%–42% of hospitalized patients. Risk factors for delirium in hospitalized patients
include vision impairment, hearing impairment, dehydration, immobility, cognitive impairment, and sleep
deprivation. Repeated reorientation of patients with cognitive impairment, early mobilization, and
minimizing unnecessary noise or stimulation are all effective interventions for reducing the risk of delirium
in hospitalized patients. Not having family members available at the time of admission has no effect on
the incidence of delirium.
Detailed recurrent visual hallucinations are part of the diagnostic criteria for which one of the following major neurocognitive disorders?
A. Major neurocognitive disorder due to Alzheimer disease.
B. Major neurocognitive disorder with Lewy bodies.
C. Major vascular neurocognitive disorder
B.- Three main classes of neuropsychiatric symptoms are observed in patients with dementia due to Lewy body disease: detailed recurrent well-formed visual hallucinations (eg, animals, small individuals), delusions, and misidentification syndromes. Visual hallucinations, which are part of the diagnostic criteria for the disorder, are most common, with a prevalence of up to 83%.
Benign cephalic pustulosis is attributed to which one of the following?
A. Bacterial infection.
B. Malassezia species.
C. Neonatal adrenal activity
D. Newborn exposure to maternal androgens
E. Sebaceous hyperplasia
B. Benign cephalic pustulosis is known to be a result of Malassezia species acquired from parents' normal skin flora.
Which one of the following is an extrapyramidal adverse effect of antipsychotic drugs that can be managed with benzodiazepines and propranolol?
A. Akathisia.
B. Drug-induced parkinsonism
C. Dystonia.
D. Neuroleptic malignant syndrome.
A. Extrapyramidal symptoms are the most common adverse effects related to first-generation antipsychotics. This group of symptoms includes drug-induced parkinsonism, akathisia (ie, a sensation of inner restlessness and inability to remain still), and dystonia. Drug-induced parkinsonism and dystonia can be managed with anticholinergic drugs, whereas akathisia can be managed with benzodiazepines and propranolol. (This is an off-label use of some anticholinergic drugs, benzodiazepines, and propranolol.
A parent brings his ill-appearing, 2-week-old newborn to your office. He reports the newborn is not feeding well and has been fussy. You note a vesiculopapular rash on an erythematous base and consider a diagnosis of herpes simplex virus (HSV) infection. Which one of the following is true of HSV 1 and 2 infections in newborns?
A. HSV cannot be acquired in utero.
B. HSV infections can be localized to the skin, eyes, and mouth or central nervous system but do not manifest in disseminated form.
C. C. Isolation precautions are not recommended until the diagnosis is confirmed.
D. D. Most neonatal infections occur through direct inoculation from the birth canal.
E. E. Transmission from mother to child at birth can be prevented with antiviral prophylaxis.
D. The majority of neonatal herpes simplex virus infection is intrapartum (from an infected birth canal), whereas 5% is acquired in utero.
Which one of the following is true of cognitive behavioral therapy for chronic pain?
A. It has been shown in studies to be ineffective.
B. It has been shown to improve pain and decrease disability over 6 months.
C. It is not an effective short-term therapy for children.
D. It is optimally effective when combined with spinal manipulation.
SKIP THIS QUESTION
B. In a Cochrane review, cognitive behavioral therapy was found to be effective in improving nonheadache pain immediately posttreatment, improving mood, and decreasing catastrophizing outcomes and disability over 6 months.
Which one of the following drugs is an acetylcholinesterase inhibitor that has been shown to reduce behavioral symptoms in patients with dementia?
A. Carbamazepine.
B. Citalopram (Celexa)
C. Galantamine.
D. Ramelteon (Rozerem)
C. Evidence supports the inclusion of acetylcholinesterase inhibitors in the pharmacologic approach to dementia with psychotic symptoms. Donepezil, galantamine, and rivastigmine are approved by the Food and Drug Administration for Alzheimer disease management and have been shown to reduce behavioral symptoms in patients with dementia, including those with psychosis. (Dementia is an off-label use of these drugs.)
Which one of the following is true of erythema toxicum neonatorum?
A. It develops after 7 days of life.
B. It is thought to be caused by an allergic process
C. It may be associated with postinflammatory hyperpigmentation when it resolves.
D. Recommended treatments include low-potency steroid ointments.
E. The trunk typically is spared but the face and extremities may be affected.
B. Although the exact cause of erythema toxicum neonatorum is unknown, studies suggest an allergic process because of high concentrations of eosinophils within lesions, presence of peripheral (blood) eosinophilia, and elevated levels of inflammatory mediators (eg, interleukins, eotaxin, aquaporins, psoriasin, nitric oxide synthases).
The use of clozapine should be restricted because of its risk of causing which one of the following adverse effects?
A. Agranulocytosis.
B. Neuroleptic malignant syndrome.
C. Prolonged QT interval.
D. Tardive dyskinesia.
A. Agranulocytosis.
Which one of the following is a major criterion for the diagnosis of Kawasaki disease?
(read more) A. Annular, hyperkeratotic, red- to salmon-colored plaques on the chest, abdomen, and back.
B. Aphthous ulcers.
C. Bilateral nasal flaring.
D. Cervical lymphadenopathy.
E. Vesiculopapular rash on an erythematous base.
SKIP THIS QUESTION
D. The five major criteria of Kawasaki disease include: nonpurulent bilateral conjunctival injection, mucocutaneous changes of lips and oral cavity (eg, cracked, erythematous lips, strawberry tongue), cervical lymphadenopathy, extremity changes (eg, erythema or desquamation of hands and feet, which may be late findings), and polymorphous rash (eg, maculopapular, scarlatiniform, multiformelike erythema).
Which one of the following is true of using acetaminophen for chronic pain management?
A. The analgesic effect is equivalent to that of nonsteroidal anti-inflammatory drugs.
B. The recommended maximum amount for use in combination products is 325 mg/dose, per the Food and Drug Administration.
C. Its use is contraindicated in patients with renal insufficiency.
D. Its use is safe with no reported gastrointestinal side effects.
B. The Food and Drug Administration has issued warnings and recently reduced the maximum amount of acetaminophen for use in combination products to 325 mg/dose.