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ABFM Questions (OB/GYN) questions and answers latest updated
Contraindication for levonorgestrel releasing IUD (where copper IUD might be preferred) women with severe cirrhosis or liver cancer, copper IUD is preferr... [Show More] ed -> levo-releasing and copper IUD have no differences in risk for DVT/PE, totes ok in smokers/nulliparous First test for painless post-meno bleeding transvag US (endometrial biopsy if TVUS no available) TVUS endometrial thickness suspicious for cancer more than 3-4 cm Best class of antidepressants for pregnant women SSRIs First line treatment for primary dysmenorrhea NSAIDs (start at onset of menses, continue for first two days) > OCP, lack of high quality evidence (good if no baby wanted) Risk factors for still birth advanced maternal age, smoking > 0.5 packs a day, congenital anomalies, BMI > 30 (vigorous exercise is okay!) "old, fat, smk" All preg should be screened for this b/w 11 and 16 weeks gestation and should be tx'ed appropriately if (+) urinalysis and urine culture screening for asymptomatic bacteriuria (cause repeat UTIs, pyelo, preterm labor if untx'ed) When group B strep screening in pregnancy should be done 35-37 weeks of gestation How to treat pregnant woman w/GBS first line? if allergic to first line? first line: ampicillin; if allergic use cefazolin When DM screening should be done in pregnancy 24-28 weeks of gestation (with a 50 g glucose dose) Drug of choice for pregnant women w/opioid abuse methadone, no long term effects noted A condition that represents an unacceptable health risk if the contraceptive method is used Migraines with aura (2-4 times more likely to have a stroke if headaches, if w/aura the risk is higher thus unacceptable risk) Normal number of arteries and veins in umbilical cord 2 arteries, 1 vein Who is legally responsible for ensuring the patient gets notified of the mammogram results? facility performing the mammogram First line therapy for menstrual abnormalities, hirsutism, and acne in PCOS hormonal contraceptives Gestational HTN after 37 weeks -> next best step? induction of labor; if less than 37 weeks do twice weekly office visits Pregnant woman has not been vaccinated for rubella (neg titers for rubella), when do you immunize? right after childbirth, MMR is live attenuated so you can't give during or shortly before pregnancy Pt w/preeclampsia is given Mg -> suddenly becomes apneic and areflexic -> NBS? this is Mg toxicity, give calcium (CaCl if central line or Ca-gluconate if peripheral line) Drugs for uterine atony and postpartum bleed Oxytocin, misoprostol, methylgonovine (don't use if HTN), carboprost (don't use if asthma) Antiemetic during pregnancy first line (after lifestyle and diet changes didn't work) doxylamine (Unisom 12.5 mg 3-4/d) and pyridoxine (vitB 10-25 mg once/d) + avoid certain foods (spicy/fat), eat high prt snacks, crackers in AM b4 rising Persistent occiput posterior fetal position has a lesser chance of what kind of delivery normal, spontaneous vaginal delivery -> higher risk of cesarean delivery and assisted vaginal delivery Young female with positive gonorrhea test and negative Chlamydia test, NBS tx? treat with ceftriaxone 250 mg IM plus (azithromycin 1 g PO once or doxycycline 100 mg x2 daily for 7 days); tx all partners in prvs 60 days as well Immunization indicated for all pregnant women at any stage of the pregnancy influenza vaccine (avoid preg 28 days after MMR or varicella vaccines; HPV not rec during preg) Healthy 30yo w/regular menses has been trying with healthy sperm analysis husband for 15mo -> NBS? confirm ovulation with a luteal-phase progesterone level above 5 ng/mL on day 21 of cycle (if confirmed, check for tube patency) Likely side effect with aromatase inhibitors (letrozole) not seen with SERMs (tamoxifen) myalgias (DVT occurs rarely); endometrial cancer can happen with long term tamoxifen use First line for N/V in pregnancy during first trimester? vitamin B6, safe and less assoc w/drowsiness vs other meds (scopolamine effective/safe during 2 or 3rd trimesters only) Which contraceptive should be used with caution due to risk of hyperkalemia when used with spironolactone? oral drospirenone/ethinyl estradiol (Yaz, Yasmin), it too can lead to hyperkalemia, don't mix with spironolactone From the list, which is a teratogen: atenolol, bupropion, metformin, fluoxetine, glargine atenolol, causes growth restriction and reduced placental weight Pap reveals normal cytology but infection with HPV serotypes that are not 16 and 18 -> NBS? return in one year for repeat pap/HPV testing; if still HPV positive a year later, get a colposcopy. If it would have been 16 or 18, colposcopy would have been indicated PCOS dx requirement? First line treatments in obese PCOS? dx'ed by high testosterone + ovulatory dysfunction or polycystic ovaries; tx: if obese lifestyle mods +/-metformin which can improve abnormal menstruation Most effective method of natural family planning? cervical mucus monitoring (can determine the beginning and end of most fertile period MC causes of secondary amenorrhea? NBS once PE, preg test, TSH are unremarkable in 2o amenorrhea pt? PCOS, menopause, hypothalamic amenorrhea, hyperprolactenemia; get hormone levels (LH, FSH) Work up for primary amenorrhea? pelvic US (anatomical), karyotyping (Turner's and androgen insensitivity syndrome) Benefits of treating gestational DM w/metformin or insulin decreased risk of operative delivery, big baby, shoulder dystocia, maternal preeclampsia (doesn't decrease chance of getting actual DM later on or perinatal death) What do you need to get on a patient before starting them on OCPs? blood pressure (severe HTN is a contraindication to OCPs), also assess if they are pregnant [Show Less]
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ABFM In training exam pearls questions and answers
Pre-exposure prophylaxis (PrEP), what meds, and what do you have check first? Emtricitabine/tenofovir gotta check Hep B first -apparently they kill hep ... [Show More] B too, so if you suddenly stop the med, then reactivated hep B can lead to liver disease entry to balloon time for PCI! 120 minutes time limit from onset of MI to balloon time should get it done w/in 12 hours Absolute contraindications to Fibrinolysis Previous hemorrhage stroke Previous ischemic stroke (4.5hrs-3months prior) Suspected aortic dissection Active bleeding (except menstruation) BP >180/110 (severe hypertension) Streptokinase 6 months prior acute cholecystitis Acute inflammation of the gallbladder wall Patient with pulmonary HTN due to left heart failure, can they have vasodilators (PDE5?) NO! can make things worse -maximize heart failure treatment! Sever's Diseaese Calcaneal apophysitis, also called Sever's disease, is a common cause of heel pain in young athletes, especially those who participate in basketball, soccer, track, and other sports that involve running. Typically the heel apophysis closes by age 15. Treatment options include activity modification, the use of ice packs and/or moist heat, stretching, analgesics, and orthotic devices. The use of therapeutic ultrasound on the active bone growth plates in children is contraindicated. in pressure ulcers what solutions to avoid, and what to use! recommended that pressure ulcers not be cleaned with povidone/iodine, Dakin's solution, hydrogen peroxide, wet-to-dry dressings, or any solutions that may impede granulation tissue formation. These sites should be cleaned with either saline or tap water and covered with hydrocolloid, foam, or another nonadherent dressing that promotes a moist environment. Chronic paraoxysmal hemicrania resembles cluster headache but has some important differences. Like cluster headaches, these headaches are unilateral and accompanied by conjunctival hyperemia and rhinorrhea. However, these headaches are more frequent in women, and the paroxysms occur many times each day. This type of headache falls into a group of headaches that have been labeled indomethacin-responsive headaches because they respond dramatically to indomethacin. normal spirometry but low DLCO chronic pulmonary embolus Antibiotic ppx for dental procedures give amoxicillin only if prior endocarditis, prosthetic valve, heart txp, or severe or repaired congenital heart -if allergic to penicillin, then give clinda!! when to refer patient with CKD to nephrology Current guidelines recommend referral to a nephrologist if a patient's renal disease is either of unknown etiology, is deteriorating quickly (eGFR decreasing by >5 mL/min/1.73 m2 per year), or is severe. Thresholds used to define severe chronic kidney disease include an eGFR <30 mL/min/1.73 m2, a urine albumin to creatinine ratio >300 g/mg, persistent acidosis or potassium imbalance, non-iron deficiency anemia with a hemoglobin level <10 g/dL, and evidence of secondary hyperparathyroidism. Causes of peripheral neuropathy common treatable causes of peripheral neuropathy, which include diabetes mellitus, hypothyroidism, and nutritional deficiencies. Additional causes of peripheral neuropathy include chronic liver disease and renal disease. It is important to consider medications as a possible cause, including amiodarone, digoxin, nitrofurantoin, and statins. Excessive alcohol use is another important consideration. In addition think MGUS, and Multiple Myeloma Failure rates of contraception The annual failure rate of combined oral contraceptive pills with typical use is 9%. Typical failure rates for other contraceptive methods are 0.2% for the levonorgestrel IUD, 6% for injectable progestin, 18% for male condoms, and 22% for the withdrawal method. mental status exam for acute changes like delerium Confusion Assessment Method (CAM) to diagnose adult ADHD, symptoms must be present before what age? Age 12 Complications of GERD in infants Gastroesophageal reflux accounts for a significant number of cases of failure to thrive, crib death, and recurrent pneumonia. Features of gastroesophageal reflux include a history of recurrent pneumonia, a low growth curve, a family history of sudden infant death syndrome, and normocytic anemia. coining "sickness leaving body" it's a south asian thing, kids have multiple red welts and superficial abrasions scattered on chest and upper back thyroid replacement in the setting of gastritis need to increase by 30% because gastritis decreases absorption of thyroid. ex: h. pylori, treat h.pylori to negate this effect cubital tunnel syndrome irritation, compression, and entrapment of the ulnar nerve in ages 5-16, what is the most common agent that causes pneumonia mycoplasma - treat with azithromycin what halts the worsening of thyroid complications such as myxedema and exophthalmos treating with methimazole If MRSA bacteremia, when do you get repeat blood cultures? 2-4 days community acquired pneumonia a type of pneumonia that results from contagious infection outside of a hospital or clinic ie hotel stay or cruise ship Polymyalgia Rheumatica (PMR) a geriatric inflammatory disorder of the muscles and joints characterized by pain and stiffness hallmark of this condition is the rapid and often dramatic response, typically within a few days, to low-dose corticosteroids. In fact, the lack of response to low-dose prednisone in such a case should prompt the physician to consider another diagnosis Post exposure prophylaxis for meningitis ciprofloxacin, 500 mg orally one time; azithromycin, 500 mg orally one time; ceftriaxone, 250 mg intramuscularly one time; or rifampin, 600 mg orally twice daily for 2 days. Treatment should begin as soon as possible after exposure but no later than 14 days. Dermatomyositis chronic systemic immunological disease involving inflammation of the skin, connective tissue, and muscles distinct dermatologic findings, including Gottron's sign (nonpalpable macules over the extensor surface of joints). Patients may also have dilated nail-fold capillaries and ragged, thickened cuticles. jones fracture The treatment plan for this type of fracture needs to account for the activity level of the patient. It has been shown that active patients have shorter healing times and return to activity sooner with surgical management. A competitive dancer would be best managed with surgery. If the nonsurgical option is chosen the patient is given an initial posterior splint and followed up in 3-5 days, then placed in a short non-weight-bearing cast for 6 weeks, at which time a repeat radiograph is taken. If the radiograph shows healing, the patient can return to gradual weight bearing. If the radiograph does not show proper healing, then the period of non-weight bearing is extended. what do asplenic patients do if they have fever and get in to see doctor for eval in 2 hours? Amoxicillin, levofloxacin, and moxifloxacin should be taken by asplenic patients with a new onset of fever if they cannot get to a medical facility within 2 hours for evaluation. Fever should be reported immediately due to the lifelong significant risk of sepsis. Unless otherwise contraindicated, asplenic patients should receive annual influenza immunization. Pneumococcal polysaccharide vaccine (PPSV23) should be given twice, with the second dose given 5 years after the first. chronic urticaria, what do you do if antihistamines don't work? add H2 blockers (doxepin can be used off label, blocks antihistamine receptors) steroids UV therapy 2nd line therapies what can you use for sensoneural hearing loss short term to reduce long term sequelae Prednisone! greatest improvement in hearing tends to occur in the first 2 weeks, corticosteroid treatment should be started immediately. The recommended dosage is 1 mg/kg/day with a maximum dosage of 60 mg daily for 10-14 days. if patient has shellfish allergy, do you wait or give steroids and epi for IV contrast? NO! There is no correlation! Just do the damn CT! Rotator Cuff Muscles (SITS) S = supraspinatus - abduction (along with deltoid) I = infraspinatus - external rotation t = teres minor - external rotation S = subscapularis - internal rotation sickle cell kids ages 2-16 should be screened for and with what? Individuals with sickle cell disease are at increased risk for vascular disease, especially stroke. All sickle cell patients 2-16 years of age should be screened with transcranial Doppler ultrasonography (SOR A). fetal alcohol syndrome a medical condition in which body deformation or facial development or mental ability of a fetus is impaired because the mother drank alcohol while pregnant associated with clinodactyly, camptodactyly (flexion deformity of the fingers), other flexion contractures, radioulnar synostosis, scoliosis, and spinal malformations. It is also associated with many neurologic, behavioral, and cardiovascular abnormalities, as well as other types of abnormalities. Dix-Hallpike maneuver Rapidly moving the pt from a sitting position to the supine position with the head turned 45 degrees to the Right. After waiting apx. 20-30 sec, the pt is returned to the sitting position. If no Nystagmus is observed, the procedure is then repeated on the Left side. preferred antidepressant in older patients Escitalopram (lexapro) herbal supplement with highest risk of drug interactions? St. John's Wort inducer of CYP3A4 and P-glycoprotein synthesis. Concurrent use of St. John's wort with drugs that are metabolized with these systems should be avoided. These include cyclosporine, warfarin, theophylline, and oral contraceptives. why recombinant zoster vaccine (shingrix) over live zoster vaccine (zostavax) better efficacy [Show Less]
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ABFM ITE questions and answers 100% correct |graded A+
CAP antibiotic that causes VF Azithromycin - The arrhythmia results from prolongation of the QT interval and is also more common in patients with a pri... [Show More] or cardiac history. Anti-DM medications for weight loss GLP1 receptor agonists e.g. Exenatide SGLT-2 inhibitor e.g. Canagliflozin Screening test with greatest potential for over diagnosis PSA Clinical manifestation of amyotrophic lateral sclerosis Asymmetric leg weakness Opioid to avoid in palliative patient with severe hepatic dysfunction Methadone - It is metabolized and cleared by the liver, and should therefore not be used in patients with severe hepatic impairment. It is, however, a reasonable option for patients with severe renal impairment. Lung cancer screening with low dose CT Chest annually Adults 55-80yo with 30 pack year history and currently smoking or quit within last 15 years NOAC with reversal agent Dabigatran Reduces alcoholism but creating an acute ethanol sensitivity Disulfiram Antidepressant to be avoided in the elderly Paroxetine (associated with more anticholinergic effects) SSRIs > SNRIs, atypical antipsychotics may be added for resistant depression Age group between which American Academy of Pediatrics recommends administration of an autism-specific screening tool 18-24 months old Most common neurological complication of Paget's disease of the bone ... Most common cardiac complication of Lyme disease Heart blocks Examination finding of those with bacterial vaginosis Vaginal pH >4.5 (normal vaginal pH should be acidic) Most common cause of medication-related adverse events across health care settings in the United States Antibiotics Screening for asymptomatic carotid artery stenosis Not recommended In anaphylaxis, which drug is most likely helpful in preventing the need for intubation? ... Barrett's oesophagus with no dysplasia ... Positive family history of colorectal cancer Individuals who have a first-degree relative with colorectal cancer or advanced adenoma diagnosed before 60 years of age or two first-degree relatives diagnosed at any age should be advised to start screening colonoscopy at 40 years of age or 10 years younger than the earliest diagnosis in their family, whichever comes first. Most common cause of hearing loss in newborns Genetic inheritance Lab findings in Von Willebrand disease ... U.S. federal labor law requires companies with >50 employees to provide which benefits for employees who are nursing mothers ... Influenza vaccination in those with potential egg allergy All currently available influenza vaccines, with the exceptions of recombinant and cell-culture-based inactivated influenza vaccines, are prepared using embryonated egg culture and can potentially provoke allergic and anaphylactic reactions. For those who report that they can eat lightly cooked scrambled eggs, vaccination can proceed without precaution or observation. Those who have experienced only hives can also receive any influenza vaccine appropriate for their age and health status. People who have experienced symptoms such as hypotension, wheezing, nausea, or vomiting, or reactions requiring emergency attention or epinephrine after eating eggs or egg-containing foods can also receive any influenza vaccine appropriate for their age and health status and also do not need to be observed. However, the vaccine should be administered by a provider who can recognize and manage severe allergic reactions. How is the Timed Up and Go test useful in GRM patients? Helps to assess the risk of falling Antidepressant that can prolong QT interval to be avoided in those on concomitant atypical antipsychotics Citalopram, Escitalopram Other SSRIs, as well as bupropion, venlafaxine, and mirtazapine, do not have this effect. Both tricyclic antidepressants and antipsychotics, commonly used in patients also taking SSRIs, can cause QT prolongation, making their combined use problematic. Antibiotic for traveller's diarrhoea Azithromycin Prevented by washing hands frequently Most effective medication for treating fibromyalgia TCAs > SSRIs (helps with some pain reduction) In a healthy full-term infant who is exclusively breastfed, iron supplementation should begin at what age in order to prevent iron deficiency anaemia? 4 months - In preterm babies (before 37w), elemental iron supplementation (2mg/kg per day) should begin at 1 month of age and should continue until 12 months of age, unless the infant had multiple blood transfusions. In primary nephrotic syndrome, other than proteinuria and low albumin, what else is commonly observed? Coagulopathy Chronic medication that can cause B12 deficiency Metformin Strongest risk factor for primary hypertension in children and adolescents Elevated BMI While Staphylococcus aureus and Streptococcus species are the most common causes of skin and soft-tissue infection, which organism should also be considered? Pseudomonas Treatment of erythrasma (Wood's lamp coral pink/red fluorescence, fine-scaled with a cigarette-paper appearance) caused by Corynebacterium minutissimum infection Erythromycin Which radiologic funding of a lung nodule is most predictive of malignancy? ... Which investigation is routine in all newborns with Down syndrome? Echocardiography Treatment duration for provoked vs unprovoked PE 3 months and indefinitely respectively In patients with symptoms indicative of pneumonia or heart failure, what investigations can be done to determine treatment of either condition or both? BNP and procalcitonin levels How to increase HDL (good cholesterol)? Add niacin Dietary recommendation in diverticulosis High fibre or take fibre supplements Side effects of prolonged PPI use C diff infection, hypoMg, hip fracture Which antiemetic blocks dopamine stimulation in the chemoreceptor trigger zone? Metoclopramide Little League shoulder is a repetitive use injury causing disruption at the proximal growth plate of the humerus Proximal humeral epiphysitis. Can be seen on plain radiographs as widening, demineralization, or sclerosis at the growth plate. Taking beta carotene and Vit E to prevent cancer and heart disease ... Fluoride supplementation should be started at what age when primary water supply is deficient in fluoride 6 months Medications that can reduce serum Vitamin D levels Rifampicin, Phenytoin Isolated posterior cruciate ligament tear Direct blow to the anterior tibia whilst knee is in flexion What should patients be periodically monitored for whilst on Amiodarone? TSH Drug of choice in depressed persons with cardiovascular disease SSRIs Antibiotics causing prolonged QT Macrolides Benign nocturnal limb pains of childhood (previously known as "growing pains") Usually occur in the evening or night time, may sometimes wake patient from sleep, short-lived (about 30min), not associated with redness/swelling/tenderness/limping. No further work-up necessary. Treatment of OSA in children Adenotonsillectomy What is most likely seen with diastolic dysfunction? A preserved ejection fraction Positive hip FADIR and FABER testing Hip labral tear Childhood vaccination carrying risk of febrile seizure in up to 2 weeks post-administration MMR Elbow Moving Valgus Stress Test Ulnar collateral ligament injury In United Stated, at what age is it recommended for cow's milk be introduced? 12 months Treatment for lateral dislocation of the patella Medically directed pressure on the patella while extending the leg Treatment of SSRI overdose ... Finkelstein's test For detecting De Quervain's Tenosynovitis, where thumb is in the fist and you ulnarly deviate looking for pain in the radial wrist. Indication for 2nd dose of pneumococcal polysaccharide vaccine in children Sickle Cell Disease Excessive femoral anteversion with normal mobility Observation Surgery should be reserved for children 8-10 years of age who still have cosmetically unacceptable, dysfunctional gaits. [Show Less]
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ABFM DIABETES questions and answers graded A+
True statements regarding nonpharmacologic therapy to reduce insulin resistance include which of the following? (Mark all that are true.) Decreasing cal... [Show More] oric intake will increase insulin sensitivity independent of weight loss Moderate alcohol intake increases insulin resistance Exercise has been shown to enhance insulin action in skeletal muscle A decrease of as little as 5% in body weight can result in a substantial reduction in insulin resistance If there are no contraindications, patients with insulin resistance syndrome should be advised to engage in 30 minutes of modest aerobic exercise at least 4-5 times/week A, C, D, E Lifestyle interventions play a pivotal role in the management of insulin resistance syndrome. Losing even 5% of body weight has been shown to substantially reduce insulin resistance. In addition, insulin sensitivity can be increased by reducing caloric intake, even if no weight is lost. Exercise is an important adjunct to weight loss, since it has been shown to enhance insulin action in skeletal muscle not only during physical activity but for up to a week following exercise. All patients with insulin resistance syndrome should be advised to engage in 30 minutes of aerobic exercise at least 4-5 times/week. Moderate alcohol intake lowers insulin resistance. Which one of the following neurologic tests is most useful for predicting the future occurrence of a diabetic foot ulcer? Pressure sensation with Semmes-Weinstein monofilament (10 g) Deep tendon reflexes of the ankle Proprioception Vibratory sensation with a 128-mHz tuning fork Light touch with a wisp of cotton A Failure to perceive a pressure sensation produced by Semmes-Weinstein monofilament indicates a loss of protective sensation in the diabetic foot and is highly predictive of foot ulceration. Traditional neurologic examination techniques for evaluating reflexes, proprioception, vibration, or light touch are highly subjective and less predictive of future ulceration. 01:07 01:23 Which of the following lipid-lowering agents can worsen glycemic control? (Mark all that are true.) Colestipol (Colestid) Ezetimibe (Zetia) Gemfibrozil (Lopid) Niacin Atorvastatin (Lipitor) D AND E Niacin is not only the most effective agent for raising HDL-cholesterol, producing an increase of 15%-35%, it also reduces triglycerides by 20%-50% and LDL-cholesterol by 5%-25%. Hyperglycemia is a side effect of niacin therapy, particularly at high doses. A dosage of 750-2000 mg/day is associated with only moderate rises in blood glucose, and at one time was considered a treatment option in patients with diabetes, particularly those with low HDL-cholesterol levels. However, the recommendations for niacin use were changed as a result of the AIM-HIGH trial (Atherothrombosis Intervention in Metabolic Syndrome with Low HDL/High Triglycerides: Impact on Global Health Outcomes), which found no incremental clinical benefit from the addition of niacin to statin therapy in patients with coronary heart disease and LDL-cholesterol levels >70 mg/dL.Recent studies support a link between statin use and the development of diabetes mellitus. In a meta-analysis of 13 studies, statin therapy was associated with a 9% increased risk for incident diabetes. Another meta-analysis corroborated this result and found that intensive-dose statin therapy was associated with a higher risk of new-onset diabetes compared with moderate-dose statin therapy. In 2012, the FDA modified the package labeling of statins to include the risk of increased blood glucose levels and the development of type 2 diabetes. The benefit of statin therapy, however, outweighs the risk; it was estimated there would be 1 additional case of diabetes for every 498 patients treated for 1 year, compared with 1 less patient experiencing a cardiovascular event for every 155 patients treated for 1 year. A 58-year-old male with type 2 diabetes mellitus comes in during the early afternoon for his annual physical examination. His current medication regimen consists of insulin glargine (Lantus), 18 units in the evening; glipizide (Glucotrol), 20 mg/day; metformin (Glucophage), 1000 mg twice a day; and acarbose (Precose), 100 mg three times a day. He suddenly becomes shaky, diaphoretic, and pale, and tells you he thinks it is because he skipped lunch before his appointment.Which of the following would be effective for managing this episode? (Mark all that are true.) Glucose tablets A sugar cube A banana A soft drink containing sugar Raisins Glucagon A AND F Acarbose, an α-glucosidase inhibitor, inhibits an enzyme present in the brush border of the proximal intestinal epithelium that breaks down disaccharides and more complex carbohydrates. As a result, if hypoglycemia were to occur in a patient on an α-glucosidase inhibitor, reversal requires either the consumption of glucose itself (as opposed to complex carbohydrates) or the injection of glucagon. Which of the following medications can cause hyperglycemia? (Mark all that are true.) Niacin Clozapine (Clozaril) Prednisone Spironolactone Ramipril (Altace) A, B, C Several medications have been shown to affect glucose homeostasis, resulting in impaired glucose tolerance and hyperglycemia. Agents associated with the development of hyperglycemia include pentamidine, niacin, glucocorticoids, thyroid hormone, diazoxide, β-adrenergic agonists, thiazide diuretics, phenytoin, and α-interferon. In addition, second-generation antipsychotic agents, particularly clozapine and olanzapine, have also been linked to the development of hyperglycemia and diabetes mellitus. Spironolactone and ramipril have not been linked to the development of diabetes. In fact, in the HOPE (Heart Outcomes Prevention Evaluation) study, the use of ramipril, an ACE inhibitor, appeared to reduce the risk for developing type 2 diabetes mellitus by 20%-35%. A 55-year-old African-American male sees you for a routine visit. His past medical history is notable for an 8-year history of diabetes mellitus and a past history of hypercholesterolemia. His current medications are atorvastatin (Lipitor), 20 mg/day, and extended-release metformin (Glucophage XR), 1000 mg/day. He also reports a history of peanut allergy manifested by lip angioedema, and carries an epinephrine auto-injector (EpiPen).On examination he has a blood pressure of 124/80 mm Hg. His hemoglobin A1c is 6.7%. A spot urine sample contains 40 µg albumin/mg creatinine.You see the patient 6 months later for a follow-up visit, and a spot urine sample has an albumin/creatinine ratio of 45 µg/mg.Which one of the following would be most appropriate initially? Have the patient return in 6 months for a repeat urine test for albumin and creatinine Order a 24-hour urine collection for creatinine Recommend that the patient reduce his daily protein intake to 1.5 g/kg/day Begin an ACE inhibitor Begin an angiotensin receptor blocker E Diabetic nephropathy develops in 20%-40% of patients with diabetes, and is the leading cause of end-stage renal disease. Persistent albuminuria in the range of 30-200 mg/24 hr (microalbuminuria) is the earliest sign of nephropathy in patients with type 1 diabetes, and is a marker for nephropathy in type 2 diabetes. Patients with microalbuminuria who progress to macroalbuminuria (>300 mg/24 hr) are likely to progress to end-stage renal disease over a period of years.Although timed 4- and 24-hour urine collections for creatinine can be used to screen for microalbuminuria, a random spot urine specimen for measurement of the albumin-to-creatinine ratio is the preferred method. A minimum of two of three tests showing a urine albumin level >30 µg/mg creatinine or more over a 6-month period confirms the diagnosis of microalbuminuria.Intensive diabetic management and the use of ACE inhibitors and angiotensin receptor blockers (ARBs) have been shown to delay the progression from microalbuminuria to macroalbuminuria in patients with type 1 or type 2 diabetes. Since the antiproteinuric effect is believed to be independent of blood pressure, current ADA guidelines recommend the use of ACE inhibitors or ARBs as first-line therapy for both type 1 and type 2 diabetic patients with microalbuminuria, even if their blood pressure is normal. Some studies, however, have raised questions about the value of early renin-angiotensin blockade for preventing microalbuminuria in normotensive patients with type 1 or type 2 diabetes, and ADA guidelines recommend against the use of these drugs for patients with normal blood pressure and no albuminuria.Compared to whites, African-Americans and Asians have a three- to fourfold higher risk of angioedema associated with the use of ACE inhibitors. The American Heart Association recommends that ACE inhibitors not be initiated in any patient with a history of angioedema.Reduction of protein intake to 0.8-1.0 g/kg/day in the early stages of chronic kidney disease, and to 0.8 g/kg/day in the late stages, may improve renal function and should be considered in patients whose nephropathy seems to be progressive despite optimal glucose and blood pressure control and the use of an ACE inhibitor and/or an ARB. True statements regarding carbohydrate intake and diabetes mellitus include which of the following? (Mark all that are true.) The glycemic index is not useful in the management of diabetes mellitus Carbohydrate sources high in protein are effective for treating hypoglycemia Low-fat diets are more effective for achieving weight loss than low-carbohydrate diets (<130 g/day) Excessive intake of sugar-sweetened beverages has been shown to increase the risk for diabetes mellitus Carbohydrates have fewer calories per gram than alcohol D AND E Weight loss is an important therapeutic objective in overweight or obese individuals with prediabetes or diabetes mellitus. Although low-fat diets have traditionally been promoted for weight loss, studies indicate that diets that provide the same caloric restriction but differ in protein, carbohydrate, or fat content are equally effective (SOR A). Both the amount and type of carbohydrates in food influence blood glucose levels. Monitoring the total grams of carbohydrates and using the glycemic index are both regarded as helpful strategies for achieving glycemic control. Dietary sucrose does not increase glycemia more than isocaloric amounts of starch, and intake of sucrose and sucrose-containing foods does not need to be restricted because of concerns about aggravating hyperglycemia in patients with diabetes mellitus. The use of nonnutritive sweeteners in place of caloric sweeteners has the potential to reduce carbohydrate intake. However, it has been shown that consumption of excessive amounts of sugar-sweetened beverages by nondiabetic persons is associated with a greater risk of developing type 2 diabetes. Although the energy content of alcohol is approximately 7 kcal/g, compared to 4 kcal/g for carbohydrates, alcohol consumption may place patients with diabetes at higher risk for hypoglycemia, especially if they are on insulin or insulin secretagogues. A 51-year-old male with type 2 diabetes mellitus controlled with diet is found to have a serum triglyceride level of 350 mg/dL, an LDL-cholesterol level of 101 mg/dL, and an HDL-cholesterol level of 45 mg/dL.Which one of the following supplements would most likely reduce his serum triglyceride levels? Vitamin E Vitamin C Omega-3 fatty acids Folate Chromium C At a dosage of approximately 3 g/day, omega-3 (or n-3) fatty acids have been reported to reduce serum triglyceride concentrations by 25%-30%, with accompanying increases in LDL-cholesterol of 5%-10%, and in HDL-cholesterol of 1%-3%. Which one of the following is INEFFECTIVE for treating pain syndromes arising from diabetic neuropathy? Tricyclic antidepressants SSRIs Duloxetine (Cymbalta) Pregabalin (Lyrica) B Control of pain represents one of the most challenging management issues in patients with diabetic neuropathy. Tricyclic antidepressants, anticonvulsants, and topical capsaicin have been shown to reduce the pain of diabetic neuropathy. Pregabalin and duloxetine are both FDA-approved for the treatment of diabetic peripheral neuropathy. Limited evidence suggests that SSRIs are no more effective than placebo. Although interventions with NSAIDs, transcutaneous electrical nerve stimulation (TENS), ACE inhibitors, and tramadol have been reported for diabetic neuropathy, systematic evaluations have not been published. At a routine health maintenance visit, a 42-year-old obese male is found to have a fasting plasma glucose level of 118 mg/dL. Which one of the following is the most appropriate initial intervention for preventing or delaying the development of diabetes mellitus in this patient? Lifestyle modification Metformin (Glucophage) A thiazolidinedione An oral sulfonylurea agent An ACE inhibitor A Based on the clinical practice guidelines of the American Diabetes Association, impaired fasting glucose (IFG) is defined as a fasting plasma glucose of 100-125 mg/dL, and impaired glucose tolerance (IGT) as a 2-hour plasma glucose of 140-199 mg/dL. These two categories have been officially termed prediabetes and are considered risk factors for future diabetes and cardiovascular disease. Lifestyle modification focusing on weight loss and physical exercise is regarded as first-line therapy for preventing or delaying diabetes mellitus in patients with prediabetes. In the Diabetes Prevention Program (DPP), lifestyle modification (5%-10% weight loss and moderate physical activity of 30 min/day) was associated with a 58% reduction of risk for developing diabetes. Metformin can be considered for very high-risk individuals (elevation of both IFG and IGT and at least one other risk factor such as hemoglobin A1C >6%, hypertension, low HDL-cholesterol, elevated serum triglycerides, or family history of type 2 diabetes mellitus in a first degree relative); in the DPP it was associated with a 31% reduction in risk. It was most effective in patients with a BMI of at least 35 kg/m2 who were under age 60. A 77-year-old obese male sees you for a routine visit. He has a 20-year history of hypertension, a 12-year history of type 2 diabetes mellitus complicated by the development of microalbuminuria and proliferative diabetic retinopathy, and a history of an inferior myocardial infarction 2 years ago. Although his diabetes had been adequately controlled with extended-release metformin (Glucophage XR), 500 mg twice daily, you recently added extended-release glipizide (Glucotrol XL), 2.5 mg once daily in the morning, because his hemoglobin A1c rose to 7.1%. He reports that since then he has episodically experienced shakiness and diaphoresis in the late morning, relieved by drinking orange juice. Several of these episodes have occurred during walks he takes with his wife before eating lunch.Which one of the following would be the most appropriate management? Reducing his metformin dosage to 500 mg in the morning Discontinuing glipizide and keeping the patient on his previous drug regimen Discontinuing glipizide and substituting nateglinide (Starlix) Advising the patient to eat lunch earlier in the day Advising the patient to delay his walk until after lunch B Although studies have clearly shown that intensive glycemic control reduces the risk for microvascular complications in patients with diabetes, it remains unclear whether it reduces the risk for cardiovascular disease as well. ACCORD, ADVANCE, and the Veterans Affairs Diabetes Trial have failed to show benefit, and the ACCORD trial actually reported an increased mortality rate in patients with type 2 diabetes treated with intensive therapy with a target hemoglobin A1c of <6.0%. Subjects in the ACCORD trial averaged 62 years of age and had diabetes for a mean duration of 10 years. Subjects either had a history of a cardiovascular disease (CVD) event between the ages 40 and 79, or had significant CVD risk and were between the ages 55 and 79. Based on the data available, the American Diabetes Association, in association with the American College of Cardiology Foundation and the American Heart Association, issued a position statement advising that less stringent hemoglobin A1c goals may be appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, poor health, or long-standing diabetes mellitus recalcitrant to therapy. A hemoglobin A1c of <7.0% is still recommended for the majority of patients with diabetes mellitus, with a target hemoglobin A1c closer to normal reserved for healthy patients with a short duration of disease and a long life expectancy (SOR C). True statments regarding dipeptidyl peptidase-4 inhibitors include which of the following? (Mark all that are true.) They are more effective than metformin for lowering hemoglobin A1c They reduce insulin resistance They augment glucagon secretion They are weight neutral They are not associated with hypoglycemia D AND E Oral dipeptidyl peptidase-4 (DPP-4) inhibitors are oral hypoglycemic agents that work by enhancing circulating concentrations of active glucagon-like peptide 1 (GLP-1) and glucose-dependent insulinotropic peptide (GIP). These agents lower glucose by increasing insulin secretion and reducing glucagon secretion in a glucose-dependent manner. Oral DPP-4 inhibitors are generally felt to be less effective than metformin and the sulfonylureas for lowering glucose, with an expected HbA1c reduction in the range of 0.5%-1.0% compared to 1.0%-1.5% for metformin and the sulfonylureas. DPP-4 inhibitors are considered weight neutral and are not associated with hypoglycemia. Side effects include nasopharyngitis, upper respiratory tract infection, and headache. A 62-year-old male sees you for the first time. His past medical history is notable for a long history of type 2 diabetes and hypertension, as well as a history of myocardial infarction 5 years ago and New York Heart Association class III heart failure. His current medications are hydrochlorothiazide, 25 mg daily; valsartan (Diovan), 320 mg daily; metoprolol succinate (Toprol XL), 50 mg daily, metformin (Glucophage), 850 mg twice daily; rosuvastatin (Crestor), 20 mg daily; and aspirin, 81 mg daily. Notable findings on examination include a blood pressure of 135/84 mm Hg and a heart rate of 58 beats/min. Laboratory findings include a hemoglobin A1C of 7.8%, an LDL-cholesterol level of 70 mg/dL, an HDL-cholesterol level of 35 mg/dL, a serum triglyceride level of 210 mg/dL, and an estimated glomerular filtration rate of 71 mL/min/1.73 m2.Which one of the following has been shown to reduce cardiovascular risk in patients such as this? Glipizide extended-release (Glucotrol XL) Liraglutide (Victoza) Niacin Pioglitazone (Actos) Saxagliptin (Onglyza) B The LEADER trial (Liraglutide Effect and Action in Diabetes: Evaluation of Cardiovascular Outcome Results) was a double-blind trial that compared the use of liraglutide, a GLP-1 analogue, to placebo in 9340 patients with type 2 diabetes at high cardiovascular risk. After a mean follow-up of 3.8 years, liraglutide was found to significantly reduce the rate of death from cardiovascular causes, as well as the first occurrence of nonfatal myocardial infarction and nonfatal stroke (hazard ratio, 0.87; 95% confidence interval [CI], 0.78 to 0.97). The rate of death from any cause was also reduced (SOR B).Cardiovascular outcome studies evaluating DPP-4 inhibitors such as sitagliptin, saxagliptin, and alogliptin have yet to demonstrate a significant reduction in adverse cardiovascular events in patients with diabetes. In addition, the SAVOR-TIMI trial (Saxagliptin Assessment of Vascular Outcomes Recorded in Patients with Diabetes Mellitus—TIMI 53) reported a higher risk for hospitalization for heart failure associated with saxagliptin treatment compared to placebo. Although a reduced risk for stroke has been reported with pioglitazone, thiozolidenediones are associated with fluid retention, which can lead to weight gain, edema, and heart failure. Their use is contraindicated in patients with New York Heart Association class III or IV heart failure. Oral sulfonylureas are potent glucose-lowering agents associated with a higher risk for hypoglycemia. Studies have not shown a reduced cardiovascular risk with their use, and the University Group Diabetes Program (UGDP) trial reported a higher risk of cardiovascular death associated with the use of tolbutamide.Although niacin might have been a consideration in the past in an effort to raise HDL-cholesterol and lower triglycerides, support for its use was dampened by the findings of the AIM-HIGH trial (Atherothrombosis Intervention in Metabolic Syndrome with Low HDL/High Triglycerides: Impact on Global Health Outcomes), which found no clinical benefit from adding sustained-release niacin to a statin in patients with known coronary heart disease and low HDL-cholesterol. A 66-year-old male who was hospitalized because of a TIA 3 months ago sees you for a follow-up visit. His past medical history is notable for impaired fasting glucose and mild hypertension. His current medications are valsartan (Diovan), 160 mg daily; rosuvastatin (Crestor), 20 mg daily; and aspirin, 81 mg daily. On examination his BMI is 30.2 kg/m2, his blood pressure is 134/86 mm Hg, and he has brown, velvety, hyperkeratotic plaques on the back of his neck and in his axilla. His laboratory studies are notable for an LDL-cholesterol level of 85 mg/dL, an HDL-cholesterol level of 35 mg/dL, and a serum triglyceride level of 174 mg/dL.Which one of the following agents may reduce his risk for stroke and myocardial infarction? Basal insulin Acarbose (Precose) Glipizide (Glucotrol) Pioglitazone (Actos) Sitagliptin (Januvia) D In addition to playing a primary role in the development of type 2 diabetes, insulin resistance is also found in more than half of patients without diabetes who experience an ischemic stroke or TIA. Although treatment of individual cardiovascular risk factors plays a major role in the management of these patients, treatment directly targeted at reducing insulin resistance may also have a role. The Insulin Resistance Intervention in Stroke (IRIS) trial was a 4.8-year multicenter double-blind study that investigated the role of pioglitazone in nondiabetic stroke and TIA patients determined to have insulin resistance based on the homeostasis model assessment of insulin resistance (HOMA-IR) index. In this trial, the use of pioglitazone was associated with a 24% reduction in stroke and myocardial infarction and a 52% reduction in the risk of developing type 2 diabetes. This potential benefit should be balanced against possible adverse events linked to thiazolidinedione use, including weight gain, edema, bone fracture, and bladder cancer. Hypoglycemia is a possible side effect of which of the following diabetes agents? (Mark all that are true.) Insulin Pioglitazone (Actos) Metformin (Glucophage) Sulfonylureas Repaglinide (Prandin) Acarbose (Precose) A, D, E Hypoglycemia is a well-known complication of insulin therapy. Since sulfonylureas and repaglinide work by enhancing insulin secretion, hypoglycemia is a complication of these two agents as well. Used alone, acarbose, metformin, and thiazolidinediones (e.g., pioglitazone) are not associated with the development of hypoglycemia. It should be noted, however, that in June 2011, the FDA issued a drug safety alert reporting that use of pioglitazone for more than 1 year may be associated with an increased risk of bladder cancer. True statements regarding dietary fat intake in patients with diabetes mellitus include which of the following? (Mark all that are true.) A Mediterranean-style diet rich in monounsaturated fats has been shown to improve glycemic control in patients with diabetes Trans fatty acids have been shown to lower LDL-cholesterol and raise HDL-cholesterol Saturated fats should provide 10% of caloric intake Omega-3 (or n-3) fatty acid supplementation is associated with a cardioprotective effect A gram of fat contains 50% more calories than a gram of carbohydrate A The primary goal with regard to fat intake in patients with diabetes is to limit saturated fat and trans fatty acids. National dietary guidelines recommend that intake of saturated fat be limited to <10% of daily calories. Intake of trans unsaturated fatty acids should be minimized, since they have been shown to raise LDL-cholesterol and lower HDL-cholesterol. A Mediterranean-style diet rich in monunsaturated fats has been found to improve both glycemic control and lipid levels in patients with diabetes. Randomized, controlled trials do not support recommending omega-3 supplements for primary or secondary prevention of cardiovascular disease. A gram of fat contains more than twice the calories of a gram of carbohydrate. True statements regarding coronary heart disease in patients with diabetes mellitus include which of the following? (Mark all that are true.) Routine screening with a cardiac stress test is recommended in asymptomatic patients with diabetes who are at increased cardiovascular risk β-Blockers should be avoided in diabetic patients with coronary artery disease, due to the risk of masking hypoglycemia and reducing insulin secretion Long-term outcomes following percutaneous transluminal coronary angioplasty are as good in diabetic patients as in nondiabetic patients The survival of diabetic patients with multivessel disease is better with coronary revascularization with coronary artery bypass graft (CABG) surgery than with percutaneous transluminal coronary angioplasty Optimal glycemic control has been shown to reduce the risk of coronary heart disease in patients with type 2 diabetes D Although atherosclerotic cardiovascular disease is the leading cause of morbidity and mortality in patients with diabetes, routine screening for coronary heart disease is not recommended since it has not been shown to improve cardiovascular outcomes provided cardiovascular risk factors are treated (SOR A). The potential benefit of β-blockers in the diabetic patient with coronary artery disease outweighs the potential risk of masking hypoglycemia or reducing insulin secretion (SOR A). Good glycemic control has been shown to reduce microvascular complications in patients with diabetes mellitus. Although the Diabetes Control and Complications Trial and the Epidemiology of Diabetes Interventions and Complications study found that intensive glycemic control initiated soon after the diagnosis of type 1 diabetes produced long-term protection from cardiovascular disease, the results of three large trials (ACCORD, ADVANCE, and VADT) published in 2008 suggested no reduction in cardiovascular disease risk with intensive glycemic control in patients with type 2 diabetes. Mortality rates after percutaneous transluminal coronary angioplasty (PTCA) are generally higher in patients with diabetes mellitus than in nondiabetic patients. The survival of diabetic patients with multivessel disease is better after coronary artery bypass graft (CABG) surgery than after PTCA. This was shown in the FREEDOM trial (Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease), a randomized trial of 1900 patients with diabetes and multivessel coronary heart disease. Treatment with CABG was associated with both a lower rate of myocardial infarction and lower mortality compared to PCI with drug-eluting stents (SOR A). A 62-year-old African-American male with a 10-year history of type 2 diabetes is diagnosed with hypertension. His current medications include metformin (Glucophage XR), 1500 mg daily; sitagliptin (Januvia), 100 mg daily; and simvastatin (Zocor), 40 mg daily. His blood pressure at today's visit is 154/94 mm Hg. His urine is negative for microalbuminuria.Which one of the following is true regarding treatment recommendations for this patient? Current American Diabetes Association (ADA) guidelines recommend treatment to a systolic blood pressure goal of <130 mm Hg and a diastolic blood pressure goal of <85 mm Hg JNC 8 guidelines recommend treatment to a systolic blood pressure goal <150 mm Hg and a diastolic blood pressure goal of <90 mm Hg The SPRINT trial supports targeting a systolic blood pressure goal of <120 mm Hg ADA guidelines recommend initiating therapy with either an ACE inhibitor or an angiotensin receptor blocker JNC 8 guidelines recommend initiating therapy with either a thiazide-like diuretic or a dihydropyridine calcium channel blocker E Although randomized clinical trials have shown the cardiovascular and renal benefit of antihypertensive treatment targeting a systolic blood pressure <140 mm Hg and a diastolic blood pressure <90 mm Hg, they have not generally demonstrated additional benefit with more intensive therapy (targeting a systolic blood pressure <120-30 mm Hg and a diastolic blood pressure <80 mm Hg) in patients with diabetes.JNC 8 guidelines recommend a target systolic blood pressure of <150 mm Hg and a target diastolic blood pressure of <90 mm Hg in individuals over 60 years of age, but the guidelines recommend a target systolic blood pressure of <140 mm Hg in individuals over 18 years of age with diabetes mellitus (SOR C). Current American Diabetes Association (ADA) guidelines generally recommend a target systolic blood pressure of <140 mm Hg and a target diastolic blood pressure of <90 mm Hg (SOR A), with lower targets, such as 130/80 mm Hg, for high-risk patients with diabetes if these goals are achievable without undue treatment burden (SOR C). The 2017 ACC/AHA hypertension guidelines take a more aggressive approach, recommending antihypertensive drug treatment be initiated at a blood pressure of 130/80 mm Hg or higher, with a treatment goal of <130/80 mm Hg in patients with diabetes.With the exception of the diabetic patients with albuminuria, ADA guidelines recommend initiating therapy with any of the antihypertensive agents shown to reduce cardiovascular events in patients with diabetes, which includes ACE inhibitors, angiotensin receptor blockers (ARBs), thiazide-like diuretics, and dihydropyridine calcium channel blockers. First-line treatment with an ACE inhibitor or ARB is recommended by the ADA for diabetic individuals with albuminuria (SOR B). In the general African-American population, including those with diabetes, JNC 8 guidelines favor initial treatment with a thiazide-like diuretic or dihydropyridine calcium channel blocker; however, in patients with chronic kidney disease, regardless of race or diabetes status, both JNC 8 and the ADA recommend initial therapy with an ACE inhibitor or ARB.SPRINT (Systolic Blood Pressure Intervention Trial) was a randomized, controlled, open-label trial that compared aggressive treatment to a target systolic blood pressure <120 mm Hg with a target of <140 mm Hg in patients at increased cardiovascular risk. Although it did find that targeting a systolic blood pressure of <120 mm Hg resulted in lower rates of fatal and nonfatal major cardiovascular events, patients with diabetes or history of previous stroke were specifically excluded from the study. Endocrinopathies associated with diabetes mellitus include which of the following? (Mark all that are true.) Cushing's syndrome Acromegaly Pheochromocytoma Gastrinoma Glucagonoma A, B, ,D, E Endogenous gluconeogenic hormones include cortisol, norepinephrine, epinephrine, glucagon, and growth hormone. Accordingly, endocrinopathies associated with excessive levels of these hormones can cause glucose intolerance and diabetes; such disorders include acromegaly, Cushing's syndrome, glucagonoma, and pheochromocytoma. Hyperthyroidism has also been shown to be associated with diabetes mellitus. In addition, somatostatinomas and aldosteronomas can cause diabetes, most likely by inhibiting insulin secretion. According to National Cholesterol Education Program guidelines, criteria for the diagnosis of metabolic syndrome include which of the following? (Mark all that are true.) A waist circumference >40 inches in males An HDL-cholesterol level <50 mg/dL in females An LDL-cholesterol level ≥160 mg/dL A serum triglyceride level ≥150 mg/dL Diastolic blood pressure ≥85 mm Hg A, B, D, E Metabolic syndrome is a constellation of cardiovascular risk factors related to hypertension, abdominal obesity, dyslipidemia, and insulin resistance. Diagnostic criteria for metabolic syndrome, according to the National Cholesterol Education Program (Adult Treatment Panel III Guidelines), include the presence of three or more of the following: (1) obesity, with a waist circumference exceeding 102 cm (40 inches) in men or 88 cm (35 inches) in women; (2) blood pressure ≥130 mm Hg systolic and/or 85 mm Hg diastolic; (3) a fasting glucose level ≥110 mg/dL; (4) a serum triglyceride level ≥150 mg/dL; and (5) an HDL-cholesterol level <40 mg/dL in men or <50 mg/dL in women. [Show Less]
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ABFM HOSPITAL MEDICINE QUESTIONS AND ANSWERS GRADED A+
A 42-year-old construction worker with a 3-day history of cough, fever, chills, dyspnea, and right posterolateral chest pain with inspiration is brought to... [Show More] the emergency department by his wife. He has been in good health until this illness, and has never been hospitalized. He does not take any routine medications, does not smoke, and drinks alcohol only occasionally.On examination he appears ill and in mild respiratory distress. His temperature is 40.3°C (104.5°F), pulse rate 130 beats/min, respiratory rate 32/min, blood pressure 136/70 mm Hg, and oxygen saturation 88% on room air. He has diminished breath sounds in the right posterolateral chest. His Pneumonia Severity Index is 97. Based on the severity of his illness you recommend hospital admission.Antibiotic choices recommended for empiric treatment in this patient include which of the following? (Mark all that are true.) Ceftriaxone (Rocephin) plus azithromycin (Zithromax) Ceftriaxone plus doxycycline Ciprofloxacin (Cipro) Clarithromycin (Biaxin) Levofloxacin (Levaquin) A, B, E Relative risk stratification should be performed for patients with community-acquired pneumonia, using a clinical prediction tool such as the Pneumonia Severity Index (PSI) or the CURB-65 (SOR A). These tools can be used along with the judgment of the physician to decide whether or not a patient can be treated as an outpatient or should be admitted to the hospital. This patient is moderately ill and, based on his presentation, has a PSI score of 97 (based on his age, respiratory rate, temperature, and pulse oximetry). This score indicates that he should initially be treated in the hospital.A macrolide plus a β-lactam is recommended for combination therapy in patients hospitalized with community-acquired pneumonia who are at low risk (PSI score of 71-130) (SOR A). In addition to a β-lactam, doxycycline can be used as an alternative to a macrolide (SOR B). A respiratory fluoroquinolone (levofloxacin, gemifloxacin, moxifloxacin) can be used as monotherapy (SOR A). Because of concerns about increasing levels of resistance, macrolides are not recommended as monotherapy for a moderately ill patient (SOR C). Ciprofloxacin, a first-generation quinolone, has no antimicrobial activity against Streptococcus pneumoniae and is therefore not appropriate treatment for community-acquired pneumonia (SOR C). A 32-year-old nonpregnant female with a history of poorly controlled type 2 diabetes mellitus is admitted to the hospital for abdominal wall cellulitis. On hospital day 2 she develops mild shortness of breath. Her physical examination is normal, with the exception of a respiratory rate of 22/min and abdominal wall erythema, warmth, and tenderness. Laboratory findings are normal with the exception of a fasting blood glucose level of 268 mg/dL and mild leukocytosis. Her D-dimer level is 250 ng/mL.True statements regarding the use of the D-dimer assay for diagnosing pulmonary embolism in this situation include which of the following? (Mark all that are true.) It has good sensitivity It has good specificity It has a good positive predictive value It has a good negative predictive value A, D D-dimer is a degradation product of cross-linked fibrin. The PIOPED II investigators recommend stratification of all patients with suspected pulmonary embolism according to an objective clinical probability assessment. D-dimer should be measured by a quantitative rapid enzyme-linked immunosorbent assay (ELISA), and the combination of a negative D-dimer with a low or moderate clinical probability can safely exclude pulmonary embolism in many patients. The sensitivity of the D-dimer assay is 90%-95% for pulmonary embolus, but D-dimer levels are normal in only 40%-68% of patients without pulmonary embolus (SOR A). A D-dimer value >500 ng/mL is considered to be abnormal. Values ≤500 ng/mL have a high negative predictive value for pulmonary embolism in patients with a low to moderate pretest probability (SOR A). A 58-year-old male with type 2 diabetes mellitus undergoes elective knee surgery. After the surgery he is restarted on all of his usual medications with intensive glucose monitoring. On his first postoperative day he is found to be confused and lethargic with a blood glucose level of 32 mg/dL.When used alone, which of the following diabetes medications can cause this problem? (Mark all that are true.) Nateglinide (Starlix) Glipizide (Glucotrol) Insulin glargine (Lantus) Metformin (Glucophage) Pioglitazone (Actos) A, B, C Some diabetes medications can lead to hypoglycemia in hospitalized patients. Both nateglinide and glipizide stimulate insulin production, which can lead to hypoglycemia (SOR B). All insulin products lower blood glucose directly, with hypoglycemia as a known side effect (SOR B). Metformin and pioglitazone both help control diabetes by sensitizing the body to the effects of insulin. These medications are not a direct cause of hypoglycemia when given at usual dosages in most situations (SOR B). An 82-year-old female is hospitalized with acute pancreatitis and intestinal ileus, and you determine that she will require total parenteral nutrition through a central venous catheter. Which of the following will decrease the likelihood of catheter-related complications in this patient? (Mark all that are true.) Placement of the catheter in the femoral vein Ultrasound-guided placement of the catheter into the internal jugular vein Routinely changing the catheter over a wire every 3-5 days Routinely moving the catheter to a different insertion site every 3-5 days Using chlorhexidine gluconate-impregnated sponges in the catheter dressings B, E Studies show that ultrasound-guided placement of the catheter into the internal jugular vein is associated with a higher success rate and a lower complication rate during insertion, even among physicians highly experienced in the procedure (SOR A). Placement of the catheter in the femoral vein is associated with a higher rate of post-insertion complications (SOR A). Routinely changing the catheter over a wire every 3-5 days has been shown to increase the rate of catheter-associated infections (SOR A). Evidence has shown no benefit from moving the catheter in terms of reducing infections, and making multiple insertions has been shown to lead to an increase in infections (SOR A). Evidence from a large, well-done, randomized, controlled trial shows a significant decrease in major catheter-related infections when chlorhexidine gluconate-impregnated sponges are used in the catheter dressing (hazard ratio 0.39) (SOR A). In this study, a major infection was avoided for every 117 catheters treated. A 68-year-old female is admitted to the hospital with pneumonia. She is penicillin-allergic and receives a dose of ampicillin/sulbactam (Unasyn). She has an anaphylactic reaction and is transferred to the intensive-care unit, where her condition stabilizes with mechanical ventilation, pressor agents, and corticosteroids.True statements regarding disclosure of the unanticipated outcome to the patient and her family include which of the following? (Mark all that are true.) Federal law requires disclosure of all medical errors or unanticipated outcomes regardless of harm Disclosure of unanticipated outcomes or medical errors is a standard of the Joint Commission The majority of states have laws that legally protect apologies for medical errors from being used as evidence of liability Most physicians believe that disclosure of serious errors reduces the risk of a lawsuit Disclosure of unanticipated outcomes and medical errors is associated with fewer malpractice claims Surgeons are less likely to disclose medical errors than other physicians B,C,D In 2005, the National Medical Errors Disclosure and Compensation (MEDiC) Act of 2005 was introduced in the U.S. Senate. The bill emphasized open disclosure of medical errors to patients, apology and early compensation, and a comprehensive analysis of the events. Congress did not pass the legislation, but in the meantime at least 34 states have passed laws requiring disclosure of medical errors, generally with limited protections regarding the use of apologies or expressions of regret as evidence of liability. Since 2001, disclosure to patients and their families of the outcomes of treatment, including unanticipated outcomes, has been a standard of the Joint Commission.Some studies suggest that disclosure results in fewer lawsuits or lower total payouts, but others show the opposite. It is not yet known what the net effect will ultimately be on lawsuits related to disclosure of medical errors as such disclosure becomes the norm, but one study found that two-thirds of American and Canadian physicians believe that disclosure reduces the risk of a lawsuit. That same study, however, found that 98% of those physicians believed that disclosure of serious errors was the right thing to do, whether or not they believed it lowered the risk of litigation. In a study regarding physicians' attitudes toward disclosing errors to patients, there were several factors associated with an increased willingness to tell patients about medical errors. These factors include the belief that doing so made patients less likely to sue, not being in private practice, being Canadian rather than a U.S. citizen, and being a surgeon. An 82-year-old male is admitted to the intensive-care unit with a 3-day history of abdominal pain, nausea, vomiting, and bloody diarrhea. He has a fever and meets clinical criteria for sepsis. His chronic medical problems include hypertension, hyperlipidemia, coronary artery disease, heart failure, type 2 diabetes mellitus, and osteoarthritis. His daily medications include lisinopril (Prinivil, Zestril), furosemide (Lasix), metformin (Glucophage), simvastatin (Zocor), and ibuprofen. He has not been eating or drinking much in the past several days, but his wife has made sure that he has taken his medications as prescribed.His initial laboratory results include a BUN of 72 mg/dL (N 8-25) and a serum creatinine level of 3.2 mg/dL (baseline 1.3; N 0.6-1.5). Despite aggressive fluid resuscitation, his urine output is only 100 mL in the first 8 hours. A general surgeon is consulted and orders abdominal CT with contrast.Which of the following would be important in the management of this patient? (Mark all that are true.) Aggressive hydration and the removal of nephrotoxic agents Diuretics to increase his urine output Infusion of dopamine at a low dosage (2 µg/kg/min) Infusion of sodium bicarbonate prior to administration of contrast media A Most cases of acute kidney injury (AKI, formerly called acute renal failure) occur as a result of decreased renal perfusion or decreased glomerular filtration. Common etiologies include dehydration from gastrointestinal fluid loss, overaggressive diuresis, and conditions that reduce effective arterial volume, such as heart failure, liver failure, and nephrotic syndrome (SOR C). Restoration of renal perfusion and glomerular filtration are the cornerstones of treatment for acute prerenal renal failure. Expansion of the circulating intravascular volume with intravenous fluids and withholding medications known to affect glomerular function are important first steps in this patient's treatment.Both NSAIDs and ACE inhibitors reduce glomerular filtration and can precipitate AKI, especially in patients with other contributing factors, such as dehydration. NSAIDs reduce glomerular filtration by inducing vasoconstriction of the afferent arterioles through inhibition of cyclooxygenase, which leads to increased levels of thromboxane A2, a potent vasoconstrictor. ACE inhibitors reduce glomerular filtration by reducing levels of angiotensin II, which allows vasodilation of efferent arterioles and reduces glomerular hydrostatic pressure.Radiocontrast media are known to be potentially nephrotoxic and are best avoided in patients with, or at risk for, AKI. Administering sodium bicarbonate is no longer recommended.Although patients with nonoliguric renal failure fare better than patients presenting with oliguria, the use of diuretics to stimulate urine output actually increases mortality and does not promote recovery of renal function (SOR B). A placebo-controlled randomized trial of low-dose dopamine in critically ill ICU patients who met criteria for sepsis with early renal dysfunction showed no benefit with regard to preventing AKI or the need for dialysis. The use of dopamine also did not reduce hospital or ICU lengths of stay or reduce mortality (SOR A). When the clinical condition demands immediate restoration of renal function to correct severe acid-base disturbances, electrolyte abnormalities, hypervolemia, or neurologic sequelae of AKI, the use of renal replacement therapy or dialysis should be considered (SOR C). CT is usually indicated for which of the following? (Mark all that are true.) Suspected aortic dissection Head trauma from a fall in a 67-year-old patient Chronic neck pain Persistent, recurrent, or chronic sinusitis in children Suspected ankle fracture A, B, D The use of CT has increased significantly in recent years due to increased availability, better resolution, and faster scan times. However, there are rising concerns about cumulative radiation exposure and an increasing need to contain costs in medicine. In an effort to assist clinicians in making wise use of all imaging techniques, the American College of Radiology (ACR) has developed appropriateness criteria that recommend modalities for various clinical problems.For suspected aortic dissection, the ACR recommends CT with contrast as the definitive test, and a radiograph as the initial test if it does not delay definitive testing. MR angiography is recommended as an alternative to CT if CT is contraindicated or unavailable.Imaging recommendations for head trauma are broken down into various types, but CT is recommended in many situations. According to the New Orleans Criteria, noncontrast CT of the head is recommended for evaluation of head trauma in patients over age 60 with minor or mild acute injuries. The Canadian CT Head Rule and the National Emergency X-Ray Utilitzation Study (NEXUS-II) use age ≥65 in their criteria.For chronic neck pain, a cervical spine radiograph is recommended. The ACR considers CT to be the gold standard for evaluating persistent sinusitis in children, as it accurately shows soft-tissue structures. For a suspected ankle fracture, radiography is the preferred imaging, assuming the patient meets the Ottawa ankle criteria. A 33-year-old male is hospitalized because of diabetic ketoacidosis, which is the initial presentation of his diabetes mellitus. Initial laboratory testing reveals a blood glucose level of 679 mg/dL, a venous pH of 7.11, a serum potassium level of 5.3 mEq/L (N 3.5-5.0), and a serum sodium level of 130 mEq/L (N 135-145). He is initially treated with intravenous normal saline and a continuous insulin drip, and intravenous potassium is added later. Four hours after treatment is started he has a blood glucose level of 210 mg/dL, a venous pH of 7.28, a serum potassium level of 3.9 mEq/L, and a serum sodium level of 134 mEq/dL.Which one of the following would be most appropriate at this time? Stopping the insulin Stopping the potassium Switching to subcutaneous insulin Changing the intravenous solution to ½-normal saline with dextrose and potassium Administering sodium bicarbonate D In a patient being treated for ketoacidosis, once the serum glucose level goes below about 250 mg/dL, dextrose should be added to the intravenous solution to decrease the risk of hypoglycemia (SOR C). The fluid should be switched to ½-normal saline when the sodium becomes normal (SOR C). Insulin should not be stopped until the acidosis is cleared, and potassium should not be stopped until all values are normal (SOR C). Continuous insulin infusion should be continued until resolution of ketoacidosis as demonstrated by a blood glucose < 200 mg/dl and a venous pH > 7.3, a serum bicarbonate > 15 mEq/l, and an anion gap < 12 mEq/L. Even with severe acidosis, adding sodium bicarbonate does not improve biochemical or clinical recovery (SOR C). You have been asked to set up a program to prevent falls in hospitalized patients. Which of the following would be effective measures? (Mark all that are true.) Asking about the number and circumstances of recent falls when patients are admitted Evaluating patients for postural hypotension Assessing vitamin D status Adding or increasing medications for anxiety or depression for patients with signs or symptoms of these problems Making certain that patients have appropriate footwear during their hospitalization Providing instructions on aerobic exercises to prevent falls while hospitalized Instructing patients with dementia about methods to prevent falls while hospitalized A, B, E Checking environmental issues and assessing each patient for fall risk can reduce the incidence of falls at home, in extended-care facilities, and in the hospital. Patients with a history of recent falls are at the highest risk for recurrent falls, and asking about this at the time of admission can identify these patients (SOR A). Patients should also be evaluated for postural hypotension, as this can be a contributor to falls, especially after prolonged bed rest (SOR B).Although it was recommended in the past, the U.S. Preventive Services Task Force (USPSTF) has found no evidence that vitamin D offers benefit in preventing falls in older adults, and the task force now recommends against vitamin D supplementation to prevent falls in community-dwelling adults 65 years or older (USPSTF D recommendation). Psychoactive medications should be decreased or discontinued to prevent falls in hospitalized patients (SOR B). Inappropriate footwear can also be a significant contributor to falls (SOR C), and balance, gait, and strength training have been shown to decrease fall risks (SOR A). While beneficial otherwise, aerobic exercises have not been shown to be effective for decreasing fall risks (SOR A). Instructing patients with dementia about fall prevention has been shown to be ineffective due to their limited understanding (SOR C). A 68-year-old male lives alone with no close relatives or friends. He is brought to the emergency department by EMS after apparently having a stroke of undetermined duration. He is medically optimized and discharge planning is now being discussed. You determine that the patient is not capable of making informed decisions about his disposition.Reasonable strategies for managing this situation include which of the following? (Mark all that are true.) Transfer the patient to an adult foster care home Transfer the patient to a nursing facility Obtain a psychiatric consultation to assist with determination of the patient's decision-making capacity Consult the ethics committee at your institution to recommend a reasonable course of action Assign durable power of attorney for health care to one of the medical social workers who is familiar with his case Work with the probate court to establish guardianship for the patient C, D, F As with any medical procedure, discharge planning should be done with the consent of the patient involved. Because this patient does not appear to have the capacity to consent to any plan, a surrogate decision maker should be sought. Most hospitals have an ethics committee available with reasonable notice, allowing the hospital to convene a multidisciplinary group of caregivers who are familiar with the legal and ethical requirements of situations such as the one presented here. Their determinations are usually not binding, but are meant to provide guidance as to what is considered legally, ethically, and culturally appropriate.The legal determination that a patient is unable to make decisions on his or her own behalf most often requires the opinion of at least two different professionals (SOR C). This can be two physicians or a physician and a psychologist. The durable power of attorney for health care is a form of advance directive that a patient creates while competent, and goes into effect when the person is unable to make medical decisions. In this case, the patient is unable to express his wishes and so cannot complete an advance directive. Most power-of-attorney forms specifically prohibit members of the medical team from being a patient's decision-making proxy.Probate court is the appropriate venue for designating a guardian (or conservator) for patients who have lost the capacity to make or communicate decisions about their own care (SOR C). This is a legal proceeding that will require due process on behalf of the patient. Counsel will be assigned to represent the patient and an attempt will be made to contact interested friends and family. Temporary guardianship may be assigned if action is required before a more permanent representative can be found. This guardian will (at the discretion of the probate judge) be allowed to manage the patient's finances, determine his/her living situation, and consent to or refuse medical care. A 32-year-old male is admitted to the hospital for management of a perirectal abscess. When you examine him he reports severe pain in the rectal area, and palpitations. His vital signs are normal, with the exception of a heart rate of 132 beats/min and a temperature of 38.9°C (102.0°F). He rates his pain as 8 out of 10. His EKG is shown below.Appropriate treatment of the patient's cardiac arrhythmia would include which of the following? (Mark all that are true.) Oral ibuprofen Intravenous digoxin Intravenous diltiazem Intravenous labetalol Intravenous morphine Carotid sinus massage A, E This patient has sinus tachycardia. Pain, fever, anxiety, hypoxia, tissue hypoperfusion, and volume loss are common causes of sinus tachycardia in hospitalized patients. Ibuprofen lowers body temperature and relieves pain, helping to decrease the heart rate (SOR B). Similarly, morphine helps lower the heart rate by decreasing anxiety and relieving pain (SOR B). β-Blockers are not indicated for sinus tachycardia resulting from pain and fever, as they do not address the underlying cause of the tachycardia (SOR A). Intravenous digoxin and diltiazem, as well as carotid sinus massage, are not indicated for sinus tachycardia (SOR A). A 6-month-old infant is brought to the emergency department by his mother because of a fever to 103.0°F, irritability, and a skin lesion on his arm that was first noticed less than 24 hours ago. On examination the lesion is 6-7 cm in diameter, erythematous, warm, and tender. It has a firm, fluctuant center about 3 cm in diameter, with a central purulent head. There have been no similar infections in household contacts.The infant is admitted to the hospital. At this time, appropriate treatment options for this patient's skin infection include which of the following? (Mark all that are true.) Incision and drainage Decolonization of offending bacteria with topical antibiotic washes Ceftriaxone (Rocephin) Clindamycin (Cleocin) Trimethoprim/sulfamethoxazole (Sulfatrim) Tetracycline A, D Historically, methicillin-resistant Staphylococcus aureus (MRSA) infections have been considered nosocomial. Since the 1990s, however, a distinct group of community-acquired strains (CA-MRSA) has emerged. The bacteria are spread by close contact and can be easily transmitted across abraded skin. For this reason, many households may have outbreaks, and athletes (especially football players and wrestlers) can contract the condition from teammates or competitors. However, only 10%-18% of patients who contract CA-MRSA have a known contact who has the disease.The infant described here shows classic signs of an infection with CA-MRSA. Abscesses similar to those seen in this patient occur in 50%-75% of patients with CA-MRSA. In cases in which no systemic signs are present, incision and drainage is usually curative without the use of antibiotics. However, this infant has a high temperature and spreading cellulitis, and requires an antibiotic in addition to surgical treatment (SOR B). Decolonization of offending bacteria with topical antibiotic washes is not a goal for an acute infection, and is recommended only for cases that are recurrent or in which a whole group of patients, such as a family or athletic team, is symptomatic (SOR C).Clindamycin is FDA approved for the treatment of MRSA infections and is appropriate in infants (SOR B). Trimethoprim/sulfamethoxazole is not FDA approved for MRSA infections, but most strains of the community-acquired bacteria are susceptible to this combination. It is safe to use in infants over the age of 2 months but may be inadequate if the infection turns out to be streptococcal (SOR C). β-Lactam antibiotics such as ceftriaxone are generally not a good treatment choice for MRSA infections (SOR B). While most isolates of CA-MRSA are susceptible to tetracyclines, these drugs are not appropriate for children under the age of 8 years because of the potential for tooth staining (SOR C). A 19-year-old male presents with a 2-day history of worsening headache, photophobia, malaise, and fever. On examination the patient is alert but in mild distress, and has a temperature of 38.3°C (100.9°F). The HEENT examination is negative, including a funduscopic examination, but nuchal rigidity is present. You perform a lumbar puncture to obtain a sample for cerebrospinal fluid (CSF) analysis.True statements regarding interpretation of the test results include which of the following? (Mark all that are true.) Xanthochromia confirms that the patient has had a subarachnoid hemorrhage A positive polymerase chain reaction test for enterovirus has high sensitivity and specificity Protein levels are typically normal in viral meningitis and elevated in bacterial meningitis A CSF glucose level of 80 mg/dL in a patient with a plasma glucose level of 120 mg/dL makes bacterial meningitis unlikely A CSF WBC count <100/mm3 is rare with bacterial meningitis B, C, E Xanthochromia is yellow, red, or orange discoloration of the cerebrospinal fluid (CSF) and can be an indication of subarachnoid hemorrhage (SOR B). It represents the presence of free hemoglobin (or a byproduct) in the CSF as a result of red blood cell (RBC) lysis, which occurs within a few hours of RBCs appearing in the CSF. Xanthochromia can also be seen when the serum bilirubin concentration is high, or when there is a traumatic lumbar puncture with >100,000 RBCs/mm3.Polymerase chain reaction (PCR) testing is rapid and highly sensitive and specific for viral meningitis, particularly for Enterovirus infections. A positive identification provides reassurance that the etiology is viral and allows for discontinuation of antibacterial therapy and for earlier hospital discharge (SOR B). PCR testing is also particularly helpful in identifying herpesvirus 1 CNS infections. While there are fairly wide ranges for CSF protein concentrations with various inflammatory conditions, infection raises the concentration (SOR B). This increase is greater with bacterial infection than with viral meningitis, which is most often associated with CSF protein in the normal range of 20-60 mg/dL.While the normal CSF glucose concentration is usually two-thirds of the plasma glucose level, it is classically lower in bacterial meningitis, and usually normal in viral meningitis. However, the CSF glucose level is normal in up to 50% of cases of bacterial meningitis, so a normal level doesn't rule out bacterial infection (SOR B). CSF WBC counts are >100/mm3 in 99% of cases of bacterial meningitis, and in the vast majority of cases WBC counts are >1000/mm3 (SOR B). A 55-year-old male was admitted to the hospital 2 days ago with complaints of chest pain and dyspnea that occurred while he was mowing his lawn and resolved at rest. He has a family history of coronary artery disease and a personal history of tobacco use and untreated borderline hypertension. He has been pain free since admission.Serial laboratory evaluation revealed a small increase in his troponin I concentration, but there was no ST elevation noted on his initial and subsequent EKGs. He underwent treadmill stress testing but was unable to reach his target heart rate due to fatigue and dyspnea. Cardiac catheterization revealed approximately 30% occlusions in the mid-left anterior descending and mid-circumflex arteries, with no intervention performed. He has recovered from the procedure without complications and is now ready for discharge.True statements regarding post-hospital management in this situation include which of the following? (Mark all that are true.) Smoking cessation can reduce his mortality Participation in a cardiac rehabilitation program has been shown to reduce morbidity and mortality and improve functional capacity Optimal blood pressure control with a target blood pressure <140/90 mm Hg is contraindicated Aspirin, β-blockers, statins, and ACE inhibitors have been shown to reduce recurrent cardiac events It is appropriate to screen the patient for depression A, B, D, E Effective and evidence-based post-hospital management of patients admitted with acute coronary syndrome can reduce recurrences of cardiac events, reduce morbidity and mortality, and improve quality of life. Treatment should be focused on secondary prevention, including appropriate medications, dietary modification, smoking cessation, and guided exercise with a goal of increased physical activity. Along with appropriate lipid management, blood pressure control, and smoking cessation, cardiac rehabilitation and efforts targeted at exercise and increased activity can reduce cardiovascular mortality, improve functional capacity, reduce myocardial ischemia, retard progression and foster reversal of coronary atherosclerosis, and reduce the overall risk of further coronary events (SOR A). Attention should also be paid to the psychosocial impact of the episode and subsequent diagnosis to reduce negative effects on quality of life.Tobacco cessation has been shown to reduce all-cause mortality in patients with established CAD (SOR A). Investigators have concluded that persons who quit smoking after a myocardial infarction (MI) or cardiac surgery reduce their risk of death by at least one-third, and that discontinuing smoking is at least as beneficial as modifying other risk factors. If a patient is willing to try to quit smoking, physicians should assist with cessation through counseling and pharmacotherapy, which are most effective when combined.Cardiac rehabilitation is standard care that should be integrated into the overall treatment plan of patients with CAD. Optimal blood pressure control with a target blood pressure of <140/90 mm Hg has been shown to reduce overall mortality following acute coronary syndrome (SOR B).The use of antiplatelet agents has been shown to reduce the risk of recurrent cardiovascular events by 25% in patients diagnosed with CAD (SOR A). Aspirin (81-162 mg daily) is recommended for all CAD patients unless contraindicated. The American Heart Association recommends combined therapy with clopidogrel for up to 12 months in patients following an acute MI or after PTCA and stent placement. β-Blockers have also been shown to reduce recurrent MI, sudden cardiac death, and mortality, and are recommended for all post-MI patients unless contraindicated (SOR A). Finally, ACE inhibitors have also been shown to increase survival and reduce the risk of major cardiovascular events in patients with vascular disease, including CAD (SOR A).Guidelines established by the National Cholesterol Education Program's Adult Treatment Panel III recommend aggressive lipid management with a goal LDL-cholesterol level of <100 mg/dL (or <70 mg/dL for optimal control). Statins, which are recommended as the first-line agent, have been shown to reduce all-cause mortality in post-acute coronary syndrome patients (SOR A). PTCA has not been shown to be superior to medical management alone in preventing death in patients with unstable angina (SOR B).Depression is about three times more common in post-MI patients than in the general population, and 15%-20% of hospitalized patients with acute MI meet the criteria for major depression. Depression is associated with a higher risk of recurrent cardiac events 1-2 years after an MI. The American Heart Association recommends screening for depression during secondary prevention of CAD, with appropriate treatment if depression is diagnosed. [Show Less]
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ABFM Board Review: MSK question and answers 100% correct
- presents with an insidious onset of pain related to a recent increase in occupational or recreational activities. - Patients also often report weakened ... [Show More] grip strength. - point of maximal tenderness is 5-10 mm distal to and anterior to the medial epicondyle. Medial epicondylitis- It is most often a tendinopathy of the flexor carpi radialis and the pronator teres 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 biceps tendinopathy neuropathy of the ulnar nerve caused by compression or traction as it passes through the cubital tunnel of the medial elbow - 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 cubital tunnel syndrome 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 triceps tendinopathy Test for it with: 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 Ulnar collateral ligament injury-- moving valgus stress test has 100% sensitivity and 75% specificity for diagnosing UCL injuries. test which has the best PPV for meniscus injuries Thessaly test: pt stands on affected leg while it is flexed 20 degrees. They internally and externally rotate the knee 3 times while holding the examiner's hand for support. Locking, catching, or joint line pain constitutes a positive test. name 3 tests which detect injuries to the ACL lachman's, anterior drawer, and the pivot shift test describe the mcmurray test passive extension of the knee while applying valgus and varus stresses to the knee [Show Less]
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ABFM CVA questions and answers 100% correct
True statements regarding the long-term prognosis for death and disability in a patient who has had a stroke include which of the following? (Mark all that... [Show More] are true.) Early recovery of neurologic function is a sign of a good prognosis The severity of the stroke as measured by the National Institutes of Health Stroke Scale can be used to predict long-term prognosis In general, lacunar strokes cause more severe disability than ischemic strokes of the major cerebral arteries The risk of recurrence of stroke is higher in the second year after a stroke than in the first year Patients who have two strokes in the same arterial territory will typically recover more quickly the second time Patients with poor function prior to the stroke are less likely to make a complete recovery to their pre-stroke state A, B, F The National Institutes of Health Stroke Scale (NIHSS) score predicts the long-term outcome for patients with stroke. The NIHSS score at 6 days is a more accurate predictor than the score in the first 24 hours (SOR B). Consistent markers of better long-term recovery include younger age, less severe initial symptoms, early recovery from symptoms, and good social support (SOR B). Lacunar infarcts are more likely to be followed by either complete recovery or minimal disability (SOR B).The risk of recurrence is highest immediately after a stroke and falls throughout the first year, reaching a plateau thereafter that is still higher than that of the general population (SOR B). Multiple strokes in the same area tend to create more severe disability than the first stroke (SOR B). Poor functional ability prior to the stroke is a poor prognostic factor for recovery (SOR B). A 74-year-old male has an acute ischemic stroke. He has a history of hypertension adequately controlled with medication. CT does not indicate any hemorrhagic component.Which one of the following is true about early anticoagulation with heparin or low molecular weight heparin in this situation? Urgent anticoagulation is recommended to prevent recurrent stroke Urgent anticoagulation is recommended to prevent neurologic worsening Urgent anticoagulation is recommended to improve neurologic outcomes Urgent anticoagulation should be avoided in stroke Initiation of anticoagulant therapy within 24 hours of treatment with intravenously administered rtPA is recommended D Research has not shown a benefit from urgent anticoagulation in preventing recurrent stroke or neurologic deterioration (SOR A), or for improving outcomes after acute ischemic strokes. Initiation of anticoagulation within 24 hours of treatment with intravenous rtPA is associated with increased risks of bleeding complications (SOR B). Urgent anticoagulation is not indicated in moderate to severe strokes, due to an increased risk of serious intracranial hemorrhagic complications (SOR A). A 67-year-old male suffers a stroke. Which of the following factors would be likely to compromise his nutrition and hydration status following the stroke? (Mark all that are true.) Depression Sensory or perceptual deficits Swallowing difficulties Unilateral lower extremity weakness Altered consciousness ALL OF THE ABOVE Nutrition and hydration can be affected by a number of factors following a stroke. Physical problems that can affect the patient's ability to eat and drink include altered consciousness, dysphagia, sensory deficits, and reduced mobility. Depression can reduce the patient's interest in food. Patients should be evaluated for nutrition and hydration status as soon as possible after admisssion, and intake and body weight should be monitored regularly (SOR C). A variety of methods should be used as necessary to maintain adequate intake of food and fluids. Well documented measures to prevent an initial stroke include modification of which of the following, by either treating or eliminating the condition? (Mark all that are true.) Cigarette smoking Obesity Migraine headaches Atrial fibrillation Hypertension A, B, D, E Risk factors for a first stroke include both modifiable and nonmodifiable risk factors. Well documented nonmodifiable risk factors include age, gender, low birth weight, and genetic factors. Modifiable risk factors that have been well documented include cigarette smoking, poor diet, physical inactivity, postmenopausal hormone therapy, obesity, and body fat distribution (SOR A). Other well-documented modifiable risk factors include medical conditions such as hypertension, atrial fibrillation, other cardiac conditions, dyslipidemia, carotid artery stenosis, and sickle cell disease (SOR A).Some modifiable risk factors have been linked to an increased risk for stroke, but the link is not well established. Medical conditions in this category include sleep apnea, metabolic syndrome, migraine, hyperhomocysteinemia, hypercoagulability, inflammation, and infection (SOR B). True statements regarding the epidemiology of stroke and TIA in the United States include which of the following? (Mark all that are true.) Cerebrovascular disease ranks among the top five causes of death Each year more men than women have a stroke More than 10 million people in the United States have had a silent stroke Approximately 15% of all strokes are heralded by a TIA Approximately half of all patients who experience a TIA fail to report it to their health care providers A, C, D, E In the United States, someone suffers a stroke approximately every 40 seconds and someone dies from a stroke every 3-4 minutes. Given the tremendous morbidity and mortality of stroke, the American Heart Association and American Stroke Association publish yearly stroke statistics to educate health care providers and the general public about key epidemiologic factors. Cerebrovascular diseases rank fourth among all causes of death, behind heart disease, cancer, and lung disease (SOR A). Every year approximately 55,000 more women than men have a stroke (SOR A). An estimated 13 million people in the United States have had a silent stroke (SOR A). Approximately 15% of all strokes are heralded by a TIA (SOR A). Approximately half of all patients who experience a TIA fail to report it to their health care providers (SOR A). A 67-year-old female had a cerebrovascular accident 1 week ago, and now has spasticity in her right upper extremity. True statements regarding treatment of her spasticity and prevention of contractures include which of the following? (Mark all that are true.) Tizanidine (Zanaflex) can be used to treat painful spasticity Benzodiazepine therapy is recommended for the treatment of spasticity and prevention of contractures Constraint-induced therapy for 90% of waking hours can improve functional use of the affected arm and reduce disability Positioning, passive stretching, and range-of-motion exercises should be performed several times daily Splinting, serial casting, and surgical correction can be considered for contractures interfering with function A, C, D, E Patients with muscle spasticity are at high risk of developing contractures following stroke. Contractures in turn increase the risk of poor hygiene, skin breakdown, pain, and loss of function. Early intervention is of the utmost importance and should be performed in a stepwise fashion beginning with positioning and passive range-of-motion exercises and proceeding to constraint-induced therapy. Pharmacotherapy may be required and the judicious use of agents such as tizanidine, dantrolene, and baclofen is important to avoid excessive sedation, which may interfere with the rehabilitation process. More severe, painful, or debilitating spasticity and contractures may require more invasive treatment such as botulinum toxin administration, intrathecal baclofen, orphenol/alcohol neurolysis. Neurosurgical procedures such as selective dorsal rhizotomy may be required in selected cases. Tizanidine has been used specifically for chronic stroke patients with painful spasticity (SOR B). Benzodiazepine therapy may have a deleterious effect on post-stroke recovery. The effectiveness of constraint-induced therapy and the use of a restraining mitt has been demonstrated in a randomized, controlled trial (SOR A). Positioning, passive stretching, and range-of-motion exercises have also been shown to provide relief in randomized, controlled trials (SOR A). There is some evidence from clinical trials that splinting, serial casting, and surgical correction may be helpful (SOR C). True statements regarding the use of warfarin (Coumadin) for primary prevention of ischemic stroke in patients with sinus rhythm include which of the following? (Mark all that are true.) Warfarin should be considered for stroke prevention in patients with elevated high-sensitivity C-reactive protein levels, particularly if they have three or more cardiovascular risk factors Warfarin may be considered in patients with severe left ventricular dysfunction with or without heart failure Warfarin should be used for stroke prevention in essentially all patients in the first 3 weeks after a myocardial infarction It is reasonable to prescribe warfarin for patients with left ventricular dysfunction and extensive regional wall-motion abnormalities following an ST-segment-elevation myocardial infarction B, D No evidence supports the use of C-reactive protein (CRP) screening as a marker of vascular risk, much less the use of warfarin in patients with elevated CRP (SOR B). Warfarin may be considered in patients with severe left ventricular dysfunction, with or without heart failure (SOR C). There is no convincing evidence to support the use of warfarin for stroke prevention in all patients following a myocardial infarction (SOR C). Warfarin can be prescribed to patients with left ventricular dysfunction and extensive regional wall-motion abnormalities or a left ventricle thrombus on an imaging study following an ST-segment-elevation myocardial infarction (SOR A). An 81-year-old male is brought to the emergency department by his wife 1 hour after the onset of right-sided weakness. She also reports that 2 months ago the patient suffered a severe concussion from a bicycling accident and was hospitalized overnight. The patient has known coronary artery disease and takes aspirin, 81 mg daily. He had a total right knee replacement 1 month ago, using spinal anesthesia. CT of the head shows no hemorrhage. His blood pressure is now 174/104 mm Hg and it has been 2½ hours since the onset of symptoms.Which one of the following would be a contraindication to the use of intravenous alteplase (Activase) in this patient? His use of aspirin His elevated blood pressure His history of recent surgery His history of a recent lumbar puncture The length of time since the stroke His history of head trauma F Inclusion criteria for treatment with intravenous (IV) alteplase during a stroke include symptoms of <3 hours' duration and the absence of evidence of intracranial hemorrhage on CT. Contraindications to thrombolysis include the following: a history of ischemic stroke, severe head trauma, or intracranial/spinal surgery within the preceding 3 months a previous history of intracranial hemorrhage symptoms and signs consistent with subarachnoid hemorrhage a structural gastrointestinal malignancy or recent bleeding event within 21 days of the stroke event infective endocarditis aortic arch dissection an intra-axial intracranial neoplasm pregnancy a treatment dose of LMWH within the previous 24 hours coagulopathy with a platelet count <100,000/mm3 INR >1.7, aPTT >40 sec, or PT >15 sec current use of direct thrombin inhibitors, factor Xa inhibitors, or glycoprotein IIb/IIIa receptor inhibitors Based on 2018 AHA guidelines, IV alteplase can be used in stroke patients taking antiplatelet monotherapy, as well as those taking an antiplatelet drug before the stroke. In addition, the guidelines regard IV alteplase as reasonable in patients with a seizure at the time of onset of the acute stroke if evidence suggests that residual impairments are secondary to stroke and not a postictal phenomenon. Intravenous alteplase can even be considered in patients with an acute ischemic stroke who may have undergone a lumbar dural puncture within the preceding 7 days, as well as carefully selected patients who have undergone major surgery in the preceding 14 days. It is recommended that patients who have elevated blood pressure (BP) and are otherwise eligible for treatment with IV alteplase should have their BP carefully lowered so that their systolic BP is <185 mm Hg and their diastolic BP is <110 mm Hg before IV fibrinolytic therapy is initiated. True statements regarding alcohol use and stroke risk include which of the following? (Mark all that are true.) To decrease stroke risk, alcohol intake should not exceed 2 drinks per day for men and 1 drink per day for nonpregnant women Nondrinkers should be advised to drink 1-2 alcoholic beverages per day to decrease their stroke risk Heavy drinkers with a history of an ischemic stroke or TIA should eliminate or reduce their consumption of alcohol to decrease their risk of stroke Chronic alcoholism and heavy alcohol intake have been shown to increase only hemorrhagic stroke risk A, C The American Heart Association/American Stroke Association 2014 guideline on stroke prevention in patients with a previous stroke or TIA lists elimination or reduction of alcohol consumption in heavy drinkers as one of the primary goals of secondary stroke prevention. While the effects of alcohol on stroke risk are controversial, the negative effects of heavy alcohol consumption (>5 drinks/day) are well documented (relative risk 1.69 when compared with nondrinkers) (evidence level 1A). Heavy alcohol use increases the risk for all forms of stroke.A protective effect has been seen in patients who consume alcohol in moderation (≤2 drinks/day for men and ≤1 drink/day for women) (evidence level IIB, SOR C).However, this is not a reason to encourage patients to begin or increase alcohol consumption (SOR C). In patients with a previous history of ischemic stroke or transient ischemic attack, American Heart Association guidelines favor which one of the following for secondary stroke prevention? A target systolic blood pressure goal of <130 mm Hg in patients with a lacunar stroke A target blood pressure goal of <140/90 mm Hg in patients with a history of a TIA or nonlacunar stroke A target blood pressure goal of <130/80 mm Hg in patients without premorbid hypertension Use of either a thiazide diuretic or a nondihydropyridine calcium channel blocker as first-line therapy A Among patients with a recent stroke or TIA, the prevalence of premorbid hypertension is approximately 70%. In these patients, studies demonstrate a 30% reduction in recurrent stroke risk with blood pressure-lowering therapies. Blood pressure-lowering treatment is recommended for both prevention of recurrent stroke and prevention of other vascular events in persons who have had an ischemic stroke or TIA and are beyond the hyperacute period (SOR A). American Heart Association (AHA) guidelines currently favor treatment with a thiazide diuretic, ACE inhibitor, or ARB, or combination treatment consisting of a thiazide diuretic plus an ACE inhibitor in patients with a history of stroke or TIA.The 2017 American College of Cardiology/AHA hypertension guidelines recommend a target systolic blood pressure goal of <130 mm Hg following a lacunar stroke in adults, and a target blood pressure of <130/80 mm Hg following a stroke or TIA in patients with premorbid hypertension. For patients without premorbid hypertension who have a blood pressure >140/90 mm Hg in the post-stroke period, the AHA recommends a target blood pressure of <130/80 mm Hg. However, in adults who have an ischemic stroke or TIA, have a systolic blood pressure <140 mm Hg and a diastolic blood pressure <90 mm Hg, and have not previously been treated for hypertension, the AHA concluded that the usefulness of initiating antihypertensive treatment ais not well established. True statements regarding stroke in patients with sickle cell disease include which of the following? (Mark all that are true.) All children with sickle cell disease should be screened for increased stroke risk with transcranial Doppler studies In children with sickle cell disease at increased risk of stroke, prophylactic transfusions reduce the risk Children with sickle cell disease who do not have a stroke over the course of 3 years while receiving prophylactic transfusion therapy can safely discontinue the treatment Routine transfusion therapy for children with sickle cell disease should be discontinued after 5 years to prevent complications of iron overload Subclinical brain ischemia in children with sickle cell disease can cause learning and behavioral difficulties A,B, E In children with sickle cell disease and abnormal cerebrovascular blood flow documented by transcranial Doppler examination, prophylactic transfusion therapy reduces their stroke risk from 10% to <1% per year (SOR A). The Stroke Prevention Trial in Sickle Cell Anemia (STOP II) tested whether transfusion for primary stroke prevention could be stopped after at least 30 months in children who had not had a stroke and in whom the transcranial Doppler flow abnormalities had been reversed. This trial was stopped early by the safety committee because of excessive events in the non-transfusion group (SOR B).Iron overload is a complication of transfusion therapy and measures should be taken to reduce its manifestations. This does not, however, create a contraindication to continued therapy (SOR B). About 20% of children with sickle cell disease are found to have "silent infarcts" on MRI, and these are associated with deterioration of cognitive function, affecting learning and behavior (SOR B). The risks and benefits of prophylactic transfusion based on silent MRI lesions are being tested in an ongoing clinical trial. Modalities shown to be beneficial in the rehabilitation of muscle weakness following a stroke include which of the following? (Mark all that are true.) Muscle strengthening Functional electrical stimulation Treadmill training with partial body weight support in patients with gait dysfunction Hyperbaric oxygen A,B,C The Department of Veterans' Affairs and Department of Defense have developed guidelines for post-stroke rehabilitation that have been endorsed by the American Heart Association and the American Stroke Association. These guidelines recommend muscle strengthening for stroke patients with muscle weakness, based on the relationship between muscle strength, function, and fall prevention (SOR C). Research has shown that training improves muscle strength and function in patients who have completed rehabilitation.The number of studies to evaluate functional electrical stimulation is small, but based on the results the guidelines do recommend its use (SOR B). A Cochrane review concluded that it does lead to reductions in glenohumeral subluxation. Other studies have looked at effects on wrist and knee extension, ankle dorsiflexion, and gait in patients with hemiplegia.Treadmill training with partial body weight support to unload the lower extremities has proven to be superior to treadmill training with the patient supporting his or her full body weight. For this reason, treadmill training with partial support of body weight is recommended as an adjunct to conventional therapy in patients with mild-to-moderate dysfunction and resulting impairment of gait (SOR B).Hyperbaric oxygen therapy for cerebral ischemia has been evaluated in a number of human and animal studies; however, there is presently no consensus regarding its efficacy. Recent randomized, controlled human studies have not shown a benefit from this therapy, although all were limited by small sample size. Important differences between animal and human studies suggest that hyperbaric oxygen might be effective within the first few hours after a stroke. There is no evidence that it would be efficacious during the rehabilitation period. Cardiac conditions that increase the risk of stroke include which of the following? (Mark all that are true.) Endocarditis Mitral stenosis Patent foramen ovale A tissue mitral valve prosthesis 1 year postoperatively A mechanical mitral valve prosthesis 1 year postoperatively A, B, C, E Endocarditis may lead to production of emboli (SOR A). Mitral stenosis increases stroke risk because increasing the size of the left atrium, especially if associated with atrial fibrillation, increases the risk of embolism (SOR A). Patent foramen ovale may be a cause of cryptogenic stroke (SOR A). Mechanical mitral valves do not become covered by endothelium, and long-term anticoagulation is necessary to prevent stroke and other complications (SOR A). A tissue prosthesis becomes covered with endothelium within months and does not pose a risk for stroke (SOR A). A 36-year-old female presents to the emergency department with right-sided upper and lower extremity weakness. She denies any history of hypertension, diabetes mellitus, high cholesterol, or smoking.Which of the following would increase the likelihood that a stroke is the cause of her focal weakness? (Mark all that are true.) Cocaine use The presence of lupus anticoagulant antibody Marfan's syndrome A history of cranial radiation in childhood for CNS lymphoma ALL OF THE ABOVE All of the factors listed increase a person's risk for stroke. The presence of lupus anticoagulant antibody has been found to confer an increased risk of stroke, as has Marfan's syndrome. A history of intracranial radiation therapy, such as for CNS lymphoma, also confers an increased risk of ischemic stroke in adulthood. Cocaine use represents a significant cause of stroke, often hemorrhagic, particularly in younger individuals. The increase in relative risk may be as great as 14 times the risk seen in age-matched individuals who do not use cocaine. You see an active 65-year-old male for a routine annual evaluation. He recently received a flyer in the mail advertising screening carotid ultrasonography at his local senior center, and asks whether you think it would be worthwhile.Which one of the following would be appropriate advice? All patients with a 10-year Framingham coronary artery disease risk >10% should be screened for carotid artery stenosis (CAS) The U.S. Preventive Services Task Force recommends against screening for asymptomatic CAS in the healthy adult population Asymptomatic women have been shown to derive a greater benefit from carotid endarterectomy than asymptomatic men Patients over the age of 80 with asymptomatic CAS have been found to benefit more from carotid endarterectomy compared to younger patients B The U.S. Preventive Services Task Force recommends against screening asymptomatic patients for carotid stenosis (SOR B). However, in the event that an asymptomatic patient is screened, the American Academy of Neurology suggests it is reasonable to consider carotid endarterectomy for patients between the ages of 40 and 75 years with asymptomatic stenosis of 60%-99%, if the patient has a life expectancy ≥5 years and the death rate from stroke or other complications of surgery can be reliably documented to be <3%. The American Heart Association and the American Stroke Association do not recommend carotid endarterectomy for asymptomatic patients over the age of 80 (SOR B). Men have been shown to derive a greater benefit than women from carotid endarterectomy (SOR B). True statements regarding the evaluation of dysphagia in stroke patients include which of the following? (Mark all that are true.) Dysphagia increases the risk of aspiration Abnormal pharyngeal sensation may predict aspiration All stroke patients should have a videofluoroscopy swallowing study or a modified barium swallow Only stroke patients with obvious swallowing difficulty should undergo a swallowing evaluation Routine screening for dysphagia in all stroke patients reduces the risk of pneumonia A, B, E It is difficult to tell which stroke patients have a high risk for pneumonia or aspiration. Routine screening reduces pneumonia risk by about threefold (SOR A). Patients who report abnormal feelings in their pharyngeal area have a higher risk of aspiration (SOR A). The more severe the dysphagia, the higher the risk for aspiration (SOR A). All stroke patients should undergo an evaluation for dysphagia (SOR A). Imaging studies are not necessary for all stroke patients (SOR A). Which one of the following statements is true regarding the acute hypertensive response in patients with stroke? It occurs only when the stroke affects areas of the brain involved in blood pressure regulation Nearly all patients who develop this problem have a previous history of hypertension Cushing's phenomenon (increased blood pressure secondary to elevated intracranial pressure) is thought to be the cause in most cases It occurs only in patients whose stroke is due to intracerebral hemorrhage Patients who experience this problem have worse outcomes E A systematic review of the literature found an association between the acute hypertensive response and death and dependency (SOR B). There seems to be no definite correlation with lesion size or location (SOR C). A significant proportion of patients who experience an acute hypertensive response to stroke do not have a history of hypertension (SOR B). The pathophysiologic response is thought to be multifactorial and related to preexisting high blood pressure, activation of the neuroendocrine systems (sympathetic nervous system, renin-angiotensin axis, and glucocorticoid system), increased cardiac output, and "white coat" hypertension (SOR B). The acute hypertensive response is seen in patients with lacunar stroke, ischemic stroke, transient ischemic response, and intracerebral hemorrhage (SOR C). Assuming that CT of the head is negative for bleeding, which one of the following patients would be a candidate for thrombolytic therapy for stroke? A 67-year-old who awakened with left arm and left leg weakness A 70-year-old with right arm and leg weakness that started 1 hour ago and whose symptoms have improved during his time in the emergency department, causing mild impairment A comatose 70-year-old with a flaccid left side whose CT shows a large area of infarct in the perfusion area of the middle cerebral artery A 72-year-old who takes warfarin and has an INR of 2.2, and whose stroke symptoms started 1 hour ago A 74-year-old with diabetes mellitus and a history of left arm and left leg weakness starting 1 hr ago, a blood pressure of 170/100 mm Hg, and a blood glucose level of 311 mg/dL E Inclusion criteria for treatment with intravenous (IV) alteplase during a stroke include symptoms of <3 hours' duration and the absence of evidence of intracranial hemorrhage on CT. Contraindications to thrombolysis include the following: a history of ischemic stroke, severe head trauma, or intracranial/spinal surgery within the preceding 3 months a previous history of intracranial hemorrhage symptoms and signs consistent with subarachnoid hemorrhage a structural gastrointestinal malignancy or recent bleeding event within 21 days of the stroke event infective endocarditis aortic arch dissection an intra-axial intracranial neoplasm pregnancy a treatment dose of LMWH within the previous 24 hours coagulopathy with a platelet count <100,000/mm3 INR >1.7, aPTT >40 sec, or PT >15 sec current use of direct thrombin inhibitors, factor Xa inhibitors, or glycoprotein IIb/IIIa receptor inhibitors Based on 2018 AHA guidelines, IV alteplase can be used in stroke patients taking antiplatelet monotherapy, as well as those taking antiplatelet combination therapy before the stroke. In addition, the guidelines regard IV alteplase as reasonable in patients with a seizure at the time of onset of the acute stroke if evidence suggests that residual impairments are secondary to stroke and not a postictal phenomenon. IV alteplase can even be considered in patients with an acute ischemic stroke who may have undergone a lumbar dural puncture within the preceding 7 days as well as carefully selected patients who have undergone major surgery in the preceding 14 days. It is recommended that patients who have elevated blood pressure (BP) and are otherwise eligible for treatment with IV alteplase should have their BP carefully lowered so that their systolic BP is <185 mm Hg and their diastolic BP is <110 mm Hg before IV fibrinolytic therapy is initiated. A 63-year-old male presents to your office because he thinks he has had a stroke. You have treated him for hypertension for several years, but he has no other chronic medical problems. On examination you note slurred speech and impaired fine motor coordination of his left hand. The examination is otherwise normal.These findings are most consistent with which type of infarct? Brain stem Cerebellar Lacunar Left middle cerebral artery Occipital lobe C The dysarthria/clumsy hand syndrome is characteristic of a lacunar (small vessel) infarct (SOR B). MRI studies of affected patients often show the infarct localized to the internal capsule or putamen. Hypertension is a major risk factor. The prognosis is generally good. Infarcts of the left hemisphere generally produce right hemiparesis, right sensory defects, and aphasia. Brain stem infarcts usually produce dysarthria, nystagmus, and disconjugate gaze. Cerebellar infarcts often result in an ataxic gait and ipsilateral limb ataxia. Occipital lobe infarcts can produce visual field defects, visual hallucinations, and color anomia. Under Medicare guidelines, which of the following would disqualify a patient from stroke rehabilitation at an inpatient rehabilitation center? (Mark all that are true.) Angina pectoris with low-level exercise A therapy program limited to speech therapy, for both speech and swallowing difficulties Fatigue after 4 hours of physical therapy Significant dementia with no likelihood of improvement with intensive therapy A predicted length of rehabilitation of less than 2 weeks A, B, D Medicare guidelines require that a patient be able to tolerate 3 hours of therapy daily to be eligible for inpatient rehabilitation. Medicare guidelines also state that the patient should be medically stable, and require therapy from multiple therapy disciplines, one of which must be physical or occupational therapy. Also, the patient must be realistically able to improve his or her situation with the therapy provided. The guidelines do not specify a time limit. A 68-year-old female has an acute ischemic stroke. CT of the head shows no bleeding or masses. Two days later she is stable but has a brief focal seizure that resolves spontaneously.Which one of the following would be most appropriate at this point? Observation only An EEG Diazepam (Valium) Levetiracetam (Keppra) Phenytoin (Dilantin) A Seizures occur in 3%-23% of stroke victims after the stroke. Early-onset focal seizures (<2 weeks post stroke) rarely recur, making anticonvulsant treatment unnecessary after the first seizure (SOR B). Early-onset seizures in this group do not adversely affect prognosis. Recurrent seizures should be treated. [Show Less]
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ABFM Epidemiology review questions and answers
what is Relative Risk? 1. ratio of outcome incidence in exposed to unexposed. 2. experimental event rate (exposed) divided by control event rate (not exp... [Show More] osed) equation 1: Relative Risk R R R R = E E R divided by C E R ( RR = EER / CER ) Relavtive Risk Reduction R R R R R R = C E R - E E R, all divided by C E R (RRR = (CER - EER)/CER)) equation 2: Absolute Risk Reduction: A R R A R R = C E R minus E E R ( ARR=CER-EER) Equation 3: Number Needed to Treat N N T N N T = 1 divided by A R R (NNT=1/ARR) Equation 4: Sensitivity Ability to detect people who have the disease - the percent True Positives. Use for screening - rule out disease. ELISA for H I V - don't want to miss anyone. Sensitivity percent true positives (Sensitivity = TP / ( TP + FN ) x 100) Sensitivity ability to detect people who have disease SNOUT SeNsitive test with a Negative result rules OUT the disease Specificity Ability to detect people who DO NOT have the disease. Used to confirm result. Western Blot for HIV good example Specificity percent % True Negatives (TN / ( FP + TN ) x 100) SPIN Specific test with a Positive result rules IN the disease [Show Less]
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ABFM KSA ASTHMA questions and answers graded A+
PT HAS MODERATE PERSISTENT ASTHMA WAKES UP WITH NIGHT TIME SX WEEKLY WHAT MEDS SHOULD SHE BE ON MODERATE PERSISTENT ASTHMA = STAGE 3 = 3 MEDS ... [Show More] = ALBUTEROL ICS + LABA PT SUSPECTED OF HAVING EXERCISE INDUCED ASTHMA Baseline pulmonary function testing reveals an FEV1= of 3.1 L IF PFT IS DONE AFTER EXERCISE = WHAT measurements OF FEV1 after exercise would support a diagnosis ofexercise-induced bronchospasm? FEV1 <2.5 15% decrease in FEV1 after exercise is COMPATIBLE WITH DIAGNOSIS OF EXERCISE INDUCE ASTHMA Airflow obstruction is defined as an FEV1 /FVC ratio LESS THAN 70%. Airway REVERSIBILITY is defined as an increase in FEV1 or FVC = BY HOW MUCH 12% WHICH ASTHMA MEDS ARE ASSOCIATED WITH BONE LOSS BOTH INHALED AND ORAL CORTICOSTEROIDS WHAT IS most common acid/base abnormality in the early stages of an asthma exacerbation? RESPIRATORY ALKALOSIS HYPERVENTILATION = LOW CO2= HIGH PH- ALKALOSIS WHICH ASTHMA MEDICATION = most effective asthma agent for preventing exacerbations, ICS WHAT IS TX OF CHOICE FOR aspirin-induced asthma LEUKOTRIENCE INHIBITORS = Montelukast PT WITH ASTHMA LIKE SX + RHINITIS + NASAL POLYPS TOW ASPIRIN INDUCED ASTHMA WHICH NSAID CAN BE USED INSTEAD OF ASPIRIN IN PT WITH ASPIRIN INDUCED ASTHMA SALSALATE CAN ALSO USE TYLENOL PT ADMITTED FOR ASTHMA EXACERBATION According to National Asthma Education and Prevention Program guidelines, hospital discharge can be considered in this patient = once the peak flow rate rises above a threshold of >420 In patients with inadequately controlled asthma, OPTIMAL MANAGEMENT OF WHAT OTHER COMORBIDITIES CAN HELP GET BETTER CONTROL OF ASTHMA GERD ALLERGIC RHINITIS OSA ALLERGIC bronchopulmonary aspergillosis ARE USE OF ICS SAFE FOR PREGNANT PTS WITH ASTHMA YES Long-acting inhaled β-agonists are less likely to be effective in which one of the following ethnic groups? AFRICAN AMERICANS USE OF LABA INHALERS (salmeterol etc) HAVE HIGH RISK OF WHAT severe asthma exacerbations NEVER PRESCRIBE MONOTHERAPY OF LABA INHALERS SHOULD ALWAYS BE USED WITH OTHER INHALERS LIKE ICS Chronic low- to medium-dose inhaled corticosteroid use in children is associated with NO LONGTERM ADVERSE AFFECT WRONG ANS= B) a significant reduction in bone mineral density Symptoms suggesting that respiratory arrest may be imminent in patients with a severe asthma exacerbatioN INCLUDE LACK OF WHEEZING BRADYCARDIA LOSS OF pulsus paradoxus due to respiratory muscle fatigue. PT HAS STAGE 1= MILD INTERMITTENT ASTHMA NO NIGHT TIME SX USES ALBUTEROL 1X/WEEK ONLY BUT HAS HISTORY OF ASTHMA EXACERBATIONS OVER PAST YR THAT WERE TX AT URGENT CARE WHAT INHALERS SHOULD THIS PT BE ON ALTHOUGH PT HAS STAGE 1= MILD INTERMITTENT ASTHMA --WHICH USUALLY IS JUST SABA FOR TX BUT DUE TO MULTIPLE EXACERBATIONS OF ASTHMA, TX THIS AS STAGE 2- mild persistent asthma = SABA + ICS [Show Less]
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ABFM Musculoskeletal questions and answers 100% correct
Most effective medication for fibromyalgia? TCAs Proper treatment for Boxer's fracture (fracture of 5th metacarpal head) ulnar gutter splint (immo... [Show More] bilizes the wrist, hand and fourth/ fifth digits). Wrist is positioned in slight extension; x 3-4 weeks of continuous splinting Goal for vertebral compression fractures? early mobilization; no not need to keep recumbent in bed until back brace is made cubital tunnel syndrome risk factors having elbow be bent for long periods of time (hairdresser) or having damage to elbow or "funny bone". Sx: similar to carpal tunnel but ulnar distribution, at worst, may start causing weakness of ring and little finger Cure rates for trigger finger after steroid injection: 54-86% CURED after injection for this musculoskeletal condition Which solution for cleansing a pressure ulcer? tap water saline (nothing else!!) which dressing for pressure ulcer? non-adherent: hydrocolloid, foam or other non-adherent dressing which therapeutic modality is contraindicated for muscle injuries until growth plate is closed? Therapeutic ultrasound is C/I on growth plate. Growth plate closes at age 15 First line for gout in patient with CKD IV? Steroids only, Colchicine and NSAIDs not used if renal dysfunction Which supplements to give at which age for breastfed babies? - 400 IU of Vitamin D per day starting in the first few days of life. Do not need vit D supplementation when baby is comusming at least 500 cc of formula or milk with Vit D per day - need to start iron supplementation at 4 months of age PCL tear symptoms posterior knee pain and pain when kneeling; painful limitation of flexion and posterior drawer sign on exam Treatment for lateral patellar dislocation: medial pressure to patella and then gently extend knee fully If patient presents after leg injury with exceptionally severe pain that is worse with stretching the calf muscles, think of ____. Which test to find out? Compartment syndrome clinical presentation? Tests to confirm compartment syndrome are tissue pressure studies Where to give corticosteroid injection for rotator cuff tendonitis vs for shoulder osteoarthritis? - Rotator cuff tendonitis steroid injection if pain interfering with sleep or function despite adequate analgesia, give injection into subacromial space - Shoulder OA steroid injection into the AC joint (intra-articular) Mechanism of most common neurological deficit related to Paget's disease? Most common deficit in Paget's disease is hearing loss. Not caused by CN 7 compression but is due to cochlear damage. Which herbal remedy helpful for joint pain? SAMe most helpful (Glucosamine and chondroitin not as effective) Alpha lipoic acid and gamma linolenic acid are helpful for: neuropathy symptoms helped with which herbal remedies? Ottawa Ankle Rules Includes: The examiner should order x-rays when the patient has ankle (within 6 cm of distal, posterior tibia or fibula) or midfoot pain + (bone tenderness at the base of the 5th metatarsal OR pain in navicular bone (between heel and ankle) OR is unable to bear weight (for four steps) when examined) Little league shoulder refers to: proximal humeral epiphysitis (usually seen in baseball pitchers age 11-16) Male with normal labs but osteoporosis, think: hypotestosteronism Hip Labral Tear Etiology Often occurs due to repetitive movements such as running or pivoting, resulting in degeneration or breakdown of the labrum Can also occur acutely due to a hip dislocation Signs of Hip labral tear: clicking sound with activity and pain in anterior groin with extreme abduction and adduction Back pain that awakens children at night differential is: osteomyelitis, diskitis (can be viral or bacterial), osteoid osteoma, osteoblastoma and spinal cord tumors Mallet finger (torn extensor tendon/ dorsal aspect of finger) avulsion of the terminal tendon (or fracture of distal interphalangeal joint) and is splinted in full extension for 8 weeks - need to consult ortho if fracture > 30% of intraarticular surface When to start bisphosphonates in those with osteoporosis? when 10 year risk of hip fracture is > 3% and patient has had osteoporosis related fractures. - Treat those with less risk factors with approximately 1200 mg of calcium and 800 IU of Vit D daily When to do surgical fixation of great toe fracture: when > 25% involvement of the joint surface (intra-articular fracture); use toe plate and short leg walking cast x 2-3 weeks if < 25% intra-articular involvement child limping with no clear preceeding injury, next step? X Ray of hip Acute lumbar pain with radiculopathy does not need imaging unless: cauda equina syndrome, suspected cancer, infection or fracture; conservatively manage x 6 weeks Proximal muscle weakness in elderly female with normal ESR and normal DTRs, think of: statin-induced myopathy - Polymyalgia rheumatica with elevated ESR - Guillian Barre with hyporeflexia Treatment of mildly displaced mid-clavicular fracture: - sling x 2-6 weeks, passive mobilization as tolerated when pain is decreased, PT starting at 4 weeks - cumbersome and not recommended: figure of 8 bandage [Show Less]
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