Maintaining Certification in Internal Medicine

QUESTIONS

A 27-year-old man presents to his primary care physician with complaints of chronic nasal congestion. About 2 months earlier, he had an upper respiratory tract infection with rhinorrhea, nasal congestion, and coughing. Since then he continues to have severe nasal congestion with minimal drainage, for which he uses oxymetazoline nasal spray (eg, Afrin, Dristan) twice daily. Physical examination reveals mild tenderness to percussion over his maxilla bilaterally. The nares are erythematous, with swollen but patent turbinates and no purulent discharge. What is the most appropriate treatment?
1. Antibiotics
2. Oral antihistamine
3. Discontinue oxymetazoline
4. Nasal saline spray
5. Nasal fluticasone (Flovent)
A 91-year-old woman is diagnosed with community-acquired pneumonia (CAP). She has not taken any antibiotics for the past 3 months and has a true allergy to erythromycin (Ery-Tab, PCI-Dispertab). The patient weighs 72 kg, which is ideal for her height. Laboratory test results include a serum creatinine level of 1.5 mg/dL. The patient has no comorbidities. Which of the following drug regimens is the appropriate treatment for this patient?
1. Levofloxacin (Levaquin) 750 mg/day
2. Doxycycline (eg, Adoxa, Doryx) 100 mg twice daily
3. Azithromycin (Zithromax) 500 mg/day plus amoxicillin/ clavulanate potassium (Augmentin) 875 mg twice daily
4. Amikacin sulfate (Amikin) 150 mg every 8 hours
A 72-year-old man presents to your office complaining of a 30-lb weight loss, shortness of breath with exertion, and cough productive of blood-tinged sputum for the past 2 months. He has a 60 pack-year smoking history. An initial chest radiograph reveals a mass in the upper lobe of the right lung. Computed tomography scan of the chest shows a 5-cm mass in the right upper lobe, with right-sided mediastinal adenopathy. Positron-emission tomography scanning reveals uptake in 3 mediastinal nodes on the right side and 1 mediastinal lymph node on the left side. What should be your next step in management?
1. Biopsy of the mediastinal nodes
2. Pulmonary function testing, followed by lobectomy of the right upper lobe, then adjuvant chemotherapy
3. Radiation therapy
4. Radiation therapy, followed by lobectomy
While examining your patient, you see this skin change on the patient's lower back (Figure 1). What symptoms do you expect her to describe?

Figure 1
1. Pruritus from urticaria
2. Pain from herpes zoster
3. Itching from allergy to clothing
4. Back pain
A 29-year-old woman presents to the emergency department after having a 5-minute generalized tonic-clonic seizure. She is postictal and unable to provide a history. Vital signs are: temperature, 98.6°F; pulse, 112 beats/min; blood pressure, 160/105 mm Hg; respiratory rate, 14 breaths/min; oxygen saturation, 97%. Primary examination reveals that her pupils are equal and reactive to light. She moves her extremities purposefully to stimulation. Her husband states the patient is generally healthy and had an uncomplicated pregnancy that resulted in a vaginal delivery 2 weeks ago. What would be the first-line treatment for her condition?
1. Lorazepam (Ativan)
2. Magnesium
3. Phenytoin (Dilantin)
4. Labetalol HCl (Trandate)
A 63-year-old man comes in for a follow-up visit 2 weeks after being discharged from the hospital following urgent coronary artery bypass grafting (CABG) for atypical angina. The CABG was successful, and the recovery course was as expected, with only a transient shortness of breath on postoperative day 3. Now he complains of restlessness, especially at night when recumbent, and shortness of breath with even the slightest exertion. He prefers sitting upright in his recliner. He denies chest pain, cough, or fever. Chest examination reveals the trachea is midline, nearly absent breath sounds from the left lower lung, with E-to-A change (egophony), and dullness to percussion halfway up the back. The electrocardiogram (ECG) is unchanged from his last ECG 2 weeks ago, abdominal examination is normal, and there is no peripheral edema. What is the most probable explanation for these clinical findings?
1. Pulmonary embolus
2. Large pleural effusion
3. Pneumothorax
4. Pneumonia
This child's eyelids (Figure 2) show the cutaneous sign of which disorder?

Figure 2
1. Dennie's pleats of atopic dermatitis
2. Heliotrope color of dermatomyositis
3. Nits of lice infestation
4. Bruising of child abuse

ANSWERS

1—C. The patient is suffering from rhinitis medicamentosa secondary to chronic use of nasal decongestants—oxymetazoline, in this case. The condition is caused by rebound swelling of the nasal mucosa and turbinates after the vasoconstrictor effect wears off, and can occur as early as after 3 to 4 days of use. Stopping the nasal spray completely will eventually relieve the congestion. Nasal saline spray may also be helpful, but it will not alleviate the symptoms if the patient does not stop using the decongestant. There is no indication for antibiotics in this case. Antihistamines and topical steroids are helpful only in patients with allergic rhinitis.

Source: Graf P. Rhinitis medicamentosa: aspects of pathophysiology and treatment. Allergy. 1997;52(suppl 40):28-34.

2—B. New guidelines for empiric antibiotic therapy in adults with CAP state that patients who have not taken an antibiotic in the previous 3 months and do not reside in an area of high Streptococcus pneumoniae resistance should be treated with doxycycline or a macrolide. This patient has an erythromycin allergy and cannot take a macrolide. She also has significantly reduced kidney function, with an estimated creatinine clearance of 28 mL/min. Amoxicillin/ clavulanate potassium at the dose mentioned is not recommended in patients with a creatinine clearance of <30 mL/min, although her allergy to erythromycin rules out option C because of cross-reactivity. Similarly, her kidney dysfunction rules out levofloxacin at the dose indicated in option A, since the recommended dosages are 250 mg/day for uncomplicated CAP and 750 mg every 48 hours for complicated CAP. IV amikacin is used in hospital-acquired pneumonia and is not appropriate for outpatient therapy. Also, the dose for amikacin is 5 mg/kg every 8 hours, not 2 mg/kg every 8 hours.

Source: Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;4(suppl 2):S27-S72.

3—A. This patient's presentation warrants biopsy of the mediastinal lymph nodes before taking further action to distinguish resectable from unresectable disease. If the patient had evidence only of ipsilateral mediastinal nodal involvement on biopsy, his stage would be IIIA (tumor [T]2, node [N]2, metastasis [M]0), which would make him a candidate for surgery after neoadjuvant chemotherapy, with or without radiation. If the contralateral lymph node revealed disease, his disease would be stage IIIB (T2, N3, M0), which is considered to be unresectable disease. Treatment would then proceed with chemotherapy and radiation. Therefore, the first step should be to determine if the disease is resectable before you can proceed with appropriate treatment.

Source: Spira A, Ettinger DS. Multidisciplinary management of lung cancer. N Engl J Med. 2004;350:379-392.

4—D. This mottled erythema in a reticular pattern is called "erythema ab igne," which is caused by chronic exposure to heat—in this case it was use of a heating pad. It has also reportedly occurred on the thighs after long-term use of laptop computers. Continued heat exposure can lead to permanent changes, including hyperpigmentation, telangiectasia, skin atrophy, and even squamous-cell carcinoma or other skin malignancies. However, the chief importance of recognizing this skin change is the clue it provides to pain that the patient may be trying to relieve. The pattern of urticaria would be the reverse: pink wheals on pale skin. This patient has no visible signs of vesiculation or scarring of herpes zoster or the eczematous dermatitis that develops in reaction to clothing.

Source: Mohr MR, Scott KA, Pariser RM, et al. Laptop computer-induced erythema ab igne: a case report. Cutis. 2007; 79:59-60.

5—B. The patient is suffering from late postpartum eclampsia, defined as seizure activity that occurs more than 48 hours after delivery and is associated with hypertension and proteinuria. Eclamptic seizures have been reported to occur up to 23 days postpartum. As many as 66% of women with late postpartum eclampsia are asymptomatic before seizure onset. Magnesium is the treatment of choice; it resolves seizures in 95% of cases. Lorazepam does not have a role in the initial treatment but may be used for refractory seizures. Phenytoin is not indicated in eclamptic patients. Hypertension usually resolves with the initiation of magnesium therapy. For refractory cases, hydralazine HCl (Apresoline) or labetalol HCl have proven efficacy.

Sources: Hirshfeld-Cytron J, Lam C, Karumanchi SA, et al. Late postpartum eclampsia: examples and review. Obstet Gynecol Surv. 2006;61:471-480.
Sibai BM, Schneider JM, Morrison JC, et al. The late postpartum eclampsia controversy. Obstet Gynecol. 1980;55:74-78.

6—B. The prevalence of pleural effusion in patients undergoing CABG is 63%. A large effusion occupying more than 25% of the hemithorax occurs only 10% of the time, but it may require thoracentesis for symptom relief. These effusions are exudates and result from inflammation. The absence of fever, tracheal deviation, and chest pain speak against infection (pneumonia), pneumothorax, or embolus as the cause.

Source: Light RW, Rogers JT, Moyers JP, et al. Prevalence and clinical course of pleural effusions at 30 days after coronary artery and cardiac surgery. Am J Respir Crit Care Med. 2002;166:1567-1571.

7—A. Dennie's pleat, also called the Dennie-Morgan fold, is an accentuated fold below the margin of the lower lid that occurs in most children with atopic dermatitis. Dennie's pleat is a useful clue to the diagnosis, even in the absence of active eczematous dermatitis. This is also a sign that the child can be expected to have the impaired skin barrier function of atopy. Other subtle signs of atopy in this patient include central facial pallor, infraorbital darkening, flaking and erythema of the cheeks, and irritation of the nares from rhinitis. Dermatomyositis can be associated with a purple-red erythema with telangiectasia of the upper eyelids. Crab lice can infest the bases of the eyelashes. The symmetrical bluish discoloration around the eyes in children with atopic dermatitis is not purpuric and should not be confused with traumatic bruising.

Source: Kiken DA, Silverberg NB. Atopic dermatitis in children, part 2: treatment options. Cutis. 2006;78:401-406.

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