QUESTION: 121

A20-year-old male has had a recent wide local excision of a 1.5 mm melanoma from the right ankle. There is no evidence of metastatic disease. The most important prognostic factor for this patient is which of the following?

Which of the following is true regarding melanoma?

Chest radiographs are not recommended as a part of a patient's follow-up surveillance.
Timely treatment of metastatic melanoma has been shown to have an effect on mean survival.
Elevated serum LDH suggests metastatic melanoma.
Patients without clinical lymphadenopathy are not at risk for metastatic involvement. E. High mitotic rate and a lower Clark level are poor prognostic signs.

Answer(s): C

Explanation:

In patients who have melanoma that is confined to the skin (i.e., no evidence of metastatic disease), the most important prognostic factor is the Breslow histologic depth of the tumor. The age of the patient and location of the tumor also play a role in prognosis, but to a lesser degree. The forearm and leg tend to have a better prognosis; scalp, hands, feet, and mucous membranes have a worse prognosis. Older persons tend to have poorer prognoses, as well. Standard treatment for melanoma involves surgical excision. Sentinel lymph node biopsy should also be performed in any patient who has a melanoma that is at least 1 mm thick. This aids in determining whether melanoma cells have metastasized to the local lymph node basin. If the sentinel lymph node biopsy is negative for melanoma cells, no further lymph node studies are necessary. However, a positive biopsy warrants complete lymph node dissection. In addition to this situation, complete lymph node dissection is indicated in the setting of clinical lymphadenopathy regardless of evident distant metastasis. High dose interferon alpha-2 therapy is aviable option for use as adjuvant therapy in patients at high risk for disease recurrence, having been shown to prolong periods of remission and possibly improve mortality. Single-agent chemotherapy is generally used in patients with stage IV melanoma and is considered more for palliative purposes.

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QUESTION: 122

A 43-year-old patient presents with his fourth episode of culture-proven shingles in a T7 distribution. What is the most likely associated underlying condition?

leukemia
lymphoma
acquired immunodeficiency syndrome (AIDS)
chro

Answer(s): C

Explanation:

The incidence and severity of shingles is increased in most immunosuppressed patients. This population includes patients with lymphoma, leukemia, or HIV; patients who have received bone marrow transplantation; and patients on chronic immunosuppressive therapy. However, HIV patients are notable for their tendency to suffer multiple recurrences of shingles.

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QUESTION: 123

A24-year-old female presents to your office for excision of a nevus. After obtaining consent and prepping the site, you anesthetize the area with 1% lidocaine. However, as you start the procedure, you note that the patient is not sufficiently anesthetized. Your partner suggests the use of lidocaine with epinephrine. The addition of epinephrine with local anesthetics is useful because of which of the following properties?

It prolongs and increases the depth of local anesthesia.
It neutralizes the irritant action of the local anesthetic agent.
It increases the rate of systemic absorption and therefore hastens the onset of action of the anesthetic agent.
It increases the pH of the anesthetic so that less anesthetic is required to produce nerve block.
It blocks neurotransmitter release (thus decreasing pain perception) via stimulation of presynaptic alpha-adrenergic receptors.

Answer(s): A

Explanation:

The duration of action of a local anesthetic is proportional to its contact time with the nerves. Therefore, if the drug can be localized at the nerve, the period of analgesia should be prolonged. Using a vasoconstrictor such as epinephrine decreases the systemic absorption of the local anesthetic. Once the absorption is decreased, the anesthetic remains longer at the desired site and is systemically absorbed at a slower rate, which allows destruction by enzymes and less systemic toxicity.

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QUESTION: 124

A64-year-old man with hypertension presents for routine follow-up of his blood pressure. His home blood pressure log reveals readings in the 150/70 range. His home monitor had previously been verified by clinic BP readings. He denies any complaints. His current medications include HCTZ 25 mg daily, metoprolol 100 mg twice daily, enalapril 20 mg twice daily, and amlodipine 10 mg daily. He states he is adherent to his medication, drug, and exercise regimen as you recommended. At this time, how would you advise the patient?

You need to take another blood pressure medication.
I need to order some tests to look for secondary causes of high blood pressure.
In spite of your efforts, you need to exercise more and lose more weight.
Your blood pressure is acceptable where it is. Continue your current regimen.
I need to refer you to a cardiologist.

Answer(s): B

Explanation:

Resistant hypertension is defined as blood pressure not at goal despite adequate doses of a three-drug regimen including a diuretic. One of the first considerations is medication compliance and white coat hypertension. White coat hypertension can be assessed by the use of ambulatory blood pressure monitoring. A patient's home monitor should be assessed for accuracy against the office monitor. The patient's technique should also be verified. One should also assess for other agents that may lead to resistant hypertension despite pharmacologic therapy (e.g., tobacco use, NSAIDs, steroids, recreational drugs, oral decongestants, herbal medications). If the above are ruled out, one should initiate a workup to assess for a secondary cause for the hypertension, which may include chronic kidney disease, coarctation of the aorta, Cushing syndrome, steroid treatment, drug-induced hypertension, pheochromocytoma, primary aldosteronism, renovascular hypertension, sleep apnea, and thyroid/ parathyroid disease.

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QUESTION: 121

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QUESTION: 123

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QUESTION: 124

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