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MKSAP13 Primary Care
MKSAP13 Primary Care
Which of the following is the most appropriate next step in the patients
management?
A. Aggressive blood pressure control for hypertensive retinopathy
B. Immediate ophthalmology referral for laser therapy for macular edema
C. Immediate ophthalmology referral for laser therapy for proliferative retinopathy
D. Routine ophthalmology referral within the next several months for background
diabetic retinopathy
E. Rapid aggressive blood glucose control to a target hemoglobin A1c of 7.0%
Primary Care Med icine:Question 14
A 52-year-old man presents as a new patient requesting an annual examination and
a serum prostate-specific antigen (PSA) measurement. He exercises, does not
smoke, and drinks alcohol infrequently. His medical records disclose well-controlled
blood pressure, a negative exercise tolerance test 4 years ago, and various
laboratory evaluations, all of which were normal. His only medication is atenolol
Previous health maintenance included a colonoscopy 2 years ago and serum PSA
values of 4.2 ng/mL 1 year ago and 3.8 ng/mL 2 years ago. The patient recalls his
prior physician telling him the value was borderline and recommending a repeat
measurement in 1 year.
Physical examination, including digital rectal examination, is unremarkable. Serum
PSA value is 5.0 ng/mL.
Which of the following is the most appropriate next step in the management of this
patient?
A. Prescribe tamsulosin therapy
B. Perform serial PSA measurements
C. Order free PSA assay
D. Refer for urologic evaluation
E. Prescribe finasteride
Primary Care Medicine:Question 15
A 60-year-old man is evaluated for painful leg ulcers. He has a history of
degenerative joint disease, obesity, hypertension, and chronic venous stasis. His
medications are acetaminophen and atenolol.
On examination, he has markedly edematous lower legs, with brawny skin
discoloration, several areas of dermal atrophy from lipodermatosclerosis, and two
shallow, tender, red-based, ulcers weeping clear exudate with some associated
crusting over the medial ankle and lower shin on the left leg. He has been using
graded compression hose over dry gauze dressings.
Which of the following is the best strategy for decreasing the patients leg ulcer pain?
A. Nonadherent dressings
B. Occlusive dressings
C. Zinc paste-impregnated bandage (Unna boot)
D. Vaseline gauze
E. Topical antibiotic ointment
Primary Care Medicine:Question 16
A 31-year-old woman seeks advice about acne. She has had acne since menarche
but continues to have cyclical lesions that embarrass her. On examination, she has
pustules on her face, back, and chest, with two cysts on her chin and forehead. She
has noticeable scarring that is well concealed with make-up. She has taken oral
contraceptives for about 5 years, without resolution of her cysts.
What is the most important factor for choosing further treatment for this patient?
A. Whether open comedones are present
B. Her willingness to avoid pregnancy
C. Her alcohol intake
D. Her plasma triglyceride levels
E. Whether she can avoid sun exposure
Primary Care Medicine:Question 17
A 26-year-old woman presents with a 3-week history of severe anal pain. She has
noticed some blood on the toilet paper and has had a 3.6-kg (8-Ib) weight loss in the
past 2 months. On physical examination, an anal fissure is present in the 3 oclock
position. The fissure bleeds minimally when palpated.
What is the best next step in the management of this patient?
A. Anoscopy
B. Colonoscopy
C. Trial of psyllium husk (MetamucilTM)
D. Trial of nitroglycerin ointment
E. Trial of botulinum toxin injections
Primary Care Medicine:Question 18
A 48-year-old man with a long history of alcohol abuse presents for ongoing care
after an inpatient stay for alcohol withdrawal. This is his third episode of acute
detoxification, with the longest period of abstinence being 4 months. He denies any
current symptoms of depression and states that he is not using any illicit drugs or
prescription medications. His last alcohol intake was 2 weeks before his visit to your
office, and he is now enrolled in an alcohol treatment program.
Which of the following pharmacologic agents would be the best adjunct to his
treatment?
A. Naltrexone
B. Paroxetine
C. Diazepam
D. Buspirone
E. Disulfiram
Primary Care Medicine:Question 19
A 35-year-old woman comes to your office to discuss family planning. She has been
in a monogamous relationship with her current partner for 9 years, and they have
both been tested for HIV infection and are negative. She hopes to become pregnant
and plans to discontinue using condoms. Her most recent Pap test was about 1 year
ago and was normal. She has had annual Pap tests for the past 15 years that have
all been normal.
When does she need to have her next Pap test?
A. Today
B. In 6 months
C. In 1 year
D. In 2 years
E. In 3 years
A. No testing
B. CT scan of the head without contrast
C. CT scan of the head with contrast
D. MRI of the head
E. Lumbar puncture
Primary Care Medicine:Question 30
A 28-year-old man presents with 4 days of upper respiratory congestion and sinus
pain. The patient has had no previous significant medical history. He notes that
initially he may have had a mild fever but has not been febrile in the past 48 hours.
He describes some yellowish nasal discharge. On examination, he has fluid behind
his tympanic membranes and moderate tenderness over his maxillary sinuses.
What is the most appropriate initial management?
A. Oral prednisone taper
B. Amoxicillin
C. Oral decongestants
D. Nasal ipratropium
E. Azithromycin
Primary Care Medicine:Question 31
A 55-year-old gardener presents with an itchy rash that has persisted for 1 to 2
weeks. He describes it as red splotches that come and go, and that are intensely
pruritic. He has not previously had a similar rash. It does not seem to be worsened
by cold, sunlight, or touch. The individual lesions persist for less than a day; he has
no pain, shortness of breath, or lip swelling. He cannot recall any new detergents,
soaps, or chemical contacts that were associated with the onset of the rash. His diet
has not changed, he has not traveled, and he feels otherwise well. His medical
history is significant for type 2 diabetes mellitus, well-controlled with metformin
therapy, which he has been taking for 4 years at a stable dose. He takes no other
regular medications. For the rash, the patient has been taking diphenhydramine, 25
to 50 mg every 6 to 8 hours, in an attempt to stop the itch. On physical examination,
he has several red, round, indurated dime-sized lesions over his arms and trunk.
What is the most appropriate next step in the management of this patient?
A. Biopsy of a skin lesion
B. Patch testing for contact irritants
C. Adding ranitidine to the diphenhydramine
D. Adding dapsone to the diphenhydramine
E. Prednisone taper
Primary Care Medicine:Question 32
A 34-year-man calls the office with the acute onset of a nosebleed. He has been
using a tissue to dab his nose for the past 5 minutes but cannot stop the bleeding.
He has not had dizziness, nausea, or vomiting. He has no history of nosebleeds,
recent trauma, or hypertension. Last week he suffered a knee-twisting injury during
a soccer game and has been using ibuprofen 400 mg twice a day for knee
discomfort. What is the most appropriate advice to give this patient as a first step in
stopping his nosebleed?
A. Pinch the nose together between the thumb and index finger
B. Lie down with the head on pillows
C. Apply a hot pack to the bridge of the nose
D. Blow the nose
E. Pack the nose with tissue
What is the most appropriate next step in the management of this patient?
A. Obtain anteroposterior, lateral, and axillary radiographs of the shoulder
B. Order an MRI of the shoulder
C. Inject the subacromial bursa with aqueous methylprednisolone, 40 mg
D. Prescribe a regular regimen of ibuprofen, 300 mg three times daily
E. Measure serum uric acid
Primary Care Medicine:Question 52
A 74-year-old man is being evaluated before cataract replacement and intraocular
lens implant. The patient has type 2 diabetes mellitus, coronary artery disease with
history of congestive heart failure after bypass surgery 4 years ago, and
hypertension. His most recent hemoglobin Al c was 7.2%. Medications include
glyburide, amlodipine, lisinopril, furosemide, and aspirin.
Which of the following laboratory evaluations is indicated in pre-operative evaluation
of this patient?
A. No laboratory tests are needed
B. Chest radiograph
C. Prothrombin time
D. Electrocardiography
E. Complete blood count with platelet count
Primary Care Medicine:Question 53
A 33-year old male carpenter presents with an intensely pruritic rash involving both
elbows, wrists, and hands. He denies any prior rash. He has no systemic symptoms,
or dyspnea or wheezing. Examination reveals an erythematous papulosquamous
eruption in both antecubital fossae, wrists, and the interdigital web spaces of both
hands, with lichenification.
Which of the following would be most appropriate initial therapy?
A. Lindane
B. Nasal swabs, with antibiotic treatment aimed at eradication of Staphylococcus
colonization
C. Systemic oral methyprednisolone
D. Elimination diet to identify food allergy
E. Topical medium potency corticosteroids
Primary Care Medicine:Question 54
A 27-year-old woman presents for evaluation. She demands thyroid medication to
make her stronger because she is now Senator for the State of California. She
reports she has been sleeping 2 to 3 hours a night for the past 2 weeks and feels
well. She has not been hungry. She tells you she left her last provider because he
was reporting information to the election canvassing board that was damaging her
election hopes.
What is the most likely diagnosis?
A. Paranoid schizophrenia
B. Paranoid personality disorder
C. Histrionic personality disorder
D. Bipolar disorder
E. Narcissistic personality disorder
Laboratory studies:
Serum sodium 140 meq/L
Serum potassium 3.2 meq/L
Serum chloride 103 meq/L
Serum bicarbonate 24 meq/L
Plasma glucose 119 mg/dL
Blood urea nitrogen 15 mgldL
Serum creatininel.1 mg/dL
What is the most appropriate next step in the evaluation of this patient?
A. Measurement of serum cortisol
B. Renal artery duplex ultrasonography
C. Exercise treadmill testing
D. Measurement of plasma metanephrines
E. Determination of plasma renin/aldosterone ratio
Primary Care Medicine:Question 59
A 39-year-old woman presents for evaluation of headaches. She had the onset of
headaches at age 17 years, with migraines occurring two or three times a month.
This pattern continued until about 3 years ago when the headaches became more
frequent, and a bothersome headache occurring on a daily basis involving both the
right and left temporal areas and her forehead. These headaches are now present
every day, are present when she wakes up in the morning, and do not respond to
therapy with a selective serotonin antagonist (a triptan). Her current medications
include zolmitriptan, 1 tablet 8 to 10 times a month; naproxen, 500 mg orally twice
a day; acetaminophen with codeine, two or three tablets daily; and amitriptyline, 75
mg orally at bedtime. On funduscopic examination, the discs are sharp; neurologic
examination is normal.
What would be the most appropriate therapeutic approach to the patient?
A. Taper all current medications
B. Stop acetaminophen with codeine
C. Begin gabapentin therapy
D. Begin riboflavin therapy
E. Begin fluoxetine therapy
Primary Care Medicine:Question 60
A 36-year-old man with type 1 diabetes mellitus presents with 3 days of right ear
pain. The pain has gradually progressed and he has noted a small amount of
drainage from the ear. He is unaware of any trauma. On examination, his
temperature is 38.1 C (100.6 F). The pinna and mastoid are not tender; the ear
canal is moderately erythematous with some thin white discharge. The tympanic
membrane is partially visualized and is unremarkable. A few small lymph nodes are
palpable. The cranial nerves are intact.
What is the most appropriate initial management?
A. Hospitalization for intravenous ticarcillin/clavulunate
B. Ciprofloxacin, 750 mg orally twice a day
C. Antibiotic and corticosteroid otic drops (Cortisporin-TC Otic Suspension)
D. Acetic acid drops
E. Amoxicillin, 500 mg orally twice a day
What is the most appropriate medication adjustment to try to improve this patients
appetite and weight loss?
A. Decrease digoxin dose from 0.25 to 0.125 mg/d
B. Decrease glipizide dose from 5 to 2.5 mg/d
C. Decrease mirtazapine dose from 15 to 7.5 mg at bedtime
D. Decrease warfarin dose from 2.5 to 2 mg/d
E. Decrease lisinopril dose from 20 to 10 mg/d
Primary Care MediCine:Question 99
A 38-year-old man is seen in follow-up for clavicular fracture sustained in a motor
vehicle accident 6 weeks ago, requesting clearance to return to work. He had been
driving alone in daylight when his car left the road at a curve and struck a tree. He
does not think he lost consciousness or struck his head, but he does not remember
leaving the road. He recalls no prodrome and remembers clearly the sound of
crunching metal from the impact. The patient does not smoke, drink, or use other
drugs. He is obese and was diagnosed with type 2 diabetes mellitus and
hypertension 3 years ago and takes metformin and enalapril as his only medications.
He has never had hypoglycemia and has no history of cardiac or neurologic diseases
including seizures.
On evaluation by medics at the site of the accident, his pulse rate was 90/min and
regular, blood pressure was 150/1 00 mm Hg, and blood glucose was 180 mg/dL. He
was alert, oriented, and complained only of anterior shoulder pain at the site of the
fracture. He was evaluated in the emergency department and has been treated
conservatively with a shoulder sling, pain medication, and physical therapy. He feels
ready to return to work.
On specific questioning, he reports three near-miss car accidents in the past 2 years;
in none of these cases is he quite sure what happened.
What is the next information you would obtain to look for an underlying explanation
for his driving history?
A. Neuropsychiatric testing
B. Polysomnography
C. 3-day blood glucose monitoring
D. Electroencephalography
E. Arrhythmia monitor
Primary Care Medicine:Question 100
You are asked to evaluate a 67-year-old man who is hospitalized for an
esophagectomy for early stage adenocarcinoma of the esophagus. The diagnosis was
made on routine biopsy of a patch of Barretts esophagus that had been followed for
6 years with serial endoscopic examination.
He does not have dysphagia. His medical history is notable for type 2 diabetes
mellitus that has been poorly controlled over the past several months.
His most recent hemoglobin A1c was 9.2% and fasting morning blood glucose levels
have often been in excess of 250 mg/dL. His diabetic medications are glyburide, 10
mg/d; and metformin, 500 mg twice daily.
He has continued on his outpatient medications since admission, but has just been
changed to an American Diabetes Association 2000 kcal/d diet.
What is the most appropriate management for this patients diabetes mellitus during
his hospital stay?
A. Increase glyburide to 10 mg twice daily and metformin to 850 mg with each meal
B. Discontinue oral medications and initiate long-acting basal glargine insulin at night
and short-acting prandial lispro insulin with each meal
C. Discontinue oral medications and initiate an insulin drip with a target blood
glucose level of 120 to 180 mg/dL
D. Discontinue his oral medications and initiate a multiple-dose regimen of
intermediate-acting NPH insulin in the morning and night combined with prandial
injections of short-acting lispro insulin with a target blood glucose level of 120 to 180
mg/dL
E. Discontinue metformin during hospitalization and add sliding-scale regular insulin
to cover excursions from target blood glucose measurements in excess of 150 mg/dL
Primary Care Medicine:Question 101
A healthy 35-year-old woman calls the office to report that her daughter was sent
home from school with head lice. The school nurse has recommended that the girl be
treated with permethrin. There is no prior history of head lice in the household. The
mother has no itching of the scalp but reports that she and her daughter have
shared combs. There are no other children at home. The mother asks for advice. You
tell the mother to launder the clothes and bedding.
What other advice should be given?
A. Disinfect the house
B. Treat herself with permethrin
C. Ask another adult to thoroughly comb her hair with a nit comb
D. Treat herself with synergized pyrethrin
E. Use lindane shampoo
Primary Care Medicine:Question 102
A 34-year-old woman presents for routine gynecologic screening. She also asks you
to examine her skin as she occasionally uses tanning salons and is concerned about
cancer, with a lesion on her back that is slowly enlarging. She burns easily and
recalls several severe burns in childhood while fishing that caused blistering. She
notes that she has more moles than most people. Family history is negative for
melanoma, but her mother also has many moles. To the patients knowledge, her
mother has never had a mole biopsied. On examination, the patient is fair-skinned
and has blue eyes. Scattered on the trunk and extremities are numerous small welldemarcated and uniformly pigmented moles, each <5 mm. There is one 8-mm
darkly pigmented lesion on the upper back that has an irregular indistinct border and
nonuniform dark brown-black hues.
What is the most important next step in the evaluation of this patient?
A. Re-evaluate in 3 months
B. Punch biopsy of the lesion
C. Refer for total body photography
D. Excisional biopsy of the lesion
E. Topical 5-fluorouracil
What is the most appropriate next step in the management of this patient?
A. Stop the warfarin and recheck the INR in 2 days.
B. Administer vitamin K, 2 to 2.5 mg orally, and recheck the INR the following day.
C. Admit the patient for observation and administration of fresh frozen plasma
D. Administer vitamin K, 5 mg orally, and recheck the INR the following day.
E. Administer vitamin K, 5 mg intravenously, and recheck the INR the following day.
Primary Care Med icine:Question 120
A 72-year-old man presents because he has seen blood in his urine. He has
paroxysmal atrial fibrillation and mild hypertension; his medications include warfarin
and hydrochlorothiazide. He smokes about 5 cigarettes a week. His pulse rate is
85/min and irregular, blood pressure is 138/86 mm Hg, and he has no
lymphadenopathy or abdominal masses. Examination of the prostate gland shows an
enlarged, nontender gland without nodules. Urinalysis in the office shows 2+ blood
and 10 erythrocytes per high-power field on microscopic examination, without casts
or crystals. Hematocrit is 35%; serum creatinine is 1.1 mg/dL. A second urinalysis 1
week later confirms 18 erythrocytes per high-power field. Cystoscopy, CTintravenous pyelography, and ultrasonography and biopsy of the prostate gland are
normal.
Which of the following is the best treatment for this patient?
A. Discontinue warfarin therapy
B. Begin finasteride therapy
C. Begin doxazosin therapy
D. Begin saw palmetto therapy
E. Begin ciprofloxacin therapy
Primary Care Med icine:Question 121
A 52-year-old woman is evaluated in the clinic for headache and sore throat that
have persisted for 48 hours. She has had a dry cough, worse at night, but no visual
changes, myalgia, or arthralgia. On examination, her temperature is 37 C (98.6 F),
and there is a mildly erythematous pharynx and tender anterior cervical
lymphadenopathy. The sinuses are nontender, the neck is supple, and the chest is
clear to auscultation. The patient cares for her two preschool grandchildren in her
home 5 days per week. The patient has no allergies.
What is best next step in the management of this patient?
A. A 10-day course of penicillin therapy
B. A 5-day course of azithromycin therapy
C. Rapid streptococcal antigen testing
D. Reassurance
E. Throat culture
ANSWERS
Primary Care Medicine:Question 1
The correct answer is A
Educational Objectives
Manage chronic warfarin therapy.
Critique
According to the recently validated CHADS-2 index, this patient has a absolute 4%
annual risk of stroke. This risk can be reduced by approximately 68% by long-term
oral anticoagulation. Warfarin therapy should be initiated at a dose of 5 mg/d. Higher
loading doses have been not been shown to hasten attainment of a therapeutic INR
and frequently produce excessively high values. Aspirin alone would reduce the risk
by approximately 15%. Recent data indicate that rate control plus long-term oral
anticoagulation improved quality of life and outcome in older patients with atrial
fibrillation more than cardioversion and treatment with antiarrhythmic agents (Van
Gelder et al. and Wyse et al). Because warfarin suppresses the levels of
anticoagulant factors protein C and protein S earlier than the procoagulant factors II,
VII, IX, and X, it can rarely produce skin necrosis. This is a serious phenomenon to
which patients with protein C deficiency are more susceptible, but its rarity makes
initial therapy with heparin unnecessary.
Primary Care Medicine:Question 2
The correct answer is D
Educational Objectives
Recognize the optimal initial medical management of obesity.
Critique
This patient is obese, with a BMI of 35, which confers high risk for complications of
obesity, including hypertension, type 2 diabetes mellitus, and cardiovascular disease,
independent of the presence or absence of other risk factors. The presence of other
risk factors, including smoking, existing hypertension, dyslipidemia, or diabetes,
would certainly further increase her risk, but she is already at high risk; it would be
appropriate to initiate treatment of her obesity prior to obtaining additional
laboratory testing.
The optimal initial management of obesity includes changes in both diet and
exercise. Typical physical activity accounts for only 15% of daily caloric expenditure.
Exercise may increase this caloric expenditure somewhat, but is not sufficient to
achieve sustainable weight loss. Current dietary recommendations include a balanced
diet with a negative caloric balance of 500 to 1000 kcal/d. A negative caloric intake
of this scale will result in a 0.5 to 1.0 kg (1 to 2 Ib) per week weight loss over the
initial 6 months of the diet.
Diets rich in fat tend to be high calorie, and saturated fats, in particular, are
implicated in cardiovascular risk. Recommended diets generally include less than
30% of caloric intake from fat. Convenience and snack foods tend to be rich in fats
and refined sugars, and are very calorie-dense. Minimizing these foods is essential
for weight loss. Excessive alcohol consumption is incompatible with weight loss.
Very-low-calorie diets and rapid weight loss are potentially harmful. Diets rich in
protein and fat, and very low in carbohydrates (the Atkins Diet) are effective for
weight loss, largely by limiting caloric intake, but are of uncertain safety in terms of
their effect on lipids.
Exercise is an essential component of sustainable weight loss. Patients who succeed
with weight loss achieve lasting changes in habits of diet and daily exercise. Exercise
has additional salutary effects on cardiovascular risk independent of weight loss.
Pharmacologic therapy with sibutramine or orlistat, although successful in short-term
weight loss, is generally reserved for patients who have not achieved weight loss
goals after trials of diet and exercise alone. These agents are most successful when
coupled with diet and exercise. Weight lost is typically regained following cessation of
pharmacologic therapy.
There is considerable interest in the potential of bariatric surgery to achieve
sustainable weight loss. Concomitant strides are being made in the endocrinology of
weight and appetite control. Leptin appears to be a hormone responsive to stores of
body fat, while the recently discovered hormone ghrelin appears to signal
preprandial hunger and satiation.
Primary Care Med icine:Question 3
The correct answer is D
Educational Objectives
Recognize the medical complications of bulimia.
Critique
This patient presents with an acute upper gastrointestinal bleed. Endoscopy reveals
erosive esophagitis and a Mallory-Weiss tear. Her laboratory findings are not
consistent with her stated history. She has hypochloremia, hypokalemia, and a high
serum bicarbonate concentration, findings that suggest prolonged vomiting not the
1-hour history given. Endoscopy results show significant reflux disease in addition to
the Mallory-Weiss tear. This combination would be most consistent with bulimia.
Bulimic patients can develop severe reflux disease and the repeated vomiting can
cause Mallory-Weiss tears. The electrolyte disturbances that occur with bulimia are
an important clue to suspecting the diagnosis. Hypokalemia and hypochloremia are
relatively common electrolyte abnormalities in bulimic patients.
Bacterial toxin-induced food poisoning would not explain the electrolyte
abnormalities or the erosive esophagitis. NSAID-induced pill esophagitis would not
cause the electrolyte disturbances seen in this patient. Although scleroderma can
lead to severe reflux esophagitis, there are no other features in this case to suggest
scleroderma.
Primary Care Medicine:Question 4
The correct answer is B
Educational Objectives
Recognize esophageal dysphagia and its most common cause, esophageal reflux
disease; recognize esophageal dysmotility and begin the workup.
Critique
Difficulty swallowing that is delayed by several seconds suggests an esophageal
rather than oropharyngeal cause of dysphagia. The most common cause of
esophageal dysphagia is esophageal reflux disease, by way of either dysmotility or
scarring and stricture formation in the lower esophagus.
Localization of symptoms to the substernal notch is common, and does not
accurately represent the site of esophageal obstruction. Esophageal malignancy
could cause the same complex of symptoms seen in this patient but is a much less
common cause of esophageal dysphasia than is reflux disease.
Achalasia usually causes unpredictable, intermittent dysphagia for both solids and
liquids, rather than the predictable symptoms with solids seen in this patient.
Cricopharyngeal spasm causes oropharyngeal obstruction and therefore should cause
immediate difficulty swallowing, rather than the delay of several seconds seen in this
patient. Plummer-Vinson syndrome occurs when esophageal webs are present in the
setting of iron deficiency anemia and is unlikely in this patient with a normal
hematocrit. The patients symptoms of dysphagia for solids, delayed by several
seconds suggest an obstruction in the esophagus. Though esophageal reflux is the
to screening women in their 40s, and the updated US Preventive Services Task Force
report recommends such screening.
Because the patient has never been sexually active, she does not need cervical
cancer screening. Some women choose to have such screening nonetheless; if she
desired cervical cancer screening, the appropriate interval given her negligible risk
(assuming her sexual history is true) would be every 3 years or more.
Colon cancer screening should begin at age 50 years unless there is a strong family
history of colon cancer developing in the 50s or earlier; this patients father
developed colon cancer at age 75 years, and so she does not need to be screened at
this time.
In addition, the patient is not at significantly elevated risk of ovarian cancer. Her
mother did not have ovarian cancer, but a maternal aunt did, in her 60s. Screening
for ovarian cancer with ovarian ultrasonography and measurement of serum CA-125
has not been shown to be beneficial.
Primary Care Med icine:Question 8
The correct answer is B
Educational Objectives
Recognize medication-induced constipation.
Critique
The patients history and findings are typical for mild to moderate constipation. Initial
measures should include an exercise program and increased fiber and fluid intake.
Bulk laxatives with adequate fluids are safe. Osmotic laxatives are safe for patients
who do not respond to these initial interventions; stimulant laxatives are generally
not used for first-line therapy or for long term. Many medications can cause or
exacerbate constipation. Among these, diuretics are notorious. Hydrochlorothiazide
may have precipitated constipation in this case, and her constipation is not
controlled. Therefore a switch to a nondiuretic antihypertensive medication is
indicated. Usually, colonoscopy and colonic transit studies are reserved for patients
who do not respond to initial measures, including treatment of diseases and
adjustment of medications that are associated with constipation.
Primary Care Medicine:Question 9
The correct answer is D
Educational Objectives
Treat erectile dysfunction in an older man with multiple medical problems.
Critique
This patient likely has an organic (vascular and/or neurogenic) cause of his erectile
dysfunction, and prostaglandin therapy (alprostadil is a synthetic form of
prostaglandin El), delivered either intra-urethrally or via intracavernous injection,
has been shown to be effective in men with erectile dysfunction from various organic
causes. lntra-urethral therapy is a reasonable choice for this patient, and the first
application should be undertaken in the physicians office because of the potential for
complications that include urethral bleeding, vasovagal response, hypotension, and
priapism.
Although diminished libido raises the possibility of hypogonadism, this patients
normal testes and normal testosterone level weigh against this diagnosis and against
a trial of testosterone replacement therapy. Sildenafil, usually a first-line agent to
treat organic erectile dysfunction, is absolutely contraindicated in men taking nitrate
therapy due to potentiation of blood pressure-lowering effects of nitroglycerin, and
therefore is not an option for this patient taking isosorbide. Although the patients
history raises the possibility of depression, he lacks vegetative symptoms or
anhedonia and he clearly has vascular disease and may also have a neurogenic
below 2.0 and 4.0 are relatively weak indicators. A likelihood ratio of 2.0, for
example, means that the probability of the condition is approximately 15% higher
than among patients without the finding. In this case, the initial suspicion of severe
aortic stenosis would be low in the absence of any other physical findings or clinical
symptoms. A 15% increase in probability makes severe aortic stenosis a possibility,
albeit relatively unlikely. An echocardiogram would be warranted to exclude severe
aortic stenosis as well as lesser degrees of stenosis.
Primary Care Med icine:Question 12
The correct answer is D
Educational Objectives
Interpret genetic susceptibility testing in an asymptomatic patient.
Critique
Testing for genetic susceptibility offers substantial promise for presymptomatic
identification of persons at high risk for cancer, potentially allowing intensified
surveillance or prophylactic interventions. Internists are often confronted with
questions of the appropriate use and interpretation of genetic susceptibility tests in
asymptomatic patients.
This patient has a high risk for breast cancer by virtue of history alone. The Gail
model is a research-based clinical prediction rule that allows estimation of individual
probabilities of breast cancer based on nongenetic risk factors obtained from
personal and family history. These factors include age, age at menarche, parity, age
at first live birth, race, and presence of a first-degree relative (mother or sister) with
known invasive breast cancer. Based on her history, this patient has a 0.8% 5-year
risk for invasive breast cancer, compared with 0.4% 5-year risk in a woman of the
same age and race but without other risk factors. Her lifetime risk for invasive breast
cancer (up to age 90 years) is 19%; for women of the same age and race without
risk factors it would be 12.5%.
Given her family history alone, her chance of testing positive forBRCA1 or BRCA2
mutations is higher than average, 15% to 30%, though some studies suggest the
risk may be lower in nonreferral populations. The presence of either mutation in
conjunction with a family history of BRCA1/BRCA2
-positive breast cancer confers a substantially higher cumulative lifetime risk of
breast cancer - 19% by age 40, 50% by age 50, and 85% by age 70. These
estimates are most reliable when the BRCA mutation status of the relative with
breast cancer is known. For this reason, most experts recommend testing the
affected individual before testing at-risk unaffected family members.
In the presence of BRCA1 or BRCA2 positive tests, the risk for breast cancer is so
much higher than baseline that screening mammography beginning at age 25 to 35
years, and yearly intervals has been recommended. However, there is no evidence of
a mortality benefit to this approach.
Primary Care Medicine:Question 13
The correct answer is C
Educational Objectives
Recognize categories of diabetic retinopathy and need for urgent referral in patients
with proliferative retinopathy.
Critique
This patient has findings of proliferative retinopathy with new vessels on the disk.
Urgent referral to ophthalmology for laser therapy is required to protect vision. Laser
photocoagulation of proliferative retinopathy has been shown to prevent blindness;
in one large trial, there was a 50% reduction in severe vision loss after 5 years.
Proliferative retinopathy refers to new vessel formation near the disk or elsewhere on
the retina; these fragile vessels become surrounded by fibrous tissue and adhere to
the posterior vitreous, and may cause vitreous hemorrhage or retinal detachment.
The patient also had hemorrhages and exudates, which are part of background, or
nonproliferative, diabetic retinopathy. However, routine referral to ophthalmology is
not a correct choice given the findings of proliferative retinopathy as noted above.
Guidelines for routine screening from the American Diabetes Association are as
follows: Ophthalmology referral for screening retinal examination is recommended
annually for patients with type 1 diabetes of more than 5 years duration, but not
before puberty. Recommendations for type 2 diabetes include annual ophthalmology
examination from the time of diagnosis. However, if the patient with type 2 diabetes
does not have proteinuria or severe hyperglycemia and has no evidence of
retinopathy by stereoscopic photographs, then the next screening examination may
be done in 4 years, with annual examinations thereafter even if no retinopathy is
identified.
Patients with macular edema also have been shown to benefit from laser therapy of
the macula to prevent vision loss, but the retinal examination described did not
include perimacular exudates as seen in macular edema. Rapid aggressive control of
glycemia in this patient could worsen the retinopathy.
Primary Care Med icine:Question 14
The correct answer is D
Educational Objectives
Manage abnormal PSA results.
Critique
Although not all experts recommend routinely checking serum PSA in men, the cutoff for abnormal values is 4.0 ng/mL. For those with an abnormal PSA, further
evaluation by a urologist is appropriate. Although his value of 5.0 ng/mL is just the
abnormal range, if the goal of screening is to find early prostate cancer then values
between 4 and 10 ng/mL deserve further testing.
When the PSA is greater then 10 ng/mL, the likelihood of locally or distally advanced
prostate cancer (stage C or D) is much greater when compared to patients with a
PSA from 4 to 10. The ability of the PSA test to discriminate between prostate cancer
and benign causes of elevated PSA values is only fair, but the specificity of the test is
better for men in their 50s when compared to men in their 70s. Tamsulosin is
prescribed for men with benign prostatic hyperplasia, but this patient has no
symptoms to suggest this disorder.
Population-based studies have suggested that a PSA increase of greater than 0.75
ng/mL per year is associated with prostate cancer. With a PSA level greater than 4
ng/mL, referral to a urologist would be preferred over further serial testing. Testing
for free PSA would provide further risk information. However, even if this patients
free PSA is greater than 25%, studies suggest his risk of prostate cancer is still 8%.
Most physicians would recommend urology evaluation. In areas of uncertainty such
as this, patient preference plays a large role in decision-making.
Primary Care Medicine:Question 15
The correct answer is B
Educational Objectives
Treat venous stasis ulcers.
Critique
Although the type of bandage does not seem to affect healing efficacy, patients
report significantly less pain when occlusive dressings (containing hydrogels or
hydrocolloid) are used compared with zinc paste-impregnated (Unna boot) or
nonadherent dressings, although this has not been studied as a primary end point.
Topical antibiotics are ineffective in this setting and complications include antibiotic
resistance and contact dermatitis. If pain is worsening as a sign of local infection,
system antibiotics are warranted. The comparative effect of Vaseline gauze has not
been studied. Of note, eutetic mixture of a local anesthetic (EMLA), a topical
anesthetic used during debridement does decrease ulcer pain but may impair ulcer
healing, and may also cause excess local skin reactions.
Primary Care Medicine:Question 16
The correct answer is B
Educational Objectives
Recognize the indications for and side effects of isotretinoin therapy for acne.
Critique
Scarring acne with cysts in a patient taking oral contraceptives is an indication for
isotretinoin therapy. Isotretinoin is highly teratogenic, and therefore, her intentions
about pregnancy and her willingness to use two forms of contraception and have
monthly pregnancy tests during treatment are key to whether she can take this
drug. Pancreatitis is a risk during therapy, and plasma triglyceride levels must be
monitored. Although alcohol is not contraindicated during therapy, it should be used
with caution. Finally, patients should be cautioned to avoid sun-exposure during
therapy because isotretinoin is sun-sensitizing.
Primary Care Medicine:Question 17
The correct answer is B
Educational Objectives
Recognize when it is appropriate to work-up an anal fissure.
Critique
This patient should undergo colonoscopy. The fissure is not in the posterior midline,
the usual location for an anal fissure. Fissures that do not occur in the posterior
midline are more likely to be due to a secondary cause. In this patient with weight
loss in addition to anal pain and bleeding, the possibility of Crohns disease should be
considered. Anal fissures in patients with Crohns disease also frequently occur in the
posterior midline (66%), but multiple fissures or fissures away from the posterior
midline (32%) are not uncommon. Early detection of underlying Crohns disease is
important because unhealed fissures in Crohns disease frequently progress to more
complicated and serious problems including anal abscess or fistula.
Primary Care Medicine:Question 18
The correct answer is A
Educational Objectives
Recognize appropriate pharmacologic management of alcohol dependence.
Critique
This patient presents with a history of alcohol dependence. Brief interventions work
for patients with at-risk alcohol use, but more aggressive therapy, potentially
including pharamcotherapy, is indicated in both alcohol abuse and dependence.
Benzodiazepines such as diazepam would be used in the acute detoxification setting.
Antidepressants and anxiolytics may play a role if an underlying psychiatric disorder
is present. Disulfiram has been used for years by leading to an accumulation of
aldehyde if alcohol is consumed. However, studies have been inconclusive on its
efficacy in enhancing abstinence. Naltrexone, an opioid receptor antagonist, has
been shown to be effective in short-term treatment as well as decreasing the
frequency of relapse.
The clues to diagnosis of iritis in this patient include eye pain rather than irritation,
lack of discharge, decrease in visual acuity, and ciliary flush described by
circumcorneal erythema on examination. About half of patients with iritis have an
underlying inflammatory arthritis or chronic infection. The patient has features
suggestive of Reiters syndrome. Acute iritis also occurs in association with HLA-B27
without systemic disease. Urgent ophthalmology referral is required for diagnostic
examination and management of iritis, usually treated with a topical corticosteroid
such as prednisone forte. Corticosteroids should not be given empirically in the
primary care setting without establishing a definitive diagnosis. Complications of iritis
include cataract, vision loss, chronic uveitis, and synechiae (adhesions between the
iris and lens capsule).
Keratitis may be associated with mild visual impairment and eye pain, except for
herpes keratitis in which there is hypoesthesia of the cornea. Characteristic skin
lesions of herpes simplex or herpes zoster are usually present with herpetic keratitis.
Keratitis in the setting of extended wear contact lenses is usually due to
Pseudomonas infection and presents with a copious purulent discharge. Copious
purulent discharge is an indication for emergent ophthalmology referral.
Primary Care Medicine:Question 26
The correct answer is D
Educational Objectives
Select the appropriate malaria chemoprophylaxis regimen for a traveler.
Critique
Mefloquine is contraindicated in patients with cardiac conduction disease, and
therefore, should not be prescribed for this traveler. The US Centers for Disease
Control and Prevention (CDC) recommends chloroquine for areas with chloroquinesensitive malaria, such as Mexico. Chloroquine prophylaxis should be started 1 week
before departure, taken 500 mg weekly while traveling, and continued for 4 weeks
after return. Chloroquine has a low rate of adverse effects and is inexpensive.
Doxycycline would provide protection but requires daily administration, causes sun
sensitivity, and nausea. Atovaquone/proguanil (MalaroneTM) is recommended for
travel to areas with chloroquine-resistant malaria. It is relatively expensive.
Primaquine is recommended after prolonged exposure to decrease the risk of
Plasmodium ovale and P. vivax
Primary Care Medicine:Question 27
The correct answer is D
Educational Objectives
Recognize that for uninfected grade 1 and 2 foot ulcers in patients with diabetes total
contact casting improves healing.
Critique
The main components of treating diabetic foot ulcers are to alleviate weight-bearing,
debride exudate and infected tissue, and treat associated infection. In this patient,
there are no signs of infection so relief of pressure on the foot is the mainstay of
therapy. For patients who find complete bed-rest difficult, a total contact cast keeps
pressure off the ulcer and thereby significantly increases the proportion of ulcers that
heal and shortens healing time. Total contact casts are contraindicated if there are
any signs of infection in the ulcer, or if osteomyelitis is present; therefore, the
presence of warmth, erythema, or exudate or exposed or infected bone precludes
their use. Neither topical antibiotics nor occlusive dressings improve healing of
diabetic foot ulcers. Intravenous antibiotics are not indicated in grade 1 and 2 ulcers
without signs of infection; such ulcers if infected may not require hospitalization
because they are likely to respond to outpatient antibiotic therapy, nonadhesive
to her recurrent falls. Orthostatic hypotension may have contributed to her most
recent fall. However, on examination she did not have significant changes in blood
pressure or heart rate upon standing, and her two other falls were not related to
orthostatic positional changes. Thus the evidence to suggest that discontinuing her
hydrochlorothiazide would reduce her risk of recurrent falls is less compelling than
that for stopping the lorazepam. Referral for physical therapy is an important
consideration for all patients with recurrent falls but this patient did not have
unstable gait and she completed a timed Get Up and Go test in less than 20 seconds,
again making this choice less compelling than stopping her lorazepam. Use of
antidepressants has been associated with increased fall risk but much of this
association may be due to confounding by indication, and there is no existing
evidence to suggest that switching sertraline to buspirone would decrease her fall
risk.
Primary Care Medicine:Question 34
The correct answer is D
Educational Objectives
Review methods of contraception which lessen menstrual flow.
Critique
This perimenopausal woman who smokes desires reduction in menstrual flow and
more effective contraception, without chance of weight gain. Combination hormonal
contraceptives would most likely be effective, but are contraindicated in her because
heavy smoking significantly increases the risk of myocardial infarction, especially in
women taking oral contraceptive pills. (The new transdermal formulation should be
assumed to have this same potential, in the absence of data showing otherwise.)
Though quitting smoking is clearly advisable, she sounds unlikely to make that
change at this time. Depot medroxyprogesterone acetate would also likely be
effective but commonly causes weight gain, the possibility of which would be
unacceptable to her. The levonorgestrel intrauterine device would be the best of
these options in this womans situation. It reduces menstrual blood loss in idiopathic
menorrhagia, provides effective contraception, has no or few systemic side effects,
and can be left in for 5 years. Endometrial ablation would be another option but has
a lower success rate at reducing menstrual blood loss than does levonorgestrel
intrauterine device, and ablation may not prevent pregnancy.
Primary Care Medicine:Question 35
The correct answer is E
Educational Objectives
Recognize fibromyalgia and understand its prognosis.
Critique
This case focuses on a patient with classic symptoms of fibromyalgia (widespread
musculoskeletal pain for more than 6 months and excess tenderness in at least 11 or
18 predefined anatomic sites). In addition to her symptoms, which have been
present for 18 months, she has also undergone several specialty work-ups, all with
negative results. The literature suggests that this in not an uncommon pattern for
patients with fibromyalgia and that further work-ups have a low likelihood of
producing positive findings. The diagnostic criteria mentioned above have been
validated in randomized controlled trials and are a basis on which to base a positive
diagnosis. There is currently no known cause for fibromyalgia, nor is there any cure.
Patients with the symptom pattern presented by this patient do not often improve by
themselves but rather continue to worsen over time. Fibromyalgia is not simply a
psychological syndrome but a biopsychosocial one and supportive care aimed at
symptom relief and coping strategies is important. Behavioral therapy and/or
patch is not beneficial. In fact, patients who wore an eye patch had more eye
discomfort and slower wound healing. Topical anesthetic is not indicated as it delays
healing, masks further damage, and can cause corneal ulceration. Topical antibiotics
are often prescribed in corneal abrasion, depending on the type of trauma and extent
of injury, but oral antibiotics are not routinely indicated. Frequency of follow-up
depends on the severity of the corneal abrasion. Severe abrasions with large area of
epithelial damage should be examined daily, and a mild abrasion may not require
repeat examination if symptoms resolve and there is no residual visual impairment.
Topical corticosteroids are not indicated.
Primary Care Medicine:Question 39
The correct answer is B
Educational Objectives
Recognize the significance of anosmia in a man with delayed pubertal development.
Critique
Primary care physicians should be able to differentiate common causes of anosmia
from more serious neuroendocrine conditions. This young man most likely has
Kallmans syndrome, a disorder characterized by hypothalamic hypogonadism and
anosmia. The anosmia is due to olfactory bulb agenesis or hypoplasia. The syndrome
may also be associated with color blindness, optic atrophy, nerve deafness, cleft
palate, renal abnormalities, cryptorchidism, and neurologic abnormalities such as
mirror movements. Defects in the KAL gene, which maps to chromosome Xp22.3,
prevent embryonic migration of gonadotropin releasing hormone (GnRH) neurons to
the hypothalamus. GnRH deficiency prevents progression through puberty. Males
present with delayed puberty and pronounced hypogonadal features, including a
small penis. Female patients present with primary amenorrhea and delayed pubertal
development.
Laurence-Moon-Bardet-Biedl syndrome is a rare autosomal recessive disorder is
characterized by mental retardation, obesity, and hexadactyly, brachydactyly, or
syndactyly. Central diabetes insipidus may or may not be associated. GnRH
deficiency is common. This patient does not have these features.
Ozena is a chronic nasal condition, associated with colonization or infection
withKlebsiella ozenae. It is characterized by nasal mucosal atrophy and foul-smelling
crusts in the nasal passages, typically seen on close nasal examination. Some
patients with Parkinsons disease will develop anosmia; this patient has no
parkinsonian features.
Primary Care Medicine:Question 40
The correct answer is D
Educational Objectives
Evaluate a patient with pruritus for a potential systemic disorder.
Critique
Although most patients with generalized pruritus have xerosis, this patient did not
improve with empiric therapy and scabies is unlikely without a characteristic rash. A
minority of patients with generalized pruritus have an underlying disorder, which is
more likely in this patient with no skin lesions other than excoriations. Laboratory
testing for hematologic causes, renal failure, cholestasis, endocrine disorders, and
chronic infection is indicated. Skin biopsy of an excoriation is unlikely to provide
useful information. Treatment with topical corticosteroids without a working
diagnosis is not appropriate. Symptomatic treatment with hydroxyzine hydrochloride
may help but does not identify the cause. Although referral to a dermatologist would
be helpful, the patient should first be evaluated for systemic causes of the pruritus.
headaches is longest with previous analgesic use (9.5 days) compared to pure
triptan withdrawal (4 days). The severity of withdrawal headaches appears to be
worse with narcotics and barbiturates than with triptans. Once the withdrawal is
complete, if headaches persist, prophylactic therapy can be started. Starting
prophylactic therapy before removing the current analgesics decreases the
effectiveness of prophylaxis. Amitriptyline has been the best studied for chronic daily
headache with the most consistent success. If she develops true migraine headaches
after dry withdrawal, triptans could be reinstated, but in a limited amount (no more
than twice a week).
Primary Care Medicine:Question 60
The correct answer is B
Educational Objectives
Recognize and treat serious otitis externa.
Critique
This patient has a moderately severe case of otitis externa. Because the ear canal is
still open and the tympanic membrane is visible, placement of a wick is not
necessary. He does not appear to have malignant otitis in which the surrounding
cartilage and bone are involved, although he is certainly at risk because of the
diabetes mellitus. Most such cases can be managed with oral antibiotics.
Staphylococcus and Streptococcus sp. must be covered, and, especially in the
diabetic patient, Pseudomonas is important. Topical therapy would be inadequate
because of the degree of inflammation, the low-grade fever, and the patients risk for
progression.
Primary Care Medicine:Question 61
The correct answer is A
Educational Objectives
Recognize causes of recurrent aphthous ulcers.
Critique
This is a classic history for recurrent aphthous ulcers. The diagnosis of aphthous
ulcers is clinical, and does not need to be confirmed by any testing. However,
aphthous ulcers can be associated with several systemic illnesses. This patient has
several worrisome signs that her ulcers could be related to a systemic illness: the
ulcers are becoming more frequent, she has lost 4.4 kg (10 Ib), and she has
abdominal pain and diarrhea recently diagnosed as irritable bowel disease. The
patient may therefore actually have inflammatory bowel disease, which is a cause of
recurrent oral ulcers. The patient should have a colonoscopy with biopsies. While HIV
and the spondyloarthropathies can both be associated with aphthous ulcers, this
patient does not have risk factors for HIV or any symptoms of arthritis.
Oral ulcers such as these are not related to herpes simplex virus infection, and
acyclovir has not been shown to be of benefit. Because this patients current lesions
are only about a week old, they do not require biopsy. If the patients illness had
features of pemphigoid or pemphigus vulgaris such as blisters preceding the ulcers,
biopsy would be of benefit to rule out those rare diseases. If the ulcers persisted for
longer than a month in any one place, then a biopsy would be warranted to rule out
malignant causes.
Hypnic headache describes headache coming on during sleep; some cases may
represent a sleep-related headache disorder, whereas other cases probably
represent one of the above diagnoses. Other conditions such as bruxism,
temporomandibular joint dysfunction, and various musculoskeletal conditions of the
cervical spine may cause headaches that are present on awakening but also occur at
other times. Nausea, vomiting, or neurologic symptoms suggest migraine or a
process causing increased intercranial pressure. Papilledema is the most important
sign to look for on physical examination. If papilledema is present, the brain should
be imaged for a possible mass lesion. Several other findings suggest that imaging of
the brain may be needed: vomiting, neurologic abnormalities, history of malignancy,
or progression in severity or frequency of headaches. Additional history from this
patients bed partner or cohabitants regarding loud snoring or gasping/choking during
sleep would be the next step to obtain information regarding possible sleep apnea. In
men shirt size greater than 17.5 inches is suggestive of sleep apnea. Herbal
medications, alcohol, and depression are not specifically associated with early
morning headaches. Past head trauma can contribute to insomnia, and a chronic
subdural hematoma might cause nocturnal headaches, but this is less likely given his
history suggestive of a sleep disorder.
Primary Care Medicine:Question 65
The correct answer is B
Educational Objectives
Recognize that laboratory testing is unnecessary in healthy patients without a history
suspicious for bleeding disorders before low-risk surgeries.
Critique
Hernia repair is generally considered to be low risk for bleeding complications:
nonvital organs are involved, the surgical site is exposed, there is limited surgical
dissection, and local hemostasis is likely to be effective. Furthermore, the patient
describes no personal or family history of bleeding or clotting disorders. No further
laboratory testing is required prior to low risk procedures (dental extraction, lymph
node biopsy, or herniorrhaphy) in patients without a history or physical examination
suggestive of bleeding disorders. Extensive preoperative testing in this setting is
expensive, rarely identifies an abnormality, and potentially delays indicated medical
care. Among patients with a history and physical examination that do not suggest a
bleeding disorder, laboratory abnormalities do not predict adverse surgical outcomes.
In one prospective study, prothrombin time, activated partial thromboplastin time,
and platelet counts were obtained in more than 3000 consecutive patients
undergoing general surgery, only 1 of 340 patients (0.3%) with a normal history but
abnormal tests required treatment of the abnormality. By contrast, 26 of 172 (15%)
of patients with an abnormal history and laboratory abnormality required treatment
of the abnormality.
In patients with a personal or family history of bleeding disorders (for example,
prolonged bleeding following dental extractions, hemarthrosis, easy bruising, or
petechiae) or prior to moderate- or high-risk procedures (for example, laparotomy,
thoracotomy, mastectomy, liver or kidney biopsy, neurosurgery, ophthalmic
surgery), it would be appropriate to obtain prothrombin time, activated partial
thromboplastin time, and a platelet count as an initial screen for bleeding disorders.
These screening tests identify patients with coagulation or platelet abnormalities and
would prompt additional testing as indicated to identify an underlying disorder.
Bleeding time is a reasonable measure of the interaction between platelets and
injured endothelium, and has been used historically as a surrogate of bleeding risk,
but does not accurately predict bleeding risk.
hypercortisolism disease (moon facies, buffalo hump, and purple abdominal striae)
and normal plasma glucose testing all suggest Cushings syndrome is not likely.
Normal renal function, absence of a renal artery bruit, and limited benefit from an
ACE inhibitor are all evidence against significant renal artery stenosis. Chronic lead
intoxication causes hypertension in the setting of chronic renal insufficiency, not
present in this case.
Primary Care Medicine:Question 76
The correct answer is C
Educational Objectives
Manage long-term anticoagulation in the perioperative setting.
Critique
Tilting disc or bileaflet mechanical prosthetic valves are associated with an estimated
8% annual risk of thromboembolic complications in the absence of anticoagulation.
Current guidelines recommend long-term anticoagulation to a target INR of 2.5 for
modern mechanical prosthetic valves at the aortic position in patients in sinus
rhythm with normal left atrial size and left ventricular function. Anticoagulation
reduces the annual thromboembolic risk to approximately 2%.
General surgeries may be safely performed if the INR is 1 .5 or less. Withholding
warfarin for four doses before scheduled surgery and then resuming warfarin therapy
on the first postoperative night may safely achieve this INR. This strategy results in a
subtherapeutic INR for approximately 2 days before and 2 days after surgery,
exposing patients to minimal thromboembolic risk. The patient in this example is
likely to be at an INR of 1 .5 the following day, without any specific intervention.
Vitamin K administration would be expected to normalize the patients INR, but
would unnecessarily prolong the time required to reinstitute long-term
anticoagulation with warfarin. Fresh frozen plasma would similarly normalize the
INR, but is expensive and not likely to significantly reduce bleeding complications
related to the planned surgery. The use of unfractionated or low-molecular-weight
heparins prior to surgery would be safe but unnecessary in a patient without specific
indication for acute anticoagulation (acute venous or arterial thromboembolism
within the past month, atrial fibrillation with prior embolic complication, or prior
recurrent venous thromboembolism).
Primary Care Medicine:Question 77
The correct answer is D
Educational Objectives
Diagnose and treat common causes of hip pain.
Critique
Pain with walking but not at rest suggests osteoarthritis of the hip, but the
snapping sensation is characteristic of iliotibial band syndrome, which is often
precipitated by initiation of exercise or an increase in intensity. This diagnosis is
further suggested by pain with adduction, which is performed by extending the
affected leg over the edge of the examination table while the patients lies on her
side. Meralgia paresthetica is caused by pressure on the lateral femoral cutaneous
nerve as it perforates the fascia of the lateral thigh and is most common in
overweight persons. It may cause pain but dysesthesia is typically more prominent
and these symptoms are unrelated to activity. The pain of trochanteric bursitis may
occur with walking but is usually most severe when lying on the affected hip. On
examination, tenderness is localized over the greater trochanter. lschial bursitis
causes pain over the ischial tuberosity when seated.
Initial therapy for iliotibial band syndrome is heat, stretching, and NSAIDs. If
symptoms persist, evaluation by a physical therapist is indicated. Although
osteoarthritis remains a possibility, radiographs can be deferred for a few weeks until
the results from conservative therapy have been evaluated. If radiographs
demonstrate degenerative changes of the hip and the pain becomes severe enough
to interfere with regular activities, the patient may wish to consider hip replacement,
at which point referral to an orthopedic surgeon would be in order. Injection of the
trochanteric bursa or a nerve conduction velocity study are not indicated
Primary Care Medicine:Question 78
The correct answer is E
Educational Objectives
Emphasize importance of screening for glaucoma and recognize major risk factors.
Critique
Primary open-angle glaucoma occurs in 2% of American adults, has an insidious
onset, and is initially asymptomatic. Therefore, screening for risk factors in primary
care is important in identifying those at high risk. Prevalence of glaucoma increases
steadily with age over 50 years. This patient has other risk factors, the most
important being black American ethnicity. The prevalence of glaucoma is 3% in black
Americans younger than 60 years, compared to 12% of those older than 70 years.
Hispanics also appear more likely to have glaucoma than white Americans. Family
history of glaucoma increases the risk somewhat if there is an affected parent, more
so if an affected sibling, but still less than black American ethnicity. Systemic
hypertension is not considered a significant risk factor. There is a weak association of
glaucoma with other medical conditions, such as sleep apnea.
Primary Care Medicine:Question 79
The correct answer is D
Educational Objectives
Recognize that major depression is a common cause of unexplained weight loss.
Critique
The patient has unexplained weight loss with symptoms typical for major depression:
fatigue, difficulty concentrating, sleep disturbance. Mirtazapine is a newer
antidepressant that is sedating. Weight gain is common with this medication.
In patients with unexplained weight loss, endoscopy of the upper and lower
gastrointestinal tracts and imaging beyond a chest radiograph are unlikely to disclose
a cause for the weight loss in the absence of more specific symptoms or laboratory
abnormalities. The patients serum thyroid-stimulating hormone concentration is
borderline low but not in a range to suggest a relapse of her Graves disease.
Primary Care Medicine:Question 80
The correct answer is C
Educational Objectives
Diagnose de Quervains tenosynovitis.
Critique
The patient has typical findings of De Quervains tenosynovitis, that is, pain localized
to the lateral wrist
over the distal radius and a positive Finkelsteins test. Corticosteroid injection into
the tendon sheath provides the most immediate relief. In the absence of trauma and
with an examination suggesting De Quervains tenosynovitis, plain radiographs are
not necessary. Osteoarthritis of the first carpometacarpal joint causes pain over the
lateral wrist but just distal to the wrist crease, nearer the base of the thumb, when
compared with De Quervains tenosynovitis. A nerve conduction study is used to
confirm carpel tunnel syndrome. Although the Tinels sign was equivocal, the clinical
scenario does not suggest carpel tunnel syndrome. Therapy with nonsteroidal anti-
paresthesias in the 4th and 5th digits and may have associated medial elbow pain. In
severe cases, hand clumsiness and reduced grip strength occur due to interosseous
muscle weakness.
Carpal tunnel syndrome affects the median nerve, causing numbness and/or
paresthesia in the thumb, index, and middle fingers and lateral half of the ring
finger. Patients with medial epicondylitis experience well-localized medial elbow pain
without radiation into the hand; elbow pain is exacerbated by lifting or use of the
forearm or wrist. Saturday night palsy occurs with compression of the radial nerve in
the spiral groove of the humerus. Ensuing symptoms include sensory loss over the
dorsum of the hand and weakness in the brachioradialis, wrist extensors, and finger
extensors. A C-7 radiculopathy, the most common form of cervical radiculopathy,
should cause sensory changes in digits 2 to 4, and motor weakness in the triceps,
forearm pronation, and wrist flexion and extension. Additionally, one might expect
symptoms to be exacerbated by neck movement.
Primary Care Medicine:Question 106
The correct answer is E
Educational Objectives
Manage sciatica without red flags.
Critique
This patient has no red flags except possible urinary problems, but has normal
sensory and rectal examinations, making cauda equina syndrome unlikely. This
patient has sciatica (-2% of all patients with back pain) involving the S1 nerve root
as demonstrated by his weak ankle jerk and dorsiflexion. The most cost-effective
method of caring for a patient in this situation is educational materials and
appropriate pain medication with bedrest and activity as tolerated for the next few
days. Although chiropractic care and/or physical therapy are slightly better than
traditional care and are preferred by patients for low-back pain, this patient has
sciatica for which neither mode of treatment has been shown to be effective. Indeed,
vigorous exercise programs or prolonged bed rest impedes recovery. Traction
therapy has not been shown to be effective for sciatica. Of note, the evidence for
corticosteroid injection or chymopapain injection suggests that, while corticosteroid
injections may provide pain relief in some patients, these treatments do not affect
intermediate or long-term outcomes and carry some risk.
Finally, although he may eventually need an MRI (-50% of asymptomatic patients in
this age group have a bulging or degenerated disc on MRI) or even surgery, at this
point he will likely recover with conservative care. In fact, 65% to 70% of patients
with sciatica recover in 12 weeks, and 10-year outcomes are almost identical (84%
recover), for return to work and neurologic findings, with or without surgery. A
recent, cohort study (Atlas et al) reported that at 5 years 19% of surgical patients
had at least one additional procedure and 16% of nonsurgical patients had opted for
surgery. Early relief from pain was reported by 70% of surgical vs 56% of
nonsurgical patients (P < 0.001) and more surgical patients were satisfied with their
condition (64% vs 46%, P < 0.001), but they were just as likely as nonsurgical
patients to be receiving disability.
Therefore, this patient should be managed with NSAIDs and perhaps muscle
relaxants or tricyclic antidepressants (for neuropathic pain) and if he is not improving
or has worsened after 4 weeks, referral should be considered. Restriction to lifting
<20 lbs is appropriate.
the basis of the tooth findings alone. In addition, it would be quite unusual for an 18year-old to have changes in her teeth from reflux in the absence of a clinical history
or symptoms. Fluoride exposure in young teeth would not result in erosions of the
enamel.
Primary Care Medicine:Question 113
The correct answer is A
Educational Objectives
Manage long-term warfarin anticoagulation in a patient with potential warfarin
sensitivity.
Critique
A rise in the INR at 48 hours signals high sensitivity to warfarin, which can be due to
other medications or to an underlying polymorphism in the cytochrome P-450
system. Older patients are also more sensitive. The standard maintenance dose of
warfarin is 4 to 5 mg/d, but this patient would likely require only 2 to 4 mg/d. After
this change in dosage, the INR should again be checked in 2 to 3 days.
Primary Care Medicine:Question 114
The correct answer is A
Educational Objectives
Understand management strategies of melanoma based on depth of lesion.
Critique
The depth of melanoma is an important feature in determining optimal management
and prognosis. The case described had a tumor depth of 0.88 mm by Breslow
oculometer, and is a stage II lesion (0.76-1 .49 mm depth: 87-94% 5-year survival).
Re-excision of the primary site is recommended with a 2-cm margin, as randomized
trials have shown similar local recurrence and overall survival rates with a narrow 2cm re-excision margin compared to a wide margin of 4 to 5 cm that is more
disfiguring and more likely to require skin grafting.
Sentinel lymph node detection is not generally indicated for thin melanomas, defined
as those <1 mm thick, which have a small chance of metastasizing. Sentinel lymph
node detection by blue dye or scanning is now commonly used for intermediate (1 .0
to 4.0 mm) or thick (>4 mm) melanomas. If there is a positive sentinel lymph node,
lymph node dissection is performed. Elective lymph node dissection is not usually
performed without clinical evidence of metastases, as several randomized trials have
not shown a benefit and the procedure has a significant rate of complications.
Primary Care Medicine:Question 115
The correct answer is D
Educational Objectives
Treat mild, intermittent symptoms of carpal tunnel syndrome.
Critique
The mainstay of treatment for intermittent, classic carpal tunnel symptoms, as this
patient has, is wrist splints, with the optional addition of anti-inflammatory
medication. Electromyography is reserved for patients who do not respond to such
conservative therapy, or to confirm the diagnosis in patients with atypical,
persistent, or severe symptoms who may require surgery. Surgical release of the
radial nerve will not help with carpal tunnel as carpal tunnel affects the median
nerve, not the radial nerve. Median nerve release is reserved for patients with
severe, persistent symptoms, or progression during conservative therapy. Although
MRI may reveal space-occupying lesion in patients with carpal tunnel syndrome,
such lesions are very rare and MRI is expensive and currently is not used in the
diagnosis of carpal tunnel syndrome, especially for such a patient with mild and
classic symptoms potentially reversible with a simple trial of conservative therapy.
Vitamin has been shown to have no benefit for patients with carpal tunnel syndrome.
Primary Care Medicine:Question 116
The correct answer is C
Educational Objectives
Recognize the signs of systemic disease associated with carpel tunnel syndrome.
Critique
Between one fifth and two thirds of patients with occupationally related carpal tunnel
syndrome were also found to have concurrent medical conditions, most commonly
diabetes mellitus, thyroid disease, and obesity. Although concurrent medical
conditions may already be known at the time of diagnosis of the carpal tunnel
syndrome, a careful review of symptoms should be performed in patients with carpal
tunnel syndrome. Bilateral carpal tunnel syndrome makes a systemic disease
somewhat more likely. In addition, recurrent, or persistent symptoms despite
therapy, or a review of symptoms suggesting pregnancy, rheumatoid arthritis,
systemic lupus erythematosus, acromegaly, myeloma, amyloidosis, diabetes
mellitus, or thyroid disease are also concerning for an associated systemic disorder.
Neither the presence or absence of Phalens or Tinels signs, nor the results of
electromyography testing have any utility in predicting presence of systemic disease.
Primary Care Medicine:Question 117
The correct answer is D
Educational Objectives
Treat vaginal symptoms in a patient who has had breast cancer.
Critique
A vaginal estrogen ring (Estring) is a ring about the size of a small diaphragm, that
slowly releases estrogen such that local symptoms are improved, but serum estrogen
levels are not changed. However, independent randomized clinical trials have not
been done. Vaginal lubricants might be effective for this patients dyspareunia, but
local estrogen therapy is likely to be more effective. The old standard, vaginal
estrogen cream, results in detectable serum levels, which may be a risk in a patient
with invasive breast cancer. Most patients also find vaginal estrogen cream messy
and inconvenient, and patients overwhelmingly prefer the vaginal ring, which is left
in place for 3 months. Increasing her tamoxifen dosage or beginning raloxifene
would not be effective or appropriate.
Primary Care Medicine:Question 118
The correct answer is D
Educational Objectives
Recognize a sudden varicocele and hydrocele as a possible harbinger of renal cell
carcinoma.
Critique
This man presents with a sudden onset new hydrocele and varicocele on the left.
Virtually all varicoceles are on the left, but appearance of a new varicocele in a man
older than 50 years, that does not reduce when the patient lies down, suggests
obstruction of the venous drainage. Since the left testicular vein drains into the left
renal vein (up to 11% of men with renal cell carcinoma have a significant varicocele
on the left), an abdominal CT should be obtained to evaluate the patient for renal cell
carcinoma. Similarly, since the right testicular vein drains into the inferior vena cava
and right varicoceles are much less common, appearance of a new right,
nondraining, varicocele should arouse suspicion for a right renal cell cancer or other
cause of vena cava obstruction.
Primary Care Medicine:Question 119
The correct answer is B
Educational Objectives
Manage warfarin drug interaction.
Critique
The single drug involved in the greatest number of serious drug interactions is
warfarin. Among the many medications that interfere with warfarin metabolism and
prolong the INR are COX-2 inhibitors, although it this case that effect is more
profound than usually observed. For that reason, it would be helpful to review other
medications that the patient might be taking, in particular Dong Quai, which contains
several natural warfarin derivatives.
The response to an elevated INR depends on its magnitude and the risk of bleeding.
For minor prolongation of the INR up to 5.0, it is usually sufficient to lower the
average dose by 5% to 20%. INR values between 5.0 and 9.0 in the absence of
active bleeding are typically managed by withholding warfarin and restarting at a
lower dose. If the patients risk of bleeding is high or the INR continues to rise after
stopping warfarin, vitamin K, 1.0 to 2.5 mg, should be administered orally. Patients
with INR values over 9.0 to 10.0 should usually receive vitamin K. Those who are
actively bleeding or have severely elevated INRs, should be hospitalized for
administration of higher doses of vitamin K in addition to fresh plasma or
prothrombin complex as required. In this case, the very high INR and history of
gastrointestinal bleeding place the patient at high risk and warrant administration of
vitamin K in a dose that is low enough not to reverse anticoagulation and risk
thrombosis of the mechanical valve.
Primary Care Med icine:Question 120
The correct answer is B
Educational Objectives
Recognize and treat benign prostatic hypertrophy as a cause of hematuria.
Critique
Several prospective trials have shown significant decreases in hematuria and
decreased need for surgery in patients with benign prostatic hypertrophy-hematuria.
A prospective study randomized 42 patients to finasteride, cyproterone acetate, or
watchful waiting and showed a significant reduction in bleeding at 9 and 12 months
in both the groups treated with finasteride and cyproterone acetate compared with
control (no difference between the two), suggesting that at least these two
antiandrogens can control bleeding in benign prostatic hypertrophy. One
retrospective review of patients treated with finasteride concluded that finasteride, 5
mg/d, decreases gross hematuria in 94% of patients with benign prostatic
hypertrophy-related hematuria, including patients taking anticoagulants, so that in
this patient, continuing his warfarin and starting finasteride is a reasonable
approach.