NP Case Studies & Practical Application 4 — Questions and Answers
Question 1: A 26-year-old woman presents requesting contraception. She has migraines with aura, smokes 10 cigarettes/day, and has a family history of DVT. Which contraceptive method is most appropriate?
- Combined oral contraceptive pill
- Levonorgestrel IUD (Correct answer)
- NuvaRing (vaginal ring)
- Combined contraceptive patch
Correct answer: Levonorgestrel IUD
Migraine with aura and smoking are absolute contraindications to combined hormonal contraceptives (Category 4); progestin-only methods like the LNG-IUD are safe.
Question 2: A 4-year-old boy is brought in for 3 days of fever (39.5°C), bilateral conjunctivitis, cracked red lips, strawberry tongue, and a diffuse polymorphous rash. On day 5, he develops desquamation of the fingertips. What is the most important treatment consideration?
- Initiate amoxicillin for presumed scarlet fever
- Administer IVIG and high-dose aspirin to prevent coronary artery aneurysms (Correct answer)
- Start systemic corticosteroids as first-line therapy
- Reassure parents that this is a self-limited viral illness
Correct answer: Administer IVIG and high-dose aspirin to prevent coronary artery aneurysms
Kawasaki disease treated within 10 days with IVIG plus aspirin significantly reduces the risk of coronary artery aneurysms.
Question 3: A 48-year-old woman with bipolar disorder is stabilized on lithium. She presents with polyuria, polydipsia, and a fine hand tremor. Serum lithium level is 0.9 mEq/L. What is the most likely cause of her symptoms?
- Lithium toxicity requiring immediate dose reduction
- Nephrogenic diabetes insipidus as a side effect of lithium (Correct answer)
- New-onset type 2 diabetes mellitus
- Hypothyroidism induced by lithium
Correct answer: Nephrogenic diabetes insipidus as a side effect of lithium
Lithium commonly causes nephrogenic DI by reducing renal collecting duct responsiveness to ADH, resulting in polyuria and compensatory polydipsia.
Question 4: A 35-year-old man presents with recurrent painful oral ulcers, genital ulcers, and anterior uveitis. He also has pustular skin lesions. He is of Middle Eastern descent. What is the most likely diagnosis?
- Systemic lupus erythematosus
- Behçet's disease (Correct answer)
- Reiter's syndrome (reactive arthritis)
- Herpes simplex virus infection
Correct answer: Behçet's disease
Behçet's disease presents with the triad of recurrent oral ulcers, genital ulcers, and uveitis, with higher prevalence along the Silk Road including the Middle East.
Question 5: A 60-year-old man with a 40 pack-year smoking history presents with hemoptysis, a 20-lb weight loss, and a hilar mass on CXR. He also notes weakness in his proximal leg muscles that improves with repeated use. The most likely paraneoplastic syndrome is:
- SIADH causing hyponatremia
- Lambert-Eaton myasthenic syndrome (Correct answer)
- Cushing's syndrome from ectopic ACTH
- Hypercalcemia from PTHrP secretion
Correct answer: Lambert-Eaton myasthenic syndrome
Lambert-Eaton myasthenic syndrome is associated with small cell lung cancer; proximal muscle weakness that improves with repetitive activity distinguishes it from myasthenia gravis.
Question 6: A 22-year-old woman presents with sudden-onset right lower quadrant pain that began periumbilically and migrated, anorexia, and a fever of 38.4°C. WBC is 14,200/μL with a left shift. Which physical exam finding most supports the diagnosis of acute appendicitis?
- Murphy's sign — inspiratory arrest with RUQ palpation
- Rovsing's sign — RLQ pain with LLQ palpation (Correct answer)
- Cullen's sign — periumbilical ecchymosis
- Grey Turner's sign — flank ecchymosis
Correct answer: Rovsing's sign — RLQ pain with LLQ palpation
Rovsing's sign is positive when palpation of the left lower quadrant produces pain in the right lower quadrant, suggesting peritoneal irritation at the appendix.
Question 7: A 55-year-old woman with rheumatoid arthritis on methotrexate 20 mg/week presents for routine follow-up. She is asymptomatic. Which laboratory monitoring is required?
- Serum uric acid and urinalysis every 6 months
- CBC, hepatic function panel, and creatinine every 4–8 weeks (Correct answer)
- Thyroid function tests annually
- Fasting lipid panel and glucose every 3 months
Correct answer: CBC, hepatic function panel, and creatinine every 4–8 weeks
Methotrexate requires regular CBC and liver function monitoring due to risks of bone marrow suppression and hepatotoxicity.
NP Case Studies & Practical Application 4
A 26-year-old woman presents requesting contraception.
She has migraines with aura, smokes 10 cigarettes/day, and has a family history of DVT.
Which contraceptive method is most appropriate?