NMS Q&A Family Medicine

92 NMS Q&A Family MedicineExamination Answers1. The answer is C. A tetracycline course orally for 3 weekswill treat successfully tropical sprue . The symptoms arenot only those of diarrhea but of malabsorption, basedon weight loss and bulky floating stools. It occurs in peoplewho have resided long periods in a tropical region. It isfelt to be caused by changes in the bowel flora and respondsto tetracycline or sulfonamides after a few weeks. Loperamideis a popular over counter medication used forsymptomatic relief for self-limited causes of communitybaseddiarrheas. The same applies to the clear liquids and“BRAT diet.” Vancomycin is used for Clostridium difficilecausedpseudomembranous colitis, a disease that complicatedantibiotic therapy; azithromycin is prescribed fordiarrhea caused by Campylobacter jejuni .2. The answer is D. The severity of disease is not directlyproportionate to the size of the amylase elevation, so thestatement that it is directly related thereto is the incorrectone. The Ranson criteria consist of five statistical indicatorsof severity upon admission. They are age 55 years, whiteblood count (WBC) 16,000 cells/mm 3 , serum glucose200 mg/dL, serum lactic dehydrogenase (LDH) 350IU/L, and aspartate transaminase (AST) 250 U/dL. Acutebiliary pancreatitis, which this patient could have, with herpast symptoms suggestive of gallbladder disease, usuallyfeatures much higher amylase levels, although the attackclinically may be relatively mild. (Her alcoholism is a morelikely cause of the disease in the illustrated case.) The mostsensitive diagnostic test is the serum amylase, which risesvirtually with the onset of illness and remains elevated forabout 4 days. However, amylase is not the most specific,given the fact that other conditions, such as perforated pepticulcer, are characterized by elevated serum amylase.Lipase elevation begins within 4 to 8 hours of the onset inacute pancreatitis and remains elevated 8 to 14 days. Seventyto eighty percent of attacks are fairly mild and leadbenign courses. This patient must be treated to preventdelirium tremens while managing the underlying condition,given her clear stigmata of alcoholism and cirrhosis.3. The answer is B. Colonoscopy starting at age 40 andevery 5 years thereafter. This fits the criterion based on theindex patient having two first-degree relatives with eithercolon cancer or adenomatous polyps before the age of 60years. Colonoscopy every 10 years is appropriate for a personof average risk beginning at the age of 50 years. Flexiblesigmoidoscopy every 5 years also is approved for people ofaverage risk, again beginning at the age of 50 as is fecal occultblood test annually (certainly the least advised routinemethod due to the numerous false-positive and false-negativeexaminations but often the most palatable for apprehensivepatients). DCBE is appropriate, as is colonoscopy, forthe high-risk patient featured but not necessary until sheattains the age of 40 years, and every 5 years thenceforth.4. The answer is C. Alosetron (Lotronex), most likelyamong the choices to give global relief from the woman’ssymptoms. This vignette describes perfectly IBS. Alosetron,a 5-HT 3 antagonist, is a member of the family of serumnorepinephrine reuptake inhibitors (SNRIs), subtypes ofwhich being studied are 5-HT 3 , 5-HT 1A , 5-HT 4 , and 5-HT 2Bantagonists. IBS is defined as a chronic noninflammatorycondition characterized by abdominal pain, altered bowelhabits (diarrhea or constipation), or bloating withoutknown organic basis. The condition should not be diagnosedin the face of alarm symptoms (e.g., hematochezia,persistent pencil stools, and unexplained anemia), and IBSpatients over 50 years of age with average risk based onfamily history should undergo standard screening for colorectalcancer according to American College of Gastroenterologyguidelines. Alosetron presently is approved in theUnited States only for “women with severe diarrheapredominantIBS,” because of serious adverse effects insome cases. However, in contrast to traditional treatmentmodalities for IBS, alosetron has an A rating for evidencebasedrecommendations. Hyocyamine, an anticholinergic,showed benefit in relieving global IBS symptoms in onlyone of three studies; tricyclic antidepressants have shownbenefit in relieving abdominal pain but are not superior toplacebo in mitigating global symptoms of IBS; loperamidehas been shown to reduce the number of stools in diarrheabut is of no benefit in relieving global; IBS symptoms;serum serotonin reuptake in inhibitors’ effectiveness hasnot been documented. A medication not among thechoices, the 5HT4 antagonist tegaserod is known to beeffective against constipation-predominant IBS in women,not diarrhea-related IBS.5. The answer is B. Giardia is a protozoan that causesnumerous GI symptoms, including nausea, vomiting,diarrhea, and steatorrhea. Giardiasis is the most common(i.e., prevalent) parasite worldwide and second in theUnited States after E . vermicularis (pinworm). The protozoanis passed by the fecal–oral route and therefore occurswhere water processing is less than optimal (being relativelyresistant to chlorination), such as in developingcountries and outdoor camping situations. In the latterscenario, it is enhanced in its communicability by its survivabilityin cold water. The pinworm, whose only host ishumans, lives in the large intestine and lays eggs on theperineum. It rarely results in more than perineal pruritus,but occasionally can cause weight loss, urinary tractinfection, and appendicitis. A . duodenale and N . americanusare the “Old World” and “New World” hookworms,