Monday MCQ 2

The answer is D. Interventions to prevent recurrences of diverticulitis include increased intake of dietary fiber, exercise, and, in persons with a body mass index (BMI) of 30 kg per m2 or higher, weight loss. Counseling for smoking cessation is recommended because smoking is associated with an increased incidence of complicated diverticulitis and less favorable outcomes (e.g., surgery at a younger age, higher risk of recurrence). Evidence from a prospective cohort study of 47,228 men in the United States found no evidence that avoiding nuts, corn, or popcorn decreases the risk of diverticulosis or diverticular complications, such as diverticulitis.

A small prospective study found that mesalamine and Lactobacillus casei are 28 effective in preventing recurrence. A meta-analysis of four randomized controlled trials with 1,660 patients who had experienced at least one episode of diverticulitis found that rifaximin (Xifaxan) plus fiber provided 1 year of complete relief and fewer complications compared with fiber alone. Additional Reading: Diagnosis and management of acute diverticulitis. Am Fam Physician. 2013; 87(9):612–620. Category: Gastroenterology system

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 The answer is B. Chest pain is common in patients with pulmonary embolism (PE). When evaluating a patient for possible PE, the presence of orthopnea suggests heart failure, fever suggests an infectious process, wheezing suggests asthma or chronic obstructive pulmonary disease (COPD), and rhonchi suggest heart failure, interstitial lung disease, or infection. These generalizations are supported by a 2008 study designed to improve the diagnosis of PE on the basis of the history, physical examination, EKG, and chest radiograph. Additional Reading: Diagnosis of deep venous thrombosis and pulmonary embolism. Am Fam Physician. 2012;86(10):913–919 Category: Cardiovascular system

The answer is D. Recognized tumor markers are most appropriate for monitoring response to therapy and detecting early recurrence. Cancer antigen (CA) 27.29 is most often used to follow response to therapy in patients with metastatic breast cancer. CA 27.29 is highly associated with breast cancer, although levels are elevated in several other malignancies (colon, gastric, hepatic, lung, pancreatic, ovarian, and prostate cancers). CA 27.29 also can be found in patients with benign disorders of the breast, liver, and kidney and in patients with ovarian cysts. CA 27.29 levels higher than 100 units per mL are rare in benign conditions.

Carcinoembryonic antigen (CEA) is used to detect relapse of colorectal cancer. CEA elevations also occur with other malignancies. Nonmalignant conditions associated with elevated CEA levels include cigarette smoking, peptic ulcer disease, inflammatory bowel disease, pancreatitis, hypothyroidism, biliary obstruction, and cirrhosis. Levels exceeding 10 ng per mL are rarely due to benign disease. Fewer than 25% of patients with disease confined to the colon have an elevated CEA level. Therefore, CEA is not useful in screening for colorectal cancer or in the diagnostic evaluation of an undiagnosed illness. A CEA level should be utilized only after malignancy has been diagnosed.

CA 19–9 may be helpful in diagnosing pancreatic abnormalities. Levels >1,000 units per mL are correlated with pancreatic cancer. Benign conditions such as cirrhosis, cholestasis, cholangitis, and pancreatitis can also result in CA 19–9 elevations, although values are usually 65 units per mL likely have ovarian cancer. Because premenopausal women have more benign causes of elevated CA 125 levels, testing for the marker is less useful in this population.

 α-Fetoprotein (AFP) is a marker for hepatocellular carcinoma. It is used to screen highly selected populations and to assess hepatic masses in patients at particular risk for developing hepatic malignancy.

 Testing for the β-subunit of human chorionic gonadotropin (β-hCG) is an integral part of the diagnosis and management of gestational trophoblastic disease. Combined AFP and β-hCG testing is an essential adjunct in the evaluation and treatment of nonseminomatous germ cell tumors and in monitoring the response to therapy. AFP and β-hCG are useful in evaluating potential origins of poorly differentiated metastatic cancer.

 Prostate-specific antigen (PSA) is used to screen for prostate cancer and detects recurrence of the malignancy. Additional Reading: Serum tumor markers. Am Fam Physician. 2003;68:1075–1082. Category: Nonspecific system

The answer is C. POTS is manifested by a rise in heart rate >30 beats per minute or by a heart rate >120 beats per minute within 10 minutes of being in the upright position. Symptoms usually include position-dependent headaches, abdominal pain, light-headedness, palpitations, sweating, and nausea. Most patients will not actually pass out, but some will if they are 43 unable to lie down quickly enough. This condition is most prevalent in white women between the ages of 15 and 50 years. Often these patients are hardworking, athletic, and otherwise in good health.

There is a high clinical correlation between POTS and chronic fatigue syndrome. Although no single etiology for POTS has been found, the condition is thought to have a genetic predisposition, is often incited after a prolonged viral illness, and has a component of deconditioning. The recommended initial management is encouraging adequate fluid and salt intake, followed by the initiation of regular aerobic exercise combined with lower-extremity strength training, and then the use of β-blockers. Additional Reading: Dizziness: a diagnostic approach. Am Fam Physician. 2010;82(4):361–368, 369; and Postural orthostatic tachycardia syndrome: a clinical review. Pediatr Neu

The answer is B. Men, like women, are at risk of developing osteoporosis that may lead to increased risk of fractures. Hypogonadism is an independent risk factor for osteoporosis. Dual-energy x-ray absorptiometry should be performed in men who are at increased risk of osteoporosis and who are candidates for drug therapy. Initial labs in men with osteoporosis should include a complete blood count, liver function testing, thyroidstimulating hormone (TSH) level, serum testosterone, creatinine, calcium, and 25-OH vitamin D levels.

Twenty-four-hour urine calcium and creatinine levels to identify hypercalciuria is indicated in men with osteoporosis that 44 occurs before the age of 60 years or if initial diagnostic methods fail to determine a cause of low bone mass. Bisphosphonates decrease the risk of vertebral fracture in men with osteoporosis. Teriparatide (Forteo) decreases the risk of vertebral fractures and can be used for treatment of severe osteoporosis. Men should have an adequate intake of calcium (1,200 mg daily) along with vitamin D (800 IU daily) to prevent osteoporosis. Additional Reading: Osteoporosis in men. Am Fam Physici

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