NMS Q&A Family Medicine

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4 NMS Q&A Family Medicinethe abdominal. Which of the following must betreated while the confusional state is being managed?(A) Acute schizophrenia(B) Wernicke’s encephalopathy(C) Alzheimer’s disease(D) Acute alcohol intoxication(E) Bipolar disease in manic phase18 A 70-year-old man is hospitalized with pneumonia,having been a 2-pack-per-day cigarette smoker for 50years. He was placed on oxygen for abnormally low arterialoxygen content. On the third day of hospitalization,he was transferred to the intensive care unit. Thatafternoon, he was found to be confused, disoriented andhaving vivid visual hallucinations of spiders crawlinginside his teacup. Which of the following is the besttreatment to manage the cognitive dysfunction?(A) Benztropine (Cogentin)(B) Diazepam (Valium)(C) Fluoxetine (Prozac)(D) Haloperidol (Haldol)(E) Modafinil (Provigil)
Urgent Care in Family Practice 5Examination Answers1. The answer is E . Oxygenation status is more importantin limiting neurological damage within the first fewhours than the other factors presented.2. The answer is C . Bilateral presentation of signs andsymptoms. The presence of bilateral symptoms and/orsigns of radiculopathy pose the question of central discherniation if present in the acute setting. This patientmanifests left-sided radiation of the pain, bilateral, albeitasymmetrically positive, straight-leg-raising tests anddecreased Achilles tendon reflex on the right.3. The answer is B . Presence or absence of visceral symptomatology.The presence of bowel or bladder controlsymptoms would pose further evidence of central herniation.Sensory loss is reasonably well-tolerated in nerveroot compression syndromes; while drug seeking isimportant in all aspects of patient care, particularly frequentin back pain, diagnosis of this issues is not urgent.Limitation of the ability to bend to lift is common in backsyndromes and important in prognostication after diagnosisand in setting activity restrictions but is not of criticalvalue to acute diagnosis. Work connectedness isrelevant to worker’s compensation claims but is not ofcritical importance medically.4. The answer is D . Check the perineum and inner thighsfor touch, sharp and dull sensation. The urgency of timelydiagnosis in this case is the possibility of acute caudaequina syndrome (CES). Alertness to that conditionshould have been stimulated by the history and physicalfindings of bilateral (and not necessarily symmetrical)symptoms and/or signs suggesting radiculopathy, that is,left lateral thigh radiation and right-sided reflex change aswell as straight-leg-raising test positive on both sides.Other combinations may include sensory changes ormotor deficits pointing to different sides. If the conditionis not diagnosed in a timely fashion, the patient is at greatrisk of various degrees and combinations of paraparesis,bowel and bladder control, and sexual impotence in themale and the equivalent in the female.5. The answer is B . 48 hours. Notice that the questionseeks the average ideal time. For this purpose, the onset ofCES is defined as when the bowel and bladder dysfunctionbegin. Incomplete CES (CESI) is defined as consistingof irritative bladder symptoms and confers a betterprognosis than urinary retention (CESR). Two-thirds ofcases will do well if diagnosed and treated by emergencylaminectomy or other posterior decompression within 48hours of the onset of bladder symptoms, whereas onlyone-third will do well if treated later than 48 hours fromthat onset. The earlier group is more likely to be in theCESI stage, and the later-treated group is more likely to beCESR. Patients are not likely to self-refer to a neurosurgeon,and due to the rarity of the condition, it is quitelikely to be overlooked in the primary care setting.6. The answer is C . CT of the lumbosacral spine. A patientwith unremitting low back pain with or without evidenceof infection must be evaluated for urgent conditions in thespinal area before other diagnoses are considered.7. The answer is D . Epidural abscess. This is a rare andcritical condition but one that is more likely to be seen inprimary care than in an orthopedic or neurosurgicalpractice. Spinal epidural abscess (SEA) must be diagnosedwithin a short time after onset (ranging from 3 to 5 days)to avoid the development of paraplegia. If emergencylaminectomy followed by antibiotics are instituted beforeneurologic symptoms and signs occur, neurological disastermay be avoided, with the latter consisting most frequentlyof paraplegia. Risk factors include diabetes,alcoholism and recent spinal tap. Patients may or may notmanifest radicular symptoms due to encroachment onneural foramina. Leukocytosis occurs in only about 2/3 ofcases and bacteremia in about 60%. There may be anoverlap of CES and SEA in that abscesses may encroachon the cauda. Pyelonephritis would manifest urine abnormalities(unless secondary to a totally obstructing urolith)but would have a lateralizing presentation and associatedCVA tenderness. Malignant metastases may pose a surgicalemergency as well but the reward is less significant formetastatic disease than for a timely diagnosis of SEA.Delay in the diagnosis of pyelonephritis is more forgivingas well as unlikely because of its more common occurrence.Vertebral body fracture due to osteoporosis is quitepainful but requires no special urgency for diagnosis, andit runs a benign course in the vast majority of cases.Cholecystitis, on occasion, may refer only to the lowerthoracic back instead of having the classic band-like referralaround the right flank. This case is taken from a medicolegalfile in which the patient was sent out of an EDdespite the unremitting pain, low fever and leukocytosisafter receiving meperidine IV with instructions to see hisprimary care physician if the pain did not remit withinthe next 2 days. Before he could see his regular doctor, heawoke in the middle of the night to void urine and felldown, becoming rapidly paraplegic. If diagnosed timelywith a CT–myelogram scan or MRI, both of which are90% sensitive, surgical treatment will guarantee a resultfree of neurological complications. “Timely” appears to
Page 3: NMS Q&AFamily Medicine3rd EDITION
Page 6 and 7: Acquisitions Editor: Susan RhynerPr
Page 9: Foreword to the First EditionFamily
Page 13: AcknowledgmentsFor the contribution
Page 16 and 17: xivContentsChapter 15 Surgical Issu
Page 19 and 20: SECTION IUrgent Carechapter 1Urgent
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Page 57 and 58: SECTION IIICardiovascular Diseasesi
Page 59 and 60: Cardiology 41(A) Systolic crescendo
Page 61 and 62: Cardiology 43Examination Answers1.
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chap ter 8Cerebrovascular DiseaseEx
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Cerebrovascular Disease 57(A) A non
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Cerebrovascular Disease 59ventricul
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chap ter 9Pediatric CardiologyExami
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Pediatric Cardiology 6315 You hear
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Pediatric Cardiology 65by placing o
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chap ter 10HypertensionExamination
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Hypertension 6915 In hypertensive p
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Hypertension 71systolic hypertensio
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74 NMS Q&A Family Medicine(A) Right
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Neurology 778. The answer is A. The
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SECTION VRespiratory Diseasesin Pri
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Pneumonia and Bronchitides 81(C) Co
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Pneumonia and Bronchitides 836. The
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chapter 13Respiratory Diseasesin Ch
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Respiratory Diseases in Children 87
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SECTION VIThe Gastrointestinal Trac
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Medical Problems of the Gastrointes
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Medical Problems of the Gastrointes
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chap ter 15Surgical Issues of theGa
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Surgical Issues of the Gastrointest
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Surgical Issues of the Gastrointest
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chap ter 16Problems of the LiverExa
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Problems of the Liver 103level, whe
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Problems of the Liver 105been inves
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SECTION VIIUrology and Nephrologyin
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Problems of the Urinary Tract 10913
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Problems of the Urinary Tract 11110
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114 NMS Q&A Family Medicine7 Which
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116 NMS Q&A Family MedicineExaminat
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118 NMS Q&A Family Medicineof malig
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120 NMS Q&A Family Medicine(D) Sulf
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124 NMS Q&A Family MedicineReferenc
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126 NMS Q&A Family Medicinecycle. H
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chapter 21Gynecology in Mature Adul
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Gynecology in Mature Adults 133amen
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Gynecology in Mature Adults 1357. T
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chapter 22Diseases of the Female Br
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Diseases of the Female Breast 139Ex
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Diseases of the Female Breast 141Re
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144 NMS Q&A Family Medicine(B) Long
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146 NMS Q&A Family Medicine(D) PIP
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148 NMS Q&A Family Medicine6. The a
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chapter 24Musculoskeletal Problemso
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Musculoskeletal Problems of the Nec
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Musculoskeletal Problems of the Nec
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chapter 25Musculoskeletal Problemso
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Musculoskeletal Problems of the Low
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Musculoskeletal Problems of the Low
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chapter 26Rheumatology in Primary C
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Rheumatology in Primary Care 165(D)
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Rheumatology in Primary Care 16710.
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170 NMS Q&A Family Medicineof 5 ft,
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172 NMS Q&A Family Medicinepresent.
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174 NMS Q&A Family Medicinenodules.
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178 NMS Q&A Family MedicineReferenc
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chap ter 31Other Infectious Disease
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Other Infectious Diseases in Primar
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Other Infectious Diseases in Primar
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SECTION XIEndocrinology inPrimary C
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Diabetes Mellitus 197normal saline
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Diabetes Mellitus 199Examination An
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Diabetes Mellitus 20116. The answer
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210 NMS Q&A Family Medicine(E) Hypo
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SECTION XIIAllergieschapter 36Atopi
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Atopic, Food, and Contact Allergies
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Atopic, Food, and Contact Allergies
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SECTION XIIIPreventive HealthCarech
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Preoperative Clearance 229180 to 22
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Preoperative Clearance 23121 Prophy
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Preoperative Clearance 233example,
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chap ter 38Obesity and Dyslipidemia
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Obesity and Dyslipidemia 23713 A 45
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Obesity and Dyslipidemia 239attriti
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chapter 39Smoking CessationExaminat
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Smoking Cessation 243Examination An
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chapter 40Exercise and HealthExamin
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Exercise and Health 247Examination
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chapter 41Concepts in Epidemiologya
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Concepts in Epidemiology and Resear
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Concepts in Epidemiology and Resear
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256 NMS Q&A Family Medicine7 What i
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258 NMS Q&A Family Medicineantigen
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260 NMS Q&A Family Medicine(B) Arra
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262 NMS Q&A Family Medicineinfectio
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264 NMS Q&A Family Medicine(D) Pulm
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272 NMS Q&A Family Medicine8 What a
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274 NMS Q&A Family Medicine12. Hepa
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276 NMS Q&A Family Medicine(D) Ever
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280 NMS Q&A Family Medicine5 Of the
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chapter 51Anxiety and PhobiasExamin
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Anxiety and Phobias 297Examination
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chapter 52Somatic Symptoms withoutO
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Somatic Symptoms without Organic Ba
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Somatic Symptoms without Organic Ba
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306 NMS Q&A Family Medicine5 A 25-y
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308 NMS Q&A Family Medicineperiorbi
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310 NMS Q&A Family Medicineand loti
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chapter 54GeriatricsExamination que
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Geriatrics 315Examination Answers1.
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chapter 55HematologyExamination que
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Hematology 31915 A 45-year-old busy
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Hematology 321Mean cell hemoglobin
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Hematology 323whereas in multiple m
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