AAFP Random 12 – Flashcards

E. Isosorbide/hydralazine (BiDil). In patients with systolic heart failure, the usual management includes an ACE inhibitor and a ß-blocker. Since this patient had angioedema with an ACE inhibitor, an angiotensin receptor blocker may cause this side effect as well. Adding metolazone is generally not necessary unless the patient has volume overload that does not respond to increased doses of furosemide. Digoxin may improve symptoms, but has not been shown to increase survival. For patients who cannot tolerate an ACE inhibitor, especially African-Americans, a combination of direct-acting vasodilators such as isorbide and hydralazine is preferred.Verapamil has a negative inotropic effect and should not be used.

D. hip fracture. Women older than 65 years of age who have low serum TSH levels, indicating physiologic hyperthyroidism, are at increased risk for new hip and vertebral fractures. Use of thyroid hormone itself does not increase the risk of fracture if TSH levels are normal.

A. Intravenous drug use. A young man with weight loss, oral thrush, lymphadenopathy, and ulcerative esophagitis is likely to have HIV infection. Intravenous drug use is responsible for over a quarter of HIV infections in the United States. Esophageal disease develops in more than half of all patients with advanced infection during the course of their illness. The most common pathogens causing esophageal ulceration in HIV-positive patients include Candida, herpes simplex virus, and cytomegalovirus. Identifying the causative agent through culture or tissue sampling is important for providing prompt and specific therapy.

D. Topical mupirocin (Bactroban). The lesions described are nonbullous impetigo, due to either Staphylococcus aureus or Streptococcus pyogenes. Topical antibiotics, such as mupirocin, but not compounds containing neomycin, are the preferred first-line therapy for impetigo involving a limited area. Oral antibiotics are widely used, based on expert opinion and traditional practice, but are usually reserved for patients with more extensive impetigo or with systemic symptoms or signs. Penicillin V and hexachlorophene have both been shown to be no more effective than placebo. Topical antibiotics have been shown to be as effective as erythromycin, which has a common adverse effect of nausea.

E. Expectant management. The purpose of obstetric management of preterm labor before 34 weeks gestation is to allow time to administer corticosteroids. Treatment does not substantially delay delivery beyond 1 week. Repeated administration of corticosteroids does not confer more benefit than a single course. Antibiotics are administered for prophylaxis of group B Streptococcus and are useful for delaying delivery if membranes are ruptured. They do not add any benefit otherwise, even though subclinical amnionitis may be a causative factor in many cases of preterm labor. Prolonged and repeated tocolysis is believed to be harmful. Tocolysis would not be indicated in this patient because she has had no cervical change and is therefore having preterm contractions, not preterm labor. Careful monitoring for fetal compromise, consultation with obstetric colleagues, and neonatal intensive-care unit involvement should be part of expectant management of preterm labor cases.

A. Fluoxetine (Prozac). SSRIs have been shown to benefit children and adolescents with depression, but there are concerns regarding their association with suicidal behavior. Fluoxetine seems to be the most favorable SSRI, and is the only one recommended by the FDA for treatment of depression in children 8-17 years old. There is limited or no evidence to support the use of lithium, venlafaxine, or St. John's wort in children and adolescents. Amitriptyline and other tricyclic antidepressants are ineffective in children and have limited effectiveness in adolescents, and safety is an issue in both of these groups.

A. along the medial border of each scapula. The typical fibromyalgia trigger points lie along the medial scapula borders, as well as the posterior neck, upper outer quadrants of the gluteal muscles, and medial fat pads of the knees. Tenderness of the anatomic snuffbox, Achilles tendons, or web spaces of the toes would most likely be related to another diagnosis.

C. Intralesional triamcinolone (Kenalog). These findings are consistent with alopecia areata, which is thought to be caused by a localized autoimmune reaction to hair follicles. It occasionally spreads to involve the entire scalp (alopecia totalis) or the entire body (alopecia universalis). Spontaneous recovery usually occurs within 6-12 months, although areas of regrowth may be pigmented differently. Recovery is less likely if the condition persists for longer than a year, worsens, or begins before puberty. The initial treatment of choice for patients older than 10 years of age, in cases where alopecia areata affects less than 50% of the scalp, is intralesional corticosteroid injections. Minoxidil is an alternative for children younger than 10 years of age or for patients in whom alopecia areata affects more than 50% of the scalp. While topical immunotherapy is the most effective treatment for chronic severe alopecia areata, it has the potential for severe side effects and should not be used as a first-line agent. Finasteride inhibits 5 ß-reductase type 2, resulting in a decrease in dihydrotestosterone levels, and is used in the treatment of androgenic alopecia (male-pattern baldness). Similarly, spironolactone is sometimes used for androgenic alopecia because it is an aldosterone antagonist with antiandrogenic effects.

C. azithromycin (Zithromax). In a young adult with community-acquired pneumonia who is not sick enough to be hospitalized, the current recommendation is to empirically treat with a macrolide antibiotic such as azithromycin. This covers the atypical organism Mycoplasma pneumoniae, which is one of the most common causes of community-acquired pneumonia. Certain fluoroquinolones such as levofloxacin also cover atypical causes, but ciprofloxacin does not. The other antibiotics listed are also ineffective against Mycoplasma.

C. Diabetes mellitus. Diabetes mellitus and cigarette smoking are significant risk factors for intermittent claudication, as are hypertension and dyslipidemia. Hyperthyroidism, hypercalcemia, and hypogonadism are not closely associated with intermittent claudication. Elevation of angiotensin-converting enzyme occurs with sarcoidosis.

A. Combining these medications has not proven to be beneficial. Varenicline works by binding to nicotine receptors in the brain, providing much lower stimulation than nicotine itself would. This has the effect of reducing the reinforcement and reward that smoking provides to the brain. However, this medication also blocks the benefit a patient would receive from nicotine replacement products. Studies have shown that using nicotine replacement products concurrently with varenicline leads to an increase in nausea, headaches, dizziness, and fatigue.

B. Hypoglycemia. Metformin is a biguanide used as an oral antidiabetic agent. One of its main advantages over some other oral agents is that it does not cause hypoglycemia. Lactic acidosis, while rare, can occur in patients with renal impairment. In contrast to most other agents for the control of elevated glucose, which often cause weight gain, metformin reduces insulin levels and more frequently has a weight-maintaining or even a weight loss effect. Gastrointestinal distress is a common side effect of metformin, particularly early in therapy.

A. Adolescents. Patients attempting to conceive are not candidates for conservative management of cervical dysplasia, because treatment of progressive disease during pregnancy may be harmful. When possible, the problem should be resolved before conception. Patients who have had three normal Papanicolaou (Pap) smears in succession are candidates for lengthened screening intervals according to some recommendations. However, once a problem is found, they should be managed the same as other cases. A negative test for HPV can be used to assess the risk of patients with atypical squamous cells of undetermined significance (ASC-US) or a low-grade squamous intraepithelial lesion (LSIL); it does not change the management of patients with a high-grade intraepithelial lesion (HSIL). HPV infection is common and transient in most young women in their first few years of sexual activity. With careful follow-up, they can be observed rather than treated for HSIL. Patients over 70 years of age no longer require screening if they have a long history of normal Pap smears, but when an abnormality is found it should be treated.

E. Hypotension, bradycardia, and hypothermia. Characteristic vital signs in patients with severe anorexia nervosa include hypotension, bradycardia, and hypothermia. Criteria for hospital admission include a heart rate <40 beats/min, blood pressure <80/50 mm Hg, and temperature <36°C (97°F). Increased cardiac vagal hyperactivity is thought to cause the bradycardia.

D. Her risk of developing esophageal adenocarcinoma is <1%. The actual risk of adenocarcinoma from Barrett's esophagus is less than 1%. Endoscopy does nothing to reduce the risk of death. Patients with Barrett's esophagus can have minimal symptoms.

D. Cluster headache. Cluster headache can be removed from the differential because it is always unilateral, although the affected side can vary. The remainder of these headache types can be bilateral, frontal, and nonthrobbing. Brain tumor headaches may be similar in character to previous headaches, but are often more severe or frequent.

A. Assisting flight attendants with the care of a fellow passenger who develops respiratory distress while in flight over the United States. Generally, Good Samaritan laws apply to situations in which the physician does not have a preexisting duty to provide care to the patient. A physician who volunteers as a standby health care provider at an event assumes a duty to care for illness or injury in the participants. Likewise, physicians have a duty to provide emergency care to a person in need within a facility where they are working, such as a medical office or an emergency department. On an airplane, there is no preexisting duty for a physician to attend to a fellow passenger who becomes ill. In addition, a specific federal law, the Aviation Medical Assistance Act, ensures that physicians have Good Samaritan protection if they provide medical assistance while in flight over the United States.

B. Oral terbinafine (Lamisil) daily for 12 weeks. Continuous therapy with oral terbinafine for 12 weeks has the highest cure rate and best long-term resolution rate of the therapies listed. Other agents and pulsed dosing regimens have lower cure rates. Topical creams are not appropriate for onychomycosis because the infection resides in the cell of the toenail. Antifungal nail lacquers have a lower cure rate than systemic therapy and should be used only when oral agents would not be safe. Toenail removal is reserved for patients with an isolated infected nail or in cases involving a dermatophytoma.

E. Olanzapine (Zyprexa). Second-generation, or "atypical," antipsychotics are associated with weight gain, elevated triglycerides, and type 2 diabetes mellitus. Olanzapine and clozapine are associated with the highest risk. Clonazepam, a benzodiazepine, does not share these risks. Thioridazine and chlorpromazine are first-generation antipsychotics, and carry less risk of these side effects. Aripiprazole, although it is a second-generation antipsychotic, has been found to cause weight gain and metabolic changes similar to those seen with placebo.

A. No testing. This patient is at risk for lung cancer, even with no symptoms. He should be encouraged to stop smoking, especially if he has concerns that may help motivate him to quit. No study has demonstrated that screening with any of the tests listed improves survival, and no major organization endorses lung cancer screening.

B. Order a chest film and EKG. This patient has pleuritic chest pain, and the fact that it is worse when supine and is accompanied by dyspnea creates additional concern. Supine pain could be due to pericarditis, which may be evident on an EKG. Dyspnea increases suspicion for pneumonia, pulmonary embolism, pneumothorax, and myocardial infarction, and a chest film and EKG are recommended to evaluate these possibilities. The lack of any significant medical history does not rule out any of these problems. Once these problems have been ruled out, a diagnosis of pleurisy would be reasonable and can be treated with an NSAID. A CBC would only indicate the possibility that infection or anemia is the cause of the problem. Omeprazole or a bronchodilator would be inappropriate treatment, as asthma and reflux are not likely in this patient.

B. BNP. This patient has heart failure with a bronchospastic component. The S3 gallop occurs with a dilated left ventricle and a right-sided pleural effusion, which are common in heart failure. A BNP level is useful in differentiating cardiac and pulmonary diseases, while a troponin I level is helpful in assessing for cardiac ischemia. Arterial blood gasses are not useful in confirming the diagnosis. A CT angiogram of the chest would be useful for diagnosing pulmonary embolism. A d-dimer test is helpful to rule out venous thromboembolic disease.

C. 75% of patients who test positive actually have breast cancer. Positive predictive value refers to the percentage of patients with a positive test for a disease who actually have the disease. The negative predictive value of a test is the proportion of patients with negative test results who do not have the disorder. The percentage of patients with a disorder who have a positive test for that disorder is a test's sensitivity. The percentage of patients without a disorder who have a negative test for that disorder is a test's specificity.

B. Nifedipine (Procardia). At present there is no approved treatment for Raynaud's disease. However, patients with this disorder reportedly experience subjective symptomatic improvement with calcium channel antagonists, with nifedipine being the calcium channel blocker of choice. -Blockers can produce arterial insufficiency of the Raynaud type, so propranolol and atenolol are contraindicated. Drugs such as ergotamine preparations and methysergide can produce cold sensitivity, and should therefore be avoided in patients with Raynaud's disease.

A. Allopurinol (Zyloprim). All of the treatments listed are commonly used in the management of gout with good success. Allopurinol decreases the production of uric acid and is effective in reducing the frequency of acute gouty flare-ups. However, it should not be started during an acute attack since fluctuating levels of uric acid can actually worsen inflammation and intensify the patient's pain and swelling. Colchicine inhibits white blood cells from enveloping urate crystals and is effective during acute attacks, as are NSAIDs such as indomethacin. Corticosteroids such as prednisone are also considered a first-line treatment for acute attacks. Compression as an adjunctive therapy may help control pain and swelling.

C. Continuing low molecular weight heparin for 6 more weeks. The risk of pulmonary embolism continues in the postpartum period, and may actually increase during that time. For patients who have had a deep-vein thrombosis during pregnancy, treatment should be continued for 6 weeks after delivery, with either warfarin or low molecular weight heparin.

A. Metformin (Glucophage). Metformin and insulin are the only agents approved for treatment of type 2 diabetes mellitus in children.

A. Post-event confusion. Up to 20% of patients diagnosed with epilepsy actually have pseudoseizures. Eye closure throughout the event is uncommon in true seizures, and a history of fibromyalgia or chronic pain syndrome is predictive of pseudoseizures. If obtained within 20 minutes of the event, a serum prolactin level may be useful in differentiating a true seizure from a pseudoseizure. An elevated level has a sensitivity of 60% for generalized tonic-clonic seizures and 46% for complex partial seizures. Other features suggestive of seizure activity include tongue biting, the presence of an aura, postictal confusion, and focal neurologic signs.

B. Double effect. The concept of "double effect" dates back to the Middle Ages. It is used to justify medical treatment designed to relieve suffering when death is an unintended but foreseeable consequence. It is based on two basic presuppositions: first, that the doctor's motivation is to alleviate suffering, and second, that the treatment is appropriate to the illness. Distributive justice relates to the allocations of resources. Death with dignity is a recently introduced concept and is not a factor in the scenario described here. Futility refers to using a treatment for which there is no rational justification. Autonomy refers to the patient's ability to direct his or her own care,which is n ot an issue in this case.

D. Institute an intensive program of good hand washing for all employees. Nosocomial infections are a significant factor in morbidity and cost in the health care field. Methicillinresistant Staphylococcus aureus (MRSA) has rapidly increased in frequency, first being found only at tertiary centers, then local hospitals, and now in the outpatient setting. In 2004, an estimated 1.5% of U.S. residents carried MRSA in the anterior nares of the nose. Of those who are found to be colonized, either at the time of hospitalization or later by a routine culture, 25% will develop a MRSA infection. However, a recent study showed that of 93 patients who became infected with the organism, 57% were not colonized at the time of infection. The study also attempted to screen all patients for MRSA on admission, but found that even though 337 previously unknown carriers were found (in addition to those already known to harbor the organism), there was not a significant decrease in the rate of MRSA infections during the study. Although MRSA infections can be serious, they comprise only 8% of nosocomial infections in the hospital, and concentrating prevention efforts only on MRSA has little effect on that 8%, and no effect on the 92% of infections caused by other organisms. Iatrogenic complications arise from trying to treat MRSA carriers, including both drug reactions and the development of other resistant organisms. Costs related to attempts at prophylaxis also go up. Culturing all hospital employees has not been proven to be of value, as employees can pick up the organism after screening, and also can spontaneously eradicate the organism without treatment. The best way to prevent complications and postoperative infections is to aggressively advocate universal and frequent hand washing and room cleaning, and use good isolation techniques and methods of preventing infection, such as strict catheter and intravenous tubing protocols.

E. No specific additional testing. Persons younger than 30 years of age who excrete less than 2 g of protein per day and who have a normal creatinine clearance should be tested for orthostatic proteinuria. This benign condition occurs in about 3%-5% of adolescents and young adults. It is characterized by increased protein excretion in the upright position, but normal protein excretion when the patient is supine. It is diagnosed using split urine collections as described in the question. The daytime specimen has an increased concentration of protein, while the nighttime specimen contains a normal concentration. Since this is a benign condition with normal renal function, no further evaluation is necessary.

E. An EKG. The workup of patients with syncope begins with a history and a physical examination to identify those at risk for a poor outcome. Patients who have a prodrome of 5 seconds or less may have a cardiac arrhythmia. Patients with longer prodromes, nausea, or vomiting are likely to have vasovagal syncope, which is a benign process. Patients who pass out after standing for 2 minutes are likely to have orthostatic hypotension. In most cases, the recommended test is an EKG. If the EKG is normal, dysrhythmias are not a likely cause of the syncopal episode. Laboratory testing and advanced studies such as CT or echocardiography are not necessary unless there are specific findings in either the history or the physical examination.

C. Amoxicillin. The American Academy of Otolaryngology published guidelines for the diagnosis and management of rhinosinusitis in adults in 2007. They cite reasonable evidence for initiating antibiotic treatment in patients with symptoms persisting for 7-10 days that are not improving or worsening (SOR B). Amoxicillin should be the first-line agent, with azithromycin or trimethroprim/sulfamethoxazole recommended for penicillinallergic patients. Broader-spectrum antibiotics such as fluoroquinolones should be reserved for treatment failures. Imaging is indicated only if other etiologies are being considered or if the problem is recurrent.

D. Sustained-release bupropion (Wellbutrin SR) has been shown to reduce the relapse rate for up to 12 months. Sustained-release bupropion has been shown to reduce the relapse rate for smoking cessation and blunt weight gain for 12 months. Beneficial effects of smoking cessation are seen even among older smokers. Evidence has now shown that smokers who switch to low-tar or low-nicotine cigarettes do not significantly decrease their health risks. The approved Food and Drug Administration medications for smoking cessation (sustained-release bupropion, nicotine patch, nicotine gum, nicotine inhaler, and nicotine nasal spray) have been shown to be safe and should be recommended for all patients without contraindications who are trying to quit smoking. The nicotine patch in particular is safe, and has been shown not to cause adverse cardiovascular effects.

B. lead-time bias. Lead-time bias is when a screening test identifies a cancer earlier, thereby increasing the time between diagnosis and death without actually prolonging life. Length-time bias is when a screening test finds a disproportionate number of cases of slowly progressive disease and misses the aggressive cases, thereby leading to an overestimate of the effectiveness of the screening. A false-positive test is one that suggests cancer when no cancer exists. The positive predictive value is the proportion of positive test results that are true positives. Attributable risk is the amount of difference in risk for a disease that can be accounted for by a specific risk factor.

D. Serologic testing for celiac sprue. In patients who have symptoms of irritable bowel syndrome (IBS), the differential diagnosis includes celiac sprue, microscopic and collagenous colitis, atypical Crohn's disease for patients with diarrhea-predominant IBS, and chronic constipation (without pain) for those with constipation-predominant IBS. If there are no warning signs, laboratory testing is warranted only if indicated by the history.

A. Observation, with repeat evaluation in 1 year. Watchful waiting with annual follow-up is appropriate for men with mild benign prostatic hyperplasia (BPH). Prostate-specific antigen (PSA) levels correlate with prostate volume, which may affect the treatment of choice, if indicated (SOR C). PSA levels >2.0 ng/mL for men in their 60s correlate with a prostatic volume >40 mL. This patient's PSA falls below this level. In men with a prostatic volume >40 mL, 5 -reductase inhibitors should be considered for treatment (SOR A). -Blockers provide symptomatic relief in men whose disease has progressed to the point that they have moderate to severe BPH symptoms (SOR A). A recent high-quality, randomized, controlled trial found no benefit from saw palmetto with regard to symptom relief or urinary flow after 1 year of therapy. The American Urological Association does not recommend the use of phytotherapy for BPH. Surgical consultation is appropriate when medical therapy fails or the patient develops refractory urinary retention, persistent hematuria, or bladder stones.

C. Otosclerosis. Otosclerosis typically presents between the third and fifth decades, and is more common in women. The chief feature of otosclerosis is a progressive conductive hearing loss. Occasionally, when lesions impinge on the stapes footplate, a sensorineural loss may occur. All of the other choices are exclusively sensorineural in character. Meniere's disease also causes fluctuating hearing loss. Noise-induced hearing loss frequently and characteristically is accompanied by tinnitus. Perilymphatic fistula is associated with sudden unilateral hearing loss with tinnitus and vertigo. Acoustic neuroma is associated with tinnitus and gradual hearing impairment.

E. Spinal cord injury. There are many risk factors for thromboembolism, including polycythemia vera, oral contraceptive use, obesity, advanced age, and spinal cord injury. Spinal cord injury induces immobility, as do obesity and advanced age. Oral contraceptives make blood more coagulable, particularly in patients with clotting factor abnormalities such as factor V Leiden. Polycythemia vera increases sludging of blood cells and increases the risk of forming clots. Clot risk is not increased by oral hypoglycemic agents, low BMI, youth, or anemia.

C. Outpatient observation with a repeat chest radiograph in 24 hours is indicated. The majority of patients presenting with spontaneous pneumothorax are tall, thin individuals under 40 years of age. Most do not have clinically apparent lung disease, and the chest pain is sometimes minimal at onset and may resolve within 24 hours even if untreated. Patients with small pneumothoraces involving less than 15% of the hemithorax may have a normal physical examination, although tachycardia is occasionally noted. The diagnosis is confirmed by chest radiographs. Studies of recurrence have found that an average of 30% of patients will have a recurrence within 6 months to 2 years. The treatment of an initial pneumothorax of less than 20% may be monitored if a patient has few symptoms. Follow-up should include a chest radiograph to assess stability at 24-48 hours. Indications for treatment include progression, delayed expansion, or the development of symptoms. The majority of patients with spontaneous pneumothoraces, and perhaps almost all of them, will have subcutaneous bullae on a CT scan.

C. Inability to take four steps either immediately after the injury or while in your office. The Ottawa ankle rules have been designed and validated to reduce unnecessary radiographs. Radiographs should be obtained for all patients with an acute ankle injury who meet any of the following criteria: inability to take four steps, either immediately after the injury or when being evaluated; localized tenderness of the navicular bone or the base of the fifth metatarsal; or localized tenderness at the posterior edge or tip of either malleolus.

C. pH 7.50, pCO2 25 mm Hg, pO2 100 mm Hg. Anxiety, shortness of breath, paresthesia, and carpopedal spasm are characteristic of psychogenic hyperventilation. Respiratory alkalosis secondary to hyperventilation is diagnosed when arterial pH is 2 elevated and pCO is depressed. Low pH is characteristic of acidosis, either respiratory or metabolic, and 2 elevated pH with elevated pCO is characteristic of metabolic alkalosis with respiratory compensation.

A. High-rate intravenous normal saline. This patient appears to be experiencing sepsis syndrome due to urinary infection. The renal failure that has resulted is almost certainly due to low perfusion of the kidneys (prerenal azotemia). This condition requires aggressive intravenous fluids to halt and reverse the reduction in nephrologic function. At times, this underperfusion can result in acute tubular necrosis (an intrinsic renal dysfunction) that may prevent excretion of any excess fluid, so the patient's fluid status should be monitored carefully. Metabolic acidosis will likely reverse with appropriate hydration, and sodium bicarbonate should be reserved for severe acidosis (<10-15 mmol/L) or for those with chronic kidney disease. Low-dose dopamine has been proven to be ineffective in acute renal failure, and this patient does not have an indication for dialysis. Intravenous furosemide is contraindicated.

C. Lifestyle modification and metformin (Glucophage). This patient has classic features of polycystic ovary syndrome (PCOS). The diagnosis is based on the presence of two of the following: oligomenorrhea or amenorrhea, clinical or biochemical hyperandrogenism, or polycystic ovaries visible on ultrasonography. Lifestyle modifications are necessary, but medications are also needed. First-line agents for the treatment of hirsutism in patients with PCOS include spironolactone, metformin, and eflornithine (SOR A). Firstline agents for ovulation induction and treatment of infertility in patients with PCOS include metformin and clomiphene, alone or in combination with rosiglitazone (SOR A). Metformin can also improve menstrual irregularities in patients with PCOS (SOR A), and is probably the first-line agent for obese patients to promote weight reduction (SOR B). In addition, metformin improves insulin resistance (diagnosed by elevated fasting blood glucose) in patients with PCOS, as do rosiglitazone and pioglitazone. Pioglitazone would not be appropriate for this patient because it causes weight gain. Oral contraceptives would improve the patient's menstrual irregularities and hirsutism, but she wishes to become pregnant. Testosterone would worsen the hyperandrogenism and would not treat the PCOS.

E. Levofloxacin (Levaquin). The major concern with regard to pneumonia in the nursing-home setting is the increased frequency of oropharyngeal colonization by gram-negative organisms. In the absence of collectible or diagnostic sputum Gram's stains or cultures, empiric therapy must cover Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenzae, and gram-negative bacteria. Levofloxacin is the best single agent for providing coverage against this spectrum of organisms.

C. Electroconvulsive therapy. Electroconvulsive therapy has been shown to be more effective than psychiatric therapy, pharmacologic therapy, and other interventions in depressed older patients. It would be particularly appropriate in this case given the patient's age, his failure to respond to medications, and the need for rapid improvement to decrease the risk of further suicide attempts.

A. Continuous positive airway pressure (CPAP). Patients with severe sleep apnea (apnea-hypopnea index >29) and concomitant cardiovascular disease benefit the most from treatment for obstructive sleep apnea. Because it is relatively easy to implement and has proven efficacy, continuous positive airway pressure (CPAP) is considered first-line therapy for severe apnea.

A. Withdraw the ventilator as requested. Competent adult patients have the right to refuse any medical intervention, even if forgoing this treatment may result in their death. Legally and ethically it does not matter whether the patient requests that care be withheld before it is started or that it be withdrawn once it is begun. All states currently allow competent patients to legally designate a health-care proxy to make these decisions for them if they become unable to communicate or are no longer competent to decide for themselves. The patient in this example has instituted such a legal advance directive and his proxy's request should be respected as his own and the care withdrawn. If there were no advance directive the decision in this case would become more difficult, and might require a family conference or the involvement of an ethics committee. A patient's condition does not need to be terminal or irreversible to allow the removal of life-sustaining therapy. Legal involvement is rarely required in situations where advance directives are already available and valid.

C. Topiramate (Topamax). Treatments likely to be beneficial for essential tremor of the hands include propranolol and topiramate. Topiramate has been shown to improve tremor scores after 2 weeks of treatment, but is associated with appetite suppression, weight loss, and paresthesias. Medications with unknown effectiveness include benzodiazepines, -blockers other than propranolol, calcium channel blockers, clonidine, gabapentin, and isoniazid.