Chronic Contitions A

Chronic Conditions
Answers
343. The answer is d. (South-Paul, pp 182-189.) The sexual response is

divided into four phases. The first is libido (or desire/interest). This phase
requires androgens and an intact sensory system. The second phase is
arousal (or excitement) and in men, involves erection. Vascular arterial or
inflow problems are by far the most common cause, though mood disor-
ders, stressors, and alcohol abuse may all play a role. Lack of attraction to
a partner would represent a disorder of desire, not arousal.
344. The answer is b. (South-Paul, pp 182-189.) In patients with

decreased sex drive, laboratory workup should be directed by the history
and physical examination findings. In a patient with no other complaints
and no physical examination findings, assessment of hormone status is
indicated. Testosterone levels should be checked in the morning, when
they peak. Free testosterone is a more accurate measure of androgen status,
as it is a measure of bioavailable testosterone. The TSH and prolactin levels
may be indicated in the presence of other complaints or physical findings.
PSA would not be helpful.
345. The answer is e. (South-Paul, pp 182-189.) Tricyclics and SSRIs fre-

quently cause sexual dysfunction. Bupropion actually decreases the orgasm
threshold and is least likely to cause sexual dysfunction.
346. The answer is b. (South-Paul, pp 182-189.) Premature ejaculation is

the most common sexual dysfunction in men, affecting about 29% of the
general population. Alprostadil is used for erectile dysfunction, but would
not positively affect premature ejaculation. Fluoxetine raises the thresh-
old for orgasm, making it an effective treatment option. Bupropion and
silendafil may decrease the orgasmic threshold and might be problematic.
Atenolol may cause erectile dysfunction, but would likely not treat prema-
ture ejaculation.
268
Chronic Conditions Answers 269
347. The answer is c. (Mengel, pp 744-759.) In men with erectile disor-

ders, obtaining a morning serum-free testosterone is appropriate. If the
level is low, the workup should continue before testosterone replacement is
considered. The next step is to obtain a FSH, LH, and prolactin level. If the
FSH and LH are low, but the prolactin is normal, the diagnosis is pituitary
or hypothalamic failure. If the FSH and LH are high and the prolactin is
normal, the diagnosis is testicular failure. If the FSH and LH are low, but
the prolactin is high, there is up to a 40% chance that the patient has a
pituitary adenoma and a CT or MRI should be ordered. A penile brachial
index can be performed to evaluate for significant vascular disease in
patients with ED, but it would not help you in following up for a low
testosterone level. The nocturnal penile tumescence evaluation would be
done to eliminate psychologic factors that inhibit arousal in the setting of
ED, but would also not help follow up an abnormal testosterone level.
348. The answer is a. (Mengel, pp 744-759.) Diagnostic and Statistical Man-

ual of Mental Disorders, 4th edition (DSM IV) classifies sexual dysfunctions
as sexual desire disorders, sexual arousal disorders, orgasmic disorders, or
sexual pain disorders. The manual describes classic symptoms of hypoac-
tive sexual desire disorder, something experienced by 15% of men and
33% of women for at least 1 of the past 12 months. Most commonly, this
is a result of relationship problems, but a growing body of evidence does
suggest androgen deficiency may play a role in some women. This would
need to be confirmed with laboratory testing. Sexual aversion disorder is
an extreme aversion to and avoidance of genital contact with a sexual part-
ner. Sexual arousal disorder refers to the inability to maintain an adequate
physiologic sexual excitement response. Dyspareunia refers to genital pain
associated with intercourse.
349. The answer is a. (Mengel, pp 744-759.) Treatment for sexual dys-

function has been studied in many settings by many people. The most
effective treatment program found to date for women with primary organsic
dysfunction is directed self-stimulation. Beginning with basic education in
anatomy and physiology, women progress through the stages of tactile and
visual self-exploration and manual stimulation. The stop-start technique is
a treatment program for premature ejaculation in men. Group therapy can
help counteract sexual myths and correct sexual misconceptions, but gen-
erally is not used for orgasmic dysfunction. Hypnotherapy may be helpful
in situations where relaxation interferes with sexual functioning. Sensate
270 Family Medicine
focus involves guided touch of a partner in areas other than the genital
area. This is helpful for couples therapy.
350. The answer is c. (Mengel, pp 644-654.) Most clinicians agree that

psychiatric disorders cannot be reliably assessed in patients who are cur-
rently or recently intoxicated. Alcohol is a depressant and may be the main
factor in the patient’s depressive symptoms. Detoxification and a period
of abstinence are necessary before an evaluation for other psychiatric dis-
orders can be effectively completed. It would be premature to treat his
depression with a medication until the patient is abstinent.
351. The answer is d. (Mengel, pp 644-654.) Most people who abuse alco-
hol have completely normal laboratory studies. However, of the tests listed
in the question, the GGT is the most sensitive. Elevated GGT is shown to
be more sensitive than an elevated MCV, ALT, or AST. The specificity of the
GGT is low; however, it is elevated in nonalcoholic liver disease, diabetes,
pancreatitis, hyperthyroidism, heart failure, and anticonvulsant use. The
ratio of AST:ALT may help distinguish between alcohol and nonalcohol-
related liver diseases, with a ratio of more than 2:1 highly suggestive of
alcoholic liver disease. The Ethyl glucuronide (EtG) urine test has recently
become popular. It detects recent alcohol consumption, but says nothing
about the level of consumption or abuse. Its value is in the monitoring of
those patients who are committed to abstinence.
352. The answer is a. (South-Paul, pp 614-625.) An elevated MCV is 96%

specific for alcohol abuse with a 63% predictive value. The GGT is 76%
specific with a predictive value of 61%. AST, ALT, and LDH are less specific
and have a worse predictive value.
353. The answer is b. (Mengel, pp 644-654.) Drugs used for addiction

work in one of four ways. They either cause the body to have a negative
reaction to an ingested drug, reduce the reinforcing effects of an ingested
drug, block the effects of the drug by binding to the receptor site, or satu-
rate the receptor sites with agonists that do not create the drug’s desired
effect. Naltrexone is known to be helpful for both opiate addiction and
alcohol addiction. Naltrexone saturates opiate receptor sites and leaves
them unavailable for opiate attachment. For alcohol abuse, naltrexone
works differently, reducing the reinforcing effect of alcohol (not allowing
patients to become “drunk”).
354. The answer is a. (Mengel, pp 644-654.) Disulfiram cause the body

to have a negative reaction to ingested alcohol, regardless of the form. As
such, it is a deterrent. The reaction to alcohol that occurs is manifested by
flushing, nausea, and vomiting. Importantly, alcohol in cough medicines,
mouthwashes, and other forms must be avoided, as the reaction does not
discriminate based on from where the alcohol comes.
355. The answer is d. (South-Paul, pp 614-625.) Disulfiram, naltrexone,

SSRIs, and acamprosate are currently used to prevent relapse of alcohol-
ism. Although the goal of abstinence cannot be met by medication alone, in
selected patients, it may improve chances for recovery. Acamprosate seems
to be the most effective of these medications. It affects both γ-aminobutyric
acid (GABA) and glutamine neurotransmission, both of which are impor-
tant in alcohol’s effect on the brain. The effects of this medication appear
to be greater and longer-lasting than naltrexone. The addition of disulfiram
can increase the effectiveness of acamprosate alone.
356. The answer is a. (South-Paul, pp 626-633.) Nicotine-replacement

therapy increases the chance that a smoker will quit. Using two forms of
nicotine replacement, like a patch and a gum, allows a baseline level of
nicotine to be in the patient’s system and allows for a bolus during times
of craving. This improves quit rates and is recommended if other forms of
nicotine replacement are ineffective alone.
357. The answer is c. (South-Paul, pp 614-625.) Varenicline is a selective

nicotinic receptor partial agonist. There are no known drug interactions,
and it is largely excreted in the urine. Dose modifications would be needed
in people with severe renal disease. Common side effects include nausea,
insomnia, and abnormal dreams. It is safe in persons with seizure disor-
ders, though bupropion is not. Varenicline is taken for 1 week before the
quit date, and therefore can be taken while a person is still smoking.
358. The answer is d. (South-Paul, pp 614-625.) Behavioral intervention

alone is an option for this patient, but you would at least double his suc-
cess rate if you add medication to this. First-line therapies include nicotine
replacement, bupropion, and varenicline. Nicotine replacement should be
used with caution when working up unstable angina. His seizure disorder
contraindicates the use of bupropion. Clonidine is not approved by the
Food and Drug Administration (FDA) for smoking cessation, but several
272 Family Medicine
studies have shown that it doubles the rate of abstinence. Clonidine

represents a second-line therapy for those who have failed the first-line
therapies.
359. The answer is c. (Bope, pp 1118-1122.) Stopping cocaine use does

not produce a significant physiologic withdrawal. Intoxication with
cocaine does produce elevated heart rate and blood pressure. The most
common problem produced by cocaine withdrawal is known as a “crash.”
The crash is characterized by extreme fatigue and significant depression.
Relapse is common during the crash because return to use provides quick
and reliable relief. Paranoia and insomnia are not recognized as symptoms
of cocaine withdrawal.
360. The answer is c. (Bope, pp 1118-1122.) Opiate withdrawal is well-

characterized, and although not life-threatening in otherwise healthy
adults, can cause severe discomfort. Symptoms from a short-acting drug
like heroin can occur within just a few hours. Withdrawal from longer-
acting opiates may not cause symptoms for days. Early symptoms include
lacrimation, rhinorrhea, yawning, and diaphoresis. Restlessness and irrita-
bility occur later, with bone pain, nausea, diarrhea, abdominal cramping,
and mood lability occurring even later.
Cocaine does not have a significant physiologic withdrawal syn-
drome, but craving is intense. Marijuana-withdrawal syndrome is also not
physiologically significant. Ecstasy can be considered a hallucinogen or a
stimulant, and withdrawal is often associated with depression, but not the
symptoms described above. Benzodiazepine withdrawal mimics alcohol
withdrawal and is associated with hypertension, tachycardia, and possibly
seizures.
361. The answer is a. (South-Paul, pp 233-248.) The picture shown

demonstrates Heberden nodes (at the distal interphalangeal joints) and
Bouchard nodes (at the proximal interphalangeal joints). These abnormali-
ties are commonly classified as osteoarthritis, but are only infrequently
associated with pain or disability. Laboratory evaluation will only rarely
show an inflammatory process, and an elevated uric acid level would be an
incidental finding.
362. The answer is b. (South-Paul, pp 233-248.) Osteoarthritis is charac-

terized as being pauciarticular. The pain is worse with activity and improved
with rest. There is often mild swelling, but warmth and an effusion are
rare. Crepitus is common, as is malalignment of the joint. RA tends to be
polyarticular and symmetric. Morning stiffness improves with activity. Gout
is abrupt in onset and monoarticular. Tendonitis and fibromyalgia are not
associated with joint swelling and crepitus.
363. The answer is c. (South-Paul, pp 233-248.) The patient’s history is

consistent with an attack of gout. The most common presentation of gout
is podagra (an abrupt, intense inflammation of the first MTP joint), but any
joint can be affected. It is characterized by an abrupt onset of monoarticular
symptoms with pain at rest and with movement. The attacks often occur
overnight, after an inciting event (excessive alcohol or a heavy meal). The
sufferer often cites exquisite pain, with even slight pressure on the joint
being quite painful. Osteoarthritis and RA would not occur so abruptly. A
stress fracture would likely not be as painful at rest, and cellulitis would
generally not be as abrupt or painful. Septic arthritis and gout may be clini-
cally indistinguishable, unless the joint fluid is analyzed.
364. The answer is e. (South-Paul, pp 233-248.) RA is characterized by

gradual, symmetric involvement of joints, with morning stiffness. Hands and
feet are usually involved first, but it may spread to larger joints. Fatigue is
a common complaint. On examination, symmetric swelling and tenderness
are common, with associated rheumatoid nodules. In the past, most people
treated the symptoms of RA with nonsteroidals until they were ineffective,
then used steroids for flares and sometimes opiates for pain. When they could
no longer manage the symptoms, primary care doctors referred the patients
to a rheumatologist. Unfortunately, this approach did not help the patients
slow the progression of their disease. The most important advancement in the
treatment of RA has been the introduction of disease-modifying antirheumatic
drugs (DMARDs). These agents not only control patient symptoms but sup-
press the underlying factors that result in synovitis, tissue reactivity, erosions,
subluxations, and other complications. These should be managed by rheuma-
tologists and started early to avoid or delay joint deformity. Therefore, early
referral to rheumatology is the best way to approach the patient with RA.
365. The answer is e. (South-Paul, pp 233-248.) Oral steroids have a strong

potential for ulcer formation, and although they may offer temporary relief,
would not be indicated for chronic osteoarthritis. Another steroid injection
would be of limited benefit, and most recommend no more than two
274 Family Medicine
injections per year to avoid hastening of the osteoarthritic process. Ketorolac

is not indicated for intra-articular injection. Hyaluronic acid injections
have been shown to provide symptomatic relief in osteoarthritis for up to
6 months, but given the malalignment demonstrated in his x-ray, knee
replacement would likely be more beneficial. Indications for replacement
include poorly controlled pain despite maximal therapy, malalignment, and
decreased mobility or ambulation.
366. The answer is d. (South-Paul, pp 233-248.) An evaluation of the joint

aspirate is strongly recommended to establish the diagnosis of gout. It is
critical to differentiate gout from infectious arthritis which is a medical
emergency, and a joint aspirate will do this rapidly and accurately. The
sedimentation rates and C-reactive protein are both nonspecific. Serum
uric acid levels can be normal or high in the setting of acute gout. A 24-hour
urine collection may help determine the most effective treatment for gout,
but is not needed for diagnosis.
367. The answer is b. (South-Paul, pp 233-248.) The crystals typical of

gout are needle-shaped and have negative birefringement. The crystals of
pseudogout are rhomboid-shaped and demonstrate positive birefringe-
ment. Infectious arthritis, osteoarthritis, and RA would not present with
crystals in the joint aspirate.
368. The answer is c. (South-Paul, pp 233-248.) Infectious arthritis, gout,

and pseudogout may all be associated with cloudy joint aspirate fluid. The
aspirate fluid obtained from a gout or pseudogout flare may also have a
WBC count of 50,000/mm3 with a high proportion of PMN leukocytes.
However, glucose levels fluid aspirated from a knee with gout or pseudog-
out would be normal.
369. The answer is d. (South-Paul, pp 233-248.) Fluid aspirated from

an osteoarthritic knee is characterized by generally clear joint fluid with
a WBC count of 2000/mm3 to 10,000/mm3. The distinguishing factor
is the PMN leukocytes. In rheumatoid arthritis, more than 50% of the
WBCs are PMNs, while in osteoarthritis, less than 50% of the WBCs are
PMNs.
370. The answer is a. (South-Paul, pp 233-248.) While a short course of

NSAID is one standard therapy for gout, another is a course of colchicine.
Colchicine is given orally, one tablet every 1 to 2 hours until pain is con-
trolled or side effects limit its use (the usual side effect is diarrhea). Most
attacks respond to the first two or three pills, and the maximum number
used in a 24-hour period is six. Corticosteroids can provide quick relief,
but should be reserved if initial therapy fails. Opiates may control pain, but
will not lead to resolution of the inflammation. Allopurinol and probenecid
are effective treatments for prevention, but should be used cautiously, as
they can precipitate a flare.
371. The answer is a. (South-Paul, pp 233-248.) Extra-articular manifesta-

tions of RA can be seen at any stage of the disease. Most common are rheu-
matoid nodules that can occur anywhere on the body, but usually subcuta-
neously along pressure points. Vasculitis, dry eyes, dyspnea, or cough can
all be seen. Cough and dyspnea may signal respiratory interstitial disease.
Cardiac, GI, and renal systems are rarely involved. When a neuropathy is
present, it is generally because of a compression syndrome, not as an extra-
articular manifestation of the disease.
372. The answer is b. (McPhee, pp 240-256.) Asthma is common, affect-

ing approximately 5% of the population. While there is a genetic compo-
nent to its development, the strongest identified predisposing factor for its
development is atopy. Obesity is increasingly being recognized as a risk
factor as well. Nonspecific predictors include exercise, upper respiratory
infections, pneumonia, gastroesophageal reflux disease, changes in weather,
stress, and exposure to environmental smoke.
373. The answer is a. (McPhee, pp 240-256.) The most important com-

ponent in the diagnosis of asthma is history. Patients with asthma typically
have recurrent episodes of wheezing, but not all asthma includes wheezing,
and not all wheezing is asthma. Cough is the only symptom in cough-variant
asthma. Allergy testing may help to identify specific allergens, but is not
useful in diagnosing asthma. A chest x-ray is useful to rule-out other causes
of cough or wheezing, but is not needed to diagnose asthma. Pulmonary
function testing is usually confirmatory, not diagnostic. Provocative testing
is indicated for the rare patient in whom the diagnosis is in question, but
should be used cautiously, as life-threatening bronchospasm may occur.
374. The answer is c. (South-Paul, pp 274-288.) Asthma is classified by

its severity, and by assessing daytime and night-time symptoms. Patients
276 Family Medicine
with symptoms less than twice a week, with brief exacerbations, and with
night-time symptoms less than twice a month are classified as having “mild
intermittent” asthma. There is no “moderate intermittent” classification.
The “mild persistent” classification refers to symptoms more than twice a
week but less than once a day, with symptoms that sometimes affect usual
activity. Night-time symptoms occur more than twice a month. The “mod-
erate persistent” classification is characterized by daily symptoms and use
of short-acting inhaler, with exacerbations that affect activity and may last
for days. Night-time symptoms occur at least weekly. “Severe persistent”
asthma is characterized by continual symptoms that limit physical activi-
ties, with frequent exacerbations and night-time symptoms.
375. The answer is d. (South-Paul, pp 274-288.) The patient described in

this question fits the “moderate persistent” classification, characterized by
daily symptoms and use of short-acting inhaler, with exacerbations that
affect activity and may last for days. Night-time symptoms occur at least
weekly.
376. The answer is c. (South-Paul, pp 274-288; McPhee, pp 240-256.) Peak

flow measurements parallel the FEV1 and are an easy and inexpensive way
to monitor asthma control. The peak flow “zone system” allows patients’
to monitor their control and participate in the clinical decision-making
around their illness. Measurements between 80% and 100% of the patient’s
personal best are in the “green zone,” and indicate that the patient is doing
well. Measurements between 50% and 80% of the personal best are in the
“yellow zone,” and are a warning to consider a step-up in therapy (review
of medication technique, adherence, and environmental control, or use
additional medication). Measurements below 50% of the personal best are
an indicator that the patient needs immediate medical attention.
377. The answer is c. (McPhee, pp 240-256.) In 2007, the National Asth-

ma Education and Prevention Program released its third expert panel re-
port providing guidelines for the diagnosis and management of asthma.
It includes a stepwise approach to increasing intensity of therapy based
on various components of control and indicators of impairment. In this
case, the patient is not well-controlled, and requires a step-up in treatment.
Inhaled corticosteroids are preferred first-line agents for all patients with
persistent asthma. The addition of an inhaled corticosteroid in this patient
will likely decrease her use of the rescue inhaler and decrease nighttime
symptoms. Changing short-acting agents would not likely be beneficial.
Long-acting β-agonists do not impact airway inflammation and should not
be used without a corticosteroid. A leukotriene receptor antagonist is an
option, but is generally thought of as a “second best” choice. Inhaled corti-
costeroids and leukotriene antagonists have replaced cromolyn in current
asthma therapy.
378. The answer is b. (McPhee, pp 240-256.) The patient described in this

question has worsening asthma symptoms and needs additional therapy.
Long-acting β-agonists are considered the most appropriate medication in
this case and are often packaged with an inhaled corticosteroid for ease of
use. A leukotriene receptor antagonist would also be appropriate. A
burst and taper of oral steroids may be appropriate for an acute flare, but
not in this case. Cromolyn has associated compliance issues as it is dosed
four times a day. Atrovent is usually not used unless there is a component
of COPD, and theophylline, though an appropriate “third-line” agent, is
not more effective than a long-acting β-agonist.
379. The answer is b. (McPhee, pp 240-256.) In this case, the patient has
had mild intermittent asthma, but is becoming persistent and requires a
step-up in therapy. Since he is intolerant of inhaled steroids, a leukotriene
modifier is the best choice. They have been shown to improve lung func-
tion and reduce the need for rescue therapy. Long-acting β-agonists should
not be used as monotherapy since they have been shown in studies to have
a small but statistically significant increased risk of severe or fatal asthma
attacks. Cromolyn therapy has been replaced by newer agents, mainly
because of compliance issues. Theophylline and oral steroids would not be
indicated in this case.
380. The answer is e. (McPhee, pp 240-256.) Multiple studies have shown

that infections with viruses and bacteria predispose to acute asthma ex-
acerbations. However, the use of empiric antibiotics is not recommended.
There is no consistent evidence to support improved clinical outcomes.
Antibiotics should be considered in cases where there is a high likelihood
of acute bacterial respiratory infection, as in the case of high fever, purulent
sputum production or radiographic evidence of lower respiratory or sinus
infection.
278 Family Medicine
381. The answer is a. (Mengel, pp 300-306.) Spondylolisthesis is an anterior

displacement of vertebrae in relation to the one below. It is the most common
cause of low back pain in patients younger than age 26, especially athletes.
Back strain is also a common diagnosis, but would generally follow an
inciting event, and pain would be associated with movement. The patient
is likely too young for osteoarthritis to be a consideration, and a lumbar
disk herniation can occur at any age, but is less likely to be the diagnosis in
this case. Neoplasm is a rare cause of low back pain.
382. The answer is b. (Mengel, pp 300-306.) Inflammatory conditions

(rheumatoid arthritis, ankylosing spondylitis, Reiter syndrome) which
cause back pain are rare, but have characteristics that are helpful in differ-
entiating them from other causes of pain. Inflammatory conditions gener-
ally produce greater pain and stiffness in the morning, while mechanical
disorders tend to worsen throughout the day with activity. A disk hernia-
tion might be associated with radiation and neurologic symptoms. A com-
pression fracture would begin suddenly, and a neoplasm is unlikely to get
better throughout the day.
383. The answer is b. (Mengel, pp 300-306.) MRI is indicated for people

whose pain persists for more than 6 weeks despite normal radiographs and
with no response to conservative therapy. Flexion/extension films would
not be helpful in identifying more concerning causes of pain. EMG is not
indicated without neurologic involvement. A bone scan and/or ESR should
be considered in those with symptoms consistent with cancer or infection.
384. The answer is a. (Mengel, pp 300-306.) It is recommended that

patients with low back pain maintain usual activities, as dictated by pain.
Neither prolonged bed rest nor traction has been shown to be effective in
returning people to their usual activities sooner. NSAIDs are effective for
short-term symptomatic pain relief. Muscle relaxants appear to be effective
as well. Opioids may be indicated in pain relief for those who have failed
NSAIDs, but are significantly sedating. Steroids can be considered in those
who have failed NSAID therapy.
385. The answer is c. (Mengel, pp 300-306.) Treatment for chronic low

back pain is challenging. NSAIDs are effective but can cause side effects if
used chronically. Muscle relaxants do not exhibit any direct effect on skel-
etal muscle and owe their efficacy to sedation. They have not been shown
to add benefit when added to NSAIDs. Opioid agents may be necessary for
acute flares of pain, but should not be used for chronic pain because of the
risk of dependency. Low-dose tricyclic antidepressants can be useful in the
treatment of chronic pain and do serve as adjuvants to other analgesics.
There is no evidence that SSRIs improve pain or function in chronic back
pain. There is no evidence that injections into facet joints or trigger pints
improve pain relief or function.
386. The answer is c. (Mengel, pp 468-479.) Chronic bronchitis is defined

as a productive cough lasting 3 consecutive months over 2 consecutive
years. Upon clinical diagnosis, office spirometry is necessary to make the
diagnosis, assess the disease severity, and monitor response to treatment.
Complete blood count may be indicated to screen for polycythemia or to
assess acute illness in the febrile patient with COPD, but is not necessary.
Arterial blood gas measurements should only be obtained if the FEV1 is
found to be less than 50% predicted. A high-resolution CT scan is not a
routine part of care unless the diagnosis is in doubt, or a procedure is being
considered. ECGs may show changes due to COPD, but are not routinely
indicated in the evaluation.
387. The answer is e. (McPhee, pp 256-262.) The single most important

intervention in smokers with COPD is to encourage smoking cessation.
However, the only drug therapy that has been shown to improve the natu-
ral history of COPD progression is supplemental oxygen in those patients
that are hypoxemic. Benefits of oxygen therapy include longer survival,
reduced hospitalizations, and better quality of life. Bronchodilators do
not alter the course of the decline in function, and COPD is generally not
a steroid responsive disease. Antibiotics can be useful to treat infection
and exacerbation, but no convincing evidence exists to support their use
chronically.
388. The answer is e. (Mengel, pp 468-479.) The patient described in the

question has risk factors and physical stigmata of COPD. Office spirometry
is helpful to diagnose COPD and assess its severity. While all the answer
choices are common measurements of airflow, the more sensitive measure
to diagnose COPD is the FEV1:FVC ratio. It is considered normal if it is
70% or more of the predicted value based on the patient’s gender, age, and
height. The TLC is not often used in the routine management of COPD, but
may be important for restrictive disease.
280 Family Medicine
389. The answer is b. (McPhee, pp 256-262.) Bronchodilators do not

alter the decline in lung function that is the hallmark of COPD, but they
do offer improvement in symptoms, exercise tolerance, and overall health
status. The most commonly prescribed bronchodilators are the anticho-
linergic ipratropium bromide and the β-agonists. Ipratropium is generally
preferred as a first-line agent because of its longer duration of action and
the absence of sympathomimetic effects. Some studies have shown that
ipratropium achieves superior bronchodilation in COPD patients. Inhaled
corticosteroids alone should not be considered first-line therapy in COPD
patients because patients receive more benefit from bronchodilators. Theo-
phylline is considered a fourth-line therapy for patients who do not achieve
adequate symptom control with other therapies, and oxygen is not indicated
until there is significant evidence of hypoxemia.
390. The answer is d. (McPhee, pp 256-262.) Antibiotics are commonly

prescribed to outpatients with COPD and have been shown to improve
outcomes when treating acute exacerbations. In the past, common agents
included amoxicillin, trimethoprim-sulfamethoxazole, and doxycycline.
However, prescribing habits have changed, and in a 2007 meta-analysis,
azithromycin, ciprofloxacin, and amoxicillin-clavulanate were found to be
more effective than older therapies. Prompt administration of antibiotics in
COPD exacerbations is appropriate, particularly in those with risk factors
for poor outcomes.
391. The answer is d. (Bope, pp 741-746.) Weight, diabetes, and hyper-

tension, by themselves, do not indicate the presence or absence of renal
insufficiency. However, most cases of chronic renal failure are caused by
diabetes and hypertension (60%), so those should be recognized as sig-
nificant risk factors. The serum creatinine level can be normal in elderly
people with chronic renal insufficiency, because they generally have less
muscle mass. Therefore, the best indicator of the presence of renal failure
is the GFR. The other tests mentioned are not sufficient tests, and normal
values in these tests do not indicate that the patient does not have renal
insufficiency.
392. The answer is e. (Bope, pp 741-746.) The kidney’s role in concentrat-

ing and diluting urine is usually retained until the GFR falls below 30% of
normal. Therefore, hyponatremia, hyperkalemia, hyperphosphatemia, and
metabolic acidosis (because of a fall in plasma bicarbonate) generally occur
in later stages of kidney disease. The kidney is the source of erythropoietin,

and anemia generally appears when the GFR falls below 60 mL/min.
393. The answer is d. (Bope, pp 741-746.) According to National Kidney

Foundation guidelines, this patient has stage 1 renal failure. ACE inhibi-
tors should be added to his regimen to prevent the evolution of microal-
buminuria to full blown proteinuria. Improvements in diet and exercise
are always appropriate, but should not take the place of the addition of
an ACE inhibitor. Checking a glycosolated hemoglobin level would not be
indicated as a screen for diabetes.
394. The answer is d. (Bope, pp 741-746.) The patient’s laboratory val-

ues and clinical picture is consistent with moderate renal failure (National
Kidney Foundation stage 3). At this point, nephrology referral is indicated.
Renal replacement therapy (transplant or dialysis) is indicated for severe
renal insufficiency (GFR <15 mL/min).
395. The answer is d. (McPhee, pp 878-886.) The long-term complications

of chronic kidney disease are many. There is a higher risk for cardiovascular
disease in this population as compared with the general population. In fact,
patients with chronic kidney disease die, primarily due to cardiovascular
disease, before reaching the need for dialysis. The reason for this is unclear,
but may be related to the uremic milieu, underlying comorbidities and the
hesitancy to perform diagnostic procedures in the setting of chronic kidney
disease.
396. The answer is c. (Mengel, pp 462-467.) Pain is the most common rea-
son for which people seek medical care. Chronic pain is defined as recurrent
or persistent pain lasting more than 3 months, and it affects around 15%
of the US population. Nociceptive pain stems from tissue damage (such as
arthritis and/or tumor). Neuropathic pain, as that described in this ques-
tion, results from the sustained transmission of pain signals in the absence
of ongoing tissue damage. It can be described as numbness (hypoesthesia),
increased sensitivity (hyperesthesia), pins and needles (paresthesia), or severe
pain usually from innocuous stimuli (allodynia).
397. The answer is a. (Mengel, pp 462-467.) Nonsteroidal anti-

inflammatory drugs (NSAIDs) are an excellent first-line medication for mild
to moderate pain, especially when there is an inflammatory component
282 Family Medicine
suspected. One NSAID is not superior to another, and periodic substitu-

tion of one with another in the class may afford an improved response.
Celecoxib (a COX-2 inhibitor) may have a better side effect profile, but
should be not be a first-line agent except in elderly patients or in patients
who have failed NSAIDs. Tramadol is a centrally acting synthetic opioid
agonist that is nonscheduled. It binds to μ-opioid receptors and inhibits
serotonin and norepinepherine reuptake. It should not be a first-line option.
While tricyclic antidepressants like amitriptyline and anticonvulsants like
gabapentin may work well in neuropathic pain, they are less well-studied
in nociceptive pain and therefore are not good first-line agents.
398. The answer is c. (Mengel, pp 462-467.) There are many agents to

choose from to treat chronic neuropathic pain. If the pain is unresponsive
to NSAIDs, one can choose a trial of a COX-2 inhibitor, but studies have
shown that tricyclic antidepressants like amitriptyline are efficacious. Anti-
convulsants would be another option. Tramadol and opioids may work to
control the pain, but may increase risk of addiction and would not be best
as a next step in this case.
399. The answer is c. (Mengel, pp 462-467.) In chronic nonmalignant

pain, there is evidence that continued escalating opioid doses results in
worsened analgesic response. This is because NMDA receptors are upregu-
lated and lead to tolerance, while pain receptors become increasingly more
sensitive to stimuli. In situations of tolerance to medication, it is appropri-
ate to switch from one opioid agent to another, usually starting at half the
equivalent dose of the alternative medication. Stopping the opioid would
result in withdrawal, and increasing the dose would be inappropriate because
of the physiologic effects described above. There is no evidence to support
the addition of a second anticonvulsant, and although antidepressants have
been shown to help in chronic pain, it is more likely that changing opioid
would provide better pain control.
400. The answer is e. (Mengel, pp 479-485.) Determining the cause of

liver disease has important implications for treatment. The most important
aspect of diagnosing alcoholic liver disease is the documentation of chronic
alcohol abuse. However, alcohol use is sometimes denied by the patient.
Alcoholic hepatitis is associated with the classic laboratory findings of a
disproportionate elevation of AST compared to ALT with both values usu-
ally being less than 300 IU/L. This ratio is generally greater than 2.0, a value
rarely seen in other forms of liver disease, including those listed in this
question (viral or autoimmune hepatitis or hematochromatosis).
401. The answer is e. (Mengel, pp 479-485.) Laboratory studies that rep-

resent acute hepatocellular injury include AST, ALT, LDH, and alkaline
phosphatase. Laboratory values that represent hepatic function include
albumin, bilirubin, and prothrombin time. Tests of hepatic function are
more suggestive of chronic disease as opposed to acute injury.
402. The answer is c. (Mengel, pp 479-485.) Varices occur secondary to

chronic high pressure in the portal veins. Bleeding from varices is the most
common cause of death in cirrhotic patients. The other potential causes of
death listed are less common.
403. The answer is b. (Mengel, pp 479-485.) Absolute contraindications

to liver transplantation include portal vein thrombosis, severe medical ill-
ness, malignancy, hepatobiliary sepsis, or lack of patient understanding.
Relative contraindications are active alcoholism, HIV or hepatitis B surface
antigen positivity, extensive previous abdominal surgery, and a lack of a
personal support system.
404. The answer is a. (Mengel, pp 485-497.) Routine laboratory testing in

a person with the new diagnosis of heart failure includes an electrocardio-
gram, a CBC, a urinalysis, serum creatinine, potassium and albumin lev-
els, and thyroid function studies. An echocardiogram is imperative to help
identify structural abnormalities of the heart and to measure the ejection
fraction. Holter monitoring is not routinely warranted, as it would not iden-
tify a cause for heart failure, but would be used to identify an arrhythmia.
Catheterization or stress testing may be important if ischemia or ischemic
cardiomyopathy is identified as a cause, but is not a routine initial test.
405. The answer is b. (Mengel, pp 485-497.) The NYHA functional clas-

sification is important for clinicians to understand, as therapy may change
as patients progress from class to class. Class I patients have no limitation
of activity. Class II patients have slight limitations, are comfortable at rest,
but have fatigue, palpitations, dyspnea, or angina with ordinary activity.
Class III patients are also comfortable at rest, but less-than-ordinary activi-
ty causes symptoms. Class IV patients have symptoms at rest and increased
symptoms with even minor activity. There is no “class V” in this system.
284 Family Medicine
406. The answer is e. (Mengel, pp 485-497.) Many noncardiac comor-

bid conditions may affect the proper diagnosis and clinical course of heart
failure. All of the interventions in this question should be done, but only
discontinuing alcohol use has actually been shown to improve function
significantly. Optimally treating COPD is important, as exacerbations from
heart failure are often difficult to distinguish from COPD exacerbations.
Optimally treating diabetes and hypertension will minimize the negative
effects of these conditions on the heart, but will not improve damage already
done. Cigarette smoking should be discontinued, but generally does not
lead to functional improvement. Those with alcoholic cardiomyopathy
actually see improvement of the left ventricular function with abstinence.
407. The answer is a. (Mengel, pp 485-497.) Many clinical trials have

shown that ACE inhibitors decrease symptoms, improve quality of life,
decrease hospitalizations, and reduce mortality in patients with NYHA class
II to IV heart failure. In addition, they slow the progression to heart failure
among asymptomatic patients with left ventricular systolic dysfunction. All
patients with heart failure should be prescribed an ACE inhibitor unless
they have a contraindication. β-Blockers are helpful, but not necessarily as
a first-line agent. Nitrates and hydralazine can be used in patients who do
not tolerate ACE inhibitors, as can ARBs. Some calcium channel blockers
(nifedipine, diltiazem, and nicardipine) may worsen systolic dysfunction.
408. The answer is d. (Mengel, pp 485-497.) Some patients have difficulty

maintaining optimal fluid balance, and a second diuretic is needed. In this
case, adding metolazone can significantly increase diuresis in the outpa-
tient treatment of heart failure with volume overload. Prolonged therapy
should be avoided. Hydrocholorozide would not enhance diuresis, nor
would triamterene. Spironolactone can be used, but is usually only con-
sidered for NYHA class III or IV patients or those with a serum potassium
level less than 5.0 mmol/L.
409. The answer is c. (McPhee, pp 385-395.) ACE inhibitors and ARBs

do not have the same effects on the neurohormonal pathways involved in
CHF. However, the valsartan in heart failure trial showed that while val-
sartin (an ARB) added to an ACE inhibitor decreases hospitalization in pa-
tients with CHF, it did not decrease mortality. The Candesartan in Heart
Failure: Assessment of Reduction in Mortality and Morbidity (CHARM)
trial showed that rates of cardiovascular death and heart failure admissions
were similar in patients with CHF that were treated with ACE inhibitors
or ARBs.
410. The answer is c. (Mengel, pp 485-497.) β-Blockers inhibit the adverse

effects of sympathetic nervous system activation in heart failure patients.
Studies have shown that three β-blockers (bisoprolol, metoprolol, and
carvedilol) can reduce symptoms, improve quality of life, and reduce
mortality. Adding diuretics does not change mortality. Nifedipine can wors-
en symptoms. Digoxin improves symptoms, but does not decrease mortality.
411. The answer is c. (Bope, pp 901-905.) Epidemiologic studies have

identified several genetic and environmental risk factors for Alzheimer dis-
ease. Increasing age is the strongest risk factor. By age of 65, 1% of the
general population meets diagnostic criteria, and the prevalence doubles
every 5 years thereafter. Family history is another major risk factor, and
individuals with a first-degree relative with the disease are four times more
likely to develop the disease themselves. Other risk factors include female
gender, low levels of education, cardiovascular risk factors, and a history
of head trauma.
412. The answer is d. (Bope, pp 901-905.) Dementia is often difficult to

distinguish from delirium or depression in the elderly. However, delirium
is generally acute in onset and associated with a loss of concentration.
Dementia’s onset is insidious, and concentration is less likely to be a problem.
Depression is associated with psychomotor slowing, while dementia is gen-
erally not. While people with dementia may complain of memory loss, it is
far more likely that the patient’s family will complain of the patient having
memory loss in dementia. Depressed patients usually present themselves
complaining of memory loss. Depressed and delirious patients will gener-
ally show poor effort in testing, while demented patients will generally
display good effort, but get wrong answers.
413. The answer is e. (Bope, pp 901-905.) Often, memory disturbances

are the presenting symptom in Alzheimers disease. Remote memories are
well-preserved initially, with the ability to recall new information being
lost early in the illness. Difficulty with word-finding is also noted early.
Decreased ability to recognize and draw complex figures is an early sign of
problems, as is the loss of the ability to calculate. Social propriety and inter-
personal skills often remain strikingly preserved until late in the illness.
286 Family Medicine
414. The answer is a. (Bope, pp 901-905.) There are no laboratory tests

of sufficient accuracy to independently confirm a diagnosis of Alzheimer
disease. The laboratory workup, which does include the blood work listed
in answer e, is primarily done to rule out other conditions that can cause or
contribute to the presenting symptoms. Structural imaging is important to
rule out other causes as well and may include either a CT scan or an MRI.
Positron-emission tomography (PET) scanning and evaluation of cerebro-
spinal fluid may be useful in very complicated cases, but are not used for
diagnosis. The mini-mental status examination, the clock drawing test, or
other brief screening tools may be most useful in the diagnosis.
415. The answer is c. (Bope, pp 901-905.) Three cholinesterase inhibi-

tors are approved for the treatment of Alzheimer disease. They include
donepezil (Aricept), galantamine (Reminyl), and rivastigmine (Exelon).
They reduce the metabolism of acetylcholinesterase, thereby prolonging
its action at cholinergic synapses. They are associated with modest
improvements in cognition, behavior, activities of daily living, and global
measurements of functioning. However, they do not change the progres-
sion of neurodegeneration.
416. The answer is d. (Mengel, pp 497-513.) The patient described has

dementia of Lewy body (DLB) type. This begins similarly to Alzheimer
disease, but then patients develop complex visual hallucinations and spon-
taneous signs of parkinsonism. Patients with Alzheimer dementia develop
delusions, but rarely have hallucinations. Antipsychotics should be avoided
in this type of dementia, unless absolutely necessary, as there is concern for
long-term neurologic damage. DLB responds to cholinesterase inhibitors,
and the other medications listed are safe if used appropriately.
417. The answer is d. (Bope, pp 901-905.) Evidence from clinical trials

has shown that donepezil can result in modest clinical improvement
versus placebo in community-dwelling patients with dementia, but found
no difference in the rates of institutionalization or progression of disease.
Patients with more advanced disease have been shown to have statistically
significant benefit from Memantine, with or without concomitant use of
an acetylcholinesterase inhibitor. Ginkgo biloba has been shown to have
mixed results in studies.
418. The answer is b. (South-Paul, pp 380-391.) The American Diabetes

Association recommends screening all persons older than 45 years for
diabetes every 3 years. Screens should start earlier in people with risk
factors including a family history of diabetes in a first-degree relative,
hypertension, obesity, high-risk ethnic groups (African American, His-
panic, Native American), a previous history of impaired glucose toler-
ance, abnormal lipids (especially elevated triglycerides and low HDL),
and women with a history of gestational diabetes or a birth of a child
greater than 9 lb. Multiple screens are available. Random glucose is easy,
but has low specificity. A 2-hour glucose tolerance test is more specific,
but is more costly and time consuming. A 1-hour glucose tolerance test
is generally used for screening pregnant women, with a 3-hour glucose
tolerance test being used for those that are positive. Urinalyses are highly
specific, but have low sensitivity. Fasting glucose is more accurate and is
generally recommended.
419. The answer is c. (South-Paul, pp 380-391.) The diagnosis of diabetes

may be made by two separate random glucose measurements more than
200 mg/dL with classic signs of diabetes (polydipsia, polyuria, polyphagia,
weight loss), a fasting glucose greater than 126 mg/dL, or a glucose reading
greater than 200 mg/dL 2 hours after a 75-g glucose load.
420. The answer is a. (South-Paul, pp 380-391.) In the past, young adults

diagnosed with diabetes were primarily type 1. However, the epidemic of
obesity in the United States has increased the rate of type 2 diabetes in
people less than 20 years old from 5% to 30% over the last decade.
C-peptide is cleaved from natively produced insulin. In people with type
1 diabetes, C-peptide levels should be low. Microalbuminuria, markedly
elevated hemoglobin A1C, and peripheral neuropathy can all occur in type
1 or 2 diabetes.
421. The answer is d. (South-Paul, pp 380-391.) The first indication of

renal compromise in diabetics is an increase in GFR. Renal lesions
develop and are followed by microalbuminuria. Uncorrected, this can lead
to macroalbuminuria, then renal failure. ACE inhibitors have been shown
to decrease end-stage renal disease and death by 41% in diabetics. Lifestyle
changes including glucose control, weight loss, and decreased protein
intake can help, but experts agree that the benefits of ACE inhibitors are
well-documented. Nephrology referral would be indicated if the creatinine
becomes elevated, or in the face of macroalbuminuria or microalbuminuria
despite maximal therapy. Even in patients who are normotensive, low-dose
ACE inhibitors are beneficial in the face of microalbuminuria.
288 Family Medicine
422. The answer is a. (South-Paul, pp 380-391.) Diabetic retinopathy is

the leading cause of blindness in the United States. The risk increases with
the length of time that the patient has had diabetes, and the condition
worsens with increasing hemoglobin A1C levels. In type 2 diabetics, it can
be seen at diagnosis. Aspirin has no effect on eye complications. It follows
a predictable pattern, with mild background abnormalities followed by
increased vascular permeability and hemorrhage. Proliferative changes
occur late in the course.
423. The answer is b. (South-Paul, pp 380-391.) ACE inhibitors are clearly

the first choice for blood pressure control in diabetic patients. They control
blood pressure effectively, help prevent progression of renal disease, and
are indicated in the presence of coronary disease and CHF. Although com-
pelling, there is insufficient evidence to recommend ACE inhibitors in all
diabetic patients. They are indicated for diabetics with systolic blood pres-
sures greater than 100 mm Hg. They can be used irrespective of creatinine
levels, though potassium should be monitored as creatinine rises. Providers
do not need to wait to see microalbuminuria prior to initiating therapy.
424. The answer is b. (South-Paul, pp 380-391.) Statins are the drug of

choice in treating hyperlipidemia in diabetes. They have been shown to
decrease the risk of coronary events and are excellent in lowering LDL.
They do have less effect on the triglyceride levels, but in many patients, the
decrease is enough to get patients to goal. Niacin will decrease triglycer-
ides, raise HDL, and lower LDL, but may increase insulin resistance. Niacin
is often used in combination with a statin or alone in patients with statin
side-effects. Fibric acid derivatives lower triglycerides and raise HDL, but
have minimal effects on LDL. Bile acid resins sequester bile acids in the GI
tract. They can increase triglyceride levels and are generally not used in
diabetics.
425. The answer is a. (South-Paul, pp 380-391.) Glycemic control is

dependent on the total caloric intake, not the type of calorie taken in. Low-
carbohydrate and high-protein diets have not been shown to improve
glucose control more than weight loss from other methods. Sucrose does
not need to be eliminated, but it may raise blood sugar more quickly
after ingestion. Formal dietary programs are not more likely to produce
long-term sustainable results unless exercise is a large component of the
plan. Increased fiber does improve glycemic control.
426. The answer is d. (South-Paul, pp 380-391.) Oral therapy for type 2

diabetes can be complicated. No evidence supports changing sulfonylureas
when one is not adequately controlling glucose levels. Biguanides act to
decrease glucose output from the liver, and can decrease hemoglobin A1C by
1.5% to 2%. However, biguanides should not be used if creatinine is higher
than 1.5 mg/dL. Meglitinides increase insulin secretion and should only be
taken before meals. They can reduce the hemoglobin A1C by 0.5% to 2% and
are most valuable if fasting sugar is adequate, but postprandial sugars are
high. Since they increase insulin levels, they are more effective when used
in combination with a medication that has a different mechanism of action.
They are excreted in the liver, therefore are safe in renal failure. Thiazoli-
dinediones decrease insulin resistance and are an excellent choice for those
with insulin insensitivity. α-Glucosidase inhibitors inhibit the absorption of
carbohydrates in the gut and can decrease the hemoglobin A1C by 0.7% to
1%. They should be avoided if creatinine more than 2.0 mg/dL.
427. The answer is d. (McPhee, pp 1140-1176.) Exenatide is a GLP-1

receptor agonist isolated from the saliva of the Gila monster. When it is
given to patients with type 2 diabetes, it lowers blood glucose and HbA1C.
Adding it to a person taking metformin and a sulfonylurea further lowers
HbA1C by 0.4% to 0.6%, and this is maintained up to 80 weeks. In addition,
patients have the added benefit of weight loss, with the average weight loss
for patients being around 10 lb.
428. The answer is b. (McPhee, pp 1140-1176.) Thiazolidinediones sen-

sitize peripheral tissues to insulin. They can be used as monotherapy, with
insulin or in combination with metformin. When used as monotherapy,
they can decrease the HbA1C by about 1 to 2 percentage points. When
added to the regimen of patients on insulin, it can reduce the insulin
dosage by 30% to 50%. In the case mentioned, if you decreased the insulin
dose by 50%, you would be unlikely to cause symptomatic hypoglycemia
or hyperglycemia in this patient. Cough and GI intolerance are not com-
monly seen. Edema is a common side effect, occurring in about 3% to 4 %
of patients using the medication. The edema occurs even more frequently
in patients receiving concomitant insulin. Other side effects include anemia
and weight gain.
429. The answer is e. (McPhee, pp 1140-1176.) Glucagon-like peptide

1 (GLP-1) is a gut-derived incretin hormone that stimulates insulin and
290 Family Medicine
suppresses glucagon secretion, delays gastric emptying, and reduces appe-

tite and food intake. Sitagliptin is a dipeptidyl peptidase-4 (DPP-4) inhibi-
tor which prolongs the activity of endogenously released GLP-1. Orally
administered DPP-4 inhibitors, such as sitagliptin reduce HbA1C by 0.5%
to 1.0%, with few adverse events and no weight gain.
430. The answer is a. (Mengel, pp 514-522.) It is important to thoroughly

understand the action of the different types of insulin preparations in order
to make therapeutic decisions about diabetic patients and their control.
Aspart, lispro (Humalog), and glulisine (Apidra) have the most rapid onset
of action, between 15 and 30 minutes. Regular insulin has an onset between
30 and 60 minutes. Neutral protamine hagedorn (HPH) has an onset
between 1 and 2 hours, as does glargine (Lantus) and detemir (Levemir).
431. The answer is e. (Mengel, pp 514-522.) It is important to thoroughly

Lispro’s and Aspart’s activity peaks early, between 30 and 60 minutes
after injection. Regular insulin peaks between 2 and 3 hours after injec-
tion. Neutral protamine hagedorn (NPH) peaks 4 to 8 hours after injection.
Glargine (Lantus) and Detemir (Levemir) do not have a predictable peak,
and last for around 24 hours.
432. The answer is d. (Mengel, pp 514-522.) It is important to thoroughly

Lispro’s and Aspart’s duration of action is between 3 and 5 hours. Inhaled
insulin lasts between 3 and 5 hours as well. Regular insulin lasts between
4 and 12 hours. Neutral protamine hadedorn (NPH) lasts for around 10
to 20 hours. The preparations with the longest duration of action include
Lantus and Levemir, with a duration of around 24 hours.
433. The answer is c. (Mengel, pp 514-522.) When using Lantus and Lis-
pro, approximately 40% to 50% of the total daily insulin requirements
should be given as Lantus, with the remaining 50% to 60% of insulin given
as Lispro before each meal, based on a preprandial glucose reading.
434. The answer is b. (Mengel, pp 514-522.) Patients with type 2 diabetes

may require insulin therapy if diet, exercise, and oral hypoglycemic agent
do not provide appropriate control. A low dose of NPH is commonly used,

estimating 0.1 U/kg of body weight, as an addition to the current regimen.
435. The answer is a. (Mengel, pp 522-538.) Treatment goals for persons

with dyslipidemias should be established based on the patient’s clinical
status and other risk factors. For patients with known coronary artery dis-
ease or diabetes, the treatment goal for LDL cholesterol is less than or equal
to 70 mg/dL. If a patient has no known coronary disease, the 10-year risk
for coronary disease should be estimated using a readily available National
Cholesterol Education Program (NCEP) risk calculator (available online). If
the 10-year risk is greater than 20%, the LDL treatment goal should be less
than or equal to 100 mg/dL. If the risk is between 10% and 20%, the LDL
treatment goal should be less than 130 mg/dL. If the risk is less than 10%,
the treatment goal should be less than 160 mg/dL.
436. The answer is d. (Mengel, pp 522-538.) Treatment goals for persons

with dyslipidemias should be established based on the patient’s clinical
status and other risk factors. If a patient has no known coronary disease,
the 10-year risk for coronary disease should be estimated using a readily
available National Cholesterol Education Program (NCEP) risk calculator
(available online). If the 10-year risk is greater than 20%, the LDL treat-
ment goal should be less than or equal to 100 mg/dL. If the risk is between
10% and 20%, the LDL treatment goal should be less than 130 mg/dL. If
the risk is below 10%, the treatment goal should be less than 160 mg/dL.
437. The answer is c. (Mengel, pp 522-538.) Several lifestyle modification

efforts are known to increase HDL cholesterol. By losing weight, a person
can expect to raise HDL by 5 to 10 points. Smoking cessation has the same
approximate effect. Adopting an exercise program is even more effective,
raising HDL by up to 15 points. Eating oat bran and decreasing life stress
can lower LDL, but is not likely to raise HDL. Additionally, alcohol, in
moderation, raises HDL cholesterol.
438. The answer is a. (Mengel, pp 522-538.) Blood lipids change acutely

in response to food intake. The triglyceride level is lowest in the fasting
state and rises by an average of 50 mg/dL postprandially. As the triglyc-
eride level rises, the total and LDL cholesterol each fall. Thus total and
LDL cholesterol tend to be higher when fasting. HDL varies little whether
fasting or not.
292 Family Medicine
439. The answer is c. (Mengel, pp 522-538.) Of all the lipid values, low
HDL is the single best predictor of an adverse outcome. However, high
HDL does not guarantee immunity from coronary artery disease. C-reactive
protein levels predict risk for myocardial infarction and stroke even better
than LDL levels do, but the level indicated in this question puts the parson
at average risk. Levels above 3.00 indicate a high risk for myocardial infarc-
tion or stroke.
440. The answer is d. (Mengel, pp 522-538.) Smoking cessation increases

HDL by 5 to 10 mg/dL, but does not affect LDL, VLDL, or triglycerides.
441. The answer is d. (Mengel, pp 522-538.) Aspirin blocks much of the

flushing that is associated with sustained-release niacin preparations. Taking
niacin at night, with food, on an empty stomach or with milk, or with a
proton pump inhibitor will not impact the side effects.
442. The answer is e. (Mengel, pp 522-538.) Fish oil is high in omega-3

fatty acids and has been shown to be beneficial in lowering cholesterol.
Fish oils work by decreasing secretion of triglycerides by the liver.
443. The answer is b. (Mengel, pp 522-538.) Gemfibrozil changes the he-

patic metabolism of lipoproteins and is a logical choice for the patient with
low HDL and elevated triglycerides.
444. The answer is d. (Mengel, pp 522-538.) Ezetemibe (Zetia) lowers

cholesterol by interfering with the absorption of cholesterol in the gut.
Used alone, it lowers LDL and triglycerides only modestly. When added to
a low-dose statin, the combination lowers LDL as much as the maximum
statin dose, but its combined use with a low-dose statin may produce fewer
adverse effects.
445. The answer is d. (McPhee, pp 1189-1200.) The different options for

medical management of hyperlipidemia include preparations that affect the
total cholesterol, the HDL, the LDL, and the triglycerides. Choice of medi-
cation depends on the desired endpoint. The following table outlines the
expected increase in HDL that would be expected using the medications
in the answer key:
Medication Increase in HDL

Lovastatin 5%-10%
Colestipol Approximately 5%
Ezetimibe Approximately 5%
Fenofibrate 15%-25%
Cholestyramine Approximately 5%
Niacin is even better than fenofibrate, increasing HDL by 25% to 35% on

average.
446. The answer is a. (McPhee, pp 1189-1200.) The following table out-

lines the expected decrease in LDL that would be expected using the medi-
cations in the answer key:
Medication Increase in HDL

Lovastatin 25%-40%
Colestipol 15%-25%
Ezetimibe Approximately 20%
Fenofibrate 10%-15%
Cholestyramine 15%-25%
The best statin for decreasing LDL is rosuvastatin. It can lower LDL by 40%
to 50%.
447. The answer is d. (McPhee, pp 1189-1200.) The following table out-

lines the expected decrease in triglycerides that would be expected using
the medications in the answer key:
Medication Decrease in TG
Lovastatin Mild
Colestipol No effect
Ezetimibe No effect
Fenofibrate Moderate
Cholestyramine No effect
Fenofibrate can be expected to decrease triglycerides by approximately 40%.

294 Family Medicine
448. The answer is b. (McPhee, pp 1189-1200.) Niacin was the first lipid-
lowering agent associated with decreased total mortality. It moderately
decreases LDL, can increase HDL by 20% to 25%, and moderately decreases
triglycerides. It causes a prostaglandin-mediated flushing that patients
often describe as “hot flashes.” This side effect can be easily moderated by
having the patient take a NSAID or aspirin at least an hour before taking
the niacin. Although niacin can increase blood sugar, it is safe for diabetics
to use.
449. The answer is e. (McPhee, pp 1266-1295.) Postexposure prophylaxis

against HIV can substantially decrease the risk of seroconversion after a
needle stick injury. Health care workers should be tested for HIV as soon as
possible after the needle stick to establish a negative baseline for potential
worker’s compensation claim should the worker subsequently seroconvert.
Therapy should be initiated using at least two medications to which the
source would unlikely be resistant. Some clinicians prefer triple therapy.
450. The answer is d. (McPhee, pp 1266-1295; Bope, pp 47-64.) Testing to

establish the diagnosis of HIV infection usually requires an ELISA followed
by a confirmatory Western blot of immunofluorescent antibody test. How-
ever, there is a “window period” of several weeks to 4 months between the
infection and seroconversion when these tests may be negative. During this
time, patients may be viremic and infectious, but not have sufficient levels
of antibodies to result in positive tests. If there is strong clinical suspicion,
plasma HIV RNA should be ordered. This, however, also needs to be inter-
preted with caution, as low level viremia may represent a false-positive test.
CD4 count is not helpful in acute HIV disease.
451. The answer is a. (McPhee, pp 1266-1295.) The incidence of cervical

dysplasia in HIV positive women is 40%. More HIV infected women die of
cervical cancer than do from AIDS, therefore Pap testing should be done
every 6 months. Some practitioners perform routine colposcopy regardless
of the Pap results, but the evidence does not support that recommendation
for all women at this point. Cone biopsy should be reserved for cases of
serious dysplasia.
452. The answer is c. (Bope, pp 47-64.) Usually, induration of 15 mm

(10 mm in high-risk patients) indicates a positive test. In HIV-infected
individuals, 5 mm is considered a positive test. PPD tests should be placed
on the initial visit in HIV-infected patients, as there is an increased risk of

progression from latent to active TB in infected individuals. Some high-risk
individuals (homeless individuals or those who use injection drugs) should
be tested annually.
453. The answer is a. (McPhee, pp 1266-1295.) Prophylaxis against M

avium complex (MAC) should be instituted once the patient’s CD4 count
drops less than 75 to 100 lymphocytes/mm3. Prophylaxis against Pneumo-
cystis pneumonia should be considered once the CD4 count drops less than
200 lymphocytes/mm3. Prophylaxis for fungal disease has been studied,
but there was no benefit in the group that had prophylaxis with regard to
mortality. Prophylaxis for herpes simplex and herpes zoster is not generally
done. CMV prophylaxis can be instituted in those with CMV IgG positivity
and with CD4 counts less than 50 lymphocytes/mm3, but it is generally
not done because ganciclovir (the primary prophylactic agent) can cause
neutropenia.
454. The answer is c. (McPhee, pp 1266-1295.) The x-ray shown is suspi-

cious for Pneumocystis pneumonia and treatment should be started imme-
diately. The treatment of choice is trimethoprim-sulfamethoxazole (TMP-
SMX) for 3 weeks. Although it would seem that corticosteroids should be
avoided in HIV-infected patients, it has been shown to improve the course
of patients with moderate to severe pneumocystic pneumonia with an oxy-
gen saturation less than 90% or a PaO2 less than 65 mm Hg. Therefore, this
patient should receive both.
455. The answer is e. (Mengel, pp 538-547.) Lifestyle modifications can

help to manage hypertension. Weight reduction is most beneficial, and sys-
tolic blood pressure can fall from up to 20 mm Hg for each 10 lb of weight
lost. A DASH diet can lower blood pressure between 8 and 14 mm Hg.
Dietary sodium reduction, increased exercise and moderation of alcohol
can be expected to lower systolic blood pressure less than 10 mm Hg.
456. The answer is e. (Mengel, pp 538-547.) The patient in this ques-

tion has stage 2 hypertension (systolic blood pressure ≥160 mm Hg, or
diastolic blood pressure ≥90 mm Hg). Since lifestyle modifications have
not helped, the next step is to institute drug therapy. JNC 7 guidelines
state that in patients with stage 2 hypertension, two-drug combination
therapy is indicated. The most common regimen would be a thiazide
296 Family Medicine
diuretic along with either an ACE inhibitor, ARB, β-blocker, or calcium

channel blocker.
457. The answer is d. (McPhee, pp 319-320.) The patient in this ques-

tion has coarctation of the aorta. The usual presentation is hypertension.
Hypertension is present in the arms, but is low or normal in the legs.
Femoral pulsations are weak or absent. Correction of the defect should
be considered if the gradient is greater than 20 mm Hg, not based on level
of blood pressure. Age is not a consideration for repair. Oftentimes, even
after surgical correction, patients continue to be hypertensive for years,
based on permanent changes in the rennin-angiotensin system. Her ECG
will likely show left ventricular hypertrophy, and her chest radiograph will
likely show rib notching. More than 50% of people with coarctation also
have bicuspid aortic valve.
458. The answer is b. (Mengel, pp 538-547.) Baseline laboratory screening

is important to assess for end-organ damage and identify patients at high
risk for cardiovascular complications. The routine tests for a newly diag-
nosed hypertensive patient include: hemoglobin and hematocrit, potas-
sium, creatinine, fasting glucose, calcium, a fasting lipid profile, urinalysis,
and a resting electrocardiogram. Other tests are not indicated unless physi-
cal examination or history makes them likely to be positive.
459. The answer is b. (Mengel, pp 538-547.) The patient described in

the question has physical examination findings consistent with renal
artery stenosis. An ACE-inhibitor renal scan or renal magnetic resonance
angiography would evaluate this. Urinary metanephrines and vanilly-
mandelic acid levels would help rule out pheochromocytoma. A chest
x-ray would be helpful if coarctation of the aorta were suspected. An
aortic CT would help to or quantify an aortic aneurysm, and an echocar-
diogram would help to identify left ventricular hypertrophy or systolic
dysfunction.
460. The answer is a. (Mengel, pp 538-547.) JNC 7 recommended that

low-dose diuretics are the most effective first-line treatment for preventing
the occurrence of cardiovascular morbidity and mortality. However, recent
AHA scientific statement reported that evidence supports the use of ACE
inhibitors, ARB, calcium channel blockers, or thiazide diuretics singly or in
combination as first-line therapy.
461. The answer is c. (Mengel, pp 538-547.) The PROGRESS study (Per-

indopril Protection against Recurrent Stroke Study) found that an ACE in-
hibitor and diuretic in combination are effective in preventing recurrent
stroke.
462. The answer is b. (Mengel, pp 538-547.) Several clinical trials have

documented the benefit of ACE inhibitors in patients with hypertension
and chronic kidney disease. Angiotension receptor blockers are also
beneficial.
463. The answer is e. (McPhee, pp 416-445.) The British Hypertension

Society developed recommendations to help practitioners devise an opti-
mal treatment regimen when combining antihypertensives. They recom-
mend that persons younger than 55 years who are not black start an ACE
inhibitor as first-line therapy (A). β-Blockers (B) can be used in this group,
but are no longer considered ideal first-line therapy. In persons who are
older than 55 years or black, the first-line therapy is either a calcium chan-
nel blocker (C) or a diuretic (D). If one medication does not control the
blood pressure, the next step is to add an agent from the other category. For
example, if you have an “A” or “B” medication, add a “C” or “D” medica-
tion. If that still doesn’t control the blood pressure, use A (or B) + C + D.
Those still resistant should consider an α-blocker or other agent.
464. The answer is b. (Mengel, pp 548-558.) Atypical angina occurs when

the patient experiences pain that has the quality and characteristics of an-
gina, or occurs with exertion, but not both. For example, atypical angina
may be a sense of heaviness not consistently related to exertion or relieved
by rest, or it may be pain with an atypical character (sharp or stabbing) but
predictably brought on by exercise and relieved by rest. Classic angina has
both features. Anginal equivalent occurs when dyspnea is the sole or major
manifestation. Nonanginal pain has neither the quality nor the precipitants
of angina. “Atypical nonanginal pain” is not a term used to describe chest
pain.
465. The answer is c. (Mengel, pp 548-558.) An anginal equivalent oc-

curs when a patient has no chest pain, but has other symptoms of cardiac
ischemia (eg, dyspnea) that is predictably precipitated by exertion and
relieved by rest. Atypical angina occurs when the patient experiences
pain that has the quality and characteristics of angina, or occurs with
298 Family Medicine
exertion, but not both. Nonanginal pain has neither the quality nor the
precipitants of angina. “Atypical nonanginal pain” is not a term used to
describe chest pain.
466. The answer is d. (Mengel, pp 548-558.) Nonanginal pain has neither

the quality nor the precipitating features of angina. Typical descriptive terms
of nonanginal pain include “stabbing,” “shooting,” “knifelike,” “jabbing,” and
“tingling.” Atypical angina occurs when the patient experiences pain that has
the quality and characteristics of angina, or occurs with exertion, but not
both. Anginal equivalent occurs when dyspnea is the sole or major manifes-
tation. “Atypical nonanginal pain” is not a term used to describe chest pain.
467. The answer is b. (McPhee, pp 342-349.) The standard provocative

test for ischemic heart disease is an exercise treadmill test. However, certain
ECG abnormalities make the standard ETT unreadable. These include left
ventricular hypertrophy with strain, left bundle branch block (shown in the
question), and ST-segment baseline abnormalities in the precordial leads. In
this case, a thallium ETT is preferred, as long as the patient can exercise.
468. The answer is d. (Mengel, pp 548-558.) Poor prognostic signs in

an ETT include failure to complete stage II of a Bruce protocol, failure to
achieve a heart rate greater than 120 beats/min (off β-blockers), onset of
ST-segment depression at a heart rate less than 120 beats/min, having
ST-segment depression greater than 2.0 mm, having ST-segment depression
lasting more than 6 minutes into recovery, poor systolic blood pressure
response to exercise, angina or ventricular tachycardia with exercise and
ST-segment depression in multiple leads.
469. The answer is e. (Mengel, pp 548-558.) Tolerance is the most sig-

nificant issue to consider when using nitrates for stable angina. Toler-
ance develops rapidly when long-acting nitrates are given. When using
a patch, it is important to have intervals of 10 to 12 hours without the
patch to retain the antianginal effect. Headache and fatigue may be
important side effects, but are more of a nuisance than an important
consideration. The medications can be used with β-blockers and calcium
channel blockers.
470. The answer is c. (Mengel, pp 548-558.) All β-blockers, regardless of

their selectivity, are equally effective in treating angina. About 20% of patients
do not respond. The dose should be adjusted to achieve a heart rate of 50

to 60 beats/min.
471. The answer is c. (McPhee, pp 1202-1206.) Current data estimates

that 65% of Americans are overweight and more than 30% are obese. Fam-
ily physicians should be familiar with the use of BMI as an indicator of
obesity and subsequent health risks. The BMI is determined by dividing
the patient’s weight in kilograms by the square of the height in meters. A
BMI greater than 25 kg/m2 is classified as overweight. A BMI greater than
30 kg/m2 is considered obese, a BMI greater than 35 kg/m2 is considered
“class II obesity,” and a BMI greater than 40 kg/m2 is considered “class III
obesity” or extreme obesity.
472. The answer is d. (McPhee, pp 1202-1206.) Unfortunately, only 20%

of patients will lose 20 lb and maintain the weight loss for 2 years using
conventional dietary techniques. Only 5% can maintain a 40 lb weight
loss. Those who are successful report continued close contact with their
health care provider. Most successful programs are multidisciplinary and
include a low-calorie diet, behavior modification, exercise, and social
support.
473. The answer is a. (McPhee, pp 1202-1206.) The history and physical

examination are of utmost importance when evaluating the obese patient.
Less than 1% of obese patients have a secondary nonpsychiatric cause for
their obesity. Hypothyroidism and Cushing syndrome are important
examples that can generally be detected by history and physical (but would
need additional testing if historical features or physical findings point in
that direction). Laboratory evaluation is necessary, however, to assess the
medical consequences of obesity, and include fasting glucose, LDL, HDL,
and triglyceride levels.
474. The answer is d. (McPhee, pp 1202-1206.) Medications to treat obe-

sity are available over the counter and by prescription. While controversy
exists, the NIH clinical guidelines state that medications may be used as
part of a comprehensive weight management plan. Appetite suppressants
can be amphetamines (but those carry a significant risk for abuse) or non-
amphetamine. Sibutramine (Meridia) is a prescription serotonin/norepi-
nephrine blocker. There is a selective cannabinoid-1 receptor antagonist
called rimonabant under investigation that looks promising, but future
300 Family Medicine
studies will help determine its place in the management of obesity. Orlistat
blocks fat absorption from the GI tract.
475. The answer is b. (McPhee, pp 1202-1206.) Bariatric surgery is an in-

creasingly more common treatment option for severe obesity. In the United
States, the most common procedure performed is the Roux-en-Y gastric
bypass. The procedure can result in substantial weight loss, up to 50% of
the initial weight in some studies. Complications are common and occur
with about 40% of the cases. Operative mortality is actually quite low 0%
to 1% in the first 30 days. Nutritional deficiencies are common postopera-
tively, and patients require life-long supplementation. Because of the risks
of the surgery, bariatric surgery is limited to those with a BMI >40 kg/m2,
or >35 kg/m2 if there are obesity-related comorbidities present.
476. The answer is e. (Mengel, pp 565-575.) Several medications are

approved in the United States for the pharmacotherapy of obesity. Unfortu-
nately, none consistently demonstrate maintenance of weight loss once the
medications are discontinued. Orlistat is a gastrointestinal lipase inhibitor and
boasts a 9% average weight loss, but a significant regain after medications are
discontinued. Phentermine is a noradrenergic agonist that allows its users to
lose 3 to 4 kg more than placebo, but regain is also very common. Sibutramine
is a mixed noradrenergic/serotonergic agonist that demonstrates a 5% to 8%
weight loss, but a significant regain of weight once off medication. Rimona-
bant is a cannabinoid receptor antagonist approved in the United Kingdom
that demonstrates 4 to 5 kg more weight loss than placebo, but demonstrates
almost 100% regain of weight once medication is discontinued.
477. The answer is d. (South-Paul, pp 298-309.) Osteoporosis is because

of poor acquisition of bone mass or accelerated bone loss. African Ameri-
cans are less at risk than Caucasians or Asians. There is no evidence that
oral contraceptive use increases risk. Obesity is considered to be protec-
tive because of increased estrogen production, as long as the person is not
sedentary. Hyperthyroidism is a common cause of accelerated bone loss.
Breast-feeding is a significant drain on calcium stores, but studies have
shown that the associated bone mineral loss is completely reversed within
12 months of weaning.
478. The answer is a. (South-Paul, pp 298-309.) Weight-bearing activity is

known to retard bone loss. While there have been no randomized clinical
trials comparing the effect of various activities on bone mass, recommended

activities include walking, jogging, weight lifting, aerobics, stair climbing,
field sports, racquet sports, court sports, and dancing. Swimming is ques-
tionable, as it is not weight-bearing. There is no data on cycling, skating,
or skiing.
479. The answer is e. (South-Paul, pp 298-309.) Primary osteoporosis

refers to deterioration of bone mass not associated with other chronic ill-
nesses or problems. History and physical are neither sensitive enough nor
sufficient for the diagnosis of primary osteoporosis. While decreased serum
calcium may indicate malabsorption or a vitamin D deficiency, it is not
useful as a diagnostic tool for osteoporosis. Measures of bone turnover, like
serum human osteocalcin levels, are of research interest, but are not useful
for screening. Imaging studies are best.
480. The answer is d. (South-Paul, pp 298-309.) Plain radiographs are not

sensitive enough to diagnose osteoporosis until total density has decreased
by 50%. Single- and dual-photon absorptiometry provide poor resolution
and are less accurate than other methods. DEXA scanning is most precise
and is the test of choice. Quantitative CT scanning is the most sensitive, but
exposes patients to significant levels of radiation.
481. The answer is c. (South-Paul, pp 298-309.) Bone densitometry pro-

vides a T-score (the number of standard deviations above or below the
mean matched to YOUNG controls) and a Z-score (the number of standard
deviations above or below the mean-matched to age-matched controls).
Z-scores are of little value to clinicians. A T-score more than 2.5 standard
deviations below the mean (a score of −2.5 or lower) indicates osteoporosis.
482. The answer is c. (South-Paul, pp 298-309.) Calcitonin directly

inhibits osteoclastic bone resorption and is considered a reasonable treatment
alternative for patients with established osteoporosis in whom estrogen-
replacement therapy is not recommended. It has the unique characteristic
of producing an analgesic effect with respect to bone pain and is often pre-
scribed for patients who have suffered an acute osteoporotic fracture.
483. The answer is c. (South-Paul, pp 298-309.) Bisphosphonates work

by binding to the bone surface and inhibiting osteoclastic activity. Vitamin
D increases absorption of calcium in the GI tract. Estrogen and selective
302 Family Medicine
estrogen receptor modulators (raloxifene or Evista) work by blocking the

activity of cytokines. Fluoride stimulates osteoblasts, but does not result in
the formation of normal bone.
484. The answer is b. (South-Paul, pp 577-584.) Depression is commonly

seen in primary care settings. In fact, it is estimated that only about 20%
of depression-related health care occurs in mental health care settings.
Nonpsychiatrists write approximately 80% of the prescriptions for anti-
depressants. Patients with major depressive disorder often present with
vague physical symptoms rather than emotional complaints. To make the
diagnosis of depression using DSM criteria, the patient must describe either
depressed mood for most of the day nearly every day for at least 2 weeks, or
loss of interest in usually enjoyable activities. Irritable mood may take the
place of depressed mood to make the diagnosis as well. In addition to one
of those two symptoms, the patient must experience other symptoms of
depression, including sleep changes, feelings of guilt or worthlessness, loss
of energy, loss of concentration, change in appetite, psychomotor speeding
or slowing, or suicidal thoughts, plans, or intent.
485. The answer is b. (McPhee, pp 996-997.) The disorder described is

posttraumatic stress disorder (PTSD)—a syndrome characterized by reex-
periencing a traumatic event. Alcohol and drugs are commonly used by the
patient to self-treat. Antidepressants are helpful to ameliorate the symp-
toms, with sertraline and paroxetine having FDA indications for treatment
of this disorder. Alprazolam can be used, but there is significant concern
for dependency problems. Sometimes antiepileptic medications can be
used, but more studies are needed, and the FDA has not approved them
for this disorder.
486. The answer is d. (Mengel, pp 690-699.) Physicians have various

treatment options for depression. Studies have shown that the combination
of medication and therapy offer the best treatment outcomes. However,
antidepressants alone are effective in about 50% to 60% of patients with
major depression. If a patient fails to respond to one medication, he or she
may respond to another. At least 80% of patients with major depression
will respond to at least one antidepressant medication. In order to prevent
relapse, treatment should continue for 6 to 9 months. ECT has a high rate
of therapeutic success, but is reserved for those who do not respond to
other modalities of treatment.
487. The answer is e. (Mengel, pp 690-699.) While many of the newer

antidepressants are well-tolerated, physicians should be familiar with the
adverse effects and contraindications for their use. Nefazodone should not
be used in patients with liver disease. Hypertension is a relative contrain-
dication to venlafaxine. Patients experiencing hypersomnia and motor
retardation should avoid nefazodone and mirtazapine. Patients who report
agitation and insomnia should avoid bupropion and venlafaxine.
Mirtazapine and tricyclic antidepressants are less preferred for patients
with obesity. Bupropion is contraindicated for patients with seizure disorder.
488. The answer is d. (Mengel, pp 699-708.) Eating disorders are psy-

chologic disorders in which the person afflicted has an altered perception
of body weight or shape and disturbances of eating behavior. Distinguish-
ing between anorexia and bulimia may be important from a treatment
standpoint. Some characteristics are common to both eating disorders,
while other characteristics may help to differentiate them. Both disorders
involve self-evaluation that is unduly influenced by body weight and/or
shape. While binge eating or purging are considered characteristics of bu-
limia, there is a binge eating/purging subtype of anorexia that involves
that behavior as well. Both bulimics and binge eating/purging subtypes of
anorexics may use diuretics, enemas, and laxatives. Both engage in inap-
propriate behaviors to prevent weight gain. However, bulimics sense a
lack of control over eating during episodes of binging, while anorexics
often feel a strong sense of control. This is a characteristic that may help
distinguish the two.
489. The answer is a. (McPhee, pp 1019-1032.) In some bipolar patients,

the diagnosis is made after the initiation of an antidepressant allows the
patient to cycle into a manic phase. All the medications listed in this
answer can be used to help bipolar disorder, but only the neuroleptics will
be of benefit in the acute phase. Lithium, valproic acid, carbamazepine,
and lamotrigine are all excellent options for maintenance once the acute
mania is under control.
490. The answer is b. (Mengel, pp 664-681.) Of children diagnosed with

ADHD, 50% to 75% will continue to exhibit symptoms into adulthood. In
adults, symptoms of ADHD may be more subtle, and symptoms may actu-
ally change. Deficits in executive function tend to be more salient (poor
organization or time management) and the “hyperactivity” of childhood
304 Family Medicine
may be replaced by restlessness. Patients with impulsivity as a child may

replace that with difficulty monitoring behavior or modulating emotional
intensity.
491. The answer is c. (Mengel, pp 664-681.) The symptoms of ADHD

can change over time. While hyperactivity and impulsivity tend to peak
between the ages of 6 and 10, inattention remains relatively stable through
the lifespan of the illness. Oppositional behavior and conduct disorders
may be comorbid, but are not necessarily features of ADHD.
492. The answer is d. (Mengel, pp 664-681.) When screening for ADHD,

a thorough history and physical should be completed, and behavioral
rating forms should be reviewed. Laboratory testing should be obtained
to rule out other causes of symptoms, and include blood chemistries, a
thyroid stimulating hormone, and a lead level. Most children with ADHD
will have normal laboratory values, but these tests can exclude other causes
of symptoms.
493. The answer is e. (Mengel, pp 664-681.) While all the symptoms list-
ed are part of ADHD, hyperactivity across multiple settings is the classic,
distinguishing feature of ADHD. Parents and teachers describe these chil-
dren as being in constant motion. Hyperactivity is the most problematic
feature for children with ADHD because it tends to be most disruptive and
socially unacceptable.
494. The answer is b. (Mengel, pp 664-681.) Stimulant medications for

ADHD are controlled substances. While it is true that they can be abused,
the preparations do not produce the euphoric effect of other stimulant
medications if taken by the oral route. Some people do produce a euphoric
effect by crushing and snorting the short-acting preparations. Regardless,
stimulants are acceptable to prescribe in adolescents. In fact, studies have
shown that treating ADHD in adolescents actually decreases the risk of
substance abuse when compared to children not treated.
495. The answer is a. (South-Paul, pp 392-402.) The most common cause

of thyroiditis is chronic lymphocytic thyroiditis (also called Hashimoto thy-
roiditis). It is the most common cause of goiter in the United States. Gener-
ally seen in middle-aged women, this generally presents with enlargement
of the thyroid, and most often there is associated tenderness. Subacute
lymphocytic thyroiditis is less common, and although an acute increase

in thyroid size is seen, it is generally nontender. Subacute granulomatous
thyroiditis usually follows a viral illness and is also associated with a mildly
painful gland. Suppurative thyroiditis is rare, and is associated with fever,
a swollen thyroid, and clinical manifestations of a bacterial illness. Invasive
fibrous thyroiditis presents as a gradually increasing gland that is firm, but
is nontender.
496. The answer is c. (Mengel, pp 634-643.) Hyperthyroidism results from

elevated levels of thyroid hormones and is less common than hypothyroid-
ism in the general population. While most people think of fatigue as be-
ing a symptom of hypothyroidism, it is actually the second most common
reported symptom for hyperthyroidism. Weight loss, tremor, anorexia, and
increased sweating all occur with less frequency. Only tachycardia is more
commonly reported.
497. The answer is e. (Mengel, pp 664-681.) Subclinical hypothyroidism

is distinguished by an elevated TSH and a normal free T4. This condition
occurs in 4% to 8% of the general population. It will progress to clini-
cal hypothyroidism at a rate of 2% to 5% per year. Risk for progression
includes the presence of thyroid autoantibodies, old age, a female gender,
and a TSH level greater than 10 mIU/L. Patients who do not progress are
considered euthyroid with a reset thyrostat, and they should be monitored
clinically and biochemically on an annual basis. Antithyroid peroxidase
levels would help to diagnose autoimmune thyroiditis, but would not be
helpful in this case. Starting thyroxine would be appropriate if the TSH was
greater than 10 mIU/L, but not if the levels were only slightly elevated.
498. The answer is a. (South-Paul, pp 392-402.) Primary hypothyroid-

ism is common, usually a result of Hashimoto thyroiditis or after Graves
disease. In this case, the TSH would be elevated, and the free T3 and T4
would be low. Secondary hypothyroidism is related to hypothalamic or
pituitary dysfunction. Iodine deficiency is a cause of primary hypothyroid-
ism. Subclinical hypothyroidism is when the TSH is elevated, but the T3
and T4 are normal. Thyroid resistance would present with the TSH, T3, and
T4 all being elevated.
499. The answer is c. (South-Paul, pp 392-402.) Thyroid receptor anti-

bodies are very specific and differentiate Graves disease from other causes
306 Family Medicine
of hyperthyroidism. The TSH and free thyroid hormones are nonspecific,

and only identify hyperthyroidism. Radionucleotide imaging is helpful in
Graves, showing diffuse uptake, but is not necessarily specific. Thyroid
ultrasonography can identify nodules, but is also a nonspecific test for dif-
ferentiating causes of hyperthyroidism.
500. The answer is b. (South-Paul, pp 392-402.) Once a thyroid nodule is

found, the next step in the workup is radionucleotide imaging. If a nodule
takes up radiotracer, it is termed a “hot” nodule. Colloidal cysts and tumors
do not take up tracer and are “cold” nodules. Therefore, “hot” nodules are
more likely benign. Neurofibromas would also be “cold.” Definitive diag-
nosis can be made through needle aspiration.

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Chronic Conditions

343. The answer is d. (South-Paul, pp 182-189.) The sexual response is

344. The answer is b. (South-Paul, pp 182-189.) In patients with

345. The answer is e. (South-Paul, pp 182-189.) Tricyclics and SSRIs fre-

346. The answer is b. (South-Paul, pp 182-189.) Premature ejaculation is

347. The answer is c. (Mengel, pp 744-759.) In men with erectile disor-

348. The answer is a. (Mengel, pp 744-759.) Diagnostic and Statistical Man-

349. The answer is a. (Mengel, pp 744-759.) Treatment for sexual dys-

350. The answer is c. (Mengel, pp 644-654.) Most clinicians agree that

352. The answer is a. (South-Paul, pp 614-625.) An elevated MCV is 96%

353. The answer is b. (Mengel, pp 644-654.) Drugs used for addiction

354. The answer is a. (Mengel, pp 644-654.) Disulfiram cause the body

355. The answer is d. (South-Paul, pp 614-625.) Disulfiram, naltrexone,

356. The answer is a. (South-Paul, pp 626-633.) Nicotine-replacement

357. The answer is c. (South-Paul, pp 614-625.) Varenicline is a selective

358. The answer is d. (South-Paul, pp 614-625.) Behavioral intervention

studies have shown that it doubles the rate of abstinence. Clonidine

359. The answer is c. (Bope, pp 1118-1122.) Stopping cocaine use does

360. The answer is c. (Bope, pp 1118-1122.) Opiate withdrawal is well-

361. The answer is a. (South-Paul, pp 233-248.) The picture shown

362. The answer is b. (South-Paul, pp 233-248.) Osteoarthritis is charac-

363. The answer is c. (South-Paul, pp 233-248.) The patient’s history is

364. The answer is e. (South-Paul, pp 233-248.) RA is characterized by

365. The answer is e. (South-Paul, pp 233-248.) Oral steroids have a strong

injections per year to avoid hastening of the osteoarthritic process. Ketorolac

366. The answer is d. (South-Paul, pp 233-248.) An evaluation of the joint

367. The answer is b. (South-Paul, pp 233-248.) The crystals typical of

368. The answer is c. (South-Paul, pp 233-248.) Infectious arthritis, gout,

369. The answer is d. (South-Paul, pp 233-248.) Fluid aspirated from

370. The answer is a. (South-Paul, pp 233-248.) While a short course of

371. The answer is a. (South-Paul, pp 233-248.) Extra-articular manifesta-

372. The answer is b. (McPhee, pp 240-256.) Asthma is common, affect-

373. The answer is a. (McPhee, pp 240-256.) The most important com-

374. The answer is c. (South-Paul, pp 274-288.) Asthma is classified by

375. The answer is d. (South-Paul, pp 274-288.) The patient described in

376. The answer is c. (South-Paul, pp 274-288; McPhee, pp 240-256.) Peak

377. The answer is c. (McPhee, pp 240-256.) In 2007, the National Asth-

378. The answer is b. (McPhee, pp 240-256.) The patient described in this

380. The answer is e. (McPhee, pp 240-256.) Multiple studies have shown

381. The answer is a. (Mengel, pp 300-306.) Spondylolisthesis is an anterior

382. The answer is b. (Mengel, pp 300-306.) Inflammatory conditions

383. The answer is b. (Mengel, pp 300-306.) MRI is indicated for people

384. The answer is a. (Mengel, pp 300-306.) It is recommended that

385. The answer is c. (Mengel, pp 300-306.) Treatment for chronic low

386. The answer is c. (Mengel, pp 468-479.) Chronic bronchitis is defined

387. The answer is e. (McPhee, pp 256-262.) The single most important

388. The answer is e. (Mengel, pp 468-479.) The patient described in the

389. The answer is b. (McPhee, pp 256-262.) Bronchodilators do not

390. The answer is d. (McPhee, pp 256-262.) Antibiotics are commonly

391. The answer is d. (Bope, pp 741-746.) Weight, diabetes, and hyper-

392. The answer is e. (Bope, pp 741-746.) The kidney’s role in concentrat-

in later stages of kidney disease. The kidney is the source of erythropoietin,

393. The answer is d. (Bope, pp 741-746.) According to National Kidney

394. The answer is d. (Bope, pp 741-746.) The patient’s laboratory val-

395. The answer is d. (McPhee, pp 878-886.) The long-term complications

397. The answer is a. (Mengel, pp 462-467.) Nonsteroidal anti-

suspected. One NSAID is not superior to another, and periodic substitu-

398. The answer is c. (Mengel, pp 462-467.) There are many agents to

399. The answer is c. (Mengel, pp 462-467.) In chronic nonmalignant

400. The answer is e. (Mengel, pp 479-485.) Determining the cause of