NMS Q&A Family Medicine

128 NMS Q&A Family MedicineExamination Answers1. The answer is A. Prescription for oxybutynin (Ditropan)orally, among the choices in the vignette. Anticholinergicmedications such as oxybutynin, tolterodine(Detrol), and also propantheline (Probanthine) reducethe hyperirritability of an oversensitive detrusor muscleand sometimes an inherently small bladder. Alpha-adrenergicagonists such as pseudoephedrine address stressincontinence and loss of urine with coughing, laughing, orotherwise straining down with the abdominal muscles, bystrengthening sphincter tone. The underlying problem instress incontinence is atrophic vaginitis, which can beaddressed closer to the root of stress incontinence, in theabsence of contraindications, by estrogen therapy systemicallyor topically. A pessary is another approach for stressincontinence by supplying an obstructive component.Bladder neck obstruction should be addressed as a causeof overflow incontinence, characterized by small spurtsof urine. It is uncommon in females in the absence of aneoplasm, whereas in males, prostatism causes overflowincontinence quite commonly.2. The answer is B. Hypothyroidism is an unlikely causeof amenorrhea. Actually, hypothyroidism is associatedwith excessive uterine bleeding, as may be iron deficiency.Each of the other choices may be associated with ordirectly cause amenorrhea. PCOS is associated withandrogen excess. Prolactinoma may result in hypogonadotropichypogonadism.3. The answer is E. Clinical hypoparathyroidism is not aside effect of bisphosphonates. In fact, parathormonerises during treatment with bisphosphonates in 10% ofcases. Esophagitis may occur after ingestion of a bisphosphonateorally if the patient does not remain upright(after taking the medication with 8 oz of water and withouteating for 40 minutes thereafter). Bone and joint painsas well as myalgias and fatigue may occur after commencementof the drugs but usually subside within a fewdays in preparations that can be taken infrequently, suchas alendronate, administered on a weekly basis. In thosecases, the pains tend to recur with each dose. Osteonecrosisis rare with bisphosphonates, but when it occurs, ittends to involve the jaw, particularly after tooth extraction.Uveitis, conjunctivitis, and scleritis may occur andmanifest pain and blurred vision. These remit after discontinuationof the drug.4. The answer is B. Thyrotoxicosis is unlikely in a youngperson with a normal heart rate. Neurotic depression isalways possible with a depressed effect. However, it is seldomexpressed in cataclysmic fashion such as it occurs inthe vignette. Premenstrual syndrome actually fits wellwith the history, except that women with premenstrualsyndrome invariably connect the symptoms with themenstrual cycle. Hypoglycemia, regardless of the rootcause, may awaken feelings of failure, guilt, and hencedepression. Incipient menopause is certainly possible,given the patient’s age, although menstrual periods haveusually begun to change toward less frequency or irregularitywhen the premenopause era presents itself.5. The answer is C. 40 IU is the level of FSH, above whicha diagnosis of ovarian failure is secure. Some might chooseA, 20 IU, but such a cut point is more liberal. The latterwould allow a lower threshold for commencing hormonereplacement therapy. At younger ages than appropriate,usually arbitrarily taken as 40 years, having menopausalsymptoms associated with FSH levels 40 IU is referredto as ovarian failure.6. The answer is D. CEE 0.625 mg daily is protectiveagainst osteoporosis; 0.3 mg of CEE will relieve the acutesymptoms such as hot flashes and the cataclysmic depressionin menopause. All the other suggested benefits ofHRT in the stem question were long considered to be trueand valid, but with random prospective studies reportedin the last 5 years, they are no longer thought to be so. Thebreast cancer risk associated with estrogen and progesteronereplacement was acknowledged but felt to be minimalat the dosages of HRT being used. Moreover, large prospectivecontrolled trials alluded to, including both theWomen’s Health Initiative and the Heart and Estrogen/Progestin Replacement Study (HERS), have indicated thatcardiovascular brain and heart disease risk appear to be infact increased with HRT, possibly because of the complicationof thromboembolic disease risk. Endometrial carcinoma,although a risk with estrogen replacementunopposed, is, however, relatively prevented by combinedestrogen replacement cycled with progesterone. To elaborate,HRT is not cardioprotective, because of the progesterone,and in fact poses an increased risk of atheroscleroticevents after 3 to 4 years of HRT.7. The answer is D. If a woman lives to the age of 80 years,she stands a one in three chances of having a hip fracture.For a man, the odds are one in six. In any event, hip fractureis associated with a 20% first-year mortality rate.Therefore, as people live increasingly long after latemidlife, the issue of prevention of osteoporosis becomescritical. This is especially so because hormone replacementtherapy has been abandoned because of the risks ofbreast cancer and cardiovascular atherosclerosis.