Management of Common Medical Conditions, Exams of Nursing

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AAFP Board Exam Review

What screening test has most potential for overdx? - Answer PSA- Overdiagnosis is the diagnosis of a disease that will not produce symptoms during a patient's lifetime. It tends to occur with cancers that have very slow rates of growth. Prostate cancer is most often a slow-growing cancer and is often present without symptoms in older men. The introduction of prostate-specific antigen (PSA) screening was accompanied by a marked rise in the rate of diagnosis of prostate cancer while mortality decreased much less significantly, and this decrease was probably largely attributable to improved treatment. What is the treatment for mallet fracture? - Answer The recommended treatment for a mallet fracture is splinting the distal interphalangeal (DIP) joint in extension (SOR B). The usual duration of splinting is 8 weeks. It is important that extension be maintained throughout the duration of treatment because flexion can affect healing and prolong the time needed for treatment. If the finger fracture involves >30% of the intra-articular surface, referral to a hand or orthopedic surgeon can be considered. However, conservative therapy appears to have outcomes similar to those of surgical treatment and therefore is generally preferred. If subluxed radial head is suspected in a child, is imaging needed? - Answer As long as there are no outward signs of fracture or abuse it is considered safe and appropriate to attempt reduction of the radial head before moving on to imaging studies. With the child's elbow in 90° of flexion, the hand is fully supinated by the examiner and the elbow is then brought into full flexion. Usually the child will begin to use the affected arm again within a couple of minutes. If ecchymosis, significant swelling, or pain away from the joint is present, or if symptoms do not improve after attempts at reduction, then a plain radiograph is recommended. A 17-year-old female sees you for a preparticipation evaluation. She has run 5 miles a day for the last 6 months, and has lost 6 lb over the past 2 months. Her last menstrual period was 3 months ago. Other than the fact that she appears to be slightly underweight, her examination is normal.

To fit the criteria for the female athlete triad, she must have which one of the following?

• Answer The initial definition of the female athlete triad was amenorrhea, osteoporosis, and disordered eating. The American College of Sports Medicine modified this in 2007, emphasizing that the triad components occur on a continuum rather than as individual pathologic conditions. The definitions have therefore expanded. Disordered eating is no longer defined as the formal diagnosis of an eating disorder. Energy availability,defined as dietary energy intake minus exercise energy expenditures, is now considered a risk factor for the triad, as dietary restrictions and substantial energy expenditures disrupt pituitary and ovarian function. Athletes who have amenorrhea for 6 months, disordered eating, and/or a history of a stress fracture resulting from minimal trauma should have a bone density test. Low bone mineral density for age is the term used to describe at-risk female athletes with a Z-score of -1 to -2. Osteoporosis is defined as having clinical risk factors for experiencing a fracture, along with a Z-score <-2. what is the work up for secondary amenorrhea? - Answer This patient suffers from secondary amenorrhea (defined as the cessation of regular menses for 3 months or irregular menses for 6 months). The most common causes of secondary amenorrhea are polycystic ovary syndrome, primary ovarian failure, hypothalamic amenorrhea, and hyperprolactinemia. With a normal physical examination, negative pregnancy test, and no history of chronic disease, a hormonal workup is indicated, including TSH, LH, and FSH levels (SOR C). A hormonal challenge with medroxyprogesterone to provoke withdrawal bleeding is used to assess functional anatomy and estrogen levels (SOR C). However, it has poor specificity and sensitivity for ovarian function and a poor correlation with estrogen levels. Pelvic ultrasonography is indicated in the workup of primary amenorrhea to confirm the presence of a uterus and detect structural abnormalities of the reproductive organs. Likewise, karyotyping can be used for patients with primary amenorrhea, as conditions such as Turner's syndrome and androgen insensitivity syndrome are due to chromosomal abnormalities. A CBC and metabolic panel would not be initial considerations in the workup of amenorrhea unless the patient has a known chronic disease which may affect the results. What's the first line treatment for primary dysmenorrhea? - Answer The first-line treatment for primary dysmenorrhea should be NSAIDs (SOR A). They should be started at the onset of menses and continued for the first 1-2 days of the menstrual cycle.

Combined oral contraceptives may be effective for primary dysmenorrhea, but there is a lack of high-quality randomized, controlled trials demonstrating pain improvement (SOR B). They may be a good choice if the patient also desires contraception. Although combined oral contraceptives and intramuscular and subcutaneous progestin-only contraceptives are effective treatments for dysmenorrhea caused by endometriosis, they are NOT first-line therapy for primary dysmenorrhea. A 24-year-old female presents with pelvic pain. She says that the pain is present on most days, but is worse during her menses. Ibuprofen has helped in the past but is no longer effective. Her menses are normal and she has only one sexual partner. A physical examination is normal. Which one of the following should be the next step in the workup of this patient? - Answer The initial evaluation for chronic pelvic pain should include a urinalysis and culture, cervical swabs for gonorrhea and Chlamydia, a CBC, an erythrocyte sedimentation rate, a β-hCG level, and pelvic ultrasonography. CT and MRI are not part of the recommended initial diagnostic workup, but may be helpful in further assessing any abnormalities found on pelvic ultrasonography. Referral for diagnostic laparoscopy is appropriate if the initial workup does not reveal a source of the pain, or if endometriosis or adhesions are suspected. Colonoscopy would be indicated if the history or examination suggests a gastrointestinal source for the pain after the initial evaluation. what can induce ovulation in PCOS? - Answer This patient fits the criteria for polycystic ovary syndrome (oligomenorrhea, acne, hirsutism, hyperandrogenism, infertility). Symptoms also include insulin resistance. Evidence of polycystic ovaries is not required for the diagnosis. Metformin has the most evidence supporting its use in this situation, and is the only treatment listed that is likely to decrease hirsutism and improve insulin resistance and menstrual irregularities. Metformin and clomiphene alone or in combination are first-line agents for ovulation induction. Clomiphene does not improve hirsutism, however. Progesterone is not indicated for any of this patient's problems. Spironolactone will improve hirsutism and menstrual irregularities, but is not indicated for ovulation induction. What is the first step for evaluating a thyroid nodule? - Answer Thyroid nodules >1 cm that are discovered incidentally on examination or imaging studies merit further evaluation. Nodules <1 cm should also be fully evaluated when found in patients with a family history of thyroid cancer, a personal history of head and neck irradiation, or a finding of cervical node enlargement. Reasonable first steps include measurement of TSH or ultrasound examination. The American Thyroid Association's guidelines recommend that TSH be the initial evaluation (SOR A) and that this be followed by a radionuclide thyroid scan if results are abnormal.

Diagnostic ultrasonography is recommended for all patients with a suspected thyroid nodule, a nodular goiter, or a nodule found incidentally on another imaging study (SOR A). Routine measurement of serum thyroglobulin or calcitonin levels is not currently recommended. CDC guidelines for a flu outbreak? - Answer The occurrence of two or more laboratory- confirmed cases of influenza A is considered an outbreak in a long-term care facility. The CDC has specific recommendations for managing an outbreak, which include chemoprophylaxis with an appropriate medication for all residents who are asymptomatic and treatment for all residents who are symptomatic, regardless of laboratory confirmation of infection or vaccination status. All staff should be considered for chemoprophylaxis regardless of whether they have had direct patient contact with an infected resident or have received the vaccine. Requesting restriction of visitation is recommended; however, it cannot be strictly enforced due to residents' rights. number needed to treat A new drug treatment is shown to reduce the incidence of a complication of a disease by 50%. If the usual incidence of this complication were 1% per year, how many patients with this disease would have to be treated with this medication for 1 year to prevent one occurrence of this complication? - Answer Considering relative risk reduction without also considering the absolute rate can distort the importance of a therapy. A useful way to assess the importance of a therapy is to determine the number needed to treat to benefit one patient. To calculate this number, the percentage of absolute risk reduction of a particular therapy is divided into 100. In the case in question, the absolute risk reduction is 0.5% (0.5×.01). Thus, the number-needed-to- treat for the example cited is 200 (100/0.5). Examination of a 2-day-old infant reveals flesh-colored papules with an erythematous base located on the face and trunk, containing eosinophils. Which one of the following would be most appropriate at this time? - Answer This infant has findings consistent with erythema toxicum neonatorum, which usually resolves in the first week or two of life (SOR A). No testing is usually necessary because of the distinct appearance of the lesions. The cause is unknown. American Urological Association guidelines define asymptomatic microscopic hematuria as which one of the following in the absence of an obvious benign cause? - Answer The American Urological Association guidelines define asymptomatic microscopic hematuria (AMH) as ≥3 RBCs/hpf on a properly collected urine specimen in the absence of an obvious benign cause (SOR C).

A positive dipstick does not define AMH, and evaluation should be based solely on findings from microscopic examination of urinary sediment and not on a dipstick reading. A positive dipstick reading merits microscopic examination to confirm or refute the diagnosis of AMH. How to manage respiratory distress in the terminally ill patient at 94% O2? - Answer Dyspnea is a frequent and distressing symptom in terminally ill patients. In the absence of hypoxia, oxygen is not likely to be helpful. Opiates are the mainstay of symptomatic treatment and other measures may be appropriate in specific circumstances. For example, inhaled bronchodilators or glucocorticoids may be helpful in patients with COPD, and diuresis may be helpful in patients with heart failure. The evidence for oxygen in patients with hypoxemia is not clear, but there is no benefit from oxygen for nonhypoxemic patients According to the guidelines developed by the JNC 8 panel, which one of the following should NOT be used as a first-line treatment for hypertension? - Answer ACE inhibitors, angiotensin receptor blockers (ARBs), calcium channel blockers, and thiazide-type diuretics all yielded comparable effects on overall mortality and cardiovascular, cerebrovascular, and kidney outcomes. They are all recommended for initial treatment of high blood pressure in the nonblack population, including patients with diabetes mellitus. B-Blockers were not recommended for the initial treatment of hypertension because one study found there was a higher rate of the primary composite outcome of cardiovascular death, myocardial infarction, or stroke with use of these drugs compared to the use of an ARB. A 67-year-old male presents with a 10-day history of bilateral shoulder pain and stiffness accompanied by upper arm tenderness. On examination there is soreness about both shoulders and the patient has great difficulty raising his arms above his shoulders. There is no visual disturbance, and no tenderness over the temporal arteries. C-reactive protein is elevated and the erythrocyte sedimentation rate is 65 mm/hr (N 0-17). Which one of the following would help to confirm the most likely diagnosis? - Answer This patient has characteristic features of polymyalgia rheumatica, a disease whose prevalence increases with age in older adults but is almost never seen before age 50. Most people will have accompanying systemic symptoms including fatigue, weight loss, low-grade fever, a decline in appetite, and depression.

There are no validated diagnostic criteria available to assist in the diagnosis. The treatment response to 15 mg of prednisone daily is dramatic, often within 24-48 hours, and if this response is not seen, alternative diagnoses must be considered. NSAIDs are not useful in the management of polymyalgia rheumatica and, in fact, are associated with high drug morbidity. Ultrasonography may be useful in making the diagnosis, with typical findings of subdeltoid bursitis and tendon synovitis of the shoulders, but synovitis of the glenohumeral joint is less common. A 45-year-old female presents to your office with a 1-month history of pain and swelling posterior to the medial malleolus. She does not recall any injury, but reports that the pain is worse with weight bearing and with inversion of the foot. Plantar flexion against resistance elicits pain, and the patient is unable to perform a single-leg heel raise. Which one of the following is true regarding this problem? - Answer The diagnosis of tendinopathy of the posterior tibial tendon is important, in that the tendon's function is to perform plantar flexion of the foot, invert the foot, and stabilize the medial longitudinal arch. An injury can, over time, elongate the midfoot and hindfoot ligaments, causing a painful flatfoot deformity. The patient usually recalls no trauma, although the injury may occur from twisting the foot by stepping in a hole. This is most commonly seen in women over the age of 40. Without proper treatment, progressive degeneration of the tendon can occur, ultimately leading to tendon rupture. Pain and swelling of the tendon is often noted, and is misdiagnosed as a medial ankle sprain. With the patient standing on tiptoe, the heel should deviate in a varus alignment, but this does not occur on the involved side. A single-leg toe raise should reproduce the pain, and if the process has progressed, this maneuver indicates progression of the problem. While treatment with acetaminophen or NSAIDs provides short-term pain relief, neither affects long-term outcome. Corticosteroid injection into the synovial sheath of the posterior tibial tendon is associated with a high rate of tendon rupture and is not recommended. The best initial treatment is immobilization in a cast boot or short leg cast for 2-3 weeks. A 76-year-old female presents with a history of bilateral shoulder pain for the past month. She reports stiffness in the morning for about 1 hour and also reports difficulty getting up when seated in a chair. Acetaminophen is ineffective for her pain. Her erythrocyte sedimentation rate is 65 mm/hr (N 1-25).

treatment for polymyalgia rheumatica? - Answer This patient has polymyalgia rheumatica, based on her history and elevated erythrocyte sedimentation rate. The initial treatment is prednisone, 15 mg per day with a slow taper over 1-2 years (SOR C). Alternative treatment includes intramuscular methylprednisolone, 120 mg every 3 weeks. There must be bilateral shoulder or hip stiffness and aching for at least one month in order to make the diagnosis of polymyalgia rheumatica. Joint swelling occurs occasionally, but neither swelling nor early morning stiffness is necessary to make the diagnosis. Polymyalgia rheumatica does not respond to NSAIDs. The erythrocyte sedimentation rate should be ≥40 mm/hr. A 71-year-old female with end-stage lung cancer was recently extubated and is awaiting transfer to hospice. She is awake and confused and has significant respiratory secretions. Which one of the following medications used for reducing respiratory secretions is LEAST likely to cause central nervous system effects such as sedation? (check one) A. Atropine B. Transdermal scopolamine (Transderm Scop) C. Hyoscyamine (Levsin) D. Glycopyrrolate (Robinul) - Answer Glycopyrrolate does not cross the blood-brain barrier, and is therefore least likely to cause central nervous system effects such as sedation. The other medications listed do cross the blood-brain barrier. Which one of the following is the most common cause of unintentional deaths in children? - Answer Unintentional injuries account for 40% of childhood deaths. Motor vehicle accidents are the most frequent cause of these deaths (58.2% of unintentional deaths). The proper use of child restraints is the most effective way to prevent injury or death, and the American Academy of Family Physicians and the American Academy of Pediatrics strongly recommend that physicians actively promote the proper use of motor vehicle restraints for all patients. Drowning accounts for 10.9% of all unintentional deaths in children, poisoning for 7.7%, fires 5.7%, and falls 1.4%. A 45-year-old male presents with shortness of breath and a cough. On pulmonary function testing his FVC is <80% of predicted, his FEV1/FVC is 90% of predicted, and there is no improvement with bronchodilator use. The diffusing capacity of the lung for carbon monoxide (DLCO) is also low. Based on these results, which one of the following is most likely to be the cause of this patient's

problem? - Answer Based on the results of pulmonary function testing, this patient has a pure restrictive pattern with a low diffusing capacity for carbon monoxide. Pulmonary fibrosis is compatible with this pattern. A patient with any of the other listed diagnoses would be expected to have an obstructive pattern on testing. normal value is about 80% A 45-year-old male presents to the emergency department with a complaint of acute, sharp chest pain relieved only by leaning forward. On examination you hear a pericardial friction rub. An EKG shows diffuse ST elevations. Echocardiography reveals a small pericardial effusion. Which one of the following is the most appropriate initial treatment? - Answer Patients with acute pericarditis should be treated empirically with colchicine and/or NSAIDs (aspirin, ibuprofen) for the first episode of mild to moderate pericarditis. B-Blockers would only be appropriate if the cause of the patient's chest pain were an infarction or ischemia. Nitrates do not relieve the pain of pericarditis. Glucocorticoids are typically reserved for use in patients with severe or refractory cases or in cases where the likely cause of the pericarditis is connective tissue disease, autoreactivity, or uremia (SOR C). When is a kid overweight according to the CDC? - Answer The recommended terminology for weight classification in children is based on age and either BMI (for children ages 2-18 years) or weight-for-length ratio (for children ages 0-2 years). Children under the age of 2 years are identified as being overweight when their weight- for-length ratio exceeds the 95th percentile for their sex. The term obese is not used for children under the age of 2 years. Children age 2-18 years are appropriately classified as underweight when their BMI falls below the 5th percentile, healthy weight when their BMI is between the 5th and 85th percentile, overweight when their BMI is between the 85th and 94th percentile, and obese when their BMI is in the 95th or greater percentile. There is currently no standard definition of childhood morbid obesity, but obesity is sometimes classified as severe or extreme when a child's BMI is at the 99th percentile or greater. What is RSV season? - Answer Respiratory syncytial virus (RSV) is a common cause of respiratory tract infections in children. The infections are usually self-limited and are rarely associated with bacterial co-infection, but in very young infants, prematurely born infants, or those with pre-existing heart/lung

conditions, the infection can be severe. In North America, RSV season is November to April. Treatment is primarily supportive, including a trial of bronchodilators, with continued use only if there is an immediate response. Corticosteroids and antibiotics are not routinely indicated (SOR B). Routine laboratory and radiologic studies should not be used in making the diagnosis, as it is based on the history and physical examination (SOR C). A 2-month-old female is brought to your office with tachypnea and a staccato cough. She is afebrile. A chest radiograph shows hyperinflation and bilateral infiltrates, and a CBC reveals eosinophilia. Which one of the following is the most likely etiologic agent? - Answer This infant has the typical findings of chlamydial pneumonia, which usually develops 1-3 months after birth and should be suspected in a young infant who has tachypnea, a staccato cough, and no fever (SOR A). Radiographs often show hyperinflation and infiltrates, and a CBC will reveal eosinophilia. What is the most appropriate treatment for community acquired pneumonia in kids? - Answer Amoxicillin is the recommended first-line treatment for previously healthy infants and school-age children with mild to moderate community-acquired pneumonia (CAP) (strong recommendation; moderate-quality evidence). The most prominent bacterial pathogen in CAP in this age group is Streptococcus pneumoniae, and amoxicillin provides coverage against this organism. Azithromycin would be an appropriate choice in an older child because Mycoplasma pneumoniae would be more common. Moxifloxacin should not be used in children. Ceftriaxone and cefdinir can both be used to treat CAP, but they are broader spectrum antibiotics and would not be a first-line choice in this age group. A 53-year-old male presents to your office with a several-day history of hiccups. They are not severe, but have been interrupting his sleep, and he is becoming exasperated. What should be the primary focus of treatment in this individual? - Answer Hiccups are caused by a respiratory reflex that originates from the phrenic and vagus nerves, as well as the thoracic sympathetic chain. Hiccups that last a matter of hours are usually benign and self-limited, and may be caused by gastric distention. Treatments usually focus on interrupting the reflex loop of the hiccup, and can include mechanical means (e.g., stimulating the pharynx with a tongue depressor) or medical treatment, although only chlorpromazine is FDA-approved for this indication.

If the hiccups have lasted more than a couple of days, and especially if they are waking the patient up at night, there may be an underlying pathology causing the hiccups. In one study, 66% of patients who experienced hiccups for longer than 2 days had an underlying physical cause. Identifying and treating the underlying disorder should be the focus of management for intractable hiccups. When compared to a figure-of-eight dressing, which one of the following modalities of treatment has been shown to have similar fracture-healing outcomes and increased patient satisfaction for nondisplaced mid-shaft clavicular fractures? - Answer When compared to a figure-of- eight dressing, a sling has been shown to have similar fracture healing rates in patients with a nondisplaced midshaft clavicular fracture. In addition, a figure-of-eight dressing is uncomfortable and difficult to adjust, and patients have reported increased satisfaction when treated with a sling. Long and short arm casts are not appropriate options to manage a patient with a clavicular fracture. Operative treatment is an option to treat displaced midshaft fractures (SOR B). It should be noted that a Cochrane review of interventions for clavicle fracture pointed out that the studies of this problem were done in the 1980s and did not meet current standards. One of the conclusions of this review was that further research should be done. How is anemia of chronic kidney disease treated when iron stores are low (low serum ferritin)? - Answer Patients with depleted iron stores will benefit from replenishment, which serves to correct an isolated iron deficiency or improve the response to erythropoiesis-stimulating agents. Iron therapy is generally initiated orally with ferrous sulfate, 325 mg 3 times a day. The effectiveness of this therapy can be monitored by checking hemoglobin, transferrin saturation, and ferritin levels at 1 and 3 months after beginning treatment. If the goals have not been achieved by 3 months, intravenous iron therapy should be considered. For patients who do not respond to iron replacement, erythropoiesis-stimulating agents such as epoetin alfa or darbepoetin alfa should be used. The goal should be to relieve symptoms such as fatigue and to achieve a hemoglobin level of 11-12 g/dL. Levels >13 g/dL increase the mortality rate, particularly from cardiovascular disease. Which one of the following is a common cause of prerenal acute kidney injury? - Answer The diagnosis of acute kidney injury (AKI) is based on elevated serum creatinine levels and is often associated with a reduction in urine output (SOR C). The causes of AKI are commonly divided into three categories: prerenal, intrinsic renal, and postrenal (SOR C). Prerenal

AKI is most commonly due to decreased renal perfusion, often because of volume depletion. In addition to vomiting and diarrhea, overuse of diuretics can lead to prerenal AKI. Intrinsic renal AKI is caused by a process within the kidneys. Glomerulonephritis and acute tubular necrosis are types of intrinsic AKI. Postrenal AKI refers to a process distal to the kidneys and is most often caused by inadequate drainage of urine. Neurogenic bladder and prostate hypertrophy contribute to extrarenal obstruction. A 77-year-old white male complains of urinary incontinence of more than one year's duration. The incontinence occurs with sudden urgency. No association with coughing or positional change has been noted, and there is no history of fever or dysuria. He underwent transurethral resection of the prostate (TURP) for benign prostatic hypertrophy a year ago, and he says his urinary stream has improved. A rectal examination reveals a smoothly enlarged prostate without nodularity, and normal sphincter tone. No residual urine is found with post-void catheterization. Which one of the following is the most likely cause of this patient's incontinence? - Answer In elderly patients, detrusor instability is the most common cause of urinary incontinence in both men and women. Incontinence may actually become worse after surgical relief of obstructive prostatic hypertrophy. Infection is unlikely as the cause of persistent incontinence in this patient in the absence of fever or symptoms of urinary tract infection. Overflow is unlikely in the absence of residual urine. Impaction is a relatively rare cause of urinary incontinence, and associated findings would be present on rectal examination. Normalization of the urinary stream and the absence of residual urine reduce the likelihood of recurrent obstruction. The prostate would be expected to remain enlarged on rectal examination after transurethral resection of the prostate (TURP). An 86-year-old mildly demented male nursing-home resident rarely leaves the facility. He has frequent fecal incontinence that is disturbing to both him and his family. He has diet-controlled diabetes mellitus and hypertension, and a history of transurethral resection of the prostate (TURP) for benign prostatic hypertrophy. An examination is remarkable only for an empty rectum and no focal neurologic findings. Which one of the following is the most likely cause of this patient's fecal incontinence? (check one) A. Decreased rectal sensation secondary to diabetes mellitus B. Decreased rectal storage capacity C. Internal sphincter weakness D. Puborectalis weakness E. Overflow - Answer Overflow incontinence is common in the institutionalized elderly, and is often due to constipating medications. Reduced storage capacity is usually seen with inflammatory bowel disease. Mild diabetes mellitus does not cause decreased rectal sensation, and puborectalis and internal sphincter weakness are uncommon in males, as they usually result from vaginal delivery.

What patient population typically has SCFE? - Answer Slipped capital femoral epiphysis (SCFE) occurs most commonly during the adolescent growth spurt (11-13 years of age for girls, 13-15 years of age for boys). While the cause is unknown, associated factors include anatomic variables such as femoral retroversion or steeper inclination of the proximal femoral physis, in addition to being overweight. African-Americans are affected more commonly as well. The patient may present with pain in the groin or anterior thigh, but also may present with pain referred to the knee. The hallmark of SCFE on examination is limited internal rotation of the hip. Specific to SCFE is the even greater limitation of internal rotation when the hip is flexed to 90°. No other pediatric condition has this physical finding, which makes the maneuver very useful in children with lower extremity pain. Orthopedic consultation is advised if SCFE is suspected. Hip extension and abduction are also limited in SCFE, but these findings are nonspecific. The knee findings in this patient are not associated with SCFE. What patient population gets Legg-Calve perthes? - Answer That is also the case for Legg-Calvé-Perthes disease, also known as avascular or aseptic necrosis of the femoral head. This condition most commonly occurs in boys 4-8 years of age. In addition to hip (or knee) pain, limping is a prominent feature. An 8-year-old female is brought to your office because she has begun to limp. She has had a fever of 38.8°C (101.8°F) and says that it hurts to bear weight on her right leg. She has no history of trauma. On examination, she walks with an antalgic gait and hesitates to bear weight on the leg. Range of motion of the right hip is limited in all directions and is painful. Her sacroiliac joint is not tender, and the psoas sign is negative. Laboratory testing reveals an erythrocyte sedimentation rate of 55 mm/hr (N 0-10), a WBC count of 15,500/mm 3 (N 4500-13,500), and a C-reactiveprotein level of 2.5 mg/dL (N 0.5-1.0). Which one of the following will provide the most useful diagnostic information to further evaluate this patient's problem? - Answer This child meets the criteria for possible septic arthritis. In this case ultrasonography is recommended over other imaging procedures. It is highly sensitive for detecting effusion of the hip joint. If an effusion is present, urgent ultrasound-guided aspiration should be performed. Bone scintigraphy is excellent for evaluating a limping child when the history, physical examination, and radiographic and sonographic findings fail to localize the pathology. CT is indicated when cortical bone must be visualized. MRI provides excellent visualization of joints, soft tissues, cartilage, and medullary bone. It is especially useful for confirming osteomyelitis, delineating the extent of malignancies, identifying stress fractures, and diagnosing early Legg-Calvé-Perthes disease. Plain film radiography is often obtained as an initial imaging modality in any child with a limp. However, films may be normal in patients with septic arthritis, providing a false-negative result.

A 56-year-old female comes in for evaluation of gradually worsening right hip pain. She describes her pain as located in the groin and dull in nature, and with activity often notes a clicking sensation associated with sharp pain. On examination her hip range of motion is intact but pain is elicited with extremes of internal and external rotation and her groin pain is exacerbated with the FABER test (knee flexion, abduction and external rotation of the leg until the ankle rests proximal to the contralateral knee) and FADIR test (knee flexion, adduction, and internal rotation of the leg). Which one of the following is the most likely diagnosis? - Answer This patient has signs and symptoms of a hip labral tear. This causes dull or sharp groin pain, which in some patients radiates to the lateral hip, anterior thigh, or buttock. The pain usually has an insidious onset, but occasionally begins acutely after a traumatic event. Half of patients also have mechanical symptoms, such as catching or painful clicking with activity. The FADIR and FABER tests are effective for detecting intra-articular pathology (the sensitivity is 75%-96% for the FADIR test and 88% for the FABER test), although neither test has high specificity. Magnetic resonance arthrography is considered the diagnostic test of choice for labral tears, as it has a sensitivity of 90% and an accuracy of 91%. However, if a labral tear is not suspected, less invasive imaging modalities such as plain radiography and conventional MRI should be used first to assess for other causes of hip and groin pain. This patient has no history of trauma or risk factors to suggest a fracture. A femoral hernia would typically present as pain that is worse with straining or lifting, associated with a palpable bulge in the upper thigh. Trochanteric bursitis typically causes lateral hip pain with point tenderness over the greater trochanter of the femur (steroids!) A 35-year-old male amateur rugby player seeks your advice because right hip pain of several months' duration has progressed to the point of interfering with his athletic performance. The pain is accentuated when he transitions from a seated to a standing position, and especially when he pivots on the hip while running, but he cannot recall any significant trauma to the area and finds no relief with over-the-counter analgesics. On examination his gait is stable. The affected hip appears normal and is neither tender to palpation nor excessively warm to touch. Although he has a full range of passive motion, obvious discomfort is evident with internal rotation of the flexed and adducted right hip. Which one of the following is most strongly suggested by this clinical picture? - Answer Gradually worsening anterolateral hip joint pain that is sharply accentuated when pivoting laterally on the affected hip or moving from a seated to a standing position is consistent with femoroacetabular impingement. Reproduction of the pain on range-of- motion examination by manipulating the hip into a position of flexion, adduction, and internal rotation (FADIR test) is the most sensitive physical finding. Special radiographic

imaging of the flexed and adducted hip can emphasize the anatomic abnormalities associated with impingement that may go unnoticed on standard radiographic series views. Although the pain associated with avascular necrosis is similarly insidious and heightened when bearing weight, tenderness is usually evident with hip motion in any direction. Osteoarthritis of the hip generally occurs in individuals of more advanced age than this patient, and the pain produced is typically localized to the groin area and can be elicited by flexion, abduction, and external rotation (FABER test) of the affected hip.Bursitis manifests as soreness after exercise and tenderness over the affected bursa. Which one of the following vaccines will slightly increase the child's risk of a febrile seizure for up to 2 weeks after administration? - Answer Fever and febrile seizures may occur after administration of several vaccines. Postimmunization seizures, especially febrile seizures, occur at a higher rate in children who have a past history of seizures or a first-degree relative with a history of seizures. The benefits of the vaccines outweigh the risks, so they are not contraindicated in this situation, although the parents need to be cautioned about the increased risk of seizure. Of the vaccines listed, the only one likely to put the child at risk for a seizure up to 2 weeks after administration is the MMR vaccine. Specifically, it is the measles component of the vaccine that is the potential culprit. A temperature of 39.4°C (103°F) or higher develops in approximately 5%-15% of susceptible vaccine recipients, usually 6-12 days after receipt of MMR vaccine. The fever generally lasts 1-2 days but may last up to 5 days. What are signs of ulnar collateral ligament injury? - Answer This patient has injured his ulnar collateral ligament (UCL). The UCL is the primary restraint to valgus stress on the elbow during overhead throwing. These injuries often occur in athletes participating in sports that require overhead throwing, such as baseball, javelin, and volleyball. Patients often report a pop followed by immediate pain and bruising around the medial elbow. The moving valgus stress test has 100% sensitivity and 75% specificity for diagnosing UCL injuries. What are signs of medial epicondylitis? - Answer Medial epicondylitis usually presents with an insidious onset of pain related to a recent increase in occupational or recreational activities. Patients also often report weakened grip strength. The point of maximal tenderness is 5-10 mm distal to and anterior to the medial epicondyle. It is most often a tendinopathy of the flexor carpi radialis and the pronator teres.

What are signs of biceps tendinopathy? - Answer Biceps tendinopathy usually presents with a history of vague anterior elbow pain and a history of repeated elbow flexion with forearm supination and pronation, such as dumbbell curls. Resisted supination produces pain deep in the antecubital fossa. What is cubital tunnel syndrome? - Answer Cubital tunnel syndrome is a neuropathy of the ulnar nerve caused by compression or traction as it passes through the cubital tunnel of the medial elbow. The onset of pain is more insidious than UCL injury, occurring with repetitive activity, and is usually accompanied by numbness and tingling in the ulnar border of the forearm and hand. If it has existed for some time, the intrinsic hand muscle may become weak. What are signs of triceps tendinopathy? - Answer Tendinopathy of the triceps insertion is more common in weight lifters or athletes who repetitively extend their elbows against resistance. Pain occurs at the posterior elbow with resisted extension, and tenderness is located over the triceps insertion. Cow's milk in the diet is not recommended until a kid is how old? - Answer Whole cow's milk does not supply infants with enough vitamin E, iron, and essential fatty acids, and overburdens them with too much protein, sodium, and potassium. Skim and low-fat milk lead to the same problems as whole milk, and also fail to provide adequate calories for growth. For these reasons cow's milk is not recommended for children under 12 months of age. Human breast milk or iron-fortified formula, with introduction of certain solid foods and juices after 4-6 months of age if desired, is appropriate for the first year of life. A 15-year-old male presents to the emergency department after suffering a lateral dislocation of his patella. Which one of the following would be the best method for reducing this dislocation? - Answer It is usually simple to reduce a lateral patellar dislocation, and these injuries rarely require acute surgical management. The proper technique is to have the patient sit or lie with the leg in a flexed position and then apply gentle medial pressure to the patella until the most lateral edge is over the femoral condyle. The leg should then be gently extended and the knee brought into full extension. This should cause the patella to slip back into place, and the knee should then be immobilized. A 68-year-old male with end-stage lung cancer is being treated for pain secondary to multiple visceral and skeletal metastases. He has been on oral ibuprofen and parenteral morphine. However, over the past few weeks he reports progressive worsening of his pain. In order to achieve better pain control his morphine dosage has been continuously titrated up. In spite of this increase he continues to report severe pain that is now diffuse and occurs even when his caregivers touch him.

Which one of the following would be most appropriate at this time? - Answer Opioid- induced hyperalgesia is characterized by a paradoxical increase in sensitivity to pain despite an increase in the opioid dosage. It is seen in patients who are receiving high doses of parenteral opioids such as morphine. Patients report the development of diffuse pain away from the site of the original pain. Allodynia, a perception of pain in the absence of a painful stimulus, is also typical in opioid-induced hyperalgesia. Strategies to manage this condition include reducing the current opioid dosage, and occasionally eliminating the current opioid and starting another opioid. The addition of non-opioid pain medications should also be considered. The addition of an anxiolytic is not likely to improve this patient's pain (SOR C). You are caring for a 70-year-old male with widespread metastatic prostate cancer. Surgery, radiation, and hormonal therapy have failed to stop the cancer, and the goal of his care is now symptom relief. He is being cared for through a local hospice. Over the past few days he has been experiencing respiratory distress. His oxygen saturation is 94% on room air and his lungs are clear to auscultation. His respiratory rate is 16/min. Which one of the following would be best at this po - Answer Dyspnea is a frequent and distressing symptom in terminally ill patients. In the absence of hypoxia, oxygen is not likely to be helpful. Opiates are the mainstay of symptomatic treatment. A 42-year-old male with a 4-year history of multiple sclerosis (MS) presents with an acute attack manifested by ataxia, incoordination, and dysarthria. Which one of the following is indicated for managing this flare-up of his MS? - Answer Corticosteroids, either orally or parenterally, are the first-line treatment for acute exacerbations of multiple sclerosis (MS) (SOR A). A Cochrane review found no significant differences in outcomes based on the route of administration. Disease-modifying agents such as interferon beta, glatiramer, and immunosuppressants such as fingolimod may decrease the frequency of exacerbations and slow the progression of MS but are not the agents of first choice for treatment of acute flareups. Pramipexole does not have a primary role in the treatment of MS, although it might be used to treat certain specific symptoms as an adjunct therapy. What is the treatment for serotonin syndrome? - Answer Serotonin syndrome is a result of increased serotonergic activity in the central nervous system and may be life- threatening. It is usually a combination of autonomic hyperactivity, neuromuscular abnormality, and mental status changes. The most common group of medications that may cause this is the SSRIs. Serotonin syndrome most commonly occurs in the first 24 hours of treatment. Patients often present with

agitation and confusion, tachycardia, and elevated blood pressure, as well as a dry mouth. While there are usually no focal neurologic findings, hyperreflexia and even spontaneous clonus may be seen. The finding of slow, horizontal movement of the eyes is also helpful in making the diagnosis. The initial management is to discontinue the offending agent, begin supportive care, and attempt to calm the patient verbally. Many times medication is needed, and the drug of choice is an intravenous benzodiazepine such as lorazepam or diazepam. If treatment for tachycardia or hypertension is needed, propranolol should not be used due to its longer activity. Haloperidol should be avoided, as it may actually increase anticholinergic activity. Flumazenil is rarely used, although it has been used for tricyclic antidepressant overdosage, and it carries a significant risk of inducing seizures. If the patient does not respond to calming with benzodiazepines, the antidote would be cyproheptadine. Which one of the following can help to minimize the pain of lidocaine (Xylocaine) injection? - Answer Lidocaine buffered with sodium bicarbonate decreases the pain associated with the injection. This effect is enhanced when the solution is warmed to room temperature (SOR B). Rapidly inserting the needle through the skin, injecting the solution slowly and steadily while withdrawing the needle, and injecting into the subcutaneous tissue also minimize the pain of injection. Which one of the following is most appropriate for patients with asplenia? - Answer Asplenic patients who develop a fever should be given antibiotics immediately. Due to the increased risk of pneumococcal sepsis in asplenic patients, vaccinations against these particular bacteria are specifically recommended. Since pneumococcal conjugate vaccine (PCV13) and pneumococcal polysaccharide vaccine (PPSV23) can interact with each other they should be given at least 8 weeks apart. Prophylactic penicillin given orally twice a day is particularly important in children under 5 years of age who are asplenic, and may be considered for 1-2 years post splenectomy in older patients. Lifelong daily antibiotics may be considered following post-splenectomy sepsis. T he risk for Haemophilus influenzae type b infection is not increased in asplenic patients, so additional vaccine is not needed for those who have already been vaccinated. Live attenuated influenza vaccine may be used in asplenic patients, unless they have sickle cell disease. You are caring for a 60-year-old female with Crohn's disease that is well controlled by infliximab (Remicade). As your staff updates her immunization status, which one of the following should be kept in mind? - Answer Zoster vaccine, a live attenuated virus vaccine, is contraindicated in this patient due to her

immunocompromised state. The other vaccines listed are safe and particularly recommended for patients with inflammatory bowel disease, given their increased susceptibility to infections. Immunosuppression is defined as:

• Treatment with glucocorticoids (treatment with the equivalent of 20 mg/day of prednisone for 2 weeks or more, and discontinuation within the previous 3 months)
• Ongoing treatment with effective doses of 6-MP/azathioprine or discontinuation within the previous 3 months
• Treatment with methotrexate or discontinuation within the previous 3 months
• Treatment with infliximab or discontinuation within the previous 3 months
• Significant protein-calorie malnutrition A 37-year-old graphic designer presents to your office with a history of several months of radial wrist pain. She does not recall any specific trauma but notes that it hurts to hold a coffee cup. Finkelstein's test is positive and a grind test is negative, and there is tenderness to palpation over the radial tubercle. Which one of the following would be most appropriate at this point? - Answer This patient has de Quervain's tenosynovitis. Finkelstein's test has good sensitivity and specificity (SOR C) in patients with a negative grind test. = rest and thumb spica wrist splint A positive grind test would be more consistent with scaphoid fracture. A hand radiograph with secondary thumb spica splinting would be appropriate for a suspected scaphoid fracture, but the insidious onset as opposed to overt trauma makes this diagnosis unlikely in thiscase. A short arm cast is not indicated in de Quervain's tenosynovitis but may be appropriate for forearm/wrist fractures. A 35-year-old right-handed softball player injures his left wrist when sliding into second base. When he sees you the next day his description of the injury indicates that he hyperextended his wrist while sliding, and the pain was later accompanied by swelling. Your examination is remarkable only for mild swelling and tenderness of the dorsal wrist, distal to the ulnar styloid. What is this injury? - Answer Triquetral fractures typically occur with hyperextension of the wrist. Dorsal avulsion fractures are more common than fractures of the body of the bone. Tenderness is characteristically noted on the dorsal wrist on the ulnar side distal to the ulnar styloid. The typical radiologic finding is a small bony avulsion visible on a lateral view of the wrist. Most studies indicate that this carpal bone has the second or third highest fracture rate after the navicular. Avulsion fractures respond well to 4 weeks of splinting and protection.

Clinical and radiologic signs do not match those expected in navicular or scaphoid fractures. Navicular fractures may initially have normal radiologic findings. Immobilization and follow-up radiographs are required. Tenderness in the snuffbox area is expected, but dorsal tenderness and swelling are not characteristic. The radiographs do not show a lunate fracture or dislocation. A wrist sprain is a diagnosis of exclusion and should not be considered too early. Which one of the following is an indication for a second dose of pneumococcal polysaccharide vaccine in children? - Answer Patients with chronic illness, diabetes mellitus, cerebrospinal fluid leaks, chronic bronchopulmonary dysplasia, cyanotic congenital heart disease, or cochlear implants should receive one dose of pneumococcal polysaccharide vaccine after 2 years of age, and at least 2 months after the last dose of pneumococcal conjugate vaccine. Revaccination with polysaccharide vaccine is not recommended for these patients. Individuals with sickle cell disease, those with anatomic or functional asplenia, immunocompromised persons with renal failure or leukemia, and HIV-infected persons should receive polysaccharide vaccine on this same schedule and should also be revaccinated at least 3 years after the first dose. A 30-year-old female reports that she and her husband have not been able to conceive after trying for 15 months. She takes no medications, has regular menses, and has no history of headaches, pelvic infections, or heat/cold intolerance. Her physical examination is unremarkable. Her husband recently had a normal semen analysis. Which one of the following would be the most appropriate next step? - Answer Although infertility issues may be very complex, the primary care physician can initiate an appropriate workup. For women who are having regular menstrual cycles, ovulation is very likely. Ovulation can be confirmed by a progesterone level ³5 ng/mL on day 21 of the cycle. If this is the case, tubal patency should be confirmed with hysterosalpingography or laparoscopy. Obstruction or adhesions would require surgical correction, but if there are none, referral for assisted reproductive technology would be appropriate. Should the progesterone level be <5 ng/mL, anovulation should be investigated with TSH, estradiol, FSH, and prolactin levels. Treatment can be initiated if findings reveal the cause of the problem, but if they are unremarkable it is reasonable to try clomiphene to induce ovulation. If this is unsuccessful, referral would be the next step. A 48-year-old male sees you for a routine health maintenance examination. His blood pressure

is 142/90 mm Hg and you recommend that he return for a repeat blood pressure measurement. Eight weeks later his blood pressure is 138/88 mm Hg. He denies any symptoms on a review of systems. He tells you that on his 40th birthday he abruptly stopped smoking after smoking a pack of cigarettes a day since his early twenties. He is adopted and cannot provide a family history. According to U.S. Preventive Services Task Force guidelines, which one of the following conditions should this patient be screened for now? - Answer U.S. Preventive Services Task Force (USPSTF) guidelines recommend that asymptomatic adults with sustained blood pressure >135/80 mm Hg be screened for type 2 diabetes mellitus using fasting plasma glucose, a 2-hour glucose tolerance test, or hemoglobin A1c measurements (USPSTF B recommendation). Screening for colon cancer with either annual high-sensitivity fecal occult blood testing, sigmoidoscopy every 5 years, or colonoscopy every 10 years is also recommended for adults between the ages of 50 and 75 years (USPSTF A recommendation). Men who have ever smoked (defined as 100 or more cigarettes) should be screened once for abdominal aortic aneurysm (USPSTF B recommendation) between the ages of 65 and 75. Similar screening is recommended in men who have never smoked, but this is a USPSTF grade C recommendation. No recommendation has been made with regard to screening for peripheral vascular disease, and the recommendation on screening for hemochromatosis is listed as inactive on the USPSTF website. A hemoglobin A1c of 7.0% would correspond to which one of the following mean (average) plasma glucose levels? - Answer A hemoglobin A1c(HbA1c) of 6.0% correlates with a mean plasma glucose level of 126 mg/dL or 7.0 1c 1c mmol/dL. A calculator to convert HbA1clevels into estimated average glucose levels is available at http://professional.diabetes.org/eAG. A rough guide for estimating average plasma glucose levels assumes that an 1cof 6.0% equals an average glucose level of 120 mg/dL. Each percentage point increase in 1c is equivalent to a 30-mg/dL rise in average glucose. An HbA1cof 7.0% is therefore roughly equivalent to an average glucose level of 150 mg/dL, and an HbA1c of 8.0% translates to an average glucose level of 180 mg/dL. His FVC and FEV1/FVC are both less than the lower limit of normal as defined by the Third National Health and Nutrition Examination Survey. Repeat testing following administration of a bronchodilator does not correct these values. Which one of the following would be most appropriate at this time? - Answer An FVC that falls below the lower limit of normal (LLN), defined as the fifth percentile of spirometry data

obtained from the Third National Health and Nutrition Examination Survey, is consistent with a restrictive pattern of pulmonary function. An FEV1/FVC less than the LLN is consistent with an obstructive defect. A mixed pattern exists when both values are below the LLN, as in this case. The patient should now be referred for full pulmonary function testing, including diffusing capacity of the lungs for carbon monoxide (DLCO). DLCO is a quantitative measure of gas transfer in the lungs. Diseases that decrease blood flow to the lungs or that damage alveoli will lead to less efficient gas exchange and result in a lower DLCO value. Bronchoprovocation (a methacholine challenge, a mannitol inhalation challenge, or exercise testing) should be performed if pulmonary function test results are normal but exercise- or allergen-induced asthma is suspected. When treating acute adult asthma in the emergency department, using a metered-dose inhaler (MDI) with a spacer has been shown to result in which one of the following, compared to use of a nebulizer? - Answer Compared to nebulizers, MDIs with spacers have been shown to lower pulse rates, provide greater improvement in peak-flow rates, lead to greater improvement in arterial blood gases, and decrease required albuterol doses. They have also been shown to lower costs, shorten emergency department stays, and significantly lower relapse rates at 2 and 3 weeks compared to nebulizers. There is no difference in hospital admission rates. You see a 5-year-old white female with in-toeing due to excessive femoral anteversion. She is otherwise normal and healthy, and her mobility is unimpaired. Her parents are greatly concerned with her appearance and possible future disability, and request that she be treated. You recommend which one of the following? - Answer There is little evidence that femoral anteversion causes long-term functional problems. Studies have shown that shoe wedges, torque heels, and twister cable splints are not effective. Surgery should be reserved for children 8-10 years of age who still have cosmetically unacceptable, dysfunctional gaits. Major complications of surgery occur in approximately 15% of cases, and can include residual in-toeing, out-toeing, avascular necrosis of the femoral head, osteomyelitis, fracture, valgus deformity, and loss of position. Thus, observation alone is appropriate for a 5-year-old with uncomplicated anteversion. A 4-year-old male is brought to your office by his parents who are concerned that he is increasingly "knock-kneed." His uncle required leg braces as a child, and the parents are worried about long-term gait abnormalities. On examination, the patient's knees touch when he stands and there is a 15° valgus angle at the knee. He walks with a stable gait.

Which one of the following should you do now? - Answer This case is consistent with physiologic genu valgus, and the parents should be reassured. Toddlers under 2 years of age typically have a varus angle at the knee (bowlegs). This transitions to physiologic genu valgus, which gradually normalizes by around 6 years of age. As this condition is physiologic, therapies such as surgical intervention, special bracing, and exercise programs are not indicated. A 77-year-old male presents with significant postherpetic neuralgia in a chest wall distribution. Which one of the following is most likely to be effective in diminishing his discomfort? - Answer Antiviral drugs are useful for treatment of acute herpes zoster but not for treatment of postherpetic neuralgia. Herpes zoster vaccine can prevent postherpetic neuralgia by reducing the incidence of herpes zoster but it has no role in the treatment of neuralgia. Neither acupuncture nor epidural corticosteroid injections are helpful in treating postherpetic neuralgia. Topical agents such as lidocaine patches and capsaicin cream or patches have been shown to reduce symptoms of postherpetic neuralgia, as have the oral agents gabapentin, pregabalin, and amitriptyline. A 50-year-old male presents to your office with a 1-hour history of an intense retro- orbital headache. This started while he was jogging and eased somewhat when he stopped, but has persisted along with some pain in his neck. Other than a blood pressure of 165/100 mm Hg, his examination is unremarkable. Noncontrast CT of the head is also unremarkable. His pain has persisted after 2 hours in the emergency department. Which one of the following would be most appropriate at this time? - Answer Early diagnosis of a nontraumatic subarachnoid hemorrhage is paramount for achieving a good outcome when a patient presents with a headache that is unusually severe and feels different than other headaches. Risk factors include smoking, hypertension, heavy alcohol use, and a family history of aneurysm or hemorrhagic stroke. The initial evaluation should consist of noncontrast CT of the head (SOR C). If it is negative or equivocal the next step would be to perform a lumbar puncture to determine whether or not the cerebrospinal fluid is xanthochromic. The absence of xanthochromia rules out subarachnoid hemorrhage (SOR C). A 40-year-old white male presents with a 5-year history of periodic episodes of severe right-sided headaches. During the most recent episode the headaches occurred most days during January and February and lasted about 1 hour. The most likely diagnosis is which one of the following? - Answer Cluster headache is predominantly a male disorder. The mean age of onset is 27-30 years. Attacks often occur in cycles and are unilateral. Migraine headaches are more common in women,

start at an earlier age (second or third decade), and last longer (4-24 hours). Temporal arteritis occurs in patients above age 50. Trigeminal neuralgia usually occurs in paroxysms lasting 20-30 seconds. A healthy 68-year-old male is seen in December for a routine examination. A review of his immunizations indicates that he received a standard dose of inactivated influenza vaccine at the health clinic in September. He received 23-valent pneumococcal vaccine (Pneumovax 23) at age

He should now receive which one of the following? - Answer The Advisory Committee on Immunization Practices advises that the 13-valent pneumococcal vaccine be given in addition to the 23-valent vaccine, preferably before the 23-valent vaccine. Only one dose of influenza vaccine is recommended per season. A single dose of 23- valent pneumococcal vaccine is all that is required. You would recommend pneumococcal vaccine for which one of the following? (check one) A. A 20-year-old male who smokes 1 pack of cigarettes daily B. A 52-year-old male with type 2 diabetes mellitus who received pneumococcal vaccine 6 years ago C. A 60-year-old male who is a long-term resident of a nursing home because of a previous stroke, and who received pneumococcal vaccine at age 54 D. A 62-year-old male with chronic renal failure who received pneumococcal vaccine at age 50 and age 55 E. A 71-year-old male with no medical problems who received pneumococcal vaccine at age 65 - Answer In October 2008 the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention recommended adding cigarette smoking to the list of high-risk conditions that are indications for the 23-valent pneumococcal polysaccharide vaccine. All persons between the ages of 19 and 64 who smoke should receive this vaccine. One-time revaccination after 5 years is recommended for persons with chronic renal failure, asplenia (functional or anatomic), or other immunocompromising conditions. The patient with chronic renal failure in this question has already received two immunizations. The diabetic patient and the nursing-home resident have both received one immunization and should not receive a second dose until age 65. The 71-year-old has already been immunized after age 65, and a repeat immunization is not recommended.

A 62-year-old male comes to your office as a new patient. He has a past history of a myocardial infarction and is currently in stage C heart failure according to the American Heart Association classification. His ejection fraction is 30%. Which one of the following medications that the patient is currently taking is potentially harmful and should be discontinued if possible? - Answer ACE inhibitors or angiotensin receptor blockers should be used in all patients with a history of myocardial infarction and reduced ejection fraction. Aldosterone receptor antagonists are indicated in patients who have a left ventricular ejection fraction £35%. Nondihydropyridine calcium channel blockers with negative inotropic effects (verapamil and diltiazem) may be harmful in patients with low left ventricular ejection fractions. Statin therapy is recommended in all patients with a history of myocardial infarction. Evidence-based B-blockers (carvedilol or metoprolol succinate) should be used in all patients with a history of myocardial infarction. You evaluate an 18-month-old male with fecal impaction and determine that disimpaction is indicated. Which one of the following would be most appropriate initially? - Answer Oral osmotics such as polyethylene glycol-based solutions are recommended as an appropriate initial approach to constipation in children because they are effective, easy to administer, noninvasive, and well tolerated (SOR C). Rectal therapies are similar in terms of effectiveness but are more invasive and less commonly used as first-line treatment (SOR A). Oral stimulants and bisacodyl rectal suppositories are not recommended for children under 2 years of age. Enemas are sometimes used as second-line therapy, but the addition of enemas to oral laxative regimens does not improve outcomes in children with severe constipation (SOR B). Manual disimpaction is a more invasive option and is not recommended as first-line treatment in young children. A school nurse discovers head lice on a fourth-grade student. When should the student be permitted to return to class? - Answer Head lice are a common and easily treated inconvenience in school-aged children that, unlike body lice, are not associated with significant illnesses. Transmission generally requires head-to-head contact, as lice cannot survive when separated from their host for more than 24 hours and do not fly or hop. Visible nits are generally present at the time of diagnosis, confirming that the infestation has been present for some time, so immediate isolation from other children would not be expected to change the natural course of events.

The American Academy of Pediatrics (AAP) recommends that children found to be infested with lice remain in class but be discouraged from close contact with others until treated appropriately with a pediculicide. The AAP position also recommends abandonment of "no nits" school policies, which prohibit attendance until no visible nits are identified. Nits can be found long after their deposition at the scalp level and generally have already hatched by the time they are easily noted at some distance from the scalp. A 42-year-old female presents with a cough productive of blood-streaked sputum for the past 3 days. Her hemoptysis was preceded by several days of rhinorrhea, congestion, and subjective fever. She estimates the total amount of blood loss to be approximately 1 tablespoon. She is a nonsmoker and her past medical history is unremarkable. Vital signs are within normal limits, and other than an intermittent cough there are no abnormal findings on the physical examination. Which one of the following would be the most appropriate next step? - Answer The first step in the evaluation of nonmassive hemoptysis is to obtain a chest radiograph. If this is normal and there is a high risk of malignancy (patient age 40 years or older with at least a 30-pack year smoking history), chest CT should be ordered. Bronchoscopy should also be considered in the workup of high-risk patients. If a chest radiograph shows an infiltrate, treatment with antibiotics is warranted. If the chest radiograph is normal the patient is at low risk for malignancy, and if the history does not suggest lower respiratory infection and hemoptysis does not recur, observation can be considered. Which one of the following is a significant risk factor for esophageal adenocarcinoma? - Answer Esophageal adenocarcinoma has become the predominant type of esophageal cancer in North America and Europe, and gastroesophageal reflux and obesity are the main risk factors. Helicobacter pylori infection, aspirin therapy, NSAID use, and Crohn's disease are not significant risk factors. In older patients with aortic stenosis and a systolic murmur, which one of the following would be most concerning? - Answer When symptoms begin to appear in a patient with aortic stenosis the prognosis worsens. It is therefore important to be aware of systolic murmurs in older patients presenting with exertional dyspnea, chest pain, or dizziness. This can be the first presentation of a downward spiral and the need for rapid valve replacement.