[MCQs] The Quizzes about Acute Complaints - Part 7 (20 test)

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Acute Complaints-7

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Question 1

You are evaluating a 33-year-old man with rectal pain and He reports that he initially felt a mass near his rectum several days ago. It was associated with some bright red blood on the toilet paper when he wiped after a bowel movement. The area became acutely painful over the last 24 hours. On examination, you note an exquisitely tender, purple nodule distal to the dentate line. What is the office-based treatment of choice for his condition?

A	Hydrocortisone suppositories
B	Rubber band ligation
C	Sclerotherapy
D	Incision and drainage
E	Excision

Question 1 Explanation:

The condition described is a thrombosed external hemorrhoid. External hemorrhoids are defined as hemorrhoids arising distal to the dentate line. When they thrombose, they are associated with acute pain and are hard and nodular on physical examination. The treatment can be safely done in the office with local anesthesia. It eliminates pain immediately and eliminates the risk of reoccurrence. Hydrocortisone would not be helpful. Rubber band ligation and sclerotherapy should be reserved for internal hemorrhoids. Incision and drainage of the hemorrhoid increases the risk of reoccurrence and can lead to infection of the retained clot.

Question 2

You are evaluating a patient in the office with He has had chronic constipation, and reports bright red blood from his rectum associated with extremely painful bowel movements. After defecation, he complains of a dull ache and a feeling of “spasm” in the anal canal. The pain resolves within a few hours. On external examination, no abnormali- ties are noted. What is his most likely diagnosis?

A	Anal fissure
B	Thrombosed external hemorrhoid
C	Internal hemorrhoid
D	Thrombosed internal hemorrhoid
E	Peri-anal abscess

Question 2 Explanation:

An anal fissure is a split in the anoderm of the anal canal. It generally occurs after the passage of a hard bowel movement. Patients present with excruciating pain on defecation with blood found on the toilet paper. After the bowel movement, the patient may complain of an ache or spasm that resolves after a couple of hours. Thrombosed external hemorrhoids would generally be visible on examination. Internal hemorrhoids are generally not painful, unless they are thrombosed because of an unreducible prolapse. If that were the case, the pain would not resolve. A peri-anal abscess may not present with bleeding, but would likely be associated with systemic signs of infection.

Question 3

A 23-year-old woman presents to your office complaining of Which of the following characteristics is more likely to be associated with migraine headaches than other types of headaches?

A	Unilateral symptoms
B	Severe in intensity
C	Nausea
D	Rhinorrhea
E	Sweating

Question 3 Explanation:

In patients with headaches, the history is the most important way to characterize the headache. Migraine headaches are usually unilateral, but so are cluster headaches. Unilateral symptoms are less helpful in differentiating between the two. Nausea is associated with migraine, and is less likely to be associated with cluster or tension headaches. Rhinorrhea and sweating are symptoms more commonly seen with cluster headaches.

Question 4

You are evaluating a patient with a Of the following, which is the most important in characterizing the type of headache the patient is experiencing?

A	History
B	Physical examination
C	Blood work
D	Imaging
E	Consultation with neurology

Question 4 Explanation:

While any and all of the choices listed as answers may be necessary in the initial evaluation of a headache, the most important way to characterize the headache is by history. Physical examination would be confirmatory. Blood work, imaging, and consultation may be important in the management, but only after the characterization of the headache as migraine, cluster, tension, or secondary headache.

Question 5

You are talking with a 24-year-old woman complaining of a She reports that before she has the headache, she experiences visual symp- toms associated with slight nausea. When the headache occurs later, it is throbbing, pulsating, and unilateral. During the headache, she experiences light sensitivity. Sleep improves the symptoms. Her symptoms are disrupt- ing her daily life, and you decide to try prophylactic therapy. Which of the following is the most studied prophylactic agent to use?

A	Beta-blockers
B	Calcium channel blockers
C	Selective serotonin reuptake inhibitors
D	Anticonvulsants
E	Ergotamines

Question 5 Explanation:

While many agents have been used as prophylactic agents to prevent migraines, beta-blockers are the most studied, and are effective. Verapamil is the only calcium channel blocker that studies show to have a prophylactic effect. There has beenAcute Complaints Answers 169 some interest in fluoxetine for prophylactic therapy, but more studies are needed. Ergotamines are used for abortive therapy.

Question 6

One of your patients has been on beta-blocker therapy for migraine prophylaxis. Her symptoms are not optimally controlled, and she is inter- ested in other What agent, when added to the beta-blocker, has a synergistic effect in the prophylaxis of migraines?

A	Calcium channel blockers
B	Tricyclic antidepressants
C	Selective serotonin reuptake inihibitors
D	Anticonvulsants
E	Ergotamines

Question 6 Explanation:

Of the choices listed, tricyclic antidepressants are the only agents proven to have additive effects in migraine prophylaxis.

Question 7

You are caring for a 33-year-old migraine He is currently complaining of an acute migraine attack, and is interested in abortive ther- apy. Which of the following options is least likely to be effective?

A	Acetaminophen
B	NSAIDs
C	5-HT agonists
D	Ergotamines
E	Narcotics

Question 7 Explanation:

Narcotics have almost no place in migraine therapy. In well-controlled studies, the use of antiemetic injections or injectable ergotamines is more likely to be helpful, and is superior to narcotics. If acetaminophen or NSAIDS are ineffective, it usually means the dose is subtherapeutic, or there is a failure to absorb the medication because of vomiting or gastric stasis.

Question 8

You are discussing migraine management with a 30-year-old She wants to use prophylactic medications, but had debilitating fatigue and symptoms of depression on beta-blockers. Which of the following medica- tions is an acceptable alternative?

A	Nifedipine
B	Verapamil
C	Diltiazem
D	Amlodipine
E	Nicardipine

Question 8 Explanation:

Verapamil appears to have some migraine prophylactic effect, but there is no evidence that other calcium channel blockers have a similar effect. Other calcium channel blockers may be helpful in suppressing cluster headaches, but have not been shown to be helpful for migraines.

Question 9

A 41-year-old man comes to the office to discuss his headache symp- toms. He first began having symptoms a couple of years He describes the headaches dramatically—“like an ice pick is going through my eye!”— and describes it as the worst pain in his life. The headaches begin suddenly, are unilateral, last up to 2 hours, and are associated with runny nose and watery eye. He gets several attacks over a couple of months, but is symp- tom free for months in-between flare ups. What is the best approach for long term management of the attacks?

A	Fluoxetine, 20–60 mg daily
B	Prednisone, 10 mg daily
C	Indomethacin, 120 mg daily
D	Nifedipine, 40–120 mg daily during the symptomatic period
E	Ergotamine, 1–2 mg daily during the symptomatic period

Question 9 Explanation:

The mainstay of therapy for cluster headaches is to provide relief from the acute attacks, then use therapy to suppress headaches during the symptomatic period. Nifedipine has been shown to be effective, as has prednisone, indomethacin and lithium. However, the medication should not be given daily, just during the symptomatic period. Fluoxetine has not been shown to be beneficial, and ergotamine is generally only helpful in the acute stage—not for prophylaxis.

Question 10

A 40-year-old man transfers to your office from out of state after moving to your He suffers from cluster headaches, and would like a medication to manage the acutely painful episodes. Which of the fol- lowing would be best for treatment of the acute episodes?

A	Indomethacin, 120 mg by mouth
B	Oxycodone, 5–10 mg by mouth
C	Sumatriptan, 50–100 mg by mouth
D	Ergotamine, 1–2 mg by mouth
E	4% lidocaine, 1 mL administered into the nostril

Question 10 Explanation:

Cluster headaches characteristically develop rapidly, achieving peak intensity within 10–15 minutes. Usually, the headaches are intensely painful and last for about 2 hours without treatment. The mainstay of treatment is oxygen, but many patients do not have access to this in their homes. In general, oral medications do not act rapidly enough to provide relief to the patients in the acute phase. Therefore, injectable or inhaled medications are preferred. Inhaled ergotamine has been shown to be helpful, as has injectable sumatriptan. Interestingly, local anesthetics administered into the nostril on the affected side have also been shown to be effective.

Question 11

You are talking with a 33-year-old woman who is complaining of She has had these headaches for 5 months, and they are increas- ing in frequency. She reports that the headaches may last anywhere from an hour to several days. They are now occurring about 5–10 times a month, without relationship to her menstrual cycle. She describes the headache as bilateral, and the pain is described as a pressure around her forehead. She denies nausea, is not sensitive to sound, but is sensitive to light during an attack. On examination, she has no obvious neurological deficit. What is the best approach to take at this point?

A	Prescribe narcotic analgesics and follow up if no improvement
B	Prescribe NSAIDs and follow up if no improvement
C	Order blood work to rule out secondary cause
D	Order a CT of the brain
E	Order an MRI of the brain

Question 11 Explanation:

Tension-stress (or muscle contraction) headaches have a formal definition, with positive and negative criteria for diagnosis, but many physicians diagnose this type of headache by exclusion (after ruling out more interesting or rare etiologies for headache). They are in fact, the most frequent of all headaches encountered in clinical practice. The episodes last from 30 minutes to several days, and headaches should occur less than 15 times per month. It requires at least two of the following characteristics: • Pressure/tightness • Bilateral • Mild to moderate • Not aggravated by activity There is generally no nausea. Either photophobia or phonophobia may be present, but not both. If criteria for this classification of headache are met, a trial of NSAIDs may be appropriate, with follow up if no improvement. Narcotics should be avoided, since the condition is generally chronic, and overuse is likely. Imaging would not be helpful or indicated at this stage.

Question 12

You are evaluating a 48-year-old woman with She reports a long history of occasional sinus headaches, usually responding to over- the-counter treatment. Over the last several months, the headaches are occurring more frequently, and are actually more painful than they have been in the past. Over-the-counter medications, effective in the past, no longer work. What is the most appropriate next step?

A	Use antibiotics to treat sinusitis and follow up if no improvement
B	Use prescription antihistamines and follow up if no improvement
C	Use prescription decongestants and follow up if no improvement
D	Use NSAIDs and follow up if no improvement
E	Obtain radiological imaging of the brain

Question 12 Explanation:

A common question in family medicine relates to whether or not to obtain radiological imaging in the case of headache. In general, these characteristics should raise suspicion, and imaging should be considered: • Headaches of recent onset or those that seem to become steadily more severe • Headaches that do not fit any of the primary classifications • Headaches that do not respond to first-line treatment • Headaches associated with development of neurological abnormalities

Question 13

You are taking care of a 36-year-old woman with mild hypertension, arthritis, and She also has been taking daily oral penicillin for a streptococcal throat infection. She notes the acute onset of hematuria, and comes to your office for evaluation. Which of the following medica- tions is most likely to cause this symptom?

A	Ibuprofen
B	Penicillin
C	Fluoxetine
D	Oral contraceptives
E	Hydrochlorothiazide

Question 13 Explanation:

There are several medications that can cause hematuria. They include penicillins, cephalosporins, sulfonamides, phenytoin, cyclophosphamide, mitotane, anticoagulants, and nitrofurantoin. Ibuprofen may cause kidney problems, but hematuria is not one of them. Oral contraceptives, SSRIs and diuretics do not commonly cause hematuria.

Question 14

A 16-year-old sexually active woman comes to your office complain- ing of blood in her She reports suprapubic pain, dysuria, and fre- quency. What is the likely diagnosis?

A	Cystitis
B	Pyelonephritis
C	Nephrolithiasis
D	Bladder cancer
E	A sexually transmitted infection

Question 14 Explanation:

Cystitis is associated with suprapubic pain, dysuria, urgency, and frequency. In women, it is a very common diagnosis, and can usually be treated based on symptoms and the result of a urinalysis only. Pyelonephritis is generally associated with systemicAcute Complaints Answers 171 signs of infection. Nephrolithiasis would cause hematuria, but would not be associated with dysuria or frequency. Bladder cancer is usually asymptomatic, but does cause hematuria. A sexually transmitted infection generally does not cause hematuria, but can cause dysuria and frequency.

Question 15

You are evaluating a 56-year-old generally healthy man who is seeing you after finding blood in his He denies pain, dysuria, frequency, or urgency. He is a smoker, and has worked for years in the printing industry. What is the most likely cause of his hematuria?

A	Acute prostatitis
B	Chronic prostatitis
C	A UTI
D	Urinary stones
E	Bladder carcinoma

Question 15 Explanation:

Painless hematuria without other symptoms is the most common presentation of bladder carcinoma. Risk factors include being male, smoking and working in the printing/leather dye insustries. Acute prostatitis and a UTI are usually associated with dysuria, fever, and urinary frequency and urgency. Chronic prostatitis is associated with urinary symptoms as well. Stones are associated with pain.

Question 16

A 16-year-old girl comes to your office complaining of blood in her She is asymptomatic, and not menstruating. Urinalysis reveals grossly pink urine, but urine dipstick is negative for blood. Which of the following foods is the likely cause?

A	Spinach
B	Strawberries
C	Raspberries
D	Beets
E	Carrots

Question 16 Explanation:

Pseudohematuria can be derived from chemical agents, foods, or vaginal bleeding. Common foods that cause this include beets, blackberries, and rhubarb. Medications that discolor the urine include chloroquine, metronidazole, phenytoin, rifampin, and sulfasalazine, among others.

Question 17

A 65-year-old African American man is seeing you because he has had blood in his urine for 1 On further questioning, you find that the blood appears at the end of micturition, and is not associated with pain, frequency, urgency, or other symptoms. Of the following, which is the most likely cause of his hematuria?

A	Urethral cancer
B	Renal cancer
C	Prostate cancer
D	Urolithiasis
E	Urethral trauma

Question 17 Explanation:

Terminal hematuria suggests either a bladder neck or a prostatic urethral lesion. Hematuria occurring throughout micturition occurs with bladder or renal lesions. Urolithiasis is associated with pain, and although urethral trauma is associated with hematuria, it would occur throughout micturition.

Question 18

You are seeing a 14-year-old boy who reports seeing blood in his He is currently asymptomatic. On urinalysis, he has more than 10 red blood cells per high-powered field, he has red cell casts, and his creatitine is

2.3 (H). What is the next step in the evaluation?

A	Intravenous pyelography
B	Renal ultrasound
C	Cystoscopy
D	Noncontrast helical CT
E	Antistreptolysin O titer

Question 18 Explanation:

In a pediatric patient with hematuria, red cell casts and an elevated creatinine, glomerulonephritis is possible. Poststreptococcal infection accounts for 50% of all cases of pediatric hematuria. The other tests described above would identify stones or tumors, but those are unlikely in this age group.

Question 19

You are evaluating a 35-year-old man with His urinalysis does not reveal casts or protein, but does show moderate blood. His urine culture is negative, as is his intravenous pyelogram, and he has a normal creatinine. Which of the following is most appropriate in this case?

A	Reassurance and periodic monitoring
B	Renal ultrasound
C	Cystoscopy
D	ASO titer
E	Renal biopsy

Question 19 Explanation:

In patients under forty with hematuria, but a normal IVP and urine culture, periodic monitoring and reassurance is appropriate. In a patient more than 40, cystoscopy or renal biopsy would be appropriate. A poststreptococcal glomerulonephritis would be unlikely in this age group, and a renal biopsy would not be needed if the creatinine is normal.

Question 20

A daycare worker presents to your office after turning “yellow.” She reports feeling feverish and fatigued, and describes right upper quadrant abdominal pain and On examination, her skin tone, conjunctivae, and mucous membranes are yellow-tinged. Serologies indicate acute hepatitis A infection. Which of the following is true about this infection?

A	She is most infectious while she is jaundiced
B	Fecal shedding of the virus continues until liver enzymes have normalized
C	Complete recovery is the norm
D	Relapses are common
E	This infection can lead to chronic infection

Question 20 Explanation:

Hepatitis A is the most commonly reported hepatitis virus, and does not lead to chronic infection. Fecal172 Family Medicine shedding of the virus occurs early, and is no longer an issue at the time of presentation. Infectiousness is highest during the prodrome, and actually decreases by the time jaundice develops. Relapses of hepatitis A are rare, but do occur. Fulminant liver disease occurs in less than 1% of patients.

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II. Preview all questions below

1.You are evaluating a 33-year-old man with rectal pain and He reports that he initially felt a mass near his rectum several days ago. It was associated with some bright red blood on the toilet paper when he wiped after a bowel movement. The area became acutely painful over the last 24 hours. On examination, you note an exquisitely tender, purple nodule distal to the dentate line. What is the office-based treatment of choice for his condition?

Hydrocortisone suppositories
Rubber band ligation
Sclerotherapy
Incision and drainage
Excision

2. You are evaluating a patient in the office with He has had chronic constipation, and reports bright red blood from his rectum associated with extremely painful bowel movements. After defecation, he complains of a dull ache and a feeling of “spasm” in the anal canal. The pain resolves within a few hours. On external examination, no abnormali- ties are noted. What is his most likely diagnosis?

Anal fissure
Thrombosed external hemorrhoid
Internal hemorrhoid
Thrombosed internal hemorrhoid
Peri-anal abscess

3. A 23-year-old woman presents to your office complaining of Which of the following characteristics is more likely to be associated with migraine headaches than other types of headaches?

Unilateral symptoms
Severe in intensity
Nausea
Rhinorrhea
Sweating

4. You are evaluating a patient with a Of the following, which is the most important in characterizing the type of headache the patient is experiencing?

History
Physical examination
Blood work
Imaging
Consultation with neurology

5. You are talking with a 24-year-old woman complaining of a She reports that before she has the headache, she experiences visual symp- toms associated with slight nausea. When the headache occurs later, it is throbbing, pulsating, and unilateral. During the headache, she experiences light sensitivity. Sleep improves the symptoms. Her symptoms are disrupt- ing her daily life, and you decide to try prophylactic therapy. Which of the following is the most studied prophylactic agent to use?

Beta-blockers
Calcium channel blockers
Selective serotonin reuptake inhibitors
Anticonvulsants
Ergotamines

6. One of your patients has been on beta-blocker therapy for migraine prophylaxis. Her symptoms are not optimally controlled, and she is inter- ested in other What agent, when added to the beta-blocker, has a synergistic effect in the prophylaxis of migraines?

Calcium channel blockers
Tricyclic antidepressants
Selective serotonin reuptake inihibitors
Anticonvulsants
Ergotamines

7. You are caring for a 33-year-old migraine He is currently complaining of an acute migraine attack, and is interested in abortive ther- apy. Which of the following options is least likely to be effective?

Acetaminophen
NSAIDs
5-HT agonists
Ergotamines
Narcotics

8. You are discussing migraine management with a 30-year-old She wants to use prophylactic medications, but had debilitating fatigue and symptoms of depression on beta-blockers. Which of the following medica- tions is an acceptable alternative?

Nifedipine
Verapamil
Diltiazem
Amlodipine
Nicardipine

9. A 41-year-old man comes to the office to discuss his headache symp- toms. He first began having symptoms a couple of years He describes the headaches dramatically—“like an ice pick is going through my eye!”— and describes it as the worst pain in his life. The headaches begin suddenly, are unilateral, last up to 2 hours, and are associated with runny nose and watery eye. He gets several attacks over a couple of months, but is symp- tom free for months in-between flare ups. What is the best approach for long term management of the attacks?

Fluoxetine, 20–60 mg daily
Prednisone, 10 mg daily
Indomethacin, 120 mg daily
Nifedipine, 40–120 mg daily during the symptomatic period
Ergotamine, 1–2 mg daily during the symptomatic period

10. A 40-year-old man transfers to your office from out of state after moving to your He suffers from cluster headaches, and would like a medication to manage the acutely painful episodes. Which of the fol- lowing would be best for treatment of the acute episodes?

Indomethacin, 120 mg by mouth
Oxycodone, 5–10 mg by mouth
Sumatriptan, 50–100 mg by mouth
Ergotamine, 1–2 mg by mouth
4% lidocaine, 1 mL administered into the nostril

11. You are talking with a 33-year-old woman who is complaining of She has had these headaches for 5 months, and they are increas- ing in frequency. She reports that the headaches may last anywhere from an hour to several days. They are now occurring about 5–10 times a month, without relationship to her menstrual cycle. She describes the headache as bilateral, and the pain is described as a pressure around her forehead. She denies nausea, is not sensitive to sound, but is sensitive to light during an attack. On examination, she has no obvious neurological deficit. What is the best approach to take at this point?

Prescribe narcotic analgesics and follow up if no improvement
Prescribe NSAIDs and follow up if no improvement
Order blood work to rule out secondary cause
Order a CT of the brain
Order an MRI of the brain

12. You are evaluating a 48-year-old woman with She reports a long history of occasional sinus headaches, usually responding to over- the-counter treatment. Over the last several months, the headaches are occurring more frequently, and are actually more painful than they have been in the past. Over-the-counter medications, effective in the past, no longer work. What is the most appropriate next step?

Use antibiotics to treat sinusitis and follow up if no improvement
Use prescription antihistamines and follow up if no improvement
Use prescription decongestants and follow up if no improvement
Use NSAIDs and follow up if no improvement
Obtain radiological imaging of the brain

13. You are taking care of a 36-year-old woman with mild hypertension, arthritis, and She also has been taking daily oral penicillin for a streptococcal throat infection. She notes the acute onset of hematuria, and comes to your office for evaluation. Which of the following medica- tions is most likely to cause this symptom?

Ibuprofen
Penicillin
Fluoxetine
Oral contraceptives
Hydrochlorothiazide

14. A 16-year-old sexually active woman comes to your office complain- ing of blood in her She reports suprapubic pain, dysuria, and fre- quency. What is the likely diagnosis?

Cystitis
Pyelonephritis
Nephrolithiasis
Bladder cancer
A sexually transmitted infection

15. You are evaluating a 56-year-old generally healthy man who is seeing you after finding blood in his He denies pain, dysuria, frequency, or urgency. He is a smoker, and has worked for years in the printing industry. What is the most likely cause of his hematuria?

Acute prostatitis
Chronic prostatitis
A UTI
Urinary stones
Bladder carcinoma

16. A 16-year-old girl comes to your office complaining of blood in her She is asymptomatic, and not menstruating. Urinalysis reveals grossly pink urine, but urine dipstick is negative for blood. Which of the following foods is the likely cause?

Spinach
Strawberries
Raspberries
Beets
Carrots

17. A 65-year-old African American man is seeing you because he has had blood in his urine for 1 On further questioning, you find that the blood appears at the end of micturition, and is not associated with pain, frequency, urgency, or other symptoms. Of the following, which is the most likely cause of his hematuria?

Urethral cancer
Renal cancer
Prostate cancer
Urolithiasis
Urethral trauma

18. You are seeing a 14-year-old boy who reports seeing blood in his He is currently asymptomatic. On urinalysis, he has more than 10 red blood cells per high-powered field, he has red cell casts, and his creatitine is 2.3 (H). What is the next step in the evaluation?

Intravenous pyelography
Renal ultrasound
Cystoscopy
Noncontrast helical CT
Antistreptolysin O titer

19. You are evaluating a 35-year-old man with His urinalysis does not reveal casts or protein, but does show moderate blood. His urine culture is negative, as is his intravenous pyelogram, and he has a normal creatinine. Which of the following is most appropriate in this case?

Reassurance and periodic monitoring
Renal ultrasound
Cystoscopy
ASO titer
Renal biopsy

20. A daycare worker presents to your office after turning “yellow.” She reports feeling feverish and fatigued, and describes right upper quadrant abdominal pain and On examination, her skin tone, conjunctivae, and mucous membranes are yellow-tinged. Serologies indicate acute hepatitis A infection. Which of the following is true about this infection?

She is most infectious while she is jaundiced
Fecal shedding of the virus continues until liver enzymes have normalized
Complete recovery is the norm
Relapses are common
This infection can lead to chronic infection

[MCQs] The Quizzes about Acute Complaints – Part 7 (20 test)

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Acute Complaints-7

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