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======================================================= Cardiovascular Board Review Questions 01 ======================================================= You see a 23-year-old gravida 1 para 0 for h... er prenatal checkup at 38 weeks gestation. She complains of severe headaches and epigastric pain. She has had an uneventful pregnancy to date and had a normal prenatal examination 2 weeks ago. Her blood pressure is 140/100 mm Hg. A urinalysis shows 2+ protein; she has gained 5 lb in the last week, and has 2+ pitting edema of her legs. The most appropriate management at this point would be: (check one) A. Strict bed rest at home and reexamination within 48 hours B. Admitting the patient to the hospital for bed rest and frequent monitoring of blood pressure, weight, and proteinuria C. Admitting the patient to the hospital for bed rest and monitoring, and beginning hydralazine (Apresoline) to maintain blood pressure below 140/90 mm Hg D. Admitting the patient to the hospital, treating with parenteral magnesium sulfate, and planning prompt delivery either vaginally or by cesarean section - ✔✔D. Admitting the patient to the hospital, treating with parenteral magnesium sulfate, and planning prompt delivery either vaginally or by cesarean section. This patient manifests a rapid onset of preeclampsia at term. The symptoms of epigastric pain and headache categorize her preeclampsia as severe. These symptoms indicate that the process is well advanced and that convulsions are imminent. Treatment should focus on rapid control of symptoms and delivery of the infant. Which one of the following is the most common cause of hypertension in children under 6 years of age? (check one) A. Essential hypertension B. Pheochromocytoma C. Renal parenchymal disease D. Hyperthyroidism E. Excessive caffeine use - ✔✔C. Renal parenchymal disease. 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. A 70-year-old male with a history of hypertension and type 2 diabetes mellitus presents with a 2-month history of increasing paroxysmal nocturnal dyspnea and shortness of breath with minimal exertion. An echocardiogram shows an ejection fraction of 25%. Which one of the patients current medications should be discontinued? (check one) A. Lisinopril (Zestril) B. Pioglitazone (Actos) C. Glipizide (Glucotrol) D. Metoprolol (Toprol-XL) E. Repaglinide (Prandin) - ✔✔B. Pioglitazone (Actos). According to the American Diabetes Association guidelines, thiazolidinediones (TZDs) are associated with fluid retention, and their use can be complicated by the development of heart failure. Caution is necessary when prescribing TZDs in patients with known heart failure or other heart diseases, those with preexisting edema, and those on concurrent insulin therapy (SOR C). Older patients can be treated with the same drug regimens as younger patients, but special care is required when prescribing and monitoring drug therapy. Metformin is often contraindicated because of renal insufficiency or heart failure. Sulfonylureas and other insulin secretagogues can cause hypoglycemia. Insulin can also cause hypoglycemia, and injecting it requires good visual and motor skills and cognitive ability on the part of the patient or a caregiver. TZDs should not be used in patients with New York Heart Association class III or IV heart failure. 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? (check one) 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. Refer for cardiac resynchronization therapy. 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. Of the following dietary factors recommended for the prevention and treatment of cardiovascular disease, which one has been shown to decrease the rate of sudden death? (check one) A. Increased intake of plant protein B. Increased intake of omega-3 fats C. Increased intake of dietary fiber and whole grains D. Increased intake of monounsaturated oils E. Moderate alcohol consumption (1 or 2 standard drinks per day) - ✔✔B. Increased intake of omega-3 fats. Omega-3 fats contribute to the production of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), which inhibit the inflammatory immune response and platelet aggregation, are mild vasodilators, and may have antiarrhythmic properties. The American Heart Association guidelines state that omega-3 supplements may be recommended to patients with preexisting disease, a high risk of disease, or high triglyceride levels, as well as to patients who do not like or are allergic to fish. The Italian GISSI study found that the use of 850 mg of EPA and DHA daily resulted in decreased rates of mortality, nonfatal myocardial infarction, and stroke, with particular decreases in the rate of sudden death. A 75-year-old male presents to the emergency department with a several-hour history of back pain in the interscapular region. His medical history includes a previous myocardial infarction (MI) several years ago, a history of cigarette smoking until the time of the MI, and hypertension that is well controlled with hydrochlorothiazide and lisinopril (Prinivil, Zestril). The patient appears anxious, but all pulses are intact. His blood pressure is 170/110 mm Hg and his pulse rate is 110 beats/min. An EKG shows evidence of an old inferior wall MI but no acute changes. A chest radiograph shows a widened mediastinum and a normal aortic arch, and CT of the chest shows a dissecting aneurysm of the descending aorta that is distal to the proximal abdominal aorta but does not involve the renal arteries. Which one of the following would be the most appropriate next step in the management of this patient? (check one) A. Immediate surgical intervention B. Arteriography of the aorta C. Intravenous nitroprusside (Nipride) D. A nitroglycerin drip E. Intravenous labetalol (Normodyne, Trandate) - ✔✔E. Intravenous labetalol (Normodyne, Trandate). Patients with thoracic aneurysms often present without symptoms. With dissecting aneurysms, however, the presenting symptom depends on the location of the aneurysm. Aneurysms can compress or distort nearby structures, resulting in branch vessel compression or embolization of peripheral arteries from a thrombus within the aneurysm. Leakage of the aneurysm will cause pain, and rupture can occur with catastrophic results, including severe pain, hypotension, shock, and death. Aneurysms in the ascending aorta may present with acute heart failure brought about by aortic regurgitation from aortic root dilatation and distortion of the annulus. Other presenting findings may include hoarseness, myocardial ischemia, paralysis of a hemidiaphragm, wheezing, coughing, hemoptysis, dyspnea, dysphagia, or superior vena cava syndrome. This diagnosis should be suspected in individuals in their sixties and seventies with the same risk factors as those for coronary artery disease, particularly smokers. A chest radiograph may show widening of the mediastinum, enlargement of the aortic knob, or tracheal displacement. Transesophageal echocardiography can be very useful when dissection is suspected. CT with intravenous contrast is very accurate for showing the size, extent of disease, pressure of leakage, and nearby pathology. Angiography is the preferred method for evaluation and is best for evaluation of branch vessel pathology. MR angiography provides noninvasive multiplanar image reconstruction, but does have limited availability and lower resolution than traditional contrast angiography. Acute dissection of the ascending aorta is a surgical emergency, but dissections confined to the descending aorta are managed medically unless the patient demonstrates progression or continued hemorrhage into the retroperitoneal space or pleura. Initial management should reduce the systolic blood pressure to 100-120 mm Hg or to the lowest level tolerated. The use of a β-blocker such as propranolol or labetalol to get the heart rate below 60 beats/min should be first-line therapy. If the systolic blood pressure remains over 100 mm Hg, intravenous nitroprusside should be added. Without prior beta-blocade, vasodilation from the nitroprusside will induce reflex activation of the sympathetic nervous system, causing increased ventricular contraction and increased shear stress on the aorta. For descending dissections, surgery is indicated only for complications such as occlusion of a major aortic branch, continued extension or expansion of the dissection, or rupture (which may be manifested by persistent or recurrent pain). According to the U.S. Preventive Services Task Force, which one of the following patients should be screened for an abdominal aortic aneurysm? (check one) A. A 52-year-old male with type 2 diabetes mellitus B. An asymptomatic 67-year-old male smoker with no chronic illness C. A 72-year-old male with a history of chronic renal failure D. A 69-year-old female with a history of coronary artery disease E. A 75-year-old female with hypertension and hypothyroidism - ✔✔B. An asymptomatic 67-year-old male smoker with no chronic illness. The U.S. Preventive Services Task Force has released a statement summarizing recommendations for screening for abdominal aortic aneurysm (AAA). The guideline recommends one-time screening with ultrasonography for AAA in men 65-75 years of age who have ever smoked. No recommendation was made for or against screening women. Men with a strong family history of AAA should be counseled about the risks and benefits of screening as they approach 65 years of age. A 36-year-old white female presents to the emergency department with palpitations. Her pulse rate is 180 beats/min. An EKG reveals a regular tachycardia with a narrow complex QRS and no apparent P waves. The patient fails to respond to carotid massage or to two doses of intravenous adenosine (Adenocard), 6 mg and 12 mg. The most appropriate next step would be to administer intravenous (check one) A. amiodarone (Cordarone) B. digoxin (Lanoxin) C. flecainide (Tambocor) D. propafenone (Rhythmol) E. verapamil (Calan) - ✔✔E. verapamil (Calan). If supraventricular tachycardia is refractory to adenosine or rapidly recurs, the tachycardia can usually be terminated by the administration of intravenous verapamil or a β-blocker. If that fails, intravenous propafenone or flecainide may be necessary. It is also important to look for and treat possible contributing causes such as hypovolemia, hypoxia, or electrolyte disturbances. Electrical cardioversion may be necessary if these measures fail to terminate the tachyarrhythmia. A 60-year-old African-American female has a history of hypertension that has been well controlled with hydrochlorothiazide. However, she has developed an allergy to the medication. Successful monotherapy for her hypertension would be most likely with which one of the following? (check one) A. Lisinopril (Prinivil, Zestril) B. Hydralazine (Apresoline) C. Clonidine (Catapres) D. Atenolol (Tenormin) E. Diltiazem (Cardizem) - ✔✔E. Diltiazem (Cardizem). Monotherapy for hypertension in African-American patients is more likely to consist of diuretics or calcium channel blockers than β-blockers or ACE inhibitors. It has been suggested that hypertension in African-Americans is not as angiotensin II-dependent as it appears to be in Caucasians. A 60-year-old African-American male was recently diagnosed with an abdominal aortic aneurysm. A lipid profile performed a few months ago revealed an LDL level of 125 mg/dL. You would now advise him that his goal LDL level is: (check one) A. <100 mg/dL B. <130 mg/dL C. <150 mg/dL D. <160 mg/dL - ✔✔A. <100 mg/dL. Most physicians realize that the goal LDL level for patients with diabetes mellitus or coronary artery disease is <100 mg/dL. Many may not realize that this goal extends to people with CAD-equivalent diseases, including peripheral artery disease, symptomatic carotid artery disease, and abdominal aortic aneurysm. ======================================================= Cardiovascular Board Review Questions 02 ======================================================= 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? (check one) A. Eisenmenger's syndrome B. Mitral stenosis C. Peripheral pulmonic stenosis D. Still's murmur E. Venous hum - ✔✔D. Still's murmur. 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. A 57-year-old male with severe renal disease presents with acute coronary syndrome. Which one of the following would most likely require a significant dosage adjustment from the standard protocol? (check one) A. Enoxaparin (Lovenox) B. Metoprolol (Lopressor, Toprol) C. Carvedilol (Coreg) D. Clopidogrel (Plavix) E. Tissue plasminogen activator (tPA) - ✔✔A. Enoxaparin (Lovenox). Enoxaparin is eliminated mostly by the kidneys. When it is used in patients with severe renal impairment the dosage must be significantly reduced. For some indications the dose normally given every 12 hours is given only every 24 hours. Although some β-blockers require a dosage adjustment, metoprolol and carvedilol are metabolized by the liver and do not require dosage adjustment in patients with renal failure. Clopidogrel is currently recommended at the standard dosage for patients with renal failure and acute coronary syndrome. Thrombolytics like tPA are given at the standard dosage in renal failure, although hemorrhagic complications are increased. A 55-year-old male who has a long history of marginally-controlled hypertension presents with gradually increasing shortness of breath and reduced exercise tolerance. His physical examination is normal except for a blood pressure of 140/90 mm Hg, bilateral basilar rales, and trace pitting edema. Which one of the following ancillary studies would be the preferred diagnostic tool for evaluating this patient? (check one) A. 12-lead electrocardiography B. Posteroanterior and lateral chest radiographs C. 2-dimensional echocardiography with Doppler D. Radionuclide ventriculography E. Cardiac MRI - ✔✔C. 2-dimensional echocardiography with Doppler. The most useful diagnostic tool for evaluating patients with heart failure is two-dimensional echocardiography with Doppler to assess left ventricular ejection fraction (LVEF), left ventricular size, ventricular compliance, wall thickness, and valve function. The test should be performed during the initial evaluation. Radionuclide ventriculography can be used to assess LVEF and volumes, and MRI or CT also may provide information in selected patients. Chest radiography (posteroanterior and lateral) and 12-lead electrocardiography should be performed in all patients presenting with heart failure, but should not be used as the primary basis for determining which abnormalities are responsible for the heart failure. A 23-year-old female sees you with a complaint of intermittent irregular heartbeats that occur once every week or two, but do not cause her to feel lightheaded or fatigued. They last only a few seconds and resolve spontaneously. She has never passed out, had chest pain, or had difficulty with exertion. She is otherwise healthy, and a physical examination is normal. Which one of the following cardiac studies should be ordered initially? (check one) A. 24-hour ambulatory EKG monitoring (Holter monitor) B. 30-day continuous closed-loop event recording C. Echocardiography D. An EKG E. Electrophysiologic studies - ✔✔D. An EKG. The symptom of an increased or abnormal sensation of one's heartbeat is referred to as palpitations. This condition is common to primary care, but is often benign. Commonly, these sensations have their basis in anxiety or panic. However, about 50% of those who complain of palpitations will be found to have a diagnosable cardiac condition. It is recommended to start the evaluation for cardiac causes with an EKG, which will assess the baseline rhythm and screen for signs of chamber enlargement, previous myocardial infarction, conduction disturbances, and a prolonged QT interval. Which one of the following is most appropriate for the initial treatment of claudication? (check one) A. Regular exercise B. Chelation C. Vasodilating agents D. Warfarin (Coumadin) - ✔✔A. Regular exercise. Claudication is exercise-induced lower-extremity pain that is caused by ischemia and relieved by rest. It affects 10% of persons over 70 years of age. However, up to 90% of patients with peripheral vascular disease are asymptomatic. Initial treatment should consist of vigorous risk factor modification and exercise. Patients who follow an exercise regimen can increase their walking time by 150%. A supervised program may produce better results. Risk factors include diabetes mellitus, hypertension, smoking, and hyperlipidemia. Unconventional treatments such as chelation have not been shown to be effective. Vasodilating agents are of no benefit. There is no evidence that anticoagulants such as aspirin have a role in the treatment of claudication. In a patient who presents with symptoms of acute myocardial infarction, which one of the following would be an indication for thrombolytic therapy? (check one) A. New-onset ST-segment depression B. New-onset left bundle branch block C. New-onset first degree atrioventricular block D. New-onset Wenckebach second degree heart block E. Frequent unifocal ventricular ectopic beats - ✔✔B. New-onset left bundle branch block. In patients with ischemic chest pain, the EKG is important for determining the need for fibrinolytic therapy. Myocardial infarction is diagnosed by ST elevation ≥1 mm in two or more limb leads and ≥2 mm in two or more contiguous precordial leads. In a patient with an MI, new left bundle branch block suggests occlusion of the left anterior descending artery, placing a significant portion of the left ventricle in jeopardy. Thrombolytic therapy could be harmful in patients with ischemia but not infarction - they will show ST-segment depression only. Frequent unifocal ventricular ectopy may warrant antiarrhythmic therapy, but not thrombolytic therapy. A 68-year-old female has an average blood pressure of 150/70 mm Hg despite appropriate lifestyle modification efforts. Her only other medical problems are osteoporosis and mild depression. The most appropriate treatment at this time would be (check one) A. lisinopril (Prinivil, Zestril) B. clonidine (Catapres) C. propranolol (Inderal) D. amlodipine (Norvasc) E. hydrochlorothiazide - ✔✔E. hydrochlorothiazide. Randomized, placebo-controlled trials have shown that isolated systolic hypertension in the elderly responds best to diuretics and to a lesser extent, β-blockers. Diuretics are preferred, although long-acting dihydropyridine calcium channel blockers may also be used. In the case described, β-blockers or clonidine may worsen the depression. Thiazide diuretics may also improve osteoporosis, and would be the most cost-effective and useful agent in this instance. A 31-year-old healthy female is admitted to the hospital from the emergency department after presenting with aching in her right shoulder and swelling in the ipsilateral forearm and hand. The only precipitating event that she can recall is digging strenuously in the back yard to put in a new garden. Ultrasonography is remarkable for a thrombus in the axillosubclavian vein. She has no prior history of clotting, takes no medications, and has no previous history of medical or surgical procedures involving this extremity. The most likely etiology for this patient's condition is (check one) A. a hypercoagulable state B. a compressive anomaly in the thoracic outlet C. use of injection drugs D. Budd-Chiari syndrome - ✔✔B. a compressive anomaly in the thoracic outlet. Thrombosis of the upper extremity accounts for about 10% of all venous thromboembolism (VTE) cases. However, axillosubclavian vein thrombosis (ASVT) is becoming more frequent with the increased use of indwelling subclavian vein catheters. Spontaneous ASVT (not catheter related) is seen most commonly in young, healthy individuals. The most common associated etiologic factor is the presence of a compressive anomaly in the thoracic outlet. These anomalies are often bilateral, and the other upper extremity at similar risk for thrombosis. While a hypercoagulable state also may contribute to the thrombosis, it is much less common. Budd-Chiari syndrome refers to thrombosis in the intrahepatic, suprahepatic, or hepatic veins. It is not commonly associated with spontaneous upper-extremity thrombosis. A 56-year-old white male presents with a 2-week history of intermittent pain in his left leg. The pain usually occurs while he is walking and is primarily in the calf muscle or Achilles region. Sometimes he will awaken at night with cramps in the affected leg. He has no known risk factors for atherosclerosis. Which one of the following would be the best initial test for peripheral vascular occlusive disease? (check one) A. Ankle-brachial index B. Arterial Doppler ultrasonography C. Arteriography D. Magnetic resonance angiography (MRA) E. Venous ultrasonography - ✔✔A. Ankle-brachial index. The ankle-brachial index (ABI) is an inexpensive, sensitive screening tool and is the most appropriate first test for peripheral vascular occlusive disease (PVOD) in this patient. The ABI is the ratio of systolic blood pressure measured in the ankle to systolic pressure using the standard brachial measurement. A ratio of 0.9-1.2 is considered normal. Severe disease is defined as a ratio <0.50. More invasive and expensive testing using Doppler ultrasonography, arteriography, or magnetic resonance angiography may be useful if the ABI suggests an abnormality. Venous ultrasonography would not detect PVOD, but it could rule out deep venous thrombosis, which is another common etiology for calf pain. A 69-year-old male has a 4-day history of swelling in his left leg. He has no history of trauma, recent surgery, prolonged immobilization, weight loss, or malaise. His examination is unremarkable except for a diffusely swollen left leg. A CBC, chemistry profile, prostate-specific antigen level, chest radiograph, and EKG are all normal; however, compression ultrasonography of the extremity reveals a clot in the proximal femoral vein. He has no past history of venous thromboembolic disease. In addition to initiating therapy with low molecular weight heparin, the American College of Chest Physicians recommends that warfarin (Coumadin) be instituted now and continued for at least (check one) A. 1 month B. 3 months C. 6 months D. 12 months - ✔✔B. 3 months. For patients with a first episode of unprovoked deep venous thrombosis, evidence supports treatment with a vitamin K antagonist for at least 3 months (SOR A). The American College of Chest Physicians recommends that patients be evaluated at that point for the potential risks and benefits of long-term therapy (SOR C). ======================================================= Cardiovascular Board Review Questions 03 ======================================================= A 35-year-old African-American female has just returned home from a vacation in Hawaii. She presents to your office with a swollen left lower extremity. She has no previous history of similar problems. Homan's sign is positive, and ultrasonography reveals a noncompressible vein in the left popliteal fossa extending distally. Which one of the following is true in this situation? (check one) A. Monotherapy with an initial 10-mg loading dose of warfarin (Coumadin) would be appropriate B. Enoxaparin (Lovenox) should be administered at a dosage of 1 mg/kg subcutaneously twice a day C. The incidence of thrombocytopenia is the same with low-molecular-weight heparin as with unfractionated heparin D. The dosage of warfarin should be adjusted to maintain the INR at 2.5-3.5 E. Anticoagulant therapy should be started as soon as possible and maintained for 1 year to prevent deep vein thrombosis (DVT) recurrence - ✔✔B. Enoxaparin (Lovenox) should be administered at a dosage of 1 mg/kg subcutaneously twice a day. The use of low-molecular-weight heparin allows patients with acute deep vein thrombosis (DVT) to be managed as outpatients. The dosage is 1 mg/kg subcutaneously twice daily. Patients chosen for outpatient care should have good cardiopulmonary reserve, normal renal function, and no risk for excessive bleeding. Oral anticoagulation with warfarin can be initiated on the first day of treatment after heparin loading is completed. Monotherapy with warfarin is inappropriate. The incidence of thrombocytopenia with low-molecular-weight heparin is lower than with conventional heparin. The INR should be maintained at 2.0-3.0 in this patient. The 2.5-3.5 range is used for patients with mechanical heart valves. The therapeutic INR should be maintained for 3-6 months in a patient with a first DVT related to travel. Which one of the following historical features is most suggestive of congestive heart failure in a 6-month-old white male presenting with tachypnea? (check one) A. Diaphoresis with feeding B. Fever C. Nasal congestion D. Noisy respiration or wheezing E. Staccato cough - ✔✔A. Diaphoresis with feeding. Symptoms of congestive heart failure in infants are often related to feedings. Only small feedings may be tolerated, and dyspnea may develop with feedings. Profuse perspiration with feedings, is characteristic, and related to adrenergic drive. Older children may have symptoms more similar to adults, but the infant's greatest exertion is related to feeding. Fever and nasal congestion are more suggestive of infectious problems. Noisy respiration or wheezing does not distinguish between congestive heart failure, asthma, and infectious processes. A staccato cough is more suggestive of an infectious process, including pertussis. Which one of the following procedures carries the highest risk for postoperative deep venous thrombosis? (check one) A. Abdominal hysterectomy B. Coronary artery bypass graft C. Transurethral prostatectomy D. Lumbar laminectomy E. Total knee replacement - ✔✔E. Total knee replacement. Neurosurgical procedures, particularly those with penetration of the brain or meninges, and orthopedic surgeries, especially those of the hip, have been linked with the highest incidence of venous thromboembolic events. The risk is due to immobilization, venous injury and stasis, and impairment of natural anticoagulants. For total knee replacement, hip fracture surgery, and total hip replacement, the prevalence of DVT is 40%-80%, and the prevalence of pulmonary embolism is 2%-30%. Other orthopedic procedures, such as elective spine procedures, have a much lower rate, approximately 5%. The prevalence of DVT after a coronary artery bypass graft is approximately 5%, after transurethral prostatectomy <5%, and after abdominal hysterectomy approximately 16%. A 13-year-old male is found to have hypertrophic cardiomyopathy. His father also had hypertrophic cardiomyopathy, and died suddenly at age 38 following a game of tennis. The boy's mother asks you for advice regarding his condition. What advice should you give her? (check one) A. He may participate in noncontact sports B. He should receive lifelong treatment with beta-blockers C. His condition usually decreases lifespan D. His hypertrophy will regress with age E. His siblings should undergo echocardiography - ✔✔E. His siblings should undergo echocardiography. Hypertrophic cardiomyopathy is an autosomal dominant condition and close relatives of affected individuals should be screened. The hypertrophy usually stays the same or worsens with age. This patient should not participate in strenuous sports, even those considered noncontact. Beta-blockers have not been shown to alter the progress of the disease. The mortality rate is believed to be about 1%, with some series estimating 5%. Thus, in most cases lifespan is normal. A 70-year-old white male has a slowly enlarging, asymptomatic abdominal aortic aneurysm. You should usually recommend surgical intervention when the diameter of the aneurysm approaches: (check one) A. 3.5 cm B. 4.5 cm C. 5.5 cm D. 6.5 cm E. 7.5 cm - ✔✔C. 5.5 cm. Based on recent clinical trials, the most common recommendation for surgical repair is when the aneurysm approaches 5.5 cm in diameter. Two large studies, the Aneurysm Detection and Management (ADAM) Veteran Affairs Cooperative Study, and the United Kingdom Small Aneurysm Trial, failed to show any benefit from early surgery for men with aneurysms less than 5.5 cm in diameter. The risks of aneurysm rupture were 1% or less in both studies, with 6-year cumulative survivals of 74% and 64%, respectively. Interestingly, the risk for aneurysm rupture was four times greater in women, indicating that 5.5 cm may be too high, but a new evidence-based threshold has not yet been defined. Which one of the following drug classes is preferred for treating hypertension in patients who also have diabetes mellitus? (check one) A. Centrally-acting sympatholytics B. Alpha-blocking agents C. Beta-blocking agents D. ACE inhibitors E. Calcium channel blockers - ✔✔D. ACE inhibitors. ACE inhibitors have proven beneficial in patients who have either early or established diabetic renal disease. They are the preferred therapy in patients with diabetes and hypertension, according to guidelines from the American Diabetes Association, the National Kidney Foundation, the World Health Organization, and the JNC VII report. A 75-year-old Hispanic male presents with dyspnea on exertion which has worsened over the last several months. He denies chest pain and syncope, and was fairly active until the shortness of breath slowed him down recently. You hear a grade 3/6 systolic ejection murmur at the right upper sternal border which radiates into the neck. Echocardiography reveals aortic stenosis, with a mean transvalvular gradient of 55 mm Hg and a calculated valve area of 0.6 cm2. Left ventricular function is normal. Which one of the following is appropriate management for this patient? (check one) A. Aortic valve replacement B. Aortic balloon valvotomy C. Medical management with beta-blockers and nitrates D. Watchful waiting until the gradient is severe enough for treatment E. Deferring the decision pending results of an exercise stress test - ✔✔A. Aortic valve replacement. Since this patient's mean aortic-valve gradient exceeds 50 mm Hg and the aortic-valve area is not larger than 1 cm2, it is likely that his symptoms are due to aortic stenosis. As patients with symptomatic aortic stenosis have a dismal prognosis without treatment, prompt correction of his mechanical obstruction with aortic valve replacement is indicated. Medical management is not effective, and balloon valvotomy only temporarily relieves the symptoms and does not prolong survival. Patients who present with dyspnea have only a 50% chance of being alive in 2 years unless the valve is promptly replaced. Exercise testing is unwarranted and dangerous in patients with symptomatic aortic stenosis. Which one of the following is considered a contraindication to the use of beta-blockers for congestive heart failure? (check one) A. Mild asthma B. Symptomatic heart block C. New York Heart Association (NYHA) Class III heart failure D. NYHA Class I heart failure in a patient with a history of a previous myocardial infarction E. An ejection fraction <30% - ✔✔B. Symptomatic heart block. According to several randomized, controlled trials, mortality rates are improved in patients with heart failure who receive beta-blockers in addition to diuretics, ACE inhibitors, and occasionally, digoxin. Contraindications to beta-blocker use include hemodynamic instability, heart block, bradycardia, and severe asthma. Beta-blockers may be tried in patients with mild asthma or COPD as long as they are monitored for potential exacerbations. Beta-blocker use has been shown to be effective in patients with NYHA Class II or III heart failure. There is no absolute threshold ejection fraction. Beta-blockers have also been shown to decrease mortality in patients with a previous history of myocardial infarction, regardless of their NYHA classification. Which one of the following is the leading cause of death in women? (check one) A. Breast cancer B. Lung cancer C. Ovarian cancer D. Osteoporosis E. Cardiovascular disease - ✔✔E. Cardiovascular disease. Cardiovascular disease is the leading cause of death among women. According to the CDC, 29.3% of deaths in females in the U.S. in 2001 were due to cardiovascular disease and 21.6% were due to cancer, with most resulting from lung cancer. Breast cancer is the third most common cause of cancer death in women, and ovarian cancer is the fifth most common. A 72-year-old African-American male comes to your office for surgical clearance to undergo elective hemicolectomy for recurrent diverticulitis. The patient suffered an uncomplicated acute anterior-wall myocardial infarction approximately 18 months ago. A stress test was normal 2 months after he was discharged from the hospital. Currently, the patient feels well, walks while playing nine holes of golf three times per week, and is able to walk up a flight of stairs without chest pain or significant dyspnea. Findings are normal on a physical examination. Which one of the following would be most appropriate for this patient prior to surgery? (check one) A. A 12-lead resting EKG B. A graded exercise stress test C. A stress echocardiogram D. A persantine stressed nuclear tracer study (technetium or thallium) E. Coronary angiography - ✔✔A. A 12-lead resting EKG. The current recommendations from the American College of Cardiology and the American Heart Association on preoperative clearance for noncardiac surgery state that preoperative intervention is rarely needed to lower surgical risk. Patients who are not currently experiencing unstable coronary syndrome, severe valvular disease, uncompensated congestive heart failure, or a significant arrhythmia are not considered at high risk, and should be evaluated for most surgery primarily on the basis of their functional status. If these patients are capable of moderate activity (greater than 4 METs) without cardiac symptoms, they can be cleared with no stress testing or coronary angiography for an elective minor or intermediate-risk operation such as the one this patient is to undergo. A resting 12-lead EKG is recommended for males over 45, females over 55, and patients with diabetes, symptoms of chest pain, or a previous history of cardiac disease. ======================================================= Cardiovascular Board Review Questions 04 ======================================================= A 73-year-old male with COPD presents to the emergency department with increasing dyspnea. Examination reveals no sign of jugular venous distention. A chest examination reveals decreased breath sounds and scattered rhonchi, and the heart sounds are very distant but no gallop or murmur is noted. There is +1 edema of the lower extremities. Chest radiographs reveal cardiomegaly but no pleural effusion. The patient's B-type natriuretic peptide level is 850 pg/mL (N <100) and his serum creatinine level is 0.8 mg/dL (N 0.6-1.5). Which one of the following would be the most appropriate initial management? (check one) A. Intravenous heparin B. Tiotropium (Spiriva) C. Levalbuterol (Xopenex) via nebulizer D. Prednisone, 20 mg twice daily for 1 week E. Furosemide (Lasix), 40 mg intravenously - ✔✔E. Furosemide (Lasix), 40 mg intravenously. B-type natriuretic peptide (BNP) is secreted in the ventricles and is sensitive to changes in left ventricular function. Concentrations correlate with end-diastolic pressure, which in turn correlates with dyspnea and congestive heart failure. BNP levels can be useful when trying to determine whether dyspnea is due to cardiac, pulmonary, or deconditioning etiologies. A value of less than 100 pg/mL excludes congestive heart failure as the cause for dyspnea. If it is greater than 400 pg/mL, the likelihood of congestive heart failure is 95%. Patients with values of 100-400 pg/mL need further investigation. There are some pulmonary problems that may elevate BNP, such as lung cancer, cor pulmonale, and pulmonary embolus. However, these patients do not have the same extent of elevation that those with acute left ventricular dysfunction will have. If these problems can be ruled out, then individuals with levels between 100-400 pg/mL most likely have congestive heart failure. Initial therapy should be a loop diuretic. It should be noted that BNP is partially excreted by the kidneys, so levels are inversely proportional to creatinine clearance. A 25-year-old female at 36 weeks gestation presents for a routine prenatal visit. Her blood pressure is 118/78 mm Hg and her urine has no signs of protein or glucose. Her fundal height shows appropriate fetal size and she says that she feels well. On palpation of her legs, you note 2+ pitting edema bilaterally. Which one of the following is true regarding this patient's condition? (check one) A. You should order a 24-hr urine for protein B. A workup for possible cardiac abnormalities is necessary C. Her leg swelling requires no further evaluation D. She most likely has preeclampsia E. She most likely has deep venous thrombosis - ✔✔C. Her leg swelling requires no further evaluation. Lower-extremity edema is common in the last trimester of normal pregnancies and can be treated symptomatically with compression stockings. Edema has been associated with preeclampsia, but the majority of women who have lower-extremity edema with no signs of elevated blood pressure will not develop preeclampsia or eclampsia. For this reason, edema has recently been removed from the diagnostic criteria for preeclampsia. Disproportionate swelling in one leg versus another, especially associated with leg pain, should prompt a workup for deep venous thrombosis but is unlikely given this patient's presentation, as are cardiac or renal conditions. A 72-year-old male with a history of previous inferior myocardial infarction sees you prior to surgery for symptomatic gallstones. He denies chest pain or dyspnea. His current medications include aspirin, 81 mg daily; ramipril (Altace), 10 mg daily; and pravastatin (Pravachol), 40 mg daily. He is in good health otherwise and has no other health complaints. He has been cleared for surgery by his cardiologist. Which one of the following should be considered before and after surgery, assuming no contraindications? (check one) A. Atenolol (Tenormin) B. Verapamil (Calan, Isoptin) C. Digoxin D. Transdermal nitroglycerin E. Intravenous nitroglycerin - ✔✔A. Atenolol (Tenormin). A recent development in the prophylaxis of surgery-related cardiac complications is the use of beta-blockers perioperatively for patients with cardiac risk factors. In a randomized, double-blind, placebo-controlled trial involving 200 patients who were undergoing elective noncardiac surgery that required general anesthesia, the effect of atenolol on perioperative cardiac complications was evaluated. Patients were eligible for beta-blocker therapy if they had known coronary artery disease or two or more risk factors. Atenolol was not used if the resting heart rate was <55 beats/min, systolic blood pressure was <100 mm Hg, or there was evidence of congestive heart failure, third degree heart block, or bronchospasm. A 5-mg dose of intravenous atenolol was given 30 minutes before surgery and then again immediately after surgery. Oral atenolol, 50-100 mg, was then given until hospital discharge or 7 days postoperatively. The results of the study showed that mortality from cardiac causes was 65% lower in the patients receiving atenolol. Another study showed similar perioperative benefit using the beta-blocker bisoprolol. In prescribing an exercise program for elderly, community-dwelling patients, it is important to note that: (check one) A. Graded exercise stress testing should be done before beginning the program B. Target heart rates should be 80% of the predicted maximum C. The initial routines can be as short as 6 minutes repeated throughout the day and still be beneficial D. Treadmill walking is especially beneficial to patients with peripheral neuropathy - ✔✔C. The initial routines can be as short as 6 minutes repeated throughout the day and still be beneficial. Initial exercise routines for the elderly can be as short as 6 minutes in duration. Even 30 minutes per week of exercise has been shown to be beneficial. Graded exercise testing need not be done, especially if low-level exercise is planned. A target heart rate of 60%-75% of the predicted maximum should be set as a ceiling. Patients with peripheral neuropathy should not perform treadmill walking or step aerobics because of the risk of damage to their feet. A 52-year-old white male is being considered for pharmacologic treatment of hyperlipidemia because of an LDL cholesterol level of 180 mg/dL. Before beginning medication for his hyperlipidemia, he should be screened for: (check one) A. Hyperthyroidism B. Hypothyroidism C. Addison's disease D. Cushing's disease E. Pernicious anemia - ✔✔B. Hypothyroidism. According to the Summary of the National Cholesterol Education Program (NCEP) Adult Treatment Panel III Report of 2001, any person with elevated LDL cholesterol or any other form of hyperlipidemia should undergo clinical or laboratory assessment to rule out secondary dyslipidemia before initiation of lipid-lowering therapy. Causes of secondary dyslipidemia include diabetes mellitus, hypothyroidism, obstructive liver disease, chronic renal failure, and some medications. A 56-year-old African-American male with longstanding hypertension and a 30-pack-year smoking history has a 2-day history of dyspnea on exertion. Physical examination is unremarkable except for rare crackles at the bases. Which one of the following serologic tests would be most helpful for detecting left ventricular dysfunction? (check one) A. Beta-natriuretic peptide (BNP) B. Troponin-T C. C-reactive protein (CRP) D. D dimer E. Cardiac interleukin-2 - ✔✔A. Beta-natriuretic peptide (BNP). Beta-natriuretic peptide (BNP) is a 32-amino acid polypeptide secreted from the cardiac ventricles in response to ventricular volume expansion and pressure overload. The major source of BNP is the cardiac ventricles, and because of its minimal presence in storage granules, its release is directly proportional to ventricular dysfunction. It is a simple and rapid test that reliably predicts the presence or absence of left ventricular dysfunction on an echocardiogram. Patients with Wolff-Parkinson-White syndrome who have episodic symptomatic supraventricular tachycardia or atrial fibrillation benefit most from: (check one) A. Episodic intravenous digoxin B. Long-term oral digitalis C. Episodic beta-blockers D. Radiofrequency catheter ablation of bypass tracts - ✔✔D. Radiofrequency catheter ablation of bypass tracts. Radiofrequency catheter ablation of bypass tracts is possible in over 90% of patients and is safer and more cost effective than surgery, with a similar success rate. Intravenous and oral digoxin can shorten the refractory period of the accessory pathway, and increase the ventricular rate, causing ventricular fibrillation. Beta-blockers will not control the ventricular response during atrial fibrillation when conduction proceeds over the bypass tract. A 72-year-old male with class III congestive heart failure (CHF) due to systolic dysfunction asks if he can take ibuprofen for his "aches and pains." Appropriate counseling regarding NSAID use and heart failure should include which one of the following? (check one) A. NSAIDs are a good choice for pain relief, as they decrease systemic vascular resistance B. NSAIDs are a good choice for pain relief, as they augment the effect of his diuretic C. High-dose aspirin (325 mg/day) is preferable to other NSAIDs for patients taking ACE inhibitors D. NSAIDs, including high-dose aspirin, should be avoided in CHF patients because they can cause fluid retention - ✔✔D. NSAIDs, including high-dose aspirin, should be avoided in CHF patients because they can cause fluid retention. If possible, NSAIDs should be avoided in patients with heart failure. They cause sodium and water retention, as well as an increase in systemic vascular resistance which may lead to cardiac decompensation. Patients with heart failure who take NSAIDs have a tenfold increased risk of hospitalization for exacerbation of their CHF. NSAIDs alone in patients with normal ventricular function have not been associated with initial episodes of heart failure. NSAIDs, including high-dose aspirin (325 mg/day), may decrease or negate entirely the beneficial unloading effects of ACE inhibition. They have been shown to have a negative impact on the long-term morbidity and mortality benefits that ACE inhibitors provide. Sulindac and low-dose aspirin (81 mg/day) are less likely to cause these negative effects. A 72-year-old male presents to your clinic in atrial fibrillation with a rate of 132 beats/min. He has hypertension, but no history of congestive heart failure or structural heart disease. He is otherwise healthy and active. The best INITIAL approach to his atrial fibrillation would be: (check one) A. Rhythm control with antiarrythmics and warfarin (Coumadin) only if he cannot be consistently maintained in sinus rhythm B. Rhythm control with antiarrythmics and warfarin regardless of maintenance of sinus rhythm C. Ventricular rate control with digoxin, and warfarin for anticoagulation D. Ventricular rate control with digoxin, and aspirin for anticoagulation E. Ventricular rate control with a calcium channel blocker or beta-blocker, and warfarin for anticoagulation - ✔✔E. Ventricular rate control with a calcium channel blocker or beta-blocker, and warfarin for anticoagulation. Five recent randomized, controlled trials have indicated that in most patients with atrial fibrillation, an initial approach of rate control is best. Patients who were stratified to the rhythm control arm of the trials did NOT have a morbidity or mortality benefit and were more likely to suffer from adverse drug effects and increased hospitalizations. The most efficacious drugs for rate control are calcium channel blockers and beta-blockers. Digoxin is less effective for rate control and should be reserved as an add-on option for those not controlled with a beta-blocker or calcium channel blocker, or for patients with significant left ventricular systolic dysfunction. In patients 65 years of age or older or with one or more risk factors for stroke, the best choice for anticoagulation to prevent thromboembolic disease is warfarin. Of note, in patients who are successfully rhythm controlled and maintained in sinus rhythm, the thromboembolic rate is equivalent to those managed with a rate control strategy. Thus, the data suggest that patients who choose a rhythm control strategy should be maintained on anticoagulation regardless of whether they are consistently in sinus rhythm. Cilostazol (Pletal) has been found to be a useful drug for the treatment of intermittent claudication. This drug is contraindicated in patients with: (check one) A. Congestive heart failure B. A past history of stroke C. Diabetes mellitus D. Third degree heart block E. Hyperlipidemia - ✔✔A. Congestive heart failure. 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. ======================================================= Cardiovascular Board Review Questions 05 ======================================================= A 35-year-old white male with known long QT syndrome has a brief episode of syncope requiring cardiopulmonary resuscitation. Which one of the following is most likely responsible for this episode? (check one) A. Sinus tachycardia B. Atrial flutter with third degree block C. Asystole D. Torsades de pointes - ✔✔D. Torsades de pointes. Patients with long QT syndrome that have sudden arrhythmia death syndrome usually have either torsades de pointes or ventricular fibrillation. Sinus tachycardia would not explain the syncope, and atrial flutter and asystole are not usual in long QT syndrome. An 83-year-old female presents to your office as a new patient. She recently moved to the area to be closer to her family. A history reveals that she has been in excellent health, has no complaints, and is on no medications except occasional acetaminophen for knee pain. She has never been in the hospital and has not had any operations. She says that she feels well. The examination is normal, with expected age-related changes, except that her blood pressure on three different readings averages 175/70 mm Hg. These readings are confirmed on a subsequent follow-up visit. In addition to lifestyle changes, which one of the following would be most appropriate for the initial management of this patient's hypertension? (check one) A. An alpha-blocker B. An ACE inhibitor C. A beta-blocker D. An angiotensin receptor blocker E. A thiazide diuretic - ✔✔E. A thiazide diuretic. Clinical trials support the treatment of systolic hypertension in the older person with a systolic blood pressure of at least 160 mm Hg. (Systolic hypertension is defined as systolic blood pressure of at least 140 mm Hg and a diastolic blood pressure of less than 90 mm Hg.) The studies most strongly support the use of thiazide diuretics and long-acting calcium channel blockers as first-line therapy. Alpha-blockers are not recommended. ACE inhibitors, beta-blockers, and angiotensin receptor blockers are used when certain compelling indications are present, e.g., in a patient with diabetes or who has had a myocardial infarction. Of the following, the INITIAL treatment of choice in the management of severe hypertension during pregnancy is: (check one) A. Labetalol (Trandate, Normodyne) intravenously B. Reserpine (Serpasil) intramuscularly C. Nifedipine (Procardia, Adalat) sublingually D. Enalapril (Vasotec) intravenously - ✔✔A. Labetalol (Trandate, Normodyne) intravenously. In pregnant women with severe hypertension, the primary objective of treatment is to prevent cerebral complications such as encephalopathy and hemorrhage. Intravenous hydralazine, intravenous labetalol, or oral nifedipine may be used. Sublingual nifedipine can cause severe hypotension, and reserpine is not indicated. Nitroprusside can be used for short intervals in patients with hypertensive encephalopathy, but fetal cyanide toxicity is a risk with infusions lasting more than 4 hours. ACE inhibitors are never indicated for hypertensive therapy during pregnancy. Which one of the following has been shown to decrease mortality late after a myocardial infarction? (check one) A. Nitrates B. Beta-blockers C. Digoxin D. Thiazide diuretics E. Calcium channel antagonists - ✔✔B. Beta-blockers. Beta-blockers and ACE inhibitors have been found to decrease mortality late after myocardial infarction. Aspirin has been shown to decrease nonfatal myocardial infarction, nonfatal stroke, and vascular events. Nitrates, digoxin, thiazide diuretics, and calcium channel antagonists have not been found to reduce mortality after myocardial infarction. Which one of the following is preferred for chronic treatment of congestive heart failure due to left ventricular systolic dysfunction? (check one) A. Diuretics B. Digoxin C. Calcium channel blockers D. ACE inhibitors E. Hydralazine (Apresoline) plus isosorbide dinitrate (Isordil, Sorbitrate) - ✔✔D. ACE inhibitors. ACE inhibitors are the preferred drugs for congestive heart failure due to left ventricular systolic dysfunction, because they are associated with the lowest mortality. The combination of hydralazine/isosorbide dinitrate is a reasonable alternative, and diuretics should be used cautiously. It is not known whether digoxin affects mortality, although it can help with symptoms. Which one of the following is most predictive of increased perioperative cardiovascular events associated with noncardiac surgery in the elderly? (check one) 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. Renal insufficiency (creatinine 2.0 mg/dL). 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. The use of automated external defibrillators by lay persons in out-of-hospital settings: (check one) A. Has been frustrated by liability concerns B. Has been hampered by an unwillingness to place the devices in public areas C. Has been shown to contribute to significant gains in full neurologic and functional recovery D. Has been eclipsed by the widespread use of internal cardiac defibrillators in high-risk patients - ✔✔C. Has been shown to contribute to significant gains in full neurologic and functional recovery. The use of automated external defibrillators (AEDs) by lay persons, trained and otherwise, has been quite successful, with up to 40% of those treated recovering full neurologic and functional capacity. At present, 45 states have passed Good Samaritan laws covering the use of AEDs by well-intentioned lay persons. There are initiatives for widespread placement of AEDs, to include commercial airlines and other public facilities. Implantable cardioverter defibrillators (ICDs) are useful in known at-risk patients, but the use of AEDs is for the population at large. A 74-year-old white male complains of pain in the right calf that recurs on a regular basis. He smokes 1 pack of cigarettes per day and is hypertensive. He has a history of a previous heart attack but is otherwise in fair health. Which one of the following findings would support a diagnostic impression of peripheral vascular disease? (check one) A. Pain during rest and exercise and the presence of swelling and soreness behind the knee and in the calf B. Pain that begins immediately upon walking and is unrelieved by rest C. Doppler waveform analysis showing accentuated waveforms at a point of decreased blood flow D. Treadmill arterial flow studies showing a 20-mm Hg decrease in ankle systolic blood pressure immediately following exercise E. An ankle-brachial index of 1.15 - ✔✔D. Treadmill arterial flow studies showing a 20-mm Hg decrease in ankle systolic blood pressure immediately following exercise. Peripheral vascular disease (PVD) is a clinical manifestation of atherosclerotic disease and is caused by occlusion of the arteries to the legs. Patients with significant arterial occlusive disease will have a prominent decrease in the ankle-brachial index from baseline following exercise, and usually a 20-mm Hg or greater decrease in systolic blood pressure. Pain during rest and exercise and the presence of swelling and soreness behind the knee and in the calf is found in those with Baker's cysts. Peripheral nerve pain commonly begins immediately upon walking and is unrelieved by rest. Doppler waveform analysis is useful in the diagnosis of PVD and will reveal attenuated waveforms at a point of decreased blood flow. Employment of the ankle-brachial index is encouraged in daily practice as a simple means to diagnose the presence of PVD. Generally, ankle-brachial indices in the range of 0.91-1.30 are thought to be normal. In a 34-year-old primigravida at 35 weeks' gestation, which one of the following supports a diagnosis of MILD preeclampsia rather than severe preeclampsia? (check one) A. A blood pressure of 150/100 mm Hg B. A 24-hr protein level of 6 g C. A platelet count <100,000/mm3 D. Liver enzyme elevation with epigastric tenderness E. Altered mental status - ✔✔A. A blood pressure of 150/100 mm Hg. The criteria for severe preeclampsia specify a blood pressure of 160/110 mm Hg or above on two occasions, 6 hours apart. Other criteria include proteinuria above 5 g/24 hr, thrombocytopenia with a platelet count <100,000/mm3, liver enzyme abnormalities, epigastric or right upper quadrant pain, and alteration of mental status. A 72-year-old white female is scheduled to undergo a total knee replacement for symptomatic osteoarthritis. She is otherwise healthy, with no history of vascular disease or deep vein thrombosis. She takes no routine medications. Which one of the following is most appropriate for prophylaxis against deep vein thrombosis? (check one) A. No prophylaxis if there are no surgical complications B. Aspirin, 325 mg daily C. Unfractionated heparin, 5000 U subcutaneously every 12 hours D. Thigh-high compression stockings E. Enoxaparin (Lovenox), 30 mg subcutaneously every 12 hours - ✔✔E. Enoxaparin (Lovenox), 30 mg subcutaneously every 12 hours. Prophylaxis is indicated with total knee or hip replacements. The two regimens recommended are low-molecular-weight heparin and adjusted-dose warfarin. These may be augmented by intermittent pneumatic compression. ======================================================= Endocrine Board Review Questions 01 ======================================================= A 49-year-old female who takes multiple medications has a chemistry profile as part of her routine monitoring. She is found to have an elevated calcium level. All other values on the profile are normal, and the patient is not currently symptomatic. Follow-up testing reveals a serum calcium level of 11.2 mg/dL (N 8.4-10.2) and an intact parathyroid hormone level of 80 pg/mL (N 10-65). Which one of the following should be discontinued for 3 months before repeat laboratory evaluation and treatment? (check one) A. Lithium B. Furosemide (Lasix) C. Raloxifene (Evista) D. Calcium carbonate E. Vitamin D - ✔✔A. Lithium. Lithium therapy can elevate calcium levels by elevating parathyroid hormone secretion from the parathyroid gland. This duplicates the laboratory findings seen with mild primary hyperparathyroidism. If possible, lithium should be discontinued for 3 months before reevaluation (SOR C). This is most important for avoiding unnecessary parathyroid surgery. Vitamin D and calcium supplementation could contribute to hypercalcemia in rare instances, but they would not cause elevation of parathyroid hormone. Raloxifene has actually been shown to mildly reduce elevated calcium levels, and furosemide is used with saline infusions to lower significantly elevated calcium levels. Which one of the following medications should be discontinued in a patient with diabetic gastroparesis? (check one) A. Exenatide (Byetta) B. Benazepril (Lotensin) C. Metformin (Glucophage) D. Hydrochlorothiazide E. Prochlorperazine maleate - ✔✔A. Exenatide (Byetta). Delayed gastric emptying may be caused or exacerbated by medications for diabetes, including amylin analogues (e.g., pramlintide) and glucagon-like peptide 1 (e.g., exenatide). Delayed gastric emptying has a direct effect on glucose metabolism, in addition to being a means of reducing the severity of postprandial hyperglycemia. In a clinical trial of exenatide, nausea occurred in 57% of patients and vomiting occurred in 19%, which led to the cessation of treatment in about one-third of patients. The other medications listed do not cause delayed gastric emptying. A frail 83-year-old male with a 10-year history of diabetes mellitus is admitted to a nursing home. His blood glucose level, which he rarely checks, is typically over 200 mg/dL. His serum creatinine level is 1.9 mg/dL. He also has had several episodes of heart failure. His current medications include glipizide (Glucotrol), lisinopril (Prinivil, Zestril), and furosemide (Lasix). Which one of the following would be most appropriate to add to this patients regimen to treat his diabetes mellitus? (check one) A. The American Diabetes Association 1800-calorie/day diet B. Metformin (Glucophage) C. Pioglitazone (Actos) D. Exenatide (Byetta) E. Insulin glargine (Lantus) - ✔✔E. Insulin glargine (Lantus). For geriatric patients in long-term care facilities, the predictable glucose control of glargine is the best approach to consider initially. The American Diabetes Association does not recommend a strict diet for frail diabetic patients in nursing homes. Exenatide is not recommended for the frail elderly because of concerns about weight loss and nausea. Heart failure precludes the use of pioglitazone, and renal failure precludes the use of metformin. A 54-year-old female takes levothyroxine (Synthroid), 0.125 mg/day, for central hypothyroidism secondary to a pituitary adenoma. The nurse practitioner in your office orders a TSH level, which is found to be 0.1 mIU/mL (N 0.5-5.0). Which one of the following would you recommend? (check one) A. Decrease the dosage of levothyroxine B. Increase the dosage of levothyroxine C. Order a free T4 level D. Order a TRH stimulation test E. Repeat the TSH level in 3 months - ✔✔C. Order a free T4 level. Although uncommon, pituitary disease can cause secondary hypothyroidism. The characteristic laboratory findings are a low serum free T4 and a low TSH. A free T4 level is needed to evaluate the proper dosage of replacement therapy in secondary hypothyroidism. The TSH level is not useful for determining the adequacy of thyroid replacement in secondary hypothyroidism since the pituitary is malfunctioning. In the initial evaluation of secondary hypothyroidism, a TRH stimulation test would be useful if TSH failed to rise in response to stimulation. It is not necessary in this case, since the diagnosis has already been made. A 55-year-old white male sees you for a routine annual visit. His fasting blood glucose level is 187 mg/dL. Repeat testing 1 week later reveals a fasting glucose level of 155 mg/dL and an HbA1c of 9.4%. His BMI is 30 kg/m2. He does not seem to have any symptoms of diabetes mellitus. In addition to lifestyle changes, which one of the following would you prescribe initially? (check one) A. Metformin (Glucophage) B. Glyburide (DiaBeta, Micronase) C. Poiglitazone (Actos) D. Bedtime long-acting insulin (Lantus, Levamir) E. Bedtime long-acting insulin and rapid-acting insulin (NovoLog, Humalog) with each meal - ✔✔A. Metformin (Glucophage). Metformin is widely accepted as the first-line drug for type 2 diabetes mellitus. It is relatively effective, safe, and inexpensive, and has been used widely for many years. Unlike other oral hypoglycemics and insulin, it does not cause weight gain. It should be started at the same time as lifestyle modifications, rather than waiting to see if a diet and exercise regimen alone will work. If metformin is not effective, a sulfonylurea, a thiazolidinedione, or insulin can be added, with the choice based on the severity of the hyperglycemia. Which one of the following most increases insulin sensitivity in an overweight patient with diabetes mellitus? (check one) A. Metformin (Glucophage) B. Acarbose (Precose) C. Glyburide (DiaBeta, Micronase) D. NPH insulin - ✔✔A. Metformin (Glucophage). Metformin increases insulin sensitivity much more than sulfonylureas or insulin. This means lower insulin levels achieve the same level of glycemic control, and may be one reason that weight changes are less likely to be seen in diabetic patients on metformin. Acarbose is an α-glucosidase inhibitor that delays glucose absorption. A 40-year-old female comes to your office for a routine examination. She has been in good health and has no complaints other than obesity. Her mother is diabetic and the patient has had a child that weighed 9 lb at birth. Her examination is negative except for her obesity. A fasting glucose level is 128 mg/dL, and when repeated 2 days later it is 135 mg/dL. Which one of the following would be most appropriate at this point? (check one) A. Diagnose type 2 diabetes mellitus and begin diet and exercise therapy B. Begin an oral hypoglycemic agent C. Order a glucose tolerance test D. Tell the patient that she has impaired glucose homeostasis but is not diabetic - ✔✔A. Diagnose type 2 diabetes mellitus and begin diet and exercise therapy. The criteria for diagnosing diabetes mellitus include any one of the following: symptoms of diabetes (polyuria, polydipsia, weight loss) plus a casual glucose level ≥200 mg/dL; a fasting plasma glucose level ≥126 mg/dL; or a 2-hour postprandial glucose level ≥200 mg/dL after a 75 gram glucose load. In the absence of unequivocal hyperglycemia the test must be repeated on a different day. The criteria for impaired glucose homeostasis include either a fasting glucose level of 100-125 mg/dL (impaired fasting glucose) or a 2-hour glucose level of 140-199 mg/dL on an oral glucose tolerance test. Normal values are now considered <100 mg/dL for fasting glucose and <140 mg/dL for the 2-hour glucose level on an oral glucose tolerance test. A 35-year-old male with a previous history of kidney stones presents with symptoms consistent with a recurrence of this problem. The initial workup reveals elevated serum calcium. Which one of the following tests would be most appropriate at this point? (check one) A. Serum calcitonin B. 24-hour urine for calcium and phosphate C. Serum phosphate and magnesium D. Serum parathyroid hormone E. Spot urine for microalbumin - ✔✔D. Serum parathyroid hormone. A patient with a recurrent kidney stone and an elevated serum calcium level most likely has hyperparathyroidism, and a parathyroid hormone (PTH) level would be appropriate. Elevated PTH is caused by a single parathyroid adenoma in approximately 80% of cases. The resultant hypercalcemia is often discovered in asymptomatic persons having laboratory work for other reasons. An elevated PTH by immunoassay confirms the diagnosis. In the past, tests based on renal responses to elevated PTH were used to make the diagnosis. These included blood phosphate, chloride, and magnesium, as well as urinary or nephrogenous cyclic adenosine monophosphate. These tests are not specific for this problem, however, and are therefore not cost-effective. Serum calcitonin levels have no practical clinical use. ======================================================= Endocrine Board Review Questions 02 ======================================================= In a patient with a solitary thyroid nodule, which one of the following is associated with a higher incidence of malignancy? (check one) A. Hoarseness B. Hyperthyroidism C. Female gender D. A nodule size of 2 cm E. A freely movable nodule - ✔✔A. Hoarseness. When evaluating a patient with a solitary thyroid nodule, red flags indicating possible thyroid cancer include male gender; age <20 years or >65 years; rapid growth of the nodule; symptoms of local invasion such as dysphagia, neck pain, and hoarseness; a history of head or neck radiation; a family history of thyroid cancer; a hard, fixed nodule >4 cm; and cervical lymphadenopathy. Which one of the following can contribute to serum calcium elevation? (check one) A. Furosemide (Lasix) B. Verapamil (Calan, Isoptin) C. Enalapril (Vasotec) D. Hydrochlorothiazide E. Allopurinol (Zyloprim) - ✔✔D. Hydrochlorothiazide. While thiazide diuretics do not cause hypercalcemia by themselves, they can exacerbate the hypercalcemia associated with primary hyperparathyroidism. Thiazides decrease the renal clearance of calcium by increasing distal tubular calcium reabsorption. Furosemide tends to lower serum calcium levels and is used in the treatment of hypercalcemia. None of the other medications would be expected to significantly affect the serum calcium level in this patient. A 60-year-old type 2 diabetic requires urgent appendectomy. Which one of the following should be withheld until normal kidney function is documented at 24 and 48 hours after the surgery? (check one) A. Acarbose (Precose) B. Glimepiride (Amaryl) C. Metformin (Glucophage) D. Nateglinide (Starlix) - ✔✔C. Metformin (Glucophage). Administration of general anesthesia may cause hypotension, which leads to renal hypoperfusion and peripheral tissue hypoxia, with subsequent lactate accumulation. Therefore, if administration of radiocontrast material is required or urgent surgery is needed, metformin should be withheld and hydration maintained until preserved kidney function is documented at 24 and 48 hours after the intervention. Which one of the following is more likely to occur with glipizide (Glucotrol) than with metformin (Glucophage)? (check one) A. Lactic acidosis B. Hypoglycemia C. Weight loss D. Gastrointestinal distress - ✔✔B. Hypoglycemia. Metformin is a biguanide used as an oral antidiabetic agent. One of its main advantages over some other oral agents is that it does not cause hypoglycemia. Lactic acidosis, while rare, can occur in patients with renal impairment. In contrast to most other agents for the control of elevated glucose, which often cause weight gain, metformin reduces insulin levels and more frequently has a weight-maintaining or even a weight loss effect. Gastrointestinal distress is a common side-effect of metformin, particularly early in therapy. U.S. Department of Transportation standards for commercial drivers would disqualify which one of the following? (check one) A. A 38-year-old male type 1 diabetic, well-controlled on insulin, whose last HbA1c was 6.0% (N 3.8-6.4) B. A 50-year-old female with uncorrected 20/40 vision in both eyes C. A 57-year-old male who had an inferior myocardial infarction 3 years ago and had a recent negative treadmill test D. A 64-year-old male who fails a whispered-voice test in one ear - ✔✔A. A 38-year-old male type 1 diabetic, well-controlled on insulin, whose last HbA1c was 6.0% (N 3.8-6.4). Insulin-dependent diabetes, even if well controlled, disqualifies a driver for commercial interstate driving. Vision of 20/40 is the minimum allowed under Department of Transportation regulations. Adequate hearing in one ear and well-compensated controlled heart disease are both allowed. Blood pressure of 160/90 mm Hg or less merits an unrestricted 2-year certification. Drivers with a blood pressure of 160/90-181/105 mm Hg can receive a 3-month temporary certification during which treatment for hypertension should be undertaken. A small child with failure to thrive is found to have a bone age that is markedly delayed relative to height age and chronologic age. The most likely etiology is: (check one) A. Cystic fibrosis B. Hypothyroidism C. Down syndrome D. Fetal alcohol syndrome E. Gonadal dysgenesis - ✔✔B. Hypothyroidism. Hypothyroidism is associated with markedly delayed bone age relative to height age and chronologic age. In cystic fibrosis, bone age and height age are equivalent, but both lag behind chronologic age. Children with chromosomal anomalies such as trisomy 21 (Down syndrome) or XO have a height age which is delayed relative to bone age. This pattern is also seen as a result of maternal substance abuse. Chronic excess thyroid hormone replacement over a number of years in postmenopausal women can lead to: (check one) A. Diffuse nontoxic goiter B. Osteoarthritis C. Osteoporosis D. Hyperparathyroidism - ✔✔C. Osteoporosis. Even mild chronic excess thyroid hormone replacement over many years can cause bone mineral resorption, increase serum calcium levels, and lead to osteoporosis. The elevated calcium decreases parathyroid hormone. Goiter is an indicator, not a cause, for hormone replacement. Osteoarthritis is not related to thyroid hormone replacement. In evaluating an adult with anemia, which one of the following findings most reliably indicates a diagnosis of iron deficiency anemia? (check one) A. Low total iron-binding capacity B. Low serum iron C. Low serum ferritin D. Microcytosis E. Hypochromia - ✔✔C. Low serum ferritin. The total iron-binding capacity is elevated, not decreased, in iron deficiency anemia. As an acute-phase reactant, serum iron may be decreased in response to inflammation even when total body stores of iron are not decreased. Microcytosis and hypochromia are both features of iron deficiency anemia occurring late in its development, but both can also be seen in the thalassemias. Serum ferritin is also an acute-phase reactant but is normal or elevated in the face of an inflammatory process. A low serum ferritin, however, is diagnostic for iron deficiency even in its early stages. Routine blood tests frequently reveal elevated calcium levels. When this elevation is associated with elevated parathyroid hormone levels, which one of the following is an indication for parathyroid surgery? (check one) A. Age >50 B. Kidney stones C. Serum calcium 0.5 mg/dL above the upper limit of normal D. Concurrent hyperthyroidism E. Increased bone density - ✔✔B. Kidney stones. Indications for parathyroid surgery include kidney stones, age less than 50, a serum calcium level greater than 1 mg/dL above the upper limit of normal, and reduced bone density. Hyperthyroidism is not a factor in deciding to perform parathyroid surgery. At a routine visit, a 50-year-old white female with a 10-year history of type 2 diabetes mellitus has a blood pressure of 145/90 mm Hg and significant microalbuminuria. Which one of the following would be an absolute contraindication to use of an ACE inhibitor in this patient? (check one) A. A previous history of angioneurotic edema B. Renal insufficiency C. Asthma D. A history of recent myocardial infarction E. A cardiac ejection fraction <25% - ✔✔A. A previous history of angioneurotic edema. Angioneurotic edema can be life-threatening, and ACE inhibitors should not be given to patients with a history of this condition from any cause. Elevated creatinine levels are not an absolute contraindication to ACE inhibitor therapy. Myocardial infarction and a reduced cardiac ejection fraction are indications for ACE inhibitor therapy. ACE inhibitors do not affect asthma. ======================================================= Gastrointestinal Board Review Questions 01 ======================================================= A 36-hour-old male is noted to have jaundice extending to the abdomen. He is breastfeeding well, 10 times a day, and is voiding and passing meconium-stained stool. He was born by normal spontaneous vaginal delivery at 38 weeks gestation after an uncomplicated pregnancy. The mother's blood type is A positive with a negative antibody screen. The infants total serum bilirubin is 13.0 mg/dL. Which one of the following would be the most appropriate management of this infants jaundice? (check one) A. Continue breastfeeding and supplement with water or dextrose in water to prevent dehydration B. Continue breastfeeding, evaluate for risk factors, and initiate phototherapy if at risk C. Discontinue breastfeeding and supplement with formula until the jaundice resolves D. Discontinue breastfeeding and supplement with formula until total serum bilirubin levels begin to decrease - ✔✔B. Continue breastfeeding, evaluate for risk factors, and initiate phototherapy if at risk. In 2004 the American Academy of Pediatrics published updated clinical practice guidelines on the management of hyperbilirubinemia in the newborn infant at 35 or more weeks gestation. These guidelines focus on frequent clinical assessment of jaundice, and treatment based on the total serum bilirubin level, the infants age in hours, and risk factors. Phototherapy should not be started based solely on the total serum bilirubin level. The guidelines encourage breastfeeding 8-12 times daily in the first few days of life to prevent dehydration. There is no evidence to support supplementation with water or dextrose in water in a nondehydrated breastfeeding infant. This infant is not dehydrated and is getting an adequate number of feedings, and there is no reason to discontinue breastfeeding at this time. 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? (check one) A. Infantile colic B. Necrotizing enterocolitis C. Hypertrophic pyloric stenosis D. Intussusception E. Midgut volvulus - ✔✔E. Midgut volvulus. 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. A previously healthy 3-year-old male is brought to your office with a 4-hour history of abdominal pain followed by vomiting. Just after arriving at your office he passes bloody stool. A physical examination reveals normal vital signs, and guarding and tenderness in the right lower quadrant. A rectal examination shows blood on the examining finger. Which one of the following is the most likely diagnosis? (check one) A. Appendicitis B. Viral gastroenteritis C. Midgut volvulus D. Meckels diverticulum E. Necrotizing enterocolitis - ✔✔D. Meckels diverticulum. Meckels diverticulum is the most common congenital abnormality of the small intestine. It is prone to bleeding because it may contain heterotopic gastric mucosa. Abdominal pain, distention, and vomiting may develop if obstruction has occurred, and the presentation may mimic appendicitis. Children with appendicitis have right lower quadrant pain, abdominal tenderness, guarding, and vomiting, but not rectal bleeding. With acute viral gastroenteritis, vomiting usually precedes diarrhea (usually without blood) by several hours, and abdominal pain is typically mild and nonfocal with no localized tenderness. The incidence of midgut volvulus peaks during the first month of life, but it can present anytime in childhood. Volvulus may present in one of three ways: as a sudden onset of bilious vomiting and abdominal pain in the neonate; as a history of feeding problems with bilious vomiting that now appears to be due to bowel obstruction; or, less commonly, as a failure to thrive with severe feeding intolerance. Necrotizing enterocolitis is typically seen in the neonatal intensive-care unit, occurring in premature infants in their first few weeks of life. The infants are ill, and signs and symptoms include lethargy, irritability, decreased oral intake, abdominal distention, and bloody stools. A plain abdominal film showing pneumatosis intestinalis, caused by gas in the intestinal wall, is diagnostic of this disease. The mother of an 4-week-old male asks about the viral gastroenteritis vaccine. You advise that it is (check one) A. routinely given at the 12-month visit B. associated with an increased risk for intussusception C. initiated at 6-12 weeks of age D. indicated only for immunocompromised children E. indicated only for children attending day care - ✔✔C. initiated at 6-12 weeks of age. Rotavirus vaccine (RotaTeq) was licensed in February 2006 to protect against viral gastroenteritis. The Advisory Committee on Immunization Practices recommends the routine vaccination of infants with three doses to be given at 2, 4, and 6 months of age. The first dose should be given between 6 and 12 weeks of age, and subsequent doses should be given at 4- to 10-week intervals, but all three doses should be administered by 32 weeks of age. Unlike the vaccine RotaShield, which was marketed in 1999, RotaTeq is not known to increase the risk for intussusception. Which one of the following is a risk factor for acute pancreatitis? (check one) A. Gastroesophageal reflux disease B. Intravenous drug abuse C. Angiotensin receptor blocker use D. Pyelonephritis E. Gallstones - ✔✔E. Gallstones. Pancreatitis is most closely associated with gallstones, extreme hypertrigliceridemia, and excessive alcohol use. Gastroesophageal reflux disease, pyelonephritis, drug abuse (other than alcohol), and angiotensin receptor blocker use are not risk factors for the development of pancreatitis. Treatment for Helicobacter pylori infection will reduce or improve which one of the following? (check one) 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. The risk of peptic ulcer bleeding from chronic NSAID therapy. 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. Which one of the following is associated with ulcerative colitis rather than Crohn's disease? (check one) A. The absence of rectal involvement B. Transmural involvement of the colon C. Segmental noncontinuous distribution of inflammation D. Fistula formation E. An increased risk of carcinoma of the colon - ✔✔E. An increased risk of carcinoma of the colon. Long-standing ulcerative colitis (UC) is associated with an increased risk of colon cancer. The greater the duration and anatomic extent of involvement, the greater the risk. Initial colonoscopy for patients with pancolitis of 8-10 years duration (regardless of the patient's age) should be followed up with surveillance examinations every 1-2 years, even if the disease is in remission. All of the other options listed are features typically associated with Crohn's disease. Virtually all patients with UC have rectal involvement, even if that is the only area affected. In Crohn's disease, rectal involvement is variable. Noncontinuous and transmural inflammation are also more common with Crohn's disease. Transmural inflammation can lead to eventual fistula formation, which is not seen in UC. A 54-year-old white female has been taking amoxicillin for 1 week for sinusitis. She has developed diarrhea and has had 6-8 stools per day for the past 2 days. Examination shows the patient to be well hydrated with normal vital signs and a normal physical examination. The stool is positive for occult blood, and a stool screen for Clostridium difficile toxin is positive. The most appropriate treatment at this time would be (check one) A. vancomycin (Vancocin) intravenously B. metronidazole (Flagyl) orally C. trimethoprim/sulfamethoxazole (Bactrim, Septra) orally D. ciprofloxacin (Cipro) orally - ✔✔B. metronidazole (Flagyl) orally. Many antibiotics can induce pseudomembranous colitis. Although oral vancomycin was once the initial drug of choice for C. difficile, oral metronidazole is now the first-line agent because of cost considerations and because of concerns about the development of vancomycin-resistant organisms. If the patient has refractory symptoms despite treatment with oral metronidazole, then oral vancomycin would be appropriate. Vancomycin given orally is not absorbed, leading to high intraluminal levels of the drug. Current thinking regarding infantile colic is that the cause is (check one) A. malabsorption B. overfeeding C. excessive air swallowing D. unknown E. parental anxiety - ✔✔D. unknown. Colic is a frustrating condition for parents and doctors alike. The parents would like an explanation and relief, and physicians would like to offer these things. At this time, however, in spite of numerous studies and theories, the cause of colic remains unknown. An outbreak of pediatric diarrhea has swept your community. You evaluate a 30-month-old male who developed diarrhea yesterday. He is still breastfed. He is alert, his mucous membranes are moist, and his skin turgor is good. He passes a liquid stool in your office. Which one of the following would be the best advice with regard to his diet? (check one) A. The mother should withhold breastfeeding B. He should consume a normal age-appropriate diet, and continue breastfeeding C. Fasting will promote intestinal mucosal recovery D. Oral intake should be limited to clear fluids, bananas, rice, applesauce, and toast (BRAT diet) - ✔✔B. He should consume a normal age-appropriate diet, and continue breastfeeding. Continued oral feeding in diarrhea aids in recovery, and an age-appropriate diet should be given. Breastfeeding or regular formula should be continued. Foods with complex carbohydrates (e.g., rice, wheat, potatoes, bread, and cereals), lean meats, yogurt, fruits, and vegetables are well tolerated. Foods high in simple sugars (e.g., juices, carbonated sodas) should be avoided because the osmotic load can worsen the diarrhea. Fatty foods should be avoided as well. The BRAT diet has not been shown to be effective. ======================================================= Gastrointestinal Board Review Questions 02 ======================================================= 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? (check one) A. pH <7.2 B. Bloody appearance C. Neutrophil count >300/mL D. Positive cytology E. Total protein >1 g/dL - ✔✔C. Neutrophil count >300/mL. Diagnostic paracentesis is recommended for patients with ascites of recent onset, as well as for those with chronic ascites who present with new clinical findings such as fever or abdominal pain. 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. A pregnant patient is positive for hepatitis B surface antigen (HBsAg). Which one of the following would be most appropriate for her infant? (check one) A. Hepatitis B immune globulin (HBIG) and hepatitis B vaccine at birth B. Hepatitis B vaccine only, at birth C. HBIG only, at birth D. Testing for HBsAg before any immunization E. No immunization until 1 year of age - ✔✔A. Hepatitis B immune globulin (HBIG) and hepatitis B vaccine at birth. Infants born to hepatitis B-positive mothers should receive both immune globulin and hepatitis B vaccine. They should receive the entire series of the vaccine, with testing for seroconversion only after completion of the vaccination series; the recommended age for testing is 9-12 months of age. 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: (check one) A. Escherichia coli B. Vibrio cholerae C. Campylobacter jejuni D. Giardia lamblia E. Rotavirus - ✔✔D. Giardia lamblia. 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. Hepatitis C screening is routinely recommended in which one of the following? (check one) A. Pregnant women B. Nonsexual household contacts of hepatitis C-positive persons C. Health care workers D. Persons with a history of illicit intravenous drug use - ✔✔D. Persons with a history of illicit intravenous drug use. Patients should be routinely screened for hepatitis C if they have a history of any of the following: intravenous drug abuse no matter how long or how often, receiving clotting factor produced before 1987, persistent alanine aminotransferase elevations, or recent needle stick with HCV-positive blood. A nurse who completed a hepatitis B vaccine series a year ago is accidentally stuck by a needle that has just been used on a dialysis patient. The patient is known to be HBsAg-positive. Your first response should be to: (check one) A. Provide reassurance only B. Test the nurse for hepatitis B antibody C. Repeat the hepatitis B vaccine series D. Administer hepatitis B immune globulin (HBIG) only E. Administer HBIG plus a booster of hepatitis B vaccine - ✔✔B. Test the nurse for hepatitis B antibody. Postexposure prophylaxis after hepatitis B exposure via the percutaneous route depends upon the source of the exposure and the vaccination status of the exposed person. In the case described, a vaccinated person has been exposed to a known positive individual. The exposed person should be tested for hepatitis B antibodies; if antibody levels are inadequate (<10 IU/L by radioimmunoassay, negative by enzyme immunoassay) HBIG should be administered immediately, as well as a hepatitis B vaccine booster dose. An unvaccinated individual in this same setting should receive HBIG immediately (preferably within 24 hours after exposure) followed by the hepatitis B vaccine series (injection in 1 week or less, followed by a second dose in 1 month and a third dose in 6 months). A 57-year-old African-American female has a partial resection of the colon for cancer. The surgical specimen has clean margins, and there is no lymph node involvement. There is no evidence of metastasis. You recommend periodic colonoscopy for surveillance, and also plan to monitor which one of the following tumor markers for recurrence? (check one) A. Prostate-specific antigen (PSA) B. Cancer antigen 27.29 (CA 27-29) C. Cancer antigen 125 (CA-125) D. Carcinoembryonic antigen (CEA) E. Alpha-fetoprotein - ✔✔D. Carcinoembryonic antigen (CEA). Prostate-specific antigen (PSA) is a marker that is used to screen for prostate cancer. It is elevated in more than 70% of organ-confined prostate cancers. Alpha-tetoprotein is a marker for hepatocellular carcinoma and nonseminomatous germ cell tumor, and is elevated in 80% of hepatocellular carcinomas. CA-125 is a marker for ovarian cancer. Although it is elevated in 85% of ovarian cancers, it is elevated in only 50% of early-stage ovarian cancers. Carcinoembryonic antigen (CEA) is a marker for colon, esophageal, and hepatic cancers. It is expressed in normal mucosal cells and is overexpressed in adenocarcinoma, especially colon cancer. Though not specific for colon cancer, levels above 10 ng/mL are rarely due to benign disease. CEA levels typically return to normal within 4-6 weeks after successful surgical resection. CEA elevation occurs in nearly half of patients with a normal preoperative CEA level that have cancer recurrence. Cancer antigen 27.29 (CA 27-29) is a tumor marker for breast cancer. It is elevated in about 33% of early-stage breast cancers and about 67% of late-stage breast cancers. Some tumor markers, such as CEA, alpha-fetoprotein, and CA-125, may be more helpful in monitoring response to therapy than in detecting the primary tumor. A 65-year-old white female comes to your office with evidence of a fecal impaction which you successfully treat. She relates a history of chronic laxative use for most of her adult years. After proper preparation, you perform sigmoidoscopy and note that the anal and rectal mucosa contain scattered areas of bluish-black discoloration. Which one of the following is the most likely explanation for the sigmoidoscopic findings? (check one) A. Endometriosis B. Collagenous colitis C. Melanosis coli D. Metastatic malignant melanoma E. Arteriovenous malformations - ✔✔C. Melanosis coli. This patient has typical findings of melanosis coli, the term used to describe black or brown discoloration of the mucosa of the colon. It results from the presence of dark pigment in large mononuclear cells or macrophages in the lamina propria of the mucosa. The coloration is usually most intense just inside the anal sphincter and is lighter higher up in the sigmoid colon. The condition is thought to result from fecal stasis and the use of anthracene cathartics such as cascara sagrada, senna, and danthron. Ectopic endometrial tissue (endometriosis) most commonly involves the serosal layer of those parts of the bowel adjacent to the uterus and fallopian tubes, particularly the rectosigmoid colon. Collagenous colitis does not cause mucosal pigmentary changes. Melanoma rarely metastasizes multicentrically to the bowel wall. Multiple arteriovenous malformations are more common in the proximal bowel, and would not appear as described. A 55-year-old white male smoker has had daily severe gastroesophageal reflux symptoms unrelieved by intensive medical therapy with proton pump inhibitors. A recent biopsy performed during upper endoscopy identified Barrett's esophagus. Which one of the following is true about this condition? (check one) A. It will regress after antireflux surgery B. It will regress following esophageal dilation C. It will regress after Helicobacter pylori treatment D. It is associated with an increased risk of adenocarcinoma - ✔✔D. It is associated with an increased risk of adenocarcinoma. Barrett's esophagus is an acquired intestinal metaplasia of the distal esophagus associated with longstanding gastroesophageal acid reflux, although a quarter of patients with Barrett's esophagus have no reflux symptoms. It is more common in white and Hispanic men over 50 with longstanding severe reflux symptoms, and possible risk factors include obesity and tobacco use. It is a risk factor for adenocarcinoma of the esophagus, with a rate of about one case in every 200 patients with Barrett's esophagus per year. Treatment is directed at reducing reflux, thus reducing symptoms. Neither medical nor surgical treatment has been shown to reduce the carcinoma risk. One reasonable screening suggestion is to perform esophagoduodenoscopy in all men over 50 with gastroesophageal reflux disease (GERD), but these recommendations are based only on expert opinion (level C evidence), and no outcomes-based guidelines are available. Which one of the following is the most common cause of bacterial diarrhea? (check one) A. Listeria monocytogenes B. Escherichia coli O157:H7 C. Shigella dysenteriae D. Campylobacter jejuni E. Salmonella enterica - ✔✔D. Campylobacter jejuni. The treatment of acute and significant diarrhea often requires a specific diagnosis. Epidemiologic studies have shown that Campylobacter infections are the leading cause of bacterial diarrhea in the U.S. A 25-year-old white male truck driver complains of 1 day of throbbing rectal pain. Your examination shows a large, thrombosed external hemorrhoid. Which one of the following is the preferred initial treatment for this patient? (check one) A. Warm sitz baths, a high-residue diet, and NSAIDs B. Rubber band ligation of the hemorrhoid C. Elliptical excision of the thrombosed hemorrhoid D. Stool softeners and a topical analgesic/hydrocortisone cream (e.g., Anusol-HC) - ✔✔C. Elliptical excision of the thrombosed hemorrhoid. The appropriate management of a thrombosed hemorrhoid presenting within 48 hours of onset of symptoms is an elliptical excision of the hemorrhoid and overlying skin under local anesthesia (i.e., 0.5% bupivacaine hydrochloride [Marcaine] in 1:200,000 epinephrine) infiltrated slowly with a small (27 gauge) needle for patient comfort. Incision and clot removal may provide inadequate drainage with rehemorrhage and clot reaccumulation. Most thrombosed hemorrhoids contain multilocular clots which may not be accessible through a simple incision. Rubber band ligation is an excellent technique for management of internal hemorrhoids. Banding an external hemorrhoid would cause exquisite pain. When pain is already subsiding or more time has elapsed (in the absence of necrosis or ulceration), measures such as sitz baths, bulk laxatives, stool softeners, and local analgesia may all be helpful. Some local anesthetics carry the risk of sensitization, however counseling to avoid precipitating factors (e.g., prolonged standing/sitting, constipation, delay of defecation) is also appropriate. ======================================================= Gastrointestinal Board Review Questions 03 ======================================================= A 32-year-old meat cutter comes to your office with persistent symptoms of nausea, vomiting, and diarrhea which began about 36 hours ago on the last day of a 5-day Caribbean cruise. His wife was sick during the first 2 days of the cruise with similar symptoms. On the ship, they both ate the "usual foods" in addition to oysters. Findings on examination are negative, and a stool specimen is negative for white cells. Which one of the following is the most likely cause of his illness? (check one) A. Escherichia coli B. Rotavirus C. Norwalk virus D. Hepatitis A E. Giardia species - ✔✔C. Norwalk virus. Recent reports of epidemics of gastroenteritis on cruise ships are consistent with Norwalk virus infections due to waterborne or foodborne spread. In the United States, these viruses are responsible for about 90% of all epidemics of nonbacterial gastroenteritis. The Norwalk-like viruses are common causes of waterborne epidemics of gastroenteritis, and have been shown to be responsible for outbreaks in nursing homes, on cruise ships, at summer camps, and in schools. Symptomatic treatment is usually appropriate. A 38-year-old male who is a new patient reports mild intermittent jaundice without other associated symptoms for the past several years. His liver function tests are normal except for a total bilirubin of 1.3 mg/dL (N 0.3-1.0) and an indirect or unconjugated bilirubin of 1.0 mg/dL (N 0.2-0.8). His CBC is normal. His past medical and surgical history is unremarkable. Findings are similar on repeat laboratory testing. The most likely cause of these findings is: (check one) A. Hepatitis C B. Wilson's disease C. Sickle cell anemia D. Gilbert's syndrome E. Drug toxicity - ✔✔D. Gilbert's syndrome. Gilbert's syndrome is the most common inherited disorder of bilirubin metabolism. In patients with a normal CBC and liver function tests, except for recurrent mildly elevated total and unconjugated hyperbilirubinemia, the most likely diagnosis is Gilbert's syndrome. Fasting, heavy physical exertion, sickle cell anemia, and drug toxicity can also cause hyperbilirubinemia. A 24-year-old white female presents to the office with a 6-month history of abdominal pain. A physical examination, including pelvic and rectal examinations, is normal. Which one of the following would indicate a need for further evaluation? (check one) A. Relief of symptoms with defecation B. Changes in stool consistency from loose and watery to constipation C. Passage of mucus with bowel movements D. Abdominal bloating E. Worsening of symptoms at night - ✔✔E. Worsening of symptoms at night. Irritable bowel syndrome (IBS) is a benign, chronic symptom complex of altered bowel habits and abdominal pain. It is the most common functional disorder of the gastrointestinal tract. The presence of nocturnal symptoms is a red flag which should alert the physician to an alternate diagnosis and may require further evaluation. The other symptoms listed are Rome I and II criteria for diagnosing irritable bowel syndrome. A 36-year-old female makes an appointment because her husband of 12 years was just diagnosed with hepatitis C when he tried to become a blood donor for the first time. He recalls multiple blood transfusions following a motorcycle crash in 1988. His wife denies past liver disease, blood transfusions, and intravenous drug use. She has had no other sexual partners. The couple has three children. Which one of the following is the best advice about testing the wife and their three children? (check one) A. No testing is required in the absence of jaundice or gastrointestinal symptoms B. No testing is required if her husband has normal liver enzyme levels C. No testing is required because tests have low sensitivity D. She should be offered testing because sexual transmission is possible E. All family members should be tested because of possible household fecal-oral spread - ✔✔D. She should be offered testing because sexual transmission is possible. Key risk factors for hepatitis C infection are long-term hemodialysis, intravenous drug use, blood transfusion or organ transplantation prior to 1992, and receipt of clotting factors before 1987. Sexual transmission is very low but possible, and the likelihood increases with multiple partners. The lifetime transmission risk of hepatitis C in a monogamous relationship is less than 1%, but the patient should be offered testing because she may choose to confirm that her test is negative. If the mother is seronegative, the children are at no risk. Maternal-fetal transmission is rare except in the setting of co-infection with HIV. Hepatitis C is insidious, and symptoms do not correlate with the extent of the disease. Normal liver enzyme levels do not indicate lack of infectivity. There is no risk to household contacts. Current HCV antibody tests are more than 99% sensitive and specific and are recommended for screening at-risk populations. A moderately obese 50-year-old African-American female presents with colicky right upper quadrant pain that radiates to her right shoulder. Which one of the following is considered the best study to confirm the likely cause of the patient's symptoms? (check one) A. Plain abdominal radiography B. Oral cholecystography C. Abdominal ultrasonography D. A barium swallow E. Esophagogastroscopy - ✔✔C. Abdominal ultrasonography. The symptom complex presented is typical of cholelithiasis. Plain radiography of the abdomen may reveal radiopaque gallstones, but will not reveal radiolucent stones or biliary dilatation. Although rarely used, oral cholecystography is 98% accurate, but only when compliance is assured, the contrast agent is absorbed, and liver function is normal. Abdominal ultrasonography is considered the best study to confirm this diagnosis because of its high sensitivity and its accuracy in detecting gallstones. A barium swallow will identify some functional and structural esophageal abnormalities, but will not focus on the suspected organ in this case. The same is true of esophagogastroscopy. A 32-year-old white female at 16 weeks' gestation presents to your office with right lower quadrant pain. Which one of the following imaging studies would be most appropriate for initial evaluation of this patient? (check one) A. CT of the abdomen B. MRI of the abdomen C. Ultrasonography of the abdomen D. A small bowel series E. Intravenous pyelography - ✔✔C. Ultrasonography of the abdomen. CT has demonstrated superiority over transabdominal ultrasonography for identifying appendicitis, associated abscess, and alternative diagnoses. However, ultrasonography is indicated for the evaluation of women who are pregnant and women in whom there is a high degree of suspicion for gynecologic disease. A positive spot urine test for homovanillic acid (HMA) and vanillylmandelic acid (VMA) is a marker for which one of the following? (check one) A. Hepatoblastoma B. Wilms' tumor C. Lymphoma D. Malignant teratoma E. Neuroblastoma - ✔✔E. Neuroblastoma. 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. A slender 22-year-old female is concerned about a recent weight loss of 10 lb, frequent mild abdominal pain, and significant diarrhea of 2 months' duration. Her physical examination is unremarkable, and laboratory studies reveal only a moderate microcytic, hypochromic anemia. Based on this presentation, which one of the following is the most likely diagnosis? (check one) A. Irritable bowel syndrome B. Villous adenoma C. Infectious colitis D. Celiac disease E. Ulcerative colitis - ✔✔D. Celiac disease. This constellation of symptoms strongly suggests celiac disease, a surprisingly common disease with a prevalence of 1:13 in the U.S. Half the adults in the U.S. with celiac disease or gluten-sensitive enteropathy present with anemia or osteoporosis, without gastrointestinal symptoms. Individuals with more significant mucosal involvement present with watery diarrhea, weight loss, and vitamin and mineral deficiencies. A 62-year-old male presents for surgical clearance prior to transurethral resection of the prostate. His past history is significant for a pulmonary embolus after a cholecystectomy 15 years ago. His examination is unremarkable except that he is 23 kg (50 lb) overweight. The most appropriate recommendation to the urologist would be to: (check one) A. Cancel the surgery indefinitely B. Place the patient on 650 mg of aspirin daily prior to surgery C. Start the patient on subcutaneous enoxaparin (Lovenox), 40 mg 1-2 hr prior to surgery and once a day after surgery D. Start warfarin (Coumadin) after surgery with a goal INR of 1.5 E. Start intravenous heparin according to a weight-based protocol 24 hours after surgery - ✔✔C. Start the patient on subcutaneous enoxaparin (Lovenox), 40 mg 1-2 hr prior to surgery and once a day after surgery. A patient with a past history of postoperative venous thromboembolism is at risk for similar events with subsequent major operations. The most appropriate treatment of the choices listed would be subcutaneous enoxaparin. Aspirin is ineffective for prophylaxis of venous thromboembolism. Warfarin is effective at an INR of 2.0-3.0. Full anticoagulation with heparin is unnecessary for prophylaxis and can result in a higher rate of postoperative hemorrhage. A 60-year-old male indicates that he occasionally brings up what appears to be undigested food long after his meal. He also admits that he sometimes chokes on food, and that his wife says he has bad breath. The most likely diagnosis is: (check one) A. Achalasia B. Esophageal reflux C. Cancer of the esophagus D. Zenker's diverticulum E. Large cervical bone spur - ✔✔D. Zenker's diverticulum. The combination of halitosis, late regurgitation of undigested food, and choking suggests Zenker's diverticulum. Patients may also have dysphagia and weight loss. The diagnosis is usually made with a barium swallow. The treatment is surgical. ======================================================= Integumentary Board Review Questions 01 ======================================================= 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 (check one) 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. perform a biopsy of the lesion. 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. A 4-year-old white male is brought to your office in late August. His mother tells you that over the past few days he has developed a rash on his hands and sores in his mouth. On examination you note a vesicular exanthem on his hands, with lesions ranging from 3 to 6 mm in diameter. The oral lesions are shallow, whitish, 4- to 8-mm ulcerations distributed randomly over the hard palate, buccal mucosa, gingiva, tongue, lips, and pharynx. Except for a temperature of 37.4°C (99.3°F), the remainder of the examination is normal. The most likely diagnosis is (check one) A. herpangina B. hand, foot, and mouth disease C. aphthous stomatitis D. herpetic gingivostomatitis E. streptococcal pharyngitis - ✔✔B. hand, foot, and mouth disease. Hand, foot, and mouth disease is a mild infection occurring in young children, and is caused by coxsackievirus A16, or occasionally by other strains of coxsackie- or enterovirus. In addition to the oral lesions, vesicular lesions may occur on the feet and nonvesicular lesions may occur on the buttocks. A low-grade fever may also develop. Herpangina is also caused by coxsackieviruses, but it is a more severe illness characterized by severe sore throat and vesiculo-ulcerative lesions limited to the tonsillar pillars, soft palate, and uvula, and occasionally the posterior oropharynx. Temperatures can range to as high as 41°C (106°F). The etiology of aphthous stomatitis is multifactorial, and it may be due to a number of conditions. Systemic signs, such as fever, are generally absent. Lesions are randomly distributed. Herpetic gingivostomatitis also causes randomly distributed oral ulcers, but it is a more severe illness, regularly accompanied by a higher fever, and is extremely painful. Streptococcal pharyngitis is rarely accompanied by ulceration except in agranulocytic patients. 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 (check one) A. benign lentigo B. lentigo maligna C. basal cell carcinoma D. squamous cell carcinoma E. keratoacanthoma - ✔✔E. keratoacanthoma. 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. A 72-year-old white male in otherwise good health complains of generalized pruritus that worsens in the winter. The itching is most intense after he bathes. He recently noticed a rash on his abdomen and legs as well. On examination you note poorly defined red, scaly plaques with fine fissures on the abdomen. No eruption is present at other pruritic sites. Which one of the following is the most likely cause of this problem? (check one) A. Stasis dermatitis B. Lichen simplex chronicus C. Xerosis D. Rosacea E. Candidiasis - ✔✔C. Xerosis. Xerosis is a pathologic dryness of the skin that is especially prominent in the elderly. It is probably caused by minor abnormalities in maturation of the epidermis that lead to decreased hydration of the superficial portion of the stratum corneum. Xerosis often intensifies in winter, because of the lower humidity and cold temperatures. Stasis dermatitis, due to chronic venous insufficiency, appears as a reddish-brown discoloration of the lower leg. Lichen simplex chronicus, the end result of habitual scratching or rubbing, usually presents as isolated hyperpigmented, edematous lesions, which become scaly and thickened in the center. Rosacea is most often seen on the face as an erythematous, acneiform eruption, which flushes easily and is surrounded by telangiectasia. Candidiasis is an opportunistic infection favoring areas that are warm, moist, and macerated, such as the perianal and inguinal folds, inframammary folds, axillae, interdigital areas, and corners of the mouth. A 32-year-old farmer comes to your office because of an upper respiratory infection. While he is there he points out a lesion on his forearm that he first noted approximately 1 year ago. It is a 1-cm asymmetric nodule with an irregular border and variations in color from black to blue. The patient says that it itches and has been enlarging for the past 2 months. He says he is so busy that he is not sure when he can return to have it taken care of. In such cases the best approach would be to (check one) A. perform a punch biopsy and have the patient return if the biopsy indicates pathology B. perform a shave biopsy and recheck in 2 months for signs of recurrence C. use electrocautery to destroy the lesion and the surrounding tissue D. perform an elliptical excision as soon as possible E. freeze the site with liquid nitrogen - ✔✔D. perform an elliptical excision as soon as possible. Despite this individual's busy schedule, he has a potentially life-threatening problem that needs proper diagnosis and treatment. Though an excisional biopsy takes longer, it is the procedure of choice when melanoma is suspected. After removal and diagnosis, prompt referral is essential for further evaluation and therapy. A shave biopsy should never be done for suspected melanoma, as this is likely to transect the lesion and destroy evidence concerning its depth, thus making it difficult to assess the prognosis. A punch biopsy should be used only with discretion when the lesion is too large for complete excision, or if substantial disfigurement would occur. Since this may not actually retrieve cancerous tissue from an unsampled area of a large lesion that might be malignant, it would be safest to refer such patients. Neither cryotherapy nor electrocautery should be used for a suspected melanoma. Which one of the following decreases pain from infiltration of local anesthetics? (check one) A. Cooling the anesthetic solution B. Using a 22-gauge needle rather than a 30-gauge needle C. Infiltrating quickly D. Infiltrating through surrounding intact skin E. Adding sodium bicarbonate to the mixture - ✔✔E. Adding sodium bicarbonate to the mixture. The pain from infiltration of local anesthetics can be decreased by using a warm solution, using small needles, and performing the infiltration slowly.It is also helpful to add sodium bicarbonate to neutralize the anesthetic since they are shipped at an acidic pH to prolong shelf life. An exception to this tip is bupivicaine (Marciane, Sensorcaine) as it will precipitate in the presence of sodium bicarbonate. It also helps to inject the agent through the edges of the wound (assuming the wound is not contaminated) and to pretreat the wound with topical anesthetics. A newborn male has a skin eruption on his forehead, nose, and cheeks. The lesions are mostly closed comedones with a few open comedones, papules, and pustules. No significant erythema is seen. Which one of the following is the most likely diagnosis? (check one) A. Erythema toxicum neonatorum B. Localized superficial Candida infection C. Herpes simplex D. Milia E. Acne neonatorum - ✔✔E. Acne neonatorum. Acne neonatorum occurs in up to 20% of newborns. It typically consists of closed comedones on the forehead, nose, and cheeks, and is thought to result from stimulation of sebaceous glands by maternal and infant androgens. Parents should be counseled that lesions usually resolve spontaneously within 4 months without scarring. Findings in erythema toxicum neonatorum include papules, pustules, and erythema. Candida and herpes lesions usually present with vesiculopustular lesions in the neonatal period. Milia consists of 1- to 2-mm pearly keratin plugs without erythema, and may occur on the trunk and limbs. 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? (check one) 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. Dog or cat hookworm (Ancylostoma species). 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. 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? (check one) 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. Topical betamethasone dipropionate (Diprolene) applied twice daily to the nail folds for 3-4 weeks. 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. A 6-month-old Hispanic female has had itching and irritability for 4-5 weeks. There is a family history of atopy and asthma. Physical examination reveals an excoriated dry rash bilaterally over the antecubital and popliteal fossae, as well as some involvement of the face. In addition to maintenance therapy with an emollient, which one of the following topical medications would be appropriate first-line treatment for flare-ups in this patient? (check one) A. A calcineurin inhibitor such as pimecrolimus (Elidel) B. An anesthetic C. An antihistamine D. An antibiotic E. A corticosteroid - ✔✔E. A corticosteroid. This child has atopic dermatitis (eczema). It is manifested by a pruritic rash on the face and/or extensor surfaces of the arms and/or legs, especially in children. There often is a family history of atopy or allergies. In addition to the regular use of emollients, the mainstay of maintenance therapy, topical corticosteroids have been shown to be the best first-line treatment for flare-ups of atopic dermatitis. Topical calcineurin inhibitors should be second-line treatment for flare-ups, but are not recommended for use in children under 2 years of age. Antibiotics should be reserved for the treatment of acutely infected lesions. There is no evidence to support the use of topical anesthetics or analgesics in the treatment of this disorder. ======================================================= Integumentary Board Review Questions 02 ======================================================= Your hospital administrator asks you to develop a community screening program for melanoma. Which one of the following is true concerning screening for this disease? (check one) A. Screening for melanoma is not indicated since the disease is rare B. Screening for melanoma is not indicated since screening takes too much time C. No definite clinical evidence has shown that screening for melanoma reduces mortality D. Because of sunbathing, female patients are the most important population to screen - ✔✔C. No definite clinical evidence has shown that screening for melanoma reduces mortality. There have been no randomized, controlled trials or other definitive data to indicate that screening for melanoma reduces mortality. There are, however, factors which indicate that screening would be beneficial, including the increasing prevalence of the disease and the fact that screening is time-effective and safe. If screening is performed, populations at greatest risk should be considered. Men, especially those over age 50, have the highest incidence of melanoma. 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: (check one) A. Pyogenic granuloma B. Leishmaniasis C. Atypical mycobacterial infection D. Squamous cell carcinoma E. Epidermal inclusion cysts - ✔✔B. Leishmaniasis. 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. U.S. military medical facilities and the CDC are coordinating treatment when indicated with sodium stibogluconate. Family physicians can play a key role in correctly identifying these lesions. A 23-year-old Hispanic female at 18 weeks' gestation presents with a 4-week history of a new facial rash. She has noticed worsening with sun exposure. Her past medical history and review of systems is normal. On examination, you note symmetric, hyperpigmented patches on her cheeks and upper lip. The remainder of her examination is normal. The most likely diagnosis is: (check one) A. Lupus erythematosus B. Pemphigoid gestationis (herpes gestationis) C. Melasma (chloasma) D. Prurigo gestationis - ✔✔C. Melasma (chloasma). Melasma or chloasma is common in pregnancy, with approximately 70% of pregnant women affected. It is an acquired hypermelanosis of the face, with symmetric distribution usually on the cheeks, nose, eyebrows, chin, and/or upper lip. The pathogenesis is not known. UV sunscreen is important, as sun exposure worsens the condition. Melasma often resolves or improves post partum. Persistent melasma can be treated with hydroquinone cream, retinoic acid, and/or chemical peels performed post partum by a dermatologist. The facial rash of lupus is usually more erythematous, and lupus is relatively rare. Pemphigoid gestationis is a rare autoimmune disease with extremely pruritic, bullous skin lesions that usually spare the face. Prurigo gestationis involves pruritic papules on the extensor surfaces and is usually associated with significant excoriation by the uncomfortable patient. You see a 16-year-old white female for a preparticipation evaluation for sports, and she asks for advice about the treatment of acne. She has a few inflammatory papules on her face. No nodules are noted. She says she has not tried any over-the-counter acne treatments. Which one of the following would be considered first-line therapy for this condition? (check one) A. Oral tetracycline B. Oral isotretinoin (Accutane) C. Topical sulfacetamide (Sulamyd) D. Topical benzoyl peroxide - ✔✔D. Topical benzoyl peroxide. The American Academy of Dermatology grades acne as mild, moderate, and severe. Mild acne is limited to a few to several papules and pustules without any nodules. Patients with moderate acne have several to many papules and pustules with a few to several nodules. Patients with severe acne have many or extensive papules, pustules, and nodules. The patient has mild acne according to the American Academy of Dermatology classification scheme. Topical treatments including benzoyl peroxide, retinoids, and topical antibiotics are useful first-line agents in mild acne. Topical sulfacetamide is not considered first-line therapy for mild acne. Oral antibiotics are used in mild acne when there is inadequate response to topical agents and as first-line therapy in more severe acne. Caution must be used to avoid tetracycline in pregnant females. Oral isotretinoin is used in severe nodular acne, but also must be used with extreme caution in females who may become pregnant. Special registration is required by physicians who use isotretinoin, because of its teratogenicity. The most appropriate initial treatment for scabies in an 8-year-old male is: (check one) A. 0.5% malathion lotion (Ovide) B. 5% permethrin cream (Elimite) C. 5% precipitated sulfur in petroleum D. trimethoprim/sulfamethoxazole (Bactrim, Septra) orally for 10 days - ✔✔B. 5% permethrin cream (Elimite). In adults and children over 5 years of age, 5% permethrin cream is standard therapy for scabies. This agent is highly effective, minimally absorbed, and minimally toxic. Painful ingrown toenails that display granulation tissue and lateral nail fold hypertrophy are best treated by: (check one) A. Antibiotic therapy B. Cotton-wick elevation of the affected nail corner C. Removal of the entire nail D. Excision of the lateral nail plate combined with lateral matricectomy - ✔✔D. Excision of the lateral nail plate combined with lateral matricectomy. Excision of the lateral nail plate with lateral matricectomy yields the best results in the treatment of painful ingrown toenails that display granulation tissue and lateral nail fold hypertrophy. Antibiotic therapy and cotton-wick elevation are acceptable for very mildly inflamed ingrown toenails. Partial nail avulsion often leaves a spicule of nail that will grow and become an ingrown nail. Phenol produces irregular tissue destruction and significant inflammation and discharge after the matricectomy procedure. A 23-year-old male returns from a Florida beach vacation, where he sustained a cut to his foot while wading. The cut wasn't treated when it happened, and it is healing, but he says that it feels like something in the wound is "poking" him. Of the following, which one would most likely be easily visible on plain film radiography? (check one) A. A wood splinter B. A glass splinter C. A plastic splinter D. A sea urchin spine - ✔✔B. A glass splinter. Almost all glass is visible on radiographs if it is 2 mm or larger, and contrary to popular belief, it doesn't have to contain lead to be visible on plain films. Many common or highly reactive materials, such as wood, thorns, cactus spines, some fish bones, other organic matter, and most plastics, are not visible on plain films. Alternative techniques such as ultrasonography or CT scanning may be effective and necessary in those cases. Sea urchin spines, like many animal parts, have not been found to be easily detected by plain radiography. A 55-year-old white female presents with redness at the scar from a lumpectomy performed for stage I cancer of her right breast 4 months ago. The patient has completed radiation treatments to the breast. She is afebrile and there is no axillary adenopathy. There is no wound drainage, crepitance, or bullous lesions. Which one of the following organisms would be the most likely cause of cellulitis in this patient? (check one) A. Non-group A Streptococcus B. Pneumococcus pneumoniae C. Clostridium perfringens D. Escherichia coli E. Pasteurella multocida - ✔✔A. Non-group A Streptococcus. Cellulitis in patients after breast lumpectomy is thought to be related to lymphedema. Axillary dissection and radiation predispose to these infections. Non-group A hemolytic Streptococcus is the most common organism associated with this infection. The onset is often several weeks to several months after surgery. Pneumococcus is more frequently a cause of periorbital cellulitis. It is also seen in patients who have bacteremia with immunocompromised status. Immunocompromising conditions would include diabetes mellitus, alcoholism, lupus, nephritic syndrome, and some hematologic cancers. Clostridium and Escherichia coli are more frequently associated with crepitant cellulitis and tissue necrosis. Pasteurella multocida cellulitis is most frequently associated with animal bites, especially cat bites. A 12-year-old male middle-school wrestler comes to your office complaining of a recurrent painful rash on his arm. There appear to be several dry vesicles. The most likely diagnosis is which one of the following? (check one) A. Molluscum contagiosum B. Human papillomavirus C. Herpes gladiatorum D. Tinea corporis E. Mat burn - ✔✔C. Herpes gladiatorum. The most common infection transmitted person-to-person in wrestlers is herpes gladiatorum caused by the herpes simplex virus. Molluscum contagiosum causes keratinized plugs. Human papillomavirus causes warts. Tinea corporis is ringworm, which is manifested by round to oval raised areas with central clearing. Mat burn is an abrasion. You are evaluating a 45-year-old male construction worker with regard to his skin and sun exposure history. Which one of the following lesions should be considered premalignant? (check one) A. Sebaceous hyperplasia B. Actinic keratosis C. Seborrheic keratosis D. A de Morgan spot E. A halo nevus - ✔✔B. Actinic keratosis. Family physicians should advise patients of the dangers of sun exposure especially those with a fair complexion who work outdoors. Although malignant melanoma is the most serious condition of those listed, actinic keratosis may lead to squamous cell carcinoma with significant morbidity. ======================================================= Random Board Review Questions 01 ======================================================= A 30-year-old previously healthy male comes to your office with a 1-year history of frequent abdominal pain, nonbloody diarrhea, and a 20-lb weight loss. He has no history of travel outside the United States, antibiotic use, or consumption of well water. His review of systems is notable for a chronic, intensely pruritic rash that is vesicular in nature. His review of systems is otherwise negative and he is on no medications. The most likely cause of his symptoms is: (check one) A. lactose intolerance B. irritable bowel syndrome C. collagenous colitis D. celiac sprue E. Crohn's disease - ✔✔D. celiac sprue. Celiac sprue is an autoimmune disorder characterized by inflammation of the small bowel wall, blunting of the villi, and resultant malabsorption. Symptoms commonly include diarrhea, fatigue, weight loss, abdominal pain, and borborygmus; treatment consists of elimination of gluten proteins from the diet. Extraintestinal manifestations are less common but may include elevated transaminases, osteopenia, and iron deficiency anemia. Serum IgA tissue transglutaminase (TTG) antibodies are highly sensitive and specific for celiac sprue, and a small bowel biopsy showing villous atrophy is the gold standard for diagnosis. This patient's rash is consistent with dermatitis herpetiformis, which is pathognomonic for celiac sprue and responds well to a strict gluten-free diet. Lactose intolerance, irritable bowel syndrome, collagenous colitis, and Crohn's disease are in the differential diagnosis for celiac sprue. However, significant weight loss is not characteristic of irritable bowel syndrome or lactose intolerance. The diarrhea associated with Crohn's disease is typically bloody. Collagenous colitis does cause symptoms similar to those experienced by this patient, but it is not associated with dermatitis herpetiformis. Which one of the following is an absolute contraindication to electroconvulsive therapy (ECT)? (check one) A. Age >80 years B. A cardiac pacemaker C. An implantable cardioverter-defibrillator D. Pregnancy E. There are no absolute contraindications to ECT - ✔✔E. There are no absolute contraindications to ECT. There are no absolute contraindications to electroconvulsive therapy (ECT), but factors that have been associated with reduced efficacy include a prolonged episode, lack of response to medication, and coexisting psychiatric diagnoses such as a personality disorder. Persons who may be at increased risk for complications include those with unstable cardiac disease such as ischemia or arrhythmias, cerebrovascular disease such as recent cerebral hemorrhage or stroke, or increased intracranial pressure. ECT can be used safely in elderly patients and in persons with cardiac pacemakers or implantable cardioverter-defibrillators. ECT also can be used safely during pregnancy, with proper precautions and in consultation with an obstetrician. A 55-year-old female presents to an urgent-care facility with a complaint of weakness of several weeks' duration. She has no other symptoms. She has been healthy except for a history of hypertension that has been difficult to control despite the use of hydrochlorothiazide, 25 mg daily; lisinopril (Prinivil, Zestril), 40 mg daily; amlodipine (Norvasc), 10 mg daily; and doxazosin (Cardura), 8 mg daily. On examination her blood pressure is 164/102 mm Hg, with the optic fundi showing grade 2 changes. She has normal pulses, a normal cardiac examination, and no abdominal bruits. A CBC is normal and a blood chemistry panel is also normal except for a serum potassium level of 3.1 mmol/L (N 3.5-5.5). Which one of the following would be best for confirming the most likely diagnosis in this patient? (check one) A. Magnetic resonance angiography of the renal arteries B. A renal biopsy C. 24-hour urine for metanephrines D. Early morning fasting cortisol E. A plasma aldosterone/renin ratio - ✔✔E. A plasma aldosterone/renin ratio. Difficult-to-control hypertension has many possible causes, including nonadherence or the use of alcohol, NSAIDs, certain antidepressants, or sympathomimetics. Secondary hypertension can be caused by relatively common problems such as chronic kidney disease, obstructive sleep apnea, or primary hyperaldosteronism, as in the case described here. As many as 20% of patients referred to specialists for poorly controlled hypertension have primary hyperaldosteronism. It is more common in women and often is asymptomatic. A significant number of these individuals will not be hypokalemic. Screening can be done with a morning plasma aldosterone/renin ratio. If the ratio is 20 or more and the aldosterone level is >15 ng/dL, then primary hyperaldosteronism is likely and referral for confirmatory testing should be considered. A 15-month-old male is brought to your office 3 hours after the onset of an increased respiratory rate and wheezing. He has an occasional cough and no rhinorrhea. His immunizations are up to date and he attends day care regularly. His temperature is 38.2°C (100.8°F), respiratory rate 42/min, and pulse rate 118 beats/min. The child is sitting quietly on his mother's lap. His oxygen saturation is 94% on room air. On examination you note inspiratory crackles in the left lower lung field. The child appears to be well hydrated and the remainder of the examination, including an HEENT examination, is normal. Nebulized albuterol (AccuNeb) is administered and no improvement is noted. Which one of the following would be most appropriate in the management of this patient? (check one) A. Laboratory evaluation B. Inpatient monitoring, with no antibiotics at this time C. Hospitalization and intravenous ceftriaxone (Rocephin) D. Close outpatient follow-up, with no antibiotics at this time E. Oral high-dose amoxicillin (90 mg/kg/day), with close outpatient follow-up - ✔✔E. Oral high-dose amoxicillin (90 mg/kg/day), with close outpatient follow-up. The diagnosis of community-acquired pneumonia is mostly based on the history and physical examination. Pneumonia should be suspected in any child with fever, cyanosis, and any abnormal respiratory finding in the history or physical examination. Children under 2 years of age who are in day care are at higher risk for developing community-acquired pneumonia. Laboratory tests are rarely helpful in differentiating viral versus bacterial etiologies and should not be routinely performed. Outpatient antibiotics are appropriate if the child does not have a toxic appearance, hypoxemia, signs of respiratory distress, or dehydration. Streptococcus pneumoniae is one of the most common etiologies in this age group, and high-dose amoxicillin is the drug of choice. For normal term infants, current practice is to introduce solid foods into the diet at what age? (check one) A. 2-4 weeks B. 2-3 months C. 4-6 months D. 7-9 months E. 1 year - ✔✔C. 4-6 months. In normal term infants, there is little evidence that solid foods contribute to well-being before the age of 4-6 months. In addition, the extrusion reflex (pushing foreign material out of the mouth with the tongue) makes feeding of solids difficult and often forced. This reflex disappears around the age of 4 months, making feeding easier. The introduction of solids at this age helps supply calories, iron, and vitamins, and may prepare the infant for later dietary diversity and healthy dietary habits. A 28-year-old male recreational runner has a midshaft posteromedial tibial stress fracture. Although he can walk without pain, he cannot run without pain. The most appropriate treatment at this point includes which one of the following? (check one) A. A short leg walking cast B. A non-weight-bearing short leg cast C. A non-weight-bearing long leg cast D. An air stirrup leg brace (Aircast) E. Low-intensity ultrasonic pulse therapy - ✔✔D. An air stirrup leg brace (Aircast). Midshaft posteromedial tibial stress fractures are common and are considered low risk. Management consists of relative rest from running and avoiding other activities that cause pain. Once usual daily activities are pain free, low-impact exercise can be initiated and followed by a gradual return to previous levels of running. A pneumatic stirrup leg brace has been found to be helpful during treatment (SOR C). Non-weight bearing is not necessary, as this patient can walk without pain. Casting is not recommended. Ultrasonic pulse therapy has helped fracture healing in some instances, but has not been shown to be beneficial in stress fractures. A 59-year-old male reports decreases in sexual desire and spontaneous erections, as well as reduced beard growth. The most appropriate test to screen for late-onset male hypogonadism is: (check one) A. free testosterone B. total testosterone C. sex hormone-binding globulin D. LH E. FSH - ✔✔B. total testosterone. A serum total testosterone level is recommended as the initial screening test for late-onset male hypogonadism. Due to its high cost, a free testosterone level is recommended only if the total testosterone level is borderline and abnormalities in sex hormone-binding globulin are suspected. Follow-up LH and FSH levels help to distinguish primary from secondary hypogonadism. A 68-year-old African-American female with primary hypothyroidism is taking levothyroxine (Synthroid), 125 μg/day. Her TSH level is 0.2μU/mL (N 0.5-5.0). She has no symptoms of either hypothyroidism or hyperthyroidism. Which one of the following would be most appropriate at this point? (check one) A. Continuing levothyroxine at the same dosage B. Increasing the levothyroxine dosage C. Decreasing the levothyroxine dosage D. Discontinuing levothyroxine E. Ordering a free T 4 - ✔✔C. Decreasing the levothyroxine dosage. Because of the precise relationship between circulating thyroid hormone and pituitary TSH secretion, measurement of serum TSH is essential in the management of patients receiving levothyroxine therapy. Immunoassays can reliably distinguish between normal and suppressed concentrations of TSH. In a patient receiving levothyroxine, a low TSH level usually indicates overreplacement. If this occurs, the dosage should be reduced slightly and the TSH level repeated in 2-3 months' time. There is no need to discontinue therapy in this situation, and repeating the TSH level in 2 weeks would not be helpful. A free T4 level would also be unnecessary, since it is not as sensitive as a TSH level for detecting mild states of excess thyroid hormone. A 40-year-old female comes to your office with a 1-month history of right heel pain that she describes as sharp, searing, and severe. The pain is worst when she first bears weight on the foot after prolonged sitting and when she gets out of bed in the morning. It gets better with continued walking, but worsens at the end of the day. She does not exercise except for being on her feet all day in the hospital where she works as a floor nurse. She denies any history of trauma. An examination reveals point tenderness to palpation on the plantar surface of the heel at the medial calcaneal tuberosity. Which one of the following should you recommend as first-line treatment? (check one) A. Taping/strapping B. Over-the-counter heel inserts C. Extracorporeal shock wave therapy D. A corticosteroid injection E. A fiberglass walking cast - ✔✔B. Over-the-counter heel inserts. Plantar fasciitis is a common cause of heel pain. It may be unilateral or bilateral, and the etiology is unknown, although it is thought to be due to cumulative overload stress. While it may be associated with obesity or overuse, it may also occur in active or inactive patients of all ages. Typically the pain is located in the plantar surface of the heel and is worst when the patient first stands up when getting out of bed in the morning (first step phenomenon) or after prolonged sitting. The pain may then improve after the patient walks around, only to worsen after prolonged walking. The diagnosis is made by history and physical examination. Typical findings include point tenderness to palpation on the plantar surface of the heel at the medial calcaneal tuberosity where the calcaneal aponeurosis inserts. Radiographs are not necessary unless there is a history of trauma or if the diagnosis is unclear. The condition may last for months or years, and resolves in most patients over time with or without specific therapy. One long-term follow-up study showed that 80% of patients had complete resolution of their pain after 4 years. Treatments with limited (level 2) evidence of effectiveness include off-the-shelf insoles, custom-made insoles, stretching of the plantar fascia, corticosteroid iontophoresis, custom-made night splints, and surgery (for those who have failed conservative therapy). NSAIDs and ice, although not independently studied for plantar fasciitis, are included in most studies of other treatments, and are reasonable adjuncts to first-line therapy. Magnetic insoles and extracorporeal shockwave therapy are ineffective in treating plantar fasciitis. Due to their expense, custom-made insoles, custom-made night splints, and corticosteroid iontophoresis should be reserved as second-line treatments for patients who fail first-line treatment. Surgery may be offered if more conservative therapies fail. Corticosteroid injection may have a short-term benefit at 1 month, but is no better than other treatments at 6 months and carries a risk of plantar fascia rupture. A 3-year-old male presents with a 3-day history of fever and refusal to eat. Today his parents noted some sores just inside his lips. No one else in the family is ill, and he has no significant past medical history. He is up-to-date on his immunizations and has no known allergies. On examination, positive findings include a temperature of 38.9°C (102.0°F) rectally, irritability, and ulcers on the oral buccal mucosa, soft palate, tongue, and lips. He also has cervical lymphadenopathy. The remainder of the physical examination is normal. The child is alert and has no skin lesions or meningeal signs. Which one of the following would be the most appropriate treatment? (check one) A. Ceftriaxone (Rocephin) intramuscularly B. Nystatin oral suspension C. Amoxicillin suspension D. Acyclovir (Zovirax) suspension E. Methotrexate (Trexall) - ✔✔D. Acyclovir (Zovirax) suspension. The history and physical findings in this patient are consistent with gingivostomatitis due to a primary or initial infection with herpes simplex virus type 1 (HSV-1). There are no additional findings to suggest other diagnoses such as aphthous ulcers, Behçet's syndrome, or herpangina (coxsackievirus). After a primary HSV-1 infection with oral involvement, the virus invades the neurons and replicates in the trigeminal sensory ganglion, leading to recurrent herpes labialis and erythema multiforme, among other things. Although some clinicians might choose to use oral anesthetics for symptomatic care, it is not a specific therapy. Antibiotics are not useful for the treatment of herpetic gingivostomatitis and could confuse the clinical picture should this child develop erythema multiforme, which occurs with HSV-1 infections. An orally applied corticosteroid is not specific treatment, but some might try it for symptomatic relief. An immunosuppressant is sometimes used for the treatment of Behçet's syndrome, but this patient's findings are not consistent with that diagnosis. Therefore, the only specific treatment listed is acyclovir suspension, which has been shown to lead to earlier resolution of fever, oral lesions, and difficulties with eating and drinking. It also reduces viral shedding from 5 days to 1 day (SOR B). ======================================================= Random Board Review Questions 02 ======================================================= You see a 22-year-old female who sustained a right knee injury in a recent college soccer game.She is a defender and executed a sudden cutting maneuver. With her right foot planted and her ankle locked, she attempted to shift the position of her body to stop an oncoming ball and felt her knee pop. She has had a moderate amount of pain and swelling, which began within 2 hours of the injury, but she is most concerned about the loss of knee hyperextension. Which one of the following tests is most likely to be abnormal in this patient? (check one) A. Anterior drawer B. Lachman C. McMurray D. Pivot shift - ✔✔B. Lachman. Anterior cruciate ligament (ACL) tears occur more commonly in women than in men. The intensity of play is also a factor, with a much greater risk of ACL injuries occurring during games than during practices. The most accurate maneuver for detecting an ACL tear is the Lachman test (sensitivity 60%-100%, mean 84%), followed by the anterior drawer test (sensitivity 9%-93%, mean 62%) and the pivot shift test (sensitivity 27%-95%, mean 62%) (SOR C). McMurray's test is used to detect meniscal tears. One of your patients has been diagnosed with monoclonal gammopathy of undetermined significance (MGUS). Which one of the following is used to determine whether his condition has progressed to multiple myeloma? (check one) A. The length of time since the diagnosis of MGUS was made B. The level of M protein C. The percentage of plasma cells in bone marrow D. Evidence of end-organ damage - ✔✔D. Evidence of end-organ damage. The diagnosis of multiple myeloma is based on evidence of myeloma-related end-organ impairment in the presence of M protein, monoclonal plasma cells, or both. This evidence may include hypercalcemia, renal failure, anemia, or skeletal lesions. Monoclonal gammopathy of undetermined significance does not progress steadily to multiple myeloma. There is a stable 1% annual risk of progression. A 60-year-old African-American male who has a 15-year history of diabetes mellitus reports a 1-week history of weakness of the lower left leg, giving way of the knee, and discomfort in the anterior thigh. He has no history of recent trauma. A physical examination reveals decreased sensation to pinprick and light touch over the left anterior thigh, and reduced motor strength on hip flexion and knee extension. The straight leg raising test is normal. The most likely cause of this condition is: (check one) A. femoral neuropathy B. diabetic polyneuropathy C. meralgia paresthetica D. spinal stenosis E. iliofemoral atherosclerosis - ✔✔A. femoral neuropathy. These findings are typical of femoral neuropathy, a mononeuropathy commonly associated with diabetes mellitus, although it has been found to be secondary to a number of conditions that are common in diabetics and not to the diabetes itself. Diabetic polyneuropathy is characterized by symmetric and distal limb sensory and motor deficits. Meralgia paresthetica, or lateral femoral cutaneous neuropathy, may be secondary to diabetes mellitus, but is manifested by numbness and paresthesia over the anterolateral thigh with no motor dysfunction. Spinal stenosis causes pain in the legs, but is not associated with the neurologic signs seen in this patient, nor with knee problems. Iliofemoral atherosclerosis, a relatively common complication of diabetes mellitus, may produce intermittent claudication involving one or both calf muscles but would not produce the motor weakness noted in this patient. Women who use low-dose estrogen oral contraceptives have a 50% lower risk of cancer of the: (check one) A. breast B. cervix C. head and neck D. lung E. ovary - ✔✔E. ovary. Women who use low-dose estrogen oral contraceptives have at least a 50% lower risk of subsequent epithelial ovarian cancer than women who have never used them. Epidemiologic data also suggests other potential long-term benefits of oral contraceptives, including a reduced risk of postmenopausal fractures, as well as reductions in the risk of endometrial and colorectal cancers. Oral contraceptives do not reduce the risk of carcinoma of the breast, cervix, lung, or head and neck. Which one of the following is most typical of polymyalgia rheumatica? (check one) A. Headache and neck pain B. A normal erythrocyte sedimentation rate C. A dramatic response to corticosteroids D. A lack of systemic symptoms and signs - ✔✔C. A dramatic response to corticosteroids. Polymyalgia rheumatica is an inflammatory disorder that occurs in persons over the age of 50. White women of European ancestry are most commonly affected. The clinical hallmarks of polymyalgia rheumatica are pain and stiffness in the shoulder and pelvic girdle. One review found that 4%-13% of patients with clinical polymyalgia rheumatica have a normal erythrocyte sedimentation rate (ESR). As many as 5% of patients initially have a normal ESR that later rises. Polymyalgia rheumatica can have a variety of systemic symptoms. Fever is common, with temperatures as high as 39°C (102°F) along with night sweats. Additional symptoms include depression, fatigue, malaise, anorexia, and weight loss. Corticosteroids are the mainstay of therapy for polymyalgia rheumatica. Typically, a dramatic response is seen within 48-72 hours. A 53-year-old male presents for a routine well-care visit. He has no health complaints. His wife has accompanied him, however, and is quite concerned about changes she has noticed over the last 1-2 years. She says that he has become quite apathetic and seems to have lost interest in his job and his hobbies. He has been accused of making sexually harassing comments and inappropriate touching at work, and he no longer helps with household chores at home. He often has difficulty expressing himself and his speech can lack meaning. The physical examination is normal. Based on the history provided by the wife, you should suspect a diagnosis of : (check one) A. Alzheimer's disease B. major depressive disorder C. frontotemporal dementia D. dementia with Lewy bodies E. schizophrenia - ✔✔C. frontotemporal dementia. This patient meets the criteria for frontotemporal dementia (FTD), a common cause of dementia in patients younger than 65, with an insidious onset. Unlike with Alzheimer's disease, memory is often relatively preserved, even though insight is commonly impaired. There are three subtypes of frontotemporal dementia: behavioral variant FTD, semantic dementia, and progressive nonfluent aphasia. This patient would be diagnosed with the behavioral variant due to his loss of executive functioning leading to personality change (apathy) and inappropriate behavior (SOR C). Speech output is often distorted in frontotemporal dementia, although the particular changes differ between the three variants. Patients with FTD often are mistakenly thought to have major depressive disorder due to their apathy and diminished interest in activities. However, patients with depression do not usually exhibit inappropriate behavior and lack of restraint. Dementia with Lewy bodies and Alzheimer's dementia are both characterized predominantly by memory loss. Alzheimer's dementia is most common after age 65, whereas FTD occurs most often at a younger age. Lewy body dementia is associated with parkinsonian motor features. Patients diagnosed with schizophrenia exhibit apathy and personality changes such as those seen in FTD. However, the age of onset is much earlier, usually in the teens and twenties in men and the twenties and thirties in women. An 88-year-old male has been hospitalized for the past 3 days after being found on the floor of his home by a neighbor and transported to the hospital by ambulance. He was cachectic and dehydrated at the time of admission, with a serum albumin level of 1.9 g/dL (N 3.5-4.7). He has received intravenous fluids and is now euvolemic. He began nasogastric tube feeding 2 days ago and has now developed nausea, vomiting, hypotension and delirium. Which one of the following is the most classic electrolyte abnormality with this condition? (check one) A. Hypocalcemia B. Hypercalcemia C. Hyperkalemia D. Hypophosphatemia E. Hyperphosphatemia - ✔✔D. Hypophosphatemia. Refeeding syndrome can be defined as the potentially fatal shifts in fluids and electrolytes that may occur in malnourished patients receiving artificial refeeding (whether enterally or parenterally). These shifts result from hormonal and metabolic changes and may cause serious clinical complications. The hallmark biochemical feature of refeeding syndrome is hypophosphatemia. However, the syndrome is complex and may also include abnormal sodium and fluid balance; changes in glucose, protein, and fat metabolism; thiamine deficiency; hypokalemia; and hypomagnesemia. When prescribing an inhaled corticosteroid for control of asthma, the risk of oral candidiasis can be decreased by: (check one) A. using a valved holding chamber B. limiting use of the inhaled corticosteroid to once daily C. adding nasal fluticasone propionate (Flonase) D. adding montelukast (Singulair) E. adding salmeterol (Serevent) - ✔✔A. using a valved holding chamber. Pharyngeal and laryngeal side effects of inhaled corticosteroids include sore throat, coughing on inhalation of the medication, a weak or hoarse voice, and oral candidiasis. Rinsing the mouth after each administration of the medication and using a valved holding chamber when it is delivered with a metered-dose inhaler can minimize the risk of oral candidiasis. A 45-year-old female presents with a 3-month history of hoarseness that is not improving. She works as a high-school teacher. The most appropriate management at this time would be: (check one) A. voice therapy B. azithromycin (Zithromax) C. a trial of inhaled corticosteroids D. a trial of a proton pump inhibitor E. laryngoscopy - ✔✔E. laryngoscopy. Hoarseness most commonly affects teachers and older adults. The cause is usually benign, but extended symptoms or certain risk factors should prompt evaluation; specifically, laryngoscopy is recommended when hoarseness does not resolve within 3 months or when a serious underlying cause is suspected (SOR C). The American Academy of Otolaryngology/Head and Neck Surgery Foundation guidelines state that antireflux medications should not be prescribed for patients with hoarseness without reflux symptoms (SOR C). Antibiotics should not be used, as the condition is usually caused by acute laryngitis or an upper respiratory infection, and these are most likely to be viral. Inhaled corticosteroids are a common cause of hoarseness. Voice therapy should be reserved for patients who have undergone laryngoscopy first (SOR A). In adults, the most common cause of right heart failure is: (check one) A. myocarditis B. left heart failure C. pulmonic stenosis D. ventricular septal defect - ✔✔B. left heart failure. Although myocarditis, pulmonic stenosis, and ventricular septal defects can be causes of right heart failure, left heart failure is the most common cause of right heart failure in adults. ======================================================= Random Board Review Questions 03 ======================================================= As the medical review officer for a local business, you are required to interpret urine drug tests. Assuming the sample was properly collected and handled, which one of the following test results is consistent with the history provided and should be reported as a negative test? (check one) A. Diazepam (Valium) identified in an employee taking oxazepam prescribed by a physician B. Morphine identified in an employee undergoing a prescribed methadone pain management program C. Morphine identified in an employee taking a prescribed cough medicine containing codeine D. Tetrahydrocannabinol above the threshold value in an employee who reports secondary exposure to marijuana E. Tetrahydrocannabinol identified in an employee taking prescribed tramadol (Ultram) - ✔✔C. Morphine identified in an employee taking a prescribed cough medicine containing codeine. Results of urine drug test panels obtained in the workplace are reported by a Medical Review Officer (MRO) as positive, negative, dilute, refusal to test, or test canceled; the drug/metabolite for which the test is positive or the reason for refusal (e.g., the presence of an adulterant) or cancellation is also included in the final report. The MRO interpretation is based on consideration of many factors, including the confirmed patient medical history, specimen collection process, acceptability of the specimen submitted, and qualified laboratory measurement of drugs or metabolites in excess of the accepted thresholds. These thresholds are set to preclude the possibility that secondary contact with smoke, ingestion of poppy seeds, or similar exposures will result in an undeserved positive urine drug screen report. Other findings, such as the presence of behavioral or physical evidence of unauthorized use of opiates, may also factor into the final report. When a properly collected, acceptable specimen is found to contain drugs or metabolites that would be expected based on a review of confirmed prescribed use of medications, the test is reported as negative. Morphine is a metabolite of codeine that may be found in the urine of someone taking a codeine-containing medication; morphine is not a metabolite of methadone. Oxazepam is a metabolite of diazepam but the reverse is not true. Tetrahydrocannabinol would not be found in the urine as a result of tramadol use. An 18-year-old male presents with a sore throat, adenopathy, and fatigue. He has no evidence of airway compromise. A heterophil antibody test is positive for infectious mononucleosis. Appropriate management includes which one of the following? (check one) A. A corticosteroid B. An antihistamine C. An antiviral agent D. Strict bed rest E. Avoidance of contact sports - ✔✔E. Avoidance of contact sports. Infectious mononucleosis presents most commonly with a sore throat, fatigue, myalgias, and lymphadenopathy, and is most prevalent between 10 and 30 years of age. Both an atypical lymphocytosis and a positive heterophil antibody test support the diagnosis, although false-negative heterophil testing is common early in the disease course. The cornerstone of treatment for mononucleosis is supportive, including hydration, NSAIDs, and throat sprays or lozenges. In general, corticosteroids do not have a significant effect on the clinical course of infectious mononucleosis, and they should not be used routinely unless the patient has evidence of acute airway obstruction. Antihistamines are also not recommended as routine treatment for mononucleosis. The use of acyclovir has shown no consistent or significant benefit, and antiviral drugs are not recommended. There is also no evidence to support bed rest as an effective management strategy for mononucleosis. Given the evidence from other disease states, bed rest may actually be harmful. Although most patients will not have a palpably enlarged spleen on examination, it is likely that all, or nearly all, patients with mononucleosis have splenomegaly. This was demonstrated in a small study in which 100% of patients hospitalized for mononucleosis had an enlarged spleen by ultrasound examination, whereas only 17% of patients with splenomegaly have a palpable spleen. Patients should be advised to avoid contact- or collision-type activities for 3-4 weeks because of the increased risk of rupture. A 65-year-old Hispanic male with known metastatic lung cancer is hospitalized because of decreased appetite, lethargy, and confusion of 2 weeks' duration. Laboratory evaluation reveals the following: Serum calcium......................... 15.8 mg/dL (N 8.4-10.0) Serum phosphorus...................... 3.9 mg/dL (N 2.6-4.2) Serum creatinine. ...................... 1.1 mg/dL (N 0.7-1.3) Total serum protein..................... 5.0 g/dL (N 6.0-8.0) Albumin.............................. 3.1 g/dL (N 3.7-4.8) Which one of the following is the most appropriate INITIAL management? (check one) A. Calcitonin-salmon (Miacalcin) subcutaneously B. Pamidronate disodium (Aredia) by intravenous infusion C. Normal saline intravenously D. Furosemide intravenously - ✔✔C. Normal saline intravenously. The initial management of hypercalcemia of malignancy includes fluid replacement with normal saline to correct the volume depletion that is invariably present and to enhance renal calcium excretion. The use of loop diuretics such as furosemide should be restricted to patients in danger of fluid overload, since these drugs can aggravate volume depletion and are not very effective alone in promoting renal calcium excretion. Although intravenous pamidronate has become the mainstay of treatment for the hypercalcemia of malignancy, it is considered only after the hypercalcemic patient has been rendered euvolemic by saline repletion. The same is true for the other calcium-lowering agents listed. A 35-year-old African-American female with symptomatic uterine fibroids that are unresponsive to medical management prefers to avoid a hysterectomy. Which one of the following would be a reason for preferring myomectomy over fibroid embolization? (check one) A. A desire for future pregnancy B. Medical problems that increase general anesthesia risk C. Religious objections to blood transfusion D. The likelihood of a shorter hospital stay and recovery time E. The minimal risk of fibroid recurrence - ✔✔A. A desire for future pregnancy. In the symptomatic patient with uterine fibroids unresponsive to medical therapy, myomectomy is recommended over fibroid embolization for patients who wish to become pregnant in the future. Uterine fibroid embolization requires a shorter hospitalization and less time off work. General anesthesia is not required, and a blood transfusion is unlikely to be needed. Uterine fibroids can recur or develop after either myomectomy or embolization. A 70-year-old African-American male undergoes routine sigmoidoscopy. He has a long history of constipation, hypertension, and diet-controlled type 2 diabetes mellitus. The examination reveals brown to black leopard spotting of the colonic mucosa. You would now: (check one) A. perform a metastatic workup B. review his medications C. prescribe oral corticosteroids D. prescribe antibiotics and a proton pump inhibitor E. check his stool for Clostridium difficile - ✔✔B. review his medications. This patient has melanosis coli, which is a benign condition resulting from abuse of anthraquinone laxatives such as cascara, senna, or aloe. The condition resolves with discontinuation of the medication. The Valsalva maneuver will typically cause the intensity of a systolic murmur to increase in patients with which one of the following conditions? (check one) A. Aortic stenosis B. Rheumatic mitral insufficiency C. Valvular pulmonic stenosis D. Hypertrophic obstructive cardiomyopathy - ✔✔D. Hypertrophic obstructive cardiomyopathy. The Valsalva maneuver decreases venous return to the heart, thereby decreasing cardiac output. This causes most murmurs to decrease in length and intensity. The murmur of hypertrophic obstructive cardiomyopathy, however, increases in loudness. The murmur of mitral valve prolapse becomes longer, and may also become louder. A 12-year-old male presents with left hip pain. He is overweight and recently started playing tennis to lose weight. He says the pain started gradually after his last tennis game, but he does not recall any injury. He is walking with a limp. On examination he is afebrile and has limited internal rotation of the left hip. What is the most likely cause of the hip pain? (check one) A. Septic arthritis B. Juvenile rheumatoid arthritis C. Transient synovitis D. Slipped capital femoral epiphysis E. Legg-Calvé-Perthes disease - ✔✔D. Slipped capital femoral epiphysis. Slipped capital femoral epiphysis is the most common hip disorder in this patient's age group. It usually occurs between the ages of 8 and 15 and is more common in boys and overweight or obese children. It presents with limping and pain, and limited internal rotation of the hip is noted on physical examination. Septic arthritis would typically present with a fever. Juvenile rheumatoid arthritis, transient synovitis, and Legg-Calvé-Perthes disease are more common in younger children. Which one of the following is associated with the use of percutaneous endoscopic gastrostomy (PEG) tubes? (check one) A. A reduced risk of aspiration pneumonia in patients with dysphagia B. Increased use of restraints C. Improved nutritional status in nursing-home residents with dementia D. Improved quality of life for patients with dementia - ✔✔B. Increased use of restraints. When a patient or nursing-home resident is losing weight or has suffered an acute change in the ability to perform activities of daily living, a decision must be made as to whether or not to place a PEG tube to provide artificial nutrition. Studies have shown that PEG tubes do not improve nutritional status or quality of life for residents with dementia, nor do they decrease the risk of aspiration pneumonia, although aspiration risk may possibly be decreased if the feeding tube is placed below the gastroduodenal junction (SOR B). Feeding tubes can also cause discomfort and agitation, leading to an increased use of restraints (SOR B). A 58-year-old white male comes to your office for follow-up after a recent bout of acute bronchitis. He reports having a productive cough for several months. He gets breathless with exertion and notes that every time he gets a cold it "goes into my chest and lingers for months." He has been smoking for 30 years. A physical examination is negative except for scattered rhonchi. A chest radiograph done 4 months ago at an urgent care visit was negative except for hyperinflation and flattened diaphragms. Which one of the following would be best for making the diagnosis? (check one) A. A chest radiograph B. CT of the chest C. Peak flow measurement D. Spirometry E. A BNP level - ✔✔D. Spirometry. It is important to distinguish between COPD and asthma because of the differences in treatment. Patients with COPD are usually in their sixties when the diagnosis is made. Symptoms of chronic cough (sometimes for months or years), dyspnea, or sputum production are often not reported because the patient may attribute them to smoking, aging, or poor physical condition. Spirometry is the best test for the diagnosis of COPD. The pressure of outflow obstruction that is not fully reversible is demonstrated by postbronchodilator spirometry showing an FEV /FVC ratio of 70% or less. A 50-year-old female presents with right eye pain. On examination, you find no redness, but when you test her extraocular muscles she reports marked pain with eye movement. This finding suggests that her eye pain is caused by: (check one) A. an intracranial process B. an ocular condition C. a retinal problem D. an orbital problem E. an optic nerve problem - ✔✔D. an orbital problem. Pain with eye movement suggests an orbital condition. Orbital inflammation, infection, or tumor invasion can lead to such eye pain. Other findings suggestive of an orbital cause of eye pain include diplopia or proptosis. If an orbital lesion is suspected, imaging studies should be performed. ======================================================= Random Board Review Questions 04 ======================================================= A 30-year-old female asks you whether she should have a colonoscopy, as her father was diagnosed with colon cancer at the age of 58. There are no other family members with a history of colon polyps or cancer. You recommend that she have her first screening colonoscopy: (check one) A. now and every 5 years if normal B. now and every 10 years if normal C. at age 40 and then every 5 years if normal D. at age 40 and then every 10 years if normal E. at age 50 and then every 5 years if normal - ✔✔C. at age 40 and then every 5 years if normal. Patients should be risk-stratified according to their family history. Patients who have one first degree relative diagnosed with colorectal cancer or adenomatous polyps before age 60, or at least two second degree relatives with colorectal cancer, are in the highest risk group. They should start colon cancer screening at age 40, or 10 years before the earliest age at which an affected relative was diagnosed (whichever comes first) and be rescreened every 5 years. Colonoscopy is the preferred screening method for this highest-risk group, as high-risk patients are more likely to have right-sided colon lesions that would not be detected with sigmoidoscopy. A 64-year-old African-American male presents with persistent pleuritic pain. The patient does not feel well in general and has had a low-grade fever of around 100°F (38°C). His medications include simvastatin (Zocor), lisinopril (Prinivil, Zestril), low-dose aspirin, spironolactone (Aldactone), furosemide (Lasix), isosorbide mononitrate (Imdur), hydralazine, carvedilol (Coreg), and nitroglycerin as needed. A chest radiograph is normal and does not demonstrate a pneumothorax. Further evaluation rules out pulmonary embolus, pneumonia, and myocardial infarction. A diagnosis of pleurisy is made. Which one of the patient's medications could be related to this condition? (check one) A. Hydralazine B. Simvastatin C. Lisinopril D. Spironolactone E. Carvedilol - ✔✔A. Hydralazine. Drug-induced pleuritis is one cause of pleurisy. Several drugs are associated with drug-induced pleural disease or drug-induced lupus pleuritis. Drugs that may cause lupus pleuritis include hydralazine, procainamide, and quinidine. Other drugs known to cause pleural disease include amiodarone, bleomycin, bromocriptine, cyclophosphamide, methotrexate, minoxidil, and mitomycin. A 30-year-old male presents to the emergency department with a sensation of a racing heart. His history is significant for known Wolff-Parkinson-White syndrome (WPW). On examination he is alert and in no severe distress. His blood pressure is 130/70 mm Hg, pulse rate 220 beats/min, and oxygen saturation 96%. An EKG reveals a regular, wide-complex tachycardia with a rate of 220 beats/min. You determine that he is stable, the EKG is consistent with WPW, and pharmacologic conversion is a safe initial therapy. Which one of the following would be the treatment of choice? (check one) A. Verapamil (Calan) B. Adenosine (Adenocard) C. Procainamide D. Digoxin - ✔✔C. Procainamide. Adenosine, digoxin, and calcium channel antagonists act by blocking conduction through the atrioventricular (AV) node, which may increase the ventricular rate paradoxically, initiating ventricular fibrillation. These agents should be avoided in Wolff-Parkinson-White syndrome. Procainamide is usually the treatment of choice in these situations, although amiodarone may also be used. Which one of the following is contraindicated in the second and third trimesters of pregnancy? (check one) A. Amoxicillin B. Azithromycin (Zithromax) C. Ceftriaxone (Rocephin) D. Ciprofloxacin (Cipro) E. Doxycycline - ✔✔E. Doxycycline. Doxycycline is contraindicated in the second and third trimesters of pregnancy due to the risk of permanent discoloration of tooth enamel in the fetus. Cephalosporins such as ceftriaxone are usually considered safe to use during pregnancy. The use of ciprofloxacin during pregnancy does not appear to increase the risk of major congenital malformation, nor does the use of amoxicillin. Animal studies using rats and mice treated with daily doses of azithromycin up to maternally toxic levels revealed no impairment of fertility or harm to the fetus. A 25-year-old medical student reads about the benefits of moderate alcohol consumption on lipid levels and begins to drink 5 ounces of red wine a day, adding 100 calories to his diet. Assuming that his diet and exercise levels stay the same, what effect will the additional 3000 calories a month have on his body weight over the next 10 years? (check one) A. They will have essentially no effect B. His weight will increase by about 25 kg C. His weight will increase slightly then stabilize D. His normal caloric expenditure will decrease - ✔✔C. His weight will increase slightly then stabilize. There is not a direct relation between daily calorie consumption and weight. An adult male consuming an extra 100 calories a day above his caloric need will not continue to gain weight indefinitely; rather, his weight will increase to a certain point and then become constant. Fat must be fed, and maintaining the newly created tissue requires an increase in caloric expenditure. An extra 100 calories a day will result in a weight gain of approximately 5 kg, which will then be maintained. You have just diagnosed mild persistent asthma in a 13-year-old African-American female. Along with patient education, your initial medical management should be: (check one) A. a short-acting inhaled β-agonist to be used only as needed B. a long-acting inhaled β-agonist daily C. a low-dose inhaled corticosteroid daily, along with a short-acting inhaled β-agonist as needed D. a low-dose inhaled corticosteroid daily, along with a long-acting inhaled β-agonist daily E. montelukast (Singulair) daily - ✔✔C. a low-dose inhaled corticosteroid daily, along with a short-acting inhaled β-agonist as needed. Inhaled corticosteroids improve asthma control in adults and children more effectively than any other single long-term controller medication, and all patients should also receive a prescription for a short-acting β-agonist (SOR A). Patients with rheumatoid arthritis should be screened for tuberculosis before starting which one of the following medications? (check one) A. Gold B. Hydroxychloroquine (Plaquenil) C. Infliximab (Remicade) D. Methotrexate (Rheumatrex) E. Sulfasalazine (Azulfidine) - ✔✔C. Infliximab (Remicade). Tumor necrosis factor inhibitors have been associated with an increased risk of infections, including tuberculosis. This class of agents includes monoclonal antibodies such as infliximab, adalimumab, certolizumab pegol, and golimumab. Patients should be screened for tuberculosis and hepatitis B and C before starting these drugs. The other drugs listed can have adverse effects, but do not increase the risk for tuberculosis. A 42-year-old male with a history of intravenous drug use asks to be tested for hepatitis C. The hepatitis C virus (HCV) antibody enzyme immunoassay and recombinant immunoblot assay are both reported as positive. The quantitative HCV RNA polymerase chain reaction test is negative. These test results are most consistent with: (check one) A. very early HCV infection B. current active HCV infection C. a false-positive antibody test D. past infection with HCV that is now resolved - ✔✔D. past infection with HCV that is now resolved. The most widely used initial assay for detecting hepatitis C virus (HCV) antibody is the enzyme immunoassay. A positive enzyme immunoassay should be followed by a confirmatory test such as the recombinant immunoblot assay. If negative, it indicates a false-positive antibody test. If positive, the quantitative HCV RNA polymerase chain reaction is used to measure the amount of virus in the blood to distinguish active from resolved HCV infection. In this case, the results of the test indicate that the patient had a past infection with HCV that is now resolved. A nursing-home resident is hospitalized, and shortly before she is to be discharged she develops a skin ulcer, which proves to be infected with methicillin-resistant Staphylococcus aureus (MRSA). Which one of the following is most important in terms of infection control when she returns to the nursing home? (check one) A. Surveillance cultures of nursing-home residents living near the patient B. Aggressive housekeeping in the patient's room C. Masks, gowns, and gloves for all those entering the patient's room D. Strict handwashing practices by all staff, visitors, and residents E. Isolation of the patient in a room by herself - ✔✔D. Strict handwashing practices by all staff, visitors, and residents. All staff, visitors, and nursing-home residents should observe strict handwashing practices in this situation. Barrier precautions for wounds and medical devices should also be initiated. Surveillance cultures are not warranted. Aggressive housekeeping practices play little, if any, role in preventing the spread of MRSA. Isolating the patient is not practical or cost-effective. Metformin (Glucophage) should be stopped prior to which one of the following, and withheld until 48 hours after completion of the test? (check one) [Show More]

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