[MCQs] The Quizzes about Chronic Conditions – Part 1 (20 test)

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Question 1

A 46-year-old man is seeing you for help with smoking In addition to this, he reports having some sexual concerns. He complains of being unable to achieve erection, despite having strong interest in sexual activity. Which of the following is true regarding disorders of this sexual response phase?

A	Overcoming this disorder may require more visual stimulation
B	Overcoming this disorder may require more emphasis on the relationship
C	Overcoming this disorder requires an intact parasympathetic nervous system
D	Overcoming this disorder requires an intact sympathetic nervous system
E	Overcoming this disorder requires the use of androgens

Question 1 Explanation: 

The sexual response is divided into four phases. The first is libido (or desire/interest). This phase requires androgens and an intact sensory system. In men, this is more visual-based, but in women it is more relationship-based. The second phase is arousal (or excitement) and in men, involves erection. This requires an intact parasympathetic nervous system and vascular system. The next phase is orgasm, and in men involves ejaculation. This phase requires an intact sympathetic system.

Question 2

A 36-year-old sees you to discuss a lack of sexual He is not having sexual fantasies and is unmotivated to begin sexual activity. He does not report depressive symptoms and has no other physical complaints. His physical examination is normal. Which of the following laboratory tests is most appropriate?

A	Total testosterone
B	Free testosterone
C	Thyroid stimulating hormone
D	Prolactin
E	Prostate specific antigen

Question 2 Explanation: 

In patients with decreased sex drive, laboratory workup should be directed by the history and physical examination findings. In a patient with no other complaints and no physical examination findings, assessment of hormone status is indicated. Testosterone levels should be checked in the morning, when they peak. Free testosterone is a more accurate measure of androgen status, as it is a measure of bioavailable testosterone. The TSH and prolactin levels may be indicated in the presence of other complaints or physical findings. PSA would not be helpful.

Question 3

You are caring for a 45-year-old man with hypertension, gastroe- sophageal reflux, and His medication list includes hydrochloroth- iazide, verapamil, terazosin, omeprazole, bupropion, and trazodone. He is complaining of ejaculatory dysfunction. Which of the medications is most likely to cause this problem?

A	Hydrochlorothiazide
B	Verapamil
C	Terazosin
D	Omeprazole
E	Bupropion

Question 3 Explanation: 

Many medications can cause sexual dysfunction. Medications that commonly cause ejaculatory dysfunction in men include beta-blockers, alpha-blockers, antipsychotics and selective serotonin reuptake inhibitors. Hydrochlorozide can cause erectile dysfunction and decreased libido. Omeprazole and bupropion often do not negatively impact sexual functioning.

Question 4

You have diagnosed a 30-year-old woman with She is concerned that medical treatment may cause sexual dysfunction. Which of the following antidepressants is least likely to cause sexual dysfunction?

A	Amitriptyline
B	Paroxetine
C	Citalopram
D	Sertraline
E	Bupropion

Question 4 Explanation: 

Tricyclics and selective serotonin reuptake inhibitors frequently cause sexual dysfunction. Bupropion actually decreases the orgasm threshold and is least likely to cause sexual dysfunction.

Question 5

A 26-year-old newlywed man comes to your office to discuss prema- ture He has had this condition since beginning sexual activity at 17 years old. He has tried behavioral methods, but these have not been successful. Which of the following medications is most likely to help this condition?

A	Alprostadil
B	Fluoxetine
C	Bupropion
D	Silendafil
E	Atenolol

Question 5 Explanation: 

Premature ejaculation is the most common sexual dysfunction in men, affecting about 29% of the 245 Copyright © 2008 by The McGraw-Hill Companies, Inc. Click here for terms of use.general population. Alprostadil is used for erectile dysfunction, but would not positively effect premature ejaculation. Fluoxetine raises the threshold for orgasm, making it an effective treatment option. Bupropion and silendafil may decrease the orgasmic threshold and might be problematic. Atenolol may cause erectile dysfunction, but would likely not treat premature ejaculation.

Question 6

You are seeing a 61-year-old patient and are concerned about sub- stance He is single, employed as a lawyer in an extremely high stress job. Which of the characteristics listed below are known to increase his risk for a substance use disorder?

A	His age
B	His marital status
C	His job as a lawyer
D	His job stress
E	His level of education

Question 6 Explanation: 

Characteristics known to influence the epidemiology of substance use disorders include gender (men are more likely to be affected than women), age (disorders become less frequent with age), marital status (single persons have a higher risk than married), employment (the unemployed are at higher risk), and level of education (less educated persons are at higher risk). Though one would expect job stress to influence substance use, studies have not shown this to be true.

Question 7

You are evaluating a 31-year-old man who is concerned about He reports depressed mood, increased irritability, anhedonia, and sleep and appetite disturbances for 3–4 weeks. He reports a long his- tory of alcohol use, and is currently drinking 6 drinks a day on the week- days, up to 12 on the weekends. His laboratory results are consistent with alcohol abuse. Which of the following is the most appropriate next step?

A	Treat with a selective serotonin reuptake inhibitor
B	Treat with bupropion
C	Recommend detoxification and abstinence
D	Recommend detoxification and abstinence and start a selective serotonin reup- take inhibitor
E	Recommend detoxification and abstinence and start bupropion

Question 7 Explanation: 

Most clinicians agree that psychiatric disorders cannot be reliably assessed in patients who are currently or recently intoxicated. Alcohol is a depressant, and may be the main factor in the patient’s depressed symptoms. Detoxification and a period of abstinence is necessary before an evaluation for other psychiatric disorders can be effectively completed.

Question 8

You suspect that a 50-year-old female patient is abusing alcohol. Which of the following is the most sensitive laboratory test to confirm this?

A	Mean corpuscular volume (MCV)
B	Alanine aminotransferase (ALT)
C	Aspartate aminotransferase (AST)
D	Gamma-glutamyl transferase (GGT)
E	Lactate dehydrogenase (LDH)

Question 8 Explanation: 

Most people that abuse alcohol likely have completely normal laboratory studies. However, of the tests listed in the question, the GGT is the most sensitive. Elevated GGT is shown to be more sensitive than an elevated MCV, ALT, AST, or LDH. The specificity of the GGT is low, however, being elevated in nonalcoholic liver disease, diabetes, pancreatitis, hyperthyroidism, heart failure, and anticonvulsant use.

Question 9

An alcoholic patient of yours is interested in pharmacologic therapy to help him in his His counselor recommended he try naltrexone, and he asks you how that medication works in alcoholism. Which of the following is the best answer for your patient?

A	If the person taking naltrexone ingests alcohol, it causes an adverse reaction
B	Naltrexone reduces the reinforcing effects of alcohol
C	Naltrexone blocks the effects of alcohol by binding to alcohol receptor sites on cells
D	Naltrexone saturates the alcohol receptor sites on cells by acting as an alcohol agonist
E	Naltrexone changes the binding sites on alcohol, making it unable to bind to cells

Question 9 Explanation: 

Drugs used for addiction work in one of four ways. They either cause the body to have a negative reaction to an ingested drug, reduce the reinforcing effects of an ingested drug, block the effects of the drug by binding to the receptor site, or saturate the receptor sites with agonists that do not create the drug’s desired effect. Naltrexone is known to be helpful for both opiate addiction and alcohol addiction. Naltrexone saturates opiate receptor sites and leaves them unavailable for opiate attachment. For alcohol abuse, naltrexone works differently, reducing the reinforcing effect of alcohol (not allowing patients to become “drunk”).

Question 10

An alcoholic patient of yours is interested in pharmacologic therapy to help him in his His counselor recommended he try disulfiram, and he asks you how that medication works in alcoholism. Which of the following is the best answer for your patient?

A	If the person taking disulfiram ingests alcohol, it causes an adverse reaction
B	Disulfiram reduces the reinforcing effects of alcohol
C	Disulfiram blocks the effects of alcohol by binding to alcohol receptor sites on cells
D	Disulfiram saturates the alcohol receptor sites on cells by acting as an alcohol agonist
E	Disulfiram changes the binding sites on alcohol, making it unable to bind to cells

Question 10 Explanation: 

Disulfiram cause the body to have a negative reaction to ingested alcohol, regardless of the form. As such, it is a deterrent. The reaction to alcohol that occurs is manifested by flushing, nausea, and vomiting. Importantly, alcohol in cough medicines, mouthwashes, and other forms must be avoided, as the reaction does not discriminate based on from where the alcohol comes.

Question 11

A 33-year-old male patient is seeing you for advice on how to quit He has tried many times in the past and has been unsuccessful. Which of the following symptoms characterize the nicotine withdrawal syndrome?

A	Hypersomnolence
B	Depressed mood
C	Psychomotor retardation
D	Lethargy
E	Amotivational syndrome

Question 11 Explanation: 

The nicotine withdrawal syndrome is a serious obstacle for patients wishing to stop smoking. Withdrawal symptoms often begin within hours after the last cigarette. Early abstinence is characterized by irritability, anxiety, restlessness, depressed mood, inattention, and insomnia. Nicotine replacement is often effective in lessening some of these symptoms, as is bupropion.

Question 12

A 25-year-old woman is trying to stop She has difficulty with sudden cravings for nicotine and wonders which nicotine replace- ment system offers the fastest delivery of nicotine. Which of the following methods of nicotine replacement delivers nicotine fastest?

A	Nicotine gum
B	Nicotine lozenges
C	Transdermal nicotine patch
D	Nicotine nasal spray
E	Nicotine inhaler

Question 12 Explanation: 

Nicotine nasal spray offers the fastest delivery of nicotine. This is followed by gum (if used correctly), lozenges, and inhalation. The nicotine patch releases nicotine the most slowly and gradually

Question 13

One of your patients has tested positive for cocaine Upon ques- tioning, he says he would like to quit, but has a difficult time with cocaine withdrawal. Which of the following symptoms is expected from cocaine withdrawal?

A	Tachycardia
B	Hypertension
C	Depression
D	Anxiety
E	Insomnia

Question 13 Explanation: 

Cocaine withdrawal does not produce a significant physiologic withdrawal. Intoxication with cocaine does produce elevated heart rate and blood pressure. The most common problem produced by cocaine withdrawal is known as a “crash.” The crash is characterized by extreme fatigue and significant depression. Relapse is common during the crash because return to use provides quick and reliable relief.

Question 14

You are caring for a 35-year-old man in the hospital, admitted with On day 2 of his hospitalization, he becomes diaphoretic, rest- less, and irritable. Within hours, he is complaining of severe pain, abdom- inal cramps, and diarrhea. Which of the following would likely be present in his urine toxicology screen?

A	Cocaine
B	Marijuana
C	Opiates
D	3,4-Methylenedioxymethampheatmine (MDMA or ecstasy)
E	Benzodiazepines

Question 14 Explanation: 

Opiate withdrawal is wellcharacterized, and although not life-threatening in otherwise healthy adults, can cause severe discomfort. Symptoms from a short-acting drug like heroin can occur within just a few hours. Withdrawal from longer acting opiates may not cause symptoms for days. Early symptoms include lacrimation, rhinorrhea, yawning, and diaphoresis. Restlessness and irritability occur later, with bone pain, nausea, diarrhea, abdominal cramping, and mood lability occurring even later. Cocaine does not have a significant physiologic withdrawal syndrome, but craving is intense. Marijuana withdrawal syndrome is also not physiologically significant. Ecstasy can be considered a hallucinogen or a stimulant, and withdrawal is often associated with depression, but not the symptoms described above. Benzodiazepine withdrawal mimics alcohol withdrawal, and is associated with hypertension, tachycardia, and possibly seizures.

Question 15

A 64-year-old woman comes to see you as a new She is inter- ested in finding the cause of her hand deformities. Upon inspection, you see the joints in her hands are nodular and enlarged as in the picture below:  

(Reproduced, with permission, from South-Paul J. Current Diagnosis & Treatment in Family Medicine, 1st ed. New York: McGraw-Hill, 2004:266.)

Which of the following laboratory findings is likely in her case?

A	Her laboratory evaluation will likely be normal
B	Her serum uric acid level will likely be elevated
C	Her sedimentation rate will likely be elevated
D	Her c-reactive protein level will likely be elevated
E	Her rheumatoid factor will likely be elevated

Question 15 Explanation: 

The picture shown demonstrates Heberden’s nodes (at the distal interphalangeal joints) and Bouchard’s nodes (at the proximal interphalangeal joints). These abnormalities are commonly classified as osteoarthritis, but are only infrequently associated with pain or disability. Laboratory evaluation will only rarely show an inflammatory process, and an elevated uric acid level would be an incidental finding.

Question 16

You are evaluating a 62-year-old man who is complaining of joint His pain involves his left knee, right ankle, and both hands. He reports that his symptoms have been present for years, but are worsening. He has more pain with activity. On examination, you note some swelling in the joints with mild tenderness and crepitus. What is the likely cause of his symptoms?

A	Rheumatoid arthritis
B	Osteoarthritis
C	Gout
D	Tendonitis
E	Fibromyalgia

Question 16 Explanation: 

Osteoarthritis is characterized as being pauciarticular. The pain is worse with activity and improved with rest. There is often mild swelling, but warmth and an effusion are rare. Crepitus is common, as is malalignment of the joint. Rheumatoid arthritis tends to be polyarticular and symmetric. Morning stiffness improves with activity. Gout is abrupt in onset and monoarticular. Tendonitis and fibromyalgia are not associated with joint swelling and crepitus.

Question 17

A 43-year-old obese patient comes to your office with a painful, inflamed, swollen He reports that the pain began suddenly last evening, without a known precipitant or trauma. The pain is exquisite, and does not allow him to move his elbow at all—in fact, even the pressure of his bed sheet on his elbow was painful. On examination, he has an elbow effusion with warmth, erythema, and intense pain with movement. Which of the following is most likely the cause?

A	Rheumatoid arthritis
B	Osteoarthritis
C	Gout
D	A stress fracture
E	Cellulitis

Question 17 Explanation: 

The patient’s history is consistent with an attack of gout. The most common presentation of gout is podagra (an abrupt, intense inflammation of the first MTP joint), but any joint can be affected. It is characterized by an abrupt onset of monoarticular symptoms with pain at rest and with movement. The attacks often occur overnight, after an inciting event (excessive alcohol or a heavy meal). The sufferer often cites exquisite pain, with even slight pressure on the joint being quite painful. Osteoarthritis and rheumatoid arthritis would not occur so abruptly. A stress fracture would likely not be as painful at rest, and cellulitis would generally not be as abrupt or painful. Septic arthritis and gout may be clinically indistinguishable, unless the joint fluid is analyzed.

Question 18

You are caring for a 31-year-old woman who complains of joint She notes that her hands seem to be stiff in the morning, and that she seems to improve with time, movement, and heat. She reports more fatigue than usual as well. On examination, her wrists are swollen bilaterally, as are sev- eral of her metacarpal-phalangeal joints on each hand. Which of the follow- ing is her most likely diagnosis?l

A	Rheumatoid arthritis
B	Osteoarthritis
C	Gout
D	Tendonitis
E	Fibromyalgia

Question 18 Explanation: 

Rheumatoid arthritis is characterized by gradual, symmetric involvement of joints, with morning stiffness. Hands and feet are usually involved first, but it may spread to larger joints. Fatigue is a common complaint. On examination, symmetric swelling and tenderness are common, with associated rheumatoid nodules. Osteoarthritis is generally less symmetric and often occurs later in life. Gout is usually monoarticular. Tendonitis and fibromyalgia would be less likely to be associated with joint swelling.

Question 19

A 70-year-old man with diabetes and long-term osteoarthritis in his knees is presenting for follow He reports that his pain has become much more severe, and says he is having difficulty with ambulation and actually becoming fairly inactive. In the past, he tried ibuprofen and naproxen, but those offered limited improvement and he developed secondary ulcers. He says that taking acetaminophen is like “taking a sugar pill”—and says it offers no help. He had some relief from steroid injections 3 months ago, and again 1 month ago, but they were short-lived. A recent x-ray is shown below:

(Reproduced, with permission, from South-Paul J. Current Diagnosis & Treatment in Family Medicine, 1st ed. New York: McGraw-Hill, 2004:267)

Which of the following is the next most appropriate step in the treatment of his condition?

A	Use oral steroids
B	Try another steroid injection
C	Inject the knee joint with ketorolac (Toradol)
D	Inject hyaluronic acid into his knee joints
E	Refer for knee replacements

Question 19 Explanation: 

Oral steroids have a strong potential for ulcer formation, and although they may offer temporary relief, would not be indicated for chronic osteoarthritis. AnotherChronic Conditions Answers 249 steroid injection would be of limited benefit, and most recommend no more than two injections per year to avoid hastening of the osteoarthritic process. Ketorolac is not indicated for intra-articular injection. Hyaluronic acid injections have been shown to provide symptomatic relief in osteoarthritis for up to 6 months, but given the malalignment demonstrated in his x-ray, knee replacement would likely be more beneficial. Indications for replacement include poorly controlled pain despite maximal therapy, malalignment and decreased mobility or ambulation.

Question 20

You are seeing a 43-year-old man who complains of recurrent flares of He notes that he gets “attacks” after drinking alcohol and asks why. Which of the following is the best response?

A	Alcohol causes the release of uric acid from the liver
B	Alcohol itself increases crystal formation in the joint
C	Alcohol alters renal excretion of uric acid
D	Alcohol contains relatively large quantities of uric acid
E	Alcohol contains sulfites that metabolize into uric acid after absorption in the gut

Question 20 Explanation: 

Alcohol alters renal excretion of uric acid, allowing buildup of serum uric acid levels. This buildup allows crystals to precipitate in the joint spaces, causing the symptoms of gout.

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II. Preview all questions below

1.A 46-year-old man is seeing you for help with smoking In addition to this, he reports having some sexual concerns. He complains of being unable to achieve erection, despite having strong interest in sexual activity. Which of the following is true regarding disorders of this sexual response phase?

1. Overcoming this disorder may require more visual stimulation
2. Overcoming this disorder may require more emphasis on the relationship
3. Overcoming this disorder requires an intact parasympathetic nervous system
4. Overcoming this disorder requires an intact sympathetic nervous system
5. Overcoming this disorder requires the use of androgens

2. A 36-year-old sees you to discuss a lack of sexual He is not having sexual fantasies and is unmotivated to begin sexual activity. He does not report depressive symptoms and has no other physical complaints. His physical examination is normal. Which of the following laboratory tests is most appropriate?

1. Total testosterone
2. Free testosterone
3. Thyroid stimulating hormone
4. Prolactin
5. Prostate specific antigen

3. You are caring for a 45-year-old man with hypertension, gastroe- sophageal reflux, and His medication list includes hydrochloroth- iazide, verapamil, terazosin, omeprazole, bupropion, and trazodone. He is complaining of ejaculatory dysfunction. Which of the medications is most likely to cause this problem?

1. Hydrochlorothiazide
2. Verapamil
3. Terazosin
4. Omeprazole
5. Bupropion

4. You have diagnosed a 30-year-old woman with She is concerned that medical treatment may cause sexual dysfunction. Which of the following antidepressants is least likely to cause sexual dysfunction?

1. Amitriptyline
2. Paroxetine
3. Citalopram
4. Sertraline
5. Bupropion

5. A 26-year-old newlywed man comes to your office to discuss prema- ture He has had this condition since beginning sexual activity at 17 years old. He has tried behavioral methods, but these have not been successful. Which of the following medications is most likely to help this condition?

1. Alprostadil
2. Fluoxetine
3. Bupropion
4. Silendafil
5. Atenolol

6. You are seeing a 61-year-old patient and are concerned about sub- stance He is single, employed as a lawyer in an extremely high stress job. Which of the characteristics listed below are known to increase his risk for a substance use disorder?

1. His age
2. His marital status
3. His job as a lawyer
4. His job stress
5. His level of education

7. You are evaluating a 31-year-old man who is concerned about He reports depressed mood, increased irritability, anhedonia, and sleep and appetite disturbances for 3–4 weeks. He reports a long his- tory of alcohol use, and is currently drinking 6 drinks a day on the week- days, up to 12 on the weekends. His laboratory results are consistent with alcohol abuse. Which of the following is the most appropriate next step?

1. Treat with a selective serotonin reuptake inhibitor
2. Treat with bupropion
3. Recommend detoxification and abstinence
4. Recommend detoxification and abstinence and start a selective serotonin reup- take inhibitor
5. Recommend detoxification and abstinence and start bupropion

8. You suspect that a 50-year-old female patient is abusing alcohol. Which of the following is the most sensitive laboratory test to confirm this?

1. Mean corpuscular volume (MCV)
2. Alanine aminotransferase (ALT)
3. Aspartate aminotransferase (AST)
4. Gamma-glutamyl transferase (GGT)
5. Lactate dehydrogenase (LDH)

9. An alcoholic patient of yours is interested in pharmacologic therapy to help him in his His counselor recommended he try naltrexone, and he asks you how that medication works in alcoholism. Which of the following is the best answer for your patient?

1. If the person taking naltrexone ingests alcohol, it causes an adverse reaction
2. Naltrexone reduces the reinforcing effects of alcohol
3. Naltrexone blocks the effects of alcohol by binding to alcohol receptor sites on cells
4. Naltrexone saturates the alcohol receptor sites on cells by acting as an alcohol agonist
5. Naltrexone changes the binding sites on alcohol, making it unable to bind to cells

10. An alcoholic patient of yours is interested in pharmacologic therapy to help him in his His counselor recommended he try disulfiram, and he asks you how that medication works in alcoholism. Which of the following is the best answer for your patient?

1. If the person taking disulfiram ingests alcohol, it causes an adverse reaction
2. Disulfiram reduces the reinforcing effects of alcohol
3. Disulfiram blocks the effects of alcohol by binding to alcohol receptor sites on cells
4. Disulfiram saturates the alcohol receptor sites on cells by acting as an alcohol agonist
5. Disulfiram changes the binding sites on alcohol, making it unable to bind to cells

11. A 33-year-old male patient is seeing you for advice on how to quit He has tried many times in the past and has been unsuccessful. Which of the following symptoms characterize the nicotine withdrawal syndrome?

1. Hypersomnolence
2. Depressed mood
3. Psychomotor retardation
4. Lethargy
5. Amotivational syndrome

12. A 25-year-old woman is trying to stop She has difficulty with sudden cravings for nicotine and wonders which nicotine replace- ment system offers the fastest delivery of nicotine. Which of the following methods of nicotine replacement delivers nicotine fastest?

1. Nicotine gum
2. Nicotine lozenges
3. Transdermal nicotine patch
4. Nicotine nasal spray
5. Nicotine inhaler

13. One of your patients has tested positive for cocaine Upon ques- tioning, he says he would like to quit, but has a difficult time with cocaine withdrawal. Which of the following symptoms is expected from cocaine withdrawal?

1. Tachycardia
2. Hypertension
3. Depression
4. Anxiety
5. Insomnia

14. You are caring for a 35-year-old man in the hospital, admitted with On day 2 of his hospitalization, he becomes diaphoretic, rest- less, and irritable. Within hours, he is complaining of severe pain, abdom- inal cramps, and diarrhea. Which of the following would likely be present in his urine toxicology screen?

1. Cocaine
2. Marijuana
3. Opiates
4. 3,4-Methylenedioxymethampheatmine (MDMA or ecstasy)
5. Benzodiazepines

15. A 64-year-old woman comes to see you as a new She is inter- ested in finding the cause of her hand deformities. Upon inspection, you see the joints in her hands are nodular and enlarged as in the picture below:

(Reproduced, with permission, from South-Paul J. Current Diagnosis & Treatment in Family Medicine, 1st ed. New York: McGraw-Hill, 2004:266.)

Which of the following laboratory findings is likely in her case?

1. Her laboratory evaluation will likely be normal
2. Her serum uric acid level will likely be elevated
3. Her sedimentation rate will likely be elevated
4. Her c-reactive protein level will likely be elevated
5. Her rheumatoid factor will likely be elevated

16. You are evaluating a 62-year-old man who is complaining of joint His pain involves his left knee, right ankle, and both hands. He reports that his symptoms have been present for years, but are worsening. He has more pain with activity. On examination, you note some swelling in the joints with mild tenderness and crepitus. What is the likely cause of his symptoms?

1. Rheumatoid arthritis
2. Osteoarthritis
3. Gout
4. Tendonitis
5. Fibromyalgia

17. A 43-year-old obese patient comes to your office with a painful, inflamed, swollen He reports that the pain began suddenly last evening, without a known precipitant or trauma. The pain is exquisite, and does not allow him to move his elbow at all—in fact, even the pressure of his bed sheet on his elbow was painful. On examination, he has an elbow effusion with warmth, erythema, and intense pain with movement. Which of the following is most likely the cause?

1. Rheumatoid arthritis
2. Osteoarthritis
3. Gout
4. A stress fracture
5. Cellulitis

18. You are caring for a 31-year-old woman who complains of joint She notes that her hands seem to be stiff in the morning, and that she seems to improve with time, movement, and heat. She reports more fatigue than usual as well. On examination, her wrists are swollen bilaterally, as are sev- eral of her metacarpal-phalangeal joints on each hand. Which of the follow- ing is her most likely diagnosis?

1. Rheumatoid arthritis
2. Osteoarthritis
3. Gout
4. Tendonitis
5. Fibromyalgia

19. A 70-year-old man with diabetes and long-term osteoarthritis in his knees is presenting for follow He reports that his pain has become much more severe, and says he is having difficulty with ambulation and actually becoming fairly inactive. In the past, he tried ibuprofen and naproxen, but those offered limited improvement and he developed secondary ulcers. He says that taking acetaminophen is like “taking a sugar pill”—and says it offers no help. He had some relief from steroid injections 3 months ago, and again 1 month ago, but they were short-lived. A recent x-ray is shown below:

Which of the following is the next most appropriate step in the treatment of his condition?

1. Use oral steroids
2. Try another steroid injection
3. Inject the knee joint with ketorolac (Toradol)
4. Inject hyaluronic acid into his knee joints
5. Refer for knee replacements

(Reproduced, with permission, from South-Paul J. Current Diagnosis & Treatment in Family Medicine, 1st ed. New York: McGraw-Hill, 2004:267)

20. You are seeing a 43-year-old man who complains of recurrent flares of He notes that he gets “attacks” after drinking alcohol and asks why. Which of the following is the best response?

1. Alcohol causes the release of uric acid from the liver
2. Alcohol itself increases crystal formation in the joint
3. Alcohol alters renal excretion of uric acid
4. Alcohol contains relatively large quantities of uric acid
5. Alcohol contains sulfites that metabolize into uric acid after absorption in the gut