UVA Family Medicine Questions

• 1. A 50 year old female with a ten year history of type II diabetes presents for regularly-scheduled follow up. She has no complaints, and just visited her ophthalmologist last week. Current medications include glyburide, metformin, and simvastatin. On physical exam, vital signs are virtually unchanged from previous visits, with temperature 37.1 C (99 F), HR 80, BP 140/83, RR 15, and O2 Sat 98% on room air. Neurological examination reveals diminished sensation to light touch and pinprick in a stocking distribution on the lower extremities bilaterally. Remainder of physical exam is benign. Laboratory evaluation reveals: Na+ 136, K+ 3.9 Cl- 104, HCO3- 25, BUN 15, Cr 1.0, Glucose 150; hemoglobin A1c: 7.1%; Urinalysis: negative for ketones, glucose, bilirubin, leukocyte esterase, or blood; moderate protein; Lipid profile: Total cholesterol 146, HDL 46, LDL 100. At this time, which of the following would be the most appropriate intervention?A. Increase simvastatinB. Increase glyburideC. Increase metforminD. Add HCTZ E. Add lisinopril

  E. Add lisinoprilAll diabetics should be on ACE inhibitor or ARB for CV and renal protection
• LDL target in patients with known coronary heart disease

  <100
• All diabetics should have a systolic less than?

  130
• 2. A 55 year old female comes to the emergency department complaining of a headache for the past six hours. Her headache began abruptly after she finished eating breakfast, and quickly increased to 8/10 throbbing pain located mainly over her right temple. The pain has been associated with mild nausea but no vomiting. She denies chronic or recurrent headaches, but did have one headache similar to this one two weeks ago, which resolved after taking ibuprofen and lying in a quiet, dark room. She has smoked one pack of cigarettes daily for 38 years. On physical exam, the patient has temperature of 37.0 C (98.6 F), pulse of 99, and BP 147/95. Neurological examination is nonfocal, but mild photophobia and nuchal rigidity are noted. Fundoscopic examination reveals no papilledema. Skin exam shows no lesions. CT of the head, obtained without contrast, reveals no abnormalities. What is the most appropriate next step in the management of this patient?A. Obtain head CT with contrastB. Lumbar punctureC. Administer im sumatriptanD. Administer oral ibuprofenE. Administer IV ceftriaxone


  B. Lumbar puncture
• 4. A 30 year old female presents to her physician with a breast mass. She first noted a small "lump" in her left breast while showering about six weeks ago. She has noted no change in the size of the mass since that time, and she denies pain or nipple discharge. Family history is significant for a paternal grandmother who had breast cancer at age 79. Physical examination reveals a soft, round, mobile 1cm mass in the lower outer quadrant of the left breast. No skin changes are noted. What is the most appropriate next step in the management of this patient?A. MammographyB. Refer patient for radical mastectomyC. Begin levonrgestrel/etinyl estradiolD. Genetic testing for BRCA1 and BRCA2 E. Ultrasound of breast mass


  E. Ultrasound of breast massMammogram is the preferred imaging study for women over 35, while women younger than 35 should get ultrasound to evaluate a breast mass. In women younger than 35, the breast tissue is often too dense to evaluate mammographically, and the incidence of breast cancer younger women is still very low.
• 5. An otherwise healthy 8 year old girl presents with two weeks of perianal pruritis. She has two younger brothers, one of whom has had similar complaints for the past few days. Physical exam reveals perianal erythema with mild excoriations. The "scotch tape test" reveals several bean-shaped white eggs. What is the most likely diagnosis in this patient?A. TrichuriasisB. EnterobiasisC. Child abuseD. Fecal soliageE. Atopic dermatitis


  B. EnterobiasisThis is a classic case of enterobiasis (answer B) or "pinworm." The most common presenting symptom is intense anal itching or pruritus ani. Other symptoms (such as abdominal pain/fullness or nausea and vomiting) may occur if the worm burden is high. Girls may also present with a vulvovaginitis or urinary tract infection if the worms migrate. Eosinophilic enterocolitis and appendicitis are rarer complications.
• First line treatment for enterobiasis?

  MebendazoleAlbendazole
• 6. A 66 year old male presents to the emergency department with chest pain. The pain began two hours ago as the patient was watching television. The pain is described as "squeezing" and is located primarily substernally with radiation to the jaw. Past medical history includes diabetes mellitus, hypertension, hyperlipidemia, and a 50 pack/year smoking habit. On physical exam, the patient appears anxious and diaphoretic. The patient is given supplemental oxygen by nasal cannula, and aspirin, morphine, and nitroglycerin are administered. EKG obtained on presentation to the ED is shown. Of the following, which is the most appropriate study to obtain next?A. AortogramB. Troponin I C. Stress echoD. Exercise stress testE. CT angiogram of chest

  B. Troponin I To evaluate ACS, EKG + serial troponins
• 7. A 73 year old male presents to his physician complaining of cough and fatigue. His cough began 6 months ago and has steadily worsened, and is now associated with occasional expectoration of mucus streaked with bright red blood. Patient has also noted worsening dyspnea on exertion and a weight loss of 15 lbs. The patient has smoked a pack and a half of cigarettes every day for the past 60 years. Past medical history is significant for bipolar disorder treated with lithium. Physical exam shows unilateral localized wheezing on the left chest and clubbing of the distal extremities. Capillary refill is brisk. No skin tenting is observed. Chest X-ray is obtained, which shows a large mass at the left hilum. Labs show: Glucose 130, Na+ 125, K+ 4.0, Cl- 91, HCO3- 25, BUN 15, Creatinine 1.0; Plasma osmolality 270 (Normal: 282-295 mOsm/kg); Urine osmolality 650 mOsm/kg (Normal: 50 - 1400 mOsm/kg). Which of the following is the most likely mechanism for this patient's hyponatremia?A. Increased oral intake of hypotonic fluidsB. Decreased oral intake of solutesC. Impaired secretion of ADH in the posterior pituitaryD. Ectopic overproduction of vasopressinE. Resistance to ADH action on the cortical and medullary collecting tubules


  D. Ectopic overproduction of vasopressinWhen you see euvolemic hyponatremia (especially on the USMLE), think SIADH! The constellation of findings in this patient, including euvolemic hyponatremia, hypotonicity (plasma osmolality <280 mOsms), inappropriately concentrated urine, and normal renal function are diagnostic for the syndrome of inappropriate ADH secretion (SIADH). SIADH has a number of causes.
• Most common causes of SIADH

  1) Cancer - ectopic production of ADH by small cell lung cancers or pancreatic malignancies2) CNS disturbances - traumatic injuries, strokes, infections, and hemorrhages can all cause increased ADH production3) Drugs - most commonly caused by antipsychotic medications or chemotherapeutics, but the old (and seldom used) insulin secretagogue chlorpropamide is a commonly-tested causative agent
• 8. A 25 year old student presents with three days of vulvar pruritis. She has had a total of six lifetime partners, and is currently sexually active with one partner and states that they "occasionally" use condoms. One year ago, she was successfully treated for a Chlamydia infection. The patient denies vaginal odor or increased vaginal discharge. Physical exam reveals slight vulvar erythema, and speculum exam shows moderate clumpy white discharge. Vaginal discharge pH is 4.0. Whiff test is negative. Wet mount results: KOH prep shows occasional budding yeast and hyphae. Saline prep shows 3 WBCs, occasional squamous cells, and no bacteria. What is the next best step in the management of this patient?A. Clotrimazole vaginal creamB. Azithromycin and recommend that her partner see a physician for Chlamydia screening and treatmentC. MetronidazoleD. CeftriaxoneE. Reassurance and f/u in 2 weeks


  A. Clotrimazole vaginal cream This is a classic case of vulvovaginal candidiasis, which is usually treated with a single dose of oral fluconazole or several days of miconazole or clotrimazole vaginal creams
• Signs/symptoms yeast infection

  vulvar pruiritis, which is often the dominant feature of a yeast infection (and may be the only complaint from the patient). Other symptoms could include dysuria, vulvovaginal irritation, or dyspareunia. Classically, the discharge of a yeast infection is described as white with a curd-like consistency (often described as "cottage cheese" like), but many real-life patients will not complain of increased discharge.
• Low pH of vaginal discharge (<4.5) points to

  Yeast
• Which infections cause a more alkaline vaginal discharge?

  Trichomoniasis Bacterial vaginosis
• How to confirm yeast infection

  The diagnosis of candidiasis should be confirmed by finding budding yeast and hyphae on the 10% KOH wet mount.
• Uncomplicated yeast infection?

  Infections are uncomplicated when the patient experiences mild to moderate symptoms, the infections are sporadic, the suspected organism is Candida albicans, and the host is otherwise healthy.
• Complicated yeast infections?

  infection occurring in a host with pre-existing conditions (uncontrolled diabetes, immunosuppression, pregnancy), severe symptoms, infection with non-albicans species, or recurrent infections (>4 per year)
• BV discharge:

  Malodorous, thin, grey-white
• Trichomoniasis discharge:

  Purulent, green-grey, frothy
• When is the whiff test positive?

  BV Trich
• Saline wet mount for BV shows?

  Increased numbers of coccobacilliClue cells (vaginal epithelial cells studded by adherent coccobacilli around the cell's edges)
• Saline wet mount for trichomoniasis will show?

  Motile trichomonads
• When is a ceftriaxone injection used for STDs?

  Acute gonorrhea
• Gonorrhea most commonly presents as:

  Cervicitis, urethritis or proctitis
• Speculum exam with gonorrhea:

  cervix is often friable and cervical discharge may be seen
• Gold standard for gonorrhea diagnosis?

  Thayer-Martin medium
• 9. A seven year old female is brought to the physician by her mother because of facial swelling and dark, cola-colored urine. These symptoms began abruptly two days ago and have been associated with anorexia and malaise. There have been no known sick contacts. Her mother states that the child is up to date with her immunizations and has been in good health except for a runny nose and sore throat around two weeks ago, which resolved after a few days without treatment. Vital signs are temperature 37.2 C (98.9 F), heart rate 95, and blood pressure of 148/86. There is diffuse edema of the lower extremities, face, and eyelids. Lungs and heart are clear to auscultation. Urinalysis shows moderate hematuria and proteinuria, and dysmorphic RBCs and occasional RBC casts are noted on microscopic examination. Based on these findings, what is the most likely diagnosis? A. IgA nephropathyB. Alport syndromeC. Thin basement membrane nephropathyD. Postinfectious glomerulonephritisE. Henoch-Schonlein purpura


  D. Postinfectious glomerulonephritis 1. Age <7 years old 2. Dark brown urine (hematuria) 3. Periorbital and peripheral edema
• Postinfectious glomerulonephritis latent period?

  Around 10 days for pharyngitis*for glomerulonephritis following streptococcal impetigo, the latent period can be as long as 3-4 weeks
• Anti-streptolysin O titer


  Positive in postinfectious glomerulonephritis, indicates recent exposure to Group A strep
• When there are casts in the urine sediment, you know it is ______

  Glomerular disease(it's only when cells get squeezed through the glomerulus that they will form casts)
• What kind of RBC finding is highly suggestive of glomerular disease

  Dysmorphic RBCs (especially acanthocytes)
• Most common cause primary glomerulonephritis?

  IgA nephropathy
• Most common presentation IgA nephropathy?

  Recurrent episodes of gross hematuria that occur around 5 days after an upper respiratory infection.
• How to confirm diagnosis of IgA nephropathy

  Renal biopsy
• IgA nephropathy course?

  Most benignACE/ARBs can minimize glomerular injury if disease progresses
• Key features of Alport Syndrome

  Glomerular hematuriaSensorineural deafnessOcular abnormalities
• Genetics of Alport Syndrome:

  Genetic mutation in collagen type IV
• Thin basement membrane nephropathy features:

  Ususally hereditary and benignGlomerular hematuria Minimal-moderate proteinuria can be seen occasionally
• How is thin basement membrane nephropathy most common detected?

  Routine UA (patients usually completely asymptomatic)
• Classic triad henoch-Schonlein purpura:

  Abdominal painVasculitic, raised skin rash Renal involvement