AAFP Practice Questions #4

AAFP Practice Questions #4

Some text here about the topic of discussion

Multiple Choice

A 30-year-old gravida 1 para 0 develops erythematous patches with slightly elevated scaly borders during her first trimester. There was a 2-cm herald patch 2 weeks before multiple smaller patches appeared. The rash on the back has a “Christmas tree” pattern. She has not had any prenatal laboratory work.This condition is associated with 

• no additional pregnancy risk

• a small-for-gestational-age newborn

• congenital cataracts

• multiple birth defects

• spontaneous abortion

​E. Spontaneous Abortion

​This patient has classic pityriasis rosea. This is generally a benign disease except in pregnancy. Theepidemiology and clinical course suggest an infectious etiology. Pregnant women are more susceptible topityriasis rosea because of decreased immunity. Pityriasis rosea is associated with an increased rate ofspontaneous abortion in the first 15 weeks of gestation. It is not associated with an increased risk for asmall-for-gestational-age newborn, congenital cataracts, or multiple birth defects.

Multiple Choice

A 30-year-old female reports that she and her husband have not been able to conceive aftertrying for 15 months. She takes no medications, has regular menses, and has no history of headaches, pelvic infections, or heat/cold intolerance. Her physical examination is unremarkable. Her husband recently had a normal semen analysis. Which one of the following would be the most appropriate next step? 

• Observation for 1 year

• TSH, free T4, and prolactin levels

• Hysterosalpingography

• An estradiol level

• A luteal-phase progesterone level

​E. Luteal Phase Progestin Level

Although infertility issues may be very complex, the primary care physician can initiate an appropriateworkup. For women who are having regular menstrual cycles, ovulation is very likely. Ovulation can beconfirmed by a progesterone level ³5 ng/mL on day 21 of the cycle. If this is the case, tubal patencyshould be confirmed with hysterosalpingography or laparoscopy. Obstruction or adhesions would requiresurgical correction, but if there are none, referral for assisted reproductive technology would beappropriate.Should the progesterone level be <5 ng/mL, anovulation should be investigated with TSH, estradiol, FSH,and prolactin levels. Treatment can be initiated if findings reveal the cause of the problem, but if they areunremarkable it is reasonable to try clomiphene to induce ovulation. If this is unsuccessful, referral wouldbe the next step.

Multiple Choice

A 34-year-old female sees you because of cramping diarrhea for the past several months following resection of her terminal ileum as treatment for Crohn’s disease. She is not aware of any exposure to individuals with similar symptoms. She has not had any fever, chills, nausea, vomiting, or myalgias, and she has not noticed any blood in her stool. She is passing several loose stools daily, mostly after meals. She has not been able to identify any clear relationship to the type of food she eats.Which one of the following would be the best initial treatment option for this patient? 

• A dairy-free diet

• Cholestyramine (Questran) daily

• A Lactobacillus probiotic supplement (Lactinex) 4 times daily

• Loperamide (Imodium) as needed

• Psyllium fiber (Metamucil) twice daily

​B. Cholestyramine

Diarrhea that develops in patients with ileal Crohn’s disease or following ileal resection is usually due to increased amounts of bile acid remaining in the stool. This affects colonic secretion and motility and various protein factors in the gut, resulting in the development of bile acid diarrhea (BAD). Although various tests can be performed to evaluate the stool, gut flora, and bowel function, a therapeutic trial with a bile acid sequestrant such as cholestyramine is most often used for both the diagnosis and treatment of BAD. Reducing fat intake may also be beneficial. Loperamide can lessen the diarrhea in some patients but should not be the primary treatment because chronic use can result in constipation. Fiber supplementation may help to produce a more formed stool and could be used as an adjunct treatment when appropriate.

Multiple Choice

The U.S. Preventive Services Task Force recommends which one of the following for women who are planning on or are capable of becoming pregnant?

• Testing for hepatitis C

• Annual pelvic examinations

• Folic acid, 0.4–0.8 mg daily

• Vitamin B12, 1000 μg daily

• Vitamin D, 400–800 IU daily

​C. Folic Acid

To prevent neural tube defects in newborns, the U.S. Preventive Services Task Force recommends folic acid, 0.4–0.8 mg daily, for all women who are planning on or are capable of becoming pregnant (USPSTF A recommendation).

Multiple Choice

A 20-year-old college student comes to the urgent care clinic with right knee pain and swelling after injuring her knee in a recreational basketball game. Her feet were planted when another player collided with her, causing her upper torso to rotate. She felt immediate pain in the knee and was unable to complete the game. Which one of the following is the most accurate and appropriate maneuver to detect an anterior cruciate ligament tear?

• The anterior drawer test

• The lever sign test

• The Lachman test

• The McMurray test

• The pivot shift test

​C. The Lachman Test

The Lachman test is the most accurate test for an anterior cruciate ligament (ACL) tear (SOR A). Accurate testing can lead to appropriate referral and treatment for ACL tears, and early detection can lead to better outcomes. The Lachman test has higher validity based on a sensitivity of 68% for partial ruptures and 96% for complete ruptures. The other two commonly used tests are the anterior drawer test, which has a sensitivity of 38% and a specificity of 81%, and the pivot shift test, which is more technically difficult than the other two tests and has a sensitivity ranging from 24% to 85%. The pivot shift test is effective if done correctly but should not be used alone to diagnose an ACL tear (SOR A).The lever sign test is a newer test that holds promise for detecting ACL tears and is easily performed in the office. However, sensitivity and specificity reports vary (SOR B). The McMurray test is used to detect meniscal tears.

​Pivot Shift: https://www.youtube.com/watch?v=qqy5IfkEvfw&t=105s

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​Lever Test: https://www.youtube.com/watch?v=T9ujIYIctdw

Multiple Choice

A 77-year-old Spanish-speaking female with end-stage heart failure has elected hospice care to be provided at home for the duration of her life. A trained interpreter is available for assistance when you see the patient and is present in the room. Which one of the following is considered a best practice when using interpreters?

• Addressing the patient directly when speaking

• Seating the interpreter closest to the clinician, slightly in front of the patient, to observe body language when translatingdy language when translating

• Asking the interpreter to serve as a witness for a consent form for hospice

• Explaining to the interpreter the entire care plan, then having him or her repeat it back to the patient

• Explaining in full detail all possible scenarios for symptom management and what to expect

​A. Address the Patient Directly

When professional interpreters participate in patient care it is important to speak directly in the first person,using “I” statements rather than statements that start with “tell her” (SOR C). It is ideal to seat theinterpreter next to or slightly behind the patient, so that the patient is the focus of the interaction.Sentence-by-sentence interpretation can prevent miscommunication errors, as opposed to expecting theinterpreter to remember every detail of a complex care plan. It is not appropriate for the medicalinterpreter to also serve as a witness to consent. Focusing on three or fewer key points rather thanover-communicating multiple complex issues increases the likelihood that the patient will comprehend theplan of care.

Multiple Choice

Which one of the following treatments has been shown to improve the quality of life for a patient with tinnitus? 

• Antidepressant therapy

• Ginkgo biloba

• Niacin

• Vitamin B12

• Cognitive-behavioral therapy

​E. CBT​

Treatments to reduce awareness of tinnitus and tinnitus-related distress include cognitive-behavioraltherapy, acoustic stimulation, and educational counseling. No medications, supplements, or herbalremedies have been shown to substantially reduce the severity of tinnitus.

​https://examine.com/supplements/ginkgo-biloba/#examine-database

Multiple Choice

A 28-year-old female who was recently diagnosed with polycystic ovary syndrome presents to discuss treatment of irregular menses. She has 2–3 menstrual periods every 6 months that happen at irregular times and can often produce heavy bleeding. She is not obese and has no significant acne or hirsutism. She does not desire pregnancy and her primary goal is to decrease the heavy menstrual bleeding. Which one of the following would be the most effective initial recommendation? 

• Dietary modifications aimed at weight loss

• Clomiphene

• Metformin (Glucophage)

• Spironolactone (Aldactone)

• Placement of a levonorgestrel IUD (Mirena)

​E. Levonorgestrel IUD

Polycystic ovary syndrome can significantly affect multiple organ systems, and menstrual irregularitiesfrom anovulatory cycles are very common. Treatment should be based on the patient’s goals and modifiedbased on her desire for fertility. In a patient who is not interested in near-term fertility and whose goal isto control menstrual irregularities, a levonorgestrel IUD is most likely to reduce the frequency, duration,and volume of bleeding. Metformin is used to treat insulin resistance, dietary modifications are used totreat obesity, spironolactone can be used to treat hirsutism or acne, and clomiphene is used to induceovulation and fertility.

Multiple Choice

An 80-year-old male sees you for the first time. He is asymptomatic except for some fatigue. His pulse rate is 50 beats/min. An EKG shows a prolonged PR interval. Which one of the following medications in his current regimen is the most likely explanation for these findings?

• Donepezil (Aricept)

• Escitalopram (Lexapro)

• Lisinopril (Prinivil, Zestril)

• Memantine (Namenda)

• Zolpidem (Ambien)

​A. Donepezil

The 2015 American Geriatrics Society Beers Criteria for potentially inappropriate medication use in older adults 65 years of age states that donepezil use should be avoided in patients with syncope, due to an increased risk of bradycardia (Moderate Evidence Level; Strong Strength of Recommendation). Donepezil is a cholinesterase inhibitor. Due to their cholinergic effect, these medications have a vagotonic effect on the sinoatrial and atrioventricular nodes. This can cause bradycardia or heart block in patients with or without underlying cardiac conduction abnormalities. Syncope has been reported with these medications. Memantine is an N-methyl-D-aspartate receptor antagonist and is not associated with bradycardia. Escitalopram, lisinopril, and zolpidem are also not associated with bradycardia.

Multiple Choice

A 6-month-old male is brought to the urgent care center with a 3-day history of rhinorrhea, cough, and increased respiratory effort. His temperature is 37.5°C (99.5°F), his heart rate is 120 beats/min, his respiratory rate is 42/min, and his oxygen saturation is 96% on room air. On examination the child appears well hydrated with clear secretions from his nasal passages, there is diffuse wheezing heard bilaterally, and there is no nasal flaring or retractions. The mother states that the child has a decreased appetite but is drinking a normal amount of fluids. Which one of the following would be the most appropriate management for this patient? 

• Supportive therapy only

• Bronchodilators

• A corticosteroid taper

• Epinephrine

• Nebulized hypertonic saline

​A. Supportive Therapy Only

This patient’s symptoms and the examination suggest viral bronchiolitis. Supportive therapy, includingadequate hydration, is recommended for treatment. Treatment with bronchodilators, epinephrine,hypertonic saline, or corticosteroids is not indicated (SOR A).