Show:
One Flew Over
Beauty Is Skin Deep
The Pen Is
Mightier
Bon Appetit
Heart
100
A 37-year-old female presents with concerns about difficulty initiating and maintaining sleep for the past 3-4 months. She is irritable and feels fatigued and sleepy during the day. After further evaluation, she is diagnosed with chronic insomnia. She asks about alternatives to hypnotic drug treatments. Which one of the following management options is best supported by current evidence? A. Diphenhydramine (Benadryl) B. Cognitive behavior therapy C. St. Johns wort D. 4 oz of red wine 30 minutes before bedtime E. Vigorous aerobic exercise 30-45 minutes before bedtime
B. Cognitive-behavioral therapy helps change incorrect beliefs and attitudes about sleep (e.g., unrealistic expectations, misconceptions, amplifying consequences of sleeplessness). Techniques include reattribution training (goal setting and planning coping responses), decatastrophizing (balancing anxious automatic thoughts), reappraisal, and attention shifting. Cognitive-behavioral therapy is recommended as an effective, nonpharmacologic treatment for chronic insomnia (SOR A). Routine use of over-the-counter antihistamines should be discouraged because they are only minimally effective in inducing sleep, may reduce sleep quality, and can cause residual drowsiness. Many herbs and dietary supplements have been promoted as sleep aids. However, with the exceptions of melatonin and valerian, there is insufficient evidence of benefit. Alcohol acts directly on GABA-gated channels, reducing sleep-onset latency, but it increases wakefulness after sleep onset and suppresses rapid eye movement (REM) sleep. It also has the potential for abuse and should not be used as a sleep aid. Moderate-intensity exercise can improve sleep, but exercising just before bedtime can delay sleep onset. Ref: Ramakrishnan K, Scheid DC: Treatment options for insomnia. Am Fam Physician 2007;76(4):517-526.
100
A 45-year-old white male consults you because of a painless, circular, 1-cm white spot inside his mouth, which he noticed 3 days ago. You are treating him with propranolol (Inderal) for hypertension, and you know him to be a heavy alcohol user. After a careful physical examination, your tentative diagnosis is leukoplakia of the buccal mucosa. You elect to observe the lesion for 2 weeks. On the patients return, the lesion is still present and unchanged in appearance. The best course of management at this time is to A. reassure the patient and continue to observe B. discontinue propranolol C. treat with oral nystatin D. order a fluorescent antinuclear antibody test E. perform a biopsy of the lesion
E. Leukoplakia is a white keratotic lesion seen on mucous membranes. Irritation from various mechanical and chemical stimuli, including alcohol, favors development of the lesion. Leukoplakia can occur in any area of the mouth and usually exhibits benign hyperkeratosis on biopsy. On long-term follow-up, 2%-6% of these lesions will have undergone malignant transformation into squamous cell carcinoma. Oral nystatin would not be appropriate treatment, as this lesion is not typical of oral candidiasis. Candidal lesions are usually multiple and spread quickly when left untreated. A fluorescent antinuclear antibody test is also not indicated, as the oral lesions of lupus erythematosus are typically irregular, erosive, and necrotic. An idiosyncratic reaction to propranolol is unlikely in this patient. Ref: Gonsalves WC, Chi AC, Neville BW: Common oral lesions: Part II. Masses and neoplasia. Am Fam Physician 2007;75(4):509-512. 2) Goldman L, Ausiello D (eds): Cecil Medicine, ed 23. Saunders, 2008, pp 1451-1452.
100
A 35-year-old female is planning a second pregnancy. Her last pregnancy was complicated by placental abruption caused by a large fibroid tumor of the uterus, which is still present. Which one of the following would be the most appropriate treatment for the fibroid tumor? A. Myomectomy B. Myolysis with endometrial ablation C. Uterine artery embolization D. Observation
A. There are numerous options for the treatment of uterine fibroids. When pregnancy is desired, myomectomy offers the best chance for a successful pregnancy when prior pregnancies have been marked by fibroid-related complications. Endometrial ablation eliminates fertility, and there is a lack of long-term data on fertility after uterine artery embolization. Observation without treatment would not remove the risk for recurrent complications during subsequent pregnancies. Ref: Evans P, Brunsell S: Uterine fibroid tumors: Diagnosis and treatment. Am Fam Physician 2007;75(10):1503-1508.
100
For 2 weeks, a 62-year-old male with biopsy-documented cirrhosis and ascites has had diffuse abdominal discomfort, fever, and night sweats. His current medications are furosemide (Lasix) and spironolactone (Aldactone). On examination, his temperature is 38.0° C (100.4° F), blood pressure 100/60 mm Hg, heart rate 92 beats/min and regular. The heart and lung examination is normal. The abdomen is soft with vague tenderness in all quadrants. There is no rebound or guarding. The presence of ascites is easily verified. Bowel sounds are quiet. The rectal examination is normal, and the stool is negative for occult blood. You perform diagnostic paracentesis and send a sample of fluid for analysis. Which one of the following findings would best establish the suspected diagnosis of spontaneous bacterial peritonitis? A. pH <7.2 B. Bloody appearance C. Neutrophil count >300/mL D. Positive cytology E. Total protein >1 g/dL
C. A neutrophil count >250/mL is diagnostic for peritonitis. Once peritonitis is diagnosed, antibiotic therapy should be started immediately without waiting for culture results. Bloody ascites with abnormal cytology may be seen with hepatoma, but is not typical of peritonitis. The ascitic fluid pH does not become abnormal until well after the neutrophil count has risen, so it is a less reliable finding for treatment purposes. A protein level >1 g/dL is actually evidence against spontaneous bacterial peritonitis. Ref: Braunwald E, Fauci AS, Kasper DL, et al (eds): Harrison’s Principles of Internal Medicine, ed 15. McGraw-Hill, 2001, p 829. 2) Tierney LM, McPhee SJ, Papadakis MA (eds): Current Medical Diagnosis & Treatment 2002, ed 41. Lange Medical Books/McGraw-Hill, 2002, pp 594-596
100
Which one of the following is the most common cause of hypertension in children under 6 years of age? A. Essential hypertension B. Pheochromocytoma C. Renal parenchymal disease D. Hyperthyroidism E. Excessive caffeine use
C. Although essential hypertension is most common in adolescents and adults, it is rarely found in children less than 10 years old and should be a diagnosis of exclusion. The most common cause of hypertension is renal parenchymal disease, and a urinalysis, urine culture, and renal ultrasonography should be ordered for all children presenting with hypertension. Other secondary causes, such as pheochromocytoma, hyperthyroidism, and excessive caffeine use, are less common, and further testing and/or investigation should be ordered as clinically indicated. Ref: Luma GB, Spiotta RT: Hypertension in children and adolescents. Am Fam Physician 2006;73(9):1558-1566.
200
Which of the following antidepressants has an FDA warning of increased risk of suicidal thinking and suicide attempts in children 8-17 years? A. venlafaxine (Effexor) B. amitriptyline C. lithium D. paroxetine (Paxil)
D. The FDA has warned against the use of paroxetine in this age range because of a possible increased risk of suicidal thinking and suicide attempts associated with the drug. Fluoxetine is the only SSRI approved by the FDA for the treatment of depression in children 8-17 years of age, although all of the antidepressants may be used off-label . Tricyclic antidepressants have more side effects and can be lethal in overdose. In children and adolescents, there is limited or no evidence evaluating the use of lithium, monoamine oxidase inhibitors, St. Johns wort, or venlafaxine. Ref: Bhatia SK, Bhatia SC: Childhood and adolescent depression. Am Fam Physician 2007;75(1):73-80
200
A 65-year-old white male comes to your office with a 0.5-cm nodule that has developed on his right forearm over the past 4 weeks. The lesion is dome shaped and has a central plug. You schedule a biopsy but he does not return to your office for 1 year. At that time the lesion appears to have healed spontaneously. The most likely diagnosis is A. benign lentigo B. lentigo maligna C. basal cell carcinoma D. squamous cell carcinoma E. keratoacanthoma
E. Keratoacanthoma grows rapidly and may heal within 6 months to a year. Squamous cell carcinoma may appear grossly and histologically similar to keratoacanthoma but does not heal spontaneously. The other lesions do not resemble keratoacanthoma. Ref: Habif TP, Campbell JL Jr, Chapman MS, et al: Skin Disease: Diagnosis and Treatment, ed 2. Elsevier, 2005, pp 404-407.
200
In patients with breast cancer, the most reliable predictor of survival is A. estrogen receptor status B. cancer stage at the time of diagnosis C. tumor grade D. histologic type E. lymphatic or blood vessel involvement
B. The most reliable predictor of survival in breast cancer is the stage at the time of diagnosis. Tumor size and lymph node involvement are the main factors to take into account. Other prognostic parameters (tumor grade, histologic type, and lymphatic or blood vessel involvement) have been proposed as important variables, but most microscopic findings other than lymph node involvement correlate poorly with prognosis. Estrogen receptor (ER) status may also predict survival, with ER-positive tumors appearing to be less aggressive than ER-negative tumors. Ref: Abeloff MD, Armitage JO, Niederhuber JE, et al (eds): Clinical Oncology, ed 3. Elsevier Churchill Livingstone, 2004, pp 2399-2401
200
Treatment for Helicobacter pylori infection will reduce or improve which one of the following? A. The risk of peptic ulcer bleeding from chronic NSAID therapy B. The risk of developing gastric cancer in asymptomatic patients C. Symptoms of nonulcer dyspepsia D. Symptoms of gastroesophageal reflux disease
A. Eradication of Helicobacter pylori significantly reduces the risk of ulcer recurrence and rebleeding in patients with duodenal ulcer, and reduces the risk of peptic ulcer development in patients on chronic NSAID therapy. Eradication has minimal or no effect on the symptoms of nonulcer dyspepsia and gastroesophageal reflux disease. Although H. pylori infection is associated with gastric cancer, no trials have shown that eradication of H. pylori purely to prevent gastric cancer is beneficial. Ref: Ables AZ, Simon I, Melton ER: Update on Helicobacter pylori treatment. Am Fam Physician 2007;75(3):351-358.
200
A 72-year-old African-American male with New York Heart Association Class III heart failure sees you for follow-up. He has shortness of breath with minimal exertion. The patient is adherent to his medication regimen. His current medications include lisinopril (Prinivil, Zestril), 40 mg twice daily; carvedilol (Coreg), 25 mg twice daily; and furosemide (Lasix), 80 mg daily. His blood pressure is 100/60 mm Hg, and his pulse rate is 68 beats/min and regular. Findings include a few scattered bibasilar rales on examination of the lungs, an S3 gallop on examination of the heart, and no edema on examination of the legs. An EKG reveals a left bundle branch block, and echocardiography reveals an ejection fraction of 25%, but no other abnormalities. Which one of the following would be most appropriate at this time? A. Increase the lisinopril dosage to 80 mg twice daily B. Increase the carvedilol dosage to 50 mg twice daily C. Increase the furosemide dosage to 160 mg daily D. Refer for coronary angiography E. Refer for cardiac resynchronization therapy
E. This patient is already receiving maximal medical therapy. The 2002 joint guidelines of the American College of Cardiology, the American Heart Association (AHA), and the North American Society of Pacing and Electrophysiology endorse the use of cardiac resynchronization therapy (CRT) in patients with medically refractory, symptomatic, New York Heart Association (NYHA) class III or IV disease with a QRS interval of at least 130 msec, a left ventricular end-diastolic diameter of at least 55 mm, and a left ventricular ejection fraction (LVEF) ≤30%. Using a pacemaker-like device, CRT aims to get both ventricles contracting simultaneously, overcoming the delayed contraction of the left ventricle caused by the left bundle-branch block. These guidelines were refined by an April 2005 AHA Science Advisory, which stated that optimal candidates for CRT have a dilated cardiomyopathy on an ischemic or nonischemic basis, an LVEF ≤0.35, a QRS complex ≥120 msec, and sinus rhythm, and are NYHA functional class III or IV despite maximal medical therapy for heart failure. Ref: Jarcho JA: Biventricular pacing. N Engl J Med 2006;355(3):288-294.
300
A 65-year-old male presents for a follow-up visit for severe depression. His symptoms have included crying episodes, difficulty maintaining sleep, and decreased appetite. He has suicidal ideations and states that he has a gun in his home. He also thinks his wife is having an affair, but she is present and is adamant that this is not true. His symptoms have not been relieved by maximum doses of sertraline (Zoloft), venlafaxine (Effexor), or citalopram (Celexa). He currently is taking duloxetine (Cymbalta), which also has failed to relieve his symptoms. Which one of the following would most likely provide the quickest relief of his symptoms? A. Counseling B. Bupropion (Wellbutrin) C. Stopping duloxetine and starting an MAO inhibitor D. Electroconvulsive therapy
D. This patient has psychotic depression with suicidal ideations and has not responded to maximum doses of several antidepressants. He is more likely to respond to electroconvulsive therapy than to counseling or a change in medication. Ref: Lisanby SH: Electroconvulsive therapy for depression. N Engl J Med 2007;359(19):1939-1945.
300
A middle-aged hairdresser presents with a complaint of soreness of the proximal nail folds of several fingers on either hand, which has slowly worsened over the last 6 months. The nails appear thickened and distorted. Otherwise she is healthy and has no evidence of systemic disease. Which one of the following would be the most effective initial treatment? A. Soaking in a dilute iodine solution twice daily to cleanse and sterilize the nail beds B. Oral amoxicillin/clavulanate (Augmentin) for up to 4-6 weeks C. Topical betamethasone dipropionate (Diprolene) applied twice daily to the nail folds for 3-4 weeks D. Evaluation for HIV, hepatitis C, psoriasis, and rheumatoid arthritis
C. Chronic paronychia is a common condition in workers whose hands are exposed to chemical irritants or are wet for long periods of time. This patient is an otherwise healthy hairdresser, with frequent exposure to irritants. The patient should be advised to avoid exposure to harsh chemicals and water. In addition, the use of strong topical corticosteroids over several weeks can greatly reduce the inflammation, allowing the nail folds to return to normal and helping the cuticles recover their natural barrier to infection. Soaking in iodine solution would kill bacteria, but would also perpetuate the chronic irritation. Because the condition is related to chemical and water irritation, a prolonged course of antibiotics should not be the first treatment step, and could have serious side effects. There is no need to explore less likely autoimmune causes for nail changes at this time. Ref: Rigopoulos D, Larios G, Gregoriou S, et al: Acute and chronic paronychia. Am Fam Physician 2008;77(3):339-346
300
Which one of the following is the most reliable clinical symptom of uterine rupture? A. Sudden, tearing uterine pain B. Vaginal bleeding C. Loss of uterine tone D. Fetal distress
D. Fetal distress has proven to be the most reliable clinical symptom of uterine rupture. The “classic” signs of uterine rupture such as sudden, tearing uterine pain, vaginal hemorrhage, and loss of uterine tone or cessation of uterine contractions are not reliable and are often absent. Pain and bleeding occur in as few as 10% of cases. Even ruptures monitored with an intrauterine pressure catheter fail to show loss of uterine tone. Signs of fetal distress are often the only manifestation of uterine rupture. Ref: Toppenberg KS, Block WA Jr: Uterine rupture: What family physicians need to know. Am Fam Physician 2002;66(5):823-828.
300
Your community recently experienced an outbreak of infectious diarrheal illness due to the protozoan Cryptosporidium, a chlorine-resistant organism. A reporter from the local newspaper asks you if there are other chlorine-resistant fecal organisms that could contaminate public drinking water. You would tell the reporter that such organisms include: A. Escherichia coli B. Vibrio cholerae C. Campylobacter jejuni D. Giardia lamblia E. Rotavirus
D. Organisms that can persist in water environments and survive disinfection, especially chlorination, are most likely to cause disease outbreaks related to drinking water. Cryptosporidium oocysts and Giardia cysts are resistant to chlorine and are important causes of gastroenteritis from drinking water. Entamoeba histolytica and hepatitis A virus are also relatively chlorine resistant. The other organisms listed are chlorine sensitive. Ref: Balbus JM, Lang ME: Is the water safe for my baby? Pediatr Clin North Am 2001;48(5):1129-1152.
300
Which one of the following is most predictive of increased perioperative cardiovascular events associated with noncardiac surgery in the elderly? A. An age of 80 years B. Left bundle-branch block C. Atrial fibrillation with a rate of 80 beats/min D. A history of previous stroke E. Renal insufficiency (creatinine 2.0 mg/dL
E. Clinical predictors of increased perioperative cardiovascular risk for elderly patients include major risk factors such as unstable coronary syndrome (acute or recent myocardial infarction, unstable angina), decompensated congestive heart failure, significant arrhythmia (high-grade AV block, symptomatic ventricular arrhythmia, supraventricular arrhythmias with uncontrolled ventricular rate), and severe valvular disease. Intermediate predictors are mild angina, previous myocardial infarction, compensated congestive heart failure, diabetes mellitus, and renal insufficiency. Minor predictors are advanced age, an abnormal EKG, left ventricular hypertrophy, left bundle-branch block, ST and T-wave abnormalities, rhythm other than sinus, low functional capacity, history of stroke, and uncontrolled hypertension. Ref: Schroeder BM: Updated guidelines for perioperative cardiovascular evaluation for noncardiac surgery. Am Fam Physician 2002;66(6):1096-1107.
400
A 79-year-old male has psychosis secondary to dementia associated with Parkinson’s disease. After exhausting all other options you decide to prescribe an antipsychotic agent. Which one of the following would be the best choice in this situation? A. Haloperidol B. Olanzapine (Zyprexa) C. Risperidone (Risperdal) D. Quetiapine (Seroquel) E. Thioridazine
D. Quetiapine is an atypical antipsychotic that has no clinically significant effect on the dopamine D2 receptor, which is responsible for the parkinsonian side effects of antipsychotic medications. Because of this, it is considered the antipsychotic of choice in patients with dementia associated with Parkinson’s disease, although its use has not been studied extensively in this clinical situation. The other atypical antipsychotics listed, olanzapine and risperidone, have some D2 receptor effect. Thioridazine and haloperidol are typical antipsychotics and have more side effects, including parkinsonian side effects; they are not recommended in this clinical situation. Ref: Rayner AV, OBrien JG, Schoenbachler B: Behavior disorders of dementia: Recognition and treatment. Am Fam Physician 2006;73(4):647-652, 653-654. 2 ) Reilly TH, Kirk MA: Atypical antipsychotics and newer antidepressants. Emerg Med Clin North Am 2007;25(2):477-497.
400
A 36-year-old member of the National Guard who has just returned from Iraq consults you because of several “boils” on the back of his neck that have failed to heal over the last 6 months, despite two week-long courses of cephalexin (Keflex). You observe three 1- to 2-cm raised minimally tender lesions with central ulceration and crust formation. He denies any fever or systemic symptoms. The most likely cause of these lesions is: A. Pyogenic granuloma B. Leishmaniasis C. Atypical mycobacterial infection D. Squamous cell carcinoma E. Epidermal inclusion cysts
B. The most likely diagnosis is cutaneous leishmaniasis, caused by an intracellular parasite transmitted by the bite of small sandflies. Lesions develop gradually, and are often misdiagnosed as folliculitis or as infected epidermal inclusion cysts, but they fail to respond to usual skin antibiotics. Hundreds of cases have been diagnosed in troops returning from Iraq, most due to Leishmania major. Treatment is not always required, as most lesions will resolve over several months; however, scarring is frequent. Ref: Markle WH, Makhoul K: Cutaneous leishmaniasis: Recognition and treatment. Am Fam Physician 2004;69(6):1455-1460. 2) Update: Cutaneous leishmaniasis in U.S. military personnel—Southwest/Central Asia, 2002-2004. MMWR 2004;53(12):264-265
400
A 17-year-old white female presents with new-onset left-sided lower abdominal pain. Color flow Doppler ultrasonography, in addition to pelvic ultrasonography, would be most useful for evaluating: A. Adnexal torsion B. Pelvic abscess C. Pelvic inflammatory disease D. Ruptured ovarian cyst
A. Color Doppler flow studies are useful for evaluating blood flow to the ovary in possible cases of adnexal or ovarian torsion. Adnexal torsion is a surgical emergency. Pelvic ultrasonography, preferably with a vaginal probe, can be beneficial in the workup of ruptured ovarian cyst, pelvic abscess, and pelvic inflammatory disease without abscess. The Doppler flow study is not required with these condition. Ref: Hamilton GC, et al: Emergency Medicine: An Approach to Clinical Problem-Solving, ed 2. Saunders, 2003, pp 670-672.
400
A positive spot urine test for homovanillic acid (HMA) and vanillylmandelic acid (VMA) is a marker for which one of the following? A. Hepatoblastoma B. Wilms’ tumor C. Lymphoma D. Malignant teratoma E. Neuroblastoma
E. Tumor markers are useful in determining the diagnosis and sometimes the prognosis of certain tumors. They can aid in assessing response to therapy and detecting tumor recurrence. Serum neuron-specific enolase (NSE) testing, as well as spot urine testing for homovanillic acid (HVA) and vanillylmandelic acid (VMA), should be obtained if neuroblastoma or pheochromocytoma is suspected; both should be collected before surgical intervention. Quantitative beta-human chorionic gonadotropin (hCG) levels can be elevated in liver tumors and germ cells tumors. Alpha-fetoprotein is excreted by many malignant teratomas and by liver and germ cell tumors. Ref: Golden CB, Feusner JH: Malignant abdominal masses in children: Quick guide to evaluation and diagnosis. Pediatr Clin North Am 2002;49:1369-1392.
400
An asymptomatic 3-year-old male presents for a routine check-up. On examination you notice a systolic heart murmur. It is heard best in the lower precordium and has a low, short tone similar to a plucked string or kazoo. It does not radiate to the axillae or the back and seems to decrease with inspiration. The remainder of the examination is normal. Which one of the following is the most likely diagnosis? A. Eisenmenger’s syndrome B. Mitral stenosis C. Peripheral pulmonic stenosis D. Still’s murmur E. Venous hum
D. There are several benign murmurs of childhood that have no association with physiologic or anatomic abnormalities. Of these, Still’s murmur best fits the murmur described. The cause of Still’s murmur is unknown, but it may be due to vibrations in the chordae tendinae, semilunar valves, or ventricular wall. A venous hum consists of a continuous low-pitched murmur caused by the collapse of the jugular veins and their subsequent fluttering, and it worsens with inspiration or diastole. The murmur of physiologic peripheral pulmonic stenosis (PPPS) is caused by physiologic changes in the newborns pulmonary vessels. PPPS is a systolic murmur heard loudest in the axillae bilaterally that usually disappears by 9 months of age. Mitral stenosis causes a diastolic murmur, and Eisenmenger’s syndrome involves multiple abnormalities of the heart that cause significant signs and symptoms, including shortness of breath, cyanosis, and organomegaly, which should become apparent from a routine history and examination. Ref: Rudolph CD, Rudolph AM (eds): Rudolph’s Pediatrics, ed 21. McGraw-Hill, 2003, pp 1755-1757.
500
Which one of the following sleep problems in children is most likely to occur during the second half of the night? A. Confusional arousals B. Sleepwalking C. Sleep terrors D. Nightmares
D. Nightmares occur in the second half of the night, when rapid eye movement (REM) sleep is most prominent. Parasomnias, including sleepwalking, confusional arousal, and sleep terrors, are disorders of arousal from non-REM (NREM) sleep. These are more common in children than adults because children spend more time in deep NREM sleep. Such disorders usually occur within 1-2 hours after sleep onset, and coincide with the transition from the first period of slow-wave sleep. Ref: Moore M, Allison D, Rosen CL: A review of pediatric nonrespiratory sleep disorders. Chest 2006;130(4):1252-1262
500
A 5-year-old white male has an itchy lesion on his right foot. He often plays barefoot in a city park that is subject to frequent flooding. The lesion is located dorsally between the web of his right third and fourth toes, and extends toward the ankle. It measures approximately 3 cm in length, is erythematous, and has a serpiginous track. The remainder of his examination is within normal limits. Which one of the following is the most likely cause of these findings? A. Dog or cat hookworm (Ancylostoma species) B. Dog or other canid tapeworm (Echinococcus granulosus) C. Cat protozoa (Toxoplasma gondii) D. Dog or cat roundworm (Toxocara canis or T. mystax)
A. This patient has cutaneous larva migrans, a common condition caused by dog and cat hookworms. Fecal matter deposited on soil or sand may contain hookworm eggs that hatch and release larvae, which are infective if they penetrate the skin. Walking barefoot on contaminated ground can lead to infection. Echinococcosis (hydatid disease) is caused by the cestodes (tapeworms) Echinococcus granulosus and Echinococcus multilocularis, found in dogs and other canids. It infects humans who ingest eggs that are shed in the animals feces and results in slow-growing cysts in the liver or lungs, and occasionally in the brain, bones, or heart. Toxoplasmosis is caused by the protozoa Toxoplasma gondii, found in cat feces. Humans can contract it from litter boxes or feces-contaminated soil, or by consuming infected undercooked meat. It can be asymptomatic, or it may cause cervical lymphadenopathy, a mononucleosis-like illness; it can also lead to a serious congenital infection if the mother is infected during pregnancy, especially during the first trimester. Toxocariasis due to Toxocara canis and Toxocara cati causes visceral or ocular larva migrans in children who ingest soil contaminated with animal feces that contains parasite eggs, often found in areas such as playgrounds and sandboxes. Ref: Rabinowitz PM, Gordon Z, Odofin L: Pet-related infections. Am Fam Physician 2007;76(9):1314-1322.
500
Which one of the following fetal ultrasound measurements gives the most accurate estimate of gestational age in the first trimester (up to 14 weeks)? A. Femur length B. Biparietal diameter C. Abdominal circumference D. Crown-rump length E. Scapulo-sacral length
D. Because the growth pattern of the fetus varies throughout pregnancy, the accuracy of measurements and their usefulness in determining gestational age and growth vary with each trimester. Crown-rump length is the distance from the top of the head to the bottom of the fetal spine. It is most accurate as a measure of gestational age at 7-14 weeks. After that, other measurements are more reliable. In the second trimester, biparietal diameter and femur length are used. During the third trimester, biparietal diameter, abdominal circumference, and femur length are best for estimating gestational age. Ref: Cunningham FG, Leveno KJ, Bloom SL, et al: Williams Obstetrics, ed 22. McGraw-Hill, 2005, p 392.
500
A 3-week-old male is brought to your office because of a sudden onset of bilious vomiting of several hours duration. He is irritable and refuses to breastfeed, but stools have been normal. He was delivered at term after a normal pregnancy, and has had no health problems to date. A physical examination shows a fussy child with a distended abdomen. Radiography of the abdomen shows a double bubble sign. Which one of the following is the most likely diagnosis? A. Infantile colic B. Necrotizing enterocolitis C. Hypertrophic pyloric stenosis D. Intussusception E. Midgut volvulus
E. Volvulus may present in one of three ways: as a sudden onset of bilious vomiting and abdominal pain in a neonate; as a history of feeding problems with bilious vomiting that appears to be a bowel obstruction; or less commonly, as failure to thrive with severe feeding intolerance. The classic finding on abdominal plain films is the double bubble sign, which shows a paucity of gas (airless abdomen) with two air bubbles, one in the stomach and one in the duodenum. However, the plain film can be entirely normal. The upper gastrointestinal contrast study is considered the gold standard for diagnosing volvulus. Infantile colic usually begins during the second week of life and typically occurs in the evening. It is characterized by screaming episodes and a distended or tight abdomen. Its etiology has yet to be determined. There are no abnormalities on physical examination and ancillary studies, and symptoms usually resolve spontaneously around 12 weeks of age. Necrotizing enterocolitis is typically seen in the distressed neonate in the intensive-care nursery, but it may occasionally be seen in the healthy neonate within the first 2 weeks of life. The child will appear ill, with symptoms including irritability, poor feeding, a distended abdomen, and bloody stools. Abdominal plain films will show pneumatosis intestinalis, caused by gas in the intestinal wall, which is diagnostic of the condition. Hypertrophic pyloric stenosis is a narrowing of the pyloric canal caused by hypertrophy of the musculature. It usually presents during the third to fifth weeks of life. Projectile vomiting after feeding, weight loss, and dehydration are common. The vomitus is always nonbilious, because the obstruction is proximal to the duodenum. If a small olive-size mass cannot be felt in the right upper or middle quadrant, ultrasonography will confirm the diagnosis. Intussusception is seen most frequently between the ages of 3 months and 5 years, with 60% of cases occurring in the first year and a peak incidence at 6-11 months of age. The disorder occurs predominantly in males. The classic triad of intermittent colicky abdominal pain, vomiting, and bloody, mucous stools is encountered in only 20%-40% of cases. At least two of these findings will be present in approximately 60% of patients. The abdomen may be distended and tender, and there may be an elongated mass in the right upper or lower quadrants. Rectal examination may reveal either occult blood or frankly bloody, foul-smelling stool, classically described as currant jelly. An air enema using fluoroscopic guidance is useful for both diagnosis and treatment. Ref: McCollough M, Sharieff GQ: Abdominal pain in children. Pediatr Clin North Am 2006;53(1):107-137.
500
Cilostazol (Pletal) has been found to be a useful drug for the treatment of intermittent claudication. This drug is contraindicated in patients with: A. Congestive heart failure B. A past history of stroke C. Diabetes mellitus D. Third degree heart block E. Hyperlipidemia
A. Cilostazol is a drug with phosphodiesterase inhibitor activity introduced for the symptomatic treatment of arterial occlusive disease and intermittent claudication. Cilostazol should be avoided in patients with congestive heart failure. There are no limitations on its use in patients with previous stroke or a history of diabetes. It has been found to have beneficial effects on HDL cholesterol levels and in the treatment of third degree heart block. Ref: Hiatt WMR: Drug therapy: Medical treatment of peripheral arterial disease and claudication. N Engl J Med 2001;344(2):1608-1621. 2) Chapman T, Goa KL: Cilostazol: A review of its use in intermittent claudication. Am J Cardiovasc Drugs 2003;3(2):117-138