Family Medicine
Certification Exam Review

Educational Objective:

Examine first-line therapy for patients with long-term low back pain without radicular symptoms.

Key Point:

Nonpharmacologic therapies are considered first-line treatment options for long-term, low back pain without radicular symptoms.

Explanation:

Long-term low back pain is one of the most common presenting symptoms in primary care. Given this patient has had symptoms for more than 3 months, nonpharmacologic therapies are considered first-line therapies for treatment. Examples include exercise, weight loss, mindfulness-based stress reduction, acupuncture, yoga, tai chi, motor control exercise, progressive relaxation, electromyography biofeedback, low level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation.

Referral to a neurosurgeon would not be appropriate as an initial treatment, given the patient has not attempted more conservative therapies for her long-term low back pain. Management with a short-acting opioid should be considered only if nonpharmacologic therapies fail, and pharmacologic therapies such as nonsteroidal anti-inflammatory drugs, certain antidepressants such as duloxetine, nortriptyline, or amitriptyline, and certain anticonvulsants such as gabapentin, pregabalin, and carbamazepine are not successful. Additional imaging studies such as MRI as part of the initial treatment plan for the patient is not appropriate, given she has no symptoms concerning for nerve impingement, radiculopathy, or a neurologic emergency such as cauda equina syndrome.

References:

Dowell D, Haegerich T, Chou R. CDC guideline for prescribing opioids for chronic pain. MMWR Recomm Rep. 2016; 65(1):1-49.

Qaseem A, Wilt TJ, McLean RM, Forciea MA; Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017;166(7):514-530.

Educational Objective: 

Discuss supplemental oxygen therapy after cardiac arrest with return of circulation.

Key Point:

Once ROSC is achieved, the 2015 update of the pediatric advanced life support guidelines recommends that blood oxygen saturation be titrated to at least 94% but less than 100% (still valid in 2020).

Explanation:

Normoxia with a partial pressure of oxygen between 60 and 300 mm Hg after ROSC has been associated with improved rates of survival when compared with hyperoxemia (partial pressure of oxygen > 300 mm Hg). Blood oxygen saturation equal to 100% may expose patients to unnecessarily high partial pressures of oxygen, which are associated with less favorable outcomes. Hypoxemia, however, is worse than hyperoxemia and should be avoided.

Reference:

American Heart Association. Web-based Integrated Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care (This site blends the 2019 Focused Updates with the 2015 AHA Guidelines for CPR and emergency cardiovascular care) – Part 12: Pediatric Advanced Life Support. (Accessed on April 17, 2020)

de Caen AR, Berg MD, Chameides L, et al. Part 12: pediatric advanced life support: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132(18 suppl 2):S526-S542

Educational Objective:

Describe the capnometer waveform that is consistent with proper tracheal intubation.

Key Point:

The desired waveform that confirms the correct intubation value is square. 

Explanation:

If the tube is properly placed, then inspiratory and expiratory flow transitions should be nearly instantaneous, creating vertical edges in the transition from inspiration (low carbon dioxide) to expiration (high carbon dioxide). This leads to a square waveform. An issue is present if there is any other type of waveform.

References:

Smith DA. Pulmonary emergencies. In: Stone CK, et al. Current Diagnosis and Treatment Pediatric Emergency Medicine. 2015:395.

Yamamoto L. Airway management. In: Schafermeyer R, et al. Strange and Schafermeyer's Pediatric Emergency Medicine. 4th ed., 2015:81-89.

Lymphogranuloma venereum (LGV) should be suspected in patients with a large, fluctuant bubo with or without systemic symptoms (fever, arthralgia, etc) and usually without an ulcer. Lymphogranuloma venereum is a sexually transmitted infection caused by specific serotypes of C. trachomatis. LGV is primarily an infection of the lymphatics and the lymphnodes (similar to herpes being an infection a nerve). It is rare in the United States but prevalent in many tropical countries. It is therefore mostly seen in patients who have been to endemic areas.

The initial manifestation appears as a painless, small genital ulcer that resolves uneventfully and often goes unnoticed. The secondary stage involves the lymphatic channels and nodes of the genitals, the pelvis, and, in male patients, the scrotum (and at this stage, the ulcer has usually resolved). Click here to view an online poster with Netter images of the various stages.

Patients typically present in the secondary stage without the original ulcer, but instead with painful unilateral inguinal lymphadenopathy with overlying erythema. The nodes will eventually drain through the skin or form a hard inguinal mass. Treatment is with doxycycline 100 mg PO BID for 21 days. The diagnosis is based on the clinical picture, epidemiologic information, and the exclusion of other causes of inguinal lymphadenopathy and genital ulcers. In the case presented, the patient’s visit to the tropics, more than any other part of his history or exam, makes it important to strongly consider lymphogranuloma venereum in the differential diagnosis.

Chancroid is rare in the United States, with fewer than 100 cases reported annually to the Centers for Disease Control and Prevention (CDC). But in the developing world, chancroid is a major cause of genital ulcerative disease, and people coming/returning to the USA may present to the health care system with this disease. In the USA, lack of familiarity with chancroid, combined with the limited availability and sensitivity of the growth medium for H. ducreyi create challenges to making the diagnosis. Clinically, the painful ulcers of chancroid mimic those of genital herpes (HSV). Genital ulcers without a bubo are indeed more consistent with a diagnosis of herpes simplex, whereas painful genital ulcerations together with a large fluctuant bubo strongly suggest a diagnosis of chancroid (versus the history of a painless ulcer followed by the development of a bubo suggesting lymphogranuloma venerum).

Condyloma acuminata causes characteristic cauliflower-like soft, fleshy lesions around the anal or urethral orifice.

Syphilis usually presents with a single painless ulcer that is not associated with any systemic ailment.

Herpes simplex infection mostly involves the pharynx and presents with fever and muscle aches. It may also cause painful vesicles on the penis or anal region but does not involve the joints or heart.

References:

Workowski KA, Bolan GA. Sexually Transmitted Diseases Treatment Guidelines, 2015. MMWR Recomm Rep 2015; 64 (No 3): pgs 33-34.

Uguhiri, Kelechi, MD, MPH, MS, Franklin Square Hospital Family Medicine Residency Program, Baltimore, Maryland. Diagnosis and Management of Genital Ulcers. Am Fam Physician. 2012 Feb1;85(3):254-262.

Pathela P, Blank S, Schillinger JA. Lymphogranuloma venereum: old pathogen, new story. Curr Infect Dis Rep. 2007;9(2):143-150.

Haugstvedt A, Thorvaldsen J, Halsos AM. Lymphogranuloma venerum as ulcerous proctitis in men who have sex with men [in Norwegian]. Tidsskr Nor Laegeforen. 2007;127(16):2094-2095.

Educational Objective:

Discuss the key features of dyshidrotic eczema.

Key Point:

Recurrent pruritic vesicles limited to the hands or feet are key features of dyshidrotic eczema.

Explanation:

Dyshidrotic eczema presents as recurrent pruritic vesicles on the hands, feet, or both extremities. Vesicles may be small or may coalesce to form larger bullae.

Scabies, herpes simplex virus (HSV) infection, and fungal infections can be vesicular, but they are not generally limited to the hands. HSV infection presents as grouped vesicles on an erythematous base, and it is more often painful than pruritic. Dermatophyte (fungal) infections can be vesicular but are associated with well-demarcated, scaly plaques. Scabies is an intensely pruritic eruption occurring as nonspecific excoriated papules, sometimes with linear burrows, and more commonly vesicular in infants. There is no history of exposure to metal to suggest allergy to metal.

Reference:

Adams DR, Marks JG Jr. Acute palmoplantar eczema (dyshidrotic eczema). Revised May 30, 2017. Accessed June 7, 2017.