FM_CASES_QUESTIONS

1 FM_CASES_QUESTIONS FM_Cases#01:---45 year old female annual exam QUESTION #1 (Case#1) A 34-year-old woman who has no past medical problems nor is currently taking any medications comes into your office because she noticed a tender lump in her left breast starting approximately one month ago. She is worried because she has an aunt who had breast cancer that was BRCA positive. Her periods have been regular since they started at the age of 12 and occur every 32 days. She is currently menstruating. She has three children aged 12, 9, and 4. On exam, her BMI is 32 and her other vital signs are stable. On breast exam, you note a mobile rubbery mass of approximately 1 x 1cm and with regular borders that is tender to palpation. You appreciate no axillary adenopathy. The rest of her physical exam is unremarkable. Of the information provided, which of the following places this patient at increased risk for breast cancer? A. Age B. Weight C. Parity history D. Family history of cancer E. Age of menarche Correct Answer Q1C1 B. Weight has been selected by the expert. QUESTION #2 (Case#1) A 64-year-old woman who is overweight with well-controlled hypertension comes to your office complaining of a lump in her breast that she noticed while showering. She denies any pain, tenderness, or skin changes. A pertinent review of systems is negative. Menarche began at the age of 10. Her first child was born when she was 29 and she had her second and last child at the age of 33. She experienced menopause at the age of 44. Her mother died of colon cancer when she was 65 and her father passed away from metastatic prostate cancer at the age of 70. She has no history of tobacco use ever and occasionally drinks a glass of wine with dinner. Her BMI is 34. Which of the information provided thus far puts the patient at decreased risk for breast cancer? A. Age B. Weight C. Age at first birth D. Age of menarche E. Age of menopause 2 QUESTION #3 (Case#1) CORRECT ANSWER: “C” C has been selected by the expert. QUESTION #4 (Case#1) A 47-year-old woman comes into your office for a health care maintenance exam. She has hypertension and type 2 diabetes. She is not sexually active and has not yet experienced menopause. There is no family history of cancer. Her blood pressure is 118/78, her BMI is 34 and the remainder of her physical exam is within normal limits. Her vaccinations are up-to-date, she has a PAP smear today and will have labs drawn. According to USPSTF, which of the following is the best recommendation to give her concerning mammography? A. Should have started at age 40 and every year thereafter B. Should have started at age 40 and every 2 years thereafter C. Start at age 50 and every year thereafter D. Start at age 50 and every 2 years thereafter E. Screening mammography is not recommended at this time CORRECT ANSWER: “D”—Start at age 50 and every 2 years thereafter Mammography has a sensitivity of 60-90% for detecting breast cancer and decreases breast cancer mortality. According to the most recent USPSTF guidelines, routine mammography is not indicated for women younger than 50 years old unless they fall into a high-risk category such as women with a BRCA mutation. The USPSTF recommends biennial testing for women between the ages of 50-74 years of age. There is insufficient evidence to assess the benefits versus risk of screenings in women after the age of 75. Other groups such as the American Cancer 3 Society (ACS) and American College of Obstetricians and Gynecologists (ACOG) recommend yearly mammograms starting at age 40, continuing as long as the woman is in good health. QUESTION #5 (Case#1) A 27-year-old woman comes into your office because she heard from her friend about a vaccination against cervical cancer and would like one. She has no medical problems and has had a Mirena IUD for three years. She has an allergy to latex and penicillin. She began having sex at the age of 18 and is currently sexually active with one partner. She occasionally uses condoms. She smokes half a pack of cigarettes per day. Her mother had endometrial cancer several years ago and had a total hysterectomy. Why is the patient not a good candidate for the Gardasil vaccination? A. Age B. Sexual activity C. Mirena IUD D. Allergy to penicillin E. Family history of endometrial cancer F. Tobacco use CORRECT ANSWER: “A”—Age Gardasil is a vaccination against HPV types 6, 11, 16, and 18 approved for females ages 9 to 26. Cervarix protects against serotypes 16, 18, 31 and 45 approved for ages 10 to 25. Both are a series of three shots and recommended for females ages 11-18, optimally before sexual debut or shortly thereafter. The patient above is too old to receive the vaccination. Though vaccination before sexual debut is preferred, sexual activity (choice b) is not a contraindication to Gardasil vaccination. The other choices are not contraindications to vaccinations. FM_Cases#02:---55 yo male annual exam A 55-year-old male with no significant past medical history presents for a routine physical exam. He last saw a doctor five years ago. Social history is remarkable for a 35- pack-year tobacco history since the age of 20. He indicates that his wife and children have urged him to quit smoking for the last few months. When you ask him if he has considered quitting, he replies, "I just don't see what the big deal is!" Which stage of change best describes this patient at this time? A. Precontemplation B. Contemplation C. Preparation D. Action E. Maintenance ANSWER:--A Precontemplation Based on this man's response, it appears he has not actively considered quitting smoking despite his family's concern. All stems refer to a different stage in the 4 Transtheoretical stages of change model. Given that he has not actively contemplated quitting, the best stage to describe this patient at this time would be the Precontemplation stage and not any of the other responses. QUESTION#2 A 55-year-old male with a past medical history that includes hypertension, Chronic Obstructive Pulmonary Disease (COPD), and hyperlipidemia presents to clinic as a new patient for a general physical exam. History reveals that he has been smoking a pack of cigarettes daily since age 20. He drinks two beers daily. He is intermittently noncompliant with his medications. Review of the state immunization database reveals that the only immunization he has received as an adult was a tetanus diphtheria shot administered 12 years ago. Which of the following vaccine combinations would be most appropriate for this patient? A. Influenza, Meningococcal, and Zoster B. Influenza, Pneumococcal, and Tda C. Influenza, Zoster, and Tda D. Meningococcal, Pneumococcal, and Tda E. Meningococcal, Pneumococcal, and Zoster CORRECT ANSWER B Influenza, Pneumococcal, & Tda Because this man has a diagnosis of COPD and smokes cigarettes, both annual Influenza and Pneumococcal vaccination are indicated. Because his last tetanus immunization was over 10 years ago and because he has not had a booster pertussis shot as an adult, a one-time TdaP is recommended. At this time meningococcal vaccine is recommended for adolescents and young adults and not indicated for this patient. Zoster vaccine is recommended to all adults at age 60 or older QUESTION#3 A 55-year-old male comes to the clinic for a visit. He has read about the dangers of being overweight and inquires about which category he fits into. He is 5' 10'' (1.78 m) and weighs 220 lbs (100 kg), BMI = 31.6. Which of the following categories most accurately describes the patient based on his BMI? A. Underweight B. Ideal C. Overweight D. Obese E. Morbidly (very severely) obese QUESTION#4 A 55-year-old white male with a family history of melanoma presents to the clinic for evaluation of a skin lesion on his back which appeared three months ago. His wife first alerted him to it, hasn't noticed it change and he has not noticed any symptoms associated with it. Physical examination reveals a 7 mm uniformly black macule that is symmetrically round with sharply demarcated borders on his upper back near the right shoulder. Which of the following characteristics would most justify it being biopsied today? A. Symmetry B. Borders C. Color D. Diameter E. Location CORRECT/BEST ANSWER D.) DIAMETER Using the ABCDE mnemonic, this nevus is not Asymmetrical, does not have irregular Borders, does not display Color variation and he does not describe any Evolution or change or symptoms. The only positive is that its Diameter is 6 mm, which is considered a red flag supporting biopsy. Location is not considered a predictive factor for melanoma. QUESTION#5 A 55-year-old male with no significant past medical history and generally healthy behaviors presents to clinic for a health care maintenance exam. He says, "I'd like to get tested for all types of cancer." He does not have any family history of cancer. Review of systems is negative for any symptoms of prostate cancer, such as urinary frequency, urgency, retention, hematuria, weight loss, or back pain. Based on current US Preventive Services Task Force guidelines, which of the following is the most appropriate recommendation to give this man concerning screening for prostate cancer? A. PSA testing is recommended B. Referral for prostate biopsy under ultrasound is an option C. The benefits and risks of screening for prostate cancer are uncertain D. Recommend against PSA screening E. First, check a digital rectal examination CORRECT/BEST ANSWER D.) Recommend AGAINST PSA screening The US Preventive Services Task Force - at the time of printing, April 2014 - recommends against screening using PSA testing because the risks of harm of detecting and treating asymptomatic prostate cancer outweigh the known benefits. Digital rectal exam, prostate biopsy, and transrectal ultrasound are not recommended as screening tests either. FM_Cases#03:---INSOMNIA Ms. Marcos is a 65-year old Latina woman with a past medical history of Type 2 diabetes, hypertension, and hypercholesterolemia who presents with six months of insomnia despite self-medication with acetaminophen, diphenhydramine, and herbal remedies. She is 5' 2" and weighs 250 lbs. When considering a differential diagnosis, which one of the following is a common cause of insomnia in the elderly? A. Sleep Apnea B. Pneumonia C. Chronic sinusitis D. Asymptomatic coronary artery disease E. Hypoparathyroidism The correct answer is A, sleep apnea. Sleep apnea occurs in 20% to 70% of elderly patients. Obstruction of breathing results in frequent arousal that the patient is typically not aware of; however, a bed partner or family member may report loud snoring or cessation of breathing during sleep. Some of the other most common causes of insomnia in the elderly are: 1. Environmental problems such as noise or uncomfortable bedding which are not conducive to sleep. 2. Drugs, Alcohol, and Caffeine such as over-the-counter, alternative, and certain recreational drugs. 3. Parasomnias such as restless leg syndrome/periodic leg movements/REM sleep behavior disorder. In restless leg syndrome, the patient experiences an irresistible urge to move the legs, often accompanied by uncomfortable sensations. In periodic leg movement and REM sleep behavior disorder, the patient experiences involuntary leg movements while falling asleep and during sleep respectively. 4. Disturbances in the sleep-wake cycle such as jet lag or shift work. 5. Psychiatric disorders such as primary depression and anxiety 6. Symptomatic cardiorespiratory disease (asthma, COPD, heart failure) 7. Pain or pruritus 8. Gastroesophageal reflux disease (GERD) due to heartburn, throat pain or breathing problems. 9. Hyperthyroidism The elderly frequently do not present with typical symptoms such tachycardia or weight loss, and therefore further laboratory studies may be required to detect this problem. Mrs. Anderson is a 60-year-old white female who comes in to clinic as a walk in appointment. She is tearful and is carrying a box of tissues in her hand. She says she doesn't know why but she has been very sad of late. She reports trouble falling asleep and staying asleep. She used to be the head of her Bridge club, but quit two weeks ago and doesn't feel like going out anymore. She also says she has lost interest in walking her dog, and now just allows him to use the doggie door to let himself out. She also says she feels weak and fatigued and no longer has the energy to do her gardening or shopping. She spends most of her day on the sofa crying while watching TV. She also reports a greatly diminished appetite. She denies suicidal or homicidal ideation, but she does have a history of a previous suicide attempt following her divorce seven years ago for which she was hospitalized. A recent CBC, CMP, CXR, TSH, U/A and CT of the head were all within normal limits. How long do the above symptoms need to be present in order to make the diagnosis of Major Depressive Disorder? A. One week B. Two weeks C. Four weeks D. Five weeks E. Eight weeks Correct Answer: B Depressed mood or anhedonia and at least five of the following eight criteria must have been present for two weeks or longer. (Mneumonic = SIG E CAPS) » Sleep Insomnia or hypersomnia nearly every day » Interest: (loss of) Anhedonia (loss of interest or enjoyment) in usual activities » Guilt Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick) » Energy (decreased) Fatigue or loss of energy nearly every day » Concentration (decreased) Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others) » Appetite (increased or decreased) » Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down) » Suicidal ideation Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide Mr. Jones is an 82-year-old white male who presents to the office for his six-month chronic disease visit. His diabetes and hypertension are controlled on his usual home medications. He reports that his wife died four weeks ago, and he is now experiencing insomnia most days of the week and fatigue and loss of energy nearly every day; is not showering or shaving; has diminished concentration while playing chess with his neighbor; and is also experiencing loss of appetite but no weight loss. He denies any suicidal ideation and has no previous suicide attempts. Mr. Jones says he often hears his wife's voice while going to bed. He says he goes to church to pray and this helps him. You are trying to determine if your patient's symptoms are normal bereavement or if you should diagnose and treat him for Major Depressive Disorder (MDD). Which feature of Mr. Jones’ case would suggest MDD rather than a normal grief reaction ? A. Insomnia B. Change in appetite C. Lack of attention to hygiene D. Hearing wife's voice E. Fatigue Ms. Rogers is a 75-year-old female who was found unresponsive in her house by her neighbor who had come over to help clean her house. An empty unlabeled pill container was found next to her on the bathroom floor. She was rushed to the ER, stabilized and is now in ICU on a mechanical ventilator. Which of the following are true regarding suicide in the elderly? A. Elderly persons attempting suicide are more likely to be married and living with their spouse. B. Elderly persons attempting suicide usually report good sleeping habits. C. Suicidal behaviors increase with age, but rates of completed suicides dont. D. Approximately 75% of the elderly who commit suicide had visited a primary care physician within the preceding month, but their symptoms went unrecognized. E. Firearms are the most common means of suicide in the elderly. • Respiratory rate: 18 breaths/minute • Oxygen saturation: 95% • Blood pressure: 152/84 mmHg • Weight: 325 lbs • Body Mass Index: 41 kg/m2 Today, her physical exam is significant for thinning hair, poor dentition, a systolic murmur heard at the left upper sternal border, an obese abdomen, and bilateral knee stiffness and pain on range of motion exam. Remainder of the physical exam is within normal limits. Which laboratory tests or studies can be done to rule out medical causes of insomnia, fatigue, and depression? A. Chest-X Ray B. CBC, CMP, and TSH C. HgbA1c, lipid panel, urine microalbumin D. CT head without contrast E. MRI brain with contrast FM_Cases#04:---Sports Injury QUESTION #1 A 41-year-old male with no significant past medical history is brought to the Emergency Department after falling to the ground in the middle of a pick-up basketball game with friends. He did not lose consciousness nor hit his head when he fell. As he landed on the ball of his foot after having taken a shot, he recalls hearing a popping sound followed by immediate pain in the posterior right ankle. On physical exam, the posterior right ankle is edematous and palpation is tender. He is unable to plantarflex his right foot. What is the most likely diagnosis of his current condition? A. Ankle ligament sprain B. Calcaneal fracture C. Achilles tendon rupture D. Ankle tendonitis E. Ankle arthritis CORRECT ANSWER:--- C. Achiles Tendon Rupture This is a classical description of an acute rupture of the achilles tendon. Middle-aged males are more commonly affected than other groups. The mechanism does not describe inversion injury making an ankle ligament sprain less likely and there is no direct trauma making fracture less likely. There is no history of overuse or chronicity making arthritis and tendonitis less likely. QUESTION #2 A 19-year-old female with no significant past medical history is involved as the driver in a motor vehicle accident and brought to the Emergency Department by EMS. She is complaining of severe pain in her right lower extremity that has been worsening since the accident. In addition, she has started to notice what she describes as "burning and tingling" in her right foot. On physical exam, her right calf is edematous and tender with tense overlying skin. There is no swelling or tenderness of the right foot or ankle but the right dorsalis pedis and posterior tibial artery pulses are barely palpable. She cannot confirm light touch of the foot and cannot wiggle her toes on command. What is the next best step in the management of this patient? A. Reassurance and icepacks q 2 hours B. Immobilize leg and ankle with a cast C. Urgent EMG of the right lower extremity D. Diagnostic imaging of right foot and ankle E. Emergent fasciotomy CORRECT ANSWER:--- E. Emergent Fasciotomy This clinical scenario describes acute compartment syndrome which is a vascular emergency. Emergent fasciotomy is the treatment of choice to relieve pressure in the calf and, if not performed, the limb could be lost due to acute ischemia. While emergent radiographs of the tibia and fibula are appropriate to evaluate for co-existent fracture, x- rays of the foot and ankle are not indicated. Reassurance, ice packs, urgent EMG and immobilization are all incorrect treatments and place the patient at risk of serious permanent adverse outcome. QUESTION #3 A 21-year-old female with no significant past medical history experienced an inversion- type injury to her right ankle while playing soccer a day prior to presentation. She remembers immediate pain and swelling but was able to weight bear and limp of f the field. She has noticed some significant swelling which is mostly still present. She has been icing the ankle since the injury as her coach recommended. Pain is still present near the lateral malleolus. Physical exam reveals that the lateral right ankle is edematous with purplish bruising, bilateral pulses are good and the patient had good sensation and motor function in both feet about equally. Palpation of the posterior edge of the lateral malleolus elicits significant pain from the patient. What is the next best step in the management of this patient? A. Reassurance B. Immobilize with cast or splint C. X-ray imaging of right ankle D. Emergent fasciotomy E. Rest, ice, Ibuprofen, compression and elevation and re-evaluate in one week CORRECT ANSWER:--- C. X-rya imaging of the Right Ankle Based on the Ottawa Ankle Rules, tenderness of the lower 6 cm of the posterior lateral malleolus may predict fracture and justifies X-ray imaging of the ankle. Tenderness of the lower anterior lateral malleolus, on the other hand, is very common in ligamentous injury such that x-rays are not warranted. Because of the possibility that a fracture exists, the other treatment options are not correct in this scenario. QUESTION #4 A 22-year-old female with no significant past medical history experienced an inversion- type injury to her right ankle while playing volleyball. The ankle quickly became edematous, but she used ice and was able bear weight on the foot. When she comes to clinic two days later, there is mininmal edema, she has good motor function, and has normal sensation. She has tenderness at the anterior lower lateral malleolus but not inferiorly nor posteriorly. X-rays are not indicated. You recommend continued relative rest and also tell the patient to keep it elevated and ice it several times during the day to help with the pain and swelling. You inform the patient that immobilization and compression is good for the conservative management of her condition. What is the best compression device to use in this situation? A. Tape B. Compression stockings C. Elastic wrap D. Semi-rigid ankle support E. Solid cast CORRECT ANSWER:--- D. Semi-Rigid Ankle Support This patient apparently has a ligamentous injury to her anterior talo-fibular ligament. In recommending the RICE mnemonic, a semi-rigid ankle support (like an Air Stirrup) provides protection from repeat inversion injury while allowing the patient to actively dorsi- and plantar- flex her foot, which aids recovery. Compression stockings and elastic wrap do not provide adequate support. A solid cast completely immobilizes the ankle and delays recovery, while the evidence supporting taping of the ankle is lacking. QUESTION #5 A 20-year-old female who is a long-standing patient at this clinic with no significant past medical history presents with first-time onset of dysuria accompanied by frequency and urgency for the past day. She thinks that there is a strange odor to her urine but denies any hematuria. In addition, she feels mild lower abdominal discomfort but denies fevers, chills, nausea, vomiting, constipation, diarrhea, or costo-vertebral angle (CVA) pain. She reports no known allergies She has never been sexually active and has no vaginal discharge nor irritation. LMP was one week ago and was typical. She wonders if using a perfumed bubble bath for the first time a few days ago might have triggered her symptoms. On exam, her vital signs are stable; she has no CVA tenderness and mild suprapubic discomfort. Urinalysis of a mid-stream catch is within normal limits, and a pregnancy test on the same sample, performed despite her history, is negative. Which of the following reflects best management in this situation? A. Insist that a pelvic exam and cervical DNA probe be performed today. B. Await urine culture results before any treatment. C. Reassure that this is not a urinary tract infection. D. Trimethoprim/sulfamethoxazole (one tab twice daily for three days). E. Urine DNA probe CORRECT ANSWER:--- D. Trimethoprim/sulfamethoxazole (one tab twice daily for three days). There is very good evidence that common typical symptoms of urinary tract infection (UTI) (e.g. dysuria and frequency) with the absence of vaginal symptoms are highly predictive of UTI in young women who have no systemic symptoms. The constellation of typical symptoms outweighs a normal urinalysis. Therefore, based on the symptoms presented, the most reasonable treatment option is to treat empirically with a standard antibiotic for a short course. It is not unreasonable to send urine for culture but management does not need to wait till that result is available. While it is always prudent to consider the possibility of sexually transmitted infection in this age group, based on the information presented about an established patient, it would be inappropriate to insist on a pelvic exam or await results of a urine DNA probe in the face of such strong UTI symptoms. FM_Cases 6 QUESTION--#1 A 60-year-old Hispanic female presents to the office complaining of increased frequency of urination and fatigue for the past several months. She denies fevers, dysuria, back pain, diarrhea and abdominal pain. She has noted some weight loss without working on diet or exercise. Her past medical history is significant for hyperlipidemia and hypertension, for which she takes simvastatin and lisinopril. She is a non-smoker and consumes one to two glasses of wine per week. Her vitals are: Heart rate: 70 beats/minute Blood pressure: 130/70 mmHg Body Mass Index: 30 kg/m2 Physical examination reveals increased pigmentation in her axilla bilaterally. Her labs are as follows: Random blood glucose: 205 mg/dL Creatinine: 0.8 mg/dL TSH: 2.1 U/L. What test is needed to diagnose diabetes mellitus? A. The random blood glucose is sufficient B. Fasting blood glucose C. An oral glucose tolerance test D. HgbA1c QUESTION--#2_ The patient in the prior vignette has made a plan to work on diet and exercise. Her A1c is found to be 8.9%. What is the best medicine to start at this time? A. A sulfonylurea B. Basal insulin C. Metformin D. Basal-bolus insulin QUESTION--#3_ A 72-year-old woman with a 30-year history of Type 2 diabetes returns to your office for routine visit. She is taking 20 units of insulin glargine every morning and five units of insulin aspart with meals. The patient notes blurry vision for the past several months and a few days of dark spots in her vision. She denies headaches or nausea. What is true regarding diabetic retinopathy? A. 75% of people with diabetes only develop retinopathy 10 years after diagnosis. B. 40% of people with severe diabetes requiring insulin have retinopathy five years after diagnosis. C. Vision changes are an early sign of retinopathy. D. Primary care physicians should examine the retina on every visit for ongoing diabetes care. The correct answer is (B). The patient's symptoms describe diabetic retinopathy. Proliferative retinopathy is prevalent in 25% of the diabetes population with ≥ 25 years of diabetes, but many patients have retinopathy much earlier. Early changes of retinopathy are asymptomatic. Patients need to see an ophthalmologist regularly for a dilated retina exam, not rely on a view of the retina from primary care physicians. Abnormalities seen include macular edema ( a common cause of blurry vision) and new blood vessel formation which can leak and cause dark spots in the vision. Diabetic eye disease often can be treated before vision loss occurs. Glaucoma (causing increased intraocular pressure) is 40% more likely in people with diabetes, but usually causes nausea, headaches, and narrowing of vision or halos around lights. QUESTION--#4_ The correct answer is (D). HHS is seen typically in patients with Type 2 diabetes. It includes very high sugars 600; ph 6.4; dehydration; and lack of ketones in the urine and blood. Diabetic ketoacidosis is more common in Type 1 diabetes, and the patient will have ketone bodies in the urine. Thiamine deficiency can cause Korsakof f syndrome, and is typically seen in alcoholics with severe malnutrition, however, this patient is not a known alcoholic and doesn't appear malnourished. Despite the confusion in this patient, stroke is an unlikely diagnosis in this case given the lack of focal deficits on exam. Cardiac arrhythmia can cause dizziness, but is less likely to cause prolonged altered mental status. QUESTION--#5_ A 61-year-old female has recently been diagnosed with Type 2 diabetes. Her fasting glucose was 240 mg/dL and her A1c was 8.9%. Her BP has been 148/90 and 146/86 at two separate office visits. Her home BP measurements have been in a similar range. Her creatinine is 0.9 and she has no known heart disease. She currently takes losartan 100 mg daily for a diagnosis of hypertension. Which of the following would be the most appropriate step in managing this patient's blood pressure? A. Make no changes to her medications as her blood pressure is at goal. B. Start lisinopril daily. C. Start amlodipine daily. D. Start metoprolol daily. The correct answer is (C). Although the patient is over age 60, and the blood pressure goal is generally 150/90 mmHg, this patient has diabetes. JNC8 indicates a goal blood pressure of 140/90 mmHg for all patients with diabetes, regardless of age. While ACE Inhibitors have been historically the main first-line treatment for patients with diabetes, JNC8 does not make this specification, and allows the choice of any of the first-line treatments for hypertensive diabetic patients. These choices would include ACE inhibitors, angiotensin II receptor blockers (ARBs), thiazides, or calcium channel blockers. Beta blockers are not part of the management of hypertension, unless the patient has another indication (eg. CHF). In this case, lisinopril would not be an appropriate choice because the patient is taking an ARB (losartan) already. The combination of an ACE inhibitor and an ARB is contraindicated due to an increase in renal failure and hyperkalemia. FM_Cases 8 --- 54 yo male with elevated BP QUESTION # 1 (Case8) A 65-year-old female presents to your office for a routine visit. She is found to have a blood pressure of 146/96. You repeat the blood pressure in her other arm and get 148/92. Her pulse is 70 and regular. Her last BP reading was one year ago and was 120/76. She has no other medical problems. Her BMI is 28. She states that she likes to walk 30 minutes every other day with her husband and has been doing that for years now. At this time, the most appropriate diagnosis is... A. white coat hypertension B. elevated blood pressure C. benign essential hypertension stage 1 D. secondary hypertension QUESTION #2 (Case8) A 68-year-old male was diagnosed with benign essential hypertension a few months ago and has been working on diet and lifestyle modifications. He has a BMI of 28, mild knee arthritis but no other medical diagnoses. He has been a patient of yours for several years, and returns today as planned. Today his blood pressure is 156/94. The remainder of his cardiovascular exam is within normal limits. After counseling the patient, he agrees to start an antihypertensive medication. His creatinine is 0.9, urinalysis is normal, and electrolytes are within normal limits. Which of the following is the most appropriate medication to begin in this patient? A. Beta blocker B. Thiazide diuretic C. Nitrate D. Loop diuretic E. Clonidine QUESTION #3 (Case8) A 54-year-old male with a history of chronic gout and GERD presents to your office for his health maintenance exam. Vitals today are BP 156/92, pulse 65, respirations 10, afebrile, BMI 29. He smokes 10 cigarettes per day, does not regularly exercise, and drinks one to two beers daily, four or five times a week. He has no current concerns, review of systems is negative, and his physical exam is unremarkable. You recommend lifestyle changes. Which of the following changes is “least” likely to improve his blood pressure? A. Smoking cessation B. DASH diet C. Weight loss D. Alcohol cessation E. Increased exercise The correct answer is D. QUESTION #4 (Case8) The 54-year-old male described in the previous question returns to see you after 6 weeks. He has been largely unsuccessful making any significant lifestyle changes and continues to engage in the behaviors described. Today, his blood pressure is 158/98, and the remainder of his physical exam is unchanged. As you consider starting an anti-hypertensive medication, which of the following medications are you least likely to consider prescribing in this patient? A. Lisinopril B. Hydrochlorothiazide C. Amlodipine D. Losartan E. All are reasonable options QUESTION #5 (Case8 A 62-year-old woman presents for follow-up of her hypertension and diabetes. In general, her chronic diseases are well controlled and she has suffered no target organ damage. Her blood pressure today is 148/88, pulse is 72 and BMI is 32. She is taking metformin 500 mg twice daily, simvastatin 10 mg daily and hydrochlorothiazide (HCTZ) 12.5 mg daily, and she is compliant with her daily medications. Her labs today include an A1C of 6.6, an LDL of 88 and a basic metabolic panel within normal limits. Which of the following management steps today do you consider the least appropriate? A. Increase HCTZ to 25 mg daily B. Make no changes as she is at her treatment goals C. Intensify her dietary changes D. Add amlodipine 5 mgs daily E. Increase her simvastatin dose to 20 mg QUESTION #1 (Case 10) FM_Cases 10 The correct answer is E. QUESTION #2 (Case 10) QUESTION #3 (Case 10) ****** QUESTION #4 (Case 10) QUESTION #5 (Case 10) QUESTION #1 (C14) FM_Cases 14 A 40-year-old male presents to the clinic with dry cough and wheezing for the past two days. He states that his symptoms began two days ago with a headache for which he took aspirin. He denies fever, but does report some continued shortness of breath. He is a smoker but only smokes 1-2 cigarettes a day for about six months. Physical exam is negative except for bilateral wheezing and erythema on the face. What is the most likely diagnosis? A. COPD B. Foreign body aspiration C. Pneumonia D. Asthma E. Pulmonary embolism QUESTION #2 (C14) QUESTION #3 (C14) An 18-year-old non-smoking male comes to the clinic with cough, chest tightness, and difficulty breathing. His past medical history is positive only for allergic rhinitis as well as an undiagnosed chronic cough primarily at night since he was 4 years old. He has no past surgical history and no recent travel. On physical exam, you notice the patient appears in mild distress, has hunched shoulders, is using accessory muscles during respiration, and is only able to talk in two to three word sentences. His vitals are: Pulse 125/min, O2 sat 88%, BP 100/70 mmHg. On auscultation, you hear wheezing on inspiration and expiration throughout both lungs. You also notice a prolonged expiratory phase. What is the most likely diagnosis? A. Cystic Fibrosis B. CHF exacerbation C. Foreign body aspiration D. Severe asthma exacerbation E. Pulmonary embolism QUESTION #4 (C14) Which of the following is a comorbid condition that needs to be controlled in order to improve asthma symptoms? A. High BMI B. Insomnia C. Atopic dermatitis D. Anxiety E. Anemia QUESTION #5 (C14) A 28-year-old male comes to the Emergency Department with shortness of breath, cough and wheezing for the last 4 hours. He states that he was diagnosed with asthma recently, and is currently using inhaled corticosteroid with a long acting B2-agonist daily to control his symptoms. His RR is 34/min; Temp: 98.8 degrees F; O2sat: 88%; BP: 130/85 mmHg. What treatment should be given to this patient first? A. Albuterol breathing treatment using a nebulizer B. Intravenous corticosteroids C. Ipratropium breathing treatment using a nebulizer D. Oxygen E. Intravenous third generation cephalosporin FM_Cases 19:---39 yo MALE with Epigastric Pain **** NOT ON REQUIRED LIST, BUT STILL KNOW IT **** Questions#1 Questions#2 Mr Gill is a 27-year-old male who presents to his primary care physician with post-prandial epigastric burning. The burning is episodic, without associated hematemesis, dysphagia, or odynophagia. In the past, he has episodically used an OTC chewable calcium carbonate to provide relief. Over the past month, he has had to increase the frequency of its use to four times daily. His blood pressure is 120/71 mm Hg, heart rate at 75/min and regular. Physical exam reveals only minimal epigastric tenderness on palpation but is otherwise normal. Which of the following is the most appropriate next step in management? Choose the single best answer. A. Upper endiscopy B. H. pylori IgG serologic testing C. Fecal immunochemical testing (FIT) D. Fecal occult blood testing (FOBT) E. 8 week trial of pantoprazole The correct answer is E. This patient displays no red flag symptoms at this time. The most widely accepted initial intervention in a patient like this is empiric treatment with a histamine-2 receptor blocker or a proton pump inhibitor such as pantoprazole. Upper endoscopy would be indicated if there were alarm symptoms or if empiric therapy did not resolve symptoms. H. pylori testing might be indicated if symptoms persisted after empiric therapy. There is not a specific concern for rectal bleeding at this time, so fecal testing for blood is not indicated Questions#3 Sally is a generally healthy 27-year-old female graduate student who presented to your office twelve weeks ago with episodic post-prandial epigastric burning. This had been bothering her for nearly six months but she had been busy with her thesis and was unable to find the time necessary for an appointment. She reported this year has been particularly stressful, with limited time resulting in increased consumption of coffee and take-out fast food. At that time, she began an eight-week trial of omeprazole. She returns now with no improvement of her symptoms. She discontinued the omeprazole one month ago because she ran out of the medication. She has no additional symptoms and physical exam is unremarkable. Which of the following is the most appropriate next step in her management? Choose the single best answer A. Refer her for an upper gastrointestinal endoscopy B. Begin treatment with triple therapy of pantoprazole, clarithromycin, and azithromycin for 14 days C. Continue omeprazole for another 4 weeks with close follow up D. Administer a urea breath test E. Switch PPI from omeprazole to pantoprazole The correct answer is D. (questions#3 case 19) This patient exhibits no alarm symptoms, but does have persistent symptoms despite adequate empiric therapy. This case warrants testing for H. pylori as a cause of symptoms. One test which is sensitive and specific for H. pylori infection is the urea breath test. The antibiotic regimen listed in choice B is for treatment of H. pylori, but a diagnosis must be made before instituting such a treatment regimen. Switching PPI’s or doing a longer treatment of the same medication would not be optimal choices, since the patient hasn’t found any relief thus far with the medication. While an upper endoscopy might assist with diagnosis, it is more invasive and in the absence of alarm symptoms, a less invasive test for H. pylori (urea breath test) is acceptable. Questions#4 Mr. Rodriguez is a 32-year-old male who presents with three months of post-prandial epigastric burning. He reports no relief with antacid therapy. He has no allergies and no significant past medical history. He denies any hematemesis, odynophagia, dysphagia, hoarseness, or sore throat. Physical exam is unremarkable other than epigastric tenderness. H. pylori IgG serology is positive. Which of the following treatment regimens will most likely be successful in treating Mr. Rodriquez? Choose the single best answer A. Omeprazole daily for 8 weeks B. Omeprazole twice daily for 4 weeks C. Omeprazole twice daily, clarithromycin 500mg twice daily, and amoxicillin 1g twice daily D. Omeprazole daily, clarithromycin 500mg twice daily, and tetracycline 500mg three times daily E. Omeprazole twice daily, tetracycline 500mg three times daily, and metronidazole 500mg twice daily The correct answer is C, The eradication of H. pylori required triple or quadruple therapy. Options include twice daily dosing of a proton pump inhibitor (PPI) plus amoxicillin plus clarithromycin; a PPI once or twice daily (OR ranitidine twice daily) plus metronidazole, tetracycline and bismuth salicylate four times daily; or, for penicillin-allergic patients, twice daily dosing of a PPI plus clarithromycin plus metronidazole. Question#5 Ms. Jones is a 35-year-old female with a significant past medical history of SLE who had been on NSAID therapy for the previous three months presented four weeks ago with heartburn. At that time, she reported episodic, mealtime epigastric burning radiating to the throat for the past few months. She has had no surgeries. Serologic testing for H. pylori IgG was reported to be positive a few days after her visit and she was begun on triple therapy. She now returns to the office for follow up. Today she denies any epigastric burning or tenderness. Physical exam is not significant. Which of the following is an accepted indication for performing repeat testing at this visit for H. pylori eradication? Choose the single best answer A. Restarting of chronic NSAID therapy for SLE B. Documentation is required for all patients with confirmed H. pylori infection C. Treatment with triple rather than quadruple therapy D. Positive serologic test prior to therapy E. Age below 40 years The correct answer is A. Indications for testing for proof of H. pylori eradication include: patients with an H. pylori-associated ulcer, persistent symptoms despite appropriate therapy for H. pylori, patients with H. pylori-associated MALT lymphoma, history of resection for early gastric cancer, and patients planning to resume chronic NSAID therapy. Documentation of eradication is NOT required for all patients who have tested positive FM_Cases 21:---12 yo FEMALE with Fever Questions#1 13- year-old girl comes to your clinic stating she has been having fever and chills for three days, and aching muscles for the last two days. She states she has also had a mild cough, but is not having any difficulty with breathing. She is up to date on vaccines and her only other medical history is having her tonsils and adenoids removed last year. On physical exam, you find her temperature to be 102.6 degrees F, pulse 96, and her BP to be 115/84. She has clear rhinorrhea and her oropharynx is mildly erythematous. The rest of her physical exam is normal, and a rapid strep test in the office is negative. A. Zanamavir B. Aspirin C. Ibuprofen D. Amantadine E. Albuterol Questions#2 Questions#3 The correct answer is A. McIsaac Decision rule allows you to calculate the need for various interventions in a patient who presents with signs/symptoms of strep throat. One point is assigned each for fever greater than • 38.0 (100.4F) degrees Celsius, • absence of cough, • tonsillar exudates, • cervical lymphadenopathy, and • age less than 15-years-old. One point is removed for age older than 45-years-old. After adding up the total points for this patient, he is found to have a score of 4, even without tonsillar exudate (see table below), and should therefore receive empiric antibiotics. Of the choices, Amoxicillin is first line therapy for strep throat. Ordering a throat culture would also be correct if that were an option Questions#4 The correct answer is E. McIsaac Decision rule allows you to calculate the need for various interventions in a patient who presents with signs/symptoms of strep throat. One point is assigned each for fever greater than 38.0 degrees Celsius, absence of cough, tonsillar exudates, cervical lymphadenopathy, and age less than 15 years old. One point is removed for age older than 45 years old. Her total points is 4 for temp, cervical lymphadenopathy, no cough, and tonsillar exudates, minus 1 point for age 45. This gives you a total score of 3, indicating the need for rapid strep test to guide further treatment (see chart above) Questions#5 The correct answer is C. Risk factors for complications of Influenza are children 5 years, increased in children less than 2 years of age, COPD, conditions that affect the ability to handle respiratory secretions/increased risk of aspiration, CHD, metabolic conditions, Chronic Renal Disease, Immunosuppression, and Long term aspirin therapy. FM_Cases 28---58 yo Male with S.O.B. QUESTIONS #1 The correct answer is E; pulmonary hypertension causing right heart failure. Chronic hypoxia causes pulmonary vasoconstriction that increases blood pressure in the pulmonary vessels. This elevation in blood pressure causes permanent damage to the vessel walls and leads to irreversible hypertension. The right heart eventually fails because the pump cannot sustain flow effectively against this pressure. Right heart failure leads to an increase in preload, with peripheral edema and increased jugular venous distention QUESTIONS #2 QUESTIONS #3 QUESTIONS #4 QUESTIONS #5 FM_Cases 29---73yo Male with Dementia QUESTION#1 The correct answer is C. Ms. Martinez has a normal mini mental status exam, her exam findings are normal with the exception of her affect. This suggests a mood disorder. As there is nothing in the history to suggest a recent loss, bereavement is not likely. QUESTION#2 QUESTION#3 QUESTION#4 QUESTION#5 FM_Cases_CLIPP02:---Infant Well Child (2,6,9months) Questions#1 You are seeing a 36-month-old boy for his well-child visit. His parents are anxious about ensuring that his development is appropriate. He passed a hearing screen at birth and, other than a few colds, has been generally healthy. He has never been hospitalized or had any serious illness. He is able to run well, walk up stairs, and walk slowly down stairs. He uses more words than the parents are able to count, but can use them only in short, two or three-word sentences. His speech is understandable. He can draw a circle, but not a cross. Neurologic examination shows normal cranial nerves, normal sensitivity, normal motor reflexes, and no Babinski sign. Which of the following is the most appropriate next step in the management of this patient? A. Perform a brain-stem auditory evoked potential hearing screen B. Perform a screening exam for autism C. Reassure the parents that the boy's development appears normal D. Refer the child to a developmental specialist for comprehensive evaluation E. Refer the child to a specialist for evaluation of his delayed motor development Questions#2 Sammy is a healthy male child brought into your office by his mother for a well-child examination. As part of your evaluation you assess his developmental milestones. He is able to run, make a tower of 2 cubes, has 6 words in his vocabulary, and can remove his own garments. What would you estimate Sammy's age to be based upon his developmental milestones? A. 12 months B. 15 months C. 18 months D. 30 months E. 36 months Correct Answer:------“C” has been selected by the expert. A. At age one year, gross motor skills include pulling to stand, standing alone, and perhaps first steps. Fine motor skills including putting a block in a cup and banging 2 cubes held in hands. At this age a child should be able to imitate vocalizations/sounds and babble. The majority of children this age will know 1 or 2 words in addition to "mama" and "dada." Social- emotional milestones at age one year are waving bye-bye and playing pat-a-cake. Running, building towers of blocks, removing clothing, and a 6-word vocabulary are more advanced skills than a 12-month-old would be expected to have. B. At 15 months of age, a child should be able to stoop and recover and walk well, put a block in a cup, have a vocabulary of a few words, wave bye-bye, and drink from a cup. Running, building towers of blocks, removing clothing, and a 6-word vocabulary are more advanced skills than a 15-month-old would be expected to have. C. At 18 months, a child should be able to walk backward, and 50-90% of children can run at this stage. An 18-month-old should be able to scribble, build a tower of 2 cubes, have 3-6 words in her or his vocabulary, and be able to help in the house and remove garments. D. At 2 ½ years of age, kids can jump up and throw a ball overhand. They can build a tower of 6-8 cubes, point to 6 body parts, name 1 picture, put on clothing, and wash and dry their hands. Sammy is only able to build a tower of 2 cubes, can remove his clothing but does not yet put clothing on, and his vocabulary is limited to 6 words-leading us to believe he is not 2 ½ years old. E. At age 3, children can balance on each foot for 1 second, wiggle their thumbs, name 4 pictures, name 1 color, name a friend, and brush their teeth with help. Sammy's vocabulary is only 6 words, he is not able to name a friend, he is only able to stack 2 cubes, and he has just starting running, but is unable to balance on each foot for 1 second. Questions#3 Mark is a 5-month-old male who is brought to the urgent care clinic with a three- day history of rhinorrhea and non-productive cough. When he was born he was large for gestational age, and his exam then was notable for macrocephaly, macroglossia, and hypospadias. On physical exam now his vitals signs are stable. He has copious nasal discharge, but his lungs are clear to auscultation. On abdominal exam, you palpate an abdominal mass on the right side just below the subcostal margin. It is 7 cm in diameter and does not cross the midline. The abdomen is soft and non-tender with active bowel sounds. What is the most likely cause of his mass? A. Wilms' tumor B. Teratoma C. Renal cell carcinoma D. Hepatoblastoma Questions#4 An asymptomatic, healthy 9-month-old female is found to have a palpable RUQ mass on exam. After further imaging and lab studies, the mass is diagnosed as a neuroblastoma that has involvement in the bone marrow as well. The mother is worried about the prognosis. Which of the following is true about the prognosis of neuroblastoma in this child? children A. Lymph node involvement is a poor prognostic factor B. Prognosis of neuroblastoma is predictable C. Children who are older than 12 months have a better prognosis than younger D. Favorable histology does not play a role in prognosis E. Non-amplification of the n-myc gene is a favorable prognostic factor. Correct Answer:--- “E” has been selected by the expert. A. Due to the effectiveness of chemotherapy, neuroblastomas with lymph node involvement are still considered favorable, especially in the setting of other favorable factors, such as young age and differentiating histology. Though distant metastasis is a significant poor prognostic factor, regional lymph nodes do not significantly affect the outcome. B. Neuroblastoma has a broad spectrum of clinical courses. Some tumors may spontaneously regress, some may mature to a benign type, and yet other tumors can be very aggressive with metastases. Age plays a role in the prognosis, as most infants have a good prognosis even with disseminated disease, while infants over 18 months of age do not do as well. C. In infants less than one year of age, neuroblastoma tumors may spontaneously regress. Stage 4S neuroblastoma is a special category that is reserved for infants less than 12 months who have resectable primary tumors and metastases to the liver, skin, and bone marrow. Overall survival is over 85 percent for babies over 6 weeks of age with Stage 4S. D. Favorable histology is a good prognostic factor in neuroblastoma, and is based on the differentiation of the cells involved. E. Non-amplification of the n-myc gene is one of the favorable genetics in neuroblastoma. Questions#5 A 9-month old baby boy comes to the clinic for a well child visit. The child is at the 50th percentile for weight, length, and head circumference. He is reaching all developmental milestones appropriately. The mother has no concerns at this visit. The child has previously received the following vaccines: 3 doses of DTaP, 3 doses of Hib, 2 doses of HepB, 3 doses of RotaV, 2 doses of IPV and 3 doses of PCV13, and no influenza vaccines. Which vaccines should the child receive at today's visit? A. Influenza, Hep B, IPV, DTaP B. Influenza, IPV C. Influenza, Hep B, IPV D. Hep B, DTaP, IPV E. Hep B, IPV, and MMR Questions#6 A 10-month-old asymptomatic infant presents with a RUQ mass. Work-up reveals a normocytic anemia, elevated urinary HVA/VMA, and a large heterogeneous mass with scant calcifications on CT. A bone marrow biopsy is performed. Which of the following histologic findings on bone marrow biopsy is most consistent with your suspected diagnosis? A. Sheets of lymphocytes with interspersed macrophages B. Small round blue cells with dense nuclei forming small rosettes C. Hypersegmented neutrophils D. Stacks of RBCs E. Enlarged cells with intranuclear inclusion bodies FM_Cases_CLIPP_13:---6 year old with chronic cough QUESTIONS#1: A 4-year-old boy who recently emigrated from eastern Europe presents with his mother to your general pediatrics clinic. His mother reports that he has a chronic nonproductive cough during the day and night, mild wheezing for one month and failure to gain weight (his weight has dropped from the 50th to the 10th percentile for his age). His mother denies any high fevers, rhinorrhea, or night sweats. Which of the following are the next best diagnostic tests? A. Chest x-ray and tuberculin skin test B. CT of nasal sinuses C. Spirometry, before and after bronchodilator therapy D. Chest x-ray and methacholine challenge E. None needed, patient likely has habitual cough Correct Answer = A has been selected by the expert. A. CXR and tuberculin skin test (TST) is the best choice. Signs and symptoms of primary pulmonary tuberculosis are few to none. Toddlers may present with nonproductive cough, mild dyspnea, wheezing, and/or failure to thrive (defined as weight 5th percentile or drop in two percentile curves for weight). In children, TB can present without systemic complaints (fever, night sweats, and anorexia), severe cough, and sputum production. Regarding diagnostic tests, the TST is a practical tool for diagnosing TB infections. All children with chronic cough (more than three weeks) should be evaluated with a chest x-ray, as other pathology-such as lung abscess or malignancy-can also be detected on CXR. B. Sinusitis is often preceded by a URI, with nasal congestion as a prominent feature, leading to nocturnal cough due to post-nasal drip. These symptoms are not seen in our patient. Furthermore, a diagnosis of sinusitis is made clinically, with CT scan obtained only in complicated cases or cases resistant to treatment. Complications include cavernous sinus thrombosis, meningitis, and epidural abscess. C. Spirometry (pulmonary function testing) before and after bronchodilator therapy is the most specific means of determining whether or not a child has reactive airways. Asthma is a very common diagnosis in pediatrics, and may present with cough that is worse at night and exacerbated by exercise and cold air. Patients with cough-variant asthma present with only cough, typically nonproductive. However, given this patient's failure to thrive, a more serious diagnosis such as TB must be considered. Also, a chest x-ray is needed in all children with chronic cough (more than three weeks). D. Although a chest x-ray is appropriate in all children with chronic cough, a methacholine challenge (for asthma) would be inappropriate in this scenario. Although asthma is a common diagnosis, given the patient's failure to thrive, a more serious diagnosis must be considered. Further, a methacholine challenge is reserved for cases in which asthma is suspected and spirometry is normal or near normal, and should be performed by trained individuals. E. Habitual cough is caused by habitual perpetuation of a cough that begins with a viral URI. Continued coughing further irritates the airway, leading to stronger stimulation to cough. The cough is typically very loud, short, dry, brassy, and spasmodic. This cough is unchanged by exercise or cold air, and classically resolves during sleep. Although the patient in this case has a dry cough, his failure to thrive points to a more serious diagnosis (e.g., TB). All children with chronic cough (persisting longer than three weeks) need a CXR. QUESTIONS#2: An 11-year old boy presents to clinic with wheezing. Mom states that in the past he has used inhaled albuterol and it has helped with wheezing and shortness of breath. On further history you find out that the patient experiences shortness of breath three times a week and is awakened at night by these symptoms once a week. What is the most appropriate outpatient therapy? A. Only rescue inhaler PRN B. Low dose inhaled corticosteroids C. Medium dose inhaled corticosteroids and course of oral corticosteroids D. Medium dose inhaled corticosteroids, LABA, and course of oral corticosteroids E. Course of oral corticosteroids Correct Answer = “ B “ B. Low dose inhaled corticosteroid is correct because this patient has mild persistent asthma. His symptoms occur 3-6 days/week and 3-4 nights/month. QUESTIONS#3: A 4-year-old patient presents with several months of cough. Mom also reports a history of red skin patches, which are pruritic, and allergies to peanuts, eggs, and mangoes. Which of the following would be characteristic of the cough that this patient would present with? A. Does not awaken patient from sleep B. Paroxysmal C. Barking cough D. Worse at night E. Associated with crackles on exam D. This choice is correct. Asthma frequently presents with nighttime exacerbations. The cough often presents with wheezing and is usually a dry cough. QUESTIONS#4: A 9-year-old male presents to your clinic with discoloration under his eyes, persistent cough, and skin rashes. He is found to have wheezing on physical exam and increased lung volume bilaterally on chest x-ray. He has struggled with these complaints over the past three years but recently his symptoms have gotten worse, affecting him every other day. He is afebrile. He is found to have wheezing on physical exam and increased lung volume bilaterally on chest x-ray. What would be the most appropriate treatment for him? A. Oral antibiotics B. Short-acting beta agonist PRN C. Short-acting beta agonist PRN with low-dose inhaled corticosteroid D. Short-acting beta agonist PRN with medium-dose inhaled corticosteroid E. Long-acting beta agonist QUESTIONS#5: A 10-year-old male comes to the clinic with a chief complaint of progressive cough for two weeks that began gradually. His cough is described as productive and wet with whitish sputum. His mother denies throat pain, vomiting, and diarrhea in his review of systems. His mother reports that he has been febrile up to 101.5°F daily. She thinks he is fatigued and has not eaten well in the past week. On exam, there is air passage throughout all lung fields, with crackles in the lower right lung field, but no other abnormal sounds. What would you likely find in your workup? A. Response to inhaled beta-agonist B. Hyperinflation in one lung field C. Alevolar consolidation in the RLL D. Positive PCR for pertussis E. Fluffy bilateral infiltrates and a large heart on chest x-ray CORRECT ANSWER = “C” has been selected by the expert. A. Response to an inhaled beta agonist is a good test for RAD or asthma. Asthma is diagnosed clinically, usually in a school-aged child, with a history of recurrent wheezing. Associated findings might atopic stigmata, such as allergic rhinitis, food allergy, and atopic dermatitis. Without details in the history, asthma is a less likely diagnosis in this setting, and in the absence of wheezing, asthma is even less likely. B. This would be consistent with a foreign body aspiration which could produce cough and fever (if bacterial superinfection occurs). This diagnosis is usually considered in younger children. Constitutional symptoms (fatigue, decreased eating) make pneumonia a better diagnosis in this clinical setting. C. Pneumonia is the most likely cause for his symptoms and a chest x-ray would be a great confirmation of your suspected diagnosis. Eliciting a complete history might reveal history of an upper respiratory infection. Localization of crackles (discontinuous inspiratory sounds) to one lobe makes pneumonia more likely. D. Pertussis can produce a lengthy cough illness, but is not associated with fever or lung findings. E. Pulmonary edema due to CHF is a symmetrical process and less likely to present with a unilateral lung finding. Pulmonary edema should be suspected with crackles, but this clinical setting leaves pulmonary edema low on our differential. FM_Cases_31:---66 yo with S.O.B.- --(CHF) QUESTIONS#1 (Case#31) Correct Answer = B.) Female Sex QUESTIONS#2 (Case#31) QUESTIONS#3 (Case#31) QUESTIONS#4 (Case#31) QUESTIONS#5 (Case#31)