4/17/2012:

An 82 year old man comes to the office because he is gradually losing erectile function.  He reports that his libido is "not what it used to be".  he also reports sleep disturbances, lower energy, and intermittent irritability but no sadness or headache.  History includes coronary artery disease, HTN, dyslipidemia, and obesity.  He takes aspirin, simvastatin, lisinopril, metoprolol, and a MVI daily.

On examination, he weighs 95 Kg (210 lb, BMI 34);  BP is 145/86, pulse 80.  CV and pulmonary examination is normal.  Testicular volume is 20 cc bilaterally, and no prostate nodules are palpable.

 

Fasting morning lab results:

Total testosterone:  166 ng/dl

LH 5 mIU/ml

FSH 7.2 mIU/mL

Total cholesterol 190

HDL 40

Which of the following tests should be ordered next?

A. PSA

B. MRI of the pituitary gland with contrast

C. Karyotyppe analysis

D. Prolactin

E. Hematocrit

 

 

 

2/7/12:  Question 12

 

Which of the following agents increases bone mass and reduces fracture risk by stimulating osteoblast activity and promoting bone formation?

A) Oral bisphosphonates

B) Estrogen

C) Human parathyroid hormone

D) Selective Estrogen receptor modulators

E) Zoledronic acid

 

Answer C

Osteoporosis medications can be considered in terms of whether they act on bone resorption (antiresorptive) or on bone formation (anabolic);  Most medications are antiresorptive (ca, vit D, Estrogen, SERM, bisphoshonates, calcitonin).

Teriparatide, human PTH, is the only anabolic therapy for osteoporosis approved by the FDA.  It increases bone mass and reduces fracture risk by stimulating osteoblast activity and promoting bone formation.

Teriparatide increases BMD and decreases risk of vertebral and non vertebral fractures in postmenopausal women with prior vertebral fractures or corticosteroid induced osteoporosis.  It also increases BMD at the lumbar spine and femoral neck in men with osteoporosis .  Its effects on hip fractures has not been assessed.

Treatment with teriparatide is associated with usually transient increases in serum calcium.  If the increases persist, they can be managed by decreasing calcium and vitamin D.

 

 

 

1/4/12:

A 70 year old Chinese American man comes to the office because he has a widespread maculopapular eruption with formation of flaccid bullae and erosions.  For 2 days before the rash, he had fever, odynophagia, and eye pain.  Over the next few days, the rash evolved to extensive sloughing and peeling of the skin.  History includes HTN, DM, and peripheral neuropathy.  Two weeks ago, he started carbamazepine at 200 mg Q 12 hrs for peripheral neuropathy.  Other meds include glipizide, felodipine, simvastatin, and enteric coated aspirin.

On examination, the sloughing and peeling involve 40% of the patient's body surface.  His oral mucosa has erosions and exudates.  He also has bilateral conjunctivitis.  The patient is admitted to the burn unit.

Which of the following is the most likely diagnosis?

A)  Bullous pemphigoid

B) Staphylococcal scalded skin syndrome

C) Disseminated Herpes Zoster

D) Toxic epidermal necrolysis

 

Answer:  D: TEN

Stevens-Johnson syndrome and TEN are severity variants of the same disease, characterized by epidermal detachment.  In SJS, skin detachment affects <10% of the body surface; in TEN, detachment affects >30% of the body.  When skin detachment is between 10-30%, the syndrome is considered overlap between SJS/TEN.  The mortality for SJS is between 1-3%, and 30% for TEN.  Often, fever and mucosal involvement develop days before the rash appears;  Initial lesions are macular and can form target lesions with purpuric centers;  The lesions can coalesce and progress to superficial flaccid bullae.  Usually at least two mucous surfaces are involved;

SJS and TEN are rare reactions to medications, most common are antibiotics, NSAIDS, and anticonvulsants.  The risk for SJS or TEN with carbamazepine is significantly increased in patients who have the HLA-B 1502 allele, which is found in individuals with ancestry from across broad areas in Asia, including South Asian Indians.  In 2007, the FDA alerted health professionals of changes to prescribing information, including a new boxed warning for carbamazepine: "Patients with ancestry in at-risk populations should be screened for the HLA-B*1502 allele prior to starting carbamazepine.  Patients who are positive for this allele should not be treated with this drug unless the expected benefit clearly outweighs the increased risk of SJS/TEN."

 

Given the Chinese ancestry of this patient, he should not have been given carbamazepine without genetic testing.

 

 

12/21/11:  Q:  A 78 year old man comes to the office because he has fatigue and weakness that have progressed over the past 6 months.  He is an avid golfer but is now unable to complete his usual round of golf.  History includes dyslipidemia and gouty arthritis well controlled for 10 years.  Medications include atorvastatin, colchicine, and allopurinol.

On examination, there is hyper pigmentation over his face and neck, but no rash.  He has weakness of the neck flexors, and he cannot rise from a chair without using his arms.  Reflexes are diminished in both legs.

Which of the following will most likely Yield the correct diagnosis?

A) EMG and Nerve conduction studies

B) MRI using fat suppression sequence

C) Sural nerve biopsy

D) Muscle biopsy using percutaneous needle

E) Open muscle biopsy

 

Answer:  E

Generalized muscle weakness that is most prominent in the proximal muscle groups suggests myositis.  Open muscle biopsy remains the gold standard for differentiating myositis from drug induced and other myopathies, dermatomyositis, polymyositis, and inclusion body myositis.  Electrodiagnostic testing will exclude neuropathy but will not distinguish myositis from other myopathies.  Needle insertion for EMG can cause tissue damage that may influence muscle morphology and complicate interpretation.  MRI can demonstrate inflammation and be useful in selecting which muscle to biopsy but still does not provide a definitive diagnosis.  Sural nerve biopsy is most useful in the evaluation of mono neuritis multiplex due to suspected vasculitis, but is not useful for evaluating the cause of myositis or myopathy without nerve involvement.  Percutaneous needle biopsy doe snot permit accurate assessment of muscle morphology.

 

 

 

 

 

 

12/13/11:  What are the Likelihood Ratios for the following clinical features that increase the probability of an MI in patients presenting with acute chest pain?

1. Chest Pain radiation to both arms: 9.7

2. Chest pain radiation with left arm pain: 2.2

3. Chest pain radiation with right shoulder pain: 2.9

4. Third heart sound present: 3.2

5. SBP < 80: 3.1

6. Rales on exam: 2.1

7. Diaphoresis: 2.0

8. N/V: 1.9

9. Hx of MI: 1.5-3

 

 

 

 

11/21/11:

A 65 year old man is brought to the office by his wife because he has recently been falling frequently and becoming more irritable and forgetful.

On examination, blood pressure 110/70.  He has poor upward gaze, masked facies, and nuchal rigidity.

 

Which of the following is most likely to be observed on physical examination?

 

A) Resting Tremor

B) Autonomic dysfunction

C) Depression

D) Axial rigidity

E) Bradykinesia

 

Answer: D.  Progressive Supranuclear Palsy is marked by supra nuclear gaze palsy with progressive voluntary gaze impairment and marked rigidity.  Onset is usually in late 50s, followed by rapid deterioration.  Other features of PSP include marked axial rigidity and a less prominent tremor than that seen in PD.  Falling and gait disturbance are common in PSP.  National Institute of Neurological Disorders and Society for PSP has proposed the following clinical diagnostic criteria:  gradual progression, onset after age 40, vertical supra nuclear ophthalmoplegia, and prominent postural instability with falls within 1 year of symptom onset.

 

 

 

10/25/11:

An 80 year old woman is admitted to the hospital with altered mental status.  It is her third admission in 3 months.  She lives with her son, who is her healthcare proxy.  He shops for the household and helps her with her medications.  History includes DM, atrial fibrillation, macular degeneration, and osteoarthritis.  Medications including warfarin, insulin glargine, lisinopril, and metoprolol.  After her last hospitalization, the patient received 2 weeks of home health care services; the nurses reported that the son purchased foods inconsistent with a diabetic diet despite receiving nutrition counseling.

On examination, the patient is lethargic and oriented only to her name.  Vital signs are within normal limits.  Blood glucose concentration is >400, Hgb A1c is 9%, and INR is 1.

The patient's mental status improves with insulin and fluids.  She reports that her son went on vacation for one week, and she was unable to administer her own medications.  The inpatient team wants to discharge the patient to a SNF for short term rehabilitation, but she states that she wants to return home.

Which of the following is the most appropriate next step in caring for this patient?

A.  Notify APS

B. Administer the MMSE

C. Assess her capacity to understand the risks and benefits of her living situation

D. Discharge her to her home with home healthcare services for 4 weeks

E.  Contact the patient's healthcare proxy (her son) to obtain permission to discharge her to a SNF

 

Answer: C

The most appropriate next step is to assess her capacity to understand the risks and benefits of returning home.  The first step is to determine whether or not the patient is willing to accept interventions.  If she is unwilling, then the physician must determine whether or not she has capacity to refuse interventions.

 

 

 

 

 

 

9/28/11

Which of the following is the most reliable screen for hearing impairment?

A)  Screening version of the Hearing Handicap Inventory for the Elderly (HHIE-S)

B) Abbreviated Profile of Hearing Aid Benefit

C) Tinnitus Handicap Questionnaire

D) Whisper Test

 

Answer: A

"Medicare offers a one time preventive examination.  Two self report measures, the screening version of the (HHIE-S) and the Dizziness Handicap Inventory, are recommended for use by physicians.  The HHIE-S is widely used to assess hearing handicap -- i.e, hearing loss that interferes with performing ADLs.  The HHIE-S consists of 10 questions regarding hearing difficulty in various situations:  half o the questions cover self reported emotional consequences of hearing loss, and half cover self reported activity limitations and restrictions.  The screen is quick and easy and inexpensive.  It has high reliability and validity, as well as adequate sensitivity and specificity.  Patients who score >8 should be referred to an audiologist to evaluate hearing and to determine the need for medical or nonmedical interventions.

 

An alternative screening tool is a hand held otoscope (AudioScope) which generates pure tones at 500, 1000, 2000, and 4000 Hz and at two intensity levels, 25 or 40 dB.  Outcome on the HHIE-S predicts need for hearing aids, whereas the AudioScope screen predicts the level of hearing impairment.

The Tinnitus Handicap Questionnaire assesses self reported handicapping effects of tinnitus.  It can be used before and after treatment to measure effectiveness of therapy for tinnitus.  The Abbreviated Profile of Hearing Aid Benefit is often used to assess outcomes with hearing aids.  It quantifies the self reported disabling effects of hearing impairment and assesses ease of communication, reverberation, speech understanding in the presence of background noise, and aversiveness to sound.

The whisper test, in which the tester whispers words at a measured distance from the patient's ear, is not as accurate a screen for hearing loss as the HHIE-S."

 

 

 

9/15/11:  Q 226.  Which of the following is the most likely cause of new onset vaginal bleeding in a 70 year old woman?

A) Pyometra

B) Endometrial cancer

C) Endometrial hyperplasia

D) Vaginal atrophy

E) Hormonal effect

 

Answer:  D:

Vaginal atrophy is the most common cause of postmenopausal bleeding.  In a series of 1,138 postmenopausal women who had bleeding, atrophy was the diagnosis in 59%.  Polyp was the next most frequent cause (12%).  Endometrial cancer and hyperplasia caused about 10% of cases, and hormonal effect caused 7%.  Cervical cancer accounted for <1%.

Even though 95% of postmenopausal bleeding is due to benign causes, all postmenopausal women with unexpected vaginal bleeding should be evaluated for endometrial cancer since it is treatable.

 

 

 

 

9/07/2011:  Q 200.  An 80 year old woman comes to the office because she recently has had difficulty eating and swallowing solid food.  she notes that when she prepares to swallow, the food scrapes her cheeks and the roof of her mouth.  History includes HTN, DM, kidney stones, and major depressive disorder.  Medications include HCTZ, metformin, and fluoxetine.  For the first time in many years, a recent dental examination revealed several cavities, which were located at the roots of the teeth.

Which of the following is the most likely explanation for these oral problems?

A) Usual aging

B) Salivary ductal stones

C) Adverse effect of metformin

D) Adverse effect of HCTZ and fluoxetine

E) Immune dysfunction

 

Answer:  D

This patient's difficulty with eating and swallowing solid foods in the context of new dental cavities is most consistent with xerostomia, or decreased saliva.  Saliva has several functions:  it is a protective cleanser with antibacterial activity, a buffer that inhibits demineralization, a lubricant, and a transport medium to taste sensors.  These functions are seriously altered in xerostomia.  Many conditions and treatments contribute to xerostomia, including radiation or chemotherapy, psychologic, endocrine or nutritional disorders; adverse medication effects (>200 commonly used medications can cause this).  Antihypertensives (especially diuretics) and antidepressants (especially first generation SSRSIs) reduce saliva flow.  Metformin is not known to decrease salivary flow.  Treatment includes good oral hygeine, flouride rinses, reduced alcohol intake, frequent water, saliva substitutes and d/c of offending meds if possible.

 

 

8/23/11:

Q 194.  A 92 year old woman has several stage I and II pressure ulcers on her buttocks and heels one week after treatment for a urinary tract infection and dehydration.  She lives in a nursing home and has advanced dementia.

Which of the following is the best tool for monitoring the healing of her pressure ulcers?

A) Braden Scale

B) Bates-Jensen Wound Assessment Tool

C) Norton Scale

D) Waterlow scale

E) Cubbin-Jackson scale

The Bates Jensen Wound Assessment Tool, also called the Pressure Sore Status Tool, is a validated instrument for assessing the healing of pressure ulcers.  Developed in 1992 and revised in 2001, it assigns a numeric score for each of the following wound characteristics:  size, depth, edges, undermining, necrotic tissue amount, exudate type, exudate amount, surrounding skin color, peripheral tissue edema, peripheral tissue induration, granulation tissue, and epithelization.

Location and shape of the wound are noted but not scored.  The Bates-Jensen Wound Assessment Tool is not a risk assessment tool, it is used once a pressure ulcer has developed.  Another validated but less time consuming tool for assessing healing is the Pressure Ulcer Scale for Healing (PUSH) which focuses on size of ulcer, amount of exudate, and tissue type.

The Braden, Norton, Waterlow, and Cubbin-Jackson scares are used to assess the risk of developing a pressure ulcer.  The Braden scale is widely used, valid and reliable and provides the best estimate of risk.  It rates sensory perception, moisture, mobility, nutrition, friction, and shear.  A score of <18 on the Braden scale indicates increased risk of development of pressure ulcers.

 

 

 

 

 

 

Q 181. A 75 year old woman is brought to the ED with RLQ pain that has gradually increased in intensity over the past 36 hours, with associated nausea and diarrhea.  She reports no relieving or exacerbating factors, and is otherwise healthy.She denies dysuria or history of UTI's.

On exam, she appears uncomfortable.  Temp is 36.9, BP 140/85, pulse 94, RR 16.  she has RLQ tenderness with no guarding or rebound.  Bowel sounds are depressed.  CBC is normal with a WBC of 9.  U/A demonstrates pyuria.  Plain xray demonstrates nonspecific changes.

Which of the following is the best next step?

A. Barium enema

B. Urine Culture

C. CT of the abdomen/pelvis

D. ultrasound of the abdomen

E. Urgent sigmoidoscopy

 

Answer C: CT of the abdomen/pelvis

Appendicitis accounts for 5% of acute abdominal cases in older adults.  Less than 1/3 of older adults have the classic presentation of epigastric abdominal pain that ultimately radiates to the right lower quadrant, with associated anorexia, n/v, fever and leukocytosis.

 

Fever and leukocytosis are absent in up to 20% of patients.

Inflammation around the ureters (from appendicitis, PID, or other abd/pelvic diseases) can cause pyuria!

Although u/s is used preferentially to dx appendicitis in some settings, CT performs better in head to head comparisons and is especially effective for dx of abdominal pain in older adults in whom multiple intra-abdominal pathologies can present similarly.

 

 

 

 

 

GRS Question of the week: 8/9/2011:  A 75 year old woman comes to the office because she has had progressive difficulty walking over the past 10 months.  The first symptom she noticed was numbness of the feet.  Over the next 4 months, the numbness became more marked, ascended her legs, and eventually involved her fingers.  As these symptoms progressed, her gait became increasingly unsteady.  she now needs assistance to walk and has stopped driving.

She had partial gastric resection for peptic ulcer disease at age 40.  History includes HTN and mild osteoarthritis.  The HTN is well controlled with an ACE inhibitor and a diuretic.  She also takes an "energy-boosting" MVI supplement.

On examination, she has leg spasticity, generalized hyperreflexia, ankle clonus, and extensor plantar responses.  She has decreased perception to light touch, pinprick, and position over the toes and fingers, and reduced vibratory sense below the knees bilaterally.  Her gait is ataxic, and Romberg's sign is positive.  The remainder of the examination is unremarkable.

Labs:

Vitamin B12: 220

Hgb: 11.9

MCV: 88

Methylmalonic acid .18 (normal)

Homocysteine 13 (normal)

Serum electrolytes, creatinine, folate, immunoelectrophoresis, paraneoplastic panel, HIV and HTLV1 are normal/negative.  MRI of the spine shows a patchy increased T2 signal in the dorsal aspect of the cord from vertebra C3 to the lower thoracic cord.

Which of the following is the most likely cause of this patient's condition?

A. Vitamin B12 deficiency

B. Zinc deficiency

C. Copper deficiency

D. Vitamin B6 deficiency

E. Vitamin A toxicity

 

Answer: C, Copper Deficiency

Copper Deficiency Myeloneuropathy is a distinct clinical entity that is being recognized with increasing frequency.  The presentation is that of a progressive syndrome with a myelopathy that has predilection for the posterior columns and corticospinal tracts.  Red flags include: sensory ataxia, leg spasticity, and peripheral paresthesias -- this may mimic B12 deficiency.  As with B12 deficiency, the neurological manifestations may occur without anemia.

A strong association has been found between copper deficiency and a history of partial or complete gastrectomy.  Copper deficiency can also be caused or worsened by chronic zinc ingestion because zinc interferes with intestinal copper absorption. Therefore whenever dietary zinc supplements are used, the potential for inducing copper deficiency must be considered.

Although this patient's clinical picture is consistent with B12 deficiency, teh normal serum MMA and homocysteine make this less likely (these concentrations are increased early in B12 deficiency and therefore these tests are very sensitive).

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