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* Family Form 2
  kennychan - 07/04/18 18:06
  1) A 42-year-old woman comes to the physician because of a 1-day history of severe pain, and warmth in her left knee. Her pain is moderately relieved with ibuprofen use. She notes that she awoke with the pain 1 day after she did an aerobic kickboxing workout. Her temperature is 37.2 C, pulse is 86/min, and blood pressure is 120/70 mm Hg. The upper aspect of the left knee is erythematous and warm to the touch with an effusion. Range of motion is limited by pain. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in management?
A) Reassurance (wrong)
B) Application of a knee brace and ice and elevation
C) MRI of the knees
D) Intravenous antibiotic therapy
E) Arthrocentesis

2) A 23-year old woman comes to the physician because of moderate pain and swelling of her right ankle after twisting it yesterday. She has no history of serious illness and takes no medication. Vital signs are within normal limits. Examination shows moderate edema of the lateral aspect of the right ankle, an ecchymosis below the lateral malleolus, and tenderness to palpation of the anterior aspect of the lateral malleolus. The posterior aspects of the lateral and medial malleoli are nontender. Neurovascular function of the ankle is intact. The patient can bear weight as she walks across the room but has been using a set of crutches. In addition to recommending 2-day ice pack application to the injury, which of the following is the most appropriate next step in management?
A) Stress x-rays of the ankle to asses ligament integrity
B) X-ray of the ankle to rule out fracture (wrong)
C) Use of a soft protective brace and early range of motion exercises
D) Splinting the ankle and referral to an orthopaedist.

3) A 57-year-old woman comes to the physician for a routine health maintenance examination. She has no history of serious illness and takes no medications. She smoked one pack of cigarettes daily for 20 years but stopped 10 year ago. Shen drinks one glass of wine daily. She does not exercise. She is employed as an office assistant. She is 168 cm (5ft 6 in) tall and weighs 65 kg (143 lb); BMI is 23 kg/m2. Her pulse is 80/min, respirations are 14/min, and blood pressure is 140/90 mmHg. The lungs are clear to auscultation. Cardiovascular examination shows no abnormalities. Serum lipid studies show:
Cholesterol total: 250 mg/dL
HDL-cholesterol 35 mg/dL
LDL-cholesterol 179 mg/dL
Triglycerides 180 mg/dL
Which of the following is the most appropriate next step in management?
a) Exercise program
b) Weight loss program
c) Glucose tolerance test (wrong)
d) 24-hour urine collection for measurement of microalbumin
e) Serum lipids studies in 1 year
f) Atenolol therapy

4) A 32-year-old woman is brought to the emergency department by her husband because of the onset of shortness of breath, profuse sweating, and chest discomfort while at a concert 30 minutes ago. She had a similar episode 1month ago while at her daughter’s school play. She has felt anxious since that time and is concerned that she is going crazy. She has monitored her pulse during the past month, and it has ranged between 70-80/min. Examination shows a pulse of 110/min and blood pressure of 140/76 mm Hg. An opening systolic click is heard over the left fourth intercostal space Which of the following is the most likely cause of her symptoms?
a) Generalized anxiety disorder
b) Hyperthyroidism
c) Mitral valve prolapse (wrong)
d) Panic disorder (likely the correct answer)
e) Paroxysmal atrial tachycardia

5) An 82 yo woman comes to the physician because of difficulty sleeping at night for 6 months. She says watches television or listens to talk radio at night because she cannot sleep. She has daytime fatigue and takes frequent naps. Her husband died 3 years ago, and she lost her pet dog of 11 years 8 months ago. She has had a 5.4 (12lb) weight loss since her last examination 6 months ago. She is 173 cm (5ft 8 in) tall and weighs 59 kg (130 lb); BMI is 20 kg/m2. Her temperature is 37.5 C, pulse is 86/min, respirations are 10/min, and blood pressure is 150/84 mm Hg. She appears disheveled and has cracked, chapped lips. Physical examinations shows no abnormalities. On mental status examination, her eye contact is poor. She answers questions with delayed, short responses, and has difficulty finding words. She describes her activities during the past few days vaguely after being asked for specific details. When asked to draw the face of a clock and indicate 1:30 on the drawing, she requires 5 minutes to complete the clock face. She must be reminded that she was to indicate 1:30, which she then proceeds to do correctly. She can recall two of three objects after 5 minutes. Which of the following is the most appropriate next step in management?

A) Emphasize the importance of good sleep hygiene
B) Recommend grief counseling
C) Suggest she get a new household pet
D) Begin donepezil therapy (wrong)
E) Begin sertraline therapy

Please give your opinions and explanation. Thanks.
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* Re:Family Form 2
  kennychan - 07/10/18 15:09
  Please help!  
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* Re:Family Form 2
  captan - 07/10/18 22:03
  1) C
2. C) Use of a soft protective brace and early range of motion exercises
3.a) Exercise program
4.d) Panic disorder
5.E) Begin sertraline therap looks like depression
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* Re:Family Form 2
  kennychan - 07/10/18 23:15
  Thank You!  
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* Re:Family Form 2
  davisfranchize - 07/19/18 15:26
  The (real) correct answers w/ explanations:

1) E*** - They want you to tap the join here since her pain is severe, joint is red/warm, and has restricted range of motion. Once you have some joint fluid, you can rule out a septic knee. You would not order an MRI without physical exam findings that are consistent w/ an MSK injury (ex: + anterior drawer test for an ACL tear). The delayed onset of "severe" symptoms is supposed to key you into arthrocentesis.

2) C - Actually one of the tougher questions I've ever had; the key here is that her tenderness is on the ANTERIOR lateral malleolus and not the posterior lateral malleolus, which otherwise would command an x-ray to rule out a fx per the Ottawa criteria. Conservative management is the board test answer here, however in clinical practice they would almost always get the x-ray.

3) A - The point of this question is that exercise can improve your lipid profiles pretty dramatically, and should be attempted before automatically starting a statin. Glucose tolerance test is wrong because it is overkill, and you would likely want a fasting glucose or A1C in order to appropriately screen a patient with hyperlipidemia for diabetes.

4) D - I missed this one as well; the fact that her symptoms are not occurring all the time suggests a panic disorder, although her fear about future episodes is only subtly mentioned in the vignette. I was thrown off by the vital signs, but obviously if she is not sweating all the time, this moves you away from an organic cause like the thyroid. Murmur is an incidental finding.

5) E - This is a patient with pseudodementia (undiagnosed/untreated depression) that would benefit from an SSRI/CBT. Make sure that you take away the knowledge of *psychomotor impairment* that is described in this one; it is part of the MDD criteria, and a concept that many students do not understand.
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* Re:Family Form 2
  captan - 07/19/18 16:06
  yes !You are right about 1 q it is E)
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* Re:Family Form 2
  kennychan - 07/23/18 15:03
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