Chlamydial pneumonia is usually seen in infants 3–16 weeks of age, and these patients frequently have

been sick for several weeks. The infant appears nontoxic and is afebrile, but is tachypneic with a prominent
cough. The physical examination will reveal diffuse crackles with few wheezes, and conjunctivitis is
present in about 50% of cases. A chest film will show hyperinflation and diffuse interstitial or patchy
infiltrates.
Staphylococcal pneumonia has a sudden onset. The infant appears very ill and has a fever, and initially
may have an expiratory wheeze simulating bronchiolitis. Signs of abdominal distress, tachypnea, dyspnea,
and localized or diffuse bronchopneumonia or lobar disease may be present. The WBC count will show
a prominent leukocytosis.
Respiratory syncytial virus infections start with rhinorrhea and pharyngitis, followed in 1–3 days by a
cough and wheezing. Auscultation of the lungs will reveal diffuse rhonchi, fine crackles, and wheezes, but
the chest film is often normal. If the illness progresses, coughing and wheezing increase, air hunger and
intercostal retractions develop, and evidence of hyperexpansion of the chest is seen. In some infants the
course of the illness may be similar to that of pneumonia. Rash or conjunctivitis may occur occasionally,
and fever is an inconsistent sign. The WBC count will be normal or elevated, and the differential may be
normal or shifted either to the right or left. Chlamydial infections can be differentiated from respiratory
syncytial virus infections by a history of conjunctivitis, the subacute onset and absence of fever, and the
mild wheezing. There may also be eosinophilia.
Parainfluenza virus infection presents with typical cold symptoms. Eight percent of infections affect the
upper respiratory tract. In children hospitalized for severe respiratory illness, parainfluenza viruses account
for about 50% of the cases of laryngotracheitis and about 15% each of the cases of bronchitis,
bronchiolitis, and pneumonia.

Pharmacologic options for benign prostatic hyperplasia and lower urinary tract symptoms include an α-adrenergic
blocker, a 5-α-reductase inhibitor (if there is evidence of prostatic enlargement or a PSA level >1.5 ng/mL), a
phosphodiesterase-5 inhibitor, or antimuscarinic therapy. The first three have proven efficacy as monotherapies.

The recommended treatment for a mallet fracture is splinting the distal interphalangeal (DIP) joint in
extension (SOR B). The usual duration of splinting is 8 weeks. It is important that extension be maintained
throughout the duration of treatment because flexion can affect healing and prolong the time needed for
treatment. If the finger fracture involves >30% of the intra-articular surface, referral to a hand or
orthopedic surgeon can be considered. However, conservative therapy appears to have outcomes similar
to those of surgical treatment and therefore is generally preferred.

Lithium, valproate, lamotrigine, and some antipsychotics (including quetiapine) are effective treatments
for both acute depression and maintenance therapy of bipolar disorders. Haloperidol is an effective
treatment for acute mania in bipolar disorders, but not for maintenance therapy or acute depression.

This patient has physical findings consistent with a necrotizing skin and soft-tissue infection, or necrotizing
fasciitis. Severe pain and skin changes outside the realm of cellulitis, including bullae and deeper
discoloration, are strong indications of necrotizing fasciitis. Antimicrobial therapy is essential but is not
sufficient by itself; aggressive surgical debridement within 12 hours reduces the risk of amputation and
death.

Patients on amiodarone can develop either hyperthyroidism or hypothyroidism. It is recommended that a

Radial head subluxation, or nursemaid’s elbow, is the most common orthopedic condition of the elbow in
children 1–4 years of age, although it can be encountered before 1 year of age and in children as old as
9 years of age. The mechanism of injury is partial displacement of the radial head when the child’s arm
undergoes axial traction while in a pronated and fully extended position. The classic history includes a
caregiver picking up (or pulling) a toddler by the arm. In half of all cases, however, no inciting event is
recalled.
As long as there are no outward signs of fracture or abuse it is considered safe and appropriate to attempt
reduction of the radial head before moving on to imaging studies. With the child’s elbow in 90° of flexion,
the hand is fully supinated by the examiner and the elbow is then brought into full flexion. Usually the
child will begin to use the affected arm again within a couple of minutes. If ecchymosis, significant
swelling, or pain away from the joint is present, or if symptoms do not improve after attempts at reduction,
then a plain radiograph is recommended.

This patient has moderate persistent asthma. Although many parents are concerned about corticosteroid
use in children with open growth plates, inhaled corticosteroids have not been proven to prematurely close
growth plates and are the most effective treatment with the least side effects. Scheduled use of a
short-acting bronchodilator has been shown to cause tachyphylaxis, and is not recommended. The same
is true for long-acting bronchodilators. Leukotriene use may be beneficial, but compared to those using
inhaled corticosteroids, patients using leukotrienes are 65% more likely to have an exacerbation requiring
systemic corticosteroids.

The first-line treatment for primary dysmenorrhea should be NSAIDs (SOR A). They should be started
at the onset of menses and continued for the first 1–2 days of the menstrual cycle. Combined oral
contraceptives may be effective for primary dysmenorrhea, but there is a lack of high-quality randomized,
controlled trials demonstrating pain improvement (SOR B). They may be a good choice if the patient also
desires contraception. Although combined oral contraceptives and intramuscular and subcutaneous
progestin-only contraceptives are effective treatments for dysmenorrhea caused by endometriosis, they are
not first-line therapy for primary dysmenorrhea.

Thyroid nodules >1 cm that are discovered incidentally on examination or imaging studies merit further
evaluation. Nodules <1 cm should also be fully evaluated when found in patients with a family history
of thyroid cancer, a personal history of head and neck irradiation, or a finding of cervical node
enlargement. Reasonable first steps include measurement of TSH or ultrasound examination. The American
Thyroid Association’s guidelines recommend that TSH be the initial evaluation (SOR A) and that this be
followed by a radionuclide thyroid scan if results are abnormal. Diagnostic ultrasonography is
recommended for all patients with a suspected thyroid nodule, a nodular goiter, or a nodule found
incidentally on another imaging study (SOR A). Routine measurement of serum thyroglobulin or calcitonin
levels is not currently recommended.

Lamotrigine is an anti-epileptic medication that is often used in bipolar disorder. It can cause
Stevens-Johnson syndrome, which is a severe disorder of the skin and mucous membranes. This most
commonly occurs in children or when the drug is initiated at a high dosage, and is also more likely to occur
in patients taking divalproex. To decrease the risk of Stevens-Johnson syndrome, it is recommended that
lamotrigine therapy be started at a dosage of 25 mg daily and titrated every 2 weeks until the goal dosage
is reached.
The occurrence of two or more laboratory-confirmed cases of influenza A is considered an outbreak in a
long-term care facility. The CDC has specific recommendations for managing an outbreak, which include
chemoprophylaxis with an appropriate medication for all residents who are asymptomatic and treatment
for all residents who are symptomatic, regardless of laboratory confirmation of infection or vaccination
status. All staff should be considered for chemoprophylaxis regardless of whether they have had direct
patient contact with an infected resident or have received the vaccine. Requesting restriction of visitation
is recommended; however, it cannot be strictly enforced due to residents’ rights.

In general, the strongest evidence for treatment, screening, or prevention strategies is found in systematic
reviews, meta-analyses, randomized controlled trials (RCTs) with consistent findings, or a single
high-quality RCT. Second-tier levels of evidence include poorer quality RCTs with inconsistent findings,
cohort studies, or case-control studies. The lowest quality of evidence comes from sources such as expert
opinion, consensus guidelines, or usual practice recommendations.

This infant has findings consistent with erythema toxicum neonatorum, which usually resolves in the first
week or two of life (SOR A). No testing is usually necessary because of the distinct appearance of the
lesions. The cause is unknown.

The American Urological Association guidelines define asymptomatic microscopic hematuria (AMH) as
≥3 RBCs/hpf on a properly collected urine specimen in the absence of an obvious benign cause (SOR C).
A positive dipstick does not define AMH, and evaluation should be based solely on findings from
microscopic examination of urinary sediment and not on a dipstick reading. A positive dipstick reading
merits microscopic examination to confirm or refute the diagnosis of AMH.

Dyspnea is a frequent and distressing symptom in terminally ill patients. In the absence of hypoxia, oxygen
is not likely to be helpful. Opiates are the mainstay of symptomatic treatment and other measures may be
appropriate in specific circumstances. For example, inhaled bronchodilators or glucocorticoids may be
helpful in patients with COPD, and diuresis may be helpful in patients with heart failure. The evidence for
oxygen in patients with hypoxemia is not clear, but there is no benefit from oxygen for nonhypoxemic
patients.

This patient most likely has ischemic colitis, given his abdominal pain, bloody diarrhea, and
cardiovascular risk factors. Peptic ulcer disease is unlikely because the nasogastric aspirate
was negative. Diverticular bleeding and angiodysplasia are painless. Infectious colitis is
associated with fever.

Inhaled corticosteroids increase the risk of bruising, candidal infection of the oropharynx, and pneumonia.
They also have the potential for increasing bone loss and fractures. They decrease the risk of COPD
exacerbations but have no benefit on mortality and do not improve FEV1 on a consistent basis.

Depression affects up to 9% of U.S. patients and can cause significant disability. The U.S. Preventive
Services Task Force recommends screening for depression in adults in practices that have systems in place
to ensure accurate diagnosis and treatment with follow–up. Brief validated depression screening tools are
readily available to assist in the diagnosis of depressed patients.
In his history, this patient gave the equivalent of positive answers to the two-question Patient Health
Questionnaire (PHQ-2), a screening instrument that is specific for depression. In other words, depression
can be ruled out when the responses are negative. Because the PHQ-2 questions are positive in this patient,
the next step is confirmation with the PHQ-9, a questionnaire that includes the two questions in the PHQ-2
plus seven additional questions.
Cardiovascular testing may be indicated in the future for this patient, but not for these symptoms. The
patient’s sleep disturbance, viewed in the context of his other depressive symptoms and positive PHQ-2,
is not likely to be due to a sleep disorder, so polysomnography is not indicated at this point. Untreated
depression is associated with worse outcomes in coronary artery disease; so postponing further evaluation
would be inappropriate for this patient.

This patient has benign nocturnal limb pains of childhood (previously known as “growing pains”). These
crampy pains often occur in the thigh, calf, or shin, occur in up to 35% of children 4–6 years of age, and
may continue up to age 19. The pathology of these pains is unknown. The pain is nocturnal, without
limping or other signs of inflammatory processes. The erythrocyte sedimentation rate and CBC are normal
in this condition but testing is indicated in patients with chronic joint pain to rule out malignancy or
infection (SOR C). Rheumatoid factor and ANA have a low predictive value in primary care settings and
are not indicated in the pediatric population without evidence of an inflammatory process (SOR C). Plain
radiographs are more useful for excluding certain conditions such as cancer than for making a diagnosis
of arthritis in children (SOR C). Reassurance of the parents is indicated in this situation, along with
instruction on supportive care and over-the-counter analgesics as necessary.

In 2014 new evidence-based guidelines for blood pressure management were published by the panel
members of the Eighth Joint National Committee (JNC 8). They looked only at randomized, controlled
trials that compared one class of antihypertensive agent to another to develop the treatment
recommendations. ACE inhibitors, angiotensin receptor blockers (ARBs), calcium channel blockers, and
thiazide-type diuretics all yielded comparable effects on overall mortality and cardiovascular,
cerebrovascular, and kidney outcomes. They are all recommended for initial treatment of high blood
pressure in the nonblack population, including patients with diabetes mellitus. B-Blockers were not
recommended for the initial treatment of hypertension because one study found there was a higher rate of
the primary composite outcome of cardiovascular death, myocardial infarction, or stroke with use of these
drugs compared to the use of an ARB.

This patient has characteristic features of polymyalgia rheumatica, a disease whose prevalence increases
with age in older adults but is almost never seen before age 50. Most people will have accompanying
systemic symptoms including fatigue, weight loss, low-grade fever, a decline in appetite, and depression.
There are no validated diagnostic criteria available to assist in the diagnosis. The treatment response to 15
mg of prednisone daily is dramatic, often within 24–48 hours, and if this response is not seen, alternative
diagnoses must be considered. NSAIDs are not useful in the management of polymyalgia rheumatica and,
in fact, are associated with high drug morbidity. Ultrasonography may be useful in making the diagnosis,
with typical findings of subdeltoid bursitis and tendon synovitis of the shoulders, but synovitis of the
glenohumeral joint is less common.

Although the American Academy of Family Physicians (AAFP) states that physicians are not compelled
to perform any act that violates their moral principles, the AAFP also states that physicians do have a
responsibility to provide resources on how to access a safe and legal abortion for women who are
considering that option. Induced abortion is safer than live childbirth. Between 1998 and 2005 in the
United States, mortality was 8.8 per 100,000 live births among women who delivered live neonates and
0.6 per 100,000 abortions among women who had legal abortions. Physicians should not broker adoptions,
either by matching pregnant women with prospective parents or by offering to adopt children from their
patients. Physicians should also not advocate or argue their personal moral position to patients.
Conscientious refusal does not excuse a physician from providing appropriate medical care, including
providing unbiased, medically accurate information regarding options and either having a referral process
for transfer of care or identifying resources where such information can be obtained.

This patient has a severe diabetic foot ulcer. It appears to be infected and there are signs of a systemic
inflammatory response. This is an indication for intravenous antibiotics. Piperacillin/tazobactam and
vancomycin would be the most appropriate choice of antibiotics because together they cover the most
common pathogens in diabetic foot ulcers, as well as MRSA, which is present in 10%–32% of diabetic
foot ulcers. This patient has recently been hospitalized and would thus be at high risk for a MRSA
infection. Moderate to severe diabetic foot ulcers are often polymicrobial and can include gram-positive
cocci, gram-negative bacilli, and anaerobic pathogens.

In patients who are euvolemic but have hyponatremia, decreased serum osmolality, and elevated urine
osmolality, the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is likely. Other
causes to rule out include thyroid disorders, adrenal insufficiency, and diuretic use. Renal function has to
be normal as well. Common drugs that cause SIADH include SSRIs (particularly in patients over 65),
chlorpropamide, barbiturates, carbamazepine, opioids, tolbutamide, vincristine, diuretics, and NSAIDs.
Treatment of the problem consists of discontinuing the offending drug. Temporary fluid restriction may
also be required.

Unintentional injuries account for 40% of childhood deaths. Motor vehicle accidents are the most frequent
cause of these deaths (58.2% of unintentional deaths). The proper use of child restraints is the most
effective way to prevent injury or death, and the American Academy of Family Physicians and the
American Academy of Pediatrics strongly recommend that physicians actively promote the proper use of
motor vehicle restraints for all patients. Drowning accounts for 10.9% of all unintentional deaths in
children, poisoning for 7.7%, fires 5.7%, and falls 1.4%.

Based on the results of pulmonary function testing (FVC is <80% of predicted, his FEV1/FVC is 90% of predicted,
and there is no improvement with bronchodilator use), this patient has a pure restrictive pattern with a low
diffusing capacity for carbon monoxide. Pulmonary fibrosis is compatible with this pattern. A patient with
any of the other listed diagnoses would be expected to have an obstructive pattern on testing.

Patients with acute pericarditis should be treated empirically with colchicine and/or NSAIDs for the first
episode of mild to moderate pericarditis. $-Blockers would only be appropriate if the cause of the patient’s
chest pain were an infarction or ischemia. Nitrates do not relieve the pain of pericarditis. Glucocorticoids
are typically reserved for use in patients with severe or refractory cases or in cases where the likely cause
of the pericarditis is connective tissue disease, autoreactivity, or uremia (SOR C).

Primary amenorrhea is defined as a history of no menses in a female 13 years of age or older with no
pubertal development, or 5 years after initial breast development, or in a patient older than 15 years.
Primary amenorrhea is typically due to chromosomal problems that lead to primary ovarian insufficiency
or anatomic abnormalities. If the patient has dysmorphic features such as short stature, a low hairline, or
a webbed neck, the suspicion for Turner’s syndrome should be high. While FSH and LH levels may be
elevated, the definitive diagnosis would be made from a karyotype.

There is no indication for cardiac testing in a low-risk asymptomatic person, and testing may lead to harm
resulting from false positives. The U.S. Preventive Services Task Force does not recommend resting or
stress EKG testing for asymptomatic low-risk patients (D recommendation). Asymptomatic patients should
be risk stratified to assess the risk of chronic heart disease, and this patient should have a lipid profile for
risk stratification. Low-risk patients do not benefit from nontraditional risk assessments, including
high-sensitivity C-reactive protein or coronary artery calcium assessment.

When compared to a figure-of-eight dressing, a sling has been shown to have similar fracture healing rates
in patients with a nondisplaced midshaft clavicular fracture. In addition, a figure-of-eight dressing is
uncomfortable and difficult to adjust, and patients have reported increased satisfaction when treated with
a sling. Long and short arm casts are not appropriate options to manage a patient with a clavicular fracture.
Operative treatment is an option to treat displaced midshaft fractures (SOR B).
It should be noted that a Cochrane review of interventions for clavicle fracture pointed out that the studies
of this problem were done in the 1980s and did not meet current standards. One of the conclusions of this
review was that further research should be done.

In children, obstructive sleep apnea (OSA) is most often due to enlarged tonsils and adenoids. OSA onset
is usually between 2 and 8 years of age, coinciding with peak tonsil growth. Adenotonsillectomy is the
primary treatment for most non-obese children with OSA (SOR B). SSRIs are sometimes effective in
treating nightmares because these medications can suppress rapid eye movement sleep. Benzodiazepines
are an option for treating sleep terrors. Methylphenidate is a stimulant used to treat
attention-deficit/hyperactivity disorder and has no benefit for OSA. The use of a mouthguard at night is
recommended for management of temporomandibular joint syndrome to reduce excessive teeth grinding
during sleep. It is not a treatment for OSA.

Chronic kidney disease (CKD) is now divided into five stages of progressively worsening function based
on the glomerular filtration rate (GFR). Stage 1 is defined as a GFR >90 mL/min/1.73 m2, while the fifth
stage, kidney failure, is defined as a GFR <15 mL/min/1.73 m2. Anemia is associated with not only stage
5 disease, where it is universal, but also with earlier stages. The National Kidney Foundation Guidelines
define anemia as a hemoglobin level £13.5 g/dL in men or £12.0 g/dL in women.
Anemia due to CKD is diagnosed by excluding other etiologies. Anemia in CKD is due to decreased
production of erythropoietin, but testing for levels is not needed, nor is a bone marrow biopsy. The
indicated tests include a CBC, reticulocyte count, ferritin level, vitamin B12 level, folate level, and
transferrin saturation (serum iron to total iron binding capacity ratio). Usually the CBC will demonstrate
a normochromic, normocytic anemia, but can show microcytosis (mean corpuscular volume <80). A
serum ferritin level <25 ng/mL is indicative of low iron stores. Some patients have a combination of iron
deficiency and anemia of chronic disease due to the kidney disease.
Patients with depleted iron stores will benefit from replenishment, which serves to correct an isolated iron
deficiency or improve the response to erythropoiesis-stimulating agents. Iron therapy is generally initiated
orally with ferrous sulfate, 325 mg 3 times a day. The effectiveness of this therapy can be monitored by
checking hemoglobin, transferrin saturation, and ferritin levels at 1 and 3 months after beginning
treatment. If the goals have not been achieved by 3 months, intravenous iron therapy should be considered.
For patients who do not respond to iron replacement, erythropoiesis-stimulating agents such as epoetin alfa
or darbepoetin alfa should be used. The goal should be to relieve symptoms such as fatigue and to achieve
a hemoglobin level of 11–12 g/dL. Levels >13 g/dL increase the mortality rate, particularly from
cardiovascular disease.

Heart failure due to diastolic dysfunction occurs in the older population. The criteria for diastolic heart
failure include symptoms and signs consistent with heart failure (including dyspnea), a nondilated left
ventricle with a preserved ejection fraction (³50%), and evidence of structural heart disease such as
diastolic dysfunction on echocardiography (SOR C).

Slipped capital femoral epiphysis (SCFE) occurs most commonly during the adolescent growth spurt
(11–13 years of age for girls, 13–15 years of age for boys). While the cause is unknown, associated factors
include anatomic variables such as femoral retroversion or steeper inclination of the proximal femoral
physis, in addition to being overweight. African-Americans are affected more commonly as well.

The patient may present with pain in the groin or anterior thigh, but also may present with pain referred
to the knee. That is also the case for Legg-Calvé-Perthes disease, also known as avascular or aseptic
necrosis of the femoral head. This condition most commonly occurs in boys 4–8 years of age. In addition
to hip (or knee) pain, limping is a prominent feature.

Upper thigh numbness in an adolescent female is a classic symptom of meralgia paresthetica, which is
attributed to impingement of the lateral femoral cutaneous nerve in the groin, often associated with obesity
or wearing clothing that is too tight in the waist or groin. Developmental dysplasia of the hip is identified
by a click during a provocative hip examination of the newborn, using both the Barlow and Ortolani
maneuvers to detect subluxation or dislocation.

Patients with symptomatic peripheral arterial disease should be started on a daily dose of either aspirin or
clopidogrel to prevent cardiovascular events such as acute myocardial infarction or stroke (SOR B).
Cilostazol is a phosphodiesterase inhibitor with both antiplatelet and arterial vasodilatory activity. It has
been shown to improve claudication symptoms by 50% compared to placebo. Likewise, pentoxifylline is
also used in the treatment of claudication symptoms but is less effective than cilostazol and is reserved as
a second-line agent. Neither agent has been shown to decrease cardiovascular events in patients with
symptomatic peripheral artery disease. Neither enoxaparin nor warfarin is indicated for symptomatic
peripheral artery disease.