Geriatric Review Questions - Section 1 of 6

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geriatric review questions – section 1 of 6 instructions this section of..she has never 1. a 69-year-old man living in new york..and without nodules, and mild to kill him. as the patient...

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Geriatric Review Questions - Section 1 of 6 pdf

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Geriatric Review Questions - Section 1 of 6 - page 1
Geriatric Review Questions – Section 1 of 6 Instructions This section of the Geriatrics Review Syllabus presents review questions. Each question is composed of a stem and 4 or 5 possible answers. Some questions will require data from the Table of Normal Laboratory Values which is attached below this page. Please mark your answers on the answer sheet provided, not on this booklet. The critiques are provided in a separate booklet. While you are not graded on you performance, I suggest you look at the critiques after you have answered a set of questions. One set contains about 40 questions. I’m sorry that those requiring graphics are not yet applicable, so just guess like you did in your med school histopath course. Have fun! she can resume her walking exercise program. Except for arthritis, her medical history is unremarkable. She has never 1. A 69-year-old man living in New York City with metastatic smoked cigarettes and has no known pulmonary, cardiac, or lung cancer and chronic obstructive pulmonary disease renal conditions. (COPD) develops worsening respiratory function secondary to an exacerbation of his COPD. He is treated with doses of On physical examination she has an athletic, ruddy appearance, morphine adequate to diminish his respiratory hunger and to is 163 cm (64 in) tall, and weighs 64 kg (141 lb). Blood eradicate the pain he experiences from bony metastases. Both pressure is 150/70 mm Hg, pulse rate is 74/min and regular, the physician and the patient are aware of the possibility that and she is afebrile. There is no peripheral lymphadenopathy, the morphine may worsen the respiratory function sufficiently the thyroid is normal in size and without nodules, and mild to kill him. As the patient does not wish ventilatory support, jugular vein distention is noted in the upright position. Chest intubation with ventilatory support is not an option. Shortly examination is normal. There is no hepatomegaly; however, the after the injection of intravenous morphine the patient dies spleen is distinctly palpable 4 cm below the left costal margin. from respiratory arrest. The extremities are free of edema and without clubbing or cyanosis. Which of the following best describes the actions and their result? Laboratory Tests (A) Active euthanasia (B) Euthanasia Hemoglobin 17.1 g/dL (C) Palliative care Hematocrit 53% (D) Physician-assisted suicide Leukocyte count 13,400/µL Platelet count 475,000/µL Serum uric acid 11.5 mg/dL 2. A 65-year-old man presents with a 6-month history of The remainder of her serum chemistries, including serum cervical solid dysphagia, regurgitation of undigested food, creatinine, blood urea nitrogen, glucose, and alkaline halitosis, and a fullness of the left neck during meals. He phosphatase are within normal limits. denies a decrease in appetite, abdominal pain, weight loss, or change in bowel habits. Laboratory studies, including complete What is the most appropriate recommendation to the blood count, electrolytes, and liver studies, are normal. orthopedic surgeon? The diagnosis can be determined by which of the following? (A) (B) (C) (D) Upper endoscopy Esophageal manometry Barium swallow Radionuclide scanning (A) Proceed to surgery, keep the patient well hydrated, and once surgery is completed start aspirin 325 mg/d. (B) Proceed to surgery, keep the patient well hydrated, and once surgery is completed start anticoagulation with intravenous heparin. (C) Proceed to surgery, keep the patient well hydrated, and during the procedure obtain a biopsy specimen of the bone marrow. (D) Delay surgery and perform a bone marrow biopsy. (E) Delay surgery and determine red blood cell mass. 3. A surgical colleague seeks your advice on managing an 73- year-old man with a low level of thyroid-stimulating hormone and an elevated thyroxine. On examining this patient, which of the signs listed below is least likely to be seen? (A) Tremor (B) Tachycardia (C) Fatigue (D) Weight loss 4. A 74-year-old woman scheduled to have hip replacement surgery for longstanding degenerative arthritis is referred by her orthopedic surgeon for a preoperative evaluation. The woman is well, active, and motivated to have surgery so that 5. A 77-year-old retired firefighter with probable Alzheimer's disease is brought to the office by his wife and daughter for follow-up examination. His wife reports that she supervises his dressing, bathing, and toileting and provides constant reassurance for her husband. He asks her the same questions several times a day. The patient's Mini-Mental State Examination score has declined from 18/30 to 16/30 over the past year.
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Geriatric Review Questions - Section 1 of 6 - page 2
What is the most effective intervention to promote continued caring for this patient in his home? (A) (B) (C) (D) Use of formal counseling services Use of respite services Use of a neuroleptic agent Use of a benzodiazepine agent (E) That vitamin E may be adversely influencing the efficacy of the donepezil, and that discontinuing the vitamin E while maintaining the donepezil would be appropriate 6. A 77-year-old man living at home presents with several complaints. For the past 3 months his sleep pattern has been interrupted by excessive coughing. On awakening in the morning he has a bitter taste in his mouth. He describes an intermittent sensation of oral burning and the sensation of a lump in his throat. He reports that sometimes he feels the air cut off in his throat and can hardly talk. He also reports experiencing an intermittent, strong pressure in his chest unrelated to exertion. On examination, the patient frequently clears his throat, and a hoarse vocal quality is apparent. Blood pressure is 145/85 mm Hg. The lungs are clear to auscultation, and normal heart sounds are present. What is the most likely diagnosis? (A) (B) (C) (D) (E) Postnasal drip Sleep apnea Gastroesophageal reflux disease Parkinson's disease Panic disorder 8. A 71-year-old woman with Parkinson's disease returns to your office 2 weeks after you placed her on one tablet of 25 mg carbidopa/100 mg levodopa 3 times daily at mealtimes. When she called 1 week ago to report that she was experiencing nausea with each dose, you reduced the dosage to one-half tablet 3 times daily. However, her nausea persists. What is the most appropriate next step? (A) Add carbidopa 25 mg 3 times daily. (B) Change to a tablet of 10 mg carbidopa/100 mg levodopa. (C) Have the patient take the carbidopa-levodopa 30 minutes before meals. (D) Replace the carbidopa-levodopa with bromocriptine. (E) Supplement the carbidopa-levodopa with perphenazine. 9. Which of the following is the least likely presenting symptom of an acoustic neuroma? (A) An attack of vertigo (B) Unilateral hearing loss (C) Unilateral tinnitus (D) Unilateral distortion of sounds (E) Disequilibrium 7. You have diagnosed mild dementia of the Alzheimer's type in a 69-year-old man whom you have followed for many years. The laboratory evaluation together with a several-year history of symptoms is consistent with this diagnosis. Although the patient can no longer work as an engineer, he still is able to visit family and friends, play tennis and golf, enjoy church, and travel with his wife. He has lost the ability to keep track of the family's finances, and his wife has taken over that responsibility. Two months ago, after obtaining a baseline Mini-Mental State Examination score, you started him on donepezil 5 mg/d, which you subsequently increased to 10 mg/d without side effects. You also prescribed vitamin E, 400 IU, twice daily. The family notes no improvement, and they are encouraging the patient to stop taking the donepezil. Concerning the efficacy of the medications, what is the most appropriate recommendation for you to make to the patient and his family? (A) That these medications do not always work, and that tapering and then stopping them would be appropriate (B) That these medications are not expected to lead to major improvement but may delay deterioration, and that continuing current treatment for an additional 4 months would be appropriate (C) That increasing the dosage of donepezil to 20 mg/d may lead to more noticeable improvement and would be appropriate (D) That plasma levels of donepezil may be above the therapeutic range, and that decreasing the dosage to 5 mg/d would be appropriate 10. A 78-year-old man presents with complaints of restless sleep at night and daytime fatigue and sleepiness. These problems have been worsening over the past 5 years. He describes social detachment and vivid nightmares about his experiences during World War II. His wife confirms the restless sleep and recently decided to sleep in a separate bedroom because of his loud snoring and occasional tendency to hit her unknowingly during sleep. Which of the following represents the best diagnostic approach? (A) Obtain a detailed 2-week sleep diary. (B) Obtain a measurement of serum melatonin and growth hormone levels. (C) Obtain neuropsychologic testing. (D) Obtain a psychiatric evaluation. (E) Obtain a sleep laboratory (polysomnographic) study. 11. An 85-year-old man who resides in a nursing home with a subacute care unit is found to have a temperature of 39.7°C (103.5°F). Past medical history includes peripheral vascular disease, hypertension, coronary artery disease, and moderate dementia. The patient's advance directives include orders NOT to transfer to the acute care hospital and NOT to initiate cardiopulmonary resuscitation but otherwise to initiate treatments. His medications include enteric-coated aspirin, nitroglycerin patch, diltiazem, and metoprolol. 2
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(D) Physical examination shows a lethargic patient with a pulse rate of 120/min and regular, respiration rate of 32/min, and blood pressure of 98/70 mm Hg. Chest is clear, cardiac examination reveals a short systolic murmur, and the abdoment is unremarkable. On neurologic examination the patient, who is usually alert and conversant, does not answer questions. Skin examination reveals dry mucous membranes, poor turgor, and a 2 × 2 cm pressure ulcer with surrounding warmth, erythema, and tenderness over the right trochanter. Laboratory tests show: leukocyte count, 23,000/µL with 85% segmented neutrophils and 10% band forms; blood urea nitrogen, 45 mg/dL; serum creatinine, 0.8 mg/dL. Chest radiograph and urinalysis are normal. Blood cultures have been ordered. After intravenous hydration with normal saline is begun, what is the most appropriate next step in the patient's management? (A) (B) (C) (D) Culture the pressure ulcer. Debride the pressure ulcer. Administer intravenous antibiotics. Institute topical antibiotic therapy. Full passive range-of-motion exercises done daily 14. A 79-year-old man in a skilled nursing facility is undergoing reconditioning therapy following surgical repair of an abdominal aortic aneurysm 1 month ago. He develops chest pain and clear electrocardiographic evidence of an acute myocardial infarction. The patient has a past history of myocardial infarction with a left ventricular ejection fraction (LVEF) of 40%. Ten years ago as an outpatient he had a peptic ulcer treated, and there have been no recurrences. His medications include aspirin 325 mg/d, enalapril 10 mg/d, and metoprolol 25 mg/d. Which of the following factors in this patient's medical history precludes use of thrombolytic therapy in the treatment of his acute myocardial infarction? (A) (B) (C) (D) (E) Age of 79 years Daily use of aspirin History of peptic ulcer disease Previous myocardial infarction with reduced LVEF Recent surgery 12. An emaciated, 67-year-old man with widespread colon cancer presents to the emergency room via ambulance. He has had persistent vomiting every few hours for the past day or more. He says he is "tired of all this" and notes that his last bowel movement was "probably yesterday." The patient reports that he is enrolled in a hospice program, but he did not think to call them about this episode, and his wife says she was too flustered to think at all. The patient is taking no drugs at the present time. In the emergency room his pulse rate is 112/min. Examination reveals a visibly distended stomach (as seen through a thin abdominal wall), very few bowel sounds, and highly concentrated urine. He has very firm stool in the rectum that is heme positive. A surgeon asked by the emergency department to evaluate the patient recommends laparotomy to relieve the bowel obstruction. What is most likely to be the best course of action at this time? (A) Home hospice care with octreotide, opioids, small sips of liquid (B) Home hospice care with prochlorperazine, nasogastric suction, opioids (C) Hospitalization with nasogastric suction, intravenous hydration, and corticosteroids (D) Optimal preoperative management and a diverting colostomy 13. An 85-year-old woman with severe osteoarthritis underwent elective right total hip replacement surgery by posterior approach 2 days ago. The prosthesis was cemented in place. She is otherwise healthy, cognitively intact, and able to comply with positioning restrictions. Rehabilitative care at this point would include: (A) Use of an abduction splint between the legs while the patient is in bed (B) Use of an elevated toilet seat (C) Touch-down weight bearing on the right lower extremity 15. An 85-year-old woman is admitted to the hospital with fever and altered mentation. Although she has a diagnosis of mild Alzheimer's disease, she has been able to live in supervised congregate housing with assistance in instrumental activities of daily living. Prior to hospitalization she was taking no medications. Physical examination reveals a lethargic patient who cannot pay attention to your commands. Her temperature is 38ºC (100.4ºF), and respiration rate is 24/min. Body mass index is normal. Skin shows adequate turgor. Cardiopulmonary examination reveals only crackles in the right lower lung field. There is no focal motor deficit on neurologic examination. A chest radiograph reveals pneumonia in the right lower lobe. Laboratory tests show a normal hematocrit, a leukocyte count of 15,000/mL, normal serum electrolytes, and a pulse oximetry of 94% on room air. Which of the following statements about this patient's delirium is accurate? (A)The delirium should respond rapidly to appropriate antibiotics. (B)Delirium increases the risk of prolonged functional impairment. (C)Delirium markedly increases the patient's risk of dying of pneumonia. (D) Physical and/or chemical restraints are essential to initial management. 16. The patient is an 88-year-old female nursing-home resident with a history of angina, an inferior myocardial infarction, transient ischemic attacks, and chronic memory impairment probably due to multiple cerebral infarctions. One morning, about 30 minutes after finishing breakfast and 1 hour after taking isosorbide dinitrate 10 mg, she was sitting at the breakfast table staring straight ahead. She was pale and unresponsive to questions from the nursing staff. When they came to her, she had a few tonic-clonic movements of her left arm and then slumped to the side. She was taken to bed, where she immediately woke up. Her blood pressure was 160/98 mm Hg and pulse rate was 56/min. The patient was admitted to the hospital for evaluation of syncope. 3
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Which of the following tests is most likely to reveal the cause of this patient's syncope? (A) Continuous electrocardiographic monitoring (B) Electroencephalography (C) Carotid sinus massage (D) Blood pressure monitoring after meals and medications (E) Computed tomography of brain (D) (E) Procainamide Amiodarone 17. A 77-year-old man with benign prostatic hyperplasia presents with a 2-month history of progressive dysphoria, social withdrawal, and difficulty in falling asleep and staying asleep. He has also recently been suffering from subjective feelings of anxiety, abdominal distress, and trembling. What is the most appropriate treatment for this presentation? (A) (B) (C) (D) (E) Lorazepam Buspirone Nefazodone Doxepin Bupropion 20. A 78-year-old community-dwelling woman in generally good health reports a "tender" area on her hard palate that she first noticed after a social event two nights ago. Upon examination, the physician notes a raised, nodular, bony mass covered by firm, pale, generally healthy-appearing mucosa. The mass measures approximately 2.5 × 1.5 cm and is located on the midline of the palate. In the center of the mass is a 2- to 3-mm cut that is slightly erythematous and appears to be in the process of healing. The patient is asked to return in 10 days. At that time, the nodular mass is still present. However, the formerly erythematous mucosa has healed, and the tenderness has resolved. What is the most likely diagnosis of this mass? (A) (B) (C) (D) Minor salivary gland tumor of the palate Palatal abscess Papillary hyperplasia Torus palatinus 18. A 76-year-old woman presents for her routine preventive health examination. She has had regular and essentially normal examinations at your practice for the last 15 years. Other than age, she has no risk factors for specific diseases. Which of the following diagnostic studies is most strongly supported by evidence to be an effective screening test for this patient? (A) (B) (C) (D) Papanicolaou smear Complete blood count Measurement of thyroid-stimulating hormone Stool for occult blood ]21. An 82-year-old retired bookkeeper with hypertension, hyperlipidemia, and mild osteoarthritis of the knees lives alone in a continuing-care retirement community. She enrolls in a health-care insurance program offering in-home geriatric assessment and limited follow-up. Problems identified during this assessment include a Mini-Mental State Examination score of 26/30, visual acuity of 20/70 in the right eye, and several small, loose rugs in her apartment. Which of the following is the most likely outcome of this assessment process? (A) (B) (C) (D) (E) Fewer visits to her primary care provider Fewer hospital admissions Increased use of home-care services Decreased likelihood of living in a nursing home Reduced number of prescription drugs 19. A 70-year-old man recovering from an anterior wall myocardial infarction is evaluated prior to discharge from the cardiac care unit (CCU). The patient has been in good health, and except for diet-controlled diabetes he has no other modifiable cardiovascular risk factors. Physical examination reveals an S gallop and a few crackles at both lung bases. Blood pressure is normal. The patient is asymptomatic on walking through the hospital corridors. On electrocardiogram, Q waves are present in the lateral precordial leads with inverted T waves. Sinus rhythm is present, with seven multifocal ventricular premature beats per minute. Chest radiograph is consistent with moderate pulmonary fibrosis at the bases. Echocardiogram shows dyskinesis of the apex and a left ventricular ejection fraction of 45%. The patient's medications in the CCU include long-acting nitrates and 325 mg of aspirin daily. What additional medication should be prescribed at this time in an effort to reduce the patient's risk of premature death from coronary artery disease? (A) (B) (C) Metoprolol Verapamil Digoxin 22. A 72-year-old woman with a 38-year history of paranoid schizophrenia is brought to your office for evaluation. She has been taking haloperidol 5 mg/d for decades and has been stable with regard to psychotic symptoms for many years. Her earlier active symptoms consisted of religious delusions and auditory hallucinations. She has done well for 15 years living in a group home and working in a fast-food restaurant. Over the last 3 or 4 years she has become increasingly forgetful and more withdrawn. She has been less interested in her assigned chores at the group home and recently has been putting the dishes away in the wrong place. Increasingly she has been taking the wrong bus to work, and on several occasions she has gotten lost. Her performance at work has also deteriorated. Recently she has lost several paychecks, whereas previously she had been very careful with her money. She also has been noticed to be wearing dirty clothes, and it has become evident that she is not bathing often enough. Over the last month she has been frightened by visual hallucinations, prompting the present 4
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office visit. On examination the woman is medically stable and without evidence of delirium or drug abuse. Laboratory tests are all normal. What is the most appropriate initial treatment to recommend? (A) Increase the dosage of haloperidol. (B) Initiate pharmacotherapy with a cholinesterase inhibitor. (C) Initiate antidepressant pharmacotherapy. (D) Decrease the haloperidol. Which of the following should be used to initiate treatment for this patient's disorder? (A) (B) (C) (D) (E) Gluten-free diet Prednisone Tetracycline Metronidazole Pancreatic enzymes 23. A 70-year-old woman whom you have been following for 6 months presents for routine examination. For about a year she has been concerned about having stomach cancer because she has reflux symptoms at night. She has had no weight loss or other constitutional symptoms, and her review of systems is otherwise unremarkable. Her appetite is normal, as are her mood, energy, and interests in her usual hobbies. Upper endoscopic examination is normal. However, no amount of reassurance will reduce her concerns about cancer. She denies any past psychiatric symptoms or treatment. This patient's diagnosis is most consistent with: (A) (B) (C) (D) Hypochondriasis Major depression with psychotic features Schizophrenia Somatization disorder 25. A 66-year-old man with mild mental retardation and recurrent major depressive disorder has been under treatment by a psychiatrist for approximately 2 years. His symptoms include a significantly depressed mood, anger, agitation, and anxiety. He lives in an apartment with one peer, and they are visited once daily by a residential support staff member. The psychiatrist has extensive experience in diagnosing and treating persons with mental retardation and mental illness. The diagnoses have been confirmed by an experienced consulting clinician. The patient has been started on four different antidepressants over the treatment period and has also received psychotherapy during this period of time. Nevertheless, his depression remains severe, and he is now considered by his caregivers to be in a deteriorating state of mental and physical health. His physician determines that he needs hospitalization. While in the hospital, what would be the most appropriate next treatment? (A) Electroconvulsive therapy. (B) Initiate therapy with a monoamine oxidase inhibitor. (C) Add propranolol or nadolol to a selective serotonin reuptake inhibitor that showed a partial response. (D) Add buspirone to the current antidepressant. (E) Continue the current antidepressant and initiate daily psychotherapy. 24. A 65-year-old woman presents with a 1-year history of increasing diarrhea, abdominal distention, and bloating associated with a 9-kg (20-lb) unintentional weight loss. Her stools are described as loose, malodorous, bulky, and floating. She notes onset of paresthesias and difficulty in walking over the past 6 months. She also has a history of a right hip fracture. Her physical examination reveals temporal wasting, pale oral mucosa, glossitis, scattered ecchymoses on her extremities, a benign abdomen, lower-extremity edema, decreased deep tendon reflexes, and ataxia. Laboratory Tests Hematocrit Potassium Calcium Magnesium Iron Albumin Protein Cholesterol Trypsinogen Stool studies Bacteria Ova/parasites Clostridium difficile Sudan stain 30% 3.0 meq/L 4.0 mg/dL 1.7 mg/dL 55 µg/dL 2.9 g/dL 5.0 g/dL 124 mg/dL Normal Negative Negative Negative 3+ 26. An 81-year-old man presents complaining of impotence. Over the past year he has had increasing difficulty obtaining and maintaining an erection that is firm enough for vaginal penetration. He states that his libido is good, that his marital relationship is without problems, and that he is proud to have been happily married for 60 years so far. Past medical history is significant for hypertension, and diet-controlled diabetes, and a myocardial infarction 5 years ago. The patient denies any dyspnea or angina. He has no known allergies and denies alcohol or tobacco use. His medications are lisinopril 20 mg/d, aspirin 325 mg/d, isosorbide dinitrate 40 mg twice daily, and a multivitamin daily. His physical examination, including genital examination, is unremarkable. Laboratory tests 1 month ago showed normal values for complete blood cell count, electrolytes, blood urea nitrogen, and serum creatinine; glycosylated hemoglobin was in the well-controlled range. What is the most appropriate next step in the management of this patient? (A) (B) day. Provide reassurance alone. Add yohimbine 5.4 mg one-half tablet 3 times per Breath testing with 14C-cholylglycine shows no abnormalities. An upper endoscopy reveals a loss of duodenal folds. Small bowel biopsies show villous atrophy. 5
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(C) Add testosterone 200 mg intramuscularly every 2 weeks. (D) Prescribe a vacuum tumescent device. (E) Prescribe sildenafil 25 mg to be taken 1 hour before sexual activity. Which of the following steps designed to prevent or forestall cardiovascular disease would be most appropriate to include in the management of this patient? (A) (B) (C) (D) Carotid auscultation Electrocardiogram Exercise counseling Lipid profile 27. An 85-year-old woman is admitted to the hospital at night for a hip fracture that followed a fall in her home. The next morning she undergoes a hemiarthroplasty. You are called as a consultant on the second postoperative day to evaluate a change in her mental status. The patient's past history is remarkable for depression, hypertension, and osteoporosis. Her current medications are morphine 5 mg subcutaneously as needed every 4 hours, calcium carbonate 500 mg orally twice daily, and hydrochlorothiazide 12.5 mg orally daily. Physical examination reveals a frail-appearing woman who is awake but moans and weeps during your interview. She has difficulty staying focused on your commands and cannot answer your questions. Vital signs are normal, as are cardiopulmonary, abdominal, skin, and neurologic examinations. A urinary catheter is in place. Laboratory studies are within normal limits except for urinalysis (4+ bacteria, 20 leukocytes, culture pending) and leukocyte count (13,000/µL). Pulse oximetry shows normal oxygen saturation. What is the most appropriate course of action at this juncture? (A) Start the patient on sertraline. (B) Discontinue morphine and substitute acetaminophen. (C) Observe and reassess in 24 hours. (D) Order noncontrasted computed tomography scan of the head. (E) Remove the catheter and treat for urinary tract infection. 28. A 92-year-old nursing-home resident has been transferred to your care. Her medical history is significant for hypertension, heart failure, osteoporosis, dementia, and a hysterectomy at age 52. Her current medications include captopril 12.5 mg 3 times daily, furosemide 20 mg daily, potassium 40 meq daily, aspirin 325 mg 3 times daily, and famotidine 20 mg daily. Conjugated equine estrogen 0.625 mg daily and medroxy-progesterone 2.5 mg daily were recently added to her regimen. Which of the following medications is most appropriately prescribed for this woman? (A) (B) (C) (D) (E) Captopril Aspirin Famotidine Conjugated equine estrogens Medroxyprogesterone 30. A healthy 85-year-old woman recently moved to your area to be closer to her family. She has enjoyed excellent health but is bothered by increasingly severe osteoarthritis of her knees. As a result, she leads a relatively sedentary life. Her physical examination is normal, aside from osteoarthritic changes in both knees. She is slightly below ideal body weight. Findings on routine laboratory studies are all normal except for a postprandial blood glucose level of 155 mg/dL, which raises a concern about diabetes. Which of the following is most likely responsible for the increased postcarbohydrate glucose level in this patient? (A) (B) (C) tissues (D) Increased body fat and decreased muscle mass Decreased insulin levels Decreased number of insulin-binding receptors in all Decreased insulin response by peripheral tissue 31. Which of the following benzodiazepines would be most appropriate for the short-term treatment of pathologic anxiety in elderly persons? (A) Diazepam (B) Chlordiazepoxide (C) Triazolam (D) Lorazepam 32. A 72-year-old woman presents with complaints of retrosternal pain and odynophagia. Three weeks ago she began taking alendronate 10 mg/d for the treatment of osteoporosis. She is otherwise in good health. Endoscopy now shows a large, deep ulcer at the gastroesophageal junction. Examination of biopsy specimens shows necroinflammatory material and acute esophagitis. The final diagnosis is alendronate-induced esophagitis and ulceration. Which of the following factors would most likely increase her risk of developing this side effect? (A) Age-related decline in esophageal motility (B) Age-related increase in gastroesophageal reflux (C) Ingestion of alendronate with inadequate amounts of fluid (D) Ingestion of alendronate at a time other than a true fasting state 29. An 83-year-old man presents for a routine preventive health examination. It has been one year since his most recent preventive examination. The patient has osteoarthritis and mild Parkinson's disease but otherwise is asymptomatic. He has no history of smoking, diabetes mellitus, hypertension, or cardiovascular disease. His blood pressure is 138/78 mm Hg. 33. A 68-year-old man presents seeking assistance to quit smoking. He has tried to quit four times previously, all within the last 5 years. On two attempts he tried to quit "cold turkey" but both times returned to smoking in less than a week. On another attempt supported by a group hypnosis session, he quit for almost 3 weeks before relapsing. The most recent attempt 1 6
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year ago was made with transdermal nicotine, but he stopped using the patches after 2 days because he developed a rash and urticaria. The patient has a history of coronary artery disease with stable angina, benign prostatic hyperplasia associated with urinary hesitancy and dribbling, and type II diabetes mellitus complicated by mild orthostatic hypotension. He currently takes isosorbide mononitrate sustained release 60 mg each morning, doxazosin 4 mg at bedtime, and glipizide sustained release 5 mg daily before breakfast. He has always experienced significant craving when he has tried to quit before, and he requests drug therapy for what he hopes will be a successful final effort to stop smoking. The most appropriate pharmacological treatment for this patient is: (A) (B) (C) (D) (E) Clonidine Buspirone Fluoxetine Bupropion Amitriptyline to the hospital from her home with community-acquired pneumonia. Prior to that she lived alone but managed her affairs independently, with occasional assistance from her daughter for strenuous tasks such as yard work and house cleaning. Her medical history includes hypertension, congestive heart failure, and osteoporosis. Her medications on transfer are digoxin 0.125 mg/d orally, hydrochlorothiazide 25 mg/d orally, and amoxicillin-clavulanic acid 250 mg orally 3 times daily for 7 days. Which of the following would be the most appropriate next step? (A) Transfer the patient to the emergency room for neuroimaging and diagnostic work-up. (B) Contact the patient's daughter to determine if current behavior is longstanding. (C) Reassure the nurse that these symptoms are probably related to a change in environment. (D) Review hospital records and examine the patient. (E) Discontinue digoxin and order a serum electrolyte panel. 34. For 65-year-old persons in the United States, life expectancy in 1995 was: (A) (B) (C) (D) Greater for black women than for white women Greater for black men than for black women Greater for white men than for black men Greater for white men than for black women 37. A 78-year-old patient with chronic obstructive pulmonary disease and chronic stable angina is admitted to the hospital for pneumonia. Because he has lower urinary tract symptoms suggestive of benign prostatic hyperplasia and an enlarged prostate gland on examination, the covering physician opts to order prostate-specific antigen (PSA) testing. The PSA test result is 9.0 ng/mL. A prostate biopsy is performed, and prostate cancer is discovered. The Gleason score is 4. Although there is much controversy surrounding treatment options for prostate cancer, there is some consensus that the most appropriate treatment for this patient would be: (A) (B) (C) (D) Brachytherapy Radiation therapy Radical prostatectomy Expectant management (watchful waiting) 35. A 90-year-old woman living in a nursing home because of moderate dementia and lack of a family caregiver has been frequently restrained in her bed and chair because of intermittent agitation and wandering behavior. One evening, after being unrestrained as part of the facility's "restraint reduction" policy, she fell while on her way to the bathroom, prompting the facility to reexamine the use of restraints and their relation to patients' risk of falls. Which of the following statements concerning restraints and their relationship to falls is most consistent with what is known? (A) Restraints are not able to prevent falls. (B) Bed rails have been shown to be an effective alternative to physical restraints. (C) Restraint use can increase risk of falls by producing muscle weakness and deconditioning. (D) Restraints are an acceptable method for managing wandering behavior. (E) Restraint reduction is not associated with increased risk of falls. 38. A 79-year-old woman presents with the chief complaint of difficulty in walking secondary to foot and leg pain. The pain occurs with weight bearing even without ambulation. The patient denies any general medical conditions and is taking no medications. On physical examination the patient is 160 cm (63 in) tall and weighs 95.5 kg (210 lb). Her pedal pulses are barely palpable bilaterally; capillary filling time is 3 sec, and ankle/arm index is .95. Neurologic examination is normal. The patient has total dystrophic onychomycosis of all toes with significant hypertrophy. Additional findings include: xerosis of both feet, especially the heels; hyperkeratosis with sublesional capsulitis below the metatarsal heads of the first, second, and fifth toes bilaterally; and hammer toes on the second to fifth toes bilaterally. What is the most likely cause of her foot and leg pain? (A) (B) Intermittent claudication Peripheral neuropathy 36. A 90-year-old woman has been transferred from an acute care hospital to a skilled nursing home and is now, for the first time, under your care. The admitting nurse has contacted you because her initial assessment found the patient to be restless, confused in speech, and easily distracted. There is no mention of delirium in the transfer summary or discharge sheet provided by the hospital. Four days earlier the patient had been admitted 7
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(C) (D) Charcot's joint Biomechanical stresses sound and ends with the second heart sound. Both a third (S½ gallop) and fourth sound are present. Which of the following cardiac abnormalities can best explain this combination of physical findings? (A) (B) (C) (D) Aortic sclerosis Aortic stenosis Mitral regurgitation Dissecting aneurysm of the ascending aorta 39. An 80-year-old man presents with vertebral compression fracture after lifting groceries from a table. Which of the following conditions is the most frequent cause of osteoporosis in this patient's age group? (A) (B) (C) (D) (E) Glucocorticoid use Testosterone deficiency Metastatic cancer Excessive alcohol use Idiopathic osteoporosis (E) Mitral valve prolapse 40. An elderly patient in sinus rhythm has a grade 3/4 apical systolic murmur heard best in the fourth left interspace midway between the apex of the heart and the sternum with modest radiation to the axilla. The murmur begins with the first heart Geriatric Review Question Critiques – Section 1 of 6 assisted suicide and euthanasia. J Am Geriatr Soc. 1995;43(5):553–562. [QUESTION 2] This patient’s history is suggestive of a pharyngoesophageal diverticulum, which is also called a Zenker’s diverticulum. Typically, a Zenker’s diverticulum occurs in persons above 50 years of age. The duration of symptoms ranges from weeks to years and can include solid and liquid dysphagia, regurgitation of undigested food, cough, and halitosis. If the diverticulum is large, a patient can sense a gurgling in the neck or a bulge in the neck during meals. Aspiration pneumonia or significant weight loss can occur with a longstanding, large Zenker’s diverticulum. The symptoms in this patient are located in the neck and warrant an assessment of this area. The diagnosis can be determined by a barium swallow with lateral views of the pharyngoesophageal junction. Upper endoscopy should be performed after the barium swallow to eliminate the possibility of mucosal abnormalities or the presence of a malignancy prior to surgical intervention. This procedure must be done cautiously because of the risk of inadvertent perforation. Passage of the endoscope is often done over a fluoroscopically placed guidewire in order to safely intubate the esophagus. Esophageal manometry is typically reserved for individuals with dysphagia with no esophageal anatomic abnormalities. Radionuclide scanning will not consistently determine the diagnosis. The usual approach to symptomatic pharyngoesophageal diverticulum is surgery. There is no consensus regarding the best surgical approach. Either diverticulectomy, diverticulectomy with cricopharyngeal myotomy, diverticular inversion with myotomy, or myotomy alone is used in the treatment of patients with Zenker’s diverticulum. References [Question 1] Euthanasia and active euthanasia are synonymous terms referring to interventions, such as lethal injections, that are specifically intended to hasten a patient’s death. Physician-assisted suicide refers to the physician’s supplying, at the patient’s request, the means by which the patient can kill him or herself. It is the expectation and intention that the means provided by the physician (eg, a potentially fatal amount of a drug) will be used solely by the patient to kill him or herself. Interventions specifically designed to palliate symptoms, even though they may result in death, are not considered euthanasia or physician-assisted suicide. Rather, they are considered palliative care. These actions may be active, such as giving medication, as in this case to palliate symptoms; or they may consist in withholding or withdrawing life-sustaining treatments that only prolong the dying process. The U.S. Supreme Court has specifically made a distinction between palliative care, which may result in or hasten death, and euthanasia or assisted suicide. The U.S. Supreme Court has made it clear that palliative care that results in death may well be appropriate, but that there is no constitutional right entitling a person to secure the assistance of a physician to actively hasten his own death. Further, the Supreme Court makes it clear that states may make physician assistance in such endeavors a criminal offense. The Supreme Court left open the possibility that individual states could decriminalize physician-assisted suicide if they so chose, but such action would have to be done through their legislative or voter- initiative processes. References 1. Lynn J, Cohn F, Pickering JH, et al. American Geriatrics Society on physician-assisted suicide: brief to the United States Supreme Court. J Am Geriatr Soc. 1997;45(4):489–499. 2. Sachs GA, Ahronheim JC, Rhymes JA, et al. Good care of dying patients: the alternative to physician- 8
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1. Boyce GA, Boyce HW Jr. Esophagus: anatomy and structural anomalies. In: Yamada T, Alpers DH, Owyang D, et al, eds. Textbook of Gastroenterology. Philadelphia: JB Lippincott Co; 1995:1174–1213. Gorman RC, Morrs JB, Kaiser LR. Esophageal disease in the elderly patient. Surg Clin North Am. 1994;74(1):93–112. Jamieson JR. Pharyngoesophageal swallowing disorders. Curr Opin Gen Surg. 1993:189–194. 2. in blood viscosity caused by the increased red blood cell mass. Polycythemia vera is a clonal disorder that is classified with other chronic myeloproliferative diseases including primary thrombocytosis (thrombocythemia), myelofibrosis, and chronic myelogenous leukemia (CML). Unlike CML, the prognosis in appropriately managed cases of polycythemia vera is excellent, with most patients living for two decades or more with the diagnosis. Polycythemia vera needs to be distinguished from other causes of elevated hemoglobin. The first order of business is to confirm that the elevated hemoglobin level reflects an expanded blood volume and not a contracted plasma volume, a condition known as stress polycythemia or Gaisböck’s syndrome. This is best accomplished by the isotope dilution technique performed in most clinical laboratories or nuclear medicine departments. Once an absolute erythrocytosis is demonstrated, other tests are used to differentiate primary (polycythemia vera) from secondary causes. Other conditions associated with erythrocytosis include chronic hypoxia, renal disease, certain tumors, androgen therapy, and abnormal, high- oxygen-affinity hemoglobins. Polycythemia vera can be differentiated from these secondary causes on the basis of medical history, pulmonary examination, serum chemistries, and erythropoietin level. Bone marrow examination is generally unnecessary, unless there is concern of other myeloproliferative disease. The major risk for patients with polycythemia vera is thrombosis, the result of the red cell mass. The platelet count is usually elevated, especially after phlebotomy therapy, but this is not the cause of the increased risk. In fact, attempts at inhibiting platelet function with chronic, low-dose aspirin may have deleterious effects for patients with polycythemia vera. Optimal therapy is phlebotomy, which can be safely performed in the great majority of patients. The goal is to aggressively reduce the hemoglobin to a safe range (10 to 12 g/dL) by twice-monthly phlebotomy. Once that range is met, the patient has become iron deficient and erythropoiesis is inhibited. At that time, phlebotomies can be scheduled at less frequent intervals, usually every 3 months. Alternative approaches are usually associated with adverse effects and should be considered only in unusual circumstances, such as the patient with no venous access. These approaches include radioactive phosphorus (32P), interferon, and chemotherapy with alkylating agents. References 1. Bilgrami S, Greenberg BR. Polycythemia rubra vera. Semin Oncol. 1995;22(4):307–326. 2. Heimpel H. The present state of pathophysiology and therapeutic trials in polycythemia vera. Int J Hematol. 1996;64(3–4):153–165. 3. Pearson TC, Messinezy Z. Polycythaemia and thrombocythaemia in the elderly. 9 3. [QUESTION 3] In managing an elderly man with a low level of thyroid-stimulating hormone (TSH) and an elevated thyroxine (T4), it is important to remember that older patients have fewer signs and symptoms of hyperthyroidism. Tremor is not seen in at least 50% of patients with hyperthyroidism who are 70 years of age or older. In a recent prospective cohort study, investigators in France compared 19 classic signs of hyperthyroidism in 34 older patients > 70 years and 50 younger patients < 50 years. They also compared older patients with age-matched controls. Three signs were found in more than 50% of the older patients: tachycardia, fatigue, and weight loss. Six signs were found significantly less frequently in older patients: hyperactive reflexes, increased sweating, heat intolerance, nervousness, polydipsia, and increased appetite. Anorexia and atrial fibrillation were found more frequently in older patients. Ninety-four percent of younger patients and only 50% of older patients had a goiter. Thus, the number of clinical signs found in older subjects was significantly smaller than that found in younger subjects. When older patients with hyperthyroidism were compared with older controls, three signs were highly associated with thyrotoxicosis: apathy, tachycardia, and weight loss. References 1. Gregerman RI, Katz MS. Thyroid diseases. In: Hazzard WR, Bierman EL, Blass JP, et al, eds. Principles of Geriatric Medicine and Gerontology. 3 rd ed. New York: McGraw-Hill, Inc; 1994:807–823. 2. Trivalle C, Doucet J, Chassagne P, et al. Differences in the signs and symptoms of hyperthyroidism in older and younger patients. J Am Geriatr Soc. 1996;44(1):50–53. [QUESTION 4] The finding of erythrocytosis in this patient represents a striking operative risk. Therefore, under elective conditions, as in this case, surgery should be delayed until the target level of hemoglobin is attained. The detection of erythrocytosis in an asymptomatic patient is the most common presentation of polycythemia vera. However, with the markedly enhanced predisposition to thrombosis, some patients present with infarction of vital organs, including brain, kidney and intestine. The reason for the predisposition to thrombosis relates to the increase
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Baillieres Clin Haematol. 1987;1(2):355–387. [QUESTION 5] Interventions that provide education or emotional support or that can relieve some of the caregiver burden are integral components of the treatment plan for patients with dementia. Although all the intervention options listed in this question are often used to care for a patient with dementia, only the use of formal counseling services for the spouse and family has been shown to substantially delay, by almost a year, nursing-home placement; median time to institutionalization was 329 days. The counseling services included several individual and family counseling sessions followed by attendance at a weekly caregiver support group, with continued access to individual counseling as needed. It is unclear which of the counseling interventions were responsible for the improved outcomes. For the Alzheimer’s patient described in the question, the use of counseling services would thus be the most effective choice in promoting continued care in his home. Use of respite services will allow appropriate supervision, socialization, and personal care while providing the caregiver some time to work or pursue other personal needs. A controlled trial has shown that caregivers are very satisfied with the relief provided by respite services, with some minimal delay in time to nursing-home placement (average 22 days) achieved. A recent reanalysis of earlier studies on the efficacy of respite services suggests that increased use of this option is associated with a reduced likelihood of nursing-home placement. A caregiver would need to purchase $5200 worth of respite services to delay nursing-home placement for one year. The prescription of a neuroleptic drug for patients with dementia is most effective for treating symptoms such as hallucination, delusion, and paranoia. These symptoms are not present in the patient described. The use of benzodiazepines in patients with dementia should be avoided, given the potential for this class of drugs to further impair mental status. This patient’s repetitive questions and need for reassurance are symptoms of Alzheimer’s disease and do not require drug therapy. Long-term drug therapy directed at the neuropathology of Alzheimer’s disease, using a cholinesterase inhibitor or antioxidants, may be associated with a reduced likelihood of nursing-home placement. References 1. Abraham IL, Onega LL, Chalifoux ZL, et al. Care environments for patients with Alzheimer’s disease. Nurs Clin NA. 1994;29(1):157–172. 2. Connell CM, Gibson GD. Racial, ethnic and cultural differences in dementia caregiving: review and analysis. Gerontologist. 1997;37(3):355–364. 10 3. 4. 5. Knopman D, Schneider L, Davis K, et al. Long-term tacrine (Cognex) treatment: effects on nursing home placement and mortality. Neurology. 1996;47(1):166– 177. Kosloski K, Montgomery RJ. The impact of respite use on nursing home placement. Gerontologist. 1995;35(1):67–74. Mittelman MS, Ferris SH, Shulman E, et al. A family intervention to delay nursing home placement of patients with Alzheimer’s disease. JAMA. 1996;276(21):1725–1731. [QUESTION 6] The patient’s complaints all fit the condition of gastroesophageal reflux disease (GERD), the most likely cause of these complaints. Primary symptoms of GERD include heartburn, regurgitation, dysphagia, odynophagia (pain produced by swallowing), acid reflux, belching, hoarseness, cough, earache, wheeze, globus (choking sensation), throat clearing, sore throat, choking, and water brash (regurgitation of an excessive accumulation of saliva from the lower part of the esophagus, often with acid material from the stomach). Postnasal drip is one of the most common causes of a chronic cough. However, postnasal drip would not explain the other signs and symptoms in this case. Sleep apnea, while associated with the feeling of air being cut off in the throat, is not associated with odynophagia, hoarseness, or the oral symptoms reported by this patient. Dysphagia may be associated with Parkinson’s disease, but oral burning and bitter taste in the mouth are not. Symptoms most often associated with Parkinson’s disease include tremor, rigidity, bradykinesia, gait abnormalities, postural changes, finger dexterity loss, and speech impairment; functional limitations in walking, eating, dressing, and bathing are frequently observed. This patient has a few symptoms which might be seen with panic disorder, namely, the chest pressure and feeling of the air being cut off. However, in panic disorder there would be no cough, early morning bitter taste, and oral burning. Furthermore, the panic symptoms would be more pervasive and more severe. References 1. Koufman JA. The otolaryngologic manifestations of gastroesophageal reflux disease (GERD): a clinical investigation of 225 patients using ambulatory 24-hour pH monitoring and an experimental investigation of the role of acid and pepsin in the development of laryngeal injury. Laryngoscope. 1991;101(4;Pt 2;Suppl 53):1– 78. 2. Kuhlemeier KV. Epidemiology and dysphagia. Dysphagia. 1994;9(4):209–217. 3. Simpson WG. Gastroesophageal reflux disease and asthma: diagnosis and management. Arch Intern Med. 1995;155(8):798–803.
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