Board Review Questions in Family Medicine Charles E. Driscoll, MD, Dean Gianakos, MD, Stacey A. Hinderliter, MD, William C. Crow, Jr, MD, David S. Gregory, MD, Terry J. Thompson, MD, Jodi V. Ettare, PharmD, Patricia Pletke, MD, Alex Wilgus, MD, and George Wortley, MD, Family Medicine Residency Program, Lynchburg, Va Published Online: June 6, 2007 - 1:21:17 PM (CDT) 1. A 63-year-old man comes in for a follow-up visit 2 weeks after being discharged from the hospital following urgent coronary artery bypass grafting (C ABG) for atypical angina. The CABG was successful, and the recovery course was as e xpected, with only a transient shortness of breath on postoperative day 3. Now he complains of restlessness, especially at night when recumbent, and shortness of breath with even the slightest exertion. He prefers sitting upright in his recliner. He denies chest pain, cough, or fever. Chest examination reveals the trachea is midline, nearly absent breath sounds fro m the left lower lung, with E-to-A change (egophony), and dullness to percussion halfway up the back. The electrocardiogram (ECG) is unchanged from his last EC G 2 weeks ago, abdominal examination is normal, and there is no peripheral ed ema. What is the most probable explanation f or these these clinical findings?
A.
Pulmonary embolus B. Large pleural effusion C. Pneumothorax D. Pneumonia 2. A woman comes to your office with her 12-year-old daughter seeking information regarding the new human papillomavirus (HPV) vaccination. Which one of the following statements is not an American Cancer Society ( ACS) recommendation regarding the administration of this vaccine?
A.
Routine HPV vaccination is recommended for girls aged 11 or older Women should continue to follow the ACS recommendations for cervical cancer screening, whether or not they have received the vaccine C. HPV vaccination is not currently recommended for women older than 2 6 years or for males D. HPV testing before initiating vaccination is recommended by the ACS B.
3. A 3-year-old girl with a history of eczema presents with a "bump" on her inner thigh. The bump appeared 1 week ago and has grown progressively larger; it is now red and painful. On examination, you note dry skin and ev idence of excoriation on her antecubital fossa and knees. A 1-cm necrotic nodule, with cloudy drainage, is seen o n the inner thigh. Around the nodule, the skin is red and tender. What should be yo ur next step in management?
A.
Intensive treatment of eczema with oral steroids Culture of the drainage, followed by treatment with oral cephalexin cephalexin (Keflex) C. Treatment as a possible brown recluse spider bite D. Empiric treatment with trimethoprim/sulfamethoxazole (TMP/SMX; Bactrim, Cotrim, Septra) B.
4. What is the most common cause of death in patients with Kawasaki disease? A.
Renal failure Cardiac sequelae C. Encephalitis and seizures D. Hepatic failure B.
5. A 5-month-old infant is brought to your office with a 2-day 2-day history of cough and nasal congestion. Physical examination shows: temperature, 99?F; pulse, 120 beats/ min; respirations, 35 breaths/min. The heart rate and r hythm are regular, with no murmur. The breath sounds are coarse, with occasional bilateral mild expiratory wheezes he ard. No
nasal flaring or retractions are evident. A clear nasal discharge is noted. Tympanic membranes appear normal. What What is the next best step in manageme nt? A.
Nebulizer treatment using levalbuterol HCl (Xopenex) 0.31 mg/3 m L Obtain a blood culture and administer ceftriaxone intramuscularly C. Assess oral intake and blood oxygenation level D. Obtain respiratory syncytial virus (RSV) swab and chest radiographs B.
6. A 17-year-old adolescent girl comes to y our office for a routine check-up check-up before leaving for college. She has no significant health problems. She will be residing in t he college dormitory. At her last visit 6 years ago, she completed her hepatitis B vaccination series and received her only varicella vaccination and second measles, mumps, and rubella (MMR) vaccine. Which of the following cluster of vaccinations should be offered at this point?
A.
Diphtheria and tetanus toxoids with acellular pertussis (DTaP) vaccine, meningococcal conjugate vaccine, che ck varicella immunity, start HPV series B. Tetanus, diphtheria, and pertussis (Tdap) vaccine; meningo coccal conjugate vaccine; a second varicella vaccination; start HPV series C. Tdap vaccine, meningococcal conjugate vaccine, check varicella immunity, start HPV series D. DTaP vaccine, a third MMR vaccine, a second varicella vaccination, start HPV series 7. An 18-year-old 18-year-old woman is seen in the office for an obstetrics visit at 18 weeks gestation. She was diagnosed 3 years ag o with moderate depression and was taking paroxetine (Paxil) 20 mg/day up until 6 months ago. She stopped it on h er own when she was feeling better. Because of significant life changes related to her preg nancy, she says she "hasn't slept in weeks" and feels lethargic and ap athetic. Questioning reveals no suicidal ideation. She thinks she may breastfeed after her baby is born, but she is not sure. Which of the following options would be the b est treatment for her depression?
A.
Recommend counseling, beg in sertraline HCl (Zoloft) 50 mg/day, f ollow-up ollow-up in 4 weeks B. Recommend counseling, begin paroxetine 10 mg/ day, increase to 20 mg/day after 1 week, follow-up in 2 weeks C. Recommend counseling, beg in bupropion HCl extende d-release (Wellbutrin XL) 150 mg/day, follow-up in 4 weeks D. Recommend counseling, but do not pres cribe medications at this time because of excess fetal risk 8. A 10-year-old girl presents to the office with a 2-day history of fever up to 102?F and a sore throat. She can swallow liquids, but anything else hurts too much. She has not had any cough or difficulty breathing but has had occasional headaches and mild, diffuse abdominal pain. You order a rapid antigen detection test, since you suspect streptococcal pharyngitis. The test result is positive. The patient has no known medi cation allergy. What should you prescribe?
A.
Oral Oral C. Oral D. Oral B.
azithromycin (Zithromax) 10 mg/kg daily for 3 days clindamycin (Cleocin) (Cleocin) 25 mg/kg daily in 3 divided doses ea ch day for 10 days penicillin V (Veetids) 250 mg 3 times daily for 10 days cefaclor (Ceclor, Raniclor) Raniclor) 20 mg/kg in 2 divided doses d aily for 5 days
9. A 44-year-old man has a pigmented lesion on his neck that his wife thinks should be removed, but it d oes not bother him, and he d oes not want it taken off. He is lightlightskinned, blond, and spends a lot of time gardening. He describes himself by s aying, "I was always ?moley.'" The lesion is variegated in color, 7 by 10 mm in diameter, flat, and asymmetric, with an irregular border. What should you do next?
A.
Punch biopsy Shave biopsy C. Excisional biopsy B.
D. No biopsy, since the patient is unconcerned a bout it 10. A 91-year-old woman is diagno sed with community-acquired community-acquired pneumonia (C A P). She has not taken any antibiotics for the past 3 months and has a true allergy to erythromycin. The patient weighs 7 2 kg, which is idea l for her heig ht. Laboratory test results include include a serum creatinine level of 1.5 mg/dL. The patient has no comorbidities. Which of the following drug regimens is the appropriate treatment for this patient?
A.
Levofloxacin (Levaquin) 750 mg/day Doxycycline (eg, Adoxa, Doryx, Periostat) 100 mg twice daily C. Azithromycin 500 mg/day plus amoxicillin/clavulanate potassium 875 mg twice daily D. Amikacin sulfate (Amikin) 150 mg every 8 hours B.
11. A 68-year-old woman with hypercholesterolemia that is controlled by diet c omplains of several weeks of diffuse stiffness and pain, particularly around her shoulders and hips. She is slow in getting out of bed. Examination of her joints is unremarkable, and she appears to have mild reduction in strength. Based on this clinical picture, what is the most useful test to order at this p oint?
A.
Creatine phosphokinase Erythrocyte sedimentation rate (ESR) C. Radiographs of the shoulders and hips D. Urine myoglobin B.
12. A right adnexal mass is found during the pe lvic examination of a 60-year-old woman. Transvaginal ultrasonography reve als a complex ovarian cyst, with both solid and cystic components. Which one of the following statements is correct?
A.
If the cancer antigen (C A)-125 blood test is normal, the physician can be reassured that this is a benign cyst B. Since the mass is partially cystic, cystic, it can be followed by transvaginal sonograms every 3 months C. A percutaneous biopsy of the solid compo nent of the mass is indicated D. The mass requires surgical excision for definitive diagnosis 13. A 41-year-old woman complains of "bleeding too m uch" from her vagina. She reports a history of menstrual cycles lasting between 19 and 23 days, with a period length of 8 days. Sometimes, she must change sanitary napkins every hour, and occasionally she needs to go home from work t o change her clothes. She also has has some light, appare ntly random, bleeding between periods. What would be the best course of management?
A.
Reassure her that she is probably perimen opausal, and that it is normal to have menstrual changes at this time. Prescribe birth control pills to regulate regulate her bleeding B. Perform pelvic ultrasound to look for fibroids and evaluate the endometrial stripe C. Check thyroid-stimulating thyroid-stimulating hormone (TSH) level, complete b lood cell (CBC) count, and follicle-stimulating hormone (FSH) level to evaluate for thyroid dy sfunction, sfunction, anemia, and confirm perimenopause D. Rule out pregnancy, perform endometrial biopsy 14. A 24-year-old male swimmer presents to the office saying he de veloped otitis externa 1 week ago. He stop ped swimming and tried using 2% acetic acid otic solution, which did not relieve his symptoms. Examination of the external canal reve als significant erythema and moderate exu date. What is the best treatment you should prescribe at this time?
A.
Hydrocortisone otic drops Initiate amoxicillin/clavulanate potassium therapy therapy C. The patient should complete a 14-day course of otic acetic acid drops B.
D. Initiate otic fluoroquinolone plus hydrocortisone drops 15. A 54-year-old man with a history of myocardial infarction presents for a follow-up follow-up visit after being hospitalized 1 month ago. His symptoms at admission were shortness of breath, orthopnea, and leg swelling. Examination revealed b ibasilar crackles, evidence of pulmonary edema on chest radiograp hs, and an elevated brain natriuretic peptide level. A parenteral diuretic improved his symptoms, producing higher urine output. Echocardiography revealed an eje ction fraction of 30%. He was discharged home with prescriptions for low-dose furosemide ( Lasix) and lisinopril (Prinivil, Zestril).
Today he is no longer symptomatic. His blo od pressure ( BP) is 135/90 mm Hg and his pulse, 90 beats/min. He has lost 5 lb since he left the hospital. Examination reveals no abnormal lung sounds or peripheral ede ma. The serum creatinine level has increased from 1.0 to 1.2 mg/dL. Which of the following interventions would be the most appropriate approach? A.
No change in therapy, but follow-up closely Increase the dose of lisinopril C. Add low-dose metoprolol (Lopressor) D. Add digoxin (Digitek, Lanoxin) B.
16. A 56-year-old man presents with a 3-day history of increasing shortness of breath, cough, and sputum production. He has not had fever or chills. He has been using his beta2-agonist metered-dose inhaler every 2 t o 3 hours. He quit smoking 2 years ago. Pulse oximetry reveals an oxygen saturation of 89%. He is audibly whee zing, using accessory muscles of respiration. He is also tachypneic. You diagnose an exa cerbation of chronic obstructive pulmonary disease (COPD). All the following statements are true, except:
A.
Supplemental oxygen should be used to correct the hypoxia Corticosteroids can reduce the risk of treatment failure C. Antibiotics should be withheld, since the patient has been afebrile D. Inhaled beta2-agonists or anticholinergics are a mainstay of treatment B.
17. The positive likelihood ratio of a test is defined as the ratio of A /B, where A is the proportion of patients who truly have the disea se and a positive test result, and B is the proportion of patients without the disease who still hav e a positive test. How is this expressed in standard statistical terminology?
A.
Sensitivity/specificity Positive predictive value/negative predictive value C. Specificity/positive predictive value D. Sensitivity/(1 minus specificity) B.
18. A 43-year-old woman presents with an asymptomatic vaginal discharge. She is scheduled for a hysterectomy the following week because of the presence of large fibroids and heavy bleeding. Phy sical examination shows a thin, white discharge coating the vaginal walls. The discharge h as a "fishy" odor, a nd clue clue cells are identified on the wet mount test. Which of the following statements is true?
A.
Treatment before her hysterectomy will decrease t he risk of infectious complications B. One of the recommended treatments is a single dose of metronidazole (Flagyl) 2 g C. Treatment of the patient's partner is indicated to prevent recurrent infection D. Restoring normal flora using Lactobacillus suppositories is effective treatment for her condition 19. A 31-year-old male recreational basketba ll player suffered an inv ersion injury injury to his ankle. When initially seen shortly after the injury, he was unable to fully bear weight on the affected leg and had point tenderness over the tip of his lateral malleolus. Swelling was noted over the lateral aspect of his a nkle. Radiographs obtained obtained at the time of injury
showed no fracture or widening of the joint space. Th e ankle was immobilized, ice was applied, and he was told to use crutches and come back in 3 days. At
this follow-up visit, examination re veals swelling and e cchymosis over the the lateral ankle. The anterior drawer sign is weakly positive whe n compared with the uninjured ankle. He is now able to partially bear weight on the injured ankle and has discarded his crutches. What would you recommend next? A.
Apply
heat to the ankle Immobilize the ankle in a walking cast for 6 weeks C. Begin range-of-motion and strengthening ankle exercises D. Repeat ankle radiographs B.
20. A 25-year-old woman presents to your office with a 2-day history of a flulike illness, with fever, headache, my algias, nausea, nausea, and chills. There is c urrently a flulike illness in the community, and she reports seve ral sick contacts. Ph ysical examination shows an illappearing young woman with mild spleno megaly. CB C count and chemistry panel screening demonstrate mild anemia (hemoglobin, 10.9 g/dL) and hypoglycemia (g lucose, 54 mg/dL). Further questioning reveals that she returned home to the United States 6 weeks ago after serving 2 ye ars in Mozambique with the Peace Corps. During those 2 years she lived in a rural village and had been ex posed to many biting insects. She insists that she took mefloquine HCl (Lariam) weekly for malaria prevention as directed, before and during her trip, as well as for the first 4 weeks after returning from Africa. What is your next step in management?
A.
Reassure her that she has a flulike illness and ask her to return in 3 days if she is not feeling better B. Check titers for tick-borne diseases (Rocky Mountain spotted fever a nd ehrlichiosis) C. Check titers for Chagas' disease D. Obtain thin and thick blo od smears for malaria 21. The number needed to treat (NNT) using a giv en therapeutic intervention can be calculated as:
A.
1/Absolute risk reduction 1/Relative risk reduction C. Positive predictive value minus negative pre dictive value D. 1/(sensitivity minus spe cificity) B.
Answers 1-B. The prevalence of pleural effusion in patients underg oing CABG is 63%. A large effusion occupying more than 25% of the hemithorax occurs only 10% of the time, but it may require thoracentesis for sy mptom relief. These effusions are exud ates and result from inflammation. The absence of fever, tracheal deviation, and chest pain speak against infection (pneumonia), pneumothorax, or emb olus as the cause.
Source Light RW, Rogers JT, Moyers JP, et a l. Prevalence and clinical course of pleural effusions at 30 days after coronary artery and cardiac surgery. Am surgery. Am J Respir Crit Care Med. 2002;166:1567-1571. 2-D. HPV testing before HPV immunization is not currently recommended by the ACS. The ACS states that it is important to offer HPV vaccinations before adolescent girls bec ome sexually active. The ACS recommends vaccinating all females aged 11 to 2 6. One study revealed that more than 50% of c ollege-aged ollege-aged women acquired an HPV infection within 4 years of first intercourse. It is estimated that vaccination may eventually prevent as many as 70% of cervical can cer cases, depe nding on how many carcinogenic HPV types can be
included in future vaccinations. However, Pap smears (and, when indicated, colpo scopies) will still be needed. Sources Saslow D, Castle PE, Cox JT, et al. American Cancer Society Guideline for human papillomavirus (HPV) vaccine use to prevent cervical cancer and its precursors. CA Cancer J Clin. 2007;57:7-28. Winer RL, Lee SK, Hughes JP, e t al. Genital human papillomavirus infection: incidence and risk factors in a cohort of female university students. Am students. Am J Epidemiol. 2003;157:218-226. 3-B. Reports of methicillin-resistant Staphylococcus aureus (MRSA) infections in children and adults are increasing. Until recently, MRS A infections were mainly seen in hospitalized patients in association with ri sk factors such as immune suppres sion. CommunityCommunityassociated MRS A can cause purulent skin and soft-tissue infections, as well as progressive necrotizing pneumonia.
Methicillin resistance in S aureus is mediated by the mecA gene, which encodes an altered penicillin-binding protein. In addition, most community-associated community-associated MRS A strains carry the virulence factor Panton-Valentine Panton-Valentine leukocidin, a cytotoxin that can cause destructive skin and soft-tissue lesions. Unlike nosocomial MRS A, most community-acquired strains are susceptible to non-beta-lactam antibiotics, such as tetracycline (Sumycin) and TMP/SMX. Susceptibility to clindamycin (Cleocin) and erythromycin (Ery-Tab, PCE Dispertab) is more variable and c omplicated. Some erythromycin-resistant erythromycin-resistant strains demonstrate inducible clindamycin resistance. The incidence of these strains strains varies across the United States. T he double-disc diffusion test can be used to determine inducible clindamycin resistance. Adequate drainage of community-associated community-associated MRS A lesions may result in healing, even if the patient is initially treated with an in effective antibiotic. In a study of children with community-associated community-associated MRS A skin infection, 94% initially treated with drainage and an ineffective antibiotic (eg, cep halexin) were improved at follow-up. Lesion size >5 cm, not initial antibiotic choice, was a predictor of the need for hospitalization in this study. The use of conventional beta-lactam beta-lactam antibiotics, such as dicloxacillin sodium, cep halexin, or amoxicillin/clavulanate potassium ( Augmentin), is still appropriate for skin i nfections. Empiric use of TMP/SMX is not recommended, because of its failure to cover the common skin pathogen group A streptococcus. Drainage of purulent collections and close follow-up follow-up are essential. If community-associated MRSA is cultured, susceptibility testing can be used used to guide further antibiotic therapy. For our patient's condition, drainage, culture, and treatment with cephalexin are most appropriate. Although eczema and scratching may have increased her risk of skin infection, oral steroids are not indicated. Many community-associated MRS A lesions are mistaken for brown recluse spider bites. This spider is confined to areas of the Southwest, South, and Central United States; it is not found along the eastern seaboard, Mdwest, or Northwest. Empiric treatment with TMP/SMX is is not appropriate for skin infection, although it may be used if culture of the drainage demonstrates susceptibility. Sources Lee MC, Rios AM, Aten MF, et al. Management and outcome of children with skin and soft tissue abscesses caused b y community-acquired community-acquired met hicillin-resistant hicillin-resistant Staphylococcus aureus. Pediatr Infect Dis J. 2004; 23: 123-127. 123-127. Siberry GK. Fighting a rising tide of MRSA infection in the young. Contemp Pediatr. 2005;22:44-53. 4-B. Coronary artery aneurysms or ectasia develop in 15% to 2 5% of untreated children with Kawasaki disease. Echocardiography is a mainstay of evaluation for this complication and is typically performed several times²at times²at the time of diagnosis, then at 2 week s, and again at 6 to 8 weeks after the disease onset. Intravenous (IV) immune globulin appe ars to have the most efficacy in reducing the pre valence of coronary artery aneury sms,
although aspirin is also usually given. This complication of cardiac sequelae is the most common cause for fatality associated with Kawasaki disease. Source Newburger JW, Takahashi M, Gerber MA, et al, for the Committee on Rheumatic Fever, Endocarditis and Kawasaki Disease; Council on Cardiovascular Disease in the Young; American Heart Association; and American Academy of Pediatrics. Diagnosis, treatment, and long-term management of Kawasaki disease. Circulation. 2004;110:2747-2771. 5-C. Assessment of oral intake and blood oxyge nation is warranted and may determine whether a trial of bronchodilator therapy is indicated. Bronchiolitis is a viral respiratory tract infection characterized by acute inflammation, edema, necrosis of the epithelial cells lining the small airways, increased mucous production, and bronchospasm. Although the most common etiology is RSV, other viruses have been implicated in this infection, including human metapneumovirus, influenza, adenovirus, and parainfluen za. Virologic testing for RSV rarely rarely alters the approach to the clinical management. The incidence of serious bacterial infection in infants with bronchiolitis is very low ( 0% to 3.7%). Routine antibiotic therapy is not helpful. Assessment
of the impact of the respiratory symptoms on feeding and hydration is of paramount importance. Mucous may obstruct the nose, making feedi ngs difficult. Nasal and oral suctioning should be performed freque ntly. Infants who cannot drink adequate amounts of fluid will become dehydrated and fatigued. Mucous thickening may occur as a result of inadequate hydration. IV fluid therapy may be required during periods of tachypnea and increased respiratory effort. Pulse oximetry has been used to assess blood oxygenation level in children with bronchiolitis, on the assumption that it can detect hypoxemia that is not detected by clinical examination. Few studies have examined the the efficacy of p ulse oximetry in predicting clinical outcomes, and it is unclear whether it would be helpful in predicting progression of disease or determining the need for supplemental oxygen. Oxygen therapy is recommended if the oxyhemoglobin saturation saturation is persistently below 90 %. Although widely used, pulse oximeters have significant shortcomings: poor probe placement and motion artifact will lead to inaccurate readings and alarms.
There is little evi dence that c orrelates chest radiography abnormalities with clinical disease severity in infants with bronchiolitis. Thus, routine chest radiography is not recommended. The use of bronchodilators, such as albuterol ( AccuNeb, Proventil) and levalbuterol, in the treatment of bronchiolitis co ntinues to be controversial. controversial. A metaanalysis of 8 randomized, controlled trials indicated that, at most, 1 in 4 infants treated with bronchodilators sh ow some improvement. Corticosteroid use has not been found to be consistently effective in decreasing the length of hospitalization hospitalization in infants or i n clinical scoring. Bronchodilators and corticosteroids may be useful for individual infants but should not be used routinely in all infants with bronchiolitis. Our infant has bronchiolitis with a normal respiratory rate and no obvious increased work of breathing. Testing for RSV and chest x-rays will not change the treatment of her mild lower airway disease. Her risk for a serious bacterial infection is low; therefore, ceftriaxone is not necessary. Sources American Academy of Pediatrics Subcommittee on Diagnosis and Managem ent of Bronchiolitis. Diagnosis and management of br onchiolitis.Pediatrics. onchiolitis.Pediatrics. 2006;118:1774-1793. Kellner JD, Ohlsson A, Gadomski AM, et al. Database Syst Rev. 2000;(2):CD001266.
Bronchodilators
for bronchiolitis.Cochrane bronchiolitis. Cochrane
6-B. In 2006, the Advisory Committee on Immunization Practices ( ACIP) recommended a 1-time Tdap booster for all adolescents older t han 11 years. DTaP should not be u sed in this age-group. Protection from me ningococcal infection is suggested as well, especially in high-risk groups, such as those residing in college dormitories. The ACIP recommends offering an HPV series to all adolescent girls to prevent cervical cancer later in life. The latest guidelines also recommend that if immunity to varicella cannot be confirmed in this age-group, a second varicella vaccine should be given to boost immunity during this highrisk adolescent period.
Source Broder KR, Cortese MM, Iskander JK, et al, for the Advisory Committee on Immunization Practices (ACIP). Preventing tetanus, diphtheria, and pertussis among adoles cents. MMWR Recomm Rep. 2006;55(RR-3):1-34. 7-A. Studies have shown that in women who stop taking antidepressants whe n they become pregnant, the risk for depre ssion relapse is 68%, with 90% of the re lapses occurring during the second trimester of pregnancy. Although paroxetine may have worked for this patient before, it, as well as bupropion, should rarely be used in pregnancy because of d ocumented adverse outcomes, specifically atrial or ventricular septal def ects. The lowest effective dose of antidepressants should always be used during pregnancy, and the dose should not be increased unless absolutely necessary. All
psychotropic drugs cross the p lacenta and will put the fetus at risk. Sertraline, fluoxetine (Prozac), and tricyclic antidepressants are preferred during pre gnancy. Sertraline is preferred when a woman is breastfeeding, although the drug still enters breast milk. Use caution when prescribing any psychotropic psychotropic agent during preg nancy, as they all pose risk for spontaneous ab ortion.
This patient's insomnia and moderate depression are reasons to treat at this time. However, women who use selective serotonin reuptake inhibitors during pregnancy may be putting their infants at risk for persistent pulmonary hypertension. Because antidepressant therapy has bee n shown to increase suicidal behavior and i deation in the 1 8- to 2 4-yearold age-group, close follow-up is indicated. Sources Cohen LS, Altshuler LL, Harlow BL, et al. Relapse of major depression during preg nancy in women who maintain or discontinue antidepressant treatment. JAMA. treatment. JAMA. 2006;295:499-507. Einarson TR, Einarson A. Newer antidepressants in pregnancy and rate s of major malformations: a meta-analysis of prospective comparative studies.Pharmacoepidemiol studies.Pharmacoepidemiol Drug Saf. 2005;14:823-827. Gonsalves L, Schuermeyer I. Treating depression in pregnancy: practical suggestions. Cleve Clin J Med.2006;73:1098-1104. Med. 2006;73:1098-1104. 8-C. In those with no know n allergy or contraindication, a 1 0-day course of oral penicillin is the treatment of choice for group A beta-hemolytic streptococci. Although there are reports that shorter courses of macrolides and cephalosporins are effective, insufficient insufficient evidence supports such therapy at this time. A 10-day 10-day course of clindamycin can be used in patients with multiple, recurrent episodes of streptococcal pharyngitis proven by c ulture or rapid antigen detection testing.
Source Bisno A L, Gerber MA, Gwaltney JM Jr, et al. Practice guidelines for the diagnosis and management of group A streptococcal pharyngitis. Infectious Diseases Society of America. Clin Infect Dis. 2002;35:113-125. 9-C. This lesion meets all the y y y
Asymmetry
Border irregularities Color variegation
ABCD
criteria for malignant melanoma:
y
Diameter >6 mm.
The patient therefore needs to be convinced that the lesion should be removed for examination. The depth of infiltration of melanoma cells ( Breslow thickness) is important for the histopathologic staging of a lesion, as well as for subsequent treatment and prognosis. Shave and punch biopsies are not appropriate, because of the risk of partial excision and erroneous staging. Source Bolognia JL.
Biopsy
techniques for pigmented lesions. Dermatol Surg.2000;26:89-90. Surg.2000;26:89-90.
10-B. New guidelines for empiric antibiotic therapy i n adults with CAP state that patients who have not taken an antibiotic in the prev ious 3 months and do n ot reside in an area of high Streptococcus pneumoniae resistance should be treated with doxycycline or a macrolide. This patient has an erythromycin allergy and cannot take a macrolide. She also has significantly reduced kidney function, with an estimated creatinine clearance of 2 8 mL/min. Amoxicillin/clavulanate potassium at the dose mentioned is not recommende d in patients with a creatinine clearance of <30 mL/min, although her allergy to erythromy cin rules out option C because of cross reactivity. Similarly, her kidney dysfunction rules out levofloxacin at the dose indicated in option A, since the recommended dosages are 250 mg/day for uncomplicated CAP and 750 mg every 48 hours for complicated CAP. IV amikacin is used in hospital-acquired pneumonia and is not be ap propriate for outpatient therapy. Also, the dose for amikacin is 5 mg/kg every 8 hours, not 2 mg/k g every 8 h ours.
Source Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the manage ment of community-acquired community-acquired pneu monia in adults. Clin Infect Dis.2007;(suppl Dis. 2007;(suppl 2):S27-S72. 2):S27-S72. 11-B. Because the most likely diagnosis is polymyalgia rheumatica, an elevated ESR (>50 mm/h) in this clinical setting is very helpful to confirm this diagnosis, even though no definitive diagnostic test is available. Since there are no localized bone or joint findings, radiographs are not neede d. The patient is not taking any medications, which makes the diagnosis of myopathy less likely.
Source Unwin B, Williams CM, Gilliland W. Polymyalgia rheumatica and g iant cell arteritis. Am arteritis. Am Fam Physician. 2006;74:1547-1554. 12-D. The finding of an adnexal mass with solid and cystic components is highly suggestive of cancer. Percutaneous biopsy should be avoided, as there is a risk of tumor spillage into the pelvic cavity. The CA-125 level is elevated in more than 80% of patients with advanced ovarian cancer, but it is neither sensitive nor specific enough t o be diagnostic. An elevated CA-125 level may be seen in many other conditions, both benign and malignant. This lesion is too high risk to be followed by serial sonograms and is so highly suggestive of cancer that it mandates early re moval and definitive diagnosis.
Source Cannistra S A. Cancer of the ovary. N Engl J Med. 2004;351:2519-2529. 13-D. Some changes in menstrual bleeding during the pe rimenopausal years are normal. Longer intervals between periods and missed periods are expected. A woman older than 35, with intervals less than 21 days, who bleeds for more than 7 day or between periods requires evaluation with endometrial biopsy. Perimenopausal women have a reduced chance of pregnancy, but it is a possibility that must be ex cluded before performing endometrial biopsy.
Measuring TSH level and C BC count may be appropriate in wome n with abnormal bleeding; however, because FSH levels normally fluctuate during per imenopause, they are unreliable for the purposes of diagnosis at this time.
transvaginal ultrasound, with or without saline infusion, may be obtained before, after, or instead of an endometrial biopsy in a woman older than 35 who has risk factors for endometrial carcinoma (eg, obesity, diabetes). The co nservative approach is to perform an endometrial biopsy, regardless of whether whether a transvaginal ultrasound is obt ained.
A
Source Ely JW, Kennedy CM, Clark EC, et al. Abnormal uterine bleeding: a management algorithm. J algorithm. J Am Board Fam Med. 2006;19:590-602. 14-D. This patient has moderate otitis externa. He f ailed initial treatment with acetic acid and therefore needs antibiotic treatment. Although mild otitis externa responds to otic acetic acid, moderate otitis externa often requires antibacterial coverage. Only a few studies have compared ototopical agents, but we do know that the se medications achieve 1000 times the local-tissue penetration of s ystemic antibiotics.
Source Osguthorpe JD, Nielsen DR. Otitis externa: review and clinical update. Am update. Am Fam Physician. Physician. 2006;74:1 510-1516. 510-1516. 15-C. The initial admission was du e to sy stolic dysfunction h heart eart failure. Adding digoxin may improve the ejection fraction rate, but the lack of symptoms a nd the likely toxicity of the drug make it a less favorable o ption. The patient's BP is not controlled and will likely contribute to a worsening prognosis if nothing else is done. Increasing the lisinopril dose may help his hypertension, but he may be overdiuresed now, and a higher dose could worsen his renal function. Adding metoprolol will likely have the m ost favorable long-term long-term benefit on his heart function. 16-C. Antibiotics should be started, because they reduce the risk of short-term short-term mortality by 77% , treatment failure by 53%, and sputum purulence by 44%. Supplemental oxygen should be used to correct the hypoxia. There has been concern about decreasing respiratory drive, hypercapnia, and subseque nt respiratory acidosis; however, most cases of CO 2 retention are thought to be the r esult of V/Q mismatch rather than depression of the respiratory center. Inhaled bronchodilators are used routinely to treat COPD. Corticosteroids improve symptoms and can reduce the risk of treatment nonresponse.
Source Ram FS, Rodriguez-Roisin R, Granados-Navarrete A, et al. Antibiotics for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2006;(2):CD004403. 17-D. Using the definition outlined in the question, the correct formula for positive likelihood ratio can be determined from the standard 2-square x 2-square:
The value of " A" can be equated t o the sensitivity of the test (the proportion of patients with a positive test who truly have the disease), or a/(a + c); and " B" can be equated to 1 minus specificity (the proportion of patients without the disease who still have a positive test), or b/(b + d). The positive likelihood ratio indicates how much a pos itive test raises or lowers the pretest probability of the presence of disease. A test with a positive likelihood ratio of 1 does n ot change the probability of the presen ce of disease and is, therefore, an esse ntially useless test²you may as well flip a coin. The larger the positive likelihood ratio of a test, the more valuable it is in increasing the likelihood of the presence of disease; the closer the po sitive likelihood ratio is to zero, the more valuable it is in de creasing the likelihood of the presence of dise ase. Note that the positive l ikelihood ratio cannot be zero, unless the the sensitivity of the test is also zero. Source Guyatt G, Rennie D, eds. Users Guides to the Medi cal Literature: Essentials of EvidenceBased Clinical Practice. Chicago, Ill: AMA Press; 2002.
18- A. The discharge is characteristic of bacterial vaginosis. Current treatment recommendations include metronidazole, 500 mg twice daily for 7 days; metronidazole gel 0.75% (MetroGel-Vaginal, Vandazole), one full applicator daily for 5 days; or clindamycin cream 2% (Cleocin, ClindaMax, Clindesse), one full a pplicator pplicator intravaginally at bedtime for 7 days. Alternative regimens include clindamycin, 300 mg orally twice daily for 7 day s, or clindamycin ovules, 100 mg intravaginally at bedtime for 3 days. A single, 2-g dose of metronidazole has the lowest efficacy and is no longer recommended as a treatment for bacterial vaginosis.
There is no evidence that treating sexu al partners reduces the recurrence of bacterial vaginosis. Bacterial vaginosis is characterized by replacement of the normal v aginal flora with high concentrations of anaerobic bacteria, but studies show that Lactobacillus suppositories are not better than placebo at 1 month after therapy. Source Workowski KA, Berman SM, for the Centers for Disea se Control and Prevention. Sexually transmitted diseases treatment guidelines, 2006 [published correction ap pears in MMWR Recomm Rep. 2006;55: 997]. MMWR Recomm Rep. 2006;55(RR-11):1-94. 19-C. Multiple studies have shown that f unctional treatment of ankle sprains with rangerangeof-motion and strengthening exercises begun 48 to 72 hours after the acute injury re sult in return to work or sports participation from 5 to 7 days soon er than immobilization. Heat is not indicated for the acute treatment of sprains. Although the patient did meet the Ottawa Ankle Criteria for radiographs (unable to fully bear weight for 4 steps and/ or point tenderness over the malleolus), repe ating radiography so soon after an initially negative study, when the patient is showing signs of improveme nt, has a very low yield.
Source Ivins D.
Acute
ankle sprain: an update. Am update. Am Fam Physician. 2006;74:1714-1720.
20-D. Malaria must always be included in the differential diagnosis of a febrile patient who has recently returned from a malaria-endemic malaria-endemic area. F ailure to consider malaria could have catastrophic consequences. Mefloquine is indicated for prevention in chloroquine-resistant areas, such as Mozambique, but it is not completely protective for Plasmodium falciparum. Furthermore, the patient is still susceptible to Plasmodium vivax and and Plasmodium ovale, since she did not take the "radical cure" with primaquine phosphate to eradicate any latent malarial parasites in the liver.
The signs and symptoms of malaria can be very nonspecific, and the condition is often mistaken for a flulike illness. Similarly, routine lab oratory test findings can be nonspecific, showing mild anemia and hypoglycemia. Theref ore, thin and thick blood smears should be "a reflex response" for any febrile patient ret urning from a malaria-endemic malaria-endemic area. Although they can have similar nonspecific nonspecific presentations, Rocky Mountain spotted fev er, ehrlichiosis, and Chagas' disease occur only in the Western hemisphere. Sources Conrad-Llles W, Van Voorhis W. Travel-acquired illnesses associated with fev er. In: Jong EC, McMullen R, eds. The Travel and Tropical Medicine Manual.3rd Manual.3rd ed. Philadelphia, Pa: W B Saunders; 2003:289-316. Thompson M, White N, Jong E. Malaria diagnosis and treatment. In: Jong EC, McMullen R, eds.The eds. The Travel and Tropical Medicine Manual. 3rd ed. Philadelphia, Pa: WB Saunders; 2003:269-288. 2003:269-288. 21- A. The NNT is the number of patients who must receive an intervention or the rapy (usually for a specific period of time) to preve nt 1 adverse outcome or produce 1 positive outcome. It is easily calculated as the inverse of the abs olute risk reduction reduction (expressed as a decimal number, not as a percentage). As an example, if the risk of de ath 1 year after a small myocardial infarction in a 40-year-old man who is treated with streptokinase (Streptase) is 2%, and his risk of death when tre ated with tissue tissue plasminogen a ctivator (tPA) is 1.76%, the NNT is 1/(0.02 -0.0176), or 1/0.0024, or ab out 417. The relative risk reduction is 12% in this case, a seemingly good r eduction, but the NNT is quite large and would imply that the true benefit of tP A in this patient is perhaps not worth the added
expense, and that streptokinase may b e a better choice. NNT is the most easily understood statistic by both clinicians and patients for explaining the benefit of a spe cific therapy. The magnitude of NNT for some comm on medical interventions is also startlingly large. Source Guyatt G, Rennie D, eds. Users Guides to the Medi cal Literature: Essentials of EvidenceBased Clinical Practice. Chicago, Ill: AMA Press; 2002:111-114.
