A 13-year-old boy is brought into the emergency room with a laceration of his right arm. According to his parents, he received the injury when he fell on the ground while playing at the family farm about 1 hour ago. He has no known history of any medical problems. His parents say that they haven't brought him to the doctor in years. On questioning, they report that he only received one of his "baby shots" and they are not sure which one that was. On examination, he is healthy appearing. He is appropriately apprehensive but calm and consolable. His right arm has a 5 cm linear laceration with visible soil particles in and about the wound. The remainder of his examination is unremarkable. You carefully clean and irrigate the wound and then primarily repair the laceration with sutures.
After the treatment given above, what would be the recommended "catch-up" immunization schedule to protect against tetanus?
A. Td every 5 years
B. Td in 6 months then booster every 10 years
C. Td in 4 weeks and 612 months then booster every 10 years
D. Td in 2 months, 4 months, 1518 months, and 5 years and then booster every 10 years
E. TIG IM every 510 years
Correct Answer: C Section: (none)
Explanation: Explanations: The disease tetanus is caused by an exotoxin produced by the anaerobic, gram-positive bacterium C. tetani. The spores of C. tetani are endemic in soil, particularly in agricultural areas. They can also be found in the intestines and feces of many animals. Human infection usually is the result of the introduction of the spores through a wound, such as a puncture or laceration. The spores can then germinate and toxins are released. Tetanus is characterized by unopposed muscle contractions and spasms. Autonomic nervous system manifestations, seizures, and difficulty swallowing may occur. Recovery may take months, but the disease is often fatal. In the developed world, most cases of tetanus occur in those who either were never vaccinated or who completed a primary vaccine series but have not had a booster in the preceding 10 years. The currently available vaccine is a toxoid which consists of a formaldehyde-treated toxin. It is available as a single antigen vaccine, combined with diphtheria (pediatric DT or adult Td) or combined with both diphtheria and acellular pertussis vaccine (DTaP). Whenever possible, tetanus toxoid should be given in combination with diphtheria toxoid to provide periodic boosting for both antigens. There is little reason to use single antigen tetanus toxoid alone. Management of a potentially contaminated wound initially involves local wound care. Necrotic tissue should be debrided, foreign material removed, and the wound irrigated.
The need for active and/or passive immunization against tetanus depends on the wound and the patient's history of immunization. A person who has completed a primary series of three or more doses of tetanus toxoid vaccine will not require passive immunization with TIG, but may require a booster of dT or Tdap. For a clean, minor wound, a Td or Tdap booster would be indicated if it has been more than 10 years since the patient's most recent booster. For all other wounds, a booster would be indicated if it has been 5 years since the most recent booster. In a person who has not completed a primary series, who is completely unimmunized, or in whom the vaccine status is unknown, initiating passive immunization with Td or Tdap is indicated for all wounds. If the wound is clean and minor then TIG would not be recommended. For all other wounds, both Td and TIG would be indicated, as the initial doses of Td/Tdap may not produce immunity and TIG can provide immediate, temporary immunity. Antibiotic prophylaxis against tetanus is not useful. As noted in explanation 9 (above), Tdap is recommended as a substitute for a single Td dose in order to address the increasing rates of pertussis being encountered in the population. As the patient in question 32 has no history of having completed a primary vaccine series and has a contaminated wound, the optimal management would be to provide both Tdap and TIG. If Tdap were not available, then utilizing Td and TIG would be an acceptable substitute, with a dose of Tdap to be given as part of his "catchup" series in the future
Question 162:
A 13-year-old boy is brought into the emergency room with a laceration of his right arm. According to his parents, he received the injury when he fell on the ground while playing at the family farm about 1 hour ago. He has no known history of any medical problems. His parents say that they haven't brought him to the doctor in years. On questioning, they report that he only received one of his "baby shots" and they are not sure which one that was. On examination, he is healthy appearing. He is appropriately apprehensive but calm and consolable. His right arm has a 5 cm linear laceration with visible soil particles in and about the wound. The remainder of his examination is unremarkable. You carefully clean and irrigate the wound and then primarily repair the laceration with sutures.
What immediate tetanus prophylaxis would be optimal in this case?
A. IM injection of adult Td vaccine only
B. IM injection of both adult Td vaccine and tetanus immune globulin (TIG)
C. IM injection of Tdap only
D. IM injection of TIG only
E. IM injection of both Tdap and TIG
Correct Answer: E Section: (none)
Explanation: Explanations: The disease tetanus is caused by an exotoxin produced by the anaerobic, gram-positive bacterium C. tetani. The spores of C. tetani are endemic in soil, particularly in agricultural areas. They can also be found in the intestines and feces of many animals. Human infection usually is the result of the introduction of the spores through a wound, such as a puncture or laceration. The spores can then germinate and toxins are released. Tetanus is characterized by unopposed muscle contractions and spasms. Autonomic nervous system manifestations, seizures, and difficulty swallowing may occur. Recovery may take months, but the disease is often fatal. In the developed world, most cases of tetanus occur in those who either were never vaccinated or who completed a primary vaccine series but have not had a booster in the preceding 10 years. The currently available vaccine is a toxoid which consists of a formaldehyde-treated toxin. It is available as a single antigen vaccine, combined with diphtheria (pediatric DT or adult Td) or combined with both diphtheria and acellular pertussis vaccine (DTaP). Whenever possible, tetanus toxoid should be given in combination with diphtheria toxoid to provide periodic boosting for both antigens. There is little reason to use single antigen tetanus toxoid alone. Management of a potentially contaminated wound initially involves local wound care. Necrotic tissue should be debrided, foreign material removed, and the wound irrigated. The need for active and/or passive immunization against tetanus depends on the wound and the patient's history of immunization. A person who has completed a primary series of three or more doses of tetanus toxoid vaccine will not require passive immunization with TIG, but may require a booster of dT or Tdap. For a clean, minor wound, a Td or Tdap booster would be indicated if it has been more than 10 years since the patient's most recent booster. For all other wounds, a booster would be indicated if it has been 5 years since the most recent booster. In a person who has not completed a primary series, who is completely unimmunized, or in whom the vaccine status is unknown, initiating passive immunization with Td or Tdap is indicated for all wounds. If the wound is clean and minor then TIG would not be recommended. For all other wounds, both Td and TIG would be indicated, as the initial doses of Td/Tdap may not produce immunity and TIG can provide immediate, temporary immunity. Antibiotic prophylaxis against tetanus is not useful. As noted in explanation 9 (above), Tdap is recommended as a substitute for a single Td dose in order to address the increasing rates of pertussis being encountered in the population. As the patient in question 32 has no history of having completed a primary vaccine series and has a contaminated wound, the optimal management would be to provide both Tdap and TIG. If Tdap were not available, then utilizing Td and TIG would be an acceptable substitute, with a dose of Tdap to be given as part of his "catchup" series in the future.
Question 163:
While you are working in the community health center, a 40-year-old male presents to you as a referral from the dental clinic. The patient reported on the intake history form at the dental office that he had rheumatic fever at the age of 7. The dentist refused to allow him to have a dental examination and cleaning until he was cleared by a medical doctor. Other than rheumatic fever, the patient has no medical history and does not take any medications. He denies chest pain, palpitations, dyspnea, or any other symptoms.
On examination, he has normal vital signs and a normal general examination. On auscultation of his heart, you hear a 2/6 systolic ejection murmur at the left upper sternal border without radiation. Review of his chart shows that he had an echocardiogram approximately 9 months ago that revealed mild mitral valve prolapse without evidence of mitral regurgitation, but otherwise normal valves and cardiac function
In patients in whom it is required, for which of the following dental procedures is bacterial endocarditis prophylaxis recommended?
A. fluoride treatments
B. taking of oral impressions
C. taking of dental x-rays
D. dental extractions
E. adjustment of orthodontic appliances
Correct Answer: D Section: (none)
Explanation: Explanations: Bacterial endocarditis is a rare, but life-threatening, disease. It occurs primarily in persons with underlying structural heart defects who develop bacteremia with organisms that are likely to cause endocarditis. Most cases of endocarditis are not a complication of invasive medical or dental procedures. Because of the risks associated with the disease, efforts should be made to prevent bacterial endocarditis when appropriate. The American Heart Association has published updated, evidence-based recommendations on the prevention of bacterial endocarditis. These guidelines are available at the American Heart Association web site (www.americanheart.org). These guidelines outline conditions for which endocarditis prophylaxis is appropriate, procedures for which endocarditis prophylaxis is necessary, and antibiotic regimens that are recommended.
Cardiac conditions are stratified into high-risk, moderate-risk, and negligible risk. Negligible risk conditions are those in which, although endocarditis may develop, the risk is no greater than in the general population. This patient has a history of rheumatic fever, which can potentially result in high-risk valvular damage. However, his echocardiogram did not reveal any such condition. Mitral valve prolapse without a regurgitant jet (which is not a complication of rheumatic fever) is considered a negligible risk condition, so the proposed dental work can proceed without delay. Of the conditions listed in question 30, only bicuspid aortic valve would require antibiotic prophylaxis, as it is a moderate-risk congenital cardiac malformation. All of the other conditions listed are considered to be of negligible risk. Procedures which require antibiotic prophylaxis are those which produce a significant bacteremia with organisms commonly causing endocarditis. For dental procedures, those that tend to cause significant bleeding from hard or soft tissues would necessitate prophylaxis. Of the procedures listed, only dental extraction is likely to do this. During the course of other procedures, if unexpected significant bleeding occurs, antibiotics within 2 hours following the procedure would be recommended
Question 164:
While you are working in the community health center, a 40-year-old male presents to you as a referral from the dental clinic. The patient reported on the intake history form at the dental office that he had rheumatic fever at the age of 7. The dentist refused to allow him to have a dental examination and cleaning until he was cleared by a medical doctor. Other than rheumatic fever, the patient has no medical history and does not take any medications. He denies chest pain, palpitations, dyspnea, or any other symptoms. On examination, he has normal vital signs and a normal general examination. On auscultation of his heart, you hear a 2/6 systolic ejection murmur at the left upper sternal border without radiation. Review of his chart shows that he had an echocardiogram approximately 9 months ago that revealed mild mitral valve prolapse without evidence of mitral regurgitation, but otherwise normal valves and cardiac function For which of the following cardiac conditions is bacterial endocarditis prophylaxis recommended?
A. cardiac pacemaker
B. isolated secundum atrial septal defect
C. previous coronary artery bypass graft
D. bicuspid aortic valve
E. the presence of any cardiac murmur
Correct Answer: D Section: (none)
Explanation: Explanations: Bacterial endocarditis is a rare, but life-threatening, disease. It occurs primarily in persons with underlying structural heart defects who develop bacteremia with organisms that are likely to cause endocarditis. Most cases of endocarditis are not a complication of invasive medical or dental procedures. Because of the risks associated with the disease, efforts should be made to prevent bacterial endocarditis when appropriate. The American Heart Association has published updated, evidence-based recommendations on the prevention of bacterial endocarditis. These guidelines are available at the American Heart Association web site (www.americanheart.org). These guidelines outline conditions for which endocarditis prophylaxis is appropriate, procedures for which endocarditis prophylaxis is necessary, and antibiotic regimens that are recommended.
Cardiac conditions are stratified into high-risk, moderate-risk, and negligible risk. Negligible risk conditions are those in which, although endocarditis may develop, the risk is no greater than in the general population. This patient has a history of rheumatic fever, which can potentially result in high-risk valvular damage. However, his echocardiogram did not reveal any such condition. Mitral valve prolapse without a regurgitant jet (which is not a complication of rheumatic fever) is considered a negligible risk condition, so the proposed dental work can proceed without delay. Of the conditions listed in question 30, only bicuspid aortic valve would require antibiotic prophylaxis, as it is a moderate-risk congenital cardiac malformation. All of the other conditions listed are considered to be of negligible risk. Procedures which require antibiotic prophylaxis are those which produce a significant bacteremia with organisms commonly causing endocarditis. For dental procedures, those that tend to cause significant bleeding from hard or soft tissues would necessitate prophylaxis. Of the procedures listed, only dental extraction is likely to do this. During the course of other procedures, if unexpected significant bleeding occurs, antibiotics within 2 hours following the procedure would be recommended
Question 165:
While you are working in the community health center, a 40-year-old male presents to you as a referral from the dental clinic. The patient reported on the intake history form at the dental office that he had rheumatic fever at the age of 7. The dentist refused to allow him to have a dental examination and cleaning until he was cleared by a medical doctor. Other than rheumatic fever, the patient has no medical history and does not take any medications. He denies chest pain, palpitations, dyspnea, or any other symptoms. On examination, he has normal vital signs and a normal general examination. On auscultation of his heart, you hear a 2/6 systolic ejection murmur at the left upper sternal border without radiation. Review of his chart shows that he had an echocardiogram approximately 9 months ago that revealed mild mitral valve prolapse without evidence of mitral regurgitation, but otherwise normal valves and cardiac function.
Which of the following would be the most appropriate management at this time?
A. Proceed with the dental work.
B. Give the patient a 2 g dose of oral amoxicillin and then perform the dental cleaning an hour later.
C. Delay the dental work until the patient can undergo a repeat echocardiogram.
D. Delay the dental work until the patient is cleared by a cardiologist.
E. Allow the patient to undergo the dental cleaning now, but caution that he will need antibiotic prophylaxis if he requires any fillings.
Correct Answer: A Section: (none)
Explanation: Explanations: Bacterial endocarditis is a rare, but life-threatening, disease. It occurs primarily in persons with underlying structural heart defects who develop bacteremia with organisms that are likely to cause endocarditis. Most cases of endocarditis are not a complication of invasive medical or dental procedures. Because of the risks associated with the disease, efforts should be made to prevent bacterial endocarditis when appropriate. The American Heart Association has published updated, evidence-based recommendations on the prevention of bacterial endocarditis. These guidelines are available at the American Heart Association web site (www.americanheart.org). These guidelines outline conditions for which endocarditis prophylaxis is appropriate, procedures for which endocarditis prophylaxis is necessary, and antibiotic regimens that are recommended.
Cardiac conditions are stratified into high-risk, moderate-risk, and negligible risk. Negligible risk conditions are those in which, although endocarditis may develop, the risk is no greater than in the general population. This patient has a history of rheumatic fever, which can potentially result in high-risk valvular damage. However, his echocardiogram did not reveal any such condition. Mitral valve prolapse without a regurgitant jet (which is not a complication of rheumatic fever) is considered a negligible risk condition, so the proposed dental work can proceed without delay. Of the conditions listed in question 30, only bicuspid aortic valve would require antibiotic prophylaxis, as it is a moderate-risk congenital cardiac malformation. All of the other conditions listed are considered to be of negligible risk. Procedures which require antibiotic prophylaxis are those which produce a significant bacteremia with organisms commonly causing endocarditis. For dental procedures, those that tend to cause significant bleeding from hard or soft tissues would necessitate prophylaxis. Of the procedures listed, only dental extraction is likely to do this. During the course of other procedures, if unexpected significant bleeding occurs, antibiotics within 2 hours following the procedure would be recommended
Question 166:
A meta-analysis of randomized-controlled trials was published comparing two methods of managing postterm pregnancies. The question studied was whether the routine induction of labor at 41 weeks' gestation would result in improved maternal or fetal outcomes compared with expectant management. The authors reported that the odds ratio for caesarian delivery rate in the induction group compared to the expectant management group was 0.88 with a 95% confidence interval (CI) of 0.780.99. A second outcome studied was perinatal mortality. For this outcome, the odds ratio for the induction group compared to the expectant management group was 0.41 with a 95% CI of 0.141.18.
The authors assessed the study as being underpowered for the outcome of perinatal mortality. Possible ways to increase the statistical power of a study include which of the following?
A. using P-value to determine statistical significance in place of 95% CI
B. performing a "case-control" study in place of a meta-analysis of randomizedcontrolled trials
C. reporting the results as a relative risk in place of an odds ratio
D. performing a subgroup analysis
E. increasing the number of subjects enrolled in a study
Correct Answer: E Section: (none)
Explanation: Explanations: The odds ratio is a frequently published statistic. The odds of an event occurring are the number of times an event occurred divided by the number of times that it did not. In medical studies, it is calculated by dividing the number of subjects who achieved a certain outcome by the number of subjects who did not. An odds ratio is calculated by dividing the odds of an event in one group by the odds of the same event in another group. This is frequently an experimental group and a control group. In the study presented in this question, the "experimental" group is the induction of labor group and the control is the expectant management group. An odds ratio of less than one means that the outcome in question occurred less often in the experimental group than in the control group. Conversely, an odds ratio of greater than one reveals that the outcome occurred more often in the experimental group than the control group. In the study presented, the odds ratios for both the outcomes of caesarian delivery and perinatal mortality are less than one, suggesting that these outcomes occurred less often in the group of women treated with induction of labor at 41 weeks' gestation compared to those treated with expectant management. A CI is a range within which the "true" result is likely to be found. A95% CI states that there is a 95% probability that the true answer exists within these bounds.
For statistics, such as odds ratios or relative risks, a 95% CI that includes the number 1 within its bounds is considered not statistically significant. This is because an odds ratio of 1 means that there is no difference in the odds of an event occurring in either group. For the outcome of caesarian delivery, the odds ratio is
0.88 with a 95% CI that does not include 1. Therefore, one can say that there is a statistically significant reduction in the number of caesarian deliveries in the induction group compared to the expectant management group. For the outcome of perinatal mortality, the odds ratio is 0.41 but the 95% CI extends up to 1.18. This result cannot be considered statistically significant. The answer to question 27 is therefore
A.
Question 167:
A meta-analysis of randomized-controlled trials was published comparing two methods of managing postterm pregnancies. The question studied was whether the routine induction of labor at 41 weeks' gestation would result in improved maternal or fetal outcomes compared with expectant management. The authors reported that the odds ratio for caesarian delivery rate in the induction group compared to the expectant management group was 0.88 with a 95% confidence interval (CI) of 0.780.99. A second outcome studied was perinatal mortality. For this outcome, the odds ratio for the induction group compared to the expectant management group was 0.41 with a 95% CI of 0.141.18.
Which of the following statements is true?
A. There was a statistically significant reduction in the number of caesarian deliveries in the induction group compared to the expectant management group.
B. There was a statistically significant reduction in perinatal mortality in the induction group.
C. There was no statistically significant difference for either outcome.
D. There was a statistically significant increase in the number of caesarian deliveries in the induction group compared to the expectant management group.
E. There was a statistically significant decrease in both the number of caesarian deliveries and perinatal mortality in the induction group.
Correct Answer: A Section: (none)
Explanation: Explanations: The odds ratio is a frequently published statistic. The odds of an event occurring are the number of times an event occurred divided by the number of times that it did not. In medical studies, it is calculated by dividing the number of subjects who achieved a certain outcome by the number of subjects who did not. An odds ratio is calculated by dividing the odds of an event in one group by the odds of the same event in another group. This is frequently an experimental group and a control group. In the study presented in this question, the "experimental" group is the induction of labor group and the control is the expectant management group. An odds ratio of less than one means that the outcome in question occurred less often in the experimental group than in the control group. Conversely, an odds ratio of greater than one reveals that the outcome occurred more often in the experimental group than the control group. In the study presented, the odds ratios for both the outcomes of caesarian delivery and perinatal mortality are less than one, suggesting that these outcomes occurred less often in the group of women treated with induction of labor at 41 weeks' gestation compared to those treated with expectant management. A CI is a range within which the "true" result is likely to be found. A95% CI states that there is a 95% probability that the true answer exists within these bounds.
For statistics, such as odds ratios or relative risks, a 95% CI that includes the number 1 within its bounds is considered not statistically significant. This is because an odds ratio of 1 means that there is no difference in the odds of an event occurring in either group. For the outcome of caesarian delivery, the odds ratio is
0.88 with a 95% CI that does not include 1. Therefore, one can say that there is a statistically significant reduction in the number of caesarian deliveries in the induction group compared to the expectant management group. For the outcome of perinatal mortality, the odds ratio is 0.41 but the 95% CI extends up to 1.18. This result cannot be considered statistically significant. The answer to question 27 is therefore
A.
Question 168:
Of the following conditions, which results in the most deaths each year in the United States?
A. acquired immunodeficiency syndrome (AIDS)
B. breast cancer
C. motor vehicle accidents
D. occupational injuries
E. medical errors
Correct Answer: E Section: (none)
Explanation:
Explanations:
The landmark 1999 Institute of Medicine report, To Err is Human: Building a Safer Health System,
estimated that between 44,000 and 98,000 Americans died each year in hospitals as a result of medical
errors. Even using the lower number, this represents more deaths than breast cancer, motor vehicle
accidents, and AIDS. About 7000 deaths are attributable to medication errors. This number alone is greater
than the number of deaths in work-related injuries. Errors in diagnosis, treatment, prevention,
communication, equipment failure, and other system failures result not only in significant morbidity and
mortality, but also an estimated 1729 billion dollars in costs. Further, there is a significant loss in trust in the
health system by patients and loss in satisfaction by patients, their families, and health care providers.
Unfortunately, many of these errors that occurred, and continue to occur, are preventable. Many hospitals,
health care organizations, and oversight agencies, including the Quality Interagency Coordination Task
Force of the Federal Government, are actively pursuing mechanisms of quality improvement to reduce this
epidemic.
Question 169:
In your role as a physician in a community health center, you agree to perform sports preparticipation examinations on students from the local high school. You have several scheduled for today. Your first appointment is with a 16-year-old male who is planning to run on the cross-country team in the Fall and play baseball in the Spring. He reports that one time he "blacked out" while running, but he has never had chest pain while exercising and he is one of the top runners on the team. He has no known medical history, denies alcohol, tobacco, recreational drug, or performance-enhancing drug use. He has a cousin who died at the age of 21 of "some kind of heart disease," although your patient is not sure of any details. On examination, he is healthy appearing and has normal vital signs, with a pulse rate of 72 and a blood pressure of 100/65. Auscultation of his heart reveals no cardiac murmur while he is lying down, a soft systolic murmur when he stands which increases on having the patient perform a Valsalva maneuver. The remainder of his examination is normal Your last patient of the day is a 16-year-old male who plans to play on the football team. He has no complaints today, no significant medical history, and no concerning family history. He denies the use of tobacco, alcohol, or any kinds of drugs. His physical examination is entirely normal. Review of his vaccinations reveals that he had a Td vaccination 3 years ago, a varicella vaccination at age 17 months, and 2 MMR vaccinations at age 17 months and 5 years. Appropriate management at this time would include which of the following?
A. MMR vaccine
B. Td vaccine
C. varicella vaccine
D. screening ECG
E. urinalysis
Correct Answer: C Section: (none)
Explanation: Explanations: Primary care physicians are frequently called on to perform preparticipation examinations on young athletes. These types of encounters can be used to serve a number of purposes, including attempting to identify conditions that may adversely affect the athlete during participation, identify conditions that may predispose the athlete to injury, provide anticipatory guidance on high-risk behaviors common to the age group being addressed, and fulfill legal conditions of the institution involved. Fortunately, the rate of sudden death in young athletes is low. In those under the age of 35, the most common cause of sudden death is congenital cardiac anomalies. Hypertrophic cardiomyopathy (HCM) is responsible for about onethird of these deaths. Unfortunately, sudden death may be the presenting symptom of HCM. Apersonal or family history of congenital heart disease, symptoms of chest pain or tightness, palpitations, dyspnea, syncope or near-syncope are important. A family history of HCM or unexplained sudden death in someone under the age of 50 is significant as well. The murmur of HCM may not be present in all persons with this disorder.
To identify the murmur, dynamic auscultation is often necessary. The heart should be auscultated while the patient is lying and then standing. As this murmur is accentuated by maneuvers which reduce cardiac preload, the murmur will get louder when the patient stands or performs a Valsalva maneuver and will diminish as the patient lies or squats. As the patient in question 22 has the concerning historical point of exertional syncope and a family history of an unexplained, early death along with a characteristic murmur on examination, further evaluation is warranted. In the 26th Bethesda Conference report, the American College of Cardiology recommends that persons with HCM should be restricted from all, except possibly for the least strenuous, athletic activity. In this case, restriction of all athletic activity until the patient can be further evaluated by a cardiologist--preferably one with experience in dealing with the evaluation of athletes--would be the most appropriate option of the choices given.
Marfan syndrome is a connective tissue disorder that typically affects the eyes, skeletal system, and cardiovascular system. Persons with Marfan syndrome are typically tall and have arm spans that are greater than their height. Signs include long, slender digits, high-arched palates, and pectus deformities of the chest. Lens dislocations in the eye are common. Detecting Marfan syndrome during a preparticipation examination is important because of the occurrence of aortic\ root dilation and the risk of sudden death caused by aortic rupture. The patient in questions 23 and 24 has multiple signs of Marfan syndrome and further evaluation would be indicated. Of the options given, an echocardiogram to evaluate the aortic root and to look for other valvular abnormalities would be indicated. These persons usually require referral to an ophthalmologist as well for a dilated eye examination to evaluate for lens dislocations. Turner syndrome is a syndrome of gonadal dysgenesis, associated with a 45, X karyotype (or another defect of the X chromosome). This syndrome is typically associated with a short stature and multiple anomalies including a webbed neck and "shield" chest. The female athlete triad is a syndrome of disordered eating, amenorrhea, and osteoporosis. It is seen most often in participants in activities that emphasize low body weights, such as gymnastics or ballet. The presence of regular menstrual cycles makes this diagnosis unlikely. Atlantoaxial instability can be associated with Down syndrome. Physicians performing preparticipation examinations on someone with Down syndrome must consider performing lateral cervical spine x-rays with flexion and extension views. This patient does not have any of the classic findings of Down syndrome. Similarly, she does not exhibit any of the classic symptoms of type 1 diabetes polydipsia, polyphagia, and polyuria. Performing serum glucose testing would therefore not be indicated. The patient in question 25 is the most typical type of patient who presents for a preparticipation examination--the healthy adolescent. This may be the only encounter that a physician will have with an adolescent, especially an adolescent male. It is in this population where a physician can use this encounter to address other age appropriate health maintenance issues. As the patient had a Td booster 3 years ago, another one at this point would not be indicated (although consideration could be given to providing a Tdap). Other vaccinations to consider would be hepatitis B and MMR, if he has not previously been adequately immunized. As he has had two MMR vaccines, he has completed the recommended series. There is no history given regarding hepatitis B vaccination and this would be something to address clinically. A nonjudgmental discussion of sexual behaviors, drug use, alcohol use, and other high-risk behaviors would also be appropriate. Screening athletes who have neither concerning symptoms nor signs with ECGs is not recommended because of the poor predictive values and significant costs involved with mass screening. ECGs should be performed without hesitation in any athlete who has a history, examination finding, or preexisting diagnosis of a potentially high-risk condition. Although some localities may require a urinalysis as part of a preparticipation examination, there is no evidence to recommend universal screening
Question 170:
In your role as a physician in a community health center, you agree to perform sports preparticipation examinations on students from the local high school. You have several scheduled for today. Your first appointment is with a 16-year-old male who is planning to run on the cross-country team in the Fall and play baseball in the Spring. He reports that one time he "blacked out" while running, but he has never had chest pain while exercising and he is one of the top runners on the team. He has no known medical history, denies alcohol, tobacco, recreational drug, or performance-enhancing drug use. He has a cousin who died at the age of 21 of "some kind of heart disease," although your patient is not sure of any details. On examination, he is healthy appearing and has normal vital signs, with a pulse rate of 72 and a blood pressure of 100/65. Auscultation of his heart reveals no cardiac murmur while he is lying down, a soft systolic murmur when he stands which increases on having the patient perform a Valsalva maneuver. The remainder of his examination is normal
Appropriate diagnostic testing would include which of the following?
A. chromosomal analysis
B. echocardiography
C. serum calcium measurement
D. fasting plasma glucose
E. cervical spine x-rays with flexion and extension views
Correct Answer: B Section: (none)
Explanation:
Explanations:
Primary care physicians are frequently called on to perform preparticipation examinations on young
athletes. These types of encounters can be used to serve a number of purposes, including attempting to
identify conditions that may adversely affect the athlete during participation, identify conditions that may
predispose the athlete to injury, provide anticipatory guidance on high-risk behaviors common to the age
group being addressed, and fulfill legal conditions of the institution involved. Fortunately, the rate of sudden
death in young athletes is low.
In those under the age of 35, the most common cause of sudden death is congenital cardiac anomalies.
Hypertrophic cardiomyopathy (HCM) is responsible for about onethird of these deaths. Unfortunately,
sudden death may be the presenting symptom of HCM. Apersonal or family history of congenital heart disease, symptoms of chest pain or tightness, palpitations, dyspnea, syncope or near-syncope are important. A family history of HCM or unexplained sudden death in someone under the age of 50 is significant as well. The murmur of HCM may not be present in all persons with this disorder.
To identify the murmur, dynamic auscultation is often necessary. The heart should be auscultated while the patient is lying and then standing. As this murmur is accentuated by maneuvers which reduce cardiac preload, the murmur will get louder when the patient stands or performs a Valsalva maneuver and will diminish as the patient lies or squats. As the patient in question 22 has the concerning historical point of exertional syncope and a family history of an unexplained, early death along with a characteristic murmur on examination, further evaluation is warranted. In the 26th Bethesda Conference report, the American College of Cardiology recommends that persons with HCM should be restricted from all, except possibly for the least strenuous, athletic activity. In this case, restriction of all athletic activity until the patient can be further evaluated by a cardiologist--preferably one with experience in dealing with the evaluation of athletes--would be the most appropriate option of the choices given.
Marfan syndrome is a connective tissue disorder that typically affects the eyes, skeletal system, and cardiovascular system. Persons with Marfan syndrome are typically tall and have arm spans that are greater than their height. Signs include long, slender digits, high-arched palates, and pectus deformities of the chest. Lens dislocations in the eye are common. Detecting Marfan syndrome during a preparticipation examination is important because of the occurrence of aortic\ root dilation and the risk of sudden death caused by aortic rupture. The patient in questions 23 and 24 has multiple signs of Marfan syndrome and further evaluation would be indicated. Of the options given, an echocardiogram to evaluate the aortic root and to look for other valvular abnormalities would be indicated. These persons usually require referral to an ophthalmologist as well for a dilated eye examination to evaluate for lens dislocations. Turner syndrome is a syndrome of gonadal dysgenesis, associated with a 45, X karyotype (or another defect of the X chromosome). This syndrome is typically associated with a short stature and multiple anomalies including a webbed neck and "shield" chest. The female athlete triad is a syndrome of disordered eating, amenorrhea, and osteoporosis. It is seen most often in participants in activities that emphasize low body weights, such as gymnastics or ballet. The presence of regular menstrual cycles makes this diagnosis unlikely. Atlantoaxial instability can be associated with Down syndrome.
Physicians performing preparticipation examinations on someone with Down syndrome must consider performing lateral cervical spine x-rays with flexion and extension views. This patient does not have any of the classic findings of Down syndrome. Similarly, she does not exhibit any of the classic symptoms of type 1 diabetes polydipsia, polyphagia, and polyuria. Performing serum glucose testing would therefore not be indicated. The patient in question 25 is the most typical type of patient who presents for a preparticipation examination--the healthy adolescent. This may be the only encounter that a physician will have with an adolescent, especially an adolescent male. It is in this population where a physician can use this encounter to address other age appropriate health maintenance issues. As the patient had a Td booster 3 years ago, another one at this point would not be indicated (although consideration could be given to providing a Tdap). Other vaccinations to consider would be hepatitis B and MMR, if he has not previously been adequately immunized. As he has had two MMR vaccines, he has completed the recommended series. There is no history given regarding hepatitis B vaccination and this would be something to address clinically. A nonjudgmental discussion of sexual behaviors, drug use, alcohol use, and other high-risk behaviors would also be appropriate. Screening athletes who have neither concerning symptoms nor signs with ECGs is not recommended because of the poor predictive values and significant costs involved with mass screening. ECGs should be performed without hesitation in any athlete who has a history, examination finding, or preexisting diagnosis of a potentially high-risk condition. Although some localities may require a urinalysis as part of a preparticipation examination, there is no evidence to recommend universal screening
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