NMS Q&A Family Medicine

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50 NMS Q&A Family Medicine21 A 65-year-old man has recurrence of symptomaticstenosis of the left iliac artery after undergoing successfulballoon angioplasty of the lesion 6 monthsearlier. Of all the following listed therapeutic interventions,which one is not indicated?(A) Smoking cessation by the patient(B) Repeat balloon angioplasty(C) Mechanical atherectomy(D) Stent placement(E) Streptokinase infusion
Peripheral Vascular Disease 51Examination Answers1. The answer is E. MRI is the best choice among the fiveoptions given for diagnosing osteomyelitis. The CT scanis less sensitive and literally carries infinitely more radiationthan the MRI (MRI has no radiation and the CT scanconveys approximately 200 times the radiation of a chestx-ray. Plain x-ray is inadequately sensitive, and the othertwo choices are significantly less sensitive.2. The answer is D. D-dimer among the listed non-invasivetests would be most sensitive for venous thrombosis.D-dimer is 95% to 97% sensitive and confers a very highpositive predictive value. A value greater than 500 ng/mL isthe cut-point above which sensitivity is significant. Veryclose to this sensitivity is that found with compressionvenous ultrasound that is 94% sensitive and also confers ahigh positive predictive value. Bone scan has no applicabilityin vascular disease; plain x-rays, of course, have low sensitivityfor soft tissue diseases. The time-honored Homan’ssign, deep calf pain caused by manual squeezing of the calf,is only 50% sensitive and is associated with many false positives,for example, myositis and local infection.3. The answer is C. The Well’s criteria comprise a pointsystem to assist in evaluating for PE. The following is atabulation of that system:Modified Well’s criteria for PE:Symptoms of DVT 3.0Other Diagnosis less likely 3.0Heart rate 100 1.5Immobilization or surgery ( 4 weeks) 1.5Previous DVT or PE 1.5Hemoptysis 1.0Malignancy 1.0A score of 6 points signifies a highprobability of PE2–6 points signifies a moderate probability of PE 2 points indicates a low probability of PEThe gold standard for diagnosis of PE is angiography. TheVQ scan has high sensitivity but low specificity—that is,high negative predictive value.4. The answer is D. Although DVT lies within the differentialdiagnosis of this case, the vignette places thepatient in the 0% to 13% probability by the Wells clinicaldecision rules (CDRs) for assistance in diagnosing DVT.The Wells CDRs, with a maximum point of 9, show thispatient to have 2 points. After 2 points are subtracted forthe possibility of another diagnosis (cellulitis) that couldaccount for the findings, the net score is 1. This confers a0% to 13% possibility of DVT (see Table 7–1 ). Therefore,the patient may be followed expectantly while he istreated symptomatically or empirically. This patient maywell have a case of cellulitis secondary to an infection ofthe great toe, for which culture, white blood cell countand differential, empiric prescription of antibiotics, andwarm compresses would be appropriate. Another strongfactor in a case like this, ignored in the Wells criteria, isthe normal D-dimer. The latter is sensitive for the presenceof intravascular thrombosis, though insignificantlyspecific.5. The answer is A. According to the Wells CDR scale,this patient has a score of 4, placing her in the highprobabilitycategory for DVT (Table 7–1). Even in the faceof negative ultrasonographic studies, a venogram shouldbe ordered, although if the Wells score were in the moderatecategory, then serial ultrasonography would be acceptable.Prescribing cefadroxil (Duricef) would be a goodchoice for infection below the waist, but there is no evidencefor infection in the vignette. Surgical exploration isinappropriate, and checking for metastatic disease has asecondary priority at this point.TABLE 7–1 Wells CDRClinical CharacteristicScoreActive cancer (within 6 months) 1Paralysis, paresis, or recent plaster immobilization 1of lower extremitiesRecently bedridden for more than 3 days or1had surgery within 12 weeksLocalized tenderness along the distribution1of deep veinsEntire leg swollen 1Calf swelling to 3 cm more expected for1symptomatic sidePitting edema confined to the symptomatic leg 1Collateral superficial veins 1Previously documented DVT 1Alternative diagnosis at least as likely as DVT 2Source : Modified from Smucny J , Cohania R . American Family Physician( 2004 ; 70 : 565 ).Notes : To determine the probability of DVT, calculate the score andplace the patient in one of the following categories: 0 lowprobability (0% to 13%); 1 to 2 moderate probability (13% to30%); 3 high probability (49% to 81%).
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NMS Q&AFamily Medicine3rd EDITION
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Acquisitions Editor: Susan RhynerPr
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Foreword to the First EditionFamily
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AcknowledgmentsFor the contribution
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xivContentsChapter 15 Surgical Issu
Page 19 and 20: SECTION IUrgent Carechapter 1Urgent
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Page 59 and 60: Cardiology 41(A) Systolic crescendo
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Page 85 and 86: chap ter 10HypertensionExamination
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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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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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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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174 NMS Q&A Family Medicinenodules.
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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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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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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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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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