A 50-year-old male presents to your office for a routine annual physical examination. He has no specific complaints for this visit other than wanting to be checked for all the usual stuff. His last visit with you was a year ago for a physical examination. At that time his examination was normal. You performed blood work that was within normal limits and included a total cholesterol of 172 with a high-density lipoprotein (HDL) of 45 and low-density lipoprotein (LDL) of 100. He reports that he had a tetanus shot 5 years ago.
Past medical history: Unremarkable Past surgical history: 1. Appendectomy at age 17
2. Vasectomy at age 43 Medications: Daily multivitamin Allergies: NKDA (no known drug allergies) Family history: Father died at age 78 of a heart attack Mother is alive at age 76. She has hypertension and osteoarthritis Brother aged 48 without known chronic medical condition Children aged 16, 14, and 8--no known chronic medical illness Social history: Married, employed as an accountant; college graduate Denies tobacco or recreational drug use Drinks one alcoholic drink (either beer or wine) a day Does not exercise on a regular basis
Which of the following interventions would be recommended for this patient?
A. pneumococcal vaccine
B. tetanus toxoid vaccine
C. complete cessation of all alcohol intake
D. beta-carotene supplementation to prevent cancer and heart disease
E. screening for depression with a patientcompleted questionnaire
Correct Answer: E Section: (none)
Explanation:
Explanations:
The United States Preventative Services Task Force (USPSTF) is an independent panel of experts in
primary care and prevention that systematically reviews the evidence of effectiveness and develops
recommendations for clinical preventative services. By carefully and systematically reviewing the available
literature, the USPSTF makes recommendations on the effectiveness of screening, counseling,
immunization, and chemoprevention using the following rating system:
A. The USPSTF strongly recommends that clinicians provide the service to eligible patients. B. The USPSTF recommends that clinicians provide this service to eligible patients. C. The USPSTF makes no recommendation for or against routine provision of the service. D. The USPSTF recommends against routinely providing the service to asymptomatic patients. I. The USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing the service. All of the recommendations of the USPSTF are available free of charge at their web site www.preventiveservices.ahrq.gov. In a 50-year-old male who is generally healthy and does not present any apparent high-risk personal or family history, the USPSTF gives a level A recommendation to blood pressure measurement as a screening tool for hypertension in adults over the age of 18, as there is good evidence that screening for, and treating, hypertension can reduce the incidence of cardiovascular disease. There is insufficient evidence to recommend for or against screening for abdominal aortic aneurysm by abdominal palpation or for screening for skin cancer by a whole body skin examination (level I recommendation).
This suggests that the evidence is lacking that performing these interventions will reduce the morbidity or mortality associated with these conditions. The USPSTF gives level D recommendations to screening for thyroid cancer by palpation and for screening for testicular cancer by palpation. Fecal occult blood testing using three selfcollected stool cards as a screening test for colon cancer has been given a level A recommendation, with good data to support reduction in colon cancer mortality from periodic screening. There is also evidence to support screening for colon cancer by flexible sigmoidoscopy or colonoscopy, with double-contrast barium enema as a possible alternative as well. Screening for lipid disorders in men over the age of 35 and women over the age of 45 also receives a level A recommendation. In general, the interval for repeat screening for an otherwise low-risk patient with lipid levels within the goal range, based on the National Cholesterol Education Project's Consensus opinion statement, would be 5 years. As this patient had lipid levels within the goal range 1 year ago, it would not be necessary to repeatthis blood test at this visit. Screening for cardiovascular disease by the routine use of electrocardiography in asymptomatic, lowrisk patients has been given a D recommendation, as there is an absence of evidence of improved health outcomes from this intervention. Screening for lung cancer by chest x-ray and for glaucoma by measurement of intraocular pressure are level I recommendations, with insufficient evidence to recommend for or against these interventions.
Question 192:
A 50-year-old male presents to your office for a routine annual physical examination. He has no specific complaints for this visit other than wanting to be checked for all the usual stuff. His last visit with you was a year ago for a physical examination. At that time his examination was normal. You performed blood work that was within normal limits and included a total cholesterol of 172 with a high-density lipoprotein (HDL) of 45 and low-density lipoprotein (LDL) of 100. He reports that he had a tetanus shot 5 years ago.
Past medical history: Unremarkable Past surgical history: 1. Appendectomy at age 17
2. Vasectomy at age 43 Medications: Daily multivitamin Allergies: NKDA (no known drug allergies) Family history: Father died at age 78 of a heart attack Mother is alive at age 76. She has hypertension and osteoarthritis Brother aged 48 without known chronic medical condition Children aged 16, 14, and 8--no known chronic medical illness Social history: Married, employed as an accountant; college graduate Denies tobacco or recreational drug use Drinks one alcoholic drink (either beer or wine) a day Does not exercise on a regular basis
Which of the following tests would be recommended for this patient?
A. fasting lipid panel
B. chest x-ray
C. electrocardiogram (ECG)
D. glaucoma screening by measurement of intraocular pressure
E. fecal occult blood test
Correct Answer: E Section: (none)
Explanation:
Explanations:
The United States Preventative Services Task Force (USPSTF) is an independent panel of experts in
primary care and prevention that systematically reviews the evidence of effectiveness and develops
recommendations for clinical preventative services. By carefully and systematically reviewing the available
literature, the USPSTF makes recommendations on the effectiveness of screening, counseling,
immunization, and chemoprevention using the following rating system:
A. The USPSTF strongly recommends that clinicians provide the service to eligible patients. B. The USPSTF recommends that clinicians provide this service to eligible patients. C. The USPSTF makes no recommendation for or against routine provision of the service. D. The USPSTF recommends against routinely providing the service to asymptomatic patients. I. The USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing the service. All of the recommendations of the USPSTF are available free of charge at their web site www.preventiveservices.ahrq.gov. In a 50-year-old male who is generally healthy and does not present any apparent high-risk personal or family history, the USPSTF gives a level A recommendation to blood pressure measurement as a screening tool for hypertension in adults over the age of 18, as there is good evidence that screening for, and treating, hypertension can reduce the incidence of cardiovascular disease. There is insufficient evidence to recommend for or against screening for abdominal aortic aneurysm by abdominal palpation or for screening for skin cancer by a whole body skin examination (level I recommendation).
This suggests that the evidence is lacking that performing these interventions will reduce the morbidity or mortality associated with these conditions. The USPSTF gives level D recommendations to screening for thyroid cancer by palpation and for screening for testicular cancer by palpation. Fecal occult blood testing using three selfcollected stool cards as a screening test for colon cancer has been given a level A recommendation, with good data to support reduction in colon cancer mortality from periodic screening.
There is also evidence to support screening for colon cancer by flexible sigmoidoscopy or colonoscopy, with double-contrast barium enema as a possible alternative as well. Screening for lipid disorders in men over the age of 35 and women over the age of 45 also receives a level A recommendation. In general, the interval for repeat screening for an otherwise low-risk patient with lipid levels within the goal range, based on the National Cholesterol Education Project's Consensus opinion statement, would be 5 years. As this patient had lipid levels within the goal range 1 year ago, it would not be necessary to repeatthis blood test at this visit. Screening for cardiovascular disease by the routine use of electrocardiography in asymptomatic, lowrisk patients has been given a D recommendation, as there is an absence of evidence of improved health outcomes from this intervention. Screening for lung cancer by chest x-ray and for glaucoma by measurement of intraocular pressure are level I recommendations, with insufficient evidence to recommend for or against these interventions.
Question 193:
A 50-year-old male presents to your office for a routine annual physical examination. He has no specific complaints for this visit other than wanting to be checked for all the usual stuff. His last visit with you was a year ago for a physical examination. At that time his examination was normal. You performed blood work that was within normal limits and included a total cholesterol of 172 with a high-density lipoprotein (HDL) of 45 and low-density lipoprotein (LDL) of 100. He reports that he had a tetanus shot 5 years ago.
Past medical history: Unremarkable Past surgical history: 1. Appendectomy at age 17
2. Vasectomy at age 43 Medications: Daily multivitamin Allergies: NKDA (no known drug allergies) Family history: Father died at age 78 of a heart attack Mother is alive at age 76. She has hypertension and osteoarthritis Brother aged 48 without known chronic medical condition Children aged 16, 14, and 8--no known chronic medical illness Social history: Married, employed as an accountant; college graduate Denies tobacco or recreational drug use Drinks one alcoholic drink (either beer or wine) a day Does not exercise on a regular basis
Which of the following office examinations would be recommended for this patient?
A. measurement of his blood pressure
B. abdominal palpation to screen for abdominal aortic aneurysm
C. testicular examination to screen for testicular cancer
D. whole body skin examination to screen for skin cancer
E. palpation of the thyroid gland to screen for thyroid cancer
Correct Answer: A Section: (none)
Explanation:
Explanations:
The United States Preventative Services Task Force (USPSTF) is an independent panel of experts in
primary care and prevention that systematically reviews the evidence of effectiveness and develops
recommendations for clinical preventative services. By carefully and systematically reviewing the available
literature, the USPSTF makes recommendations on the effectiveness of screening, counseling,
immunization, and chemoprevention using the following rating system:
A. The USPSTF strongly recommends that clinicians provide the service to eligible patients. B. The USPSTF recommends that clinicians provide this service to eligible patients. C. The USPSTF makes no recommendation for or against routine provision of the service. D. The USPSTF recommends against routinely providing the service to asymptomatic patients. I. The USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing the service. All of the recommendations of the USPSTF are available free of charge at their web site www.preventiveservices.ahrq.gov. In a 50-year-old male who is generally healthy and does not present any apparent high-risk personal or family history, the USPSTF gives a level A recommendation to blood pressure measurement as a screening tool for hypertension in adults over the age of 18, as there is good evidence that screening for, and treating, hypertension can reduce the incidence of cardiovascular disease. There is insufficient evidence to recommend for or against screening for abdominal aortic aneurysm by abdominal palpation or for screening for skin cancer by a whole body skin examination (level I recommendation). This suggests that the evidence is lacking that performing these interventions will reduce the morbidity or mortality associated with these conditions. The USPSTF gives level D recommendations to screening for thyroid cancer by palpation and for screening for testicular cancer by palpation. Fecal occult blood testing using three selfcollected stool cards as a screening test for colon cancer has been given a level A recommendation, with good data to support reduction in colon cancer mortality from periodic screening. There is also evidence to support screening for colon cancer by flexible sigmoidoscopy or colonoscopy, with double-contrast barium enema as a possible alternative as well. Screening for lipid disorders in men over the age of 35 and women over the age of 45 also receives a level A recommendation. In general, the interval for repeat screening for an otherwise low-risk patient with lipid levels within the goal range, based on the National Cholesterol Education Project's Consensus opinion statement, would be 5 years. As this patient had lipid levels within the goal range 1 year ago, it would not be necessary to repeatthis blood test at this visit. Screening for cardiovascular disease by the routine use of electrocardiography in asymptomatic, lowrisk patients has been given a D recommendation, as there is an absence of evidence of improved health outcomes from this intervention. Screening for lung cancer by chest x-ray and for glaucoma by measurement of intraocular pressure are level I recommendations, with insufficient evidence to recommend for or against these interventions.
Question 194:
A 14-year-old girl is admitted to the medical unit due to dehydration. She is found to be severely underweight, at 75% of expected weight. She has no significant medical problems, but she stopped menstruating 9 months ago after having regular periods since age 12. She has no prior psychiatric history and is a very successful student and athlete at school. She denies feeling depressed but does admit to feeling tired. When confronted about her weight loss, she does not appear concerned, stating, "I was very fat and still have more weight to lose." Which of the following treatment modalities is the most effective for her gaining weight?
A. amitriptyline (Elavil)
B. behavioral therapy
C. fluoxetine (Prozac)
D. growth hormone
E. lithium
Correct Answer: B Section: (none)
Explanation: Explanations: This girl meets criteria for anorexia nervosa, restricting type. The efficacy for tricyclic antidepressants such as amitriptyline in anorexia nervosa is quite limited. While some studies have demonstrated benefit with SSRIs such as fluoxetine in anorexia after adequate weight has been restored, the evidence for gains in weight restoration is lacking. Neither growth hormone injections nor lithium have promoted weight gain in anorexic patients. The best evidence for the short-term treatment of anorexia nervosa lies with behavioral interventions while the patient is in a structured inpatient or partial hospital setting; the treatment modalities often include individual (cognitive-behavioral), group, and family therapies.
Question 195:
An 82-year-old woman is admitted to the surgical ward after suffering a fracture of her right hip due to a fall down her stairs. Her surgery and recovery are uneventful, but 3 days later, the nurses are frustrated when she does not let them take her vitals or draw blood. On interview, she exhibits drowsiness with occasional agitation. She is unable to answer questions well and is oriented only to person. She also picks at the empty air and begins yelling and swinging at the nurse who is present. 90.
Which of the following most likely represents her mortality rate in 6 months after discharge?
A. 020%
B. 2040%
C. 4060%
D. 6080% E. 80100%
Correct Answer: B Section: (none)
Explanation: Explanations: This patient exhibits signs and symptoms of delirium. An EEG is very sensitive for delirium. Localized spikes would be seen in a patient with seizure activity. Random activity is characteristic of the normal, awake state. Lowvoltage fast activity is very specific to delirium secondary to alcohol or sedative/hypnotic withdrawal. Triphasic delta waves are characteristic of delirious states caused by hepatic failure. All other causes of delirium, however, demonstrate diffuse slowing on EEG. Medications, such as antipsychotics and benzodiazepines, may be helpful in reducing the agitation often seen in delirium. Soft restraints may also be necessary to permit the treatment team to perform appropriate examinations, tests, or procedures and to prevent the pulling out of intravenous access, feeding tubes, and so on. Behavioral interventions may be employed to reinforce orientation to person, place, and time. Some of these interventions may include the use of pictures, lights, clocks, or calendars. The primary and essential approach in the management of patients with delirium, however, is to determine and treat the underlying cause. The presence of a delirium is a poor prognostic sign. The mortality rate for 1 year after a delirium is approximately 50%. The mortality rate for 6 months after an episode of delirium is approximately 25%.
Question 196:
An 82-year-old woman is admitted to the surgical ward after suffering a fracture of her right hip due to a fall down her stairs. Her surgery and recovery are uneventful, but 3 days later, the nurses are frustrated when she does not let them take her vitals or draw blood. On interview, she exhibits drowsiness with occasional agitation. She is unable to answer questions well and is oriented only to person. She also picks at the empty air and begins yelling and swinging at the nurse who is present. 90.
Which of the following is the most important in managing this patient?
A. haloperidol (Haldol) to decrease agitation
B. lorazepam (Ativan) to regulate sleep
C. soft restraints to prevent injury
D. techniques to promote orientation
E. treatment of underlying condition
Correct Answer: E Section: (none)
Explanation: Explanations: This patient exhibits signs and symptoms of delirium. An EEG is very sensitive for delirium. Localized spikes would be seen in a patient with seizure activity. Random activity is characteristic of the normal, awake state. Lowvoltage fast activity is very specific to delirium secondary to alcohol or sedative/hypnotic withdrawal. Triphasic delta waves are characteristic of delirious states caused by hepatic failure. All other causes of delirium, however, demonstrate diffuse slowing on EEG. Medications, such as antipsychotics and benzodiazepines, may be helpful in reducing the agitation often seen in delirium. Soft restraints may also be necessary to permit the treatment team to perform appropriate examinations, tests, or procedures and to prevent the pulling out of intravenous access, feeding tubes, and so on. Behavioral interventions may be employed to reinforce orientation to person, place, and time. Some of these interventions may include the use of pictures, lights, clocks, or calendars. The primary and essential approach in the management of patients with delirium, however, is to determine and treat the underlying cause. The presence of a delirium is a poor prognostic sign. The mortality rate for 1 year after a delirium is approximately 50%. The mortality rate for 6 months after an episode of delirium is approximately 25%.
Question 197:
A 68-year-old retired male is accompanied by his son and daughter to a family medicine clinic. They are concerned about their father's health, as they have noticed him becoming gradually more "confused" over the past year. While he had always been capable of managing to live alone, he has not been keeping up with his bills. The patient explains that he needs his bifocals, but both of his children quickly interrupt, stating that he has glasses but misplaces them frequently. He also frequently loses his keys and forgets to shut his door. The management of the condominium has complained because they recently found him wandering around the lobby and pool in the middle of the night while dressed in his underwear. He has no medical problems and takes only an aspirin daily. His MSE is significant for defensiveness to questioning with some irritability. His Mini-Mental State Examination is 19/30, with notable memory deficits and wordfinding difficulties.
Which of the following will be the most likely course of his illness?
A. gradual progression
B. no worsening
C. rapid progression
D. steady improvement
E. stepwise progression
Correct Answer: A Section: (none)
Explanation: Explanations: This patient presents with a dementia, most likely Alzheimer's type. Although some cases have been found to have a genetic component, genetic testing is not routinely performed. Neuropsychological testing may be used to specify or confirm the presence of cognitive deficits. Cerebrospinal fluid and MRI may be used to rule-out other causes of dementia but are not necessarily used to diagnose Alzheimer's disease. Although dementia of the Alzheimer's type is a clinical diagnosis, the final diagnosis can only be made by a neuropathologic examination, which classically demonstrates senile plaques, neurofibrillary tangles, and neuronal loss. (Synopsis, p. 331) Preferential atrophy of the frontotemporal regions is consistent with Pick's disease, which may present similarly to Alzheimer's disease. Huntington's disease, another cause of dementia, is characterized by a severe movement disorder. It demonstrates striking atrophy of the caudate nucleus along with possible cerebral atrophy. Dilatation of the ventricles without atrophy is the hallmark of NPH, one of the few potentially reversible causes of dementia. The classic triad of NPH is dementia, gait disturbance, and urinary incontinence. The second most common cause of dementia is vascular dementia, which is often caused by uncontrolled hypertension. It results in multiple small infarcts of the white matter surrounding the ventricles. Alzheimer's dementia, the most common cause of dementia, is characterized by diffuse cerebral atrophy and dilatation of the ventricles.
Question 198:
An 82-year-old woman is admitted to the surgical ward after suffering a fracture of her right hip due to a fall down her stairs. Her surgery and recovery are uneventful, but 3 days later, the nurses are frustrated when she does not let them take her vitals or draw blood. On interview, she exhibits drowsiness with occasional agitation. She is unable to answer questions well and is oriented only to person. She also picks at the empty air and begins yelling and swinging at the nurse who is present. 90.
An electroencephalogram (EEG) performed on this patient would most likely show which of the following?
A. diffuse slowing
B. localized spikes
C. low-voltage fast activity
D. random activity
E. triphasic delta waves
Correct Answer: A Section: (none)
Explanation:
Explanations: This patient exhibits signs and symptoms of delirium. An EEG is very sensitive for delirium.
Localized spikes would be seen in a patient with seizure activity. Random activity is characteristic of the
normal, awake state. Lowvoltage fast activity is very specific to delirium secondary to alcohol or sedative/
hypnotic withdrawal. Triphasic delta waves are characteristic of delirious states caused by hepatic failure. All other causes of delirium, however, demonstrate diffuse slowing on EEG. Medications, such as antipsychotics and benzodiazepines, may be helpful in reducing the agitation often seen in delirium. Soft restraints may also be necessary to permit the treatment team to perform appropriate examinations, tests, or procedures and to prevent the pulling out of intravenous access, feeding tubes, and so on. Behavioral interventions may be employed to reinforce orientation to person, place, and time. Some of these interventions may include the use of pictures, lights, clocks, or calendars. The primary and essential approach in the management of patients with delirium, however, is to determine and treat the underlying cause. The presence of a delirium is a poor prognostic sign. The mortality rate for 1 year after a delirium is approximately 50%. The mortality rate for 6 months after an episode of delirium is approximately 25%.
Question 199:
A 68-year-old retired male is accompanied by his son and daughter to a family medicine clinic. They are concerned about their father's health, as they have noticed him becoming gradually more "confused" over the past year. While he had always been capable of managing to live alone, he has not been keeping up with his bills. The patient explains that he needs his bifocals, but both of his children quickly interrupt, stating that he has glasses but misplaces them frequently. He also frequently loses his keys and forgets to shut his door. The management of the condominium has complained because they recently found him wandering around the lobby and pool in the middle of the night while dressed in his underwear. He has no medical problems and takes only an aspirin daily. His MSE is significant for defensiveness to questioning with some irritability. His Mini-Mental State Examination is 19/30, with notable memory deficits and wordfinding difficulties.
A definitive diagnosis of this patient's most likely condition would require which of the following?
A. cerebrospinal fluid tests
B. genetic testing
C. MRI
D. neuropathologic examination
E. neuropsychological testing
Correct Answer: D Section: (none)
Explanation: Explanations: This patient presents with a dementia, most likely Alzheimer's type. Although some cases have been found to have a genetic component, genetic testing is not routinely performed. Neuropsychological testing may be used to specify or confirm the presence of cognitive deficits. Cerebrospinal fluid and MRI may be used to rule-out other causes of dementia but are not necessarily used to diagnose Alzheimer's disease. Although dementia of the Alzheimer's type is a clinical diagnosis, the final diagnosis can only be made by a neuropathologic examination, which classically demonstrates senile plaques, neurofibrillary tangles, and neuronal loss. (Synopsis, p. 331) Preferential atrophy of the frontotemporal regions is consistent with Pick's disease, which may present similarly to Alzheimer's disease. Huntington's disease, another cause of dementia, is characterized by a severe movement disorder. It demonstrates striking atrophy of the caudate nucleus along with possible cerebral atrophy. Dilatation of the ventricles without atrophy is the hallmark of NPH, one of the few potentially reversible causes of dementia. The classic triad of NPH is dementia, gait disturbance, and urinary incontinence. The second most common cause of dementia is vascular dementia, which is often caused by uncontrolled hypertension. It results in multiple small infarcts of the white matter surrounding the ventricles. Alzheimer's dementia, the most common cause of dementia, is characterized by diffuse cerebral atrophy and dilatation of the ventricles.
Question 200:
A 68-year-old retired male is accompanied by his son and daughter to a family medicine clinic. They are concerned about their father's health, as they have noticed him becoming gradually more "confused" over the past year. While he had always been capable of managing to live alone, he has not been keeping up with his bills. The patient explains that he needs his bifocals, but both of his children quickly interrupt, stating that he has glasses but misplaces them frequently. He also frequently loses his keys and forgets to shut his door. The management of the condominium has complained because they recently found him wandering around the lobby and pool in the middle of the night while dressed in his underwear. He has no medical problems and takes only an aspirin daily. His MSE is significant for defensiveness to questioning with some irritability. His Mini-Mental State Examination is 19/30, with notable memory deficits and wordfinding difficulties. An MRI performed would most likely demonstrate which of the following findings?
A. atrophy of frontal and temporal lobes
B. caudate nucleus atrophy with cortical atrophy
C. diffuse cortical atrophy with dilatation of ventricles
D. dilatation of cerebral ventricles without cortical atrophy
E. subcortical white matter infarcts
Correct Answer: C Section: (none)
Explanation: Explanations: This patient presents with a dementia, most likely Alzheimer's type. Although some cases have been found to have a genetic component, genetic testing is not routinely performed. Neuropsychological testing may be used to specify or confirm the presence of cognitive deficits. Cerebrospinal fluid and MRI may be used to rule-out other causes of dementia but are not necessarily used to diagnose Alzheimer's disease. Although dementia of the Alzheimer's type is a clinical diagnosis, the final diagnosis can only be made by a neuropathologic examination, which classically demonstrates senile plaques, neurofibrillary tangles, and neuronal loss. (Synopsis, p. 331) Preferential atrophy of the frontotemporal regions is consistent with Pick's disease, which may present similarly to Alzheimer's disease. Huntington's disease, another cause of dementia, is characterized by a severe movement disorder. It demonstrates striking atrophy of the caudate nucleus along with possible cerebral atrophy. Dilatation of the ventricles without atrophy is the hallmark of NPH, one of the few potentially reversible causes of dementia. The classic triad of NPH is dementia, gait disturbance, and urinary incontinence. The second most common cause of dementia is vascular dementia, which is often caused by uncontrolled hypertension. It results in multiple small infarcts of the white matter surrounding the ventricles. Alzheimer's dementia, the most common cause of dementia, is characterized by diffuse cerebral atrophy and dilatation of the ventricles.
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