Review Questions 1C

Front 1

Your patient is three days post acute blood loss related to surgery. You find the hemoglobin has improved from 7.2 g/dL to 9 g/dL. Would you expect the reticulocyte count to be decreased, normal, or increased?

Back 1

Increased

Reticulocytes offer a window into the production of RBCs in the bone marrow. The reticulocyte is elevated 3 to 4 days after acute blood loss as a normal response to anemic conditions and the resultant need to produce more RBCs.

Front 2

Iron deficiency anemia is a common incidental finding on routine CBCs. As a provider, you check a CBC on one of your patients during their annual exam. Lab results show slightly decreased hemoglobin, decreased serum iron, increased total iron-binding capacity, decreased transferrin saturation and a decreased ferritin. You decide to supplement this patient with iron. What is the most accurate and complete education to provide to your patient at this time?

Back 2

I would like to start you on 150mg oral iron supplementation for 4-6 months until we can recheck your ferritin level to see that your anemia has corrected. You will have the best iron absorption if you take it with a glass of orange juice 30 minutes before a meal. Common side effects include nausea, constipation, heartburn and black stools.

Treatment for iron deficiency anemia includes 150-200mg of elemental iron daily, available in many formulations. Absorption is aided by ascorbic acid and is best absorbed on an empty stomach. Therapy usually continues 4-6 months until the repeat ferritin is greater than 50mcg/L. Patients should be aware of common side effects such as GI upset, constipation and dark stools so they are not alarmed.

Front 3

A 64 year old Asian man presents with a 6 months history of increasingly severe peripheral neuropathy and oral irritation. PE indicates pale conjunctiva and smooth, red, shiny tongue. Lab results are as follows: Hgb 6.2g/dl (normal range: 12-14g/dl) Hct 20% (normal range: 36-42%) RBC 2.1mil (normal range: 4.2-5.4mil) MCV 132fl (normal range: 80-96fl) RDW 19% (normal range: 11-15%) WBC morphology shows hyper-segmented neutrophils The most likely cause of this anemia is:
A. Vitamin B12 deficiency
B. Iron deficiency
C. Beta thalassemia
D. Chronic disease

Back 3

A. Vitamin B12 deficiency.

Anemia caused by Vitamin B12 deficiency often reveals symptom of neurologic dysfunction and smooth, red, shiny tongue (Low, 2008). Lab value also indicates this is macrocytic anemia. Characteristic of macrocytic anemia is decreased Hgb, elevated MCV, elevated RDW, hyper-segmented neutrophils (Low, 2008). Iron deficiency is common etiology of microcytic anemia which will indicate low MCV with elevated RDW (Low, 2008). Beta thalassemia is common etiology of microcytic anemia with normal RDW, at risk ethnic group for beta thalassemia is African, Mediterranean and Middle Eastern ancestry (Low, 2008). Anemia of chronic disease is common etiology of normocytic anemia which will indicate normal MCV and normal RDW (Low, 2008).

Front 4

As kidney function declines with increasing age, the incidence of chronic kidney disease (CKD) increases. Anemia is a common complication of CKD in the older adult, and manifests as a deficiency in the production of erythropoietin. Erythropoietin is an erthyropoiesis-stimulating hormone produced by the kidneys. What is the typical treatment of anemia in older adults with CKD?

Back 4

Erythropoiesis-stimulating agents (ESA’s) are the cornerstone of treatment for anemia in older adults with CKD.

ESA’s stimulate the body’s natural process for the production of red blood cells. When clinically indicated, iron stores should be replenished before and during ESA therapy in order to prevent weakened erythropoiesis due to a true or functional iron deficiency anemia (Halter et. al., 2009).

Front 5

Clinical presentation including a malar rash, arthritis, kidney disease and pancytopenia leads the NP to lean towards what diagnosis?

Back 5

Systemic Lupus Erythematosus

SLE can affect the heart, kidneys, lungs and brain. Eleven criteria have been chosen to classify lupus. If 4 of these 11 are present, a diagnosis can be made. They are malar rash, discoid rash, photosensitivity, oral ulcers, arthritis, Serositis, kidney disease, neurologic disease, hematologic disorders, immunologic abnormalities and a positive ANA.

Front 6

A patient arrives at the clinic with general muscle pain, weakness, night sweats and anorexia. You, as the astute NP, decide that this sounds like vasculitis. The patient is over age 50 and complains of headaches and scalp tenderness. What other signs would you look for to confirm Giant Cell Arteritis?

Back 6

Swollen temporal arteries and jaw pain.

Giant cell arteritis affects those over age 50 and generally presents with constitutional signs consistent with vasculitis and headaches and jaw pain. Jaw claudication consisting of pain with chewing and relief with rest is very common.

Front 7

An older female patient comes to the clinic. She is complaining of joint stiffness in both hands and both feet. She figured the pain would be better with rest, but she is having terrible pain in the morning. She also has a cough. The NP tells her she is going to need to have which lab test to get a better idea of what is going on:
A. anti-double-stranded DNA antibody to confirm SLE
B. joint aspiration to identify urate cyrstals to confirm gout
C. cyclic citrullinated peptides (anti-CPP) to confirm RA.

Back 7

Cyclic citrullinated peptides (anti-CPP) to confirm rheumatoid arthritis.

\RA usually presents with morning stiffness greater than 30 minutes. Interstitial lung disease presenting with a cough and dyspnea is common. Rheumatoid factor and anti-CPP are present in 70-80% of cases.

Front 8

A patient comes in and says he thinks he has gout. His friend has gout and he is having pain and would like medicine to treat this. Which symptoms make the NP think he most likely does indeed have gout?
A. First metatarsophalangeal joint is affected in both feet and also he has pain in his hands and hips.
B. He has pain when he wakes up in the middle of the night in his left big toe. He is complaining of some fatigue and fever as well.
C. He has the most pain in the morning when he wakes up and it stays around for thirty minutes to a couple of hours. He is having fatigue, anorexia and low-grade fever.
D. He has pain in the joints of both hands. He has been having the pain gradually build up over a couple of months.

Back 8

B. He has pain when he wakes up in the middle of the night in his left big toe. He is complaining of some fatigue and fever as well.

Gout generally wakes people up and involves only one joint to start out with. Systemic signs can be involved because of inflammation and cytokines. Gout generally develops in one day and can last for several hours or weeks if left untreated.

Front 9

A patient has a confirmed acute gout attack confirmed by a needle aspiration. What should the NP NOT suggest to the patient?
A. NSAIDS in the first 24-48 hours if the patient has no kidney issues, HF or peptic ulcer disease.
B. Rest the joints for 1 to 2 days.
C. Exercise will help the inflamed joint.
D. Limit your alcohol intake.

Back 9

C. Exercise will help the inflamed joint.

Nonpharmacological treatment of gout includes resting the joints for 1 to 2 days. This usually allows the patient to take less medications. Alcohol is known to induce gout and decreasing/eliminating it is important. Controlling weight and stopping diuretics is also helpful for patients with gout.

Front 10

Cindy is a 25-year-old female with heavy menstrual bleeding and a history of anemia. She presents to the clinic today with fatigue and exercise intolerance. Thinking Cindy has iron deficiency anemia (IDA), you order a CBC, which comes back normal. A better early indicator of IDA would be:

Back 10

Ferritin.

Ferritin is the first laboratory change in IDA. This change is followed by a decrease in serum iron and increase in transferrin. Lastly, there will be changes in the CBC.

Front 11

John, age 56 is a severe alcoholic. He presents for increasing fatigue and “getting winded” when walking 3 blocks to the liquor store. Among other things, you want to assess the patient for anemia. Besides routine labs for anemia, a new NP on top of her game might also what lab value:

Back 11

A folate level.

Alcoholism is one of the common causes of folate deficiency, which can cause megaloblastic anemia. Not only to alcoholics have poor dietary intake, but also alcohol prevents adequate folate metabolism.

Front 12

Anemia related to hyperthyroidism, gastric bypass surgery, and celiac disease would have a ___ mean corpuscular volume (MCV).

Back 12

High

These diseases are common causes of vitamin B 12 and Folate malabsorption, which can cause macrocytic anemia. Macrocytic anemia is characterized by a high MCV.

Front 13

Which grouping of lab values is helpful in distinguishing iron deficiency anemia (IDA) from B-Thalassemia minor?

Back 13

Iron studies (Ferritin, serum iron, total iron binding capacity, and transferrin saturation)

IDA and B-Thalassemia minor can present similarly and are both characterized by a low to normal hemoglobin and low mean corpuscular volume. However, patients with B-Thalassemia should have normal iron studies whereas patients with IDA will have abnormal iron studies.

Front 14

George is an 81-year-old male who was recently diagnosed with new iron deficiency anemia (IDA). After starting him on iron supplementation, you know you must also work him up for which other disease?

Back 14

Gastrointestinal cancer

Older adults with IDA should be worked up for gastrointestinal cancer even if their stools do not contain occult blood, as colon cancer is a common cause of IDA in this age group.

Front 15

62 year old woman presents with complains of pain, numbness, and burning in her hands and feet. She states that there are a characteristic white, blue, and then red changes after she has been outside scraping the windshield of her car after a snowfall. What diagnosis does this lead you to look at?

Back 15

Raynaud’s Phenomenon

The vasospasm of Raynaud’s phenomenon causes classic tricolor change of first white (pallor), then blue (cyanosis), and then red (reperfusion hyperemia) after the vasospasm ends (Buttaro, 2008, p. 1194).

Front 16

What is the most commonly used assay for lupus anticoagulant?

Back 16

Dilute Russell’s viper venom test (DRVVT)

A prolonged activated partial throboplastic time (aPTT) may suggest the presence of a lupus anticoagulant; however, the most commonly used assay for lupus anticoagulant is the dilute Russell’s viper venom test (DRVVT) (Buttaro, 2008, p. 1203).

Front 17

Based on socioeconomic factors and reduced access to health care which ethnic group generally has more severe systemic lupus erythmatosus?

Back 17

African Americans

African Americans generally have more severe disease and a poorer prognosis. The reasons for this are unclear but may relate, in part, to socioeconomic factors and reduced access to healthcare (Buttaro, 2008, p. 1205).

Front 18

Rare individuals that maintain a normal CD4 T-cell count indefinitely and never develop AIDS are called:

Back 18

Long-term non-progressors or elite controllers

However some individuals progress to AIDS in a few years (occasionally as short as 1 year), and some rare individuals (known as long-term nonprogressors or elite controllers) maintain a normal CD4-count indefinitely and never develop AIDS (Buttaro, 2008, p. 1254).

Front 19

A 45 year old presents to clinic with complaints of lack of sleep due to extreme pain in his big toe. He describes the pain as almost cramp-like sensation or a dislocation. He states that the toe was warm, red and swollen with decreased ROM. For what disease are you as the NP planning on working him up?

Back 19

Acute Gout

Acute gout is characterized by rapid onset and buildup of pain. The first attack often begins at night and wakes the patient form sleep. During an acute flare, the patient endures exquisite pain associated with warmth, redness, swelling, and decreased ROM. The initial episode is usually monoarticular in men (Buttaro, 2008, p. 916).

Front 20

Reducing flares, managing systemic disease manifestations and allowing the tapering of steroids are some the primary rationales for prescribing _____ in patients with SLE.

Back 20

Hydroxychloroquine

Hydroxychloroquine has been shown to be an effective treatment for SLE, reducing MS, serosal and cutaneous manifestations of SLE. Additional benefits include a reduced dependence on steroids and decreased disease flares. Hydroxychloroquine also has a more desirable safety profile when compared to chloroquine.

Front 21

When CD4 counts drop below _______, the risk for HIV- associated complications begins to rise steadily

Back 21

200/mm3

Occasionally, opportunistic infections may occur when an individual has a CD4 count of greater than 200, but the majority of infections are seen when severe immune dysfunction is present as the CD4 count drops to less than 200.

Front 22

Dietary recommendations for treatment of gout include:

Back 22

A balanced diet with 40% of caloric intake derived from carbohydrate, 30% from protein, and 30% from fat; replacement of refined carbohydrates with complex and saturated fats with mono- and polyunsaturated.

Dietary changes that increase insulin sensitivity promote a reduction in serum urate.

Front 23

Raynaud’s phenomenon causes a classic, tricolor skin change that progresses from ______to ______ to ________.

Back 23

White to blue to red

Raynaud’s is a reversible vasospasm of vasculature in the extremities. Pallor occurs first, as there is decreased oxygenation blood delivery to the extremities. This decreased oxygenation then results in cyanotic extremities and blue skin coloring. Lastly, there is reperfusion hyperemia of the digits after the vasospasm ends and blood flow is re-established.

Front 24

True or False: You should expect to see age-related changes in the white blood cell count and differential of an older adult.

Back 24

False

Normal aging does not change the white blood cell count or differential. If a change is present, suspect a disease process such as infection or malignancy (Klepin & Powell, 2009).

Front 25

Your 67-year-old female patient has been diagnosed with Class II rheumatoid arthritis and will start on methotrexate therapy. Which assessment must be performed prior to starting methotrexate?
A. tuberculosis skin testing and chest x-ray
B. intake assessment for physical therapy and occupational therapy
C. eye exam
D. depression inventory

Back 25

A. tuberculosis skin testing and chest x-ray

There is a higher chance of latent tuberculosis infection becoming reactivated when immunosuppressive therapy is started, so tuberculosis must be ruled out. Physical and occupational therapy should be offered to every patient with rheumatoid arthritis, but it is not necessary to complete an intake assessment prior to starting methotrexate. Eye exams are important prior to starting antimalarial drugs, such as hydroxychloroquine. Assessment of depression is important throughout the treatment of chronic illness.

Front 26

Your 20-year-old male patient requested testing for possible HIV infection. His ELISA was positive, and his Western Blot was negative. Does your patient have HIV?
A. Yes, this combination of test results is diagnostic for chronic HIV infection.
B. Probably, but the ELISA must be repeated to be sure.
C. Probably not, but the Western Blot must be repeated to be sure.
D. No, this combination of test results rules out chronic HIV infection.

Back 26

D. No, this combination of test results rules out chronic HIV infection.

ELISA is a screening test with very high sensitivity but low specificity. The fact that the Western Blot was negative means that the ELISA result was a false positive.

Front 27

Which of the following is NOT a common approach to treatment for gout?
A. limiting alcohol consumption
B. thiazide diuretics
C. NSAIDs
D. weight reduction

Back 27

B. thiazide diuretics

Thiazide diuretics are not used for gout management and can cause serious side effects when combined with allopurinol. Limiting alcohol consumption, encouraging weight reduction (through a sensible diet, usually one low in purines), and NSAIDs are all common treatments for gout.

Front 28

A patient that presents with signs of anemia, low hemoglobin, and MCV <80 fL likely has what common nutrient deficiency?
A. Vitamin B12
B. Vitamin D
C. Iron
D. Folate

Back 28

C. Iron

Iron deficiency anemia is the most common type of anemia in the world and the most common nutrient deficiency. MCV <80 fL is classified as microcytic.

Front 29

Sickle cell disease, anemia of chronic disease, aplastic anemia, and hemolytic anemias are classified as:
A. Microcytic
B. Macrocytic
C. Normocytic

Back 29

C. Normocytic

These anemias have a MCV that falls in the 80-90 fL range.

Front 30

What should your patient take with their iron supplement to enhance absorption?
A. Soy protein
B. Bran flakes
C. Tea or coffee
D. Green leafy vegetables
E. Ice cream
F. Citric or ascorbic acid

Back 30

F. Citric or ascorbic acid

Front 31

A patient presents with complaints of peripheral neuropathy and ataxia. Their CBC reveals low hemoglobin and a MCV of 130 fL; additionally, the peripheral smear shows hypersegmented neutrophils and oval macrocytes. What type of anemia does this patient have?
A. Sickle cell anemia
B. Megaloblastic anemia
C. Thalassemia
D. Hemolytic anemia

Back 31

B. Megaloblastic anemia

Findings on the CBC that suggest macrocytic anemia include low hemoglobin levels and MCV of more than 100 fL. The peripheral smear is also helpful in diagnosis of megaloblastic anemia.

Front 32

People who have had a partial gastrectomy, an ileal resection, a personal history of alcoholism, or a prolonged history of strict veganism are all at increased risk for what anemia?
A. Microcytic due to increased risks for GI bleed
B. Normocytic due to antibody reactions
C. Macrocytic due to vitamin B12 and folate deficiency

Back 32

C. Macrocytic due to vitamin B12 and folate deficiency

Alcoholism is a common cause of folate deficiency because of alcohol’s interference with folate metabolism and the usually poor dietary habits related to alcoholism. It would take several years of a strict vegan diet for megaloblastosis to occur. Patients who have had partial or total gastrectomy, ileal resection, or any other evidence of gastric atrophy or intestinal malabsorption should receive prophylactic monthly parenteral vitamin B12 therapy and daily folic acid supplements.

Front 33

You have just started your new job working at the Red Door Clinic and are reviewing the guidelines for the management of HIV infection with your colleagues. Initiation of highly active antiretroviral therapy (HAART) should attempt to balance the benefits of the treatment with the disadvantages in certain patient populations. You know that one absolute indication for HAART treatment is in which patient population?

Back 33

Pregnant women with HIV

Highly active antiretroviral therapy can reduce mother-to-child vertical transmission from approximately 25% to less than 2% without concerns of significant fetal toxicity.

Front 34

A 47-year-old male presents to the clinic with complaints of a headache, intense sweating and heart palpitations during exercise. The gym personnel immediately sent him to the clinic today because his headache was severe and his blood pressure was 200/105, which he states is unusually high for him. He states that these episodes occur several times per week and usually last on average 20-30 minutes. The episodes usually happen during exercise but he also experienced them during a coughing episode last week. His family medical history is significant for his father having an adrenal disorder that needed surgery. Knowing this information, what is one important adrenal disorder to include in his list of differential diagnoses?

Back 34

Pheochromocytoma

Pheochromocytomas often present with new onset moderate to severe hypertension that is difficult to catch on exam because of the substantial variations during episodes. The abnormal production of catecholamines result in intense physical symptoms such as headache, diaphoresis and palpitations. Ten percent are also considered familial.

Front 35

Joint paint occurs in 80-90% of patients with systemic lupus erythematosus. Which class of medications is employed first-line for the management of joint and serositis pain in this patient population?

Back 35

Nonsteroidal anti-inflammatory drugs (NSAIDs)

NSAIDs, including the COX-2 selective NSAIDS, are useful in reducing the local inflammatory response caused by the deposition of immune complexes in the tissues and joints.

Front 36

Gout is a metabolic disorder that is strongly influenced by dietary habits. The traditional gout prevention diet includes adherence to what type of dietary modifications?

Back 36

Low-purine, low-protein, alcohol restricted diet

Limiting meals with meats including fish rich purines as well as the restriction of alcohol can reduce serum urate levels and are helpful in preventing gouty attacks.

Front 37

Gastrointestinal blood loss, peptic ulcer disease, malabsorption syndromes, normal to heavy menstrual periods, pregnancy, infancy and adolescence are all causes of what kind of anemia?

Back 37

Iron Deficiency Anemia

Gastrointestinal blood loss, peptic ulcer disease, varices, malignant disease, diverticulitis (with severe menorrhagia), malabsorbtion syndromes (mild or severe), inadequate diet, normal or heavy menses, blood donation, polycythemia vera treated with phlebotomy, and growth conditions that require more iron (infancy, adolescence and pregnancy) are all conditions that cause iron deficiency anemia. Iron deficiency anemia is the most common type of anemia as well as the most common nutrient deficiency.

Front 38

A patient with vitamin B12 and folate deficiency would present with which classification of anemia and what would the mean corpuscular volume (MCV) value be?

Back 38

Macrocytic anemia with an MCV >100fL

Vitamin B12 and folate deficiency are the most common types of macrocytic anemia. The MCV index value for macrocytic anemia is >100fL, which shows that the red blood cells in this sample are larger than average (Buttaro et al., 2013, p. 1141 and 1149).

Front 39

What medication can be used to help prevent vasospasm in patients with Raynaud’s phenomenon?

Back 39

Nifedipine

Nifedipine can help to prevent vasospasm in patients with Raynaud’s phenomenon (Buttaro et al., 2013, p. 1195).

Front 40

Your 68 year old patient presents to you with classic symptoms of anemia: fatigue, decreased exercise tolerance, dyspnea, pale conjunctiva, tachycardia, etc. He has a history of coronary bypass surgery 3 years ago. You run the necessary diagnostic tests and confirm he indeed has iron deficiency anemia. His hgb is 9.0g/dL. Your next step should be:

Back 40

Consult with a physician

Physician consultation is recommended for hemoglobin values of less than 10g/dL in patients with known CAD and for any patient with postural vital sign changes or active bleeding. MD consultation is also recommended for sickle cell crises, suspected aplastic anemia, or hemolytic anemia.

Front 41

You have determined that your patient has anemia based on his labs. Now you need to determine what type of anemia he has. Name the most useful component of the CBC (specifically within the RBC parameters) that will guide you in determining the cause of your patient’s anemia.

Back 41

MCV

The most useful RBC index is the MCV. The MCV is a direct measurement averaging the RBC size. Based on the MCV, anemias are classified as microcytic (MCV <80fL), normocytic (MCV 80 to 90fL) or macrocytic (MCV > 100fL).

Front 42

A 47 years old men presents to the clinic to see his NP for a regular checkup. He has no previous medical or surgical history. As part of the checkup nurse practitioner orders routine laboratory tests; relevant findings are as followed: Hemoglobin: 11 g/dL Hematocrit 33% Reticulocyte count: 0.2 % MCV: 120 fl What are some possible etiologies for this condition?
A. Chronic blood loss
B. Vitamin B12 or Folate deficiency
C. Iron deficiency
D. Polycythemia

Back 42

B. Vitamin B12 or Folate deficiency

The tests are indicative of a macrocytic anemia. However, macrocytic anemia is not a diagnosis itself, and a cause for the anemia must always be pursued. Vitamin B 12 deficiency and Folate deficiency are the primary causes of macrocytic anemia. Other causes are possible, (hypothyroidism, alcoholism, myelodysplastic syndrome, pharmaceutical agents, especially antimetabolites such as methotrexate) but they are not listed in the question.

Front 43

A 66 year old man with renal failure and generally poor health begins dialysis treatment. One year later, he complains of increased shortness of breath while walking. Laboratory findings showed that he has normocytic anemia. Which of the following factors is this patient lacking and is responsible for his anemia?
A. Erythropoietin
B. Folic acid
C. Iron
D. Vitamin B 12

Back 43

A. Erythropoietin

Erythropoietin is a glycoprotein that is synthesized in the kidney and stimulates red blood cell production. In patients with renal failure, the lack of erythropoietin synthesis results in normocytic anemia. When it becomes severe, the administration of erythropoiesis-stimulating agents (ESAs) is generally required, along with the repletion of iron stores and the correction of other causes of anemia.

Front 44

A 55 year old woman complains of episodic “attacks” of headache, palpitations, and profuse perspirations. She states that episodes usually last 15-20 minutes and usually precipitated by activities and cough. Her pulse is 140 beats/minute and blood pressure 180/120 mm Hg. Which of the following laboratory tests would be most useful in finding the cause of her hypertension?
A. Serum electrolytes
B. Urine for free cortisol, 24 hours
C. Urine for metanephrines, 24 hours
D. Urine for 17-ketosteroids, 24 hours

Back 44

C. Urine for metanephrines, 24 hours

This patient has pheochromocytoma. The classic triad of symptoms in patients with a pheochromocytoma consists of episodic headache, sweating, and tachycardia. A 24-hour urinary fractionated catecholamines and metanephrines should be the first test in patients with suspicion for pheochromocytoma. A. Serum electrolytes is incorrect - most useful in diagnosing primary aldosteronism (Buttaro, 2011, p. 1059). B. Urine for free cortisol and D. Urine for 17-ketosteroids, 24 hours is incorrect. These tests are used for the diagnosis of Cushing’s syndrome.

Front 45

A 35 year old mother of three presents to the clinic for a routine checkup. She reports that she has been feeling weak and tired for the past 4 months, and has been having constipation. For the past two months, she has also experienced a general lack of interest in her hobbies, and finds it difficult to get out of bed each morning to care for her children. On physical examination she appears to be shivering slightly. She weighs 25 lbs more than she did at her last visit 12 months ago. BP 120/75 mm Hg, HR is 55/min, and respirations are 16/min. A 5 cm, non-tender neck mass is palpable, and her skin is dry and cold to touch. Her NP orders blood tests that reveal the following: Hgb: 10.7 g/dL TSH: 14 nU/mL T3: 60ng/dL Total thyroxine (T4): 3.2 ng/dL Thyroid peroxidase antibodies: positive. What is the diagnosis?

Back 45

This patient has chronic autoimmune thyroiditis

Autoimmune thyroiditis is differentiated from other causes of hypothyroidism by the presence of thyroid antibodies (Buttaro, 2011, p. 1134). Levothyroxine and regular monitoring of TSH and T3/T4 levels is most appropriate management for this patient.

Front 46

A 29 year old female with no known past medical history presents to the urgent care in moderate respiratory distress. Patient recently emigrated with her family from India and she does not speak English. On a physical examination she is a thin and ill-appearing woman with mild SOB at rest and a non-productive chough. Auscultation of the lungs reveals bibasilar crackles with relatively clear middle and upper lung fields. Her oral cavity reveals a white film on her tongue and buccal mucosa. T 101.8 F, HR 120/min, BP 122/66 mm Hg, RR 26, and O2 sats 90 %. Patient’s chest Xray shows bilateral, diffuse infiltrates with “ground glass” appearance. What is the most likely diagnosis?

Back 46

Pneumocystosis

Pneumocystosis is a pneumonia caused by the opportunistic fungal pathogen Pneumocystis jiroveci. The classic findings on chest radiography consist of diffuse, bilateral infiltrates without evidence of distinct hilar adenopathy. They are often described as having a “ground glass” appearance.

Front 47

Lupus can be a serious, life altering diagnosis. A young woman, with a history of SLE, presents to you clinic after having a miscarriage. You know that some patients with SLE develop a syndrome characterized by hypercoagulability, thrombosis and fetal loss. They’re also at increased risk for HTN, strokes, Libman-Sacks endocarditis, and valvular heart disease. What is the name of this syndrome that we should be aware of?

Back 47

Antiphospholipid Syndrome

These women may require anticoagulation for thrombosis or pregnancy prophylaxis. Practitioners should remember that they are not good candidates for combined hormonal contraception, and are at high risk for complications with pregnancy.

Front 48

In microcytic iron deficiency anemia, what is important to tell patients regarding taking iron supplements?

Back 48

Iron is absorbed best when taken 30 minutes before meals.

It can be taken with food but this will minimize absorption. However, iron supplements can cause nausea or GI upset, and may be tolerated better with food. The therapeutic dose is 150-200mg per day in divided doses. This should be considered for 4 to 6 months or until ferritin levels improve. Iron can cause black stools.

Front 49

When beginning a urate-lowering drug (such as allopurinol), it is important to know what their mechanism of action is, and patient instruction should include:

Back 49

That ULT’s work by mobilizing deposited crystals. Therefore, they can actually precipitate a gout flare up.

They should not be started during an acute flare up, wait 6-8 weeks, begin low and increase slowly. Ultimately they should achieve improvement in the crystal deposition over time, resulting in cessation of gouty flares.

Front 50

What are medications that can help the patient, who is experiencing frequent discomfort, diagnosed with Raynaud’s Phenomenon?

Back 50

Nifedipine, Gingko Biloba, and Aspirin

Nifedipine is a calcium channel blocker, which helps prevent vasospasms associated with the diagnosis. Gingko has been studied and found to reduce attacks by 56% compared to placebo. Finally, ASA should be considered in those with secondary Raynaud’s and a history of ischemic ulcers.

Front 51

What is the difference between Primary and Secondary Raynaud’s Phenomenon?

Back 51

In Primary Raynaud’s there is no associated autoimmune disorders, and rarely any autoantibodies present. In Secondary Raynaud’s, patients have these signs associated with an autoimmune disorder such as scleroderma, lupus, or other disorders.

Front 52

In order to diagnose a patient with AIDS, the patient must have a laboratory documentation of the HIV infection and either a CD4 cell count of less than 200/mm3 or

Back 52

one of a broad spectrum of opportunistic infections, malignant neoplasms, and nonspecific syndromes

The AIDS case definition now requires that an individual has laboratory documentation of HIV infection and either one of a broad spectrum of opportunistic infections, malignant neoplasms, and nonspecific syndromes, or a CD4 count of less than 200/mm3 (Buttaro, 2013, p.1253).

Front 53

A patient presents to your clinic with severe pain in their great left toe. The pain awakened him last night and lasted for about 3 hours. They report it is still quite painful, but better than it was overnight. He has not been able to walk on their left foot at all since last night. What diagnostic test needs to be performed to diagnose gout?

Back 53

Needle aspiration of the joint to look for monosodium urate crystals

Definitive diagnosis of gout occurs when MSU crystals are identified in the joint fluid or tophus. MSU crystals are observed in more than 95% of patients experiencing attacks of gouty arthritis (Buttaro, 2013, p. 9917).

Front 54

What is the definitive way to diagnose an acute leukemia?

Back 54

Bone marrow aspiration and biopsy @While careful examination of the blood smear is important in the diagnosis of leukemia, 10% of patients have normal blood smears. A bone marrow aspiration and biopsy are definitive for diagnosis. The bone barrow contents will be hypercellular with a higher number of blast cells (60-90%) and a decrease in the normal types of cells (Buttaro, 2013, p. 1168).

Front 55

Your patient has a known history of Systemic Lupus Erythematosus and you know to obtain a urinalysis in follow-up visits because of their higher risk of what complication?

Back 55

Lupus nephritis

Lupus nephritis develops in 25-50% of patients with SLE. Protein in the urine found on urinalysis is a symptom of this. Hemodialysis or kidney transplant may be necessary in the end stages of this disease. Urinalysis should always be obtained during follow up visits to look for kidney complications of SLE (Buttaro, 2013, p. 1202-1203).

Front 56

The best way to assess the body’s iron stores is to order?

Back 56

Serum ferritin

This is the first the labs to become abnormal with changing iron stores.

Front 57

An established patient of your with known Raynaud’s phenomenon wants to try some kind of complementary and alternative medicine and heard that there is an herb that might help. What herb might you suggest?

Back 57

Ginkgo Biloba

At this time Ginkgo Biloba has been found to the reduce the number of Raynaud’s attacks by 56% compared with placebo.

Front 58

What specific physiological event does the reticulocyte count evaluate?

Back 58

The bone marrows production of RBC.

Low values (< 0.5%) indicate decreased RBC production. High values (>2%) indicates the normal bone marrow response to anemia.

Front 59

What key iron study defines iron deficiency anemia and helps distinguish it from anemia of chronic disease?

Back 59

The hallmark iron study in IDA is low serum ferritin.

Serum ferritin represents the body’s total iron stores. Of note this lab may not be low if it is early in the deficiency. Anemia of chronic disease has a normal or increased serum ferritin.

Front 60

Your patient tells you that their diet is strictly vegan. What vitamin deficiency is your biggest concern?

Back 60

Vitamin B12 deficiency

Most people who eat meat regularly have no difficulty obtaining an adequate amount of Vitamin B12 in their daily diets. Strict vegetarians are at risk for a dietary deficiency of Vitamin B12. It usually takes many years of a strict vegan diet before megaloblastosis occurs (Buttaro, 2013, p. 1148).

Front 61

Lupus is a multisystem disease that increases risk of specific chronic diseases. These diseases are a result of the treatments for lupus as well as the disease itself. What chronic complications are more likely in a patient with lupus, and what steps should the PCP take to prevent these complications?

Back 61

Osteoporosis: calcium/vitamin D supplements, earlier DEXA scans, bisphosphonate therapy as indicated. Ischemic heart disease: lifestlyle modification, control of HTN and HLD. Nephritis: control HTN, screen for kidney disease, avoid nephrotoxic drugs. Cervical dysplasia: routine paps.

Patients are more at risk for osteoporosis due to the use of corticosteroids, chronic inflammation, and reduced physical activity. Ischemic heart disease results from endothelial damage due to chronic inflammation, HTN and lipid abnormalities that can be caused by chronic kidney disease, and corticosteroid use. Nephritis is a direct consequence of the disease and results from deposition of immune complexes in the kidney, chronic inflammation, and other cellular-level changes.

Front 62

What is the definitive diagnostic test for gout?

Back 62

Aspiration of MSU crystals from the affected joint.

The pathophysiology of gout involves an alteration in normal purine metabolism. This results in hyperuricemia and monosodium urate crystal precipitate out of the blood. These crystals are deposited in joints, soft tissue, and kidneys and result in the signs and symptoms associated with the disease.

Front 63

What group of medications are considered first line therapy in Raynaud’s phenomenon?

Back 63

Calcium channel blockers

These medications work to dilate the peripheral vessels and prevent the vasoconstriction that causes disease symptoms. Our book specifically mentions Nifedipine.

Front 64

How is HIV infection confirmed?

Back 64

With the presence of HIV-1 antibodies (known as serologic testing). It can be completed with two different tests: an enzyme-linked immunosorbent assay (ELISA) or Western blot testing.

ELISA testing has a very high sensitivity leading to near-zero false-negatives but a significant number of false-positives. In the U.S., if ELISA is positive, a Western blot test is automatically performed.

Front 65

There are multiple diseases that are indicative of AIDS. Name three.

Back 65

Pneumocysitis carinni, Mycobacterium tuberculosis, Toxoplasma gondii, Mycobacterium avium-intracellulare complex, Streptococcus pneumoniae, Varicella-zoster virus, Hepatitis B virus, Influenza virus, Candida species, Cryptococcus neoformans, Histoplasma capsulatum, Cytomegalovirus, and Coccidioidomycosis.

Front 66

What is the typical clinical presentation of Raynaud’s phenomenon?

Back 66

Classic tricolor changes indicative of vasospasm from Raynaud’s phenomenon include white, followed by blue and finally red colored skin. People with Raynaud’s may also present with pain, numbness and burning.

These color changes are most commonly found on in the fingers, ears, nose, face, knees and nipples. White skin color is indicative of pallor; blue skin color indicates cyanosis and the final color change, red, results from resolution of vasospasm causing reperfusion hyperemia.

Front 67

What pharmacotherapy is most commonly used to treat systemic vasculitis?

Back 67

Corticosteroids such as prednisone

Drug-induced vasculitis may be treated by simply avoiding the offending agent whereas Wegener’s granulomatosis (WG), microscopic polyangiitis (MPA), polyarteritis nodosa (PAN), lupus vasculitis and rheumatoid vasculitis may need additional immunosuppressive therapy, such as cyclophosphamide, methotrexate or azathioprine.

Front 68

There are several important patient education topics to discuss with patients with systemic lupus erythematosus. Name three.

Back 68

Patients with SLE should avoid prolonged sun exposure, engage in moderate physical activity, take omega-3 polyunsaturated fatty acids, consume adequate calcium and vitamin D, and have regular medical checkups.

Many people with SLE are photosensitive and sun exposure can cause lupus rash and/or exacerbation of disease. Exercise helps improve mood, maintain cardiopulmonary health and avoid obesity. Fish oil has a beneficial effect on SLE disease process and vascular function. Patients with SLE are at increased risk of osteoporosis so adequate calcium and vitamin D are vital to maintaining bone health. Women with SLE have a higher incidence of cervical dysplasia and HPV infection making regular health checkups very important.

Front 69

James is a 29 year old American Indian male who comes in with excruciating right ankle pain on a scale of 10/10 that woke him up at 3 a.m. He is crying and clenching his teeth in pain. He is unable to bear weight on it and he walks leaping holding onto things. When you attempted to palpate the swollen, erythematous and warm, he pushed your hand away in pain. He has taken Ibuprofen 400 mg without relief. He had been out with his friends and went to Red Lobster and ate quite bit of lobsters and for the past 2 months, he has been binge drinking after long day of work and school. Vital Signs - T 100.9 P 98 RR 24 BP 140/80 Wt 180 lb Ht 5’ 8”. What is the most likely diagnosis of James?

Back 69

Acute gout flare

Common sites for acute gout flare are the feet, ankles and knees with symptoms of swelling, redness, warm, fever and pain. This usually precedes binge alcohol drinking and eating purine rich meats and seafoods.

Front 70

MS. Jane is 27 year old female that you have been seeing for past 4 years presents to your clinic for annual visits. During the visit, she tells you she was diagnosed with HIV a month ago at STD clinic. She was referred to HIV specialist in one of the metro clinics. Her hematological lab tests are normal with CD4 count is 532 cells per cubic millimeter and HIV-1 RNA is 70,000 copies per millimeter (Viral load). She is asymptomatic and physical examination is normal. She asks you, why she is not started on antiretroviral therapy?

Back 70

Two values of CD4 and HIV-1 RNA are needed prior to initiating antiretroviral therapy.

This helps to establish a firm baseline value for therapy and to determine disease stage, short- term and long-term risks of opportunistic complications.

Front 71

A 26 year old female who just had a baby 4 months ago was diagnosed with iron deficiency anemia (IDA) last week with the following lab values: Hgb10, Ferritin level 20, MCV 75 and Hematocrit 30. What type of treatment would be appropriate for this 26 year old?

Back 71

Oral iron supplements with iron rich foods.

IDA based on the values, initiate treatment with oral supplements with diet foods rich in iron for 2-3 months, then reassess.

Front 72

When evaluating a CBC with reticulocyte count in a patient you diagnosed with iron deficiency anemia, you normally expect to see to see the reticulocyte count do what?
A. Increase
B. Decrease
C. Stay the same
D. A reticulocyte count tells us nothing about the anemia

Back 72

Decrease

Decreased reticulocyte count is seen in IDA, aplastic anemia, untreated megaloblastic anemia, radiotherapy, marrow tumors, and myelodysplastic syndromes.

Front 73

You are planning a pharmacologic treatment for a patient with acute gout, all of the following would be considered treatment except?
A. NSAIDs
B. Colchicine
C. Allopurinol
D. Corticosteroids

Back 73

Allopurinol

Correct allopurinol is used daily for treatment of chronic gout.

Front 74

In which of the following scenarios would a person most likely contract an HIV infection?
A. Unprotected vaginal sex with an infected individual
B. Unprotected anal sex with an infected individual
C. Infant born to a mother with untreated HIV
D. Having oral sex with an infected individual

Back 74

Infant born to a mother with untreated HIV.

Risk is 20-30% during pregnancy and delivery.

Front 75

All of the following are expected findings in a patient with systemic lupus erythematosus except?
A. hirsutism
B. joint pain
C. history of Raynaud’s phenomenon
D. malar (butterfly) rash

Back 75

A. Hirsutism

This is not an expected finding of lupus, you may see hair loss.

Front 76

In which of the following patients is oral iron therapy an appropriate treatment option?
A. A patient with severe anemia
B. A patient with macrocytic anemia
C. beta-thalassemia minor
D. A woman in her 2nd trimester of pregnancy

Back 76

A woman in her 2nd trimester of pregnancy.

Second and third trimesters of pregnancy increase iron demands.

Front 77

You are seeing a 49 year old woman to provide preoperative clearance before a scheduled cholecystectomy. You review the results of the complete blood count and note she has a normocytic anemia with a hemoglobin of 11.5 g/dL (12-16g/dL). While considering etiology, you note her nutritional intake has been poor recently due to abdominal discomfort and she has a history of menorrhagia. What lab values do you anticipate as explore your high pretest probability for iron-deficiency anemia?

Back 77

Low serum ferritin, low serum iron, low transferrin saturation, and elevated total iron binding concentration (TIBC). @Iron deficiency anemia is commonly an incidental finding during routine CBC since mild to moderate anemia is not associated with signs or symptoms. Laboratory values gradually change as the deficiency progresses.

Front 78

Jim is a 56 year-old man who has been successfully treated with NSAIDs for multiple acute gouty arthritis attacks in his right great toe over the past few years. Lifestyle and dietary modifications have been somewhat helpful in reducing his uric acid levels and the frequency of attacks, but he is wondering if there is more that can be done. You discuss starting allopurinol. “So I’ll take that instead of the naproxen?” he asks. You respond,
A. “Yes, allopurinol will bring down your uric acid levels and prevent reoccurrence of gout attacks.”
B. “We’ll continue the naproxen for now as a prevention strategy since the initiation of allopurinol can actually cause a gout attack. If you’re feeling good, we’ll check your uric acid level in a couple months and, if it’s down, you can stop taking the naproxen in about 6 months.”
C. “Since they work best together, we usually keep people on both indefinitely. However, we’ll closely monitor your uric acid levels and kidney function since these medicines can cause problems with kidney disease.”
D. “Yes, but if you get another gout attack we’ll have to stop the allopurinol and go back on the naproxen during the attack.”

Back 78

B. “We’ll continue the naproxen (Indocin) for now as a prevention since the initiation of allopurinol can actually cause a gout attack. We’ll check your uric acid level in a couple weeks and, if it’s down, you can stop taking the Indocin.”

Antiinflammatory prophylaxis is recommended when urate lowering therapy is initiated. It should be continued if there is any clinical evidence of continuing gout disease activity and/or the serum uric acid level has not yet been achieved, usually for 6 months.

Front 79

A 65 year old man you are seeing in clinic tested positive for HIV last year, his CD4 count at that time was 450, but has yet to initiate treatment. He tells you that he does not think it is worth it to start taking medications because he is an old man and will not get AIDS before he dies. You respond:

Back 79

"It is up to you if you want to begin treatment, however, the time it takes for HIV to become AIDS varies between individuals. Treatment with Anti-retroviral medication significantly lengthens the time it takes to get AIDS."

The average time from initial HIV infection to first complication of AIDS is 8 years, but some individuals develop AIDS much faster. HAART can allow individuals to have a normal life expectancy. HAART should be started when a patient’s CD4 count is less than 500/mm (Buttaro,2013).

Front 80

A 46 year old African American male presents today with a hemoglobin of 10.7, a decrease in RBC, elevated LDH levels, and slight hyperbilirubinemia. He has a negative Coombs test. What are the top three diagnoses on your differential diagnosis list after getting these lab results back?

Back 80

Sickle cell disease, Glucose-6-phosphate dehydrogenase deficiency, and hereditary disorders such as Hereditary spherocytosis and hereditary elliptocytosis.

Sickle cell disease, Glucose-6-phosphate dehydrogenase deficiency, and hereditary disorders present with low hemoglobin, decreased RBCs, elevated LDH levels, and slight hyperbilirubinemia . We can rule out autoimmune hemolytic anemia because the patient has a negative Coombs test, (Buttaro,2013).

Front 81

A young couple, pregnant with a girl, comes to you with questions about their family history of hemophilia. The woman is not a carrier for the gene and the husband has hemophilia B. They want to know what the chances are that their child will have hemophilia. What is your response?

Back 81

None

Since Hemophilia is an X-linked recessive disorder and the woman is not a carrier this child has no chance of getting the disease. (Buttaro,2013).

Front 82

What does the specificity of a screening test indicate?

Back 82

True negative; the degree to which those individuals without the disease would test negative.

On the other hand, sensitivity of the test indicates true positive; the degree to which those individuals with the disease would test positive.

Front 83

A MCV value of 85 fl falls within which classification of anemia?

Back 83

Normocytic

Microcytic anemia has a MCV < 80 fl, macrocytic anemia has a MCV > 100 fl, and normocytic anemia has a MCV 80-99 fl.

Front 84

A 55 year old male presents to the clinic with a red, swollen, warm big toe on his left foot. He states that he was woken up two nights ago with extreme pain. He denies any recent trauma. What is the most likely diagnosis?

Back 84

Gout

Gout occurs most commonly is men older than 40. Also, the first attack usually occurs at night and affects the first metatarsophalangeal joint on one side only. The joint is usually warm, swollen, red, with decreased range of motion.

Front 85

A 33 year old African American woman has been newly diagnosed with SLE. Her primary complaints are fatigue and joint pain. What would be appropriate behavioral modification to manage her new diagnosis?

Back 85

Avoidance of prolonged sun exposure, modest physical exercise, and diet modification.

Sun exposure may cause lupus rash and worsen disease activity, physical activity helps maintain cardiovascular fitness and improve mood, and diet modification help prevent deficiencies and related complications common in lupus (i.e. osteoporosis and hypercholesterolemia).

Front 86

Characteristics of large vessel vasculitides are major organ artery involvement and causes aneurysms. What are the characteristics of small and medium vessel vasculitides?

Back 86

Ischemia typically affecting skin, kidneys, lung, GI tract, and nervous system.

Small- and medium-vessel vasculitides result in ischemia in disease specific systems at the level of small arteries, arterioles, or capillaries.

Front 87

In managing chronic gout, it is important to keep in mind the goal of therapy is to achieve complete resolution of MSU crystals. What are the complications associated with uncontrolled gout?

Back 87

Nephrolithiasis and gouty nephropathy

Increased uric acid solubility increases urine pH and may result in spontaneous renal stone formation, overtime accumulation of crystals in the renal parenchyma causes giant cell inflammation resulting in proteinuria and impaired renal function.

Front 88

AIDS diagnostic criteria require laboratory documentation of HIV infection and either one of a broad spectrum of opportunistic infections, malignant neoplasm, and nonspecific syndromes or what?

Back 88

Have a CD4 cell count <200/mm3

CD4 T lymphocyte is the primary cell targeted in HIV infection, AIDS-defining conditions rarely occur before the CD4 T-cell falls below 200 cells/mm3.

Front 89

Erika is a 29 yo with HIV infection. She is in the clinic today for an annual exam and HIV monitoring. She was started on HAART therapy 6 months ago and today her RT-PCR is 69 copies/mL. What would be the next step in managing her viral load?

Back 89

Assess for viral resistance, medication compliance, and appropriateness of HAART.

The short term goal of HAART is suppression of viral replication below the level of assay detection (<48 copies/mL for RT-PCR) within 6 months of initiating HAART therapy.

Front 90

Mrs. Sims presents to the clinic with hemoglobin of 9g/dl. She complains of fatigue, malaise, dyspnea, slight confusion and pallor of the mucus membranes. You suspect anemia. What are the initial tests you are going to order for diagnostic purposes?

Back 90

Complete CBC, platelet count, white cell differential, RBC morphology, reticulocyte count, peripheral blood smear

All of these blood tests are to do a complete diagnostic workup for anemia is easily available and minimally invasive.

Front 91

Mrs. Jones, a 33 year old female presents to the clinic complaining of changing color on her hands of white, blue and red. During these color changes, her fingers are numb, tingling, burning and painful. What do you think she may have?

Back 91

Raynaud’s phenomenon @The classic tricolor formation of white or blanched, blue and red are symptoms of Raynaud’s. During the colors of white and blue, patients feel numbness, tingling, and coldness. Red color signifies the blood returning to the fingers and can be burning and painful.

Front 92

Complete the sentence: The _____, one of the most recognizable features of SLE, is observed in only 35% of patients.

Back 92

Malar or butterfly rash

The butterfly rash is a photosensitive rash that occurs over the bridge of the nose and the cheeks. It is only seen in 35% of patients, yet it is the most recognizable features of SLE.

Front 93

What is the most common drug prescribed for gout?

Back 93

Allopurinol (Zyloprim)

It is once a day has great efficacy and can be increased as needed. Caution should be used with those in renal failure and the geriatric population.

Front 94

You are seeing a 65 year old female for a routine physical today. During the interview she mentions that she has lost a few pounds without even dieting. She reports feeling not as energetic as in years past and when she is out in the sun she seems to get a rash. She does not remember getting rashes in years past. You notice she has a purple tint around her eyes and on her extremities. You note the name of this purplish tint as what?

Back 94

Heliotrope

A Heliotrope rash is a violet or purplish shin discoloration of the extremities and on the face around the eyes. It is common in people who have Dermatomyositis.

Front 95

What are the current Centers for Disease Control and Prevention recommendations for screening patients for Human Immunodeficiency Virus?

Back 95

All patients aged 13-64 in all health care settings, all patients starting treatment for tuberculosis, all patients seeking care for a sexually transmitted disease, and all patients who are at high risk for HIV should get screened yearly.

The Centers for Disease Control and Prevention considers consent for medical treatment enough to encompass informed consent about Human Immunodeficiency Virus screening too. They recommend this screening in all health care settings for the above mentioned groups.

Front 96

Your 65 year old female patient presents to the clinic for her routine wellness check. You realize she has signs and symptoms of anemia, possibly secondary to an iron deficiency. What are two interventions to help with her anemia?

Back 96

Iron supplements and a diet with iron rich foods.

Iron- deficiency anemia is generally treated with iron supplements. Recommending foods high in iron content should not be left out.

Front 97

What class of medication is the most common cause of drug-induced leukocytosis?

Back 97

Corticosteroids

Corticosteroids are associated with increases in white blood cells, primarily neutrophilia. Corticosteroids cause reduced neutrophil adhesion and release for the marrow stores.

Front 98

Tim, your patient, was just diagnosed with iron deficiency anemia. You are analyzing his results for the following lab tests: hemoglobin, serum iron, total iron-binding capacity, and serum ferritin. Which test(s) would you expect to be elevated?

Back 98

Total Iron Binding Capacity

Laboratory studies in iron deficiency anemia show a slight decrease to marked decrease in hemoglobin. Serum iron and serum ferritin are also decreased. Total iron-binding capacity is increased.

Front 99

Today, you are seeing Teresa in clinic for a routine follow-up visit. She is 29 years old and was diagnosed with systemic lupus erythematosus (SLE) two years ago. When she arrives for her appointment, she tells you that she needs to use the bathroom and then asks if you would like a urine sample. Should you obtain a urine sample from Teresa?

Back 99

Yes

For patients with SLE, a urinalysis should always be obtained during follow-up visits to screen for lupus nephritis.

Front 100

Which body system is most commonly affected in individuals with lupus?

Back 100

Musculoskeletal

Joint symptoms/arthritis occurs in over 90% of patients with lupus at some point during their illness. Joint symptoms are often the earliest manifestations of the disease.

Front 101

Today, you are seeing Lisa in clinic. She is a 43 year old female. Her chief complaint today is fatigue. To investigate the cause of her fatigue, you order the following labs: CBC, serum iron, TIBC, and plasma ferritin. When analyzing the lab results, you note that her hemoglobin is low (8 g/dL) and her MCV (mean cell volume) is low. You also note that her serum iron is low, her TIBC is elevated, and her plasma ferritin is markedly reduced. Based on these laboratory values, you decide that she has anemia. What is the most likely cause of her anemia?

Back 101

Iron deficiency anemia

In a classic case of iron deficiency anemia, serum iron is low, TIBC is elevated, transferrin saturation is reduced, and hemoglobin is also low.

Front 102

In evaluating a patient with a microcytic anemia, the next lab order should include obtaining serum:
A. Vitamin B12
B. Folate
C. Ferrintin
D. Haptoglobin

Back 102

C. Ferrintin

Vitamin B12 deficiency and folate deficiency are common causes of macrocytic anemia. Haptoglobin is a marker of hemolytic anemia.

Front 103

Vegan patients should supplement the diet with:
A. Vitamin A
B. Vitamin C
C. Vitamin B12
D. Folic acid

Back 103

C. Vitamin B12

Vitamin B12 is predominantly animal source. While Vitamin A, Vitamin C and folic acid can be readily obtained in vegetables and fruits.

Front 104

In providing education about the best way to take PO iron supplement to maximize the absorption, advise patient to take the medication with (select all that apply):
A. With an antacid
B. On empty stomach
C. With orange juice
D. With tea

Back 104

B. On empty stomach and C. With orange juice

Maximum absorption of iron occurs if it’s ingested 30 minutes before meals. Vitamin C may enhance absorption of iron. Calcium and tea significantly inhibit iron absorption . Vitamin C may enhance absorption of iron.

Front 105

A Risk factor for folate deficiency anemia is:
A. Menorrhagia
B. Alcohol abuse
C. Chronic blood loss
D. Bone marrow failure

Back 105

Alcohol abuse

Menorrhagia and chronic blood loss are risk factors for iron deficiency anemia while bone marrow failure is a cause of aplastic anemia.

Front 106

Which laboratory finding will distinguish anemia of chronic disease (ACD) from iron deficiency anemia (IDA)?
A. Hemoglobin
B. Serum Ferritin
C. MCV
D. MCHC

Back 106

Serum Ferritin and TIBC

Iron studies, especially the serum ferritin level, usually differentiate between a true IDA, ACD, and thalassemia. The ferritin level is normal or increased in ACD and decreased in IDA. The TIBC is normal or low in ACD and increased in IDA. In ACD, serum iron levels may be low, but total iron stores are normal or elevated. Ferritin reflects total body iron stores so that is why ferritin levels are normal or increased in ACD. In ACD, total iron stores are actually normal or even elevated. It is IDA where iron stores are depleted and is reflected as a low serum iron level, decreased ferritin, increased TIBC, and decreased transferrin saturation.

Front 107

An alcoholic patient is diagnosed with an unspecified anemia with neurologic deficits. The patient reports some decreased vibratory sensation, peripheral neuropathy, and ataxia (loss of voluntary coordination or movement). Based on these findings alone, what type of anemia would you be most suspicious of? A. Vitamin B12 deficiency anemia B. Folate deficiency anemia C. Iron deficiency anemia D. β-thalassemia major

Back 107

Vitamin B12 deficiency anemia

A severe vitamin B12 deficiency includes signs and symptoms of marked anemia and neurologic deficits.

Front 108

One important strategy for preventing further episodes of iron deficiency anemia (IDA) is to provide nutritional counseling. Which of the following food sources would interfere with iron absorption? High-fiber bread, citrus fruit, eggs, or leafy green vegetables?

Back 108

High-fiber bread

Nutrition counseling for IDA should include assessment of the patient’s dietary intake. The assessment should include quantity and timing of iron ingestion along with other substances that can interfere with iron absorption such as tea, coffee, chocolate, dairy products, alcohol, and other high-fiber foods. Calcium can significantly inhibit iron absorption. Ascorbic acid may enhance absorption of iron; therefore concurrent ingestion of foods rich in vitamin C such as orange juice should be encouraged.

Front 109

What examination should always be included in an HIV-infected patient with a CD-4 count below 100/mm3?

Back 109

A retinal examination

Normal range of CD4 count ranges from 500-1700/mm3. The comprehensive physical examination should always include general health assessment and assessment for detection of complications with particular attention to the focal and cognitive neurologic exam. When the CD4 count is below 100/mm3 the examination should always include a retinal examination for cytomegalovirus and other causes of retinitis.

Front 110

Nonpharmacologic management strategies of gout include diet modification, avoidance of alcohol intake and which other strategy would you also recommend, rest or increased range of motion exercises to the affected joint?

Back 110

Rest the affected joint

Joint motion may increase inflammation because of gouty arthritis, whereas rest and cold applications to the affected joints may allow for earlier resolution and less medication use.

Front 111

A 78-year-old female who presents with two-month history of increasing weakness, body aches, intermittent generalized headache, now avoids eating due to jaw pain. Considering all symptoms, which one leads you to suspect cranial giant cell arteritis (GCA) is her most likely diagnosis?

Back 111

Jaw pain

Jaw pain associated with talking or chewing is a strong indicator of GCA with high specificity.

Front 112

What is the first lab value to become abnormal when iron stores are becoming depleted in those patients with suspected iron deficiency anemia?

Back 112

Ferritin levels

Serum ferritin levels reflect total body iron stores and will be abnormal even before iron deficiency anemia is reflected in RBC morphology. Serum ferritin levels are directly proportional to iron stores. Normal ferritin levels for women are 12-150 micrograms/L, for men are 10-345 microgram/L.

Front 113

How is Reynaud’s Phenomenon diagnosed?

Back 113

Clinical history of the classic tricolor changes

The vasospasm of Reynaud’s phenomenon causes classic tricolor changes first to white (with loss of blood flow to the area), then blue (when blood flow restriction is causing cyanosis), and then red (as the area is reperfused) when the vasospasm ends and usually involves the digits. Primary versus secondary Reynaud’s is diagnosed through capillaroscopy on the nail fold.

Front 114

True or False, once a patient experiencing an acute gout flare notes a resolution to his/her symptoms and the flare has subsided, they are no longer considered to have gout.

Back 114

False @Even though the patient is not experiencing a flare, he or she is still considered to have gout and is in the intercritical stage until another flare occurs.

Front 115

Ms. Johnson is a 68 yo post-menopausal woman with a diagnosis of Giant Cell Arteritis by her rheumatologist. She has been prescribed prednisone at a dose of 80 mg/day over the next month with a planned steroid taper to treat her condition. Ms. Johnson presents to you today for a wellness exam. What area of her nutrition and intake will be important to assess today in light of her recent diagnosis and treatment?

Back 115

Calcium and Vitamin D intake/supplementation

Any patient requiring steroids for longer than one month duration should be maintained with supplemental calcium and Vitamin D and assessment of bone health should occur. Especially for Ms. Johnson as her age and post-menopausal status already put her at increased risk for Osteoporosis.

Front 116

A 28 year old female with a seizure disorder presents to your clinic with a history of sporadic episodes of fatigue, arthralgia, oral ulcers, and rash. Her ANA lab test comes back positive. In reviewing her current list of medications, you may be suspicious about the cause of her SLE symptoms if she were taking a(n) ______.

Back 116

Anticonvulsant

SLE symptoms can be drug induced and have been known to develop in patients taking procainamide, hydralazine, quinidine, anticonvulsants and antithyroid medications.

Front 117

Patients with a diagnosis of vasculitis will often require a lengthy course of steroids and are at increased risk of contracting what infectious disease?

Back 117

Pneumocystis pneumonia

Patients who are requiring high dose steroid treatment tend to need prophylaxis against Pneumocystis pneumonia.

Front 118

A patient newly diagnosed with HIV infection should undergo testing for concurrent infection with hepatitis B and C as well as tuberculosis. When screening for tuberculosis, the reliability of the purified protein derivative (PPD) response is questionable if the CD4 counts have dropped to less than _____.

Back 118

200/mm3

Reliability of the PPD test is compromised if CD4 counts drop below 200/mm3 and are essentially worthless below 50/mm3; the test should be repeated once ART has commenced and viral load has declined.

Front 119

A 38 year old male of Middle Eastern descent is a new patient at your clinic and has come in for his annual exam and is feeling well. A CBC reveals a hemoglobin of 11.5, a MCV of 69 and a serum ferritin level within normal range. Based on these findings, you would be suspicious that the patient has _____ and you may need to refer him for genetic counseling.

Back 119

Beta-thalassemia minor

Beta thalassemia is most frequently found in people with an ancestry of Mediterranean, Middle Eastern, African, or Asian. It is the result of a genetic mutation of the beta globin chains found in the hemoglobin molecule and follows an autosomal dominant pattern. Two parents with beta-thalassemia minor could have a child with beta-thalassemia major that would result in a profound life-threatening anemia and reduced life expectancy for the offspring, thus the need for genetic counseling.

Front 120

When considering a diagnosis of systemic lupus erythematosus (SLE) which one of the following are not part of the revised criteria for classification? A. Malar rash B. Positive finding for antiphospholipid antibodies C. Discoid rash D. Night sweats E. Joint tenderness, swelling, or effusion

Back 120

Night sweats

Of the 11 criteria contained within the revised criteria classification of SLE all of the findings are indicative of SLE except night sweats (pps.1201-1202).

Front 121

When it is necessary to evaluate the presence of a possible folate deficiency many hematologic findings can be viewed. Which one of the following answers is the best evaluator of folate deficiency? A. Mean corpuscular volume (MCV) B. Reticulocyte count C. RBC folate D. Serum folate E. Segmented neutrophils

Back 121

RBC folate

While serum folate can be indicative actual folate deficiency, it may be influenced by diet, alcohol, and poor intake. Thus the best measure of folate deficiency is the evaluation of RBC folate levels (p. 1217).

Front 122

When providing education to a patient or family about vasculitis, it is important for them to be aware of signs that indicate a change or worsening of their condition. All of the following are warning signs EXCEPT: A. Sudden headache B. Shortness of breath C. Hemoptysis D. Sensory loss E. New rash

Back 122

Shortness of breath

While the presence of shortness of breath is concerning it is not one of the symptoms of the worsening of vasculitis. New rash, sensory loss, vision loss, and sudden headache

Front 123

Gout is the most common inflammatory arthritis in men over the age of 40. At the time of an initial attack one joint is more frequently affected than any other. Which of one of the listed joints is most often involved? A. The instep B. First metatarsophalangeal joint (MTP) C. Second distal interphalangeal joint (DIP) D. Knee

Back 123

First metatarsophalangeal joint (MTP)

It is thought an estimated 50% of first gout attacks occur in the MTP. The other joints often affected include: instep, heels, knees, wrists, fingers, and elbows (p. 916).

Front 124

Vitamin B12 and folate deficiencies are the primary causes of what type of anemia?

Back 124

Macrocytic anemia

Vitamin B12 deficiency and folate deficiency are the primary causes of macrocytic anemia.

Front 125

Mr. B is a hospitalized patient with a Hgb of 10.2, serum ferritin of 270 ng/mL, his total iron stores are normal to slightly elevated, he has not had surgery recently and is not suffering from a hematologic malignant neoplasm. You see type II diabetes and rheumatoid arthritis on his problem list in EPIC. What type of anemia are you concerned about given what you know about Mr. B?

Back 125

Anemia of chronic disease (ACD)

ACD is the most common type of anemia in hospitalized patients; 52% of hospitalized patients with anemia who were not iron deficient, undergoing hemolysis, or suffering from a hematological malignant neoplasm met the criteria for ACD.

Front 126

What type of immune cell is the main target of the human immunodeficiency virus (HIV)?

Back 126

CD4 T lymphocytes (CD4 T-cells)

Various cells are susceptible to HIV infection but the CD4 T lymphocyte is the primary target. Subsequently, the rate of immune dysfunctions progression in HIV positive patients is monitored by the decline of the CD4 T-cell count in peripheral blood.

Front 127

True or False: Patients with systemic lupus erythematosus (SLE) are advised to get routine, prolonged sun exposure.

Back 127

False

Avoidance of prolonged sun exposure is recommended for SLE because many patients are photosensitive and sun exposure may precipitate lupus rash and exacerbation of disease activity.

Front 128

What is the definitive standard for the diagnosis of gout in the presence of pain associated with warmth, redness, swelling, and decreased range of motion in an affected joint?

Back 128

Needle aspiration to assess for monosodium urate (MSU) crystals.

Even when clinical appearance strongly suggests gout, diagnosis has to be confirmed with needle aspiration.

Front 129

Acute chest syndrome is associated with what type of anemia?

Back 129

Sickle Cell Disease

ACS is the most common cause of death in sickle cell patients and the second most common reason for hospitalization after pain crisis.

Front 130

A 28 year old woman presents in January in Minnesota complaining of numb, white fingers whenever she walks her dog outside. What class of medications is considered first line therapy to treat this condition?

Back 130

Calcium channel blockers

CCBs are vasodilators and may help prevent vasospasm in Raynaud’s phenomenon, which is characterized by vasospasm in the fingers, toes, ears, nose, knees, or nipples resulting in pallor (due to decreased blood flow) and numbness, tingling, and coldness in the affected area(s).

Front 131

You are managing the primary healthcare of a young woman with lupus. Which standard laboratory test should be done at every visit?

Back 131

Urinalysis

Lupus nephritis can develop at any point in patients without previous renal involvement. Other renal function tests should be monitored frequently for changes as well.

Front 132

A 50-year-old male patient presents with frequent gouty flares for many years. It has been two months since his last flare and he is hoping to start a medication to prevent future flares. He has no other health problems or underlying pathologic conditions. What two medications classes do you prescribe?

Back 132

Urate-lowering therapy (such as allopurinol) and anti-inflammatories (NSAID or colchicine)

ULT reduces serum urate levels which results in the disappearance of monosodium urate crystals in the tissue. Use of anti-inflammatory medications is indicated because the initiation of ULT often results in gouty flares.

Front 133

Previously, life expectancy after HIV diagnosis was predicted by CD4 count and viral load because of the introduction of effective anti-retroviral therapies. What is now the primary predictor of life expectancy in a person newly diagnosed with HIV?

Back 133

Ability to tolerate and adhere to ART

Patients who are less than 95% adherent to medication therapy in HIV are at high risk for viral resistance to treatment. Under ideal conditions, life expectancy may not be altered by HIV infection.

Front 134

Which of the follow is NOT a common differential diagnoses of Lupus?
A. Mixed connective tissue disorders
B. Fibromyalgia
C. Parkinson’s Disease
D. Rheumatoid Arthritis

Back 134

C. Parkinson’s Disease

Front 135

What are some common clinical presentations in an elderly person who is HIV positive?

Back 135

Fatigue, pain in the hands or feet (peripheral neuropathy), problems sleeping, muscle or joint pain (myalgias or arthralgias), problems having sexual intercourse, lower than normal cholesterol levels, leucopenia, anemia, and transaminitis (elevated liver enzymes). Menopause at a median age of 46 versus 51; hypogonadism in men.

Front 136

A patient comes to the clinic for their annual exam and their Western Blot test comes back with one band (indeterminate). The patient is at low-risk of a PHI (Primary HIV Infection) and is asymptomatic. What should you follow up plan be to further decipher the indeterminate blot test?

Back 136

Wait 3 months and repeat serologic testing.

If there is a low likelihood of a PHI, serologic testing should be repeated after allowing sufficient time for seroconversion to occur. If testing is repeated in 1 month, most patients will continue to test positive. However, if testing is repeated at 3 months, close to 100% will have converted and no further testing is indicated if the result is negative.

Front 137

What is the most common drug treatment for someone with Raynaud’s phenomenon?

Back 137

Nifedipine

Nifedipine, a calcium-channel blocker, can be prescribed to help prevent vasospasms with Raynaud’s.

Front 138

Out of the following conditions, which does a HIV positive patient person not need to be closely monitored for despite CD4 counts? A. Latent TB B. MRSA C. HPV D. Hepatitis B

Back 138

B. MRSA

An HIV infected patient should be routinely screened for latent TB, HPV, STDs, Hepatitis B and C, and cardiovascular disease.

Front 139

If a patient has a positive fecal occult blood test and does not have iron deficiency anemia what test should be performed? If a patient is not having any symptoms, are more tests warranted?

Back 139

Colonoscopy; No

A patient with no iron deficiency anemia and a positive fecal blood test should have a colonoscopy. If the patient is experiencing upper GI symptoms, then an endoscopy should also be performed.

Front 140

A 23 year old woman comes to see you complaining of fatigue and increased bruising. Her PMH includes tonsillectomy at age 17, menorrhagia occurring monthly and chronic controlled anxiety. You order a CBC to evaluate for anemia, suspecting which type?

Back 140

Microcytic, Iron deficiency

Most common type of anemia, often affects reproductive age women. Most common type of anemia and most common nutritional deficiency in the world. It should be suspected in conditions of chronic blood loss or GI bleed.