Docsity
Log inSign up
Docsity
Prepare for your exams
Prepare for your exams

Study with the several resources on Docsity

Earn points to download
Earn points to download

Earn points by helping other students or get them with a premium plan

Guidelines and tips
Guidelines and tips
Sell on Docsity
Sell on Docsity
Log inSign up

Prepare for your exams

Study with the several resources on Docsity

Find documents

Prepare for your exams with the study notes shared by other students like you on Docsity

Search Store documents

The best documents sold by students who completed their studies

Search through all study resources
Docsity AINEW

Summarize your documents, ask them questions, convert them into quizzes and concept maps

Explore questions

Clear up your doubts by reading the answers to questions asked by your fellow students

Earn points to download

Earn points by helping other students or get them with a premium plan

Share documents
download point icon20 Points

For each uploaded document

Answer questions
download point icon5 Points

For each given answer (max 1 per day)

All the ways to get free points
Get points immediately

Choose a premium plan with all the points you need

Study Opportunities

Choose your next study program

Get in touch with the best universities in the world. Search through thousands of universities and official partners

Community

Ask the community

Ask the community for help and clear up your study doubts

University Rankings

Discover the best universities in your country according to Docsity users

Free resources

Our save-the-student-ebooks!

Download our free guides on studying techniques, anxiety management strategies, and thesis advice from Docsity tutors

From our blog

Exams and Study
Go to the blog

Medical Case Studies: Diagnosis and Treatment, Exams of Nursing

University of SouthamptonNursing

A series of medical case studies, each focusing on a specific patient scenario. The cases cover a range of medical conditions, including tuberculosis, osteomyelitis, hodgkin lymphoma, de quervain's tenosynovitis, osteoarthritis, rotator cuff injury, and more. For each case, the document provides a brief description of the patient's symptoms, relevant medical history, and diagnostic findings. It then presents multiple-choice questions related to the diagnosis and treatment of the condition, followed by the correct answer and a brief explanation. A valuable resource for medical students, residents, and practicing physicians seeking to enhance their knowledge of common medical conditions and their management.

Typology: Exams

2024/2025

Available from 02/18/2025

NurseTakshif
NurseTakshif 🇬🇧

4

(4)

1.3K documents

1 / 31

Toggle sidebar

This page cannot be seen from the preview

Don't miss anything!

bg1
BUTTARO EXAMS WITH VERIFIED QUESTIONS
AND CORRECT ANSWERS
A 25-year-old patient has a tuberculosis (TB) skin test which reveals an area of induration of 12
mm. The patient is a recent immigrant from Mexico and lives in a homeless shelter. What is the
recommended treatment for this patient?
a. Administer the bacillus Calmette-Guérin (BCG) vaccine
b. Begin isoniazid (INH) preventive therapy
c. Order isoniazid (INH) and Rifampin d. Perform regular TB skin testing every few months
- ANSWERS-B -Patients younger than 35 who have any risk factors for TB and with an area of
induration 10 mm should be considered for INH preventive therapy. This patient is an immigrant
from Mexico and lives in a homeless shelter, so TB preventive therapy is acceptable. BCG vaccine
is not helpful. INH and Rifampin are used if patients develop symptoms or if there is antibiotic
resistance.
A 3-year-old child has marked pain in one leg localized to the upper tibia with refusal to bear
weight. The child has a high fever and a toxic appearance. Which type of osteomyelitis is most
likely?
a. Chronic osteomyelitis
b. Hematogenous osteomyelitis
c. Osteomyelitis from a contiguous focus
d. Peripheral vascular disease osteomyelitis
- ANSWERS-ANS: B
Young children are more likely to have hematogenous osteomyelitis, especially with acute
symptoms. Chronic osteomyelitis is more common with underlying diseases such as diabetes.
Contiguous focus osteomyelitis occurs when organisms are introduced from a puncture wound,
foreign body, or adjoining soft tissue infection. Peripheral vascular causes are more common in
chronically ill patients.
A 30-year-old male patient is diagnosed with Hodgkin lymphoma. Initial lab work reveals a
WBC of 20, hemoglobin of 10.1 gm/dL, a serum albumin of 3 g/dL, and lymphopenia of 0.5.
Staging studies identify stage III disease. What is this patient's prognostic score?
a. 2
b. 3
c. 4
d. 5
- ANSWERS-C -Risk factors for lymphoma include age >45 years, male gender, serum albumin
<4, Hb <10.5, stage IV disease, WBC >15, and lymphopenia <0.6. This patient has 4 risk
factors.
pf3
pf4
pf5
pf8
pf9
pfa
pfd
pfe
pff
pf12
pf13
pf14
pf15
pf16
pf17
pf18
pf19
pf1a
pf1b
pf1c
pf1d
pf1e
pf1f

Partial preview of the text

Download Medical Case Studies: Diagnosis and Treatment and more Exams Nursing in PDF only on Docsity!

BUTTARO EXAMS WITH VERIFIED QUESTIONS

AND CORRECT ANSWERS

A 25-year-old patient has a tuberculosis (TB) skin test which reveals an area of induration of 12 mm. The patient is a recent immigrant from Mexico and lives in a homeless shelter. What is the recommended treatment for this patient? a. Administer the bacillus Calmette-Guérin (BCG) vaccine b. Begin isoniazid (INH) preventive therapy c. Order isoniazid (INH) and Rifampin d. Perform regular TB skin testing every few months

  • ANSWERS-B - Patients younger than 35 who have any risk factors for TB and with an area of induration 10 mm should be considered for INH preventive therapy. This patient is an immigrant from Mexico and lives in a homeless shelter, so TB preventive therapy is acceptable. BCG vaccine is not helpful. INH and Rifampin are used if patients develop symptoms or if there is antibiotic resistance. A 3-year-old child has marked pain in one leg localized to the upper tibia with refusal to bear weight. The child has a high fever and a toxic appearance. Which type of osteomyelitis is most likely? a. Chronic osteomyelitis b. Hematogenous osteomyelitis c. Osteomyelitis from a contiguous focus d. Peripheral vascular disease osteomyelitis
  • ANSWERS-ANS: B Young children are more likely to have hematogenous osteomyelitis, especially with acute symptoms. Chronic osteomyelitis is more common with underlying diseases such as diabetes. Contiguous focus osteomyelitis occurs when organisms are introduced from a puncture wound, foreign body, or adjoining soft tissue infection. Peripheral vascular causes are more common in chronically ill patients. A 30-year-old male patient is diagnosed with Hodgkin lymphoma. Initial lab work reveals a WBC of 20, hemoglobin of 10.1 gm/dL, a serum albumin of 3 g/dL, and lymphopenia of 0.5. Staging studies identify stage III disease. What is this patient's prognostic score? a. 2 b. 3 c. 4 d. 5
  • ANSWERS-C - Risk factors for lymphoma include age >45 years, male gender, serum albumin <4, Hb <10.5, stage IV disease, WBC >15, and lymphopenia <0.6. This patient has 4 risk factors.

A 40-year-old woman reports pain at the thumb base in one hand radiating to the distal radius. The provider learns that the woman knits for a hobby and is able to elicit the pain by asking the patient to pour water from a pitcher. Which condition is suspected in this patient? a. Carpal tunnel syndrome b. Palmar fibrosis c. De Quervain's Tenosynovitis d. Trigger finger

  • ANSWERS-C - De Quervain's tenosynovitis causes pain as described and occurs more in women between 30 and 59 years who engage in activities requiring excessive repetitive motions, such as knitting. Carpal tunnel syndrome presents with intermittent wrist pain, numbness, and tingling radiating from the palm to the thumb, index finger, middle finger, and medial aspect of the ring finger. Palmar fibrosis causes contractures, usually of the ring finger. Trigger finger causes nodules in tendons that catch on the finger pulley and impede movement. A 45-year-old patient has mild osteoarthritis in both knees and asks about nonpharmacologic therapies. What will the provider recommend? a. Aerobic exercise b. Glucosamine with chondroitin c. Therapeutic magnets or copper bracelets d. Using a cane or walker
  • ANSWERS-A-Aerobic exercise helps with cardiovascular conditioning and weight reduction as well as improved range of motion, decreased pain, and strengthening of supporting structures. Randomized controlled studies have failed to demonstrate significant pain relief with glucosamine. Therapeutic magnets and copper have not been proven to be effective. A young patient with mild symptoms will not need assistive devices and should focus on conditioning. A 45-year-old patient reports a recent onset of unilateral shoulder pain which is described as diffuse and is associated with weakness of the shoulder but no loss of passive range of motion. What does the provider suspect as the cause of these symptoms? a. Acromioclavicular joint disease b. Cervical radicular pain c. Glenohumeral arthritis d. Rotator cuff injury
  • ANSWERS-: D --Rotator cuff injury is usually characterized by diffuse pain, weakness of the joint, but no change in range of motion. Acromioclavicular joint disease is associated with anterior- superior shoulder pain. Glenohumeral arthritis has similar symptoms, but with loss of range of motion. Cervical radicular pain is characterized by pain distal to the elbow A 50-year-old patient presents with supraclavicular lymphadenopathy. Which action is correct? a. Consult with an oncologist for evaluation. b. Perform testing for sexually transmitted infections. c. Reassure the patient that this will resolve. d. Treat empirically with an antibiotic
  • ANSWERS-A- In patients over 40 years old, supraclavicular lymphadenopathy is likely to be cancerous in 90% of cases, so an oncologist should be consulted. STI causes are not associated with supraclavicular lymphadenopathy. Because this is likely to be cancer, reassuring the patient is not appropriate. Empirical antibiotic therapy is not indicated.

severe deficiency, characterized by neurologic findings, which this patient does not have. Methylmalonic acid level will decrease. A 60-year-old patient reports new onset of bilateral shoulder pain with morning stiffness lasting approximately 1 hour. Which will be included in initial diagnostic testing for this patient? (Select all that apply.) a. Antinuclear antibodies b. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) c. Liver function tests (LFTs) d. Protein electrophoresis e. Serum calcitonin

  • ANSWERS-B, C, D-- ESR, CRP, and protein electrophoresis are included in the initial diagnostic workup when polymyalgia rheumatica is suspected. ANA testing is not specific for this disorder. Serum calcitonin is not indicated. A 65-year-old patient who has not had an influenza vaccine is exposed to influenza and comes to the clinic the following day with fever and watery, red eyes. What will the provider do initially? a. Administer LAIV influenza vaccine b. Begin treatment with an antiviral medication c. Observe for improvement or worsening for 24 hours d. Perform a nasal swab for RT-PCR assay
  • ANSWERS-D-Samples to isolate the virus should be collected within 12 to 36 hours of onset of illness and this should be performed to confirm the disease. Administration of the LAIV influenza vaccine will not prevent symptoms in this patient, is not recommended in persons over 59 years of age, and is contraindicated when also giving antiviral medications. Antiviral drugs should be started within 48 hours of onset of illness and may be started empirically while waiting on cultures because this patient is higher risk than younger patients. Because identification of the virus and effectiveness of treatment are time-limited, it is not correct to watch and wait for symptoms to worsen. A 70-year-old patient reports frequent infections, shortness of breath, fatigue, and palpitations. An exam reveals pallor and petechiae. The provider orders a peripheral blood smear and bone marrow biopsy. Which findings are consistent with a diagnosis of myelodysplasia? (Select all that apply.) a. Anisocytosis and poikilocytosis of erythrocytes on peripheral smear b. Defects in cellular maturation in all cell lines in bone marrow aspirate c. Hypercellular bone marrow with peripheral cytopenia d. Larger than normal megakaryocytes in bone marrow e.Smaller than normal granulocytes in the peripheral blood smear
  • ANSWERS-A,b,C,D-- The key finding in MDS is packed, hypercellular bone marrow with peripheral cytopenia. Erythrocytes in peripheral blood will show anisocytosis, poikilocytosis, or basophilic stippling. The bone marrow will have defects in all cellular maturation. Megakaryocytes in bone marrow will be smaller than normal. Granulocytes in peripheral blood will be larger than normal. A child developed cervical lymphadenopathy after a scabies infestation. One node remains enlarged 6 months after the infestation but has not increased in size. The physical examination reveals a non-tender, non-erythematous node. What will the provider tell the child's parents? a. The child may need surgical intervention. b. The child should see a pediatric oncologist.

c. The node will need to be biopsied. d. This node is most likely benign.

  • ANSWERS-D--A nodule lasting up to a year without change in size is likely to be benign, especially since the cause is known. Unless there is enlargement or infection, surgical intervention and biopsy are not indicated, and the child does not need to be evaluated by an oncologist. A child has a primary immunodeficiency and the parent asks the provider about vaccines. What will the provider tell this patient? a. Avoid all vaccines since immunizations can cause disease in this child b. Immunized with all recommended childhood vaccines to prevent serious disease c. Some vaccines are contraindicated in those with T-cell involvement only d. The child may need more vaccine boosters than other children
  • ANSWERS-C - Children with T-cell disorders should not receive live-virus vaccines, but children with humoral deficiency may be given the vaccine. Vaccines are important to help prevent disease and children with immunodeficiency should receive any vaccines that are safe for them. Not all vaccines are recommended, since live-virus vaccines can cause disease in certain children A child has a recent history of leg pain, unexplained bruising, and nosebleeds. The provider notes petechiae and diffuse lymphadenopathy. A complete blood count reveals a white blood cell (WBC) of 30,000 cells/mm3 and near normal red blood cell (RBC) and platelet counts. What will the provider do next to manage this patient? a. Order coagulation studies to evaluate for coagulopathies b. Perform biochemical studies to look for hyperuricemia c. Refer to a specialist for a bone marrow aspirate and biopsy d. Repeat the complete blood count in 2 weeks
  • ANSWERS-C --Patients with acute lymphocytic leukemia (ALL) may have normal blood counts even when the marrow has been replaced with leukemic cells, so a bone marrow aspirate and biopsy is required for the definitive diagnosis. Coagulation and biochemical studies may be performed after the diagnosis is known to evaluate for complications. Waiting and repeating the CBC in 2 weeks is not recommended since the definitive diagnosis is made by bone marrow biopsy. A child presenting with a high fever, bilateral conjunctivitis, and a desquamating rash is presumed to have a vasculitic disease. What is the likely treatment for this child? a. Antibiotic therapy for 10 to 14 days b. Aspirin (ASA) and intravenous immunoglobulin (IVIG) c. High-dose prednisolone therapy d. Immunosuppressant medications
  • ANSWERS-B- This patient has symptoms of Kawasaki disease. Because of the risk for coronary aneurysms and death, ASA and IVIG are indicated. Antibiotics, prednisolone, and immunosuppressants are not useful. A child weighing 20 kg has been diagnosed with iron-deficiency anemia and will begin taking an oral iron preparation. What will the provider teach the child's parents about administration of this medication? a. Iron supplements should be given with food. b. The child must take the iron for 3 months. c. The correct dose is 30 mg twice daily. d. The iron is stopped when the hemoglobin increases.
  • ANSWERS-C-- The dose for children is 3 mg/kg/day in divided doses. This child should get 60 mg/day, which is 30 mg/dose twice daily. Iron supplements are best absorbed on an empty

c. Transmission of the organism only occurs with prolonged attachment of the tick. d. Unless the child develops systemic symptoms, treatment is not indicated

  • ANSWERS-C - To transmit the spirochete to humans, the tick must be attached for an extended period of time of at least 36 hours. Serologic testing early in the disease may not be helpful. Antibiotic prophylaxis is not recommended. Treatment may begin with the presence of a localized rash. A patient brought to an emergency department after a diving accident is receiving inhaled 100% oxygen. What is the goal of this intervention? a. Enhancing oxygen delivery to ischemic tissues b. Improving oxygen saturations c. Preventing the need for recompression therapy d. Reducing the risk of neurological symptoms
  • ANSWERS-A - Breathing 100% oxygen increases the extraction of nitrogen from tissues and can enhance oxygen delivery to ischemic tissues. It is not given to improve oxygen saturations, because the oxygen level is not of concern. Patients will still need recompression therapy. Oxygen is not given to minimize neurological symptoms A patient comes to a provider with reports of unilateral arm pain and weakness with mild neck pain. The provider notes that the patient prefers holding the affected arm crossed in front of the throat. A history reveals a recent onset of sexual dysfunction. What does the provider suspect based on this history? a. Axial neck pain b. Cervical myelopathy c. Diabetic neuropathy d. Facet joint pain
  • ANSWERS-B- Patients with neurological symptoms have radicular neck pain, which is usually greater in one arm and involves neurological findings. Patients with concurrent lower extremity findings may have cervical myelopathy and should be evaluated immediately. Axial neck pain does not involve neurological findings. Diabetic neuropathy typically does not include neck pain. Facet joint pain is a cause of axial neck pain, associated with injuries and headaches A patient diagnosed with Epstein-Barr virus-associated infectious mononucleosis (EBV-IM) also has group A beta-hemolytic streptococcal pharyngitis and is being treated with amoxicillin. On the third day of treatment, the patient develops a rash. A urinalysis is normal. What does this indicate? a. A reaction to the amoxicillin b. A streptococcal rash c. Hematologic complications d. Hemolytic-uremic syndrome
  • ANSWERS-A- 80% to 100% of patients with IM who are taking amoxicillin will develop a rash. A streptococcal rash appears at the onset of symptoms, not 3 days after initiation of antibiotics. This rash does not indicate hematologic complications or hemolytic-uremic syndrome. A patient diagnosed with myelodysplastic syndrome (MDS) and presenting with severe neutropenia and anemia is given erythropoietin (EPO) with improvement in hemoglobin. Which

intervention has been shown to prevent infection in patients with MDS who have severe neutropenia? a. Anti-thymocyte globulin and cyclosporine b. Granulocyte-macrophage colony-stimulating factor (GM-CSF) c. Intravenous immunoglobulin infusions d. Prophylactic treatment with fluoroquinolones

  • ANSWERS-D --Prophylactic antibiotic therapy with fluoroquinolones in neutropenic patients has been shown in a large meta-analysis to decrease the incidence of serious infections and reduce all-cause mortality. Anti-thymocyte globulin and cyclosporine is immune suppression treatment used to reduce the need for transfusions. GM-CSF is given when there is active infection but does not decrease the actual number of infections. IVIG is not used for these patients and is not a prophylactic measure A patient experiences a second gouty flare and the provider decides to begin urate-lowering therapy (ULT). How should this be prescribed? a. Begin with a high-loading dose and gradually decrease. b. Start ULT during the current flare for best results. c. Start ULT in 5 weeks along with an anti-inflammatory drug. d. ULT should be suspended during future gouty flares.
  • ANSWERS-ANS: C Beginning therapy with a urate-lowering drug during an acute flare will prolong the flare. Typically, ULT is begun 5 to 6 weeks after a flare and should be given with an anti-inflammatory drug, since the initial period of ULT administration is associated with flares. ULT dosing should start low and gradually increase. It is not recommended to stop ULT during future flares, but to treat those flares while continuing the ULT. A patient experiencing shoulder pain is seen by an orthopedic specialist who notes erythema, warmth, and fluctuance of the shoulder joint. What is the next step in treatment for this patient? a. Admit to the hospital for intravenous antibiotics. b. Inject lidocaine into the joint and reassess in 5 to 10 minutes. c. Order a plain radiograph of the shoulder to identify possible fracture. d. Perform a shoulder ultrasound to further evaluate the cause.
  • ANSWERS-: A --Immediate referral is indicated for patients who present with symptoms consistent with septic bursitis, such as with the symptoms above. Lidocaine is injected into a painful joint to evaluate for improvement to determine whether bursitis or tendonitis is present as a result of impingement. This exam is not consistent with fracture. An ultrasound is not indicated. A patient expresses concern about contracting West Nile virus (WNV) infection after a family member becomes ill with the disease. What will the provider tell this patient? a. Human hosts may become reservoirs for infection for WNV. b. Humans may transmit the virus to mosquitoes after a bite. c. Humans must be bitten by a mosquito infected by a bird. d. Human-to-human transmission is possible with this disease.
  • ANSWERS-C-- Birds are reservoir hosts for the virus and avian-mosquito-human transmission is how the disease is contracted. Humans do not sustain high-level viremias long enough to become reservoir or amplifying hosts. Human-to-human transmission does not occur.

a program of balanced rest and exercise, and occupational therapy to improve function. NSAIDs are used for short periods. Splinting is not recommended. A patient has chronic radicular neck pain that no longer responds to over-the-counter NSAIDs and physical therapy measures and reports having difficulty sleeping. Which medication will the provider order? a. A skeletal muscle relaxant b. A tricyclic antidepressant c. An opioid analgesic d. Gabapentin

  • ANSWERS-D-Gabapentin is useful for central pain syndromes and radiculopathy and can help to restore sleep. Skeletal muscle relaxants are useful for muscle spasms. A tricyclic antidepressant is useful for some chronic neck pain, although gabapentin is more specific to this patient's symptoms. Opioid analgesics should be used cautiously. A patient has had mild acute diarrhea for 8 days. The patient is alert with normal vital signs and no abdominal discomfort but appears mildly dehydrated. Which tests will the provider perform? (Select all that apply.) a. BUN and creatinine b. Complete blood count c. Serum electrolytes d. Stool for fecal leukocytes e. Stool for occult blood
  • ANSWERS-A, B, C-- A CBC, serum electrolytes, BUN, and creatinine are standard tests for evaluation of electrolyte derangement and dehydration and should be performed in patients who appear dehydrated. Stool samples for fecal leukocytes and occult blood are taken for patients with high temperatures, bloody diarrhea, and abdominal pain. A patient has marked swelling of a shoulder joint with erythema and severe pain. The provider suspects a bacterial cause. Which culture will be most helpful to determine the cause of these symptoms? a. Blood culture b. Synovial fluid culture c. Urethral culture d. Urine culture
  • ANSWERS-ANS: B Synovial fluid culture is the most important exam for diagnosis of septic arthritis. Blood culture may be positive in only 10% of cases. Urethral culture is performed if gonococcal arthritis is suspected. Urine culture is not helpful A patient has osteomyelitis related to vascular insufficiency. Which initial consultation is necessary? a. Infectious disease consultation b. Neurosurgical consultation c. Surgical consultation d. Wound care specialist consultation
  • ANSWERS-ANS: C Because patients with vascular insufficiency who develop osteomyelitis may need debridement or draining of lesions, a surgical consult is necessary. Infectious disease consults are obtained for

patients with resistant organisms or complex wounds. Neurosurgical consults are needed for patients with epidural abscess. Wound care consults are needed for patients with progressive or chronic wounds. A patient has pain on the plantar aspect of the heel with weight bearing after rest. The pain is worsened with dorsiflexion of the foot. What is the initial treatment for this patient? a. A series of steroid injections b. Avoiding all high-impact activities c. Night splints d. Wearing flat shoes only

  • ANSWERS-B- This patient has signs of plantar fasciitis. The initial treatment includes avoiding all high-impact activities. A single steroid injection may be given with subsequent injections if no improvement. Night splints are part of second-tier treatment. Flat shoes should be avoided. A patient has recurrent lumbar pain which is sometimes severe. The patient reports that prescription of nonsteroidal anti-inflammatory drugs (NSAIDs) is no longer effective for pain relief. What will the provider recommend? a. Adjunctive treatment with physical therapy b. Beginning treatment with opioid analgesics c. Complementary and alternative therapies d. Referral to an interventional spine physician
  • ANSWERS-D-- Patients with recurrent or chronic lower back pain may benefit from lumbar epidural corticosteroid injection performed by an interventional spine physician. Physical therapy is often used for acute injury if no improvement in 4 to 6 weeks. Opioid analgesics are not usually effective. A patient has secondary Raynaud's phenomena with severe digital ischemia. Which treatment is indicated for this patient? a. Ginkgo biloba b. Intravenous prostaglandin E c. Oral nifedipine d. Sildenafil as needed
  • ANSWERS-B--Intravenous prostaglandin E1 is reserved for patients with secondary Raynaud's phenomenon who have severe digital ischemia. Ginkgo biloba is associated with adverse effects and has not been shown to be effective. Nifedipine is used to prevent vasospasm in milder cases. Sildenafil may be used as a vasodilator in milder cases. A patient has swelling and tenderness in the small joints of both hands and reports several weeks of malaise and fatigue. A rheumatoid factor (RF) test is negative. What will the primary care provider do next? a. Begin treatment with a biologic disease-modifying anti-rheumatic (DMARD) drug b. Order radiographic tests, a CBC, and acute-phase reactant levels c. Reassure the patient that the likelihood of rheumatoid arthritis is low d. Refer the patient to an orthopedic specialist for evaluation and treatment
  • ANSWERS-B-- The patient has signs of rheumatoid arthritis (RA); the RF test may be negative initially but will become positive in 70% to 80% of patients. The provider's next step is to order tests to confirm the diagnosis and to provide a baseline to monitor disease progress and response

significantly effective for axial disease. Biologic anti-tumor necrosis factor medications are given only after failure of two NSAIDs. Corticosteroid injections are not indicated A patient is diagnosed with mild restless leg syndrome (RLS) which occasionally interferes with sleep. Which initial treatment will be helpful? a. A continuous positive airway pressure (CPAP) devices b. A dopaminergic agonist c. Hot baths and exercise d. Supplemental iron

  • ANSWERS-C - Patients with mild restless leg syndrome (RLS) may benefit from massage, hot baths, exercise, and good sleep hygiene. CPAP is used for obstructive sleep apnea. Dopaminergic agonists are useful medications but have a risk of rebound or augmentation of effects. Supplemental iron is used in patients with low ferritin levels A patient is diagnosed with osteoporosis. What is the recommended treatment once the diagnosis is made? a. Bisphosphonate therapy b. Calcium and vitamin D c. Estrogen replacement d. Yoga and weight-bearing exercises
  • ANSWERS-A- Bisphosphonates are FDA-approved treatment for osteoporosis and will help improve bone density and reduce the risk of fractures. Calcium and vitamin D may help prevent osteoporosis but must be taken from an early age. Estrogen replacement is used to prevent osteoporosis. Yoga and exercise help with balance and muscle strength to help prevent falls. A patient is diagnosed with polymyalgia rheumatica (PMR) with giant cell arteritis. Which dose of prednisolone will be given initially? a. 15 mg daily b. 20 mg daily c. 30 mg daily d. 60 mg daily
  • ANSWERS-D - Although the usual starting dose to treat PMR is 15 to 20 mg daily, a higher dose of 60 mg daily is used when there is evidence of concomitant giant cell arteritis. A patient is diagnosed with rheumatoid arthritis (RA) after a review of systems, confirmatory lab tests, and synovial fluid analysis. What will the provider order initially to treat this patient? a. Disease-modifying anti- rheumatic (DMARDs) drugs b. Long-term glucocorticoid therapy c. Non-pharmacological treatments d. Nonsteroidal anti-inflammatory drugs (NSAIDs)
  • ANSWERS-A --Treatment with DMARDs should be initiated as soon as the diagnosis of RA is established to achieve disease modification. Long-term glucocorticoid therapy is not recommended because of adverse effects. NSAIDs are not first-line drugs and increase the risk of cardiac and renal complications. NSAIDs are used as adjunctive and not first-line therapy. A patient is experiencing small-volume, non-inflammatory stools. Which organisms may be suspected in this case? (Select all that apply.) a. Clostridium difficile b. Cryptosporidium

c. Escherichia coli d. Giardia e. Shigella

  • ANSWERS-B, C, D-- small-volume, non-inflammatory stools occur with infections of the small intestine and are due to enteric viruses, enterotoxic bacteria, such as E. coli, and noninvasive parasites, such as Giardia and Cryptosporidium. Infections of the lower intestine are characterized by frequent, large-volume inflammatory diarrhea and C. difficile and Shigella are among the likely pathogens. A patient is noted to have prolonged bleeding after an intravenous needle is removed. A subsequent laboratory test reveals a prolonged activated partial thromboplastin (aPTT) time with a normal prothrombin time (PT). Based on this result, the provider may suspect alteration in function of which factor? a. Factor V b. Factor VII c. Factor VIII d. Factor X
  • ANSWERS-C-- Factor VIII is part of the intrinsic system, which aPTT measures. The other factors are part of the extrinsic system, which is measured by PT A patient is seen in the clinic with reports of constant fatigue. The patient's spouse reports that the patient moves and kicks the legs frequently during sleep. What treatment will the provider anticipate once a diagnosis of the underlying cause is confirmed? a. An anti-oxidant diet b. Cognitive behavioral therapy c. Iron supplements d. Melatonin daily at bedtime
  • ANSWERS-C-This patient most likely has restless leg syndrome which may result from low ferritin levels and which is treated with iron supplements. Anti-oxidant diets and cognitive behavioral therapy are sometimes used to treat non-specific CFS. Melatonin has not been shown to be effective A patient is suspected of having leukemia and the provider orders biochemical studies and a bone marrow aspirate and biopsy. The results include white blood cells (WBCs) greater than 200,000 cells/mm3 normal red blood cells (RBCs), hyperplastic myeloid cells, and the absence of serum leukocyte alkaline phosphatase. Which test will the provider order to confirm a diagnosis in this patient? a. Chest radiograph b. Coagulation studies c. Philadelphia chromosome test d. Serum protein electrophoresis
  • ANSWERS-C-- The findings from the complete blood count (CBC) and bone marrow biopsy, along with a positive Philadelphia chromosome test, confirm the diagnosis of chronic myelogenous leukemia. A chest radiograph and serum protein electrophoresis may be performed to evaluate for associated symptoms. Coagulation studies are usually performed as part of the diagnostic workup for acute lymphocytic leukemia (ALL).

c. internally rotate the shoulder. d. shrug the shoulders.

  • ANSWERS-A-- If pain is caused by impingement on the acromion, the patient will reflexively shrug when asked to abduct the arm to reduce the pain. Adduction of the arm does not elicit this response. The shrug elicited is reflexive and not intentional. Internal rotation may be performed to evaluate generalized muscle weakness. A patient reports a history of recurrent lower back pain for 6 months. The patient describes the pain as a deep ache and stiffness that is worse upon awakening and improves after walking. Which findings will the examiner elicit to help make a clinical diagnosis of ankylosing spondylitis? (Select all that apply.) a. Assessment of the degree of lumbar lordosis b. Evaluation of lateral thoracic spine flexion c. Measurement of chest expansion d. Noting the degree of cervical kyphosis e. Observation for scapular asymmetry
  • ANSWERS-A, B, C--Examination of the spine will show loss of the normal lumbar lordosis, decreased thoracic spine flexion, and diminished chest expansion. Cervical kyphosis is not assessed. Scapular asymmetry evaluates for scoliosis. A patient reports a neck mass that has been present intermittently for 5 or 6 weeks which varies in size. The provider palpates a lymph node measuring 1.25 cm. Which test will provide proper histologic diagnosis for this patient? a. Bone marrow aspirate b. Computed tomography (CT) scan with intravenous (IV) contrast c. Lymph node biopsy d. Positron emission tomography (PET) scan
  • ANSWERS-C - The lymph node biopsy is used to provide proper histologic diagnosis and precise classification. Bone marrow aspirate identifies the presence of dysplastic cells. PET and CT scans will identify the presence of other lesions A patient reports daily, recurrent fever associated with sweating, chills, and recent weight loss. What may this type of fever indicate? a. An underlying disease caused by animal bites b. Fever related to an immunocompromised state c. Possible exposure to tropical diseases d. Tuberculosis (TB) or lymphoma
  • ANSWERS-D - Hectic fever, or recurring fever associated with weight loss, sweating, and chills is concerning for tuberculosis or lymphoma. Fever from animal bites or travel to tropical areas is diagnosed after a history of exposure. A patient reports elbow pain and the examiner elicits pain with resisted wrist flexion, forearm pronation, and passive wrist extension on the affected side. What is a likely cause of this pain? a. Lateral epicondylitis b. Medial collateral ligament instability c. Medial epicondylitis

d. Ulnar neuritis

  • ANSWERS-C- Medial epicondylitis will produce pain as described above. Lateral epicondylitis may result in pain with passive wrist flexion and active wrist extension. A patient reports numbness and weakness of the wrist with pain focuses on the radial aspect of the joint. During physical examination, what will the examiner do to help diagnose this condition? a. Applying press to the focus area b. Flexing the thumb while placing a finger on the metacarpophalangeal joint c. Passively extending the thumb and observe for puckering of the skin d. Placing the thumb on the palm while deviating the hand toward the ulna
  • ANSWERS-A - Applying pressure to the volar or radial aspect of the wrist will elicit pain in patients with a ganglion cyst which has symptoms described above. Flexing the thumb while the examiner places a finger on the metacarpophalangeal joint will elicit a pop when the digit is extended in patients with trigger finger. Puckering of the skin occurs with palmar fibrosis. Placing the patient's thumb on the palm while deviating the hand toward the ulna will elicit pain in patients with tenosynovitis. A patient reports persistent lower back pain and constipation. A digital rectal examination reveals a mass at the sacrum. What will the primary care provider do to manage this patient? a. Order spinal radiographs in 3 months b. Perform an MRI of the sacrum c. Refer the patient to an oncologist d. Schedule the patient for a biopsy
  • ANSWERS-C-- Patients with chordoma, which is a type of sarcoma with a predilection for the sacrum, will have these symptoms and a palpable mass coming out of the sacrum. A referral to an oncologist is necessary. These tumors have a significant risk for malignancy, so waiting 3 months is not an option. The oncologist will order a CT and body scan and possibly biopsy or surgery A patient reports recent mild fatigue and palpitations. A complete blood count reveals a decreased hemoglobin level and a normal ferritin level. What other findings are likely to be present? a. Decreased hematocrit b. Decreased MCV, MCH, and MCHC c. Elevated total iron-binding capacity d. Paresthesias, koilonychia, and pica
  • ANSWERS-A-This patient has signs of milder iron-deficiency anemia and will also have a low hematocrit level. The RBC indexes are the last to change as the anemia becomes more severe. When the ferritin level drops, the TIBC will become elevated. Paresthesias, koilonychia, and pica occur with more severe anemia. A patient reports severe back pain located in the lumbar spine. To evaluate whether the patient has axial pain or radicular pain, which assessment is necessary? a. Asking the patient to perform the Valsalva maneuver b. Assessing reflexes and asking about tingling or numbness c. Determining whether the pain is present with prolonged sitting d. Noting whether pain is mitigated with frequent position shifts
  • ANSWERS-A --Associated neurological signs are present with radicular pain and include numbness, tingling, weakness, and reflex changes. The other symptoms occur with both axial and radicular pain.

inflammation and joint mobility. Injections are not recommended more than 3 to 4 times per year. The duration of pain relief is variable A patient who has recently traveled has acute diarrhea which began the day after returning home. What are recommended treatments for this type of diarrhea? (Select all that apply.) a. Ciprofloxacin for 3 days, twice daily b. Loperamide at bedtime and after each stool c. Oral fluid replacement d. Quinolones daily for 2 to 4 weeks e. Sulfamethoxazole twice daily for 5 days

  • ANSWERS-A, B, C Ciprofloxacin may be given for 3 days for traveler's diarrhea, as well as loperamide. Oral fluid replacement is recommended. Because of widespread antibiotic resistance to sulfamethoxazole and quinolones, these drugs are not recommended. A patient who is a distance runner reports pain in one heel that is worse in the morning and seems to improve with exercise. The provider notes localized swelling and a bony prominence at the heel. What is the initial treatment for this condition? a. Cessation of all sports activities and exercise b. Crutches and partial weight bearing c. Physical therapy for ultrasound therapy d. Referral to an orthopedist for MRI and evaluation
  • ANSWERS-A --This patient has symptoms consistent with Achilles tendonitis. Immediate cessation of sports and exercise is the first step in management. Crutches and partial weight bearing may be indicated if symptoms do not improve with rest and NSAIDs. Physical therapy is used as adjunctive therapy. Symptoms that do not improve require referral. A patient who is a distance runner reports pain in one heel that is worse in the morning and seems to improve with exercise. The provider notes localized swelling and a bony prominence at the heel. What is the initial treatment for this condition? a. Cessation of all sports activities and exercise b. Crutches and partial weight bearing c. Physical therapy for ultrasound therapy d. Referral to an orthopedist for MRI and evaluation
  • ANSWERS- A patient who is taking prednisolone 20 mg daily to treat polymyalgia rheumatica reports blurred vision. What will the provider do? a. Discontinue the medication b. Increase the prednisolone dose to 60 mg daily c. Prescribe NSAIDs to treat the inflammation d. Refer to a rheumatologist immediately
  • ANSWERS-D--Sudden vision loss, diplopia, and other visual disturbances may indicate giant cell arteritis (GCA) and requires immediate referral to rheumatology. The primary provider should not change the medication regimen without a consult. A patient who reports traveling to an area where West Nile virus (WNV) is endemic presents with fever, arthralgia, and rash for the last 7 days. What initial testing is recommended to confirm a diagnosis of WNV? a. ELISA for CSF antibodies b. ELISA for serum IgM c. PCR assays of CSF

d. PCR assays of serum

  • ANSWERS-B--Serologic testing is the most effective method to confirm clinical suspicion of WNV infection and ELISA for detection of IgM in serum at 6 to 8 days indicates recent infection. CSF may be tested but is more invasive. PCR assays are low yield because of the transient nature of viremia in humans A patient with acute myelogenous leukemia (AML) who has a high white blood cell count and diffuse lymphadenopathy is hospitalized during the induction phase of chemotherapy. What monitoring and interventions are critical to assess for complications during this phase of care for this patient? (Select all that apply.) a. Administration of sodium bicarbonate and allopurinol b. Assessment for bruising and petechiae c. Close monitoring of absolute neutrophil counts d. Daily renal function and chemistry values e. Meticulous assessment of hydration status
  • ANSWERS-A,D, E--This patient has a high WBC load and diffuse lymphadenopathy, so is at increased risk for acute tumor lysis syndrome (ATLS). Close monitoring of renal function, serum renal chemistry values, and hydration status is essential. Adding sodium bicarbonate and allopurinol help to minimize risk. Thrombocytopenia causing bruising and petechiae, along with neutropenia, are common complications of chemotherapy but these symptoms generally occur 7 to 10 days after initiation of therapy. A patient with chronic hip pain cannot take nonsteroidal anti-inflammatory drugs (NSAIDs) and tells the provider that acetaminophen is minimally helpful. What might the provider recommend initially to improve pain relief? a. A fentanyl patch b. Capsaicin c. Glucosamine d. Lidocaine patches
  • ANSWERS-B-Topical capsaicin has been shown to provide short-term pain relief and has fewer side effects than oral agents. It is an appropriate initial therapy. Fentanyl is a narcotic analgesic and should be reserved for more severe pain. Glucosamine and lidocaine may be helpful for some patients A patient with elbow pain without localized erythema or warmth is diagnosed with bursitis of the elbow and serum laboratory results are pending. What is the initial treatment while waiting for these results? a. Aspiration of the bursal sac for culture b. Corticosteroid injection into the bursal sac c. Elbow pads, NSAIDs, rest, and ice d. Physical and occupational therapy
  • ANSWERS-ANS: C-- Initial therapy includes conservative measures for comfort. Until infection is suspected, based on the white blood count and inflammatory markers, and without localized signs of infection, aspiration of the bursal sac is not indicated. Corticosteroids should not be injected into the bursal sac until infection has been excluded. Physical and occupational therapy should not precede comfort measures.