Charles E. Driscoll, MD, Director; Dean G. Gianakos, MD, Associate Director; William C. Crow, Jr, MD, Faculty; David S. Gregory, MD, Faculty; Therese Namenek, DPP, Faculty; Patricia A. Pletke, MD, Faculty; Brenda L. Stokes, MD, Faculty; Alex M.Wilgus, MD, Faculty; George C.Wortley, MD, Faculty; Lynchburg Family Medicine, Residency Program, Lynchburg, Va
1. A 58-year-old white man presents for a routine physical examination. His history is unremarkable. Family history includes carotid endarterectomy surgery in a younger brother and in his mother (at age 66) and myocardial infarction in his father at age 53. His blood pressure (BP) is 140/78 mm Hg, and his pulse is 78 beats per minute (bpm). The rest of the examination is unremarkable. He is a nonsmoker. Of the following tests, which one should you recommend to him now?
2. A 49-year-old man without significant past medical problems presents with a 3-day history of prandial epigastric pain and emesis. His BP is 156/94 mm Hg and pulse is 110 bpm. His mouth is dry and the abdomen is diffusely tender, without rebound. Laboratory findings include a white blood cell (WBC) count of 7.6 x 109/L (with normal differentials), normal serum alkaline phosphatase and bilirubin levels, but a serum amylase concentration of 216 U/L (normal, 25-155 U/L) and a lipase level of 943 U/L (normal, 14-280 U/L). He does not smoke and his medication history is unremarkable. You diagnose acute pancreatitis. Of the following tests, which is considered unnecessary before initiating treatment?
3. In writing the admission orders to treat a dehydrated patient with acute pancreatitis, you administer an intravenous (IV) resuscitative fluid bolus. After fluid resuscitation, which of the following dietary strategies would optimize a quick recovery?
4. Two days after admission for acute pancreatitis with dehydration, which of the following studies would best help to assess the patient's mortality risk?
5. A 42-year-old male smoker was recently diagnosed with alpha-1 antitrypsin deficiency. This deficiency is associated with all the following conditions, except:
6. A 23-year-old woman with moderate persistent asthma presents to the office for a routine checkup. She is currently using a low-dose inhaled corticosteroid. She says she feels fine; however, she needs to use her beta-2 agonist rescue inhaler at least once a day. What should be your next step in management?
7. A 40-year-old woman has a 2-cm firm mass in the upper outer quadrant of her right breast. You order a mammogram. The laboratory reports "dense breasts with extensive fibrocystic changes, and no definite mass seen." Which of the following strategies would be the most appropriate for this patient?
8. A 28-year-old woman complains of several weeks' duration of pruritus and redness of the vaginal introitus. She believes she has a "yeast infection." She is nulliparous, and medical history is significant for type 2 diabetes mellitus of 4 years' duration, as well as severe sinusitis 8 weeks ago requiring a 2-week course of amoxicillin/potassium clavulanate (Augmentin). Over-the-counter topical yeast medications (eg, fluconazole) have not been effective. Vaginal examination shows a thick, milky white discharge with reddened, swollen labia. A wet mount reveals small oval yeastlike organisms. What is the next appropriate step in her care?
9. A 34-year-old man complains of severe fatigue, which has become enough of a problem that he has to go to bed shortly after arriving home from work. He has also developed a craving for ice. He denies any abdominal pain or change in bowel habits but does describe persistent heartburn. His hemoglobin level is 114 g/L (normal, 140-170 g/L), mean corpuscular volume is 67 mm3 (normal, 80-10 067 mm3), and ferritin level is 8.4 μg/L (normal, 15-200 μg/L). Despite treatment with a proton pump inhibitor, his heartburn persists, and he is referred for upper gastrointestinal (GI) endoscopy. This does not reveal any abnormality or a bleeding site, although an esophageal biopsy is consistent with "mild esophagitis." For "completeness," an air contrast barium enema is performed, which reveals a fullness and distention of the right cecum thought to be consistent with a leiomyoma. What should the next step in management be?
10. A 26-year-old single woman complains of recurrent periods of fatigue, irritability, crying spells, and insomnia, which last a few days and affect her work and social relationships. During the past year, the intensity of the symptoms has increased, but she has had these symptoms since her early 20s. She also reports sudden symptom relief at the onset of her menses. Results of the physical examination and baseline laboratory work, including thyroid panel, are normal. Use of oral contraceptive (OC) pills has had little effect. You suspect that this patient is suffering from premenstrual dysphoric disorder. What is the next step in management?
11. During her autumn college break, an 18-year-old freshman comes to your office very upset because of her recent weight gain. You notice that she has gained 19 lb since you last saw her 5 months ago. Upon further inquiry, she discloses feeling out of control with food and admits to binge eating several times a day, mostly in the evening. She denies vomiting after her binges, stating that she tried unsuccessfully. She also denies use of diet pills, laxatives, diuretics, or ipecac syrup. She is very depressed over this weight gain, feels unattractive, and tends to stay alone in her room, avoiding social contacts. She started drinking alcohol. Her grades are poor as she has difficulty concentrating, her mind being absorbed by thoughts about food. She is desperate for a quick fix. What would you do next?
12. Which of the following statements about adolescent sexuality is true?
13. A 45-year-old African American hypertensive man presents to your office for an annual examination. He is asymptomatic. His father was diagnosed with prostate cancer at age 55. Physical examination shows an area of firmness in the right lobe of the prostate. His prostate-specific antigen (PSA) level is 3.8 ng/mL. What should be the next step in management?
14. A mother and baby present to your office for evaluation. The mother reports that yesterday, as she looked in on her 8-month-old baby during the afternoon nap she saw a bat in the corner of the room; she took the child out of the bedroom and when she returned to the room, the bat had left. Physical examination of the child shows no bite marks. The child is up-to-date with immunizations. What is the appropriate next step in management?
15. You are assisting with event coverage for a benefit marathon run (26.2 miles). The air temperature is 70°F and the relative humidity is 60% at the 9 AM start time. Five and a half hours later, a 28-year-old woman crosses the finish line. She is confused and unsteady on her feet. Her friends bring her to the medical tent for evaluation. They say that she was drinking well at all water stations until the end of the race. Examination shows she is disoriented to place and day. She appears well hydrated, with some edema noted on her hands and feet. Her rectal temperature is 99.9°F, and her reflexes are hypoactive. Her glucose level is 76 mg/dL. She then vomits. What is the appropriate approach to management?
16. A 40-year-old recreational tennis player injures his left ankle. He limps into your office 3 days later. He has been applying ice and wearing an elastic wrap. His medical history is suggestive of an inversion ankle injury. He reports that he continued to play for 15 minutes after the injury but stopped because of increasing discomfort. Physical examination shows the lateral aspect of the ankle is swollen, with ecchymosis below the lateral malleolus. Palpation reveals tenderness anterior to the lateral malleolus but no tenderness over the base of the fifth metatarsal. Anterior drawer and talar tilt tests are negative. The patient says he wants to play in a tournament in 2 months. Which of the following approaches is the correct treatment?
17. The nurse calls you to evaluate a 23-year-old woman, gravida 3, para 2, who delivered an 8 lb 2 oz infant 3 hours ago. She is having heavy vaginal bleeding and passing large clots. She required oxytocin (Pitocin, Syntocinon) for augmentation of labor and had an epidural for labor. A second-degree laceration was repaired, and she was given an oxytocin infusion after delivery. The patient's BP is 110/74 mm Hg, and her pulse is 88 bpm. What is the next appropriate step in management?
18. A 32-year-old woman presents to your office at 32 weeks' gestation for a routine prenatal visit. Her pregnancy has been uncomplicated. Her only complaint is an occasional headache that is relieved with acetaminophen. Fundal height is 31 cm, and fetal heart rate is 144 bpm. Her BP is 142/90 mm Hg, and she has 1+ protein on urine dipstick testing. What is the next appropriate step in management?
19. You are called to the emergency department to evaluate a 2-month-old baby boy with vomiting and diarrhea. His mother reports he started vomiting yesterday and has not kept down any formula since. The diarrhea started today with 5 watery stools that are yellow-green in color and foul smelling. His mother has noticed no blood or mucous in the stool. Physical examination shows he is lethargic, with a respiratory rate of 50 breaths per minute and pulse of 160 bpm. He weighs 11 lb. He has a sunken fontanelle and the mucous membranes are dry. Capillary refill time is 3 seconds. After several attempts, an antecubital IV site is obtained. What is the next appropriate step in management?
20. A 26-year-old woman comes in for a routine pelvic examination and a Pap smear. She has had regular yearly Pap smears since age 22, and they have all been normal. She has one current male sexual partner and has had 5 partners overall. She has no known history of STDs. The result of this Pap smear is atypical squamous cells of undetermined significance. What is the appropriate next step?
1—B. A family history of vasculopathy should trigger an evaluation for treatable causes, with an initial focus on major risk factors, namely hyperlipidemia. With a totally normal examination, carotid and cardiac echographic studies are not warranted. The benefit of lowering homocysteine levels to reduce risk has not been proven.
2—B. Patients with acute pancreatitis have only a small chance of pancreatic pseudocyst, which would be the main reason to obtain an abdominal CT. If a patient is not improving with treatment as expected or has a history of chronic pancreatitis, an abdominal CT scan would be appropriate to assess for necrosis or the development of a pseudocyst. A right upper quadrant ultrasound and plain film x-ray can reveal obstructing gallstones, pancreatic calcifications, or abdominal free air. Basic metabolic profile and levels of lactate dehydrogenase, aspartate aminotransferase, and hematocrit are all included in the initial Ranson's criteria used to determine mortality risk.
3—E. Enteral feeding that bypasses the stimulation of pancreatic enzyme secretion but allows for otherwise normal gut function is the preferred means for maintaining nutrition in patients with pancreatitis. This is a lower-risk alternative to total or partial parenteral nutrition, does not stimulate pancreatic secretion (unlike a clear liquid diet), and provides the needed nutrition to recover from such an illness (unlike maintenance crystalloid fluids).
4—C. This information is part of the 48-hour reassessment for Ranson's criteria, which also includes measurement of hematocrit, Po2, and base deficit. Finding a cause for the pancreatitis may help prevent recurrences but will not help predict mortality. Likewise, gallbladder ultrasound and repeat measurements of WBC count and lipase, bilirubin, and liver transaminase levels are not helpful in determining mortality risk.
5—B. Alpha 1-antitrypsin deficiency is a known cause of chronic obstructive pulmonary disease and should be suspected in middle-aged smokers who present with cough and dyspnea and demonstrate airflow obstruction on spirometry. Emphysematous changes are most striking at the lung bases on chest x-ray or CT scan.
6—E. Asthma patients who have more than 2 episodes of asthma symptoms per week and more than 2 nocturnal episodes per month are by definition not well controlled. This patient is having daily symptoms and therefore needs additional therapy. Adding a long-acting beta-2 agonist to an inhaled corticosteroid regimen has been shown1 to be more effective than increasing the dose of an inhaled corticosteroid, and it reduces the chance of experiencing adverse effects from corticosteroids.
1. National Heart, Lung, and Blood Institute, National Asthma, Education and Prevention Program. Guidelines for the diagnosis and management of asthma—update on selected topics 2002. Bethesda, MD: US Department of Health and Human Services. NIH Publication no. 02-5075. Available at www.nhlbi.nih.gov/guidelines/asthma/index.htm.
7—B. A dominant breast mass on physical examination requires further evaluation even if the mammogram is negative. Mammographic interpretation is frequently difficult in younger patients because of the presence of dense breast tissue. A sonogram is frequently required. Mammograms become easier to interpret in older patients as the breast tissue becomes increasingly replaced by fat.
8—B. The patient probably has vaginitis caused by (which is responsible for about 14% of vulvovaginal candidiasis cases).1 This is more probable after antibiotic use in patients with diabetes. , which is identified by germ tube testing, is resistant to conventional treatments.
J Lower Genital Tract Dis.
1. Martens MG, Hoffman P, El-Zaatari M. Fungal species changes in the female genital tract. 2004;8:21-24.
9—C. Even though this patient is young, this case has disturbing features. A young man should not have iron deficiency anemia. Esophagogastroduodenoscopy does not identify a bleeding site or provide an adequate explanation for his anemia. Colon cancer, especially cecal cancer, can be associated with intermittent bleeding, so even 3 consecutive stool samples that are negative for blood are not proof that he is not bleeding. Cecal cancer can mimic leiomyoma on air contrast barium enema. On colonoscopy, the patient was found to have invasive cecal cancer.
10—B. Before treating premenstrual dysphoric disorder, an accurate diagnosis must be established by asking the patient to track her symptoms. Several tracking journals are available for accurate reporting. If the suspected diagnosis is confirmed, low-dose SSRI therapy taken intermittently during the luteal phase of the menstrual cycle has been shown to be helpful.1 Buspirone is not indicated for the treatment of premenstrual dysphoric disorder.
1. Halbreich U, Bergeron R, Yonkers KA, et al. Efficacy of intermittent, luteal phase sertraline treatment of premenstrual dysphoric disorder. 2002;100:1219-1229.
11—C. This patient's symptoms are characteristic of binge-eating disorder, which is characterized by episodes of binge eating without bulimia. The prevalence is 2% in the general population and 45% in obese persons.1 Although cognitive behavioral therapy may help reduce binge-eating, it does not seem to affect weight. Most studies have focused on the use of SSRIs and d-fenfluramine (no longer available in the United States). Fluoxetine reportedly reduces both binging frequency and body weight.2 Preliminary studies suggest that sibutramine is a possible adjunctive treatment for bingeeating disorder, but serious adverse reactions have been reported.3 As a result, physicians must closely supervise patients taking this drug.
1. Carter WP, Pindyck LJ. Pharmacologic treatment of binge-eating disorder. 2003;10:31-36.
J Clin Psychiatry.
2. Arnold LM, McElroy SL, Hudson JI, et al. A placebo-controlled, randomized trial of fluoxetine in the treatment of binge-eating disorder. 2002;63:1028-1033.
Arch Gen Psychiatry.
3. Appolinario JC, Bacaltchuk J, Sichieri R, et al. A randomized, double-blind, placebocontrolled study of sibutramine in the treatment of binge-eating disorder. 2003;60:1109-1116.
12—D. Coital intercourse has greatly increased over the past 25 years. Most recent data indicate that 61% of boys and 60% of girls have had intercourse by the time they leave high school.1 Lesbian adolescents are at lowest risk of STDs, while adolescent homosexual boys are at higher risk for STDs, such as syphilis, gonorrhea, nonspecific urethritis, and cytomegalovirus and hepatitis C infections. About 2% to 10% of this age population identify themselves as homosexual.2 A negative self-image in gay males leads to high-risk behaviors as well as to depression and suicide attempts. Studies suggest that one third of adolescent male homosexuals attempt suicide.3
MMWR Surveill Summ.
1. Grunbaum JA, Kann L, Kinchen SA, et al. Youth risk behavior surveillance—United States, 2001. 2002;51:1-62.
J Pediatr Health Care.
2. Bidwell RJ. The gay and lesbian teen: a case of denied adolescence. 1988;2:3-8.
J Adolesc Health.
3. Remafedi G. Suicidality in a venue-based sample of young men who have sex with men. 2002;31:305-310.
13—C. A PSA of 3.8 ng/mL is above the expected range of 0 to 2.0 ng/mL for a 45-year-old man. In African Americans, risk for prostate cancer increases about 10 years earlier than in whites (age 40 vs 50, respectively), and their cancers tend to be more aggressive. Even if the PSA level had been normal, a transrectal ultrasound and biopsy would be indicated in a patient with an abnormal prostate examination.
14—C. The Centers for Disease Control and Prevention recommend giving rabies immune globulin and 5 doses of rabies vaccine to a child who is found alone in a room with a bat if the bat cannot be tested for rabies. A normal examination cannot exclude skin or mucus membrane exposure to the rabies virus.
15—D. You have excluded hyperthermia and hypoglycemia by your evaluation. The history and examination all point to hyponatremia as the cause of the patient's mental status changes. Further hydration may result in seizures or death. She requires blood work for electrolyte measurement and hospital care.
16—C. The patient has no signs that suggest the need for x-ray according to the Ottawa ankle rules. There is no evidence to suggest that surgical repair of a stable ankle provides better outcomes. Early mobilization with strengthening and proprioceptive exercises would give this man the best chance of returning to play at his former competitive level.
17—C. This patient has a postpartum hemorrhage and needs to be evaluated for the cause. Initial management should always include fluid resuscitation. While you are en route to the hospital, the nurses can begin IV fluid administration and crossmatch her blood. The most common cause of postpartum hemorrhage is uterine atony. Other causes include tissue trauma, retained products of conception, and clotting disorders. The patient has already received oxytocin, which is the drug of choice for treatment, so methylergonovine would be appropriate once the source of the hemorrhage has been determined.
18—D. This patient probably has gestational hypertension and needs an evaluation for preeclampsia. Gestational hypertension is defined as a systolic BP of 140 mm Hg or a diastolic BP of 90 mm Hg on at least 2 measurements obtained at least 6 hours apart after 20 weeks' gestation in a previously normotensive patient. Preeclampsia is gestational hypertension with proteinuria of 300 mg protein during a 24-hour urine collection. Preeclampsia is a multisystem disease and laboratory evaluation is required. Fetal evaluation is also appropriate at this time. This patient does not need to be admitted unless the results of the laboratory testing and the physical examination are abnormal or the antepartum fetal testing results are not reassuring.
19—B. This infant's history and clinical assessment are consistent with hypovolemic shock. The first step would be to give the infant a bolus of isotonic normal saline or lactated Ringer's solution at 20 cc/kg. The infant should then be reassessed clinically for further treatment. This is considered an emergency, and fluid resuscitation should not be delayed for laboratory or radiologic evaluation.
20—D. A small but important minority of women with atypical squamous cells of undetermined significance has high-grade squamous intraepithelial lesions on colposcopy and biopsy. Testing for high-risk HPV subtypes is an effective method of determining the need for colposcopy. An accepted alternative is repeat Pap smear testing, with colposcopy performed if the Pap smear reveals atypical squamous cells of undetermined significance or a higher-grade lesion.