1.

Even though it is not common, a new pleural effusion in a patient already on anti-tuberculosis treatment may occur and must be studied, because this can progress despite the clinical improvement of the patient. There is no need to change therapy, unless there is proof of a new infection or drug resistance. Some authors advocate the use of steroids in this setting, but this is not a universally accepted practice. There have been reported cases of new pleural effusions or lung infiltrates during the course of treatment of tuberculosis in patients who are recovering from the disease. The new effusions are usually exudates with lymphocytic predominance. Granulomatous lesions can be found on biopsies, but AFBs are not usually present. Thoracentesis is usually sufficient for diagnostic and therapeutic purposes. It is extremely rare to find new evidence of tuberculosis, as this new effusion is usually an enhanced immunologic response. It is not an indicator of failure of therapy or drug toxicity. If the patient is having systemic symptoms (such as ongoing fever, weight loss, etc.), a bacterial infection or empyema could be suspected, prompting the need for broad-spectrum antibiotic coverage, and maybe even chest tube placement 2. The consumption of undercooked meat during pregnancy may be associated with congenital toxoplasmosis, which can manifest as microcephaly or other abnormalities, such as chorioretinitis, MR, deafness, & seizures Domestic cats are definite hosts for T. gondii Humans can acquire the infection by: (1) the consumption of raw or undercooked meat of infected animals (including lamb, beef, or game), or (2) contact with cat feces Other congenital infections of the TORCH group can also result in microcephaly Asymmetric growth retardation (normal weight, decreased head circumference) is not characteristic for poor infant feeding Maternal smoking during pregnancy is associated with low-birth-weight infants, not microcephaly Excessive maternal caffeine consumption during pregnancy seems to be associated with an increased risk of spontaneous abortion and stillbirth Vast experience with the use of methyldopa & magnesium sulfate (for the treatment of PIH and preeclampsia) indicates that these drugs are unlikely to be associated with long-term adverse outcomes 3. Rupture of chordae tendineae should be suspected in healthy individuals who develop flash pulmonary edema (heart failure) associated with an acute mitral regurgitation. The patient presents with signs and symptoms of acute heart failure (sudden onset of shortness of breath, diaphoresis, Pallor). His EKG findings reveal occasional PVC; there are no signs of ischemia or ventricular hypertrophy. His pathologic murmur (systolic murmur that is heard in the apex, radiates to the axilla, increases with the grip maneuver, and decreases with Valsalva) is characteristic of mitral regurgitation, which may lead to acute heart failure. Acute MR is usually characterized by a soft, decrescendo systolic murmur (can be early, midsystolic or holosystolic), a decreased first heart sound, and the presence of a fourth heart sound. The 4 common causes of acute heart failure are papillary muscle rupture secondary to ischemia, infective endocarditis, rupture of chordae tendineae, and chest wall trauma secondary to mitral valve rupture. The most common cause of isolated, severe acute mitral regurgitation in adults is rupture of chordae tendineae with or without associated myxomatous disease. The diagnosis is confirmed by echocardiography. Myocardial infarction can be complicated by acute mitral regurgitation when there is rupture of the papillary muscle; however, this patient does not have evidence of ischemia in the EKG. Patients with pulmonary embolism can develop acute cor pulmonale; however, in such a setting, the EKG will show right axis deviation, right bundle branch block or both. The above patient clearly has acute pulmonary edema. Spontaneous papillary muscle rupture usually presents in elderly people who have acute chest pain or as a complication of MI. None of these are present here. The patient has features compatible with Ehlers-Danlos syndrome. This condition can cause a myxomatous degeneration of the mitral valve, leading to acute rupture of chordae tendineae. Pes planus and scoliosis are frequent, though not specific findings. The skin can be velvety or thin, and is usually covered with multiple characteristic "cigarette-paper" scars, due to its frailty and easy

bruisability. A past history of hernias and mitral valve prolapse is not uncommon. Joint hypermobility and skin hyperextensibility ("rubber man syndrome") can be dramatic in severe cases. Thyrotoxicosis can lead to acute, high-output, heart failure; however, this will not explain the MR. Skin changes of thyrotoxicosis can be confounded with those found in Ehlers-Danlos, but other characteristic signs & symptoms are lacking. Rheumatic fever is a common cause of mitral regurgitation in young individuals; however, the course of the disease is chronic, and the patients usually have evidence of left ventricular and atrial hypertrophy in the EKG. Marfan syndrome can affect the valvular apparatus, causing degeneration of the mitral & aortic valves. The presentation is usually chronic, progressive MR, and rarely, acute regurgitation due to ruptured chordae tendineae. This patient does not have arachnodactyly, loose joints or increased arm span, which are characteristic of Marfan syndrome. Educational Objective: Marfan or Ehlers-Danlos syndrome must be suspected in patients with connective tissue abnormalities and an acute MR secondary to chordae tendineae rupture, although a primary, pre-existing mitral valve prolapse (MVP) is the most common cause. Some cases may be idiopathic (individuals who experience rupture of the chordae tendineae without previous MVP or connective tissue disease), but an etiology can be found in most occasions. 4. Organ transplantation from cadaveric donors has become increasingly common in the past few years. Most of the organs are obtained from brain dead donors. The successful recovery of viable organs for transplantation depends on appropriate identification and medical care of brain dead patients. It also depends on the speed of recovery of the organs from the potential donors, with a shorter time interval between brain death and organ recovery leading to better outcomes. Any delay in organ procurement leads to an increase in the number and severity of complications; therefore, this patient should be immediately transferred to a specialized transplant center. Brain dead organ donors should ideally be managed in an intensive care setting. The goal of intensive medical care is to achieve hemodynamic stability and maintain physiologic homeostasis to improve the viability of the organs. Particular attention should be paid to maintain a normotensive and euvolemic state. One of the goals is to provide optimal ventilator support to prevent hypoxia and hypercapnia. Completely discontinuing or changing the ventilator setting is not appropriate when the patient is hemodynamically stable. Hypotension is very common in brain dead patients. It is related to the loss of sympathetic tone, systemic infections, volume depletion secondary to losses and diabetes insipidus. Adequate volume resuscitation is therefore an important step in ensuring donor organ viability. IV hydration should be continued to maintain euvolemia and an adequate urine output. Waiting for a cardiac arrest before procuring the organs is not the standard of care, and is not recommended. Educational Objective: Coordination of care between the different teams involved in organ procurement is a crucial step in the management of brain dead organ donors. 5. This patient is deeply demented, completely dependent on others for her care, and is most likely developing pneumonia. Her current condition has made her incapable of making any decisions regarding her health. She needs a surrogate decision-maker to speak on her behalf, and to preserve her right of autonomy. Her son seems to be the most appropriate person for this position, as he is the only direct relative who is constantly visiting her. The physician must always consider the patient’s clinical picture and prognosis, and respect the opinion of the surrogate decision-maker. Although it is very unusual, dementia can be an indicator of a terminal condition, and aspiration pneumonia commonly presents towards the last episodes of the disease. If the patient or surrogate feels that no further therapy should be given since the disease is non-reversible, and because the patient’s quality of life is poor, the physician has no right to give further treatment. In this case, the physician has to respect the son’s request that his mother receive only oxygen therapy Studies have shown that it is safe to treat elderly patients with pneumonia in a nursing home if they are not critically ill. However, this patient should be transferred to the hospital if her son wants her to be treated with antibiotics and full supportive care. Pain treatment may eventually be needed if the shortness of breath does not improve with oxygen therapy; however, it is not indicated at this point. It is the physician’s duty to always act in the patient’s best interest. In this case, he may at least alleviate the patient’s pain and give comfort, despite the seriousness of the disease. It is unethical to

do nothing even when the patient’s prognosis or quality of life is poor. Giving oxygen therapy is the most appropriate next step in management because aside from this step being requested by the surrogate, doing so may control the patient’s symptoms. Giving antibiotics to the patient may indicate the physician’s inattention and lack of regard for the family (or surrogate’s) decision Educational Objective: Severely demented patients in nursing homes have a poor quality of life and can be viewed as individuals who are in the terminal phase of a prolonged and debilitating illness. The physician has no right to give or withhold potential life-saving measures based on only his own values, personal evaluation, or opinion of what the acceptable quality of life is. Decisions regarding the treatment of acute and life-threatening conditions have to be made with the surrogate, who acts to preserve the patient’s right to autonomy. On the other hand, the physician cannot be forced to provide unnecessary therapy only because the surrogate of relatives request so. 6. Studies have shown that adolescents in a private practice setting are very concerned about the prospect of gaining weight secondary to OCP use. However, available data has demonstrated that OCPs do not cause an increase in body weight or percent body fat. Occasionally adolescents voice other concerns about OCP use, including fears of developing blood clots, birth defects, & infertility, but these concerns are more common in the lower socioeconomic groups. Confidentiality concerns, cost, desire to have children, and partner’s opposition are rarely cited by adolescents as reasons not to use OCPs 7. Physicians are often faced with difficult scenarios involving the withdrawal of life-sustaining treatment. The situation may arise when a patient is rendered incompetent or is unable to participate in decision-making, and does not have any advance directives. In such situations, the physician must still recognize and respect the patient’s autonomy and right to make healthcare decisions. It is the physician’s responsibility to act in the patient’s best interest by identifying a surrogate who must make healthcare decisions for the patient based on substituted judgment. The surrogate speaks on the patient's behalf, and must have the most knowledge on what the patient would have done or wanted if he were able to make his own healthcare decisions. The patient’s spouse or next of kin usually acts as the surrogate decision-maker in the absence of a formally or legally designated surrogate. The patient’s son appears to have some insight into his father’s wishes when he claimed that "he would have never wanted to live like this." The patient may have previously expressed his wishes regarding life-sustaining treatment to his son. The son should therefore be asked to provide more information and reasoning behind the decision to withdraw mechanical ventilation at this point. Telling the son that mechanical ventilation cannot be discontinued without an advance directive is incorrect. The son can assume the role of surrogate decision-maker as long as the physician believes that he is acting in the patient’s best interest. The physician should discuss the situation with the son in greater detail before involving the family. Understanding the reason and thoughts behind the son's opinion should be attempted to ascertain if he can act as the patient's surrogate decision maker. Once a surrogate is identified, the decision to withdraw or maintain ventilatory support can then be made. Important: Before making any decisions regarding the withdrawal of life support measures, it is important for a physician to act in the patient's best interest by identifying a surrogate, with whom he must effectively communicate and discuss all issues and concerns. Quite frequently, a physician is faced with a situation wherein multiple first-degree relatives cannot agree on the approach to medical care, despite appropriate and adequate counseling. In such cases of conflict, the hospital’s ethics committee should be involved to act as a mediator between the different family members. In extreme cases, the case may need to be taken to court, where a guardian is appointed to assist in the medical decision-making. All the family members should be involved in the decision-making process regarding the withdrawal of mechanical ventilation. Important: The hospital ethics committee should be involved if a conflict exists between multiple family members regarding the appropriate approach to the patient's medical care despite adequate mediation by the physician.

8. Analgesic nephropathy is seen in patients with heavy, long-term use of aspirin, phenacetin, acetaminophen or other nonsteroidal antiinflammatory drugs. Cumulative amounts of analgesics play a very significant role in the pathophysiology of analgesic nephropathy. Chronic necrosis of the renal papilla with calcification is typically seen. Acute papillary necrosis can also occur and lead to acute renal colic. Urine examination reveals hematuria, proteinuria, and pyuria. The urine culture is usually sterile. The associated anemia is out of proportion to the renal failure, & this is possibly due to GI blood loss. Discontinuation of the analgesic causes stabilization or even improvement in renal function Patients with pyelonephritis have renal colic, but the presentation is not sudden. Fever & dysuria are also commonly observed with this disease A unilateral ureteric calculus will not lead to an increase in the BUN & Creatinine levels Prerenal azotemia is associated with a decrease in renal perfusion and an increase in the BUN level > creatinine; the urine specific gravity is high. Allergic interstitial nephritis characteristically produces azotemia, skin rashes, and eosinophilia. Urine eosinophils can be detected by using Hansel’s stain 9. Annual screening for prostate cancer should be performed between the ages of 50 and 70 using digital rectal examination and measurement of serum PSA levels; however, those with a higher risk for prostate cancer (i.e., African-Americans, those with a significant family history) should begin annual screening at 45 years of age

10. This patient presents with polyarticular joint pain of acute onset (< 6 weeks). The two important differential diagnoses that should be considered in patients with such a scenario are viral arthritis and early systemic rheumatic disease. Since the duration of the patient's symptoms is relatively short, and there exists a temporal relationship with an upper respiratory infection, viral arthritis should be the primary consideration. Rheumatoid arthritis (RA)-like symptoms with small joint involvement and a weakly positive RF test are especially characteristic for parvovirus infection. In this case, appropriate diagnostic tests should be ordered and the patient should be carefully followed-up RA is unlikely if there is no evidence of synovitis and the symptoms are of < 6 weeks duration (The hallmarks of synovitis include soft tissue swelling, warmth over a joint and joint effusion) SLE may be a possibility, but a more widespread symptomatology is usually more typical of this diagnosis. Furthermore, this patient does not fulfill the diagnostic criteria for SLE. Rheumatic fever occurs after streptococcal pharyngitis and may initially manifest with inflammatory joint disease, but involvement of the small joints is not common and joint involvement is migratory in nature. Sarcoidosis is a systemic disease that may have joint manifestations, but accompanying symptoms (e.g., pulmonary symptoms, erythema nodosum, neurological symptoms) are usually present. Viral arthritis is typically self-limited and of short duration. Therapy is generally directed at the relief of symptoms and maintenance of function; therefore, patients are treated with simple analgesic and anti-inflammatory drugs. Physical and occupational therapy may be employed if required to maintain or improve function Joint deformity is a very uncommon complication in these patients. Rheumatoid arthritis can cause significant joint deformities without appropriate long-term treatment. Joint deformities are less characteristic for other systemic diseases such as SLE and rheumatic fever, but involvement of other organs may be significant in these diseases 11. Assessment of immune status is important in patients with HIV infection in terms of susceptibility to various opportunistic agents and available options for treatment and prophylaxis. Currently, two indicators of disease progression in HIV patients are emphasized as important tools for the assessment of disease progression: viral load and CD4 count. CD4 lymphocyte count is an indicator of the current level of immunosuppression, and is referred to by some authors as, ‘the immunologic damage that has already occurred.' Viral load is a good marker of disease activity, or the potential for future damage to the immune system. It is referred to as ‘the damage that is about to occur.’

Therefore, plasma viral load has prognostic significance at any level of CD4 count in patients with HIV infection. Other than absolute CD4 lymphocyte count, CD4 percentage and CD4/CD8 ratio are sometimes used to assess immune status in patients with HIV infection, but these are less useful indicators. p24 and p41 antibodies are used as serological markers to diagnose HIV infection, but are not employed to assess the severity of the disease. 12. The patient in the vignette has a clinical presentation consistent with a partial small bowel obstruction. The presence of air in the distal colon makes the diagnosis of complete obstruction less likely. Partial small bowel obstruction should be initially managed with observation and supportive treatment (e.g., intravenous hydration, nasogastric suctioning and correction of electrolyte abnormalities). If the patient fails to improve in the next 12 to 24 hours, early surgical intervention is recommended. Patients with partial small bowel obstruction should be managed by conservative therapy initially before proceeding to invasive interventions; however, patients with signs of impending strangulation (incarcerated hernias) or mesenteric ischemia should undergo urgent surgical intervention to prevent further deterioration of the clinical status. Colonoscopy has no role in the management of patients with small bowel obstruction. A rectal tube is not indicated in patients with small bowel obstruction. 13. Lesbian women often conceal their sexual orientation from their primary care physicians. Recent developments and legislations regarding same sex marriages have encouraged more homosexual couples to "come forward" or reveal their sexual orientation. It is important for primary care physicians to be sensitive and knowledgeable to their special needs and concerns. Human papilloma virus (HPV) infection has been strongly linked with the development of cervical intraepithelial neoplasia (CIN) and cervical cancer. Sexual intercourse, especially with multiple new partners, is the main risk factor for the acquisition of HPV infection. The risk of acquiring HPV infection (and, hence, CIN/cervical cancer) is much lower in lesbian women if they do not engage in sexual intercourse with men. Transmission of HIV infection, though rare, can occur via exposure to cervical and vaginal secretions of an HIV-infected patient. Lesbian women have a lower risk of contracting syphilis and Chlamydia infections than heterosexual (women who have sex with men) or bisexual women (women who have sex with both men and women). Lesbian women should be given Hepatitis B vaccination. Although they are at much lower risk of acquiring hepatitis B infection than gay men, they can still acquire the infection via vaginal and cervical secretions, especially if they have multiple or new partners. 14. Central venous catheters are very commonly used in hospitalized patients and in outpatient settings. Catheter-related infections are a major complication of their prolonged use. Common clinical features include sudden onset of fever with chills, hypotension, altered mental status, and nonspecific GI symptoms. Local infection at the insertion site, exit site, or subcutaneous tunnel manifests as erythema, induration, and tenderness at the site, with pus coming out of the exit site. The general approach in treatment depends on a variety of factors - local vs. systemic infection, type of device used (tunneled vs. non-tunneled), the infecting organism, and the status of the host (immunocompromised or neutropenic). In the above vignette, suspicion of a systemic infection (fever, chills, with altered mental status) in an immunocompromised patient with a tunneled catheter (Hickman, Broviac, Groshong, or Quinton) as a suspected source warrants the removal of the catheter. The patient should also be started on empiric therapy with vancomycin (for gram positive organisms) and gentamicin (for gram negative bacilli). This should be continued until final microbiologic identification of the causative organism is obtained. The outcomes with central catheter-related infections are significantly affected by the speed of initiation of anti-microbial therapy. Waiting for laboratory data and culture results can lead to an inappropriate delay in treatment and can adversely affect clinical outcomes. The catheter tip should be sent for cultures after removal of the catheter; however, initiating empiric antibiotics remains as the priority. Rifampin with a fluoroquinolone has been used in some preliminary studies for Staphylococcus aureus infections, and there have been good results; however, these drugs should not be used as an empiric therapy for suspected infections.

Metastatic infections and complications are common in patients with Staphylococcus aureus infections. Examples include septic thrombophlebitis, infective endocarditis, osteomyelitis, and rarely, retinitis. The diagnosis is suspected by persistent bacteremia or unchanged clinical status despite adequate treatment. This patient appears to have developed vertebral osteomyelitis or diskitis (infection of the intervertebral disk space), which is a well-recognized complication of catheter-related systemic infections. It usually presents with an insidious onset of low back pain, local tenderness to spinal percussion, reduced back mobility, and spasm of nearby muscles. MRI is the investigative procedure of choice for vertebral osteomyelitis (highly sensitive in detecting vertebral osteomyelitis and/or diskitis). Typical MRI findings in vertebral osteomyelitis include decreased signal intensity in the disk and adjacent vertebral bodies, loss of endplate definition, contrast enhancement of the disk, adjacent vertebral bodies and involved paraspinal and paravertebral soft tissues. Finally, a CT-guided needle biopsy is generally necessary to confirm the clinical and/or radiographic suspicion of the presence of vertebral osteomyelitis or diskitis. Typical radiographic changes of vertebral osteomyelitis consist of destruction of the vertebral bodies with collapse of the intervening disk space. Plain radiographs are often normal in the early phases of infection. The appropriate therapy for vertebral osteomyelitis is to continue vancomycin alone for at least six weeks. Prolonged therapy (12 weeks) is usually required for patients with extensive bone destruction, adjacent soft tissue or paravertebral infection. Switching to linezolid or adding gentamicin is not recommended as long as the bacteria are susceptible to the drug. 15. An upright chest x-ray is the initial test of choice to confirm the diagnosis of pneumothorax. The accumulation of air occurs primarily in the apical and lateral regions when the patient is upright, and is usually seen as a convex white visceral pleural line on x-ray. As little as 50 ml of pleural gas can be visible on upright x-ray. It has been stated that an expiratory x-ray may significantly improve the rate of detection of pneumothorax; however, it has been shown that this statement is incorrect. As an example, one study of 85 patients with pneumothoraces and 93 controls found that inspiratory and expiratory upright chest radiographs have equal sensitivity for pneumothorax detection. Furthermore, considering the limitations of expiratory radiographs, only inspiratory films are recommended as the initial examination of choice for pneumothorax detection. A lateral decubitus chest x-ray may be used to look for a small pneumothorax, but it is not routinely employed as the initial test of choice. CT scan is not recommended for routine use, but may be helpful in selected cases (e.g., to distinguish between a large bulla and a pneumothorax) 16. Ampicillin-associated maculopapular rash is a well-known phenomenon in patients with infectious mononucleosis. The reported incidence of this reaction is as high as 80%. It is believed that this vasculitic rash is immune-mediated, and is caused by circulating IgG and IgM antibodies toward penicillin derivatives. Such antibodies have actually been demonstrated in patients with EBVassociated infectious mononucleosis. The rash does not represent immediate or delayed hypersensitivity to ampicillin, which can be used safely when the infection subsides. Supportive treatment and observation are the mainstays of treatment for individuals with infectious mononucleosis. Supportive treatment includes acetaminophen and NSAIDs for fever, throat pain and malaise, as well as adequate nutrition, fluids, and rest. The antibiotic should be discontinued. Corticosteroids are reserved for patients with severe complications such as impeding airway obstruction, liver failure, or aplastic anemia. Although acyclovir is effective in inhibiting EBV replication, it has not been shown to have significant clinical benefits in patients with infectious mononucleosis. 17. Most often occurring in middle-aged women, Sjogren’s syndrome (SS) is a chronic and progressive autoimmune disorder characterized by lymphocytic infiltration of the exocrine glands. Primary symptoms include dry eyes and dry mouth secondary to lacrimal and salivary gland involvement. The syndrome is commonly associated with other autoimmune conditions, such as SLE or scleroderma. To establish that the dryness experienced by the patient is secondary to SS, laboratory evaluation for characteristic autoantibodies (i.e., anti-Ro/SSA or anti-La/SSB) should be undertaken. Quantifying breakup time after fluorescein staining of the cornea is a means of measuring tear film instability. Since this test requires slit lamp examination, it is usually performed by an ophthalmologist. Although

fluorescein staining is a useful means of objectifying patient complaints about dry eyes, it is not a definitive method of diagnosing Sjogren’s syndrome. The instillation of Rose Bengal into the eye will stain areas of devitalized tissue. This staining allows for the objective measurement of damage to conjunctival and corneal epithelial cells. Since the Rose Bengal test requires slit lamp examination, it is usually performed by an ophthalmologist. Although Rose Bengal staining is a useful means of objectifying patient complaints about dry eyes, it is not a definitive method of diagnosing Sjogren’s syndrome. Parotid gland biopsy is not commonly performed when evaluating patients for Sjogren’s syndrome. The Schirmer test is used to measure tear production. The test involves inserting a small piece of filter paper into the lower eyelid to quantify the extent of wetting within a certain time frame. Although the Schirmer test is a useful means of objectifying patient complaints about dry eyes, it is not a definitive method of diagnosing Sjogren’s syndrome. Patients with suspected Sjogren’s syndrome (SS) should have the diagnosis confirmed with a labial salivary gland biopsy, which is considered the "gold standard." The biopsy sample is obtained from a normal-appearing portion of the lower lip, and the classic histologic finding in SS is focal collections of lymphocytes. Anti-centromere antibodies are suggestive of CREST syndrome, not Sjogren’s syndrome. Although an elevated erythrocyte sedimentation rate is found in up to 70% of patients with SS, this finding is not specific and cannot be used to confirm the diagnosis. Malignant lymphoproliferative disorders are more common in patients with Sjogren’s syndrome (SS). The lymphocytic infiltration of exocrine glands seen in SS is typically accompanied by polyclonal B-cell activation, as evidenced by the presence of autoantibodies anti-Ro/SSA and anti-La/SSB. The resulting chronic, excessive B-cell stimulation contributes to the increased incidence of non-Hodgkin's lymphoma (extranodal marginal zone B-cell lymphoma) in this patient population. Studies indicate that the time between the onset of SS and the diagnosis of non-Hodgkin’s lymphoma varies from 4 to 12 years. Fortunately, this increased incidence of lymphoma is not associated with an elevated risk of death in the SS patient population. T-cell lymphoma is associated with infection with human Tlymphotrophic virus, type 1 (HTLV-1). There is no known association between this condition and Sjogren’s syndrome. Acute pancreatitis is associated with mumps infection, which can cause parotid gland inflammation. Pancreatitis has not been associated with Sjogren’s syndrome. The risk factors for development of carcinoma of the salivary glands are radiation exposure, Epstein-Barr virus infection, genetic factors (e.g., tumor gene inactivation), environmental factors (e.g., exposure to silica dust or kerosene), and dietary factors (e.g., reduced fruit and vegetable intake). 18. Most antibiotics are not neurotoxic, but some are associated with an increased risk of seizures. Conditions that would predispose an individual to antibiotic-induced seizure include renal insufficiency, older age, pre-existing CNS disease, and concomitant use of proconvulsant drugs. Of all antibiotics, beta-lactams are the most commonly associated with adverse CNS events. Specifically, penicillins, cephalosporins, monobactams, carbapenems (including imipenem), and fluoroquinolones are the antibiotics most likely to trigger seizures 19. The patient's history, physical examination findings, thyroid function test results, and thyroid scan results (focal uptake) are very characteristic of a toxic nodule. Graves' disease is the most common cause of hyperthyroidism; however, focal uptake in the thyroid scan rules out this disease. Subacute and painless thyroiditis are both uncommon in elderly patients. These diseases demonstrate a diffuse reduction in radioiodine uptake.

This patient most likely has Marfan syndrome (MFS), a disease characterized by arachnodactyly, increased arm span relative to height, and valvular (mitral or aortic) insufficiency. Dural ectasia is the most common finding (present in more than 90% of patients), and usually requires an MRI of the lumbar spine for the confirmation of the diagnosis. Ectopia lentis can be seen in 50-80% of the patients with MFS, and is characterized by an upward displacement of the lens. Aortic dilatation can

be seen in 50% of the children with MFS and 70-80% of the adults. Some of these patients will eventually develop aortic insufficiency. 20. Diffuse esophageal spasm manifests with chest pain and dysphagia. The etiology is unclear, although in many patients it is associated with emotional factors and functional gastrointestinal disorders. Manometric studies demonstrate high amplitude peristaltic contractions. In contrast to achalasia, the lower esophageal sphincter usually has a normal relaxation response. Manometric findings may be intermittent, thus making the diagnosis difficult. The esophagogram is frequently normal, although the classic corkscrew esophagus is seen occasionally. Treatment is with antispasmodics, dietary modulation, and psychiatric counseling. Surgery is very rarely required for this disorder. Zenker’s diverticulum is a disorder of the proximal esophagus generally seen in females. The diverticulum may vary in size and is generally asymptomatic in presentation. The occasional patient may present with complaints of food sticking in the throat, halitosis, and regurgitation. There is no pain associated with the diverticulum. Treatment is surgery. In achalasia, the lower esophageal sphincter does not relax (high tone). Histopathology reveals hypertrophied, inner circular muscle with the absence or degeneration of ganglia in Auerbach’s plexus. Manometry will show the absence of peristalsis. The cause is not known, but a similar condition in South America is caused by the parasite, Trypanosoma cruzi. An esophagogram typically reveals a dilated esophagus with a bird’s beak narrowing of the distal esophagus. Therapy is balloon dilation of the narrowed esophagus or surgery. Scleroderma is a collagen vascular disorder which can present with loss of distal peristalsis of the esophagus. There is complete atrophy of the esophageal smooth muscle and fibrosis. The lower esophageal sphincter becomes incompetent (low tone) with time, leading to reflux esophagitis and a stricture. The condition is progressive and difficult to treat. Esophagitis can be due to several causes, the most common being Herpes, Candida, or a Cytomegalovirus. Esophagitis generally occurs in immunocompromised individuals (e.g., those with AIDS, malignancy, diabetes) and may present with dysphagia, oral thrush, or odynophagia. Endoscopy with washings, culture, and biopsy may reveal the cause. **Extremely high yield question for USMLE. Understand the pathophysiology, the presence of and the absence of peristalsis, and LES tone in all of the above conditions. 21. Patients with borderline personality disorder suffer from considerable instability in self-image, moods, impulse control, and relationships. Relatively minor events or disagreements are often interpreted as threatening a relationship, causing many borderline patients to respond with dramatic displays of anger or self-harm. Marked changes in mood can occur throughout the day. When primitive idealization occurs, the patient views another individual as perfect and without flaw, and is unable to tolerate any evidence to the contrary. This often happens when the borderline patient interacts with a "savior," someone (such as the physician, in this case) who has cared for her in a time of crisis. Compensation results when an individual overemphasizes achievements in one sphere because of failure in another. One example would be an unattractive individual focusing on scholastic success. Projection occurs when an individual attributes his thoughts or desires ‘especially those that are socially unacceptable’ to another person. One example would be a woman who resents a coworker’s success and says, "He doesn’t like me." Reaction formation is the overcompensation for uncomfortable impulses. One example is a man who is attracted to other men but behaves in a homophobic manner. The hallmark of borderline personality disorder is splitting, a phenomenon in which all external objects are classified as wholly good or wholly bad (a categorization that may abruptly change based on one positive or negative encounter). Patients with borderline personality disorder tend to use a psychological defense mechanism known as splitting, in which all external objects are classified as wholly good or wholly bad. Primitive idealization is one aspect of splitting in which another individual is viewed as perfect. *Extremely important question for USMLE step-3 Dialectical behavior therapy is one of the most successful means of treating borderline personality disorder. It is an intensive process and may take more than a year of therapy before improvement is seen. Unlike traditional psychotherapy (which analyzes unconscious motives), dialectical behavior

therapy focuses on behavior modification and the building of skills. Important issues to address during therapy sessions include the establishment of appropriate boundaries, validation of the patient’s experience, assumption of responsibility for one's own actions, management of feelings on both sides, promotion of reflecting before acting rather than being impulsive, reduction of tendency to engage in splitting, and the setting of limits on self-destructive behaviors. Selective serotonin reuptake inhibitors can help reduce mood lability and temper outbursts in borderline patients; however, medications are not first-line in the treatment of this disorder, and should only be used as a supplement to psychotherapy. Tricyclic antidepressants are contraindicated because of the high risk of suicide attempts. 22. A 32-year-old white female with no significant past medical history comes to the office because she has noticed a small lump in her left breast. She is married, has no children, and works as an attorney in a very busy local bureau. She does not use tobacco, alcohol, or drugs. There is no history of breast cancer in the family. Her last menstrual period was five days ago. On physical examination, you find a 1.5 cm round, smooth, soft, mobile, mildly tender mass in the left breast. No axillary nodes, skin lesions, or nipple discharge are found. Which of the following is the most appropriate next step in her management? A. Fine needle aspiration of the lesion B. Breast ultrasound C. Mammogram D. Reevaluation three weeks from now E. Order serum BRCA1 and 2 Explanation: Female patients younger than 35 years have a decreased risk of breast cancer, especially if there is no positive family history. The patient is a busy woman who needs a fast answer to her problem. At the same time, the characteristics of her breast mass - smooth, soft, mobile, and round - usually correspond to a breast cyst, which may easily be assessed through fine needle aspiration (FNA). (Choice C) A mammogram is not usually recommended in patients less than 35 years of age because the breast tissue at this age is too dense to allow good imaging. (Choice B) If the mass has no cystic characteristics, or if the patient refuses FNA, a breast ultrasound is indicated. (Choice D) Benign lesions are supposed to decrease in size 3 to 10 days after menstruation, not three weeks later. Since the patient came five days after her menstrual period, reevaluation of the lesion will not be useful. (Choice E) BRCA tests are not advisable. Educational Objective: Even though breast cancer is rare in women younger than 35 years, every breast lesion must be taken seriously. Patients can be reevaluated 3 to 10 days after the menstrual period to look for regression. If the lesion appears cystic, FNA should be done unless the patient declines. If the mass looks solid, is too small, or cannot be felt, ultrasound is the next step to determine if biopsy is needed. 40% of people answered this question correctly. Case 26 The following vignette applies to the next 2 items

A 56-year-old African American male presents with several months history of a swallowing difficulty. He says, ‘It started with meat sticking in my throat and then got worse.’ He now has to drink a lot of fluids with his meals. He denies choking episodes, shortness of breath, voice change and heartburns, but notes that sometimes he coughs during meals. He has lost several pounds during the last two months. His past medical history is insignificant. He smokes 2 packs of cigarettes daily and consumes 6-8 bottles of beer on weekends. He is not sexually active. His blood pressure is 120/70 mmHg and heart rate is 80/min. His lungs are clear on auscultation. Neck palpation reveals no lymph node enlargement. Item 1 of 2 What is the best initial step in the management of this patient? A. Chest x-ray B. CT scan of the chest C. Barium swallow D. Upper GI Endoscopy E. Bronchoscopy Explanation: Dysphagia is an alarm symptom that warrants immediate evaluation. A thorough history and physical examination can provide important clues to the correct diagnosis and appropriate tests to be run. In this case, the progressive dysphagia to solids indicates a high probability of mechanical obstruction vs motility disorder. Considering this patient's risk factors (e.g., age, smoking, alcohol, weight loss), esophageal cancer is likely. In patients with suspected upper esophageal lesions, it is always safer to proceed first with barium swallow than with endoscopy. (Choice D) Although many physicians consider endoscopy as the initial test of choice, barium swallow can be run initially in certain patients. Intubation of the proximal esophagus during endoscopy is done relatively blindly, thereby risking perforation in patients with an upper esophageal pathology. (Choice B) CT scan of the chest can be a part of the work-up after the diagnosis is established. It is useful in assessing the extent of the disease and helps to choose an appropriate treatment strategy. (Choice E) Bronchoscopy is sometimes employed to detect tracheal and bronchial involvement in patients with upper esophageal lesions. (Choice A) A chest x-ray will convey little diagnostic information in this situation. Educational Objective: If an upper esophageal lesion is being suspected, it is always safer to proceed with barium swallow first before doing an endoscopy. 71% of people answered this question correctly. Item 2 of 2 Endoscopy reveals an upper esophageal mass with irregular contours that partially obstruct the lumen of the esophagus. What is the most likely histological type of the tumor? A. Mucoepidermoid B. Adenoid cystic C. Squamous cell D. Small cell E. Adenocarcinoma

including mucoepidermoid carcinoma and adenoid cystic carcinoma. a well-known metaplastic complication of GERD. alcohol consumption.Explanation: The two most common histological types of esophageal cancer are squamous cell carcinoma and adenocarcinoma. the incidences of these two types are almost equal. (Choice E) Adenocarcinoma is more common in Caucasians and usually arises from Barrett’s esophagus. . Squamous cell carcinoma is more common in African Americans and shows a significant association with smoking. 88% of people answered this question correctly. and some dietary factors. It is more common in African Americans and shows a significant association with smoking. Adenocarcinoma is more common in Caucasians and usually arises from Barrett’s esophagus. gastroesophageal junction and gastric cardia region. It usually affects the upper and middle parts of the esophagus. It is associated with obesity. Several decades ago. are rare. The two differ in their pathophysiology and patient risk profile. It typically affects the distal esophagus. and some dietary factors. (Choices A and B) Other histological types of esophageal cancer. squamous cell carcinoma was clearly predominant. alcohol consumption. accounting for up to 90% of esophageal cancer. Nowadays. Educational objective: Squamous cell carcinoma usually affects the upper and middle parts of the esophagus. but shows little association with alcohol consumption.

On physical examination. Probing of the ulcer is suspicious for entering into the first metatarsal head. and eventually developed some purulent discharge. 48% of people answered this question correctly. Of all the noninvasive tests. Majority of patients require long-term parental antibiotic treatment and resection of the affected bone. MRI is most accurate. Two weeks ago. Ankle jerks are absent. which is generally confirmed using a non-invasive test. Item 1 of 2 Which of the following non-invasive modality has the highest accuracy for diagnosing osteomyelitis in his foot? A. He complains of mild fever and chills.7 C). There is no significant tenderness in the left foot. MRI scan B. It is important to diagnose osteomyelitis because the treatment may vary once the diagnosis is established. Culture swab from ulcer base C. a small ulcer formed. His blood pressure is 165/94 mm Hg. Neck examination reveals a left carotid bruit. He has hypertension. Peripheral pulsations are not felt in both feet. Other systems are unremarkable. Culturing pus coming out from ulcer E. and temperature is 100 F (37. he is 6’0" (180 cm) tall. Aspiration from surrounding erythematous skin D. The gold standard for diagnosing osteomyelitis is bone biopsy. Blood culture B. (Choices B. particularly if the response to antibiotic(s) and surgical debridement is poor. Culture of deep tissue obtained by curettage .Case 27 The following vignette applies to the next 2 items A 65-year-old male presents to the emergency department with an ulcer on his left foot. Plain radiograph E. C. enlarged. He is currently on a mixed split regimen of insulin. There is a significant sensory impairment up to the knees in both lower extremities. He has a 20 pack-year history of smoking. Probing into the bone is highly suggestive of osteomyelitis. The surrounding skin is erythematous and warm. WBC scan D. In this case. with a sensitivity of 99% and specificity of 88%. Technetium bone scan C. and weighs 152 lb. it might be prudent to consult a vascular surgeon. There is some purulent foul-smelling discharge oozing from this ulcer. with suboptimal glycemic control. heart rate is 96/min regular. because there is a suspicion of significant ischemia. for which he is on captopril and hydrochlorothiazide. The amount of purulent discharge increased during the past week. Examination of the left foot revealed a 3x2-cm ulcer with a necrotic base on the medial aspect of the first metatarsophalangeal joint. He denies pain in his left foot. (71 kg). CT scan Explanation: The patient’s clinical features are highly suggestive of osteomyelitis. D and E) The specificity and sensitivity of other non-invasive tests is much lower. He has had type-2 diabetes mellitus for the past fourteen years. The lesion started as an erythematous patch on the medial aspect of his left forefoot three weeks ago. Item 2 of 2 Which of the following is the most useful to obtain a microbiologic diagnosis in this patient? A. Educational objective: MRI is the most accurate test in diagnosing osteomyelitis in the vertebrae and in diabetic foot. His hypercholesterolemia is being managed with pravastatin.

aureus. you note that her right leg is externally rotated. The most commonly involved organisms are S. She is unable to walk or bear weight on her right leg. Pressure stockings D. Warfarin alone C. coumadin and unfractionated or low molecular weight heparin (LMWH) have shown that the LMWH group has superior results when compared with the other two groups. Candida. They are not sufficient to prevent DVT as sole agents because they are only effective in preventing DVT formation in calf veins. coli. and should be given unless contraindications for its use are present. and D) A superficial swab from the ulcer. (Choice C) Pressure stockings and intermittent pneumatic compression are used as adjuvants to other therapies. . group B Streptococci. Educational Objective: Organisms isolated from cultures of specimens from deep curettage correlate closely with cultures obtained from surgical resection of the deep tissue in patients with infected foot ulcers. Inferior vena cava filter Explanation: Approximately 250. and needle aspiration do not always reflect the correct etiologic organism. C. She is scheduled for right hip replacement. deep infections require parental antibiotic therapy with a broad range for microbes. 4-7% of DVT patients suffer from fatal pulmonary embolism. (Choice A) Blood cultures are positive in about 40% of patients with foot infection. Pseudomonas. The majority of foot infections in diabetics are caused by mixed aerobic and anaerobic organisms (80%). Development of venous thromboembolism in these patients is one of the major causes of postoperative morbidity and mortality. LMWH is therefore considered to be the therapy of choice. Peptococcus and Clostridium. It can be used as first line if any contraindication to the use of LMWH exists. Administration of coumadin should be started on the day of admission. E. Most superficial skin infections require outpatient oral antimicrobial therapy against S.000 hip fractures occur every year in the United States. (Choice B) Coumadin is considered a second line prophylactic agent. while extensive. aureus. and the target INR of 2 to 3 is achieved for adequate prophylaxis. Which of the following is the most appropriate course of action to prevent deep venous thrombosis in this patient? A. Because of this. including anaerobes. Studies comparing the prophylactic effects of aspirin. congestive heart failure and osteoporosis. The x-ray of the right hip shows a fracture in the neck of the femur. Her past medical history is significant for hypertension. Major surgical debridement may be necessary. thromboembolic prophylaxis has been recommended for these patients. coronary artery disease. (Choiced B. Antimicrobial therapy for diabetic foot infections should be individualized. Aspirin alone B. Bacteroides. Low molecular weight heparin E. myocardial infarction.Explanation: Establishing a correct microbiological diagnosis will help in choosing the proper antibiotic(s) treatment. Organisms isolated from cultures of specimens from deep curettage correlate closely with cultures obtained from surgical resection of the deep tissue. 51% of people answered this question correctly. and have no prophylactic effect on pelvic vein thrombosis. culture of the purulent discharge. Case 28 A 75-year-old female is brought to the emergency room after she fell in her bathroom. Proteus. and all the movements involving the right hip joint are very painful. On examination.

In this case. Item 1 of 3 What is the relative risk (RR) of ischemic stroke for smokers compared to non-smokers? A. A cohort study conducted using a random sample from this population showed that the five-year risk of ischemic stroke is 1:1.05)/0. It is recommended as a sole prophylactic agent against thromboembolism only if both heparin and coumadin (warfarin) are contraindicated. 10% B. RR = 1. ARP is a measure of excess risk.1 = 0. the five-year risk of the exposed (smokers) is 0. Educational Objective: Relative risk is a measure of outcome in follow-up studies. Case 29 The following vignette applies to the next 3 items It is estimated that the prevalence of smoking in a population is 50%.0 Explanation: Relative risk represents a measure of outcome in follow-up studies. the relative risk is 0. RR = 1.5 (50%). 50% E. divided by the risk of the unexposed. It estimates the proportion of the disease in exposed subjects that is attributed to exposure status. 33% D. and the risk of the unexposed is 0.000 in non-smokers.5 E.05 = 2.5:1.1 – 0.0. RR = 3.1/0. The following interpretation is valid in this case: A five-year risk of stroke in smokers is twice that of non-smokers. 75% Explanation: In this scenario.000 in smokers and 0.0 D. The first approach uses the following formula: ARP = (Risk in exposed – Risk in unexposed)/Risk in exposed = (0.05 (0. which is also called etiologic fraction. (Choice E) Inferior vena cava filter placement is indicated in patients who have contraindications to anti-coagulation. Educational Objective: LMWH is considered to be the prophylactic therapy of choice for preventing deep vein thrombosis in patients at high risk. you should calculate the attributable risk percent (ARP). Two approaches can be used to calculate ARP.5:1000). RR = 2.(Choice A) Aspirin is used as a third line agent after heparin and coumadin.1% (1:1000). It is the risk ratio which compares the risk among the exposed to the risk among the unexposed. It is also used in patients who develop DVT despite ongoing anticoagulation treatment. It is the risk of the exposed. 25% C. RR = 2. Item 2 of 3 What percentage of the strokes observed in smokers is attributed to their smoking status? A. 78% of people answered this question correctly. The other approach uses relative risk (RR) to calculate ARP: .0 B. therefore.5 C.

05)/0.1 x 0.05%). including vital signs. not only in exposed subjects. not only in the exposed subjects. The following interpretation is valid in this case: 50% of the ischemic strokes observed in smokers can be attributed to their smoking status. PARP estimates the proportion of the disease in the population that is attributed to the exposure. She asks that you re-examine her now. 25% C. Case 30 The following vignette applies to the next 3 items A 27-year-old woman with no medical history presents to your office complaining of recent onset chest pain. You reassure her that the more serious causes of chest pain are highly unlikely.5 + 0.5 = 0. or 50%). 50% E.075 = 0. Her description of the chest pain is vague and nonspecific even when pressed for details. and the prevalence of exposure in the population (0. On the day of the second appointment. Unlike attributable risk percent.075 – 0. Laboratory evaluation and an electrocardiogram are normal and suggest no etiology for her chest pain. PARP can be calculated using the following approach: PARP = (Risk in the total population – Risk in unexposed)/Risk in the total population Knowing the risk of stroke in exposed (0.5 (50%). 33% D.1%). the risk in unexposed (0.ARP = (RR – 1)/RR = (2 – 1)/2 = 0. but she insists upon scheduling a follow-up appointment for next week. PARP is the measure of excess risk in the total population. she arrives after your office is closed and intercepts you in the parking lot. She is a very attractive woman dressed in revealing clothing and mentions that she is one of your neighbors.075%. It estimates the proportion of the disease in exposed subjects that is attributed to exposure status.075 The risk in the total population is 0. Now we can calculate PARP: PARP = (0. Item 1 of 3 What is the most appropriate next step? . 75% Explanation: In this scenario. Item 3 of 3 What percentage of the strokes observed in the population is attributed to smoking? A.33 (33%) The following interpretation is valid in this case: 33% of the ischemic strokes observed in the population can be attributed to smoking. Educational Objective: ARP is a measure of excess risk. Unlike attributable risk percent. you should calculate the population attributable risk percent (PARP). is unremarkable. Physical examination. PARP is the measure of excess risk in the total population.05 x 0. 10% B. and could therefore have been eliminated if they had not smoked.5. Educational Objective: PARP estimates the proportion of the disease in the population that is attributed to the exposure. it is possible to calculate the risk in the total population: Risk in the total population = 0. although she is quite dramatic in her presentation and at one point becomes teary-eyed.

Histrionic personality disorder E. When you refuse. it is best to be pleasant but firm in reiterating that the patient must schedule an appointment to be seen during normal business hours (Choice D). Item 2 of 3 Appropriate action is taken. she should be advised it is necessary to return the next day. Performing a brief examination in the parking lot (Choice B) is highly inadvisable. Antisocial personality disorder B. It is important to maintain professional environs and boundaries with all patients. The patient responds by insisting that you comment on her appearance. Sending her to the emergency department by ambulance (Choice E) is inappropriate since she is stable and her condition is not urgent. the best response is to calmly establish definitive boundaries that allow for appropriate medical treatment while also maintaining a professional doctor-patient relationship. Educational Objective: When a patient behaves seductively or makes sexual overtures. Briefly examine her in the parking lot C. Performing a full examination in the office now (Choice C) despite the late hour is not ideal because it suggests a willingness to accommodate even unreasonable requests made by the patient. The task of properly diagnosing and managing the medical and psychiatric disorders of these patients is therefore quite challenging and invariably requires patience and insight on the behalf of the physician. Generally. especially those who are behaving in an inappropriate or seductive manner. Send her to the emergency room by ambulance Explanation: Frequently encountered in the primary care setting. Which of the following conditions is she most likely suffering from? A. Borderline personality disorder C. Dependent personality disorder D. Narcissistic personality disorder Explanation: . Perform full examination in the office D. Since she is stable and failed to arrive at the appointed time. difficult patients tend to elicit strong reactions from their physicians. with a verbally abusive or physically threatening patient) after all attempts to establish a successful relationship have failed and fair warning has been given. termination of the doctor-patient relationship is done as a last resort in extreme cases (eg. When a patient behaves seductively or makes sexual overtures. If a patient in stable condition insists upon being examined outside of the office. Transferring this patient now (Choice A) certainly avoids the difficulties inherent in dealing with her. she becomes extremely upset. It is important to document the termination in writing and to ensure that the patient is not abandoned before she establishes care with a new physician. Inform her that an examination is not possible now and suggest she return to the office tomorrow during business hours E. the best response is to calmly establish definitive boundaries that allow for appropriate medical treatment while also maintaining a professional doctor-patient relationship. 91% of people answered this question correctly.A. as she is dressed in a sexually provocative manner. but is likely premature at this stage. Refuse care and refer her to another physician B.

the physician will terminate the doctor-patient relationship prior to entering a sexual or romantic relationship with a patient. lack of remorse. who is also your patient D. and consistent irresponsibility are also hallmark features. Accept her offer but do not document any personal interactions in her chart C. and are sometimes known to exaggerate their own accomplishments. moods. patients with histrionic personality disorder (Choice D) display a persistent pattern of gratuitous emotionality and attention seeking as evidenced by five or more of the following criteria: 1) discomfort when not the center of attention. Patients with narcissistic personality disorder (Choice E) are grandiose and desire adulation and admiration from other people. 8) exaggerates intimacy of relationships. this patient is aware that you are single. They may envy and exploit others. argue that it is never appropriate to date a patient ‘even years’ after the doctor-patient relationship ended (Choice E). Refuse her offer and inform her that you are prohibited from dating patients Explanation: It is the American Medical Association’s formal position that any sexual interaction occurring between a doctor and patient constitutes professional misconduct. and exaggerated behavior and emotion. 6) dramatic. Patients with antisocial personality disorder (Choice A) frequently violate the rights of others and the rules of society. . Because of the inherent power structure of the doctor-patient relationship and the commonality of transference and counter-transference. Educational Objective: Histrionic personality disorder is characterized by gratuitous emotionality and attention seeking. What is the most appropriate response? A. Refuse her offer and report the incident to her boyfriend. Impulse control is poor and suicidal behaviors are common. theatrical. 3) rapid shifting and shallowness of emotion. Reporting the incident to the patient’s boyfriend (Choice C) would be a violation of the confidential nature of the doctor-patient relationship and is therefore inappropriate. You find her attractive. Patients with dependent personality disorder (Choice C) crave being cared for by others and are often excessively clingy or submissive. it is always considered inappropriate to date a current patient (Choices A and B). Behaving in a dramatic. Item 3 of 3 As your neighbor.According to the DSM-IV. Many ethicists. Whether or not any personal interactions are documented. sexually provocative manner is common in patients with this personality disorder. It is expected that at the least. Physical aggressiveness. Patients with borderline personality disorder (Choice B) have unstable and intense interpersonal relationships. 2) behaves in a sexually seductive or provocative manner. 75% of people answered this question correctly. She invites you to have dinner with her at a nearby restaurant later this week. Refuse her offer and admit her to the acute-care psychiatric ward for stabilization E. 4) usage of physical appearance to draw attention. 5) speech is vague and impressionistic. 7) easily influenced by others. sexual contact would allow for the potential exploitation of patients or the clouding of a physician’s judgment. Accept her offer and document all personal interactions in her chart B. and self-image. however. "Splitting" may be observed.

and looks shorter than the right one. Although she appears to be dysfunctional and to have some serious psychiatric issues. non-tender and non-distended. An x-ray of the hip reveals a trochanteric fracture of the left femur. The heart sounds are normal. Educational Objective: At the least. Because of her advanced age & dementia. and severe disability places her at an extremely high risk for perioperative complications. glimepiride and atorvastatin.Admission to the psychiatric ward for stabilization (Choice D) is appropriate when the patient is at imminent risk of harming herself or others. Her left leg is rotated outwards. and says that she is willing to sign consent forms so that her grandmother can undergo hip surgery to alleviate her pain. argue that it is always inappropriate to date a patient “even years” after the doctor-patient relationship ended. Since this patient’s granddaughter seems to provide ample social support. She lives at home with her granddaughter. She has been bedridden for the past two years due to morbid obesity and advanced Alzheimer’s dementia. there is no evidence of imminent danger. performing the surgical procedure will make no difference. there is no need to send her to a nursing home. Her medications include aspirin. The type of surgery. enalapril. Physical examination shows an obese. (Choice C) Although the decision to send the patient to a nursing home may be affected by her disability or need for surgical intervention. mildly dehydrated elderly woman. These have shown that hip pain due to a fracture is not an indication for surgery because conservative measures can effectively control pain symptoms. she may become more disabled and need nursing home placement D. donepezil. and the lungs are clear. Instead of surgery. Which of the following is the most appropriate statement about the patient’s condition? A.1 C (97 F). An ecchymotic area is present on the lateral aspect of the left thigh. blood pressure is 170/85 mmHg. surgery will be an unnecessary risk E. The ideal candidates who may benefit from a surgical intervention are elderly patients who were ambulatory prior to their hip fracture. Surgery will not offer benefits in her case and can be dangerous C. Passive movement of the left lower extremity is extremely painful. (Choices A and E) Several studies have evaluated and discussed the role of conservative therapy in patients who are unable to undergo hip surgery. alert. however. external traction will be preferred Explanation: The patient is not a good candidate for surgery. one of the main considerations is her current available social support. Many ethicists. Her temperature is 36. pulse is 100 /min and respirations are 18/min. Bowel sounds are normal. The possibility of a successful rehabilitation and recovery is difficult to predict or evaluate before surgery because this heavily relies on the surgical outcome and the patient’s response to the procedure. the patient’s age. hypercholesterolemia. There is no rebound tenderness or rigidity. Her granddaughter is concerned about the fracture. the pain will persist B. The abdomen is soft. Case 31 An 84-year-old Caucasian woman is brought to the emergency department because of severe pain in her left hip and leg. diabetes mellitus type 2. multiple comorbidities. hydrochlorothiazide. If surgery is not done. She fell from the bed while sleeping. . a physician should terminate the doctor-patient relationship prior to entering a sexual or romantic relationship with a patient. Her other medical problems include hypertension. Since the patient is already bedridden. (Choice D) Advanced age and dementia should not preclude surgical intervention if the procedure offers the opportunity to improve or at least partially restore function and the quality of life of the patient. 95% of people answered this question correctly. If surgery is not performed. and coronary artery disease.

Which of the following is the most likely diagnosis in this patient? A. but. a physician must always look at the entire clinical picture and prognosis before suggesting or refusing a surgical intervention. petechiae. as conservative therapy can also effectively control this symptom. Chickenpox Explanation: The clinical scenario described is highly suggestive of Henoch-Scholein purpura. The peripheral smear shows RBC fragments. The skin lesions are symmetric. the risks may outweigh the benefits. An antecedent upper respiratory infection is present in 50% of patients. however. Renal failure 5. His temperature is 36. The patient’s age. Acute intermittent porphyria E. and respirations are 20/min. Educational Objective: Even in cases where the risk is high. (Choice A) Hemolytic uremic syndrome typically develops in patients younger than two years old. (Choice B) Thrombotic thrombocytopenic purpura (TTP) is a serious disorder characterized by the following classical pentad: 1. If the patient has other serious medical problems. Physical examination reveals a symmetric. blood pressure is 110/65 mmHg. upper respiratory tract infection several days ago. . and skin lesions are absent. and classically progress from an erythematous. On the other hand. the benefit of surgery is minimal. Abdominal pain is a presenting symptom in 1015% of patients. functional status. (Choice D) Acute abdominal pain is common in patients with acute intermittent porphyria. pulse is 105/min. The LDH is elevated due to hemolysis. and confusion. Hemolytic uremic syndrome B. If the patient is already bedridden. He had a mild. only the absence of benefits may prompt the physician to refuse a procedure. pallor. Both TTP and HUS are very serious conditions. Hemolytic uremic syndrome (HUS) and TTP comes under a spectrum of diseases. erythematous. quality of life. Pain alone is not an indication for surgery. Thrombotic thrombocytopenic purpura C. Severe thrombocytopenia 2. macular rash to papular purpura. Case 32 A 7-year-old Caucasian boy is brought to the emergency room by his mother because of abdominal pain of acute onset. Henoch-Schonlein purpura D. Fever Patients with TTP generally present with fever. systematic reviews have concluded that other forms of conservative therapy such as external traction may cause more pain. If a patient has more neurologic symptoms and less renal failure.7 C (98 F). and require emergent plasmapheresis. The abdomen is mildly tender on physical examination. and personal values must all be considered to determine if the patient will benefit from hip surgery. involve dependent parts of the body. PT and PTT are usually normal. The joints and kidneys are also commonly involved. his past medical history is insignificant. therefore.. macular rash on his lower extremities that progresses to papules after several hours. if a patient has significant renal failure and less neurologic symptoms. and presents as abdominal pain and diarrhea (usually bloody) that progresses to acute renal failure. otherwise. presence of comorbidities. Microangiopathic hemolytic anemia (RBC fragments) 3. the disease is considered HUS. the disease is considered TTP.On the other hand. Fluctuating neurological signs 4. it is unusual before 18 years of age.

Educational Objective: NGU usually presents 5 to 10 days post-exposure. Educational Objective: Classical clinical manifestations of Henoch-Scholein purpura include abdominal pain. Ofloxacin E. arthralgias. Examination shows no abnormalities.(Choice E) Chickenpox may present as erythematous lesions early in the course of the disease. He states that he continues to have dysuria and some watery urethral discharge. Therapy is the same as for cervicitis in women: azithromycin or doxycycline.) The urethral discharge is typically mucoid or watery in NGU. The patient might have difficulties adhering to this type of therapy. the rash appears on the scalp. however. The incubation period is usually 5 to 10 days post-exposure. Azithromycin D. He is unemployed and does not have any medications. trunk. A urethral swab is done and sent to the laboratory. Ceftriaxone C. (Choice B) Ceftriaxone is indicated for gonococcal urethritis. skin lesions. Item 1 of 2 Which of the following is the most appropriate pharmacotherapy? A. except for a clear watery urethral discharge. and is preferred in this case to assure patient adherence. and proximal limbs. Metronidazole Explanation: The patient’s history and physical examination findings are highly suggestive of non-gonococcal urethritis (NGU). and has been smoking one pack of cigarettes daily ever since. He has had these symptoms for five days. (According to the patient’s information. complaining of dysuria and a watery urethral discharge. He started smoking when he was 14. Ofloxacin is effective against gonococcal infections. and the 100 mg tablets should be taken twice daily. compared to 2 to 7 days for gonococcal infection. Azithromycin (1 g) is given as a single oral dose. He uses marijuana and "crack" almost daily. and is characterized by dysuria and a mucoid or watery urethral discharge. Ureaplasma urealyticum or Mycoplasma genitalium. Item 2 of 2 The patient returns ten days later with his elder brother. Therapy consists of a single dose of azithromycin or a 7-day course of doxycycline. while in gonococcal urethritis. Doxycycline B. The patient remembers having sexual intercourse with a prostitute almost two weeks ago. which is therefore less preferred. Case 33 The following vignette applies to the next 2 items A 19-year-old man comes to the student health center. and renal involvement. which are responsible for the majority of cases of NGU. and then progresses sequentially to form vesicles. (Choice D) Ofloxacin has not been shown to be effective against Chlamydia trachomatis. (Choice A) Doxycycline is given for 7 days. 85% of people answered this question correctly. He has no other medical problems. exposure may have occurred 9 to 10 days before the initiation of symptoms. His brother confirms that the patient has not been re-exposed to . the secretion is purulent and abundant. Rates of success with either regimen are around 90%. and drinks alcohol on weekends. face.

E. two days ago. The objective is to treat Trichomonas and resistant NGU agents. He sent her for serologic testing for Rocky Mountain spotted fever. B. The rest of her physical examination is unremarkable. It is seen throughout the United States. Treatment is instead aimed at covering Trichomonas and resistant NGU pathogens. generalized body aches. E. C. and does not take any medications regularly. and has a major . Start azithromycin. in 90% of the cases. Chlamydia or Ureaplasma.any sexual partner. She goes to the same place in Long Island with her friends during spring break every year. followed by 7 days of erythromycin (500 mg every six hours). Item 1 of 2 Which of the following is the most appropriate next step in her management? A. Explanation: The patient has non-gonococcal urethritis (NGU). Repeat the serologic testing for Rocky Mountain spotted fever in one week. blood pressure is 122/74 mmHg. Start doxycycline. D. Rickettsia rickettsii.8 C (100F). The results of the urethral swab are negative for Chlamydia and Neisseria gonorrhoeae. heart rate is 92/min. her temperature is 37. which. the Center for Disease Control (CDC) guidelines do not recommend repeating the treatment with doxycycline or azithromycin (Choices C and E). B. Start the patient on treatment for Rocky Mountain spotted fever. responds to therapy with azithromycin or doxycycline. Case34 The following vignette applies to the next 2 items A 26-year-old Caucasian female comes to see you in the office with complaints of fatigue. (Choice D) Ofloxacin will be effective for enteric bacteria and gonococcus. which requires high doses of the drug (800 mg six times a day). and respiratory rate is 16/min. the results of which were inconclusive at that time. 36% of people answered this question correctly. and low-grade fever for the past four days. Explanation: Rocky Mountain spotted fever is a tick-borne rickettsial infection caused by an intracellular gramnegative organism. On examination. headache. D. and has never had any problems in the past. Which will be the most appropriate next step in management? A. There is evidence of a fine petechial rash over both wrists and the left ankle. She is otherwise in good health. Obtain a skin biopsy of the petechial lesions. Another alternative is erythromycin monotherapy. Follow her platelet counts serially. New York. Educational Objective: NGU that is refractory to antibiotic therapy must be treated with metronidazole and erythromycin. Start ofloxacin. and that he took the medication as indicated. according to CDC recommendations. If re-exposure and non-adherence are ruled out. (Choice A) There are no current indications to refer the patient to the urologist. Perform Weil-Felix test now. She has just returned from a hiking and camping trip in Long Island. C. Refer the patient to the urologist. Metronidazole is given as a single dose (2 grams). Start metronidazole. and not for Trichomonas. She saw a local physician there on the first day of her symptoms.

on the patient’s presentation in the right setting (endemic area in spring or early summer). myalgias and headaches. enzyme immunoassay. Repeating the serology in this patient after one week would delay the initiation of treatment. Patients should be started on treatment early. reliable. Cephalexin D. lethargy. There is no single.e. It has a higher incidence of side effects. focal neurological signs. and to the central body. In severe. and spreads to the palms. (Choice B) Weil-Felix test was used in the past to detect cross-reacting antibodies. The results of biopsies also take some time. Such symptoms include: low-grade fever. this can cause a potentially fatal delay in the management of the patient. It is a petechial rash which usually begins on the ankles and wrists. (Choice D) Thrombocytopenia is one of the many fatal complications of this disease. Most of the patients become symptomatic five to seven days after the tick bite. based on her symptoms and epidemiology. when outdoor activities are at their peak. and is not recommended for the diagnosis of Rocky Mountain spotted fever. it is not useful during the first five days of illness because the antibodies are typically seen 7-10 days after the onset of illness. or complement fixation test can be used to confirm the diagnosis of Rocky Mountain spotted fever. since the delay in treatment is associated with a higher mortality rate. skin lesions do not typically appear before the third to fifth day of illness. It is usually seen in spring and early summer. Early symptoms of the infection are nonspecific and can be misleading. and is only reserved for pregnant females and for patients who are unable to tolerate tetracycline. Doxycycline B. however. leading to death. and multiorgan dysfunction. The rash of Rocky Mountain spotted fever is typically seen on the third to fifth day of illness. without waiting for confirmatory tests. It is typically continued for at least three days after defervescence. Simply monitoring the platelet counts serially is not recommended. Any delays in treatment can lead to potentially fatal complications and higher mortality rates. Early initiation of therapy is indicated for all patients suspected of having Rocky Mountain spotted fever. (Choice D) Chloramphenicol is an alternative option for the treatment of patients with suspected Rocky Mountain spotted fever.prevalence in the southeastern and central states. The diagnosis and the decision to treat patients should be based clinically . It is a nonspecific test. Educational Objective: Patients with suspected Rocky Mountain spotted fever should be treated empirically (without waiting for confirmation of the diagnosis). Levofloxacin Explanation: Doxycycline is the treatment of choice in both children and adult patients with proven or suspected Rocky Mountain spotted fever. Chloramphenicol E. fulminant cases. . and is based on the clinical picture and epidemiologic setting. Erythromycin C. The patient should be started on treatment for Rocky Mountain spotted fever once the diagnosis is suspected. (Choice C) Biopsy of the skin lesions for Rickettsia can confirm the diagnosis of Rocky Mountain spotted fever. and worsen her prognosis. confusion). seizures. the patient may develop changes in mental status (i. therefore. diagnostic test during the early phase of the illness. soles. (Choice A) Although serologic testing with indirect fluorescent-antibody testing. Item 2 of 2 Which of the following is the most appropriate treatment for patients diagnosed with Rocky Mountain spotted fever? A.

It is an unreliable indication of deep venous thrombosis. Item 2 of 2 Which of the following is considered the most ominous sign of compartment syndrome? A. Educational Objective: Early physical signs of acute compartment syndrome include tightness. One of the most suggestive signs of compartment syndrome is pain out of proportion to the injury. the patient complains of significant pain in his left calf. Paresthesia B. prolonged external compression. Loss of arterial pulse C. At present. weakness. Compartment syndrome seems likely. The leg was stabilized in a plaster cast. He pleads for better analgesia. burns. Open reduction and internal fixation were performed immediately after the patient arrived in the emergency department. Case 35 The following vignette applies to the next 2 items You are called to see a 32-year-old African American man with no past medical history who sustained a mid-shaft fracture of his left tibia during a motor vehicle accident. or mottling of the extremity. Early physical signs of acute compartment syndrome include tightness. Hypesthesia and paresthesia may be documented as well. Acute compartment syndrome is more commonly associated with cyanosis. C. pallor. Mottling of the extremity . fractures. and pain with passive muscle motion. The loss of deep tendon reflexes (Choice C) can be seen in association with acute compartment syndrome. weakness. the capillary blood perfusion is reduced until it can no longer maintain tissue viability. Erythema B. Item 1 of 2 Which of the following is an early sign of compartment syndrome in a limb? A. cephalexin and levofloxacin are not recommended for the treatment of Rocky Mountain spotted fever. Pulses are present bilaterally in his lower extremities. Continuous morphine was provided for analgesic effect.(Choices B. and pain with passive muscle motion (Choice D). One of the most suggestive signs of compartment syndrome is pain out of proportion to the injury. Such events cause either a decrease in compartment size or an increase in compartment pressure. Loss of deep tendon reflexes D. and E) Erythromycin. but is typically a later finding. Pain or increased resistance with dorsiflexion of the foot is known as Homans sign (Choice B). Erythema (Choice A) is typically seen with venous congestion. and snake bites. He appears very uncomfortable and is sweating and shifting restlessly in bed. Tissue ulceration and necrosis Explanation: The events most commonly responsible for compartment syndrome include crush injuries. Tissue ulceration and necrosis (Choice E) would be a very late finding of compartment syndrome. Pain with passive muscle motion E. As the intracompartmental pressure rises. Homans’ sign C. Educational Objective: Doxycycline is the treatment of choice for patients with Rocky Mountain spotted fever.

A positive Thompson test is further evidence of an Achilles tendon rupture. . No foot movement on calf muscle compression. Pallor of the extremity E.D. she heard a loud snap. Treatment includes splitting of the cast and underlying padding. This typically occurs in men over the age of 40 who do not perform a regular leg-conditioning program. The most common symptoms are severe pain in the calf and the inability to stand up on the toes. While she was running on a racetrack. Treatment includes splitting of the cast and underlying padding. after which she felt an "excruciating pain" in her left calf area. However. as that signifies a cessation of blood flow to the extremity. while nerve tissue has impairment of function after 30 minutes of ischemia and irreversible loss of function after 12-24 hours. the foot responds with plantar flexion. they can be seen in conjunction with arterial pulses that are diminished and not absent. Case 36 A 36-year-old Caucasian woman comes to the emergency department and complains of severe left calf pain. after she had her first baby. Explanation: Rupture of the Achilles tendon may occur after abrupt calf muscle contraction. which can decrease the compartment pressure by 50-85%. if any symptoms do not resolve within an hour after cast removal and the pressure measurement remains elevated. The patient may note an audible snap at the time of injury. Excruciating pain does sometimes persist after cast removal (Choice E) and is not always cause for increased concern. She just started retraining a week ago for an upcoming race. or lying prone on an examination table with his feet hanging over the edge. Which of the following is the best clinical sign that will support this diagnosis? A. which can decrease the compartment pressure by 50-85%. Increased plantar flexion of the ankle on calf muscle compression B. On the affected side. Treatment consists of immediate immobilization of the lower leg and surgical repair of the tendon as soon as possible. It is therefore not considered the most ominous finding of compartment syndrome. Increased dorsiflexion of the ankle on calf muscle compression D. Mottling (Choice C) and pallor (Choice D) of the extremity are physical findings occasionally associated with acute compartment syndrome. and are therefore not considered the most ominous findings of compartment syndrome. there is no foot response. This test is performed with the patient kneeling on a chair. Excruciating pain that persists after cast removal Explanation: The most ominous sign of compartment syndrome is the loss of the arterial pulse. but she stopped running two years ago. She was a marathon runner in the past. However. Paresthesia (Choice A) is an early finding and can be associated with arterial pulses that are diminished and not absent. Educational Objective: The most ominous sign of compartment syndrome is the loss of the arterial pulse. Decreased dorsiflexion of the ankle on calf muscle compression E. as that signifies a cessation of blood flow to the extremity (Choice B). When the examiner squeezes the calf muscle on the normal side. fasciotomy is indicated. The physical findings are highly suggestive of a complete Achilles tendon rupture. Normal function will be regained in approximately two-thirds of patients if fasciotomy is performed within 12 hours of the onset of compartment syndrome. Decreased plantar flexion of the ankle on calf muscle compression C. Muscle tissue has impairment of function after 2-4 hours of ischemia and irreversible loss of function after 4-12 hours.

The risk of 45. She informs you that she is a lesbian now. X does not increase with increased maternal age. short webbed neck. She has had three heterosexual partners in the past four years. Which of the following is the best response? A. The recurrence risk is close to 25% D. A positive Thompson test further supports the diagnosis. XXY). Educational Objective: No increased recurrence risk is present after having an infant with Turner syndrome. more homosexual couples are now coming forward with their sexual orientation. (Choice B) Interestingly. Case 38 A 20-year-old Caucasian woman comes to see you in the office for a regular follow-up visit. No increased recurrence risk is present after having an infant with Turner syndrome. X). The mother is concerned about the recurrence risk of such an anomaly in subsequent pregnancies. It is important for a primary care physician to be knowledgeable and sensitive to their special needs and concerns. I agree with you. She wants to discontinue getting regular Pap smears now that she is not having sexual intercourse with men. and a cardiac murmur) is typical for Turner syndrome. Which of the following is the most appropriate response? A. E. You should have a Pap smear done every 3 . Explanation: Lesbian women often conceal their sexual orientation from their primary care physicians. Her last Pap smear two years ago was negative. With more recent developments and legislations regarding same sex marriages. and does not have any heterosexual partners. Case 37 A female infant born at term to a 28-year-old Caucasian woman has dorsal feet and hands edema. The recurrence risk is approximately 50% B. The risk increases with maternal age C. this explains why there is no Barr body on the buccal smear. unlike Down’s syndrome and Klinefelter’s syndrome (47. The recurrence risk is close to 10% E. You should still get a Pap smear every now and then. It is characterized by monosomy of the X chromosome (45. Sexual intercourse. Human papilloma virus (HPV) infection has been strongly linked with the development of cervical intraepithelial neoplasia (CIN) and invasive cervical cancer. short webbed neck. The recurrence risk is close to that of the general population Explanation: The clinical scenario described (dorsal feet and hands edema. the risk of having an infant with monosomy for the X chromosome does not increase with advance maternal age. Less common chromosomal abnormalities that can be present in patients with Turner syndrome include X chromosome mosaicism and Xp deletion. Buccal smear reveals no Barr body. and a cardiac murmur. Lesbian women still need . is the main risk factor for the acquisition of HPV infection. C. You should still get regular Pap smears every year.5 years. D. You should get a regular Pap smear if your other lesbian partner is HPV (human papilloma virus) positive. especially with multiple partners. there is no need for further Pap smears. B.Educational Objective: A complete Achilles tendon rupture leads to severe pain in the calf and the inability to stand up on the toes.

2% Platelet count 40. blood pressure is 130/80 mmHg.000/cmm Coagulation Tests Prothrombin time 19 sec INR 1. On day six of her hospitalization. Her symptoms gradually resolve over the next five days.. Her temperature is 36. The risk of cervical neoplasia is highest in lesbian women who have had sex with more than one male sexual partner. B and E) Increasing the screening interval or not screening lesbian women at all can lead to the delayed diagnosis and treatment of high-grade cervical intraepithelial neoplasia and cervical cancer.000/cmm Leukocyte count 10.78 PTT 60 sec . and takes no medications. The risk of acquiring HPV infection (and CIN/cervical cancer) is lower in lesbian women if they do not engage in sexual intercourse with men. and respirations are 22/min. The patient's pulse oximetry showed 94% on 4-liters of oxygen.to undergo routine screening for cervical cancer. Her baseline labs reveal the following: CBC Hb 13 g/dL Hct 38% Platelet count 240. or at the age of 21. Her partner’s HPV status does not change her risk of cervical cancer due to her previous sexual history. She has smoked one pack of cigarettes daily for the last 20 years. she complains of pain and pallor in her left arm.7 C (98 F). whichever is earlier. 64% of people answered this question correctly. She has had these symptoms for the past two days. The patient’s labs reveal: CBC Hb 12. whichever is earlier. She has no other medical problems. have been infected with HPV.6 g/dL Hct 37. Physical examination reveals a pale and tender distal left arm with diminished pulses. (Choices A. pulse is 98/min. V/Q scan of the chest reveals a high probability for pulmonary embolism. (Choice C) The patient should have an annual Pap smear even if her partner is HPV negative. and have been treated for an abnormal cervical cytology test in the past. The risk is also increased with cigarette smoking.000/cmm Leukocyte count 8. or at the age of 21. Case 39 The following vignette applies to the next 3 items A previously healthy 62-year-old African-American woman is hospitalized because of shortness of breath and chest pain.06 You start her on anticoagulation with unfractionated heparin and warfarin. Educational Objective: Annual screening by Papanicolaou smear is recommended for all women (including lesbian women) approximately three years after the onset of vaginal intercourse. have an early age at first coitus with men. Annual screening by Papanicolaou smear is recommended for all women approximately three years after the onset of vaginal intercourse.000/cmm Coags Prothrombin time 14 sec INR 1.

Warfarin induced skin necrosis D. Warfarin-induced thrombocytopenia Explanation: This patient had an arterial thrombosis of the left arm following the administration of unfractionated heparin. (Choice A) Even though his PT/INR is subtherapeutic. Most of these patients do not develop thrombocytopenia. and breasts. hemorrhage. This patient is well anticoagulated. Heparin-induced thrombocytopenia C. Type II HIT is a more serious immune-mediated disorder characterized by the formation of antibodies against heparin-platelet factor 4 complex. causing platelet activation and aggregation. The lesions are seen over the extremities. mesenteric) ischemia. Heparin-induced skin necrosis E. and cerebral sinus thrombosis. his PTT is therapeutic. High-dose warfarin induces a transient hypercoagulable state by causing a rapid reduction in protein C levels on the first day of therapy. trunk. Subtherapeutic anticoagulation B. It presents as an area of erythema. which is a well-known complication of heparin therapy. clinical course. Two forms of HIT have been recognized. means that the Educational Objective: HIT should be suspected in patients receiving heparin anticoagulation if they present with thrombocytopenia. (Choice C) Warfarin-induced skin necrosis has been reported in patients within the first few days of taking high doses of warfarin. which quickly progresses to purpura. The platelet count usually returns to normal with discontinuation of heparin. 74% of people answered this question correctly.000 to 60. although distal extremities can also be involved. She has developed heparin-induced thrombocytopenia (HIT). (Choice D) Heparin-induced skin necrosis is also a well-known complication of unfractionated heparin use. Spontaneous bleeding is unusual. Item 2 of 3 Which of the following is the most appropriate next step in the management of this patient? A. thrombosis with thrombocytopenia. and is usually associated with a lesser degree of fall in the platelet count (nadir platelet count of 100. venous limb gangrene. or a > 50% fall in the platelet count. 4. Patients have the platelet count in the range of 30. Immune-mediated HIT is associated with both venous and arterial thrombosis. and severity of the disease. and limb and organ (kidneys. myocardial infarction.000/microliter). pulmonary embolism. The heparin-platelet factor 4 antibody complex then binds to the platelet surface. The major manifestations of venous thrombosis are deep venous thrombosis. Type I HIT is seen within two days of initiation of heparin therapy. depending upon the onset.Item 1 of 3 Which of the following is the most likely cause of her condition? A. Arterial thrombosis can lead to strokes. such as the abdomen. leading to thrombocytopenia and platelet-rich clots.10 days after the initiation of treatment. It is not associated with thrombocytopenia. Discontinue warfarin .000/microliter. and there are no clinical consequences. It usually involves areas rich in fat. It typically develops 4 to 10 days after the initiation of heparin therapy. and necrosis.

and prevent antibody formation. Monitoring prothrombin time frequently B. (Choice A) Prothrombin time is used to monitor the effects and adjust the dose of warfarin. Substitution of unfractionated heparin with low molecular weight heparin D. such as danaparoid. as well as the development of HIT. They should be used for the prophylaxis and treatment of patients with HIT with or without thrombosis. It should be started at the same time as (or within 24 hours of) heparin administration. They should be anticoagulated with direct thrombin inhibitors for the prevention or treatment of thromboembolic complications. Educational Objective: . are associated with a much lower incidence of HIT compared with unfractionated heparin. The choice of agent depends on the coexisting medical conditions.000/microliter. All such patients should be anticoagulated with direct thrombin inhibitors such as lepirudin or argatroban. (Choice D) Low molecular weight heparin should not be substituted for unfractionated heparin because it can also cross react with heparin-induced antibodies. LMWH and heparinoids. not heparin. Another option is to limit heparin use to less than five days in order to prevent an antibody response. (Choice D) Initiating warfarin early can minimize the duration of heparin use. Discontinue unfractionated heparin C. even after the discontinuation of heparin. It will not prevent the formation of heparin-platelet factor 4 antibodies and their clinical consequences. The patients with HIT still remain at risk for thrombosis. while the dose of argatroban should be adjusted in patients with hepatic dysfunction. Initiating warfarin after 3 – 5 days of heparin therapy E.) (Choice B) Warfarin therapy alone may increase the risk of venous gangrene in patients with deep vein thrombosis. Discontinue unfractionated heparin and warfarin. Item 3 of 3 Which of the following would have been the most useful strategy in preventing the above condition? A. Using higher doses of heparin early in the course of treatment Explanation: The best way to prevent HIT is to use low molecular weight heparin (LMWH) instead of unfractionated heparin whenever possible.B. initiate argatroban Explanation: The first and the most important intervention in a patient with suspected or documented HIT is the immediate cessation of exposure to all heparin products. (Choices E and F) Development of HIT is independent of the dose used. Educational Objective: Exposure to both heparin and warfarin should be discontinued in patients with HIT. It does not affect the development of HIT. and has been reported to occur even with heparin flushes and the use of heparin-coated catheters. initiate low molecular weight heparin E. and induce more antibody formation. (Lepirudin should be used with caution in patients with renal insufficiency. Discontinue heparin and warfarin. Monitoring platelet counts frequently C. Discontinue warfarin and unfractionated heparin D. Its use should be avoided in the absence of other anticoagulants until the platelet count rises above 100. (Choice B) Monitoring the platelet counts will lead to early detection and treatment of HIT.

multiple 24-hour urine collections may be required to make a diagnosis of pheochromocytoma. His blood pressure is 126/84 mmHg. The thyroid is normal to palpation and without any obvious nodules. Start diuretics C. Many of these patients have a lower intravascular volume.7C (98F) and respirations are 16/min.The best way to prevent heparin-induced thrombocytopenia is by substituting unfractionated heparin with low molecular weight heparin. Urinary vanillylmandelic acid (VMA) can also be used with other tests as a screening test. Item 1 of 3 Which of the following is the most appropriate next step? A. it would be extremely difficult to interpret some of the biochemical test results. MRI of the abdomen E. Biochemical confirmation of the diagnosis is required before imaging is performed to localize the tumor. He has had at least two similar episodes for the past one and a half months." He currently has no medications. Measurement of urinary metanephrine and catecholamine levels is a good screening test that is used for biochemical diagnosis. During his prior visit to the ED for an identical episode. temperature is 36. he is more or less asymptomatic. (Choice D) MRI/CT is performed to localize the tumor only after biochemical confirmation of pheochromocytoma has been achieved. If these drugs are immediately started. some centers use measurement of plasma free metanephrine levels as the initial screening test. Confirmation of the diagnosis with these biochemical tests is required . his blood pressure was 149/98 mmHg. (Choice E) Treatment with alpha-blockers is not started before the biochemical diagnosis of pheochromocytoma is confirmed because these increase serum catecholamine and metanephrine levels. Both tests are ordered simultaneously. For this reason. pulse is 86/min. Alpha blockade Explanation: The patient has clinical features suggestive of pheochromocytoma. VMA has low sensitivity but higher specificity. He is requesting for "a presciption for some pills to prevent the recurrence of the symptoms. By the time you see him. A 24-hour urine collection is superior to spot urinary collection. metanephrine. Measure blood pressure after two weeks in the office B. Investigations should be started without further delay. Educational Objective: A biochemical diagnosis of pheochromocytoma is typically made by measurement of plasma free metanephrine levels or a 24-hour urine collection for measurement of catecholamine. which can be further aggravated by giving diuretics. Physical examination reveals a thin young male who appears anxious and diaphoretic. (Choice B) Diuretics are not good initial therapeutic agents for controlling the hypertension of patients with pheochromocytoma. and vanillylmandelic acid levels. Urine levels can be altered by a number of drugs and foods. (Choice A) This patient has features that are highly suggestive of pheochromocytoma. Case 40 The following vignette applies to the next 3 items A 29-year-old male comes to the emergency department (ED) because of palpitations and a severe headache. A 24-hour urinary metanephrine and free catecholamines D.

investigations to localize his tumor can be performed. The chances of intraoperative complications are much higher with inadequate preoperative alpha blockade. is required preoperatively to restore the intravascular volume. What is the next best step in the management of this patient? A. Approximately 10% of patients have bilateral adrenal pheochromocytomas. Beta-blockers are only given to patients who are adequately alpha blocked. MIBG can also be performed in patients with biochemically confirmed pheochromocytoma. Adequate alpha blockade preoperatively reduces intraoperative complications. and 10% are extraadrenal in location. but the CT or MRI are unable to localize the tumor. and the patient is taken for surgical removal of the tumor. MIBG scan is performed in patients who have borderline biochemical values.g. The sensitivity of MIBG scan is 70%. but with the CT showing an adrenal mass. although MRI can be more sensitive in localizing extraadrenal pheochromocytoma. Beta-blocking agent D. Patients should be treated for 10-14 days preoperatively before surgical resection can be performed. During the procedure. Which of the following is the most appropriate therapy for this patient’s hypotension? .before imaging is performed for tumor localization. Metaiodobenzylguanidine (MIBG) scan Explanation: Alpha blockade is started after biochemical confirmation of the diagnosis of the pheochromocytoma is made. *Extremely important question for USMLE step-3 Item 2 of 3 The diagnosis is confirmed. CT/MRI of adrenals B. (Choice A) CT/MRI is typically done while the patient is on alpha blockade. along with liberal salt and fluid intake. (Choice C) Beta-blocking agents started before alpha blockade can lead to paradoxical increase in the blood pressure. Alpha blockade.. In addition. A number of drugs (e. Majority of patients require 40-80 mg of phenoxybenzamine daily. His blood pressure falls from 110/89 mmHg to 80/50 mmHg. alpha-blockers) can interfere with the biochemical test results. Alpha-blocking agent C. Removal of tumor E. Educational Objective: Alpha blockade is done for 10-14 days preoperatively to control hypertension and restore intravascular volume. *Extremely important question for USMLE step-3 Item 3 of 3 The appropriate steps are taken. While the patient is started on a preoperative surgical regimen. he rapidly becomes hypotensive. (Choice E) MIBG resembles norepinephrine and is taken up by pheochromocytomas. The most common agent used for preoperative preparation is the long-acting noncompetitive alpha-blocker phenoxybenzamine. MRI can sometimes differentiate benign from malignant pheochromocytoma. (Choice D) Removal of the tumor (after localization) is performed after adequate alpha blockade. CT and MRI have equal sensitivities for tumor localization. Beta blockade is only preformed after alpha blockade is complete.

specificity 85%. (Choices D & E) Dopamine and dobutamine are less effective in patients with pheochromocytoma and intraoperative hypotension because majority of these patients are on preoperative long-acting alpha blockade. Sensitivity C. Sensitivity D. Possible benefits of colloid are rapid restoration of intravascular volume and decreased chances of pulmonary edema. *Extremely important question for USMLE step-3 Case 41 Several tests have been developed to measure the serologic markers of breast cancer. These tests have different specificities and sensitivities for the early stage of breast cancer.A. Sensitivity B. (Choice B) Intravenous colloid may have theoretical benefits compared to crystalloid normal saline. some patients with pheochromocytoma have intraoperative complications. Intravenous phentolamine bolus D. In this case. specificity 75%. specificity 90% 97% 94% 92% 90% . specificity 65%. Finally. Studies have not shown that colloids are superior to the use of crystalloid solution in the management of acute hypotension. Dobutamine infusion Explanation: Even with adequate preoperative alpha blockade. Educational Objective: Intraoperative hypotension in patients with pheochromocytoma responds to an intravenous bolus of normal saline. (Choice E) Increasing the sensitivity of the test will increase the negative predictive value. the test with the highest specificity is the best choice. (Choice C) Intravenous phentolamine is used for acute hypertension intraoperatively. Dopamine infusion E. Sensitivity E. If positive. Vasopressors are less effective than a bolus of normal saline. Sensitivity Explanation: A high specificity increases the positive predictive value (PPV) of the test: PPV = True Positives / (True positives + False positives) Confirmatory tests must have a high specificity. the vascular response to vasoconstrictors is reduced. One of the important intraoperative complications is hypotension. therefore. colloids are more expensive than normal saline. Educational Objective: 80%. Bolus of normal saline followed by continuous normal saline infusion B. The use of colloid is not superior to the use of normal saline bolus for the management of intraoperative hypotension. thereby leading to a marked decrease in the vascular tone. The resulting intraoperative hypotension responds nicely to a normal saline bolus followed by infusion. Intravenous colloid bolus C. This generally occurs after the removal of the tumor. which of the following tests will have the highest predictive value for the disease? A. which is followed by a decrease in circulatory catecholamine levels and alpha blockade. since this high specificity decreases the number of false-positive results and helps ‘RULE OUT’ the disease. Intravenous bolus of phentolamine is used for acute severe hypertension (not hypotension) during surgery for pheochromocytoma. specificity 70%.

Address the patient by first name as well B. There is some debate regarding whether a patient should ever be called by first name.’ followed by her surname E. She denies any chest pain or difficulty in breathing." (Choice C) should be used if the patient has indicated it to be her preference.’ followed by her surname D.Confirmatory tests must have a high specificity. "Madam President" or "Madam Ambassador"). therefore. Smith" or "Mr. What is the appropriate response on the part of the attending physician? A. Using this form of address with all patients may be interpreted as sarcasm. Keep in mind that some women do not want reference made to their marital status. Her daily medications include L-thyroxine and hydrochlorothiazide. In addition. If an attending wants to discuss the matter of proper salutation with the resident.g. 45% of people answered this question correctly. Case 43 The following vignette applies to the next 2 items A 55-year-old Caucasian woman is admitted to the hospital with symptoms of left leg pain and swelling of two weeks duration. if a patient is called by her first name. Openly reprimanding the resident (Choice E) is excessively harsh if the resident otherwise appeared to have good intentions in speaking with the patient. Smith" and not by first name. This high specificity helps ‘RULE OUT’ the disease by decreasing the number of false-positive results. even if they so request it. 35% of people answered this question correctly. who may feel obligated to defend the resident." is more often used. The doctor-patient relationship may needlessly suffer if the doctor speaks informally without direct permission to do so. Addressing the patient by the first name (Choice A) is presumptive and risks alienating the patient.. and by increasing the positive predictive value. During morning rounds." as that properly demonstrates the respect due the patient (Choice D). it is best to do so outside of the patient’s presence. it is best to err on the side of formality rather than informality. Address the patient with the salutation ‘Madam’ followed by her surname C. Ultimately. then the physician too must be called by his first name. which is why the salutation "Ms. Keep in mind as well that older patients or patients with a different cultural heritage (such as the woman in this question) are often very sensitive to being spoken to in a manner that they perceive as disrespectful. It also creates an awkward situation for the patient. Address the patient with the salutation ‘Mrs. some ethicists insist that the level of formality in address must be applied mutually. Reprimand the resident and send him from the room Explanation: New patients should always be addressed as "Ms. Smith. she has been on hormone replacement therapy (HRT) with estrogenprogestin combination for the last two years for intractable postmenopausal symptoms. The salutation of "Mrs. Educational Objective: New patients should be addressed as "Ms. Case 42 A 70-year-old widowed African-American woman is admitted late one night to the hospital for an acute exacerbation of her congestive heart failure. the medical team responsible for this woman’s care meets with her for the first time. The salutation of "Madam" (Choice B) is typically used for individuals of high standing (e. Smith" or "Mr. Address the patient with the salutation ‘Ms. The senior resident begins to ask the patient some questions about her medical history and addresses her by first name. She has a past medical history of hypothyroidism and hypertension. She smokes a . Specifically.

The primary goal of therapy is to prevent clot extension and prevent acute pulmonary embolism. Anticoagulation is indicated for all patients with symptomatic proximal DVT. Lower extremities Doppler reveal the presence of left proximal femoral deep vein thrombosis. HRT should be tapered gradually because an abrupt discontinuation can precipitate a flare of postmenopausal symptoms. (Choice A) HRT has been associated with an increased risk of venous thromboembolism (VTE). and the Women's health initiative have suggested a two-fold increase in the risk of VTE with HRT use. and should be overlapped for at least four to five days. she has pitting edema and warmth over the left lower leg. Therapy with heparin should be continued for at least five days. as long as she promises to quit smoking B. warfarin should always be started after the patient has been under the cover of unfractionated or LMW heparin. Discontinue hormone replacement therapy immediately B. There is no need to repeat the ultrasound. She should stop HRT and switch to tamoxifen for hot flashes .3. Oral anticoagulation with warfarin can be started simultaneously. She can continue HRT. Item 1 of 2 Which of the following is the most appropriate next step in the management of this patient? A. HRT should therefore be discontinued in patients with an increased risk of DVT or a documented DVT. She wishes to continue taking HRT as it makes her ‘look and feel good. You counsel her regarding the side effects of continuing hormone replacement therapy and the duration of anticoagulation. (Choice E) DVT documented by an initial ultrasound should be treated with full anticoagulation. however. which can rarely lead to warfarin-induced skin necrosis. Patients with DVT or pulmonary embolism should be treated with unfractionated intravenous heparin or low molecular weight (LMW) heparin. Start her on warfarin 5 mg a day C. Start her on weight-based unfractionated heparin E. (Choice F) The patient has no clinical features of an acute pulmonary embolization Educational Objective: Anticoagulation with heparin followed by warfarin is indicated in all patients with symptomatic deep vein thrombosis.0) for at least two days. (Choices B and C) Warfarin causes a rapid reduction in the protein C levels on the first day of therapy. Treatment with intravenous unfractionated or LMW heparin should be continued until the INR (International normalized ratio) has been therapeutic (2. On physical examination. She should stop HRT and continue warfarin for at least three months D. LMW heparin is generally recommended over unfractionated heparin. if she agrees to daily subcutaneous. especially in the first year of use. Item 2 of 2 You manage the patient appropriately. Start her on warfarin 10 mg a day D. Furthermore. if she takes warfarin for at least six months C.0 . She can continue HRT without any additional risks. She can continue HRT. Observational studies. low-molecular eight heparin therapy E. Repeat the ultrasound in a week Explanation: The patient has developed a deep vein thrombosis (DVT) of the left femoral vein. This induces a transient hypercoagulable state. For these reasons. and she is ready for discharge on the fifth hospital day.’ Which of the following is the most appropriate response? A. the HERS trial. it takes time to have a therapeutic effect.pack of cigarettes a day.

highly suggest an overdose of aspirin or another drug that causes metabolic acidosis. non-tender. patients with a first thromboembolic event in the presence of a reversible risk factor should be treated with anticoagulation for at least three months. Examination reveals an awake. No motor or sensory focal deficit is present. respirations are 26/min. A 12lead electrocardiogram (EKG) shows sinus tachycardia. metabolic acidosis. or a recurrent thromboembolic event should be treated for a prolonged period of time. patients with an idiopathic first event. Anxiety B. It is not recommended to increase the duration of anticoagulation or to switch to LMW heparin in order to facilitate the continuing use of HRT. There are guidelines based on the evidence-based recommendations of the sixth ACCP Consensus Conference on Antithrombotic therapy. cough or chest pain. She denies shortness of breath. vomiting.4 F). The initial manifestations of salicylate intoxication are tinnitus. Drug overdose E. D. Pulmonary embolism D. She has no known drug allergies. Her temperature is 38 C (100. The abdomen is soft. Lungs are clear. She uses marijuana occasionally and drinks one glass of beer daily. Diastolic heart failure C. The patient is given intravenous fluids and 1-liter oxygen per nasal cannula. and should not be recommended. and non-distended. along with her history of illicit drug intake and aspirin use. She is placed on continuous EKG monitoring. B. After a few hours. and F) All patients on HRT with a documented DVT should be strongly urged to stop hormone replacement therapy. blood pressure is 120/80 mm Hg. but mildly drowsy young woman with dry mucus membranes. A portable chest x-ray reveals no abnormalities: the lung fields are clear. In contrast. She has smoked one pack of cigarettes daily for the past twenty years. According to these guidelines. Smoking cessation alone will not prevent the future episodes of thromboembolism. and hyperventilation eventually develop. there is no cardiomegaly or effusions. these have been present for the past few hours. She complains of nausea. bowel sounds are present. fluoxetine and low-dose prednisone. Laboratory tests are ordered. (Choice E) Tamoxifen has no role in the prevention of hot flashes in postmenopausal women. Her medications include aspirin. Meningeal signs are absent. In contrast. Fever. who noticed that she had been "breathing heavily" and had been restless for the last couple of hours. Case 44 A 38-year-old Caucasian woman is brought to the emergency department by her coworkers. nausea. (Choices A. when she started to become drowsy. Hyperventilation without dyspnea is suggestive of . Acute bacterial pneumonia Explanation: The patient’s symptoms. a depressed level of consciousness will ensue. and mild gastrointestinal discomfort. and oxygen saturation is 99% at room air. Heart sounds are normal. pulse is 100/min. There is no rebound tenderness or rigidity. continuing risk factor. these may increase the risk of endometrial hyperplasia and cancer due to the loss of the protective effects of progesterone. restlessness. dizziness and tinnitus. Her other medical problems include rheumatoid arthritis and depression. vomiting. Item 1 of 2 Which of the following is the most likely cause of her condition? A.Explanation: It is important to consider the presence or absence of risk factors before deciding on the duration of anticoagulation therapy. Educational Objective: A first episode of thromboembolism in the presence of reversible or time-limited risk factors should be treated for at least three months to prevent recurrence. Estrogen-only preparations carry the same risk of causing venous thromboembolism.

as well as the patient’s denial of dyspnea.25 pO2 110 mm Hg pCO2 20 mm Hg Which of the following is the most appropriate next step in management? . tachycardia and tachypnea. (Choice A) The presence of fever. the patient is a potential drug abuser. there is no clinical evidence of heart failure in this case. Item 2 of 2 The patient continues to be drowsy.8 C (100 F). Educational Objective: Dyspnea is the subjective sensation of labored or difficult breathing. Metabolic acidosis must be suspected as the cause of hyperventilation (compensatory respiratory alkalosis) without dyspnea if there is no evidence of cardiac or pulmonary disease. (Choice E) The patient does not have a history of cough. arterial blood pH 7. however. but she is now easily arousable. nausea. there are no other indications of cardiac or pulmonary compromise. blood pressure is 120/70 mm Hg. dyspnea or sputum production. pulse is 104/min. Her laboratory tests reveal the following: CBC Hb 13.9 mg/dL Serum K 4. (Choice B) Although diastolic dysfunction can be suspected in a patient with signs and symptoms of heart failure with a normal ejection fraction. normal chest x-ray and mild fever. and there are signs and symptoms compatible with compromise of other organs.e. For these reasons. Her temperature is 37.8 mg/dL Aspartate aminotransferase 150 U/L LFT Total bilirubin 1. drowsiness.3 mEq/L Bicarbonate 17 mEq/L Serum creatinine 1. points to an organic cause of her disease. Athletes and well-trained individuals develop dyspnea only when doing hard work or exercise..8 g/dL Ht 41% MCV 91fl Platelet count 320. while sedentary subjects may experience it even after minor efforts.respiratory alkalosis. this diagnosis cannot fully explain the patient’s other presenting characteristics (i. The chest xray is clear. Aside from tachycardia and tachypnea. (Choice C) Pulmonary embolism can present with sinus tachycardia. and her oxygen desaturation is 99%. Hyperventilation associated with metabolic acidosis is hardly ever accompanied by dyspnea. which may be a compensatory response to the metabolic acidosis.000/cmm Leukocyte count 6. and oxygen saturation is 100% with one-liter nasal cannula. respirations are 28/min. oxygen saturation is 99%. vomiting and tinnitus).3 mg/dL Alkaline phosphatase 200 U/L Alanine aminotransferase 110 U/L Gases.6 mg/dL Blood glucose 75 mg/dL Direct bilirubin 0. drowsy state without being hypoxic.000/cmm Segmented neutrophils 70% Bands 2% Eosinophils 2% Lymphocytes 18% Monocytes 8% Serum chemistry Serum Na 145 mEq/L Chloride 108 mEq/L BUN 30 mg/dL Calcium 9. the possibility of pneumonia is very unlikely.

Therapy is aimed at eliminating the offending agent through gastric lavage and administration of activated charcoal. with a pH of 7. (Choice C) The patient is dehydrated. Intravenous antibiotics B. Other abnormal findings are the moderately elevated aminotransferases. Repeat cytology in 6 months B. and there is no evidence of infection. antibiotics are not needed because the cause of her hyperthermia is drug overdose. while the white blood cell count is normal.25. transient hepatotoxicity. Gastric lavage and alkalinization of the urine Explanation: The patient has moderate metabolic acidosis. Case 45 A 36-year-old Caucasian nulligravida presents to your office for a routine check-up. severe encephalopathy and non-cardiogenic pulmonary edema. Intravenous furosemide D. Educational Objective: Salicylate overdose presents with high anion gap metabolic acidosis. and a high-grade squamous intraepithelial lesion (HGSIL) is present. and the results indicate that the sample is satisfactory. (Choice A) Even though the patient is febrile. Lactulose and metronidazole will not be useful here. It is important to determine salicylate serum levels. acute renal failure and depressed mental status. Oral lactulose and metronidazole C.A. because a friend of hers was recently diagnosed with invasive cervical cancer. Values greater than 35 mg/dL indicate significant acidosis. Therapy consists of gastric lavage. The clinical vignette is consistent with aspirin overdose. ranging from 8-16). You perform a Pap smear. Her anion gap is high (normal anion gap: 12. Proceed with colposcopy C. Aspirin causes uncoupling of the oxidative phosphorylation. (Choice D) Non-invasive mechanical ventilation is not needed as the patient does not have pCO2 retention and is not in ventilatory failure. Do excisional biopsy E. She is concerned about the possibility of cervical cancer. Do HPV testing D. (Choice B) The encephalopathy in this case is due to intoxication and metabolic acidosis. administration of activated charcoal. which can be due to dehydration or acute interstitial inflammation. which is associated with the development of acute renal failure and transient hepatotoxicity. which can lead to coagulopathy. Her past medical history is insignificant. a bicarbonate level of 17 mEq/L and an anion gap of 20 (obtained by subtracting the values of bicarbonate and chloride from the sodium). vomiting can be induced. not hepatic disease. compensatory respiratory alkalosis. Her slightly elevated BUN and creatinine levels indicate mild renal failure. and alkalinization of the urine is indicated to enhance aspirin excretion. Giving furosemide will aggravate her dehydrated status and renal failure. Which of the following is the next best step in the management of this patient? A. Non invasive mechanical ventilation E. resulting in hyperthermia. Reassure and repeat Pap smear in 12 months Explanation: . If the mental status is optimal. and alkalinization of the urine to enhance secretion.

she appears to be normal and playful. thelarche. Lab investigations in patients with hypothalamic hamartoma reveal gonadotropin levels in the pubertal range and elevated estrogen levels. pubarche. Hypothalamic hamartoma C. Adrenal tumor D.HGSIL revealed on Pap smear indicates a 1-2% probability of already having invasive cervical cancer and a 20% probability of acquiring invasive cervical cancer if left untreated. Educational Objective: If a Pap smear reveals a high-grade squamous intraepithelial lesion (HGSIL). (Choice C) HPV testing may be indicated if cytologic examination reveals atypical squamous cells of undetermined significance (ASCUS). FSH. Excessive androgen production can . and estradiol levels are within normal range for her age group. TSH and prolactin levels are within normal limits as well. change in genitalia. She has 3 cm of breast tissue on both sides. (Choice C) Adrenal tumors which lead to the excessive production of estrogen are exceedingly uncommon. Benign premature thelarche B. McCune-Albright syndrome Explanation: The clinical features in this patient are consistent with benign premature thelarche. and menarche. Their final height is generally not compromised. (Choice B) Hypothalamic hamartomas secrete GnRH and cause central isosexual precocious puberty in both males and females. rapid increase in height. Immediate referral for colposcopy and endocervical curettage is indicated. Case 46 An 18-month-old girl is brought to the office by her mother because of bilateral breast enlargement for the last three months. The results of HPV testing may influence the decision to proceed with a colposcopy in such cases. What is the most likely cause of this patient's breast enlargement? A. or change in body habitus. The treatment for benign premature thelarche is expectant because majority of the patients remain stable or have reversal of the breast enlargement in a few months. Her genitalia are normal. Her height and weight are at the 75th percentile on the growth curve for normal females (her weight and weight has remained at the 75th percentile on this growth chart for the last year). visual problems. Majority of these patients will require treatment with a GnRH analog. and menstrual bleeding. Ovarian tumor E. growth of axillary or pubic hair. She has no known medical problems. There is no history of headaches. which is characterized by bilateral breast enlargement not accompanied by other signs of isosexual precocious puberty. The rest of the physical examination is within normal limits. a diagnostic excisional procedure should be performed. On physical examination. increase in bone maturity. Central precocious puberty is characterized by rapid acceleration of height. These other signs of precocious puberty include rapid increase in height. She has stage 1 pubic hair and no axillary hair or odor. immediate referral for a colposcopy is indicated. (Choice D) If colposcopy suggests HGSIL. increase in bone age. adrenarche. Patients with benign premature thelarche have a normal hormone profile. Adrenal tumors can produce cortisol and androgen. appearance of axillary and pubic hair. Her LH. 79% of people answered this question correctly. (Choices A and E) Repeating the cytology in 6 or 12 months is not correct because invasive cervical cancer can be missed.

metformin is typically held before or at the time of procedure. and is characterized by accelerated height and bone age. sepsis. Major contraindications include renal insufficiency (creatinine more than 1. He has a strong family history of premature coronary artery disease. and weighs 180 lbs. (Choice D) Estrogen production from an ovarian tumor can lead to peripheral precocious puberty. On examination. The cause of precocious puberty in McCune-Albright syndrome is excessive production of estrogen from ovarian cysts. It should not be restarted unless normal renal function is documented following the procedure. This patient does not have any features to suggest McCune-Albright syndrome. Excessive cortisol secretion leads to Cushing’s syndrome. The patient has had diabetes for the past six years. He went to the emergency department about 7 days ago following an episode of chest pain. hepatic dysfunction. fibrous dysplasia of the bone. (Choice E) McCune-Albright syndrome consists of "café-au-lait" spots. and congestive heart failure.000 mg twice daily) for the past several years. His chemistry profile and CBC from his last emergency department visit were normal. Discontinue aspirin E. This syndrome has similar clinical features as hypothalamic hamartoma. Stop hydrochlorothiazide C. His blood pressure is 136/70 mmHg and pulse rate is 66/min. 1. He also has a history of hypertension that is controlled with atenolol (50 mg once daily) and hydrochlorothiazide (12. he is 5?6" (165 cm) tall. Because of its potential to cause renal dysfunction when a large amount of contrast is being infused. The rest of the clinical examination is normal. Treatment is usually surgical. He smokes one pack a day.cause virilization in females (heterosexual precocious puberty) and peripheral isosexual precocious puberty in males. . Case 47 A 46-year-old male with type-2 diabetes mellitus is scheduled to undergo cardiac catheterization in two days for an undiagnosed episodic chest pain. (82 kg).5 mg once daily). Baby aspirin (81 mg once daily) was started on his last emergency room visit. No change in therapy until cardiac catheterization Explanation: Metformin was approved in the United States for the treatment of type-2 diabetes after its use in the rest of the world showed that the chances of lactic acidosis are minimal when used in patients without any contraindications. Increase atenolol D. The treatment of benign premature thelarche is expectant because majority of patients remain stable or improve in a few months.4 mg/dl in females or creatinine clearance less than 60 ml/min). 58% of people answered this question correctly. What is the next best step in this patient?s care? A. He does not perform selfmonitoring of his blood sugar. and has been on metformin (1. and menstrual bleeding. He was admitted overnight. Educational Objective: Benign premature thelarche occurs at 18 to 24 months of age and is characterized by breast enlargement without other features of precocious puberty. His EKG revealed nonspecific ST-T changes. and precocious puberty. and he left against medical advice when three sets of cardiac enzymes were negative. The patient has been having retrosternal chest pain radiating to his arm for the past 15 days. and drinks alcohol socially. The pain is gradually becoming more frequent.5 mg/dl in males. Hormonal profile reveals elevated estradiol in the presence suppressed LH and FSH. Stop metformin B. alcoholics.

there is no tenderness or guarding. Send him for stat endoscopy E. red colored blood. It should also be stopped in patients who are at risk to develop renal failure. Item 1 of 3 What is the next best step in the management of this patient? A. Spider angiomas and palmar erythema can be identified on closer inspection. The cardiovascular examination is within normal limits. Give the patient intravenous propranolol Explanation: Based on the above presentation. While in the ED. There is evidence of mild hepatomegaly. Perform the endotracheal intubation B. His clothes are dirty and torn. Adequate control and protection of the airway should always be a priority in the initial management of all patients with active or recent variceal bleeding. because it may cause platelet dysfunction that can last for more than a week. associated with any problems with cardiac (Choice C) There is no need to increase atenolol dosage. Case 48 The following vignette applies to the next 3 items A 46-year-old Hispanic man is brought by the police to the emergency department (ED). He is extremely drowsy. Initiate aggressive fluid resuscitation C. His abdomen is soft. and respiratory rate is 12/min. (Choice E) Metformin needs to be discontinued before cardiac catheterization. he has a large emesis with gross bright. sepsis. This can be initially done by keeping the patient in a left decubitus position or by gastric decompression via the insertion of a nasogastric tube. His breath smells of alcohol. the patient is most likely suffering from an acute variceal hemorrhage secondary to chronic alcoholic liver disease. In procedures where an increased risk for bleeding is expected. the complications of bleeding and its treatment are responsible for a significant amount of morbidity and mortality in these patients. Educational Objective: Metformin use is contraindicated in patients with renal failure. If the . because the patient appears to be adequately beta-blocked. hepatic dysfunction. He has decreased breath sounds at the lower base of the right lung. and severe heart failure.(Choice B) Hydrochlorothiazide is usually not catheterization. disoriented and unresponsive to any of your questions. Start the patient on IV octreotide D. a procedure that involves infusion of a high load of contrast agents. In patients who are disoriented and unresponsive. blood pressure is 96/75 mmHg. heart rate is 110/min. and there is evidence of vomitus on his lips and clothes. Acute variceal hemorrhage is a major cause of death in patients with chronic liver disease or cirrhosis. the airway can be secured via endotracheal intubation to prevent the risk of aspiration and its complications during active bleeding or its treatment. aspirin should be discontinued at least seven days before the procedure. He has a disheveled appearance. Apart from the acute blood loss. especially when used in low doses. and control active bleeding. such as those who will undergo angiography. and has cool extremities. 37% of people answered this question correctly. His temperature is 36 C (97 F). prevent the complications of bleeding and its treatment. (Choice D) Aspirin can be continued safely during cardiac catheterization. The police found him unresponsive on a bench in a nearby park. The primary goal of management of patients with variceal hemorrhage is to maintain hemodynamic stability.

The upper GI endoscopy shows large esophageal varices with evidence of recent bleeding. and remains high for the first six weeks following the cessation of active bleeding. You suspect that he is having acute alcohol withdrawal. He is admitted to the hospital for further observation and management. (Choices B and D) Endoscopic treatment with band ligation or sclerotherapy is the treatment of choice for active variceal bleeding. he appears to be hemodynamically stable. Give the patient intravenous propranolol Explanation: Urgent upper GI endoscopy with either injection sclerotherapy or band ligation is the definite treatment of choice for patients with active variceal hemorrhage. (Choice E) Intravenous propranolol has no role in the management of active variceal bleeding. as in the above vignette. On his fourth day of hospitalization. Sengstaken-Blakemore tube insertion E. heart rate is 96/min.patient is hemodynamically unstable at the initial presentation. large varices. he becomes extremely disoriented and belligerent. should be a priority in all patients with active variceal hemorrhage. He is started on treatment for alcohol withdrawal. Some of the known risk factors for early re-bleeding include an age greater than 60 years. If there is any evidence of hemodynamic compromise. Item 2 of 3 The initial appropriate steps were taken for the patient. Repeat endoscopy and band ligation B. (Choice B) Although the patient has had an acute bleeding episode. which is treated with injection sclerotherapy. it is important to secure his airway with endotracheal intubation at this point before instituting any specific therapy. aggressive fluid resuscitation and airway management should be performed simultaneously. It is generally successful in controlling acute bleeding in 80-90% of the patients. Sengstaken-Blakemore tube insertion for balloon tamponade or TIPS procedure should be employed to achieve hemostasis only if the endoscopic treatment fails to control the bleeding. (Choices C and D) The patient should not be sent for any specific treatment before securing his airway. . All patients with a recent variceal hemorrhage are at a high risk of recurrent hemorrhage or early re-bleeding. followed closely or simultaneously by hemodynamic resuscitation. more definitive treatment with either balloon tamponade or portosystemic shunt should be used to control the active bleeding. This risk of re-bleeding is greatest within the first 48-72 hours. What is the most appropriate next step in the management of this patient? A. he has another episode of large bloody emesis. Educational Objective: Airway protection. and respiratory rate is 13/min. and his condition improves over the next day. a repeat endoscopy with band ligation should be attempted initially to achieve hemostasis. Perform a Transjugular intrahepatic portosystemic shunt C. and the presence of renal failure. His current temperature is 36. If the patient continues to bleed despite endoscopic treatment. In all patients who have another episode of variceal bleeding more than 48 hours after the initial endoscopic treatment. blood pressure is 112/66 mmHg. Airway protection should be the priority at this time.2 C (97. High-dose intravenous octreotide D. The patient in the above vignette has marked disorientation and can deteriorate rapidly with further recurrent episodes of bleeding. aggressive resuscitation and airway protection should be done simultaneously. therefore. severe initial bleeding. On the second day of hospitalization.4 F).

if left untreated. Follow-up endoscopy every six months Explanation: All patients with a history of variceal hemorrhage are at high risk for re-bleeding or recurrent variceal hemorrhage. Item 3 of 3 The appropriate step is taken. Educational Objective: Non-selective beta-blockers (propranolol or nadolol) have been shown to reduce the risk of re-bleeding in patients with a history of variceal hemorrhage. Cimetidine D. but not isolate them C. This is likely due to reduction in the portal pressure or hepatic vein pressure gradient seen with the use of non-selective beta-blockers. and she has no history of recent travel. (Choice E) Regular endoscopic treatment with band ligation is the treatment of choice for long-term management of variceal hemorrhage. In addition to providing counseling to completely stop alcohol consumption. propranolol (non-selective beta-blockers) has been shown to reduce the risk of recurrent variceal hemorrhage. Of all the above available options. the patient is ready for discharge. Therefore. the parents of her classmates insisted on having their children screened for giardiasis. 74% of people answered this question correctly. it is important to institute specific measures to prevent recurrent variceal hemorrhage. and returns to baseline by six weeks. Isolate all carriers B. proton pump inhibitors or prostaglandin analogs have not been shown to reduce the risk of recurrent variceal hemorrhage. Her past medical history is insignificant. Treat all carriers and people at risk . Her stool sample is positive for Giardia lamblia trophozoites. however. After hearing about her condition. (Choices A. One week later. Twenty percent of the class turned out to be positive for Giardia cysts on stool ova and parasite test.(Choice C) Somatostatin or intravenous octreotide can initially be used in patients with suspected acute variceal hemorrhage. which of the following is the treatment of choice to reduce recurrent bleeding? A. Treat all carriers and their family members D. Follow-up endoscopy alone has no role in the prevention of recurrent bleeding. It should not replace endoscopic treatment as a more definite procedure of choice for acute variceal hemorrhage. and D) H2 blockers (Cimetidine). This risk is greatest in the first few days. Prostaglandin analogs E. Case 49 A 12-year-old Caucasian female develops an episode of severe diarrhea that requires hospitalization. Recurrent bleeding is one of the important causes of death in such patients. Proton pump inhibitors B. Treat only symptomatic carriers E. Treat all carriers. Which of the following is the best strategy to manage giardiasis in this case? A. approximately 70% of the patients suffer from recurrent variceal bleeding within the first year from the initial bleeding episode. C. Educational Objective: Endoscopic therapy with either band ligation or sclerotherapy is the definite procedure of choice for early re-bleeding in patients with recent variceal hemorrhage. Propranolol C.

His mouth is open wide and his tongue is protruding. except in specific instances such as in outbreak control and for prevention of household transmission by toddlers to pregnant women and patients with hypogammaglobulinemia or cystic fibrosis. (Choice A) Asymptomatic infection occurs in approximately 60 percent of people exposed to Giardia. Symptomatic patients with giardiasis should receive appropriate treatment. he appears toxic. The threshold for performing intubation should be very low. Since the outpatient setting is inadequate for such procedures. He is leaning forward and moving around restlessly. if a lateral neck radiograph is deemed necessary. C and E) Asymptomatic carriers are not usually treated.Explanation: Giardiasis has several routes of transmission: person-to-person. and (2) in male homosexuals. Case 50 A 6-year-old boy is brought to the pediatrician after a sudden onset of fever and difficulty in breathing. it will reveal a swollen epiglottis (the "thumbprint sign") in classic epiglottitis. it is imperative that an ambulance be called so the child’s condition can be properly addressed by emergency personnel. However. When it does occur. (Choices B. he was complaining of a sore throat and some trouble swallowing yesterday. Call ambulance and send to emergency department Explanation: With the introduction of the Haemophilus influenzae type b vaccine in 1985. According to his mother. His voice is muffled. Perform laryngoscopy in office C. Respiratory arrest is easily provoked at this stage. however. Asymptomatic cyst carriage can last over six months. because he is at great risk for respiratory arrest. What is the most appropriate course of action? A. . food-borne and waterborne. Personto-person transmission occurs in two settings: (1) in institutions where there is fecal incontinence and poor hygiene (e. epiglottitis is diagnosed solely by the clinical presentation. (Choice A) Frequently. except in specific instances such as outbreak control and for prevention of household transmission by toddlers to pregnant women and patients with hypogammaglobulinemia or cystic fibrosis. Educational Objective: Asymptomatic carriers of Giardia lamblia are not usually treated. In the child in this case.g. Administer corticosteroids and racemic epinephrine E. 38% of people answered this question correctly. Refer to local pediatric hospital for laryngoscopy D. epiglottitis has become much less common in recent years. but these symptoms resolved after he received some over-the-counter analgesics. some daycare centers). and treatment should be focused on relieving any airway obstruction and treating the infection. Obtain lateral neck radiograph B. an endotracheal intubation should be performed before the radiograph is obtained.. (Choices B and C) Laryngoscopy can be used to exclude other causes of airway obstruction in a cooperative child. it causes an inflammatory edema of the epiglottis that impinges upon the airway. There is no need to isolate asymptomatic carriers once appropriate hygienic measures are undertaken. it is not recommended for cases of suspected epiglottitis as it may worsen the patient's condition. On physical examination.

The patient is admitted to the hospital. Oxygen saturation on room air by pulse oximetry is 91%. These children should be kept in respiratory isolation. but may be beneficial in patients with an underlying chronic lung disease and in those with prior wheezing episodes. blood pressure is 90/60 mm Hg. decongestants. 55% of people answered this question correctly. Respiratory isolation and ribavirin therapy D. Short course of corticosteroids C. patients who are hypoxic or cannot feed because of distress should be hospitalized. His past medical history is insignificant. mild upper respiratory symptoms. In healthy infants and young children. Treatment should be focused on relieving any airway obstruction and treating the infection. Respiratory isolation and erythromycin for 7-10 days Explanation: This patient presents with a clinical picture that is most consistent with bronchiolitis: young age (less than 2 years). Respiratory isolation and trial of bronchodilators B. Case 51 The following vignette applies to the next 3 items A 9-month-old Caucasian male is brought to the emergency department on one winter night with oneday history of poor appetite. and the cost for a course of therapy is substantial. and all his vaccinations are up-to-date. and respirations are 40/min. Educational Objective: Although there is no strong evidence that inhaled bronchodilators are effective in patients with bronchiolitis. life-threatening infection. . (Choice B) Corticosteroids are not routinely recommended. Educational Objective: Epiglottitis is a serious. Humidified oxygen and tube or intravenous feedings are indicated. (Choice C) Although ribavirin is a nucleoside analogue with good in vitro activity against RSV. The liver edge is palpable. The liver and spleen are palpable because of hyperinflation of the lungs. He has been meeting all developmental milestones appropriately. and expectorants are of no value in the treatment of patients with bronchiolitis. Item 1 of 3 Which of the following is the best management for this patient? A. Lung auscultation reveals expiratory wheezing and prolonged expiration. pulse is 150/min.3 C (101 F). most clinicians discontinue these drugs. Administer decongestants and expectorants E. mild-to-moderate fever and wheezing are typical. Chest-x ray shows hyperinflation.(Choice D) Corticosteroids and racemic epinephrine have not been shown to be helpful in the treatment of epiglottitis. It is usually reserved for patients with severe disease. studies examining its effect in children have been conflicting. The threshold for performing intubation should be very low. but these are not enlarged. (Choices D and E) Antibiotics. Therapy in most cases consists of supportive measures. however. nasal discharge and wheezing. Although there is no strong evidence that inhaled bronchodilators are effective in patients with bronchiolitis. it is a routine practice to administer these and observe the patient's clinical response. His temperature is 38. He has no known allergies. it is a routine practice to administer these (nebulized albuterol or epinephrine) and observe the patient for any effect. If no prompt clinical response is seen. bronchiolitis is usually a self-limited disease.

Asthma E. (Choice C) These children are not prone to cystic fibrosis (CF). Lung abscess C. Which of the following diseases is the child at risk of developing? A. it takes 4 days to 2 weeks for the results to be reported. his mother asks about what she should expect in the future. Educational Objective: Diagnosis of RSV is quickly made by detection of RSV antigen in nasal or pulmonary secretions by ELISA. or may present with a cavitary lesion in the lung. Sputum induction and Gram stain E. Educational Objective: . (Choice E) Aspergillosis infections generally occur in immunocompromised patients. Pneumonia B. (Choice B) Lung abscess is not seen with respiratory syncytial virus. Item 3 of 3 While you are giving the appropriate management to this patient. Rapid detection of antigen in nasal secretions C. (Choice C) Diagnostic serology is not helpful in infants because this also detects maternal antibodies. up to 30% of patients hospitalized with severe infection will subsequently develop reactive airway disease later in childhood (Choice A) A secondary bacterial infection of the middle ear is the most common complication (1020%) of RSV bronchiolitis. CF is a congenital condition and is not acquired from any infection.5-1%). Urinary antigen assays Explanation: Rapid detection of RSV antigen in nasal or pulmonary secretions utilizing antigen capture technology is now available and can be performed in less than 30 minutes. but bacterial pneumonia is very rare (0. Disseminated Aspergillus infections are only seen in immunocompromised individuals. Cystic fibrosis D. 63% of people answered this question correctly. Aspergillus infections are not related to prior respiratory syncytial infections. (Choice B) Even though the definitive diagnosis is made by tissue culture.Item 2 of 3 Which of the following is the most appropriate next step in the diagnosis of his condition? A. Rapid tissue culture B. Serology for antibody detection D. The disease may present as an allergic reaction involving the lung. Aspergillosis Explanation: Although mild RSV infection does not produce apparent long-term pulmonary sequelae in most individuals. The sensitivity and specificity of such tests exceed 90 percent.

Agents with a short half-life (e. Which of the following is the treatment of choice at this time? A. The joint aspirate in gout shows characteristic negatively birefringent crystals of monosodium urate. Item 1 of 2 What is the next step in making the diagnosis? A. Colchicine C. Indomethacin D. NSAIDS are effective in more than 90% of patients with acute gout. The diagnosis should be confirmed by needle aspiration of the joint fluid. X-ray of the great toe D. Item 2 of 2 The diagnosis of acute gout is made. Arthrocentesis C. The patient does not allow further examination due to intense pain. He was sleeping peacefully at night. He denies trauma to the affected part. Methotrexate Explanation: NSAIDS are used as the first line agents in the treatment of acute gout in most patients. 68% of people answered this question correctly. Allopurinol B. when he woke up with sudden severe pain in his left great toe. Educational Objective: A diagnosis of acute gout is confirmed by arthrocentesis by the demonstration of negatively birefringent crystals. He never had this kind of problem in the past. . MRI E. Physical examination shows normal vital signs.g.. There is no skin rash.A secondary bacterial infection of the middle ear and future risk of bronchial hyperreactivity are the most common complications of RSV bronchiolitis. the joint fluid should be cultured if there is any suspicion for an infectious process. (Choice A) Serum uric acid is not used for making a diagnosis of acute gout because the uric acid levels can be normal or even low during an acute attack. Allopurinol B. His left great toe is inflamed and swollen. Probenecid E. Case 52 The following vignette applies to the next 2 items A 50-year-old obese man comes to the emergency department with a painful left great toe. (Choices C & D) Radiologic imaging plays no role in the diagnosis of acute gout. Serum uric acid can be normal during acute gout and is not useful in making the diagnosis. He smokes 1 pack of cigarettes daily and drinks alcohol regularly. 82% of people answered this question correctly. therefore. Aspergillosis Explanation: The patient has features suggestive of acute monoarticular gout. An infection can coexist with acute gout.

Colchicine and glucocorticoids can also be used. there are high chances of flare-up of the disease.005. (Choices A and D) In this scenario. Lower doses are advocated in elderly patients.39 and p = 0. Due to its potential serious toxicity. Educational Objective: Acute gouty arthritis is treated with NSAIDs as first line therapy. Intra-articular glucocorticoids may be used in elderly patients with renal failure. colchicine is not the first line agent in most patients with acute gout. Case 53 A large-scale clinical trial was conducted to assess the effect of carvedilol (a mixed alpha. 79% of people answered this question correctly. 0. (Choices A and D) Hypouricemic therapy with allopurinol or probenecid should not be started during acute gout. Other anti-inflammatory agents such as colchicine or glucocorticoids can be used. (Choice B) Negative correlation means that as serum sodium level decreases. serum noradrenaline level increases. Strong correlation was observed B. negative) of linear association between two variables. It does not necessarily imply causality. . the association is weak because the value of the correlation coefficient is close to 0.indomethacin and ibuprofen) are most effective. The association does not reach statistical significance E. NYHA class III-IV. (Choice E) Methotrexate is not indicated in the treatment of acute or chronic gout. r = . but does NOT necessarily imply causality. (Choice B) Colchicine can be used in the treatment of acute gout. a marker of the degree of neurohumoral activation: correlation coefficient. (Choice C) It is very important to know that the correlation coefficient shows the strength of association. The sign of the correlation coefficient indicates positive or negative association. Negative correlation is observed Explanation: A negative correlation is present between serum sodium level and serum noradrenaline level. As serum sodium level increases serum noradrenaline level also increases C. and the range of plausible values is from -1 to 1. When hypouricemic therapy is started during an acute episode. The closer the value is to its margins (-1 or 1).6 mg is given every hour until there is relief of symptoms or GI toxicity occurs. Typically. Serum sodium changes cause serum noradrenaline changes D. High doses of colchicine are associated with serious toxicity. Majority of the patients become asymptomatic in 5-7 days. which is indicated by the negative sign of the correlation coefficient.005. A total of 2 to 3 mg can be given. The ‘null’ value for the correlation coefficient is 0 (no association). The study showed that serum sodium level correlated with serum noradrenaline level. although it is statistically significant: p = 0. Hypouricemic therapy is never used during an acute episode of gout. Educational Objective: The correlation coefficient shows the strength and the direction (positive. the stronger the association. Which of the following statements correctly describes the association between serum sodium level and serum noradrenaline level observed in this study? A.0.and betablocker on the clinical course of chronic heart failure).

and eye color. She has already undergone menopause. Based on recommendations from her friends. Topical isotretinoin D. Periods of exacerbation and remission are expected. telangiectasias.48% of people answered this question correctly. with or without a course of oral antibiotics. and multiple telangiectasias on the nose and cheeks. It is important that patients with rosacea use mild cleansers and sunscreens regularly while also avoiding irritants. An excellent initial treatment for this condition is topical metronidazole. minocycline. Educational Objective: Rosacea is a chronic acneiform condition characterized by vascular dilation in the central face. Physical examination reveals a reddening of the central face. or lotion. However. Oral griseofulvin B. Which of the following complications is most frequently associated with this condition? . The oral antibiotics commonly used include tetracycline. Oral griseofulvin (Choice A) is not prescribed for the treatment of rosacea. she has developed new blemishes on her nose. Item 2 of 2 The appropriate action was taken. she modified her diet and tried various herbal preparations and skin creams. Symptoms generally include facial erythema (both transient and nontransient). but facial erythema may persist despite treatment. a not unexpected finding as Demodex mites are frequently found in increased numbers in the skin scrapings of patients with rosacea. erythematous papules on the chin. Her skin is very fair otherwise. blonde-haired Caucasian woman presents to clinic requesting treatment for "this unattractive redness of my facial skin. Topical metronidazole E. doxycycline. Case 54 A 49-year-old blue-eyed. especially in those patients with refractory symptoms. and the consumption of spicy foods or alcohol. hair. It may also be used in conjunction with topical antibiotics. cheeks. Item 1 of 2 Which of the following is the most appropriate treatment of this condition? A. gel. Topical clindamycin (Choice B) can be used in the form of a solution. although comedones are not present. The metronidazole may need to be applied daily on a long-term basis to maintain remission. It is most common in adults ages 30 to 60 years and occurs more often in individuals with light skin. further evaluation is indicated before this treatment can be recommended as appropriate first-line therapy. Therapy is usually successful in reducing the number and severity of the inflammatory lesions. but is generally considered less effective than topical metronidazole. Some clinical data suggests that topical permethrin (Choice E) improves symptoms of rosacea. Topical clindamycin C. but nothing has alleviated her symptoms. with or without a course of oral antibiotics. She has no history of dermatological problems and did not have acne as a teenager. and erythromycin. and papules and pustules. Topical permethrin Explanation: Rosacea is a chronic acneiform condition characterized by vascular dilation in the central face. One of the most frequently used initial treatments for this condition is topical metronidazole (Choice D). The inflammatory lesions seen generally appear identical to those found with acne. She has also noticed that she now flushes intensely in response to extreme temperatures." She reports that in the past three months. emotion. Topical isotretinoin (Choice C) is appropriate for those patients with papular or pustular lesions unresponsive to initial therapies. and chin.

increased frequency of micturition. except for a BUN level of 33mg/dl (normal 10-20 mg/dl) and glucose level of 320 mg/dl. blepharitis. red eye. coli and K. Her past medical history is significant for type-2 diabetes for the past ten years. Oral antibiotics Explanation: There are a number of infections which predominantly occur in diabetic individuals. Parental antibiotics and immediate nephrectomy D. and headache. is not typically associated with rosacea. cough. Although it is more common in the fair-skinned. blood pressure of 100/70 mm Hg. performed 2 weeks ago. vomiting. 3 + glucose. Physical examination reveals a middle-aged woman in distress. Squamous cell carcinoma Explanation: Patients with rosacea often report experiencing ocular symptoms. in contrast. keratitis. Glaucoma C. She also complains of chills. Endophthalmitis (Choice C) is classically associated with corneal ulcers and ocular infections with organisms such as Pseudomonas. Educational Objective: Patients with rosacea may also experience ocular symptoms. There is marked tenderness in her left flank. with a temperature of 102 F(39 C). and heart rate of 100/min. Rosacea.A. Chalazion B. Emphysematous pyelonephritis is one of them. Besides IV hydration and glycemic control. CBC reveals polymorphonuclear leukocytosis. Case 55 A 66-year-old postmenopausal female comes to the emergency department and complains of fever and left flank pain for the past four days. non-radiating. Parental antibiotics and surgical drainage E. blepharitis. Classically. WBC casts and positive leucocyte esterase. . was 8. hypertension. conjunctivitis. Accompanying symptoms may include nausea. Sinus infections (Choice D) can arise when mucosal edema obstructs the ostia. The pain in her left flank is described as agonizing. squamous cell carcinoma (Choice E) presents as an ulcerated nodule or superficial erosion of sun-damaged skin or lip. The chalazion is characterized by a granulomatous inflammation of a meibomian gland and presents as a painless. with extensive perinephric stranding. Glaucoma is not typically associated with rosacea. Parental antibiotics B. usually causes a more focal and superficial ocular irritation. foreign body sensation. She denies any hematuria. Complaints frequently include burning or foreign body sensations. and Mycobacterium. dyspnea. pneumoniae are the most common organisms involved. Sinusitis is not typically associated with rosacea. Her HBA1c. Urine examination shows 1+ protein. vomitings. episcleritis. Sinusitis E. keratitis. episcleritis. Yersinia. nausea. Acute angle-closure glaucoma (Choice B) is manifested as a painful. Complaints frequently include burning. Blood cultures are drawn. Endophthalmitis D. and chalazion (dysfunction of the meibomian gland). what is the best next step in this patient's care? A. The basic metabolic panel is normal. and aggravated by motion. and dysuria. often subsequent to viral upper respiratory tract infections. pea-sized nodule within the eyelid.2 % (normal 4-6%). Air is seen in the left kidney and perinephric space. dyslipidemia and osteoporosis. Her fasting blood glucose levels have been ranging between 100-140 mg/dl. E. many WBCs. and skin rash. conjunctivitis. CT scan of the abdomen shows a fluid collection in the left flank. and chalazion (Choice A). Parental antibiotics and percutaneous drainage C.

The diagnosis is made on CT scan. constipation. The daughter in the above vignette started engaging in sexual activities only three months ago. emphysematous cholecystitis is seen commonly in males. (Choices A and E) Parental antibiotics alone are not generally sufficient. and oral antibiotics are usually ineffective. or at the age of 18 years (recently changed to 21 years) whichever is earlier. All patients require urgent removal of the infected gall bladder and parental antibiotics. Crepitus on abdominal examination is very suggestive of emphysematous cholecystitis. Clostridia and E. screening for cervical intraepithelial neoplasia (CIN) or cancer should be started three years after the onset of sexual intercourse. She also complains of intense fatigue. Early initiation of sexual activity. which depicts gas within the gall bladder. and wants you to convince her daughter to have a cervical Papanicolaou smear done. Emphysematous cholecystitis also occurs predominantly in diabetics. Reassure the mother and tell her that you will do the Pap smear at this time. Explanation: Human papilloma virus (HPV) infection is a sexually transmitted infection strongly linked with the development of cervical intraepithelial neoplasia (CIN) and cervical cancer. Tell the mother that you will do the Pap smear if she has engaged in unprotected intercourse. Reassure the mother & tell her that a Pap smear is not necessary at this time. an immediate nephrectomy is necessary. coli are the most common organisms responsible for emphysematous cholecystitis. There is no reason to start screening her for cervical cancer by Pap smear at this time. Open surgical removal of the infected gall bladder is preferred over laparoscopic removal. Case 58 A 30-year-old female presents with tingling and numbness in both of her distal lower extremities for the last three months. Educational Objective: Cervical cancer screening should be started three years after initiation of sexual intercourse or at the age of 18 years (some say 21 years). which occurs more commonly in females. (Choices C and D) The initiation of cervical cancer screening does not depend on the history of multiple partners or unprotected intercourse. Tell the mother that you will do the Pap smear if she has been exposed to multiple partners. Case 57 A 45-year-old female patient of yours comes to see you in the office. She has been your patient for the last 20 years. nausea and vomiting. Her symptoms are gradually worsening. She was . The most common symptoms are fever. multiple new sexual partners. headaches or visual changes. The mother should be assured and informed of the facts regarding the timing of exposure and initiation of screening. are the main risk factors for the acquisition of HPV infection and cervical cancer. C. She is aware of the risk of cervical cancer with sexual activity. She is accompanied by her 14year-old daughter. She denies weight change. skin dryness. According to the guidelines. Educational Objective: Parenteral antibiotics and immediate nephrectomy is indicated in patients with advanced emphysematous pyelonephritis. (Choice B) Mild pyelonephritis is managed with a combination of parental antibiotics and percutaneous drainage. What is the most appropriate response in this setting? A. Tell her that she does not need a Pap smear until she is 18 years of age. If abscess and gas extend into the perinephric space.Treatment is guided by the extent of involvement of the perinephric space. and you have an excellent rapport with her. B. and high-risk partners (partners with HPV infection). D. This is due to the fact that high-grade cervical cytologic abnormalities due to HPV usually do not occur until three to five years after HPV exposure. (Choice D) Surgical drainage does not offer a significant advantage over percutaneous drainage. right upper quadrant pain. E. Her daughter became sexually active three months ago. As compared to emphysematous pyelonephritis. Screening for cervical cancer by cytologic examination/Pap smear is an effective way of detecting early pre-invasive and invasive carcinoma.

Increase her levothyroxine dose to improve her fatigue B. Pernicious anemia results from the autoimmune destruction of parietal cells. The rest of the physical examination is unremarkable. Her blood pressure is 114/78 mm Hg and heart rate is 72/min. Her menstrual cycles have been irregular for the last six months. organomegaly.200 per cubic millimeter. (Choice E) Folate levels may be obtained to determine the cause of marocytic anemia.diagnosed with primary hypothyroidism secondary to Hashimoto’s thyroiditis when she was 10 years old. The lack of intrinsic factor leads to vitamin B12 deficiency. weakness. leading to achlorhydria and decreased production of the intrinsic factor. M-proteins and skin changes) syndrome. The red blood cells are macrocytic due to ineffective erythropoiesis secondary to defective nucleic acid synthesis. Pain and temperature sensations appear normal. Her total WBC count is 3. Her mucous membranes are moist and pale. which resulted from atrophic gastritis (pernicious anemia).000 per cubic millimeter. Her platelet count is 300. therefore. lateral column (brisk reflexes) and peripheral nerves (loss of ankle jerks) indicate neurologic involvement due to Vitamin B12 deficiency. Symptoms and signs are more prominent in the lower than the upper extremities. Her tongue appears to be bald. Vibration and proprioception are decreased in both of her lower extremities distally. endocrinopathy.2 mcg/dL (normal 4-12 mcg/dL) and TSH level is 2. Her last menstrual period was two months ago. She does not have any scleral icterus. Involvement of the posterior column (loss of proprioception). (Choice A) Increasing the levothyroxine dose is not the appropriate choice for this patient because her thyroid function tests are within normal limits. She weighs 152 pounds and is 5’4" tall. She does not smoke or drink alcohol. Lab investigations reveal a hemoglobin of 8 g/dL and hematocrit of 24%. Vitamin B12 deficiency in pernicious anemia is due to a deficiency of intrinsic factor secreted by the stomach. loss of proprioceptive and vibratory sensations. SPEP is done to look for an M-spike. Neurologic involvement in Vitamin B12 deficiency is characterized by subacute combined degeneration of the spinal cord and peripheral neuropathy. Basic serum chemistries are within normal limits. Measure folate levels Explanation: The patient's primary hypothyroidism predisposed her to other autoimmune disorders such as pernicious anemia. Stool obtained from the rectal examination is negative for occult blood. She is sexually active with one partner. She is currently on 100 mcg per day of levothyroxine orally.5 to 5 micro IU/mL). the patient's history of autoimmune hypothyroidism and characteristic neurological picture is more suggestive of vitamin B12 deficiency. Her ankle jerks are absent. Measure serum B12 levels E. (Choice B) Although neurologic involvement can indicate cord compression. Item 1 of 2 What is the next best step in the management of this patient? A. She denies the use of recreational drugs. (Choice C) Endocrinopathy with polyneuropathy can be seen with POEMS (polyneuropathy. Severe spasticity. but other reflexes are brisk. The intrinsic factor-vitamin B12 complex is then carried to the terminal ileum for receptor-mediated absorption. Serum protein electrophoresis D. Her thyroid is nonpalpable. and peripheral nerve involvement can occur. Educational Objective: Patients with primary hypothyroidism are predisposed to get other autoimmune diseases such as pernicious anemia. MRI is unnecessary.4 micro IU/mL (normal 0. Babinski and Romberg’s signs are positive. 87% of people answered this question correctly. Neurologic involvement is characterized by involvement of posterior and lateral columns in the spinal cord known as 'subacute combined degeneration' and leads to ataxia. Perform MRI of the spine to look for spinal cord compression C. This patient does not have organomegaly or skin changes. Dietary vitamin B12 binds to the intrinsic factor secreted by the parietal cells in the gastric mucosa. however. Her mother also has hypothyroidism. . Her Total T4 level is 8. the history and other features of this patient suggest otherwise. The fatigue in this patient is most likely due to anemia.

which can sometimes be very severe and life threatening. I can't seem to work. Hypokalemia results following the uptake of potassium by newly forming red blood cells. She has been struggling to quit cigarette smoking for the past year. Withdrawal symptoms are extremely common in patients attempting to quit. But this time. Prescribe bupropion. irritability. C. I can't sleep. The patients' serum potassium levels should therefore be monitored during the first 48 hours. I'm really determined to quit. E. These generally peak in the first three to four days after smoking cessation. TSH level B. She recently got married. and she is really interested in quitting before that time comes. B. such as buproprion or nicotine replacement. Serum potassium level D. Close monitoring and supplementation of potassium is required during this period. I need your help. (Choices A. Current recommendations for the management of smoking cessation involve a combination of behavioral therapy and a pharmacologic intervention. or depressed mood. and I get very anxious and frustrated. White blood cell count Explanation: Treatment with vitamin B12 in patients with moderate to severe megaloblastic anemia can cause hypokalemia. frustration. "Every time I try to quit smoking. D. They are planning to have a child next year. She has multiple failed attempts to quit smoking in the past.Item 2 of 2 Which of the following is most crucial to monitor during the first few days of treatment in the above patient? A. Case 59 A 36-year-old female comes to see you in the office for smoking cessation counseling. and her husband does not smoke at all. and usually resolve in the next three to four weeks. Some of the common symptoms include restlessness. anxiety. Ask her to change her job. decreased concentration. and are especially pronounced in patients with a long history of heavy cigarette smoking. Nicotine replacement therapy (gum. These symptoms and the associated intense craving for cigarettes are responsible for the majority of relapses seen in patients. which is bad because my job is very demanding. patch or inhaler) acts by maintaining a low level of nicotine in the . I can't take it anymore. Explanation: Cigarette smoking causes significant physiological and psychological dependence. She has a 50-pack-year history of smoking. I start shaking really bad. Platelet count E. Encourage her to continue her attempts at smoking cessation. Prescribe a low-dose nicotine spray. Eventually. Some physicians transfuse packed red blood cells in patients with severe megaloblastic anemia before Vitamin B12 supplementation to prevent hypokalemia. Educational Objective: Patients with moderate to severe megaloblastic anemia can have severe hypokalemia during the first 48 hours of treatment with vitamin B12. Hemoglobin level C." Which of the following is the most appropriate next step in her management? A. and I start smoking again. D & E) These parameters are not necessary to monitor during the first few days of B12 therapy. Prescribe a high-dose nicotine patch. Potassium is replaced depending on the measured serum potassium levels. and currently smokes two to three packs of cigarettes daily. Most smokers typically make several attempts to quit before they are able to quit successfully. B. insomnia. She works as a legal assistant in a very reputable law firm in the city. She says. doctor.

21-hydroxylase deficiency C. but signs of androgen excess are not typical. XYY karyotype may manifest as severe acne. It can be caused by late-onset congenital adrenal hyperplasia. typically an excess of sex steroids. Severe hypothyroidism D.blood. of growth. Abnormal karyotype 47. His height corresponds to 98 percentile and his weight to 85 percentile for his age. (Choice A) Hypothalamic dysfunction leading to precocious puberty is usually less dramatic in presentation. . while precocious pseudopuberty is caused by a gonadotropin-independent process. (Choice D) Klinefelter’s syndrome may present with a height that is higher than normal. enlarged testicles and penis. pubic hair growth. Hypothalamic dysfunction B.’ His past medical history is insignificant. Case 60 A 7-year-old Caucasian boy is brought to your office by his mother because of a sudden acceleration of growth and a ‘very annoying rash. typically an excess of sex steroids. Abnormal karyotype 47. This patient presents with signs of severe androgen excess (e. She should initially receive high-dose nicotine replacement therapy. (Choice C) Severe hypothyroidism is a rare cause of precocious puberty that is characterized by the slowing. Physical examination reveals severe cystic acne involving his face and shoulders. (Choices C and D) The patient needs a specific intervention to ameliorate her withdrawal symptoms in addition to moral support and behavioral therapy. Educational Objective: Nicotine replacement therapy is extremely helpful in ameliorating the symptoms of nicotine withdrawal in the early stages of smoking cessation. Sequential development of the following is typically present: testicular enlargement.g. but precocious puberty is not characteristic. XXY E. (Choice B) Nicotine replacement therapy is preferred to buproprion for the management of withdrawal symptoms in the early stages of smoking cessation. a growth spurt. and coarse pubic and axillary hair. severe cystic acne. It is preferred for the amelioration of withdrawal symptoms during the early stages of smoking cessation. significant growth acceleration) which suggests precocious pseudo-puberty. Which of the following is the most likely diagnosis in this patient? A. penis enlargement. (Choice A) A low-dose nicotine inhaler is unlikely to ameliorate the withdrawal symptoms of a patient with a history of heavy smoking. not acceleration. and lastly. Precocious puberty is caused by premature activation of the hypothalamus-pituitary-gonad (HPG) axis. XYY Explanation: It is very important to distinguish between the two most common presentations and causes of precocious pubarche in order to facilitate the proper treatment. Educational Objective: Precocious pubarche with signs of severe androgen excess is suggestive of precocious pseudopuberty that is caused by a gonadotropin-independent process. (Choice E) 47.

although he was not feeling well. and normocytic. The patient was started on intravenous ceftriaxone and oral azithromycin. a reliable diagnosis in this setting can only be established by performing a bone marrow biopsy. She has had fever.000/cmm Segmented neutrophils 84% MCV 84 fl Leukocyte count 10. Her temperature is 38.4 g/dL Platelet count 450.000/cmm Lymphocytes 16% The chest x-ray showed an alveolar infiltrate in the left base. headache that began during the night and got worse in the morning. productive cough. She denies any previous illness. Educational Objective: Anemia of chronic disease (ACD) can be difficult to distinguish from iron deficiency anemia in the setting of an acute bacterial infection. Serum Transferrin saturation E. Examination showed decreased breath sounds and crackles at the left base. and shortness of breath for the past 24 hours. Case 62 A 32-year-old Caucasian female comes to the emergency department (ED) and complains of a generalized. additional hematologic tests are done.. while the serum transferrin level and TIBC will be decreased. Although RA usually causes anemia of chronic disease. On the third day of treatment. left lower lobe pneumonia. She says that her husband went to work today. throbbing. and these show the following: Ferritin 300 ng/mL (NV 15-120) Iron 44 mcg/dL (NV 50-170) TIBC 200 mcg/dL (NV 250-450) Which of the following is the most appropriate diagnostic test for this patient’s anemia? A. chills. (Choices C and E) Because of the patient's acute infection. Her other medical problems include hypertension and rheumatoid arthritis. blood pressure is 150/90 mmHg. who has a similar type of headache and nausea. (Choice D) The serum transferrin saturation (serum iron/TIBC) and iron levels will not distinguish between anemia of chronic disease and iron deficiency anemia because both will present with diminished levels. Fecal occult blood per rectum was negative.9 C (102 F). Erythropoietin levels B. (Choice A) Measurement of erythropoietin levels can help with decisions regarding the most adequate treatment of anemia of chronic disease in a patient with RA. normochromic. This is not used to diagnose the anemia itself. the ESR and ferritin levels will be abnormally increased. She has also brought in her 8-year-old son. Erythrocyte sedimentation rate (ESR) Explanation: This patient has rheumatoid arthritis (RA). pulse is 106/min. Her medications include enalapril and naproxen. anemia. the best test to confirm the diagnosis and rule out iron deficiency anemia is a bone marrow biopsy.Case 61 A 74-year-old Chinese-American woman is brought to the emergency department. Her laboratory tests reveal the following: CBC Hb 9. Serum Transferrin D. In this setting. Bone marrow biopsy C. and . and respirations are 22/min.

For example. and respirations are 16/min. nausea. (Choice C) CBC with differential would not assist in the differential diagnosis of this case. kerosene heater). blood pressure is 120/76 mm Hg. Observer’s bias may be present B. Which of the following is the most likely explanation of such a conclusion? A. The diagnosis is confirmed by carboxyhemoglobin level measurement. but also for the timing of the events. Case 63 A randomized. (Choicees A and B) Other diagnoses such as subarachnoid hemorrhage and acute meningitis are unlikely in this case. No neck rigidity or meningeal signs are present on physical examination. The results are confounded D. malaise and dizziness.has no idea what might have brought these symptoms on. The investigators conclude that the treatment is effective. nausea. (Choice E) Acetaminophen intoxication may initially manifest as nausea and vomiting. (Choice E) Interestingly. pulse is 90/min. but eventually leads to liver damage..g. patients in the treatment group may live longer than the patients in the placebo group despite the fact that a two-year mortality risk is the same for both groups. Severe poisoning may result in seizures. The potential causes of the problem may be poorly functioning heating systems or improperly vented fuel-burning devices (e. Time-to-event data were analyzed E. Lumbar puncture C. Which of the following tests can confirm the most probable diagnosis in this patient? A.7C(98F). and are more common during cold winters in cold climates. The absence of acetaminophen intake in the history also makes the diagnosis unlikely. Serum acetaminophen level Explanation: The clinical scenario described is highly suggestive of carbon monoxide (CO) poisoning. Two-year risk was calculated Explanation: Time-to-event data analysis is becoming more popular in the analysis of follow-up studies and clinical trials. Educational Objective: Clinical symptoms of CO poisoning include throbbing headache. Non-contrast CT scan of the head B. syncope and coma.’ It accounts not only for the number of events in both groups. Delayed neuropsychiatric syndrome develops in up to 40% of patients with significant CO poisoning. double-blinded clinical trial was conducted to assess the role of multidrug chemotherapy in the treatment of patients with stage III and IV stomach cancer. Clinical symptoms of CO poisoning include throbbing headaches. malaise and dizziness. the median survival time may be three months for the placebo group and nine months in . This type of analysis is called ‘survival analysis. The most important feature that should be emphasized is the involvement of several people that have similar symptoms. Selective survival may be an issue C. Several people simultaneously presenting with a headache is an important clue. 120 patients in the treatment group (80%) and 80 patients in the placebo group (80%) died during the follow-up period. Interestingly. Her temperature is 36. Carboxyhemoglobin level E. 150 patients in the treatment group and 100 patients in the placebo group were followed for 24 months. CBC with differential D. accidental CO poisoning has seasonal and regional variations. The diagnosis is confirmed by carboxyhemoglobin level measurement.

It is widely agreed that the most important aspect of treatment is prompt incision and drainage of the abscess (Choice E). His temperature is 38. Educational Objective: Survival analysis is used to analyze follow-up studies and clinical trials. constant pain that may be accompanied by fever or malaise. but also for the timing of the events.the treatment group. Item 1 of 2 What is the most appropriate next step in the management of this patient? A. It accounts not only for the number of events in both groups. He denies drinking alcohol or using recreational drugs. Purulent material may be seen if the abscess has begun to drain spontaneously. He has not experienced symptoms like this before. strict control of diabetes is very important in reducing the complications associated with wound healing. (Choice B) Selective survival is not a likely explanation of the conclusion given by the investigators. Perianal and small ischiorectal abscesses are often drained in the office. he notes that the pain has increased significantly over the past 24 hours. Incise and drain the mass Explanation: Anal abscesses arise when one or more of the several glands that encircle the anus become blocked and the bacteria within grow unchecked. and pulse is 90/min. The mass fluctuates upon palpation. There is a hot. However. Admission to the hospital for intravenous antibiotics (Choice D) is unnecessary in a patient with localized infection. He finds he is unable to pass stool because of the pain. Increase the insulin dose and discharge home B. Patients with anal abscesses typically present with severe. mass located between the anus and the left ischial tuberosity. (Choice A) Observer’s bias is reduced by the double-blinding technique. but larger ischiorectal abscesses typically require surgical intervention. (Choice C) Randomization is an effective tool to control for confounding. Prescribe bupropion and discharge home C. he was diagnosed with diabetes mellitus. therefore. Ten years ago. Case 64 The following Vignette applies to the next 2 items A 50-year-old male comes in to the emergency department complaining of unremitting pain in an area of his right buttock near the anus. Physical examination commonly reveals erythematous. immunosuppression. He is currently on insulin. Oral antibiotics (Choice C) should also be prescribed to those patients who have diabetes mellitus. However. . Increasing the insulin dose (Choice A) or prescribing bupropion (Choice B) are inappropriate because they do not treat the abscess. antibiotics are an adjunct to and not a substitute for incision and drainage of the abscess. Although he is uncertain when the discomfort first began. blood pressure is 128/86 mm Hg. He smokes half a pack of cigarettes per day but would like to quit. Admit to the hospital and start intravenous antibiotics E.1C (100. Prescribe oral antibiotics and discharge home D. tender. time-to-event analysis in the study presented may explain the conclusion that the treatment group did better.6F). indurated skin or a fluctuant mass over the perianal or ischiorectal space. extensive cellulitis. or valvular heart disease.

He has chronic hepatitis C.3 C (101 F). he is advised to promptly schedule a follow-up visit with his primary care physician. Fecal occult blood is negative. Incontinence (Choice D) and hemorrhoids (Choice E) are not commonly associated with anal abscesses. the skin overlying the drainage site). There is no rebound tenderness and hepatomegaly. She states that he has been having fever. Fecal impaction (Choice C) could be of concern in a patient with an anal abscess who had been unable to pass stool for a long period before presenting for treatment. but irritable. The patient’s laboratory tests reveal the following: CBC Hb 8. abdominal pain with distention.000/cmm Leukocyte count 8. Such fistulas require surgical repair. He is currently awake. Surgical repair is usually necessary to eliminate the fistula while preserving fecal continence. loss of appetite. shifting dullness is observed. extensive cellulitis. Patients with anal abscesses are at greatest risk of developing which of the following conditions? A. Soft tissue infection (Choice A) is rarely a concern when the initial mass has been properly incised and drained. and hallucinations.8 g/dL Ht 26% Platelet count 80. Antibiotics should also be prescribed in those patients who have diabetes mellitus. or valvular heart disease. blood pressure is 100/50 mmHg. Incontinence E. Mild intention tremors are present. Treatment with ribavirin and pegylated interferon failed two years ago. bowel sounds are present. however. vomiting. It does not commonly occur subsequent to treatment of anal abscess. he was diagnosed eight years ago. He does not drink alcohol. nausea.000/cmm Segmented neutrophils 80% . Fecal impaction D. Educational Objective: Fifty percent of patients with anal abscesses will go on to develop a chronic fistula from the involved anal gland to the overlying skin. There are no focal motor or sensory deficits. immunosuppression. Patients with fistulas typically present with an anal abscess that persists after incision and drainage. an anal fistula (Choice B) is a tunneling between the anus or rectum and another epithelial lined space (eg.Educational Objective: Anal abscesses should be treated with prompt incision and drainage. and respirations are 20/min. Fistula C. icteric mucus membranes and clear lung fields. pulse is 108/min. or with a pustule-like lesion in the perianal or ischiorectal area that continually drains. Hemorrhoids Explanation: While an anal abscess is an infection within one or more of the anal spaces. Case 66 The following vignette applies to the next 2 items A 45-year-old Caucasian man is brought to the emergency department by his wife. Physical examination reveals dry. His temperature is 38. Fifty percent of patients with anal abscesses will go on to develop a chronic fistula from the involved anal gland to the overlying skin. To minimize risk of complications. Item 2 of 2 The patient is treated appropriately. Soft tissue infection B. His abdomen is tender and distended.

Item 2 of 2 The patient responds well to the treatment.8 g/dL Coagulation Profile: Prothrombin time 20 sec PTT 38 sec A paracentesis is performed. Educational Objective: SBP is a serious condition and is diagnosed when > 250 neutrophils/mm3 is found in the peritoneal fluid. (Choice B) Blood transfusion is not indicated now. antibiotic therapy must not be delayed while the results are pending. as in this case. Blood transfusion is usually reserved for patients with hemoglobin levels less than 8 g/dL. This is most likely due to spontaneous bacterial peritonitis (SBP). which is diagnosed when there are more than 250 neutrophils/mm3 in the ascitic fluid of a patient with nephrotic syndrome or cirrhosis. He is discharged from the hospital. He is currently less agitated and more oriented. (Choice C) Mannitol is used with lactulose only in the more advanced stages of HE (Choices A and D) Repeated paracentesis and peritoneo-venous shunt are treatments for refractory ascites. as there is no evidence of ongoing blood loss. Four weeks later. Therapeutic paracentesis B. Blood transfusion and antibiotics C. Which of the following is the most appropriate response? . Mannitol and lactulose D. Peritoneo-venous shunt E. not for SBP. Management involves the administration of lactulose. Empiric antibiotic therapy must be started immediately while waiting for the culture results. he returns with his wife for a follow-up visit. The presence of tremors is suggestive of stage 2 HE.5 mg/dL Alkaline phosphatase 520 U/L Aspartate aminotransferase 98 U/L Alanine aminotransferase 85 U/L Albumin 2. Cultures are not always positive in this condition. however.Bands 3% Lymphocytes 17% LFT Total bilirubin 5. His new laboratory tests show the following: Total bilirubin 2. Lactulose and antibiotics Explanation: This patient is developing hepatic encephalopathy (HE). The results are the following: Leukocytes 900/mm3 Neutrophils 65% RBC 3/cmm Item 1 of 2 Which of the following is the most appropriate pharmacotherapy? A.2 mg/dL Direct bilirubin 2.3 mg/dL Alkaline phosphatase 380 U/L Aspartate aminotransferase 78 U/L Alanine aminotransferase 43 U/L Albumin 2. especially if there are other clinical indicators of infection.8 mg/dL Direct bilirubin 1.6 g/dL Prothrombin time 19 sec The patient’s wife is very concerned and asks about his prognosis.

hepatic enzymes are mildly elevated and AST is higher than ALT. He needs a liver transplant D. Child-Turcotte-Pugh (CTP) score components are used to select the candidates for liver transplantation. She has had recent problems with maintaining her weight. Furthermore. the score can be calculated and a prognosis given without an observation period. B. Case 67 A 23-year-old Caucasian college student comes to the student health center for the evaluation of lowgrade fever. and when the patient is young and is not currently using alcohol.5 2.8 (g%) None Stage 3-5 >17 sec . There is nothing much we can do E. Educational Objective: A clinical and biochemical evaluation of a patient with cirrhosis and chronic hepatitis is important to determine if he/she is a candidate for surgery. (Choice B) Studies have shown that approximately 7% (over a period of five years) of patients with hepatitis-C and cirrhosis die from hepatocellular cancer. despite her attempts to gain weight to stay in the college weightlifting team. We have to observe him for a couple of months for an accurate prognosis Explanation: The patient has possible cirrhosis secondary to chronic hepatitis-C infection. (Choice E) Because the acute event has been controlled. he has hyperbilirubinemia and hypoalbuminemia. He has a very high risk of hepatocellular carcinoma C. Which of the following is the most important in the medical history. and > 10 Class A: CTP score 6 Class B: CTP score 7-9 Class C: CTP score > 10 Liver transplantation should be considered in all cirrhotic patients with CTP > 7 (Choice A) The patient's prognosis is not good. malaise. sharing this information rather than advising the patient to undergo a liver transplantation is inappropriate. He needs a liver transplant. History of allergies Bilirubin (mg/dl) Encephalopathy <2 2-3 Stage 1-2 >3 Ascites Absent Slight/responsive Moderate-severe Prothrombin time <15 sec 15-17 sec Albumin >3. the Child-Pugh score of liver damage can be calculated. She also complains about a recurrent dry and itchy rash over her face and axilla. and should be obtained in detail to help diagnose this patient? A. The episodes will diminish with age. His prognosis is good B.A. She has lost 15 pounds in the past two months. which points towards profound liver damage. In addition. For cholestatic disorders the bilirubin categories are < 4.8-3. but treatment is not usually effective. and was working three jobs at one time to keep up with her finances.5 <2. She admits that she has been under a lot of stress recently. 4-10. Liver transplantation is a treatment option when the disease has progressed and there is no other treatment available. Sexual history C. His prothrombin time remains prolonged. (Choice D) His disease is not terminal at this point. With the laboratory data available. and dry cough for the past two weeks. Points 1 2 3 .

typical EEG pattern. pulse is 92/min and . Educational Objective: Obtain a detailed sexual history in all young patients who present with weight loss and nonspecific complaints. Case 68 A 4-year-old Caucasian boy is brought to your office by his mother because of frequent staring spells that last about 10-20 seconds. Staring spells will disappear in the teenage years. (Choices A. and asks you about the treatment and prognosis.D. The episodes will increase with age. and can even exacerbate the condition (e. No myoclonic activity is noted. and treatment is not usually effective. Interestingly. The physical examination should also be focused. and can be one of the presenting complaints of the disease. The risk of persistence of the condition is higher in patients who develop generalized tonicclonic seizures.8C (100 F). especially if generalized tonic-clonic seizures are absent. and D) The occupational history. and previous history of allergies are not as important as a detailed sexual history in this patient. The episodes will not change with age. Her past medical problems include hypertension and obesity.g. A detailed sexual history must be obtained. especially if generalized tonic-clonic seizures are absent. His past medical history is significant for three episodes of otitis media and one episode of severe diarrhea that required hospitalization. no neurologic signs. Family history E. persistent cough. Which of the following is the best response to her concern? A. which includes a history of sexual exposure and the use of intravenous drugs in the past. E. family history. C. but treatment is not usually effective. blood pressure is 130/80 mm Hg. The episodes will diminish with age. She has smoked one pack of cigarettes daily for the past 25 years. gabapentin). This condition is usually responsive to ethosuximide or valproate. although high doses may be required to control it effectively. juvenile myoclonic epilepsy (JME) is characterized by a late onset of absence seizures with myoclonic activity. and treatment is not usually effective. but treatment is usually effective. unintentional weight loss in the past few weeks. and this should include the patient's sexual orientation and past history of unprotected sexual intercourse. Her temperature is 37. Educational Objective: The prognosis in patients with childhood absence epilepsy. Unlike CAE. Case 69 A 42-year-old Caucasian woman comes to the emergency department because of right-sided neck pain. The episodes will diminish with age. New-onset seborrheic dermatitis (erythematous and pruritic rash on the face and axilla) is commonly seen in HIV-infected patients. She works as an executive secretary. and no myoclonic activity. She does not drink alcohol. and is associated with life-long seizures. We have to observe him for a couple of months for an accurate prognosis Explanation: The index of suspicion for HIV infection should be high in any young patient who presents with nonspecific or vague symptoms and a significant. The episodes will not change with age. and treatment is usually effective. D. She takes enalapril and hydrochlorothiazide. and dyspnea for the past three days. The mother is concerned about the child’s condition. and the search for clues of HIV infection or Acquired Immunodeficiency Syndrome (AIDS) must be exhaustive. The neurologic examination is normal. is good. This patient should be screened for risk factors for HIV infection. B. C. is good. many traditional anti-epileptic drugs are not effective in absence epilepsy. The prognosis in patients with CAE. A staring spell is provoked at the EEG lab. and a generalized 3/second spike and wave activity is observed. Explanation: The clinical scenario described is consistent with childhood absence epilepsy (CAE): age of onset (4-8 years).

family history or smokers) and presents with dyspnea. neck pain and swelling. Order magnetic resonance imaging (MRI) of the neck and chest Explanation: The patient’s history. There is moderate swelling and erythema of the neck. Pertinent physical findings are edema and erythema of the neck (which may sometimes compromise the face). which will determine the particular therapeutic regimen required to manage the underlying malignancy. 63% of people answered this question correctly. CT scan is very useful because it can reveal the extent of obstruction and provide a histopathologic diagnosis (via percutaneous biopsy). . Start broad-spectrum antibiotic therapy B. dysphagia.g. ocular proptosis and lingual edema. A chest x-ray reveals a right apical lung mass. The classic presentation of SVCS begins with dyspnea. such as in patients with mediastinitis and deep neck infection. and reevaluate with the results E. Advanced disease is manifested by cyanosis. however. Prepare for endotracheal intubation D. it is not necessary at this point. collateral veins in the thorax. however. or chills. chest pain and syncope. CBC and chemistry panel. and has cervical and upper extremities venous dilatation. Antibiotic therapy may be subsequently needed if the patient is found to have an infection. persistent cough. Order a neck and chest computerized tomography (CT) scan with contrast C. and does not offer any visual advantage over computed tomography. fever. (Choice C) Immediate endotracheal intubation may be performed if there exists a risk of sudden airway occlusion. (Choice D) Biochemical and hematological tests may be obtained after CT scan evaluation. to make us suspect mediastinitis. Examination shows decreased breath sounds in the upper part of the right lung. which will reveal an obstruction of the superior vena cave due to the pulmonary mass. and dilated veins of the arms and neck. and increased venous marks in the right arm. moderate right jugular vein dilatation. and radiologic findings suggest superior vena cava syndrome (SVCS) secondary to a lung malignancy. this patient does not have a history of esophageal disease. Order thyroid tests. or an intravenous thrombus. The best diagnostic test for SVCS is a contrast CT scan of the chest and neck. orthopnea..respirations are 22/min. Which of the following is the most appropriate immediate step in the management of this patient? A. At least 80% of the cases of SVCS are due to bronchogenic carcinoma. the metastatic nodes. (Choice A) The erythema of the patient is due to venous occlusion and possible thrombosis. or when venous access cannot be obtained for contrast-enhanced studies. physical findings. fascial fullness and neck pain. (Choice E) Magnetic resonance imaging (MRI) is a more expensive procedure. It is only used when a patient is allergic to the contrast dye used in CT scan. Educational Objective: Superior vena cava syndrome must be suspected in any patient who has a high risk of malignancy (e. and progresses into hoarseness. The best diagnostic test to perform is computerized tomography of the neck and chest. upper respiratory tract infection. not to facial or neck cellulitis.

arterial blood gas measurement and frequent clinical evaluation for signs of respiratory muscle fatigue. The rest of the neurological examination. and heart rate is 96/min. All patients with suspected Guillain-Barre syndrome and clinical signs and symptoms of progressive respiratory compromise should be hospitalized immediately and closely monitored for signs of respiratory failure. Provide respiratory support E. they either recover completely or have only minor neurological deficits.6C (99. which is an acute inflammatory demyelinating ascending polyneuropathy characterized by progressive flaccid paralysis and areflexia. He has to pause several times during your interview to breathe. The physical examination reveals bilateral symmetric weakness or flaccid paralysis and absent deep tendon reflexes in the extremities. Measurements of bedside vital capacity provide the most useful information regarding the degree of respiratory impairment. The breathing difficulty got much worse when he woke up this morning. with approximately 2/3 of the patients presenting with a history of upper respiratory or gastrointestinal infection in the proceeding 2 to 4 weeks (Campylobacter jejuni. The diarrhea resolved spontaneously. His temperature is 37. bedside spirometry. (Choices A and B) Blood culture and intravenous antibiotics have no role in the management of patients with Guillain-Barre syndrome. Epstein-Barr virus.8F). Most patients with GBS have spontaneous remission. respirations are 28/min. the muscles of respiration. including a detailed cranial nerve examination. His shortness of breath started four days ago and is progressively getting worse. Approximately 25 to 30% of patients with GBS will eventually develop neuromuscular respiratory failure and need respiratory support with mechanical ventilation. The patient usually presents with progressive lower extremity weakness that may ascend rapidly over days to involve the upper extremities. He has been vacationing in the United States along with his girlfriend for the past two months. One week later. . cranial nerves and eventually. Obtain stat serum chemistry and electrolytes Explanation: The patient in the above vignette has a classic presentation of acute Guillain-Barre syndrome (GBS). Deep tendon reflexes are also absent bilaterally. alcohol or tobacco use.Case 70 The following vignette applies to the next 2 items A 24-year-old Italian man is brought to the emergency department by his girlfriend for the evaluation of difficulty in breathing. This includes continuous pulse oximetry monitoring. is normal. Respiratory failure is an important and common cause of death in these patients. he was extremely weak and could not get up from his bed and started to have some difficulty in breathing. Give botulinum antitoxin D. cytomegalovirus. Three days later. or herpes simplex viruses infections). Start intravenous antibiotics B. Urgent intubation and mechanical ventilation should be considered for the patients with rapidly progressive respiratory compromise to decrease the risk of complication and mortality. he felt a fine tingling sensation in his toes and feet. blood pressure is 142/62 mmHg. He denies any history of intravenous drug abuse. but he felt very weak and fatigued afterwards. Item 1 of 2 What is the next best step in the management of this patient? A. His lungs and cardiovascular examination are unremarkable. He also had bloody bowel moments at that time. He has no significant past medical history or family history. and he decided to come to the emergency room. The pathogenesis is immunologically mediated. or risk factors for HIV disease. His neurological examination reveals a flaccid paralysis of the bilateral lower extremities. rapidly progressive disease. Send blood cultures C. prolonged mechanical ventilation. and the presence of associated comorbidity. Some of the factors associated with a poor outcome include older age. His girlfriend tells you that he had suffered from an episode of gastroenteritis two weeks ago.

and the mean diastolic BP was 88 mmHg. According to the study results. progressive respiratory failure.(Choice C) Therapy with botulinum antitoxin is indicated in patients with progressive symptoms of suspected botulism. Antitoxin and immunoglobulin E. (Choices C and D) Botulinum antitoxin is extremely useful in patients with progressive weakness and suspected botulism. the mean values were 143 mmHg and 92 mmHg. Antitoxin alone is enough D. bulbar palsy.03 for systolic BP and 0. Clindamycin and Vancomycin Explanation: The first step in the management of patients with Guillain-Barre syndrome (GBS) is to triage the severity and provide appropriate respiratory support for patients with signs of respiratory failure. Plasmapheresis and/or administration of intravenous immunoglobulin (IVIG) are the mainstays of therapy for patients with severe and progressive GBS. however. As a subset of the study.04 for diastolic blood . Patients with signs of respiratory failure should be promptly intubated and supported with mechanical ventilation until the resolution of respiratory muscle weakness. The indications for plasmapheresis are: severe flaccid paralysis. in the low-dose group. Case 71 The following vignette applies to the next 2 items A follow-up study was conducted to assess the role of different treatment regimens on the risk of cardiovascular outcomes. Measurements of bedside vital capacity provide the most useful information regarding the degree of respiratory impairment. Daily administration of IVIG for two weeks may also be used to treat patients with GBS because it has been shown to be as effective as plasmapheresis. Educational Objective: Plasmapheresis or intravenous immunoglobulin is the mainstay of therapy for patients with severe and progressive GBS. some improvement still occurs even when it started late in the course of disease. After the airway is secured. Plasmapheresis is not usually indicated for ambulatory patients with mild or non-progressive disease. (Choice E) There is no indication for obtaining urgent electrolytes and serum chemistry at this point. High dose intravenous steroids with a gradual taper C. and patients on mechanical ventilation. Plasmapheresis B. (Choices B and E) Antibiotics and corticosteroids have no role in the management of patients with GBS. the mean systolic blood pressure (BP) in the high-dose group was 139 mmHg. It is most effective when it is started within seven days of the onset of symptoms. All patients with suspected GBS should be hospitalized. It has no role in the management of patients with GBS. A two-sample t test gave a p value of 0. Item 2 of 2 What is the therapy of choice for the patient's condition? A. specific therapy should be instituted as early as possible. These patients classically present with an acute onset of bilateral cranial nerve neuropathies with symmetric descending flaccid paralysis. Corticosteroids have no role in the management of patients with GBS 72% of people answered this question correctly. regardless of the severity of the illness. respectively. two treatment regimens were evaluated: highdose hydrochlorothiazide (100 mg) and low-dose hydrochlorothiazide (25 mg). Educational Objective: Campylobacter jejuni infection is the most frequent precipitant of Guillain-Barre syndrome (GBS).

the high-dose hydrochlorothiazide group is set as a reference group! Compared to high-dose hydrochlorothiazide treatment.4.5 times. E. as the resulting interpretation will differ strikingly. B. This means that the patients taking a low dose of the drug have an almost equal risk of sudden death with the patients taking placebo. The relative risk of 0. Low-dose hydrochlorothiazide decreases the risk of sudden death almost 3 times. For instance.4 therefore indicates a protective effect of a lower dose of the drug.4 (95% Confidence Interval 0.55) Item 1 of 2 Which of the following is the best statement concerning the results of the study? A. (Choices B and C) The results presented have no information on the ‘baseline’ risk of sudden death in the cohort. C. when compared to the high-dose group. Educational Objective: During the interpretation of the measures of effect. Item 2 of 2 Another subset of patients in this cohort were given placebo. Which of the following is the best statement concerning the risk of sudden death in this cohort? A. The dose of the drug is not significantly related to the risk of sudden death. The risk of sudden death decreases by 60% with a lower dose of hydrochlorothiazide.4).0. in this case. the risk of sudden death for the highdose group is 2. although the mean systolic and diastolic BP are higher when compared to the low-dose hydrochlorothiazide group. a low-dose group is compared to a high-dose group. It mentions that the RR of sudden death when comparing low-dose hydrochlorothiazide treatment to placebo is close to 1 (null value). therefore. The risk of sudden death in the cohort is high. .25 . High-dose hydrochlorothiazide has no additional benefit in lowering BP. Low-dose hydrochlorothiazide reduces the risk of sudden death in the cohort by 40%.pressure differences between the two groups. E.0 when compared to the low-dose hydrochlorothiazide group. High-dose hydrochlorothiazide increases the risk of sudden death by 60%.0). B. and their risk of sudden death was assessed. The relative risk (RR) of sudden cardiac death comparing the low-dose group to the high-dose group was 0.5 is the inverse value of 0. the inverse of the estimate is obtained. (Choice E) The effect is statistically significant because the confidence interval does not contain the null value (1. C. Explanation: The scenario assesses your understanding of risk and relative risk (RR) concepts. Relative risk is a measure of effect that can be calculated in follow-up studies. which reduced the risk of sudden death by 60%. Explanation: The scenario described emphasizes the pitfalls in interpreting the measures of effect. as the resulting interpretation will differ strikingly. be careful in determining which groups are being compared. High-dose hydrochlorothiazide increases the risk of sudden death approximately 2.5 times higher. To switch the groups when computing for the RR. D. High-dose hydrochlorothiazide doubles the risk of sudden death in the cohort. It compares the risks between two groups. (Choice A) High-dose hydrochlorothiazide treatment seems to be more effective in reducing BP than the low-dose regimen (Note the p values for the two-sample t test). Hydrochlorothiazide is a safe drug regardless of the dose. This group's RR of sudden death is very close to 1. when compared to the low-dose group and placebo group (2. D. no conclusions about risk reduction in the cohort (no treatment) would be valid. Note that in this computation. the RR of sudden death in the lowdose drug group is 0. low-dose hydrochlorothiazide treatment appears to protect from the occurrence of sudden death. Be very careful in determining which groups are being compared. On the other hand.

(Choice D) Many cases of angioedema have been described with ARBs including losartan. heart failure. although the incidence is much lower than with ACE inhibitors. He never had such an episode before. His blood pressure is 150/95 mmHg and heart rate is 80/min. and prostate cancer in his father.. This patient experienced a life-threatening episode of angioedema. Clonidine C. it is likely that both kinin-dependent and kinin-independent mechanisms have a role. Selective beta-blockers have been shown to be well-tolerated and equally beneficial in diabetic patients as in non-diabetics. (Choices B and C) Clonidine and terazosin are not considered first-line agents for the treatment of hypertension. low-dose group) = 1/0. placebo) = 1.2 to 0.5 times. (Choice A) Re-trial of an ACE inhibitor is not recommended.4 RR (high-dose group vs. diabetic nephropathy).0 Summarizing the results of the study.g.RR (low-dose group vs. when compared to low-dose treatment and placebo. Although the exact mechanism of ACE inhibitor-induced angioedema is unclear. although switching to an angiotensin receptor blocker (ARB) may be considered in selected patients. He was treated with corticosteroids and fresh frozen plasma infusion. metoprolol is the most appropriate treatment option in this patient. it is best to use alternative drugs. Terazosin D. high-dose group) = 0. His past medical history is significant for diabetes diagnosed two years ago and hypertension diagnosed two weeks ago. Which of the following is the best treatment option for hypertension in this patient? A. high-dose hydrochlorothiazide treatment seems to increase the risk of sudden death by 2. Educational Objective: Switching the groups when computing for the RR means obtaining the inverse of the estimate Case 72 A 54-year-old Caucasian male is hospitalized for an episode of life-threatening angioedema.5 RR (low-dose group vs. and has no compelling indication for ARB therapy (e. His family history is significant for diabetes mellitus and stroke in his mother. Metoprolol Explanation: The episode of angioedema is most likely related to the treatment of recently diagnosed hypertension with an ACE inhibitor. therefore. if possible.4 = 2.7%. Educational Objective: ARBs can be used very cautiously in selected patients with ACE inhibitor-induced angioedema. Captopril B. however. . The incidence of this complication is 0. Losartan E.

hypoesthesia. The pain is worsened on palpation and passive movements of the foot. numbness or hypoesthesia.. paresis. (Choice A) Fat embolism is infrequently seen in patients with long bone or pelvic fractures. Neurological examination reveals motor weakness and hypoesthesia of the distal right leg. or axilla). however. Educational Objective: Acute compartment syndrome usually occurs after a traumatic event and causes pain. and the neurologic deficit presents as decreased vibration sense. and blood pressure is 140/82 mmHg.2 C (99 F). multiple rib fractures and a contusion over her right lower leg. 87% of people answered this question correctly. Patients usually present with a triad of hypoxemia. Neural compression Explanation: Acute compartment syndrome refers to ischemic tissue damage secondary to elevated pressures in the enclosed compartments of the lower legs or forearm. where she sustained a right humerus fracture. When the tissue pressure in an enclosed compartment exceeds the perfusion pressure. Physical examination reveals a tense swelling around the right calf region. The next morning. neurological abnormalities (i. anterior chest wall. It is a rare cause of compartment syndrome and does not compromise blood circulation and neuromuscular function. and drug overdose. The pain is typically worsened by passive movements of the involved muscles. Acute compartment syndrome usually has a lag period of a few hours before irreversible nerve injury and muscle necrosis occurs. Deep venous thrombosis C. a tight cast or dressing after trauma. most commonly tibial fractures. Case 73 The following vignette applies to the next 4 items A 24-year-old female is admitted to the hospital after a motor vehicle accident. Fat embolism B. heart rate is 96/min. (Choice D) Vascular occlusion secondary to a motor vehicle accident usually presents more suddenly and dramatically. Late features include extremity paralysis and absent distal pulsation (pulseless paralysis). Patients usually present with severe pain which is out of proportion to the extent of injury. (Choice E) Nerve compression may occur in a patient after a motor vehicle accident and possible bone fracture. . Her temperature is 37.e. and a petechial rash (involving the head. Item 1 of 4 Which of the following is the most likely diagnosis? A. neck. Majority of the cases involving the lower extremities are due to a traumatic event. respiratory rate is 18/min. the resulting diminished tissue perfusion and compromised blood flow to the muscles and nerves inevitably lead to ischemic tissue necrosis. (Choice B) Deep venous thrombosis usually does not present acutely in a setting of motor vehicle accident in an otherwise healthy young patient.15% of people answered this question correctly. Acute compartment syndrome D. decreased two-point discrimination. confusion). Other causes include a crush injury or other long bone fractures in a motor vehicle accident. it does not lead to blood flow compromise and muscle necrosis (pain with passive movements of the involved muscles). and diminished to absent pulses in the involved limb. Sensory nerves are usually affected earlier than the motor nerves. Acute vascular occlusion E. a nurse calls to inform you that she is complaining of severe pain in her right lower leg.

Order a nerve conduction study Explanation: Compartment syndrome is characterized by an increase in the tissue pressure in the enclosed myofascial compartments of the extremities. and subsequently causes acute tubular necrosis and acute renal failure. causing tissue necrosis. Thrombocytopenia Explanation: Acute compartment syndrome results in markedly diminished to absent tissue perfusion within hours of the inciting event. Item 3 of 4 Which of the following is the most appropriate next step in the management of this patient? A. Start the patient on anticoagulation C. Rhabdomyolysis and renal failure C. (Choices A. It is therefore important to measure the tissue or compartment pressure early in the course of management. Gangrene of the limb E. (Choice A) Oxygen is usually used in the supportive treatment of patients with fat or cholesterol emboli. Disseminated intravascular coagulation B. Myoglobin is directly toxic to the renal tubules. Laboratory studies typically reveal markedly elevated creatinine kinase levels and the presence of myoglobin in the urine (positive dipstick for blood in the absence of RBC’s in the urine). (Choice E) Nerve conduction studies are helpful in the diagnosis and localization of the site of nerve damage. D. muscle infarction. (Choice C) Venous Doppler ultrasonography is useful for the diagnosis of deep venous thrombosis. and rhabdomyolysis. It is not helpful for the diagnosis of compartment syndrome. especially if the diagnosis is in question. Order venous Doppler ultrasonography D.Item 2 of 4 Which of the following is the most common life-threatening complication of the above condition? A. which releases myoglobin into the peripheral circulation. Educational Objective: Rhabdomyolysis and subsequent development of acute renal failure is one of the most common and severe life-threatening complications of acute compartment syndrome. C. When the elevated tissue or compartment pressure reaches its threshold level. Acute renal failure and its complications (electrolyte disturbances) are one of the most common life-threatening complications of acute compartment syndrome. The current general consensus for the threshold value is greater than 30 mmHg. disseminated intravascular coagulation. Pulmonary embolism D. . the capillaries collapse. The exact value for the tissue pressure at which blood flows to the muscle and nerve tissue stops is controversial. pulmonary embolism. 24% of people answered this question correctly. Check the tissue pressure E. E) Thrombocytopenia. (Choice B) Anticoagulation is usually required for patients with deep venous thrombosis. Administer oxygen B. and this eventually leads to tissue and muscle necrosis. and gangrene of the limb are not usually seen in patients with acute compartment syndrome.

(Choice B) Obtaining a hypercoagulable panel may be useful in patients with idiopathic deep venous thrombosis. Which of the following is the best next step in management? A. There is no hepatosplenomegaly.Educational Objective: Direct measurement of the compartment or tissue pressure is the diagnostic procedure of choice for patients with suspected acute compartment syndrome. and respirations are 28/min. (Choice E) Venous Doppler ultrasonography is useful to diagnose deep venous thrombosis. Any delay in treatment leads to irreversible muscle and nerve damage. It is not indicated in patients with acute compartment syndrome. Continue with oxygen therapy B. Item 1 of 3 . She is concerned because on multiple occasions in the past 48 hours.0C (98. or demonstration of discomfort when passing stool. (Choice A) Oxygen therapy has no role in the management of patients with acute compartment syndrome. and appears to be experiencing mild discomfort. Item 4 of 4 The appropriate step was taken for the patient. The boy was born at term via normal spontaneous vaginal delivery and has no pertinent medical history. Surgical decompression aims to restore the capillary blood flow and tissue perfusion. excessive crying. His temperature is 37. Case 74 The following vignette applies to the next 3 items A six-month-old well-nourished African-American boy is brought to the pediatrician by his mother. His abdomen is soft and nontender. the child passes stool that looks like currant jelly.6F). and contains gross amounts of blood and mucous. He is now sitting very quietly in his mother’s lap. Review the results of venous Doppler ultrasonography Explanation: Acute compartment syndrome is a surgical emergency. Surgical decompression aims to relieve the pressure within the enclosed compartment and to restore the blood flow to muscles and other tissues within 6-10 hours of the initial symptoms. Consult a vascular surgeon D. Educational Objective: An emergent fasciotomy is the definitive treatment in patients with acute compartment syndrome. A compartment pressure of 30 mmHg or greater warrants an emergent fasciotomy (also known as compartment release). Some patients may develop a persistent sensory or motor deficit after an episode of acute compartment syndrome despite early fasciotomy. Immediately after being examined. It has no role in the diagnosis or management of patients with acute compartment syndrome. pulse is 132/min. Perform urgent fasciotomy E. His anterior fontanelle is slightly depressed. The rectal examination is unremarkable. she has discovered evidence of rectal bleeding in her son’s diaper. 80% of people answered this question correctly. Obtain a hypercoagulable panel C. (Choice C) A consultation with a vascular surgeon is necessary in patients with vascular injury or occlusion. The mother reports that her son has no history of vomiting. She denies any history of trauma or foreign body ingestion. blood pressure is 84/56 mm Hg.

intussusception is the telescoping of a proximal portion of intestine into a more distal portion of intestine. (Choice C) CT scans of the abdomen may allow for the diagnosis of intussusception. barium enema remains as the preferred means of diagnosis and therapy. * If you don’t find barium enema in the choices choose ultrasonography. Abdominal plain films B. and peritonitis. The classic image seen on ultrasound is that of a "bull?s eye. Educational Objective: The barium enema (not barium swallow) contrast is a preferred means of diagnosing intussusception because it is also therapeutic. a finding known as the "crescent sign. A sausage-shaped mass may be palpated on the right side of the abdomen." signifying layers of intestine nestled within intestine. (Choice A) Abdominal plain films occasionally demonstrate a soft-tissue density extending into the gaseous pockets within the large bowel. Request a nurse to witness the informed consent . Have the father telephoned for oral consent D. and up to 20% of patients may have no evident pain. The most common presentation involves intermittent. severe. therefore. (Choice E) Ultrasonography is also an excellent choice as its sensitivity and specificity near 100%. It is not commonly used in the diagnosis of intussusception. The resulting venous and lymphatic congestion can cause significant intestinal edema and may ultimately result in ischemia. CT scan of abdomen D. Technetium 99m scan E. but are less preferred because they require sedation of young children and are time-consuming. crampy abdominal pain accompanied by intense crying and vomiting. Ultrasonography is also an excellent choice as its sensitivity and specificity near 100%. this is an unusual and not well-studied technique. The diagnosis is most commonly confirmed with a barium enema contrast study. Interestingly. Which of the following is the most appropriate next step? A. Have the father brought in for written consent C. Have another adult relative brought in for written consent E. Reduction of the intussusception through this method is successful 75-90% of the time. (Choice D) A Meckel scan with technetium 99m is often used to highlight ectopic gastric mucosa. Barium enema C.Which of the following diagnostic tests would be most useful in the management of this patient’s condition? A. This study is preferred because it is both diagnostic and therapeutic. reduction of the intussusception through this method is successful 7590% of the time. *Extremely important question for USMLE step-3 Item 2 of 3 The appropriate diagnostic test is selected and the mother agrees to the proposed treatment. the classic triad of pain. a palpable mass." Frank intestinal obstruction and pneumoperitoneum may also be found. Although there have been some reports of reducing the intussusception under ultrasound guidance. and "currant-jelly" stool (containing blood and mucous) is observed in less than 15% of patients. Ultrasound of abdomen Explanation: The second most common cause of small bowel obstruction in infants and toddlers. perforation. Document the mother’s informed consent and proceed with diagnostic testing and treatment B. The boy’s father is not present.

Fistulas (Choice B) are not common complications of intussusception reduction. It is unlikely to occur secondary to usage of barium contrast enemas. . risks. alternatives. Stricture Explanation: The complication of greatest concern when reducing an intussusception with a barium or air contrast study is perforation of the bowel. including the nature. (Choice D) Contacting another adult relative to provide consent is only appropriate if that individual has the legal authority to act on the child’s behalf while the mother does not. However. the physician should document the consent and include it in the medical chart.Explanation: Obtaining informed consent formally ensures that the patient is an informed participant in his health care decisions. However. It is generally considered sufficient to document the informed consent of one parent and then proceed with diagnostic testing and treatment. several concepts must be conveyed. a blood draw). The same standards apply if the patient is a minor. he must be considered competent. unless the mother does not have the legal authority to act on the child’s behalf. Educational Objective: When providing health care to minors. Renal failure (Choice D) is of greatest concern when performing radiological studies that use intravenous contrast.has been known to occur in the portion of intestine involved. which occurs in <1% of patients (Choice C). and the child’s mother asks about potential complications. with the exception that the custodial parent or legal guardian retains the legal authority to provide consent. this is a rare occurrence. and his consent must be voluntary. The risk of small bowel obstruction secondary to postoperative adhesions (Choice A) is of concern after any abdominal surgery and is thought to occur in up to 5% of patients who undergo operative reduction of an intussusception. Renal failure E. whether accomplished operatively or nonoperatively. 88% of people answered this question correctly. To properly equip the patient with adequate knowledge to make such decisions. It is not a likely complication if the reduction is accomplished with barium contrast enema. The perforation usually occurs on the distal aspect of the intussusception. The risk of this complication occurring is greatest in two groups: infants younger than six months old who have demonstrated symptoms for at least three days and those patients who appear to have small bowel obstruction. Once such a discussion occurs.whether accomplished by operative or nonoperative means -. Stricture (Choice E) occurring 4-8 weeks after the reduction -. it may be appropriate to have the nurse obtain informed consent from the patient’s mother. Item 3 of 3 The risks and benefits of the preferred curative procedure are discussed. more complex procedures warrant an in-depth discussion between the physician and patient. it is generally sufficient to document the informed consent of one parent who has legal custody of the child and then proceed with diagnostic testing and treatment. (Choice E) If the procedure is a simple one (eg. (Choices B and C) It is not necessary to contact the child’s father for written or oral consent. Fistula C. and benefits of the procedure. Which of the following is most likely? A. Adhesions B. For a patient’s consent to be deemed valid. It is rarely necessary to have support staff witness the informed consent if the physician is already present. Perforation D.

Sputum analysis is positive for acid-fast bacilli. the PPD test should be repeated in three months. Perform chest X-ray. He does not smoke or consume alcohol. All his vaccinations are up-to-date. Which of the following is the best statement concerning this patient’s recreational activities? A. Decongestants (e. which occurs in <1% of patients. He regularly works out at a gym twice a week. D. the PPD test should be repeated in three months. monotherapy with INH is necessary. If the results are negative. Start treatment with isoniazid (INH). a chest x-ray should be taken to check for signs of infection. Case 76 A 25-year-old Caucasian male presents to your office for pre-travel counseling. If the results are negative. Consider otoscopic examination and audiometry before diving. Repeat PPD test in three months. E. Case 75 A 45-year-old immigrant from Eastern Europe is brought to the emergency department because of several weeks history of progressive back pain. Explanation: Scuba diving is associated with a range of pressure-related injuries.g. and to educate him about the basic measures that help prevent them (e.g. Identifying health care workers and other individuals who were exposed is very important. Which of the following is the best next step in infection prevention among the exposed staff? A. pseudoephedrine) can be used before diving. and he takes inhalational steroids as needed to treat it. E. anti-tuberculosis treatment should be instituted. and denies any recreational drug use.. The most common condition associated with scuba diving is ear barotrauma. the patient was isolated. It is important to inform the patient about the possibility of such injuries. D. discourage flying in a plane within 24 hours of diving). His past medical history is insignificant. and the three staff members that were in close contact with him are tested with PPD. Public health authorities should be notified if active infectious tuberculosis is revealed. Educational Objective: PPD testing should be promptly performed on individuals exposed to active infectious tuberculosis. The patient’s work-up reveals bilateral cavitary lesions in the pulmonary apices. an investigation of the people at risk should be undertaken. He should use steroids before diving if he has symptoms of allergy. and appropriate preventive measures should be initiated. PPD test results turn out to be negative in all of them. The physical examination is within normal limits. He is not taking any medications and denies drug abuse. (Choices B and D) In people with positive PPD test results. C. PPD testing should be promptly performed on exposed individuals. Antibiotics can be used to prevent diving-associated medical conditions. No further measures are necessary. Consider pulmonary function tests before diving activities.Educational Objective: The complication of greatest concern when reducing an intussusception with a barium or air contrast study is perforation of the bowel. B. He plans to fly his private airplane and engage in scuba diving in the Caribbean islands. Start treatment with at least three drugs. Immediately after obtaining this information. if positive. This patient has an increased susceptibility . C.. His past medical history is significant for allergic rhinitis since childhood. B. Explanation: If tuberculosis precautions were not promptly instituted upon admission of a patient with an active infection. (Choice C) If PPD conversion occurs.

Erb’s palsy D. Shoulder traction during delivery is the most probable cause of diaphragmatic paralysis in this case. but may occur in diaphragmatic paralysis. type-1 since she was 11 years of age. Physical examination reveals decreased movement of the rib cage on the right side and abdominal flattening. 20% of people answered this question correctly. Spina bifida Explanation: Diaphragmatic paralysis of the newborn usually results from a phrenic nerve injury. (Choice A) Ipsilateral and less frequently contralateral hypoplastic lung is characteristic for diaphragmatic hernia. which can block drainage due to mucosal edema and discharge. The prenatal course was complicated by two episodes of mild viral infection during the second trimester. The delivery was complicated by mild shoulder dystocia. (Choices D and E) There is no indication to perform pulmonary function tests or audiometry in this patient. Educational Objective: Studies have shown that the use of non-sedating decongestants (specifically pseudoephedrine) before diving reduces the incidence of ear and sinus barotraumas by 75%. Studies have shown that the use of non-sedating decongestants (specifically pseudoephedrine) before diving reduces the incidence of ear and sinus barotraumas by 75%.to ear and sinus barotraumas because of his history of allergic rhinitis. Which of the following favors most the diagnosis of diaphragmatic paralysis over diaphragmatic hernia in this case? A.g. It is not related to any of these conditions. and a weak cry shortly after birth. (Choice D) Sacral agenesis is a rare anomaly observed in children of diabetic mothers. (Choice B) Antibiotic prophylaxis is not recommended for scuba divers. such as Erb’s palsy. (Choice B) Mediastinal shift to the unaffected side typically occurs in a diaphragmatic hernia. (Choice E) The other causes of diaphragmatic paralysis (e. . cyanosis. Mediastinal shift to the left C. diaphragmatic hypoplasia. neural and neuromuscular disorders) are very rare. and the infant demonstrates tachypnea. Hypoplastic right lung B. The two most common causes of phrenic nerve injury are birth injury and cardiothoracic injury. Case 77 A male infant is born at term to a 30-year-old Caucasian primigravida. (Choice A) The patient should be instructed to avoid diving activities if he has any symptoms of allergy. It is therefore reasonable to suggest the use of such drugs to the patient.. such as Erb’s palsy. 61% of people answered this question correctly. The mother has had diabetes mellitus. Sacral agenesis E. It is typically accompanied by the signs of brachial plexus injury. Educational Objective: Diaphragmatic paralysis in a newborn is typically caused by birth trauma or cardiothoracic surgery. It is typically accompanied by the signs of brachial plexus injury.

The patient now appears comfortable. on the other hand. (Choice D. Case 79 . it is now accepted that patients with simple febrile seizures have a slightly increased risk of subsequent epilepsy in latter life compared to the general population. E. There is no way to predict the prognosis of his condition. he has a slightly increased risk compared to the general population. Basic metabolic panel results are all normal. a cumulative duration of greater than 30 minutes. Had the question particularly asked about the recurrence of febrile seizures during childhood. Explanation: The generally accepted criteria for febrile seizures are: Age less than six years No past history of afebrile seizures Temperature greater than 38 C No evidence of CNS infection / inflammation No metabolic disturbances present which may produce seizures Febrile seizures may be subdivided into 2 forms: simple and complex. E) Multiple prospective studies have established a slightly increased risk for subsequent epilepsy in latter life of patients with childhood febrile seizures. B. pulse 120/min and respiratory rate 22/min. There is a significantly increased risk compared to the general population. Chest auscultation reveals bilateral rhonchi and wheezing. it is now accepted that patients with simple febrile seizures have a slightly increased risk of subsequent epilepsy in latter life compared to the general population. Educational Objective: Febrile seizures are divided into simple and complex febrile seizures. The mother adds that the patient has had a cough with fever for the past three days. The jerking episode lasted for about one minute. While giving the necessary treatment to the patient. postictal paresis). as mentioned above. The patient’s history is classic for a simple febrile seizure. D. compared to the general population. afebrile seizures) in latter life. What do you tell her? A. A simple febrile seizure is characterized by the absence of focal features. and for seizures occurring in series. Contrary to previous thinking.e. a cumulative duration of less than 30 minutes. Complex febrile seizures. This form of seizures is more common. a duration of more than 15 minutes. the mother expresses her concern about the possibility of her child having epilepsy. a duration of less than 15 minutes for an isolated event. There is currently a high risk compared to the general population. There is no increased risk compared to the general population. It is important to note that the question specifically asks about prognosis. Chest x-ray shows bilateral pulmonary infiltrates. are characterized by focal features (i. C. (Choice A. regardless if this case was a simple or complex febrile seizure for the first time. and if occurring in series. C) Contrary to previous thinking. but this will decline as the patient grows older. and is associated with only a mild elevation of the risk for subsequent epilepsy (i.e. therefore. then the answer would be ‘significantly elevated risk’.Case 78 A mother brings her 1-year-old son to the emergency department with complaints of “a brief episode of jerky movements all over his body”. There is a slightly increased risk compared to the general population. Vital signs are as follows: temperature 104 F (40 C). and not recurrence.

and fibromyalgia. diabetes. specificity ? 90% Explanation: A screening test must have a high sensitivity. specificity ? 90% B. Some of these conditions are: a history of wrist trauma or fracture. Sensitivity ? 70%. hypothyroidism. Her other medical problems include osteoporosis. Item 1 of 2 Which of the following conditions is least associated with the diagnosis of carpal tunnel syndrome? A. Case 80 The following vignette applies to the next 2 items A 58-year-old Caucasian woman comes to see you in the office with complaints of right wrist pain for the past 2 months. A variety of local or systemic conditions have been associated with carpal tunnel syndrome because they can cause external compression of the median nerve. The Phalen maneuver was performed in the office. Sensitivity ? 65%. end stage renal disease and dialysis. It is not associated with an increased incidence of carpal tunnel syndrome. Diabetes mellitus B. menopause. a history of wrist fracture. This high sensitivity helps to ‘RULE IN’ the disease by decreasing the number of false-negative results. hypothyroidism and end stage renal disease. and is associated with numbness and a tingling sensation in the same distribution. You make a clinical diagnosis of carpal tunnel syndrome. obesity. 81% of people answered this question correctly. and similar symptoms were reproduced after 30 seconds. thus. giving as few false-negative results as possible. coronary artery disease. End stage renal disease D. Wrist trauma Explanation: Carpal tunnel syndrome (CTS) is due to an entrapment of the median nerve on the volar surface of the wrist. Hypothyroidism E. Educational Objective: A screening test must have a high sensitivity. many diseased people would be labeled healthy. rheumatoid arthritis. diabetes mellitus. . Sensitivity ? 85%. specificity ? 97% C. specificity ? 94% D. This high sensitivity helps to ‘RULE IN’ the disease. acromegaly.Several tests have been developed to measure the serologic markers of breast cancer. These tests have different specificities and sensitivities for the early stage of breast cancer. and by increasing the negative predictive value. the test with the highest sensitivity and good specificity is the best choice. The pain is located in the thumb and first 2 fingers. Osteoporosis C. hypertension. Sensitivity ? 80%. Which of the following tests could be the best screening test for the early detection of breast carcinoma if applied to a population with a stable incidence of the disease? A. Osteoporosis is characterized by a progressive loss of bone mineral density and an increased risk of bone fractures. The symptoms get worse at night. Furthermore. pregnancy. Sensitivity ? 75%. specificity ? 92% E. and with activities requiring prolonged flexion or extension of her wrist. (Choice B) Choosing a highly specific test with low sensitivity would give more false-negative results. the high sensitivity increases the negative predictive value (NPV) of the test: NPV = True negatives / (True negatives + False Negatives) In this case.

which can lead to carpal tunnel syndrome. Symptoms usually get worse at night. tight blood sugar control alone will not improve the symptoms of carpal tunnel syndrome. (Choice E) Direct trauma or compression by callus formation can cause median nerve entrapment. (Choice D) CTS should be suspected in patients with hypothyroidism and wrist pain / paresthesias. the first 2 fingers and the lateral half of the ring finger). A trial of carpal tunnel injection with glucocorticoids may be helpful in patients with persistent pain despite conservative management. but this effect is short lived. Surgical release of volar carpal ligament E. ischemic damage to the median nerve. Observation and tight blood sugar control B. ESRD / dialysis and direct trauma are associated with the development of carpal tunnel syndrome. Case 81 . and with prolonged use of the wrist. Furthermore. 72% of people answered this question correctly. these treatment regimens are associated with a higher incidence of complications. Educational Objective: Wrist splints are an effective initial way of improving the symptoms of patients with carpal tunnel syndrome. and to reduce the pressure on the nerve in the carpal tunnel. hypothyroidism. conservative treatment is usually enough to relieve the symptoms and prevent the progression of the disease and its complications. and infiltration of the carpal tunnel with amyloid fibrils all seem to play a role in its pathogenesis. It is believed to be due to the deposition of mucopolysaccharides in the carpal tunnel. particularly in activities involving repeated flexion or extension of the wrist. Continuous wrist splint D. or atrophy of the thenar eminence. (Choice C) Carpal tunnel syndrome is commonly seen in patients with end stage renal disease (ESRD) and dialysis. Surgical treatment is indicated in patients with persistent pain despite the abovementioned measures. It is especially useful to reduce the nighttime symptoms. Educational Objective: Diabetes mellitus. it can cause permanent nerve injury with a claw hand deformity. Corticosteroid injection into the carpal tunnel Explanation: Carpal tunnel syndrome (CTS) occurs due to a compression of the median nerve in the carpal tunnel. steroid injection is not a benign procedure. (Choice B and E) A short course of oral glucocorticoids may relieve the pain. Direct compression. The initial symptoms are pain and paresthesias in the median nerve distribution (the thumb. The initial treatment is directed at measures which can help reduce the pressure on the median nerve. motor weakness. A trial of a short course of oral prednisone C. (Choice A) Although diabetes has been associated with the development of CTS. Item 2 of 2 Which of the following is the most appropriate initial approach to manage her symptoms? A. In the majority of the patients. however. (Choice D) The majority of patients usually respond to conservative measures (wrist splints) and local injections of glucocorticoids. Continuous wrist splinting is a simple and effective way to keep the wrist in a neutral position. therefore. this has to be performed by highly-skilled physicians only. In the worstcase scenario.(Choice A) Evidence from clinical studies support the association between the presence of diabetes and the development of carpal tunnel syndrome. The etiology appears to be multifactorial in these patients.

Intravenous hydrocortisone 100 mg every six hours C. He is developing progressive shortness of breath. Educational Objective: ARDS is associated with a mortality rate of 35-40%. controlled studies have shown that the effect of NO compared to placebo.7 C (98 F). mechanical ventilation that delivers lower tidal volumes (< 6 ml/kg) and limits plateau pressure (< 30 CmH2O) has been shown to be relatively more effective than other strategies such as NO inhalation. surfactant decreases the alveolar surface tension and reduces the chances of atelectasis. Administration of surfactant B. and respiratory rate is 26/min. Prostacyclins E. Among the different strategies. She is using her accessory muscles of respiration and has an audible wheeze. Among the different strategies. exogenous surfactant. Mechanical ventilation that delivers lower tidal volumes & limits plateau pressure Explanation: Development of pulmonary contusions secondary to chest wall trauma is an important etiological factor of ARDS. Administer 0.A 35-year-old male has been hospitalized for two days after being involved in a motor vehicle accident where he sustained multiple severe injuries. double blind. She has a history of allergies to peanuts. He has no previous medical history or any known lung abnormalities. her vital signs reveal a temperature of 36. his 56-year-old wife suddenly complains of shortness of breath and generalized itching. Administer 1 mg of intravenous Glucagon B. It facilitates the mucous clearance and helps to suppress inflammation. and steroids. and is being maintained on 100% oxygen. however. A chest x-ray shows diffuse bilateral pulmonary infiltrates. Early administration of methyl prednisone C.5 mL of 1:1000 epinephrine subcutaneously . large multicenter. His family history is not significant. Unfortunately. use of prostacyclins. Case 82 A 60-year-old man comes to the emergency department for evaluation of left foot pain. Lung examination reveals diffuse wheezing on both sides. (Choice A) Theoretically. heart rate is 124/min. including rib fractures. On physical examination. Her skin is flushed and has urticarial rash all over her body. studies have also failed to demonstrate significant effects of prostacyclins on mortality. There was no significant difference found in 28 days mortality in both arms of these studies. blood pressure is 88/60 mmHg. (Choice B) Although steroids are frequently used in clinical practice in such situations. Which among the following is the most useful strategy to decrease mortality in ARDS patients? A. (Choice C) NO is a vasodilator which should theoretically improve V/Q mismatch. and he believes that the cookie had peanuts in it. Studies comparing the effects of low tidal volume and limited plateau pressure to that of high tidal volume and plateau pressure have shown a significant reduction in mortality in the first group (32% vs. He does not smoke. Some studies have even demonstrated increased infections in patients using steroids. While waiting in the triage area. (Choice D) Prostacyclins have similar effects as NO since it increases oxygenation and decreases pulmonary pressures. was modest and inconsistent. drink alcohol. Inhaled nitric oxide (NO) D. Her husband tells you that she was eating a cookie in the waiting area when her symptoms started. 40%). mechanical ventilation that delivers lower tidal volumes (< 6 ml/kg) and limits plateau pressure (< 30 CmH2O) has been shown to be relatively more effective. Steroids are helpful. studies have not shown any beneficial effect on the acute phase. or use any illicit drugs. studies have failed to demonstrate any significant positive outcome on 30 days mortality in these patients. You bring her into the examination room. in reducing the intensity of the fibro-proliferative phase of ARDS in later stages. however. however. Which of the following is the most appropriate next step in the management of this patient? A. You strongly suspect ARDS. ARDS is associated with a mortality rate of 35-40%.

and wheezing secondary to bronchospasm. Educational Objective: Subcutaneous or intramuscular administration of 0.5 mL of 1:1000 epinephrine subcutaneously or intramuscularly. If the disease presents before 2 years of age. intravenous contrast dye.D. She is asymptomatic. and insect stings. and has never had a sickle cell crisis. (Choice B) Hydrocortisone or other intravenous corticosteroids are only effective in preventing the late phase reaction. Her mother also has sickle cell disease. Splenic infarction B. Start albuterol nebulization Explanation: The patient has a clinical syndrome consistent with an anaphylactic reaction. patients can develop laryngeal edema. causing anaphylactic shock. angioedema. Glucagon acts through receptors other than beta receptors and causes positive inotropic and chronotropic effects. Severe hypotension and cardiovascular collapse can occur secondary to peripheral vasodilation and hypovolemia. (Choice D) Terbutaline is a beta 2-receptor agonist and is effective in reversing the bronchospasm. Stroke E. removal of the offending agent and obtaining adequate intravenous access. Bone infarction C. It occurs in about 20% of the patients with sickle cell disease. which could lead to a series of ischemic events. She has sickle cell disease. Anaphylaxis is a lifethreatening immediate IgE-mediated hypersensitivity reaction to exogenous stimuli.5 mL of 1:1000 epinephrine should be used as an initial pharmacologic therapy for patients with symptoms of anaphylaxis. generalized pruritus or urticaria. Patients with bronchospasm and hypotension should be administered 0. (Choice A) Glucagon should be administered to patients with anaphylaxis if they have a history of concurrent beta-blocker use. It does not reverse the hypotension and should not be used alone in the initial stages. shortness of breath. . A few common exogenous causes of anaphylaxis are foods (peanuts. Splenic sequestration D. however. Epinephrine is the preferred drug in patients with anaphylaxis as it can reverse both bronchospasm and hypotension induced by massive histamine release. angiotensin-converting enzyme inhibitors). This may be repeated for every 10-15 minutes up to a total of 3 doses.3-0. splenic sequestration is the most common. or other sea foods). one-third of these patients will be affected. fish. Case 83 A healthy 6-year-old African-American girl is brought to the physician for a routine follow-up visit. such ischemic events are less common complications than splenic sequestration. The symptoms of anaphylaxis typically develop within 5-60 minutes of exposure to the allergen. or severe bronchospasm leading to respiratory failure. Administer 0. In severe cases. Her physical examination is normal. (Choice A) The falciform red blood cells in sickle cell disease may cause vascular occlusion. Acute coronary ischemia Explanation: Among the above complications. They should not be used as an initial drug of choice in patients with anaphylaxis. She is not taking any medications. drugs (beta-lactam antibiotics. Patients typically have a feeling of flushing. The initial management consists of rapid assessment of patient’s airway and cardiopulmonary status.3 to 0.25 mg of terbutaline subcutaneously E. Which of the following complications is most likely to occur in this patient? A. such as splenic infarction.

as well as some neurovegetative symptoms such as dizziness. Treatment is aimed at decreasing the speed of the passage of fluids and food into the small gut. Start alprazolam. It is not as common as the other complications of sickle cell disease. The patient is a food handler. Splenic sequestration is the second most common. and quit two months ago. A high-protein and low-carbohydrate diet is advised. the most common initial symptom of sickle cell disease is dactylitis. C. Start metoclopramide. Educational Objective: Dumping syndrome is a common complication of gastrectomy. generalized sweating. diarrhea. and are seen mainly in the adult population. smaller. D. and are especially uncommon in the pediatric population. A change in the diet usually relieves the symptoms. as well as smaller but more frequent meals throughout the day. such as ischemic events. (Choice A) Metoclopramide stimulates the contraction of the lower esophageal sphincter and increases gastric emptying. The latter complication is also a differential diagnosis in a patient with sickle cell acute chest syndrome. but will not control the other features of dumping syndrome. Examination reveals a mildly distended abdomen with increased bowel sounds. Which of the following will be the most appropriate therapeutic intervention? A. Explanation: The patient has dumping syndrome. nausea and vomiting. A high protein diet. He is complaining of diarrhea. He has smoked one pack of cigarettes a day for twenty years. (Choice C) A low-fiber diet may improve the diarrhea. He does not use alcohol or drugs. He had a partial gastrectomy for a bleeding gastric ulcer one month ago. This leads to abdominal pain. which develops in 40% of patients. (Choices D and E) Stroke and acute coronary ischemia are rare complications. (Choice D) The diet should be low (not rich) in carbohydrates. are not as frequent. (Choice E) Alprazolam is helpful for neurovegetative (not digestive) symptoms. generalized sweating. Start a low-fiber diet. and dyspnea. a complication of gastrectomy. Liquid and food passage through the stomach into the jejunum is faster. and occurs in about 20% of patients. and fractionated. His medications are omeprazole and antacids. Educational Objective: In children. but more frequent food portions are advised. and the postsurgical scar is healing well. Case 84 A 43-year-old Chinese-American man comes to the office. Start a high protein diet. E.(Choice B) Bone infarction is a complication that can lead to osteomyelitis in the affected bone. Case 85 . He also has dizziness. postprandial nausea and vomiting for the past five days. It may worsen the symptoms. cramping abdominal pain. and shortness of breath. B. Other complications. The epigastrium is mildly tender. Start a high carbohydrate diet.

vision and gait. Classic MRI findings in PML consist of multiple demyelinating. non-enhancing lesions with no mass effects. Which of the following is the most likely diagnosis? A. You are aware that the girl's father works as a taxi driver and is an alcoholic. Her school grades have dropped significantly. a human polyomavirus. You attempt to talk to the young girl. demyelinating lesions with no mass effects. and weakness and a tingling sensation in the right upper and lower extremities. He was diagnosed with AIDS fourteen months ago.. Educational Objective: Multiple focal neurological deficits in an immunocompromised patient (i.A 28-year-old man with acquired immune deficiency syndrome (AIDS) is hospitalized for the treatment of Pneumocystosis carinii pneumonia and esophageal candidiasis. (Choices B. C and D) Although toxoplasmosis. Acute stress disorder Explanation: Although it may not necessarily be the correct diagnosis. but these usually tend to be symmetrical. especially if the family . you have known her to be a very cheerful and lively girl. patient with AIDS) suggest a diagnosis of PML. these are associated with ring-enhancing lesions and show a mass effect on MRI. who is your close friend. PML predominantly involves the cortical white matter. but the brainstem and cerebellum may also be involved. Anxiety disorder D. An immunocompromised patient with focal neurological deficits should raise the suspicion for PML. Adjustment disorder C. The usual findings on MRI are non-enhancing. In the hospital.e. His current medications include zidovudine. but the pupillary reflexes are intact. The lesions typically do not produce a mass effect. Focal neurological deficits are not characteristic of this disease. CNS lymphoma and brain abscess are all common in AIDS patients. and the onset of symptoms is usually gradual. lamivudine and indinavir. Which of the following diagnoses should you consider at this point? A. he is being treated with trimethoprim . On his fourth day in the hospital. Major depression with melancholic features B. There is no effective treatment for PML. The right upper and lower extremities exhibit exaggerated deep tendon reflexes and diminished sensations of touch and motor strength. Brain abscess E.sulfamethoxazole (Bactrim) and intravenous fluconazole (Diflucan). MRI of the brain reveals non-enhancing demyelinating lesions in the parietal-occipital region of the left cerebral hemisphere with no mass effect. It is caused by the JC virus. but she just bursts into tears. he complains of decreased vision on the right side. MRI findings may be similar to those of PML. The most common presenting symptoms are hemiparesis and disturbances in speech. and has started wetting her bed. The exact mode of transmission is unknown. Toxoplasmosis C. Case 87 A 10-year-old girl is brought to your office by her mother. Progressive multifocal leukoencephalopathy B. HIV encephalopathy Explanation: Progressive multifocal leukoencephalopathy (PML) is an opportunistic infection seen in immunocompromised patients. physical or sexual abuse should be highly suspected in children (especially females) with sudden behavioral problems. She has been sleeping poorly at night. and this diagnosis is best confirmed with MRI. (Choice E) HIV encephalopathy usually presents with dementia as the predominant symptom. CNS lymphoma D. and the mean duration of survival from the time of diagnosis is six months. She also refuses to sleep at night until her father returns home and goes to bed. Your friend is extremely concerned because the girl has had a recent change in behavior. Prior to this office visit. Physical examination reveals visual field defects in both eyes. Physical abuse E. Cranial nerve deficits may occasionally develop. There is an apparent symptomatic improvement with therapy. She has become irritable and cranky.

The most commonly used techniques are saline and KOH preparation for microscopy. This is important to avoid frequent misdiagnosis and inappropriate treatment. a detailed history may reveal some stressors. there is no mention of any particular stressful event. she noticed the presence of a whitish. and cervix. Even a diagnosis by history and physical examination by a physician is not reliable and should always be confirmed in the office by microscopy. Schedule an appointment to see you in the office C. and rarely. Case 88 A 32-year-old African-American female calls you in the office and complains of a moderate amount of vaginal discharge and intense pruritus. vagina. (Choice B) Adjustment disorder is usually an abnormal behavioral response to an identifiable stressor. (Choice C) A diagnosis of anxiety disorder requires the presence of a pattern of nervousness about several different issues. and self-diagnosis and treatment by the patient is unreliable. What is the most appropriate response? A. some systemic disorders. bacterial vaginosis. The response is usually disproportionate to what would be normally expected with the given stressor. however. The vaginal secretions have characteristic pseudohyphae in candidiasis. it is imperative to rule out the diagnosis of physical abuse before any other disorder or disease is considered. She is concerned. Common infectious causes are vulvovaginal candidiasis. Approximately one week ago. In order to possibly protect the child from further harm. (Choice E) Acute stress disorder always develops in response to a traumatic event and presents as recurrent thoughts or flashbacks of the event associated with hypervigilance and avoidance of stimuli associated with the event. especially if the family has an unstable economic background or if the child's parents have a history of drug/alcohol abuse. this diagnosis should be considered only after physical abuse has been ruled out. Bacterial vaginosis is confirmed by the presence of clue cells in the smear. 62% of people answered this question correctly. and trichomoniasis. In this case. Motile trichomonads and an abundance of polymorphonuclear cells are found in patients with trichomoniasis. . She was diagnosed with insulin-dependent diabetes 20 years ago. Prescribe a single 400 mg dose of fluconazole D. which usually resolve with OTC antifungal creams. Nevertheless. She has been in a monogamous relationship for the last two years. malodorous vaginal discharge. Educational Objective: Always maintain a high index of suspicion for physical/sexual abuse in children (especially females) with sudden behavioral problems. The etiology includes infections of the vulva. this diagnosis should be considered after ruling out physical abuse. (Choice A) Major depression is certainly an important differential diagnosis because poor sleep and irritability are symptoms of depression in the pediatric age group. Continue the antifungal cream for another two weeks B. irritants. but physical abuse needs to be ruled out first. Ask her about her blood sugar control in the last month E. and asks you what she should use this time. Obtain a more detailed sexual history Explanation: Vulvovaginitis is an extremely common condition in the sexually active age group. She has been using an over-the-counter (OTC) antifungal cream for a week now. hormonal disorders. and the noninfectious causes are chemicals. Most of the symptoms of vaginitis are nonspecific.has an unstable economic background or if the child's parents have a history of drug/alcohol abuse. She gets similar vaginal infections approximately twice or thrice a year. A detailed history could possibly detect an underlying anxiety disorder. however.

it should be remeasured using a venous blood sample. (Choice C) The hematocrit reaches its maximum value when the infant is approximately two hours of age. His temperature is 37. to some extent. For this reason. The nurse observes one episode of apnea. Recheck the hematocrit from a sample obtained from a central line E. (Choices A and B) The hematocrit can be falsely elevated in capillary samples. and the diagnosis should always be confirmed by microscopy to avoid inappropriate treatment. Recheck the hematocrit by performing a new heel prick in 12 hours D. Item 1 of 2 What is the most appropriate next step in management? A. it is important to recheck the hematocrit levels 12 to 24 hours after delivery if the hematocrit value is borderline high. but should not replace microscopy for confirmation of the diagnosis. Item 2 of 2 One day later. This may give a clue to the diagnosis. (Choice D) Tight blood sugar control is important to prevent recurrences of vulvovaginal candidiasis. Educational Objective: Neonatal polycythemia is diagnosed when the peripheral venous hematocrit is higher than 65%. High hematocrit levels that are obtained from capillary samples (usually from the heel) are only screening values that need to be confirmed through venous blood sampling. it is paramount to obtain a sample of venous blood. the baby appears plethoric. Peripheral venous hematocrit is usually 5 to15% lower than hematocrit taken from a capillary sample. but laboratory evidence is required for appropriate therapy. (Choice E) A detailed sexual history can provide further evidence of a specific infection. (Choice D) There is no need to obtain a venous sample from a central line because the procedure is invasive. Case 89 The following vignette applies to the next 2 items An African-American male newborn is evaluated immediately after an uncomplicated vaginal delivery. For this reason. or a hemoglobin level greater than 22 g/dL. 44% of people answered this question correctly. sleepy and with no appetite.4 C (99. Recheck the hematocrit by performing a new heel prick in one hour B. Recheck the hematocrit from a sample of peripheral blood Explanation: Neonatal polycythemia is defined as a hematocrit higher than 65%. and the result does not have any diagnostic or therapeutic significance. Educational Objective: Clinical features of vaginitis are very nonspecific. The physical examination is unremarkable. pulse is 170/min and respirations .3 F). however. The sample must be venous (not capillary) blood. Blood samples from the heel through simple prick method reveal a hematocrit of 70%. If the hematocrit is greater than 65% with a heel prick. His mother has no medical problems.(Choices A and C) Continuing the antifungal cream or prescribing fluconazole is inappropriate in the absence of a specific diagnosis. Recheck the hematocrit by performing a new heel prick immediately C. the patient is found to be highly irritable.

Irrigate the wound with normal saline C. Start antibiotics D. plethoric newborn who is hypotonic and poorly responsive. Cyanosis of the fingertips is observed. blood group. and the knife was firmly implanted in his skull. abdominal distention and hypotonia. which of the following is the most important next step in the management of this patient? A. cardiac and respiratory compromise. Case 90 A 24-year-old man is brought to the emergency department (ED) by the police after he was arrested for fighting in the streets.0 mEq/L Bicarbonate 26 mEq/L Serum Creatinine 0. PTT. During the fight. These signs and symptoms are due to blood hyperviscosity. Treatment consists of intravenous hydration and partial exchange transfusion. he was struck with a knife on his head. Laboratory tests reveal the following: CBC Hb 22. An initial physical examination reveals that he is minimally responsive to verbal or tactile stimuli. Infants usually appear plethoric and lethargic. Treatment consists of adequate hydration and partial exchange transfusion. Order a chest x-ray C. Amantadine and symptomatic support B. jaundice. hematocrit of 68%) of symptomatic neonatal polycythemia. Peripheral cyanosis may occur. Educational Objective: Neonatal polycythemia can be a life-threatening disease that causes apnea. hyperbilirrubinemia. There is no other evidence of injury on his body. poor feeding.6 mg/dL Blood Glucose 40 mg/dL The patient receives intravenous glucose and is transferred to the neonatal intensive care unit. including the brain and gut.. (Choices B and C) Apnea and hypoglycemia can be markers of neonatal sepsis. and crossmatch .0 g/dL Platelet count 320. Recheck the hematocrit from a sample of peripheral blood Explanation: The patient has signs and symptoms of polycythemia. There are no focal neurologic deficits. Examination reveals a drowsy. however. (Choice A) The patient’s neurologic signs and symptoms are non-focal. Hypoglycemia. pathology.000/cmm Segmented neutrophils 70% Bands 3% Lymphocytes 25% Monocytes 2% Serum Chemistry Serum Na 146 mEq/L Chloride 110 mEq/L BUN 16 mg/dL Calcium 9. of which 3 cm has penetrated his skull. His vital signs are within normal limits.6 mg/dL Ht 68% Leukocyte count 10. Prepare the patient for partial exchange transfusion E. and apnea are common presentations of neonatal polycythemia. and are caused by a metabolic. What is the most appropriate next step in management? A. The estimated length of the knife is 14 cm.are 60/min. Newborns with this condition develop irritability. Obtain a stat PT. Remove the knife from his skull B. hypoglycemia. which decreases blood flow to different tissues.e. While in the ED.000/cmm Serum K 4. not by a structural. drowsiness. this patient has the classical clinical picture and laboratory findings (i.

This should be attempted in the operating room. Recheck the hematocrit from a sample of peripheral blood Explanation: The patient has presented to the emergency department with a penetrating injury to his skull. especially during the process of removal of the knife. (Choice B) Local wound management is not an emergency. she was vaccinated against the ‘flu. while amantadine and rimantadine can decrease the seizure threshold in epileptic patients. . Rimantadine and symptomatic support E. Beyond this period. headaches. Amantadine and symptomatic support B. it should not be attempted without obtaining any prior information. Case 91 It is influenza season. except for oropharyngeal hyperemia and mild cervical lymphadenopathy. and weakness. Acetaminophen and symptomatic support D. (This is true for all patients with a penetrating injury or trauma to any body part. (Choice A) Even though immediate removal of the knife seems appropriate. In conclusion. and a 53-year-old Caucasian female with a history of asthma. Furthermore.D. Maintenance of an adequate airway and hemodynamic stability are the first steps in acute management. Always attempt to identify and correct any reversible cause of coagulopathy. and anticipate the need for blood transfusions in such patients. Her physical examination is unremarkable. all such patients should receive immediate laboratory studies to identify any reversible coagulopathy that may increase the risk of bleeding. epilepsy. This also includes blood typing and crossmatching. Which of the following is the most appropriate next step in the management of this patient? A. (Choice E) Acetaminophen use is preferred over aspirin use to avoid the risk of Reye’s syndrome (associated with aspirin use). amantadine and rimantadine should be started within the first 30-48 hours of the onset of sypmtoms. Aspirin and symptomatic support Explanation: It takes about two weeks to mount an adequate immunologic response against the influenza virus after proper vaccination. Zanamivir and symptomatic support C. A and D) Therapy with zanamivir must be started within the first 30 hours of symptoms to be effective. and obesity comes to your clinic because of a four-day history of fever. symptomatic treatment with acetaminophen (Tylenol) is preferred. Ten days ago. especially in the pediatric population. Her sister was recently sick. Removal of the knife may lead to an increase in the bleeding due to opening up of the dural venous sinuses. Before this time. myalgia. Obtain a CT scan of the head to assess the damage E. The patient is concerned that she got the ‘flu’ despite being vaccinated against it. in case there is an urgent need for a blood transfusion during the course of his treatment and hospitalization. he is still at high risk for subsequent deterioration secondary to acute blood loss within the next few hours. This is further compounded by the lack of availability of any pertinent medical history due to his mental status. and can be done at a later stage. zanamivir can exacerbate asthma by inducing bronchospasm. Therapy with drugs such as zanamivir. Educational Objective: Maintenance of adequate hemodynamic stability is the most important step in the management of a patient with a penetrating injury. (Choice D) It is important to ensure the patient's hemodynamic stability before proceeding with any further radiographic imaging. the patient is vulnerable to the infection.’ Her throat swab for influenza viral antigen was positive. (Choices B. while amantadine and rimantadine should be given at least within the first 48 hours.) Even if he has normal hemodynamic parameters at this point.

with intracellular gram-negative diplococci. At about 6:00 p. Inadequate dose of the antibiotic C. which indicates that he has choked his major airway. never forget your ABCs of resuscitation. Antibiotic resistance of the organism B.Educational Objective: Treatment for influenza must be started immediately. Repeat exposure to the infectious agent D. Based on her description of the incident. He is sexually active. Give him something to drink Explanation: No matter what the nature of the emergency is. The Heimlich maneuver is recommended in children older than one year of age. give a series of five abdominal thrusts (the Heimlich maneuver) with the child standing or sitting. give blows on the back with chest thrusts. he returns to the clinic because of persistent urethral discharge. If the patient is seen after this period. you receive a phone call from one of your patients saying that her 4-year-old son. (Choices C and D) Rigid bronchoscopy (procedure of choice for foreign body aspiration) or laryngoscopy is appropriate to consider after the child has been brought to the hospital. Wrong choice of the antibiotic Explanation: .. and give a series of five blows on the back and five chest thrusts. Case 92 You are an on-call physician in your community hospital. What is the most likely cause of his persistent symptoms? A. became short of breath. or within the first 48 hours when using rimantadine or amantadine. you strongly suspect foreign body aspiration. while playing with his elder brother’s toys. He needs immediate rigid bronchoscopy D. (Choice A) As explained above. A week later. this is recommended in a child less than one year of age. do it while the patient is lying down. If visualized. Case 93 A 20-year-old college student presents to the student health center with a five day history of dysuria and mucopurulent urethral discharge. only symptomatic therapy with acetaminophen is suggested. Perform the Heimlich maneuver C. what else should you recommend? A. He needs immediate laryngoscopy E. Educational Objective: Never forget your ABCs of resuscitation no matter what the nature of emergency is. but denies any recent new sexual partners. started coughing all of a sudden. especially in vulnerable patients. If the child is unconscious. For children less than one year of age. You treat the patient with a single dose of ceftriaxone (125 mg intramuscularly). After the abdominal thrusts. Below this age. and appeared cyanotic.m. and the child has become cyanotic. Coinfection with another organism E. 62% of people answered this question correctly.The history in this case is very suggestive of foreign body aspiration. it should be removed. examine the airway for a foreign body. Gram’s stain of the discharge shows multiple white blood cells per high power field. If the child is older than one year. within the first 30 to 36 hours when using zanamivir and oseltamivir (neuraminidase inhibitors). It is very important to immediately evacuate his airway before doing anything else. it is strongly recommended to hold the child upside down. In addition to advising her to call 911 immediately for help. To hold her son upside down and blow on his back B.

regressive behavior or social isolation. sometimes they think that the dead person or animal is only sleeping and will later wake up or come back to life). Refer both children to psychotherapy D. B. the boy has been crying uncontrollably. after which the child gradually accepts the fact that death is not reversible. The older child is an eight-yearold boy and the younger is his 6-year-old sister. according to their ages. and E) Ceftriaxone (125 mg intramuscularly) is one of the preferred and most commonly used agents against gonococcal infection. Case 94 Two Caucasian children are brought to the physician by their mother. Neisseria gonorrhoeae is extremely susceptible to broad-spectrum cephalosporins. Educational Objective: Bereavement in children can present in different ways. Educational Objective: All the patients diagnosed with gonococcal urethritis should also be treated empirically with an agent active against C. or >10 WBCs on microscopy of the first voided urine. according to the child’s age. They can react in different manners: with sadness. Both children do not have any medical problems.The patient in the above scenario is suffering from gonococcal urethritis. Ever since the family dog died. and do not need to be referred to psychotherapy. Patients with gonococcal infection are frequently co-infected with Chlamydia trachomatis. gonorrhoeae is possible.g. guilt. such as doxycycline 100 mg orally twice a day for 7 days. (Choice C) Repeat exposure to N. This reaction usually lasts for some days. Coinfection with Chlamydia is more likely. Start both children on sedative medications E. which is effective in more than 99% of the cases. these children think that death is only temporary (e. 75% of people answered this question correctly. Children who are between 3 and 7 years old usually react to the loss of a loved person or pet with disbelief.. It is diagnosed by the presence of > 5 WBCs per high power field in urethral secretions. or azithromycin 1 gm orally as a single dose. At this age. trachomatis. (Choices A. nightmares. All the patients diagnosed with gonococcal urethritis should also be treated empirically with an agent active against C. (Choice D) Sedative medications are indicated only for those children who develop unmanageable hysteric crisis or panic attacks. including ceftriaxone. or azithromycin 1 gm orally as a single dose. presence of leukocyte esterase. B. inability to concentrate. while his sister looks calm and believes that everything will be fine. such as doxycycline 100 mg orally twice a day for 7 days. The diagnosis is confirmed with a Gram stain smear and culture of a urethral swab specimen. uncontrollable tearing. On the other hand. but it is too early to have symptomatic disease from reexposure after adequate treatment. rage. according to the child’s age. Their developmental and growth milestones are normal. and are not on any medication. Those who are younger than 7 years tend to react with disbelief. The current recommended dose is 125 mg intramuscularly. and those younger than 5 years have magical . Both children are normal Explanation: Bereavement in children can present in different ways. The most common symptom of urethritis is painful urethral discharge. Refer the 6-year-old child to psychotherapy C. trachomatis. and C) Each of the two siblings has reacted appropriately. older children (greater than 7 years) are already aware that death is final. What is the best way to approach this situation? A. Refer the 8-year-old child to psychotherapy B. (Choices A.

severely thrombocytopenic children with ITP should be treated with corticosteroids and/or intravenous immunoglobulin.thoughts about death and can feel guilty or responsible. Children older than 7 years accept death as final and can experience depression. In the clinical scenario described. no intervention is the best choice because the coin is already in the stomach. Up to 90% of foreign bodies that have made it into the stomach will be passed without difficulty. The patient’s mother insists that something should be done immediately. Pyloric obstruction is rare and manifests as persistent vomiting.g. A plain radiograph reveals a coin located in the child’s stomach. Emergency splenectomy B. and gingival bleeding. Educational Objective: Symptomatic. No intervention Explanation: Gastrointestinal foreign bodies typically occur in toddlers. 64% of people answered this question correctly. Case 96 A 3-year-old Caucasian boy is brought to the emergency department by his mother because she saw him putting coins in his mouth. D. Endoscopic removal E. . The child is asymptomatic. Fluoroscopy-guided removal D.000/?L. What is the best means of managing this girl?s condition? A. Coins are the most common GI foreign bodies. Ipecac syrup B. Laboratory evaluation reveals a platelet count of 4. Administration of packed red blood cells D. manifested as petechiae. Her hemoglobin and WBC counts are normal. Administration of platelets E. Laparotomy C. purpura. prednisone or methylprednisolone) and intravenous immunoglobulin (Choice B).000/?L) should be treated with corticosteroids (e. anxiety or have regressive behavior. the condition is typically characterized by a sudden onset of bleeding. because exploring objects by placing them in the mouth is a characteristic behavior pattern of this group. Administration of cryoprecipitate Explanation: Platelet-specific autoantibodies are the presumed pathogenesis of idiopathic thrombocytopenic purpura. epistaxis. The father believes he had a similar episode as a child. Administration of packed red blood cells.. Case 95 A father brings his 4-year-old girl to the emergency department of the local children’s hospital because she has developed scattered ecchymoses and petechiae all over her body within the last few hours. It would not be appropriate in this child. Commonly. and E) have not been demonstrated to improve patient symptoms or outcome. Symptomatic patients with moderate to severe thrombocytopenia (<30. and are therefore not indicated. Administration of prednisone C. Splenectomy (Choice A) may be indicated in children with chronic ITP who persistently experience hemorrhagic symptoms. What is the next best step in the management of this patient? A. In children. More severe bleeding is rare. platelets. there is a history of infection in the several weeks prior to presentation. or cryoprecipitate (Choices C.

signs of intoxication or withdrawal. evidence of drug use on physical examination (eg. Physical examination reveals septal perforations. Admit him to the hospital D. He has a history of keeping his appointments but has missed the last three visits. Prescribe naloxone Explanation: Drug abuse is a common occurrence.(Choices C and D) Foreign bodies can become lodged in any of the areas of esophageal physiologic narrowing. perforation) have developed. It is important to seek the patient’s permission before testing. his parents asked him to move out of their house. knowledge that is of help when weighing different treatment options. Item 1 of 2 What is the next best step in the management of this patient? A. so as to not jeopardize his trust. Such cases require immediate attention and removal. Referral to a detoxification program (Choice B) is certainly of help in addressing drug addiction but should not be the next step taken. Case 97 The following Vignette applies to the next 2 items A 22-year-old Caucasian man comes to clinic for routine follow-up of his mild asthma. Several weeks ago. (Choice B) Laparotomy is indicated only when serious complications (e. Educational Objective: Up to 90% of foreign bodies that have made it into the stomach will be passed without difficulty. His temperature is 37. answering various questions with very brief replies.. Refer him to a detoxification program C. . therefore. The best evidence of long-term drug use is obtained from a thorough history and a positive toxicology screen (Choice A). he becomes a little more animated and says that lately he spends time with a new group of friends that "really know how to party. however. he seems distracted and uninterested. Prescribe methadone E. It is important to screen everyone for addiction because a significant portion of patients will relay such information only when specifically asked. He says that he began using drugs mostly because he had been feeling anxious about some college courses. (Choice A) Ipecac syrup is not indicated in the management of patients with a GI foreign body.7C (99. The toxicology screen is also beneficial in that it reveals exactly which drugs are currently used by the patient. Today.g. pulse is 86/min and respirations are 15/min. it is thought that 10-16% of people seen in an outpatient general medicine practice suffer from problems related to addiction. septal perforation)." Further questioning reveals that he has been using cocaine for the past six months. Obtain a toxicology screen B. or an altered mental status.9F). blood pressure is 120/82 mm Hg. After inquiries about his social life are made. he feels more happy and confident. no intervention is usually necessary. Admission to the hospital (Choice C) would be warranted if there was evidence of drug withdrawal or if the patient was deemed to be a danger to himself or others. He dropped out of college last quarter and was fired from his job as a waiter for absenteeism. Some of the widely accepted indications for toxicology screening include a history of alcohol or other drug use. After "shooting up" though. There are blue-black lines on his arms bilaterally. At one point he states he would like to hurry the visit along so he can get home sooner. accordingly. so he is currently staying with some of the new friends.

Attendance in twelve-step programs such as Alcoholics Anonymous is often credited as essential in the maintenance of long-term abstinence from drug or alcohol use. Educational Objective: Drug rehabilitation programs are the preferred means of initiating recovery from drug addiction. Naloxone (Choice E) is a narcotic antagonist and can be used to reverse the effects of opiates. he should be placed in a drug rehabilitation program that can better accomplish the short. While the supreme goal of drug abuse treatment is the achievement of long-term abstinence. Inpatient hospitalization E.and long-term goals of recovery. however. Once such a patient is medically stable. It would therefore be most appropriate to recommend that this patient enter a drug rehabilitation program (Choice C) as a means of initiating his recovery from drug addiction. His medical history is also significant for hypercholesterolemia. Item 2 of 2 Appropriate action was taken. It is helpful in cases of opioid overdose. it is also frequently associated with feelings of ambivalence and denial on the part of the patient. Enrollment in drug rehabilitation programs provides patients with a highly structured. and is often incorporated into drug rehabilitation programs. Psychotherapy B. however. which is well managed with atorvastatin. Group therapy C. drugfree environment in conjunction with intensive individual and group therapy. Alcoholics Anonymous) are the preferred means of maintaining drug and alcohol abstinence. Recently. Much like other chronic problems. He was recently begun on an insulin regimen that allowed for excellent glycemic control. Educational Objective: The best evidence of long-term recreational drug use is obtained from a thorough history and a positive toxicology screening. Effective drug treatment must take these issues into account and motivate the drug user to change his behaviors and modes of thinking. It is rarely sufficient when used in isolation. and the minimization of the medical and social consequences of drug abuse. Providing alternative medication Explanation: Drug addiction may involve physical and/or psychological dependence. but it is not considered to be a primary first-line treatment of alcoholism.Methadone (Choice D) is used as maintenance for those patients addicted to heroin. Which of the following treatment modalities would be the most appropriate means of initiating his recovery from drug addiction? A. as it provides social support and accountability while also offering addicts insight into their illness. Psychotherapy (Choice A) can be of benefit for some addicted individuals. this patient has been missing his follow-up . however. Disulfiram is one drug occasionally prescribed to discourage drinking in alcoholics. an improvement in the patient?s functionality. while group therapy programs (eg. Medication (Choice E) is not normally indicated in the treatment of cocaine addiction. the short-term goals include the reduction of drug use. Group therapy (Choice B) is an extremely powerful tool for most people in recovery. Drug rehabilitation program D. Inpatient hospitalization (Choice D) would be indicated in a patient who was experiencing physical withdrawal symptoms or who posed a danger to himself or others. It satisfies the craving for opioids without causing the euphoria associated with heroin. Case 98 You are the primary care physician for an obese 42-year-old Caucasian man who was diagnosed with diabetes mellitus five years ago.

irritability. Stevens-Johnson syndrome (Choice D) may appear on presentation as a more severe form of erythema multiforme. and vomiting. Gingko has been associated with a number of side effects. Aconite is an ingredient in some Chinese herbal medicines used to treat pain or heart failure. sulfonamides. quinacrine. pulse is 120/min. hoarseness. Cardiac arrhythmias D. After four months elapse. including the inhibition of platelet-activating factor (Choice E). patients were concurrently taking anticoagulant medications. headaches. and isotretinoin. and torsade de pointes. Psychosis (Choice A) may arise as a side effect of multiple prescription medications. Psychosis B. Examination of the lung is normal. After thorough inquiry. carbidopa. Case 99 A healthy 42-year-old Caucasian woman comes to the clinic with fever. including the inhibition of platelet-activating factor. bundle branch block with junctional escape rhythm. It is characterized by erosion of mucous membranes. sinus bradycardia with first-degree heart block. nausea. Hepatotoxicity (Choice B) has been associated with usage of unsaturated pyrrolizidine alkaloids. bidirectional tachycardia. Bleeding and platelet dysfunction Explanation: Gingko biloba leaf extract is an increasingly popular herbal supplement that many patients use as a "memory booster" because of its suggested propensity for increasing cerebral blood flow. Several cases of serious intracerebral bleeding associated with gingko use have been reported. amantadine). At this visit. Her temperature is 38. It is known to cause serious and sometimes fatal arrhythmias (Choice C). the patient presents to the office. diarrhea. Other herbal supplements known to cause liver toxicity include ephedra.3 C (101 F). Some studies have suggested that gingko is at least somewhat effective in the treatment of intermittent claudication and Alzheimer?s disease. the patient admits that he began to use the herbal preparation gingko biloba.1%. aminopenicillins.appointments despite frequent reminders from your office staff. carbamazepine). including ventricular or supraventricular tachycardia. cephalosporins) and anticonvulsants (eg. sore throat. chills. antidyskinetics (eg. Hepatotoxicity C.s always better to use natural medicines. It is most notorious for an increased risk of bleeding and a potentiation of the effects of anticoagulant therapy through various mechanisms. including seizures. quinolones. in most cases. dry cough. headaches. Drugs that are known to cause this condition include antibiotics (eg. levodopa. Both tests were within normal limits previously. Educational Objective: Gingko biloba leaf extract is used by many patients as a "memory booster" because of its suggested propensity for increasing cerebral blood flow. He is proud to use herbal remedies because "it. restlessness. chaparral. loss of appetite. including comfrey. and a Chinese medicine called jin bu huan. Some examples include corticosteroids. appetite suppressants. blood pressure is 120/70 mmHg. borage leaf. These compounds are found in several herbal supplements." Which of the following is a wellknown side effect of ginkgo biloba? A. 56% of people answered this question correctly. phenytoin. It is most notorious for increasing the risk of bleeding and its potentiation of the effects of anticoagulant therapy through various mechanisms. and respirations are 20/min. and atypical target lesions. his fasting blood glucose is 142 mg/dL and his glycosylated hemoglobin level is 8. Examination shows pharyngeal erythema and exudates that are forming membranes and tender cervical lymphadenopathy. small blisters on purpuric macules. germander. The patient is treated with penicillin G . and coltsfoot. and nausea. She is a paramedic. Stevens-Johnson syndrome E. lamotrignine.

Anaphylaxis D.. (Choices A. or bleeding complications . Neurotoxicity B. They noted that although several other studies reported this side effect. neuritis.e. meta-analysis can be used to increase the sample size. which thereby increases the power of the analysis. B. B. Pool the data from several trials. (Choice C) Stratified analysis is used to control confounding factors. Erythema multiforme C.g. In this case. it is difficult for a single. Its prompt recognition in patients with pharyngitis. Diphtheria antitoxin is made with horse serum. (Choice A) Conducting a new large-scale clinical trial is not ethical at this point because a serious complication (e. hepatotoxicity. Which of the following is the best method to further investigate the above mentioned association? A. This treatment puts the patient in a greater risk for which of the following complications? A. Conduct a new large-scale clinical trial. Review the medical charts to re-ascertain the events. epinephrine must be always available. and is of little value in this case. erythema multiforme. Ignore the possible association between the drug and acute myositis. E. diphtheria antitoxin should be administered as soon as possible to avoid complications such as myocarditis. thus. Hepatotoxicity E. D. and E) There are no reports of neurotoxicity. Bleeding diathesis Explanation: Diphtheria is a serious condition that can be life threatening. Meta-analysis is a useful epidemiologic tool that is employed to increase the power (i. If the outcome is rare or the difference between the groups is small. A decision is made to start the patient on diphtheria antitoxin to avoid further cardiac or neurologic complications.and admitted because of poor oral intake. the risk of hypersensitivity or serum sickness is approximately 10%. rarely. nephritis. or. none of these studies statistically obtained a significant difference in the occurrence of severe acute myositis between the treatment and placebo groups. who reports that the throat culture is positive for Corynebacterium diphtheriae. There is also a lesser risk of anaphylaxis. cervical adenopathy. C. Case 101 Researchers want to further investigate the association between a new hypolipidemic drug and the occurrence of severe acute myositis. the risk of hypersensitivity or serum sickness is approximately 10%.. Explanation: Pooling the data from several studies to perform an analysis is called meta-analysis. Educational Objective: Diphtheria antitoxin is made with horse serum. There is also a lesser risk of anaphylaxis. Do stratified analysis on multiple risk factors. and low-grade fever is extremely important. (Choice B) Reviewing the medical charts may be used if misclassification of the events is suspected. D. even large-scale study to detect the difference and reach statistical significance. thus. the ability to detect the difference in the outcome of interest between groups) of a study. If there is a high suspicion. For these reasons. You receive a call from the laboratory staff. . The major disadvantage of metaanalysis includes concomitant ‘pooling’ of the biases and limitations of individual studies into one analysis. acute severe myositis) can be induced by the drug.

Kava D. and peripheral vascular disease. benzodiazepines. dementia. it can interact with aspirin or warfarin. including the use of alternative remedies. She wants your advice on this matter. It does not have any significant adverse effects. She tells you that she recently started taking some "diet supplements" due to the advice of one of her friends. In the absence of any known clinical information on their safety and efficacy. A lot of these substances are taken without any specific diagnosis. She has been your patient for the last eight years. Licorice inhibits the enzyme 11-beta hydroxysteroid dehydrogenase. and metabolic alkalosis. herbal medicines) has been steadily increasing in the United States for the last several years. however. Case 102 A 42-year-old female comes to see you in the office for a follow-up visit regarding her hypertension. due to the recommendations of family. . This side effect is severe. macular degeneration. Chronic ingestion of licorice can cause or aggravate hypertension in patients. drug safety should be investigated. leading to a potential risk of spontaneous bleeding. Black cohosh E. Horse chestnut Explanation: The use of complimentary and alternative medicine therapies (e. Educational Objective: Meta-analysis is conducted by pooling the data from several studies to increase the statistical power. Which of the following herbal preparations is associated with hypertension? A. these substances have the potential to cause adverse effects. (Choice C) Kava has been used for the treatment of various disorders. It should be used with caution in patients already on antihypertensive medications. The available cortisol binds to mineralocorticoid receptors and causes hypertension. friends. her home blood pressure readings became high. Its concomitant use with alcohol. (Choice D) Black cohosh has been used for the treatment of premenstrual syndrome and menopausal symptoms. Its excessive use can cause hypotension. during which her blood pressure has been stable on hydrochlorothiazide and amlodipine. or other prescription sedatives can potentiate their effect and cause excessive drowsiness or disorientation. It is used for the treatment of mild memory loss. Ginkgo C.(Choice E) Ignoring the possible association between the drug and acute myositis is not a good choice. After starting the supplements. dietary supplements. (Choice B) Ginkgo has been marketed as an antioxidant. Her blood pressure in the office today is 152/88 mmHg.. and media without prior consultation with the patient’s primary care physician. thereby preventing the conversion of cortisol to cortisone. therefore. 36% of people answered this question correctly. It is therefore extremely important to ask patients in detail about their current and recent over-the-counter medication use. hypokalemia.g. Licorice B. The scenario described is a good example of the usefulness of meta-analysis.

and the pulses are greatly reduced to absent. while a history of gradually progressive symptoms in a previously symptomatic patient is consistent with thrombosis. heart rate is 86/min. the surgical specimen should be sent for histopathologic examination to ascertain the exact source of the emboli. Ginkgo does not have any significant adverse effects. Some of the well-recognized causes of cardiac emboli include atrial fibrillation. and a diastolic murmur is heard over the cardiac apex. Echocardiogram D. Histologic examination of the embolus E. with a few coming from the arterial aneurysms or atherosclerotic plaques. and should not be used in patients with a history of hypertension. it can interact with aspirin or warfarin. Item 1 of 2 Which of the following is the most appropriate next step in the management of this patient? A. Acute ischemia of the limb due to acute arterial occlusion usually presents with five Ps. The left foot also appears pale and cooler than the right foot. Angiographic examination of the left lower extremity C. a prior history of myocardial infarction and ventricular dysfunction. The sudden onset of symptoms in a previously asymptomatic patient is most likely due to an embolus. atrial myxoma. paresthesias and paralysis. Hypercoagulation workup Explanation: The patient has a classic presentation of acute arterial occlusion. the heart rhythm is regular. Most of the emboli are from a cardiac source. The abdomen is soft. The lungs are clear on auscultation.2 C (99 F). endocarditis. pallor. After an embolectomy. nontender and without any palpable masses. femoral pulses. Doppler examination of bilateral lower extremities B. bilateral. pulselessness. The neurological examination is within normal limits. or warfarin. The pain started suddenly when he was sitting at his desk at college and has progressed gradually. The skin of the lower extremities is cool and pale. Acute arterial occlusion is usually the result of (1) an embolus from a distal source. On cardiovascular examination. Almost all the patients present with a gradually progressive pain. It is important to find the exact cause of cardiac emboli to prevent future recurrences. and the presence of a prosthetic aortic valve. Case 103 The following vignette applies to the next 2 items A 25-year-old Hispanic college student comes to the emergency department with complaints of sudden onset of left foot pain for the past hour. and respiratory rate is 14/min. Examination of the extremities reveal adequate. leading to a potential risk of spontaneous bleeding. The sudden onset of dramatic symptoms in this patient is most consistent with an embolic source of acute arterial occlusion. pain. He denies any history of similar episodes in the past or recent trauma to his left leg. valvular disease. (2) acute thrombosis due to a previously diseased vessel. The vascular surgeons are immediately called. On the left side. His temperature is 37. It can inhibit platelet aggregation and can cause bleeding in patients already on aspirin. and the patient is taken to the operating room for urgent embolectomy. where an embolus obstructing the entire lumen of the left popliteal artery is removed. blood pressure is 120/80 mmHg. The onset of symptoms can help in differentiating the etiology of arterial occlusion. The sensations on the left foot are intact and he is able to make voluntary movements. aspirin-containing products. the popliteal and dorsalis pedis pulses are absent. or (3) direct trauma to the involved artery. 41% of people answered this question correctly. There is no tenderness on palpation of the lower left leg or foot. Educational Objective: The use of licorice can cause or aggravate hypertension in patients.(Choice D) Horse chestnut has been used in patients with venous insufficiency or chronic venous stasis. however. . usually in the distal extremity.

(Choice E) Hypercoagulation workup is important to look for inherited thrombophilias causing venous thrombosis. resulting in embolization of the part of the myxoma to the systemic circulation. Educational Objective: Left atrial myxomas can present with signs and symptoms of mitral valve obstruction (diastolic murmur or "tumor plop"). There is no such history in this patient. These can be extremely friable. Some large tumors may initially present with signs and symptoms of mitral valve obstruction (diastolic murmur or "tumor plop"). thereby causing acute arterial occlusion in otherwise healthy patients.(Choices A and B) Doppler or angiographic examination of the lower extremities is used for the diagnosis of acute arterial occlusion. Prolonged immobilization B. Since this patient appears to have acute arterial occlusion from a cardiac embolic source. The diagnosis is usually made by echocardiography (either transthoracic or transesophageal echocardiography). the hypercoagulation workup is not indicated at this point. rapidly worsening heart failure in otherwise young healthy individuals. and the remaining arise from the right atrium and left ventricle. Item 2 of 2 Which of the following is the most likely cause of the patient’s condition? A. however. it should be excised as soon as possible to reduce the risk of recurrent embolization. These can also present with systemic embolization. (Choice D) An echocardiogram is an important part of the diagnostic workup since this may identify a source of emboli. with a stalk arising from the atrial septum. These are not helpful in locating the source of the emboli. Most of these arise from the left atrium. . or new onset atrial fibrillation. Educational Objective: Histopathologic examination of the embolectomy specimen is extremely useful in locating the origin of the embolus which caused the acute arterial occlusion. Left ventricular thrombus Explanation: Based on the clinical presentation. 54% of people answered this question correctly. Once the diagnosis of atrial myxoma is made. 5% of people answered this question correctly. or new onset atrial fibrillation. (Choice A) Prolonged immobilization. Thromboangiitis obliterans E. rapidly worsening heart failure in otherwise young healthy individuals. Atherosclerosis of the abdominal aorta D. Left atrial myxoma C. the most likely cause of acute embolic arterial occlusion in this 25year-old previously asymptomatic male is left atrial myxoma. can cause deep venous thrombosis. (Choice E) A left ventricular thrombus is usually seen in patients with a prior history of myocardial infarction or severely reduced LV function. (Choices C & D) Thromboangiitis obliterans or atheroemboli is an unlikely cause of acute arterial occlusion in a young and otherwise previously healthy patient. The tumors are typically pedunculated. Histologic examination is therefore more important since this can differentiate a cardiac source from a peripheral one. Atrial myxomas are the most common primary cardiac tumors. approximately 20% of the emboli can arise from a peripheral arterial source. along with other underlying risk factors. It does not cause acute arterial occlusion.

Fill it with saline moisten sterile gauze E. Fill it with sterile water C. the nurse brings an insulated cooling container to transport the severed thumb. all amputated body parts should be retrieved and brought to the emergency room. For transportation purposes. Your hospital does not have a facility for digit replantation and reconstructive surgery. all attempts should be made to retrieve and replant the digit in the hope to preserve function. Left ventricular thrombus Explanation: Recent technologic advances have led to successful replantations of various body parts including fingers. Fill it with sterile saline solution B. They were able to retrieve the severed finger and brought it to the emergency room. Five minutes later. the amputated part should be wrapped in saline-moistened sterile gauze and sealed in a sterile plastic bag. Wrap it in sterile gauze. As a general rule. At your request. moisten it with Ringer’s lactate and antibiotic solution and place it in a sterile sealed plastic bag E. You provided the patient with initial wound care and achieved hemostasis with a compression dressing. ear. Since the thumb or finger amputation can especially compromise the function of the hand. moisten it with sterile water and place it in a sterile sealed plastic bag C. genitalia. Item 2 of 2 The appropriate step is taken. This has led to the preservation of the function and appearance of most body parts. she asks you "What do you want to use to fill up the container?" Which of the following is the most appropriate response? A. Before putting the plastic bag in the container. Wrap it in sterile gauze. as well as an improved quality of life for the patient. Educational objective: As a general rule. Leave it empty and just put the plastic bag in it Explanation: . 65% of people answered this question correctly. and you decided to transfer the patient to a nearby tertiary care center. when the paramedics bring in a 24-year-old man after being involved in a motor vehicle accident. the amputated part should be wrapped in saline-moistened sterile gauze and sealed in a sterile plastic bag. Fill it with ice only D. At the scene of the accident. the medics noted that he had sustained a traumatic amputation of his right index finger. For transportation purposes.Case 104 The following vignette applies to the next 2 items You are working in the emergency department of a small community hospital. Fill it with sterile saline solution B. all amputated body parts should be retrieved and brought to the emergency room. thumbs. "How do you want me to preserve his severed finger?" Item 1 of 2 Which of the following is the most appropriate response? A. and arms severed in various accidents. the nurse approaches you and asks. Wrap it in sterile gauze. (Choices A and D) It is not recommended to keep the amputated thumb or body part in Ringer’s lactate or an antibiotic solution. moisten with sterile saline and place it in a sterile sealed plastic bag D.

skin-colored or reddish plaque that develops into a nodule with a central keratin plug. 83% of people answered this question correctly. 69% of people answered this question correctly. It can be confused with an atypical melanocytic nevus. as this could lead to injury to the vessels and other tissues. She does not have any other complaints. (Choice C) Seborrheic keratosis is rare before the age of 30. and it rarely appears before the age of 40. Administer intralesional corticosteroids. because excision can be curative if the lesion is identified early. . It also has a "stuck on" appearance. and is a welldemarcated lesion. Verruca vulgaris Explanation: Malignant melanoma is a concern if a nevus increases in size and develops irregular borders. Item 1 of 2 Which of the following is the most likely diagnosis? A. Melanoma lesions are usually asymmetric. slightly elevated macule with slightly irregular borders on the left cheek. Pigmented basal cell carcinoma C. It should also not be immersed in water as this may make the replantation technically more difficult. Keratoacanthoma B. These lesions can appear spontaneously or develop over a previously atypical nevus. (Choice A) Keratoacanthoma is common on the cheek. this disease is infrequent in the Asian population. Item 2 of 2 Which of the following is the most appropriate statement in this patient’s management? A. she already noticed a small mole on her left cheek. Case 105 The following vignette applies to the next 2 items A healthy 24-year-old Japanese woman comes to the physician because of a lesion on her left cheek. (Choice B) Basal cell carcinoma is usually pink or red in color. An excisional biopsy is the next best step. with color variegation. with a "warty" form. Her social history is not significant. Vital signs are within normal limits. It appears as a solitary. Examination shows a 4 cm dark brown. Two years ago. (Choice E) Verruca vulgaris has the same warty appearance as seborrheic keratosis. however. Educational Objective: The severed part should be sealed in a sterile plastic bag and placed on ice for transportation purposes. A biopsy is not required since the clinical presentation is so classic B. but this lesion has recently grown in size.After adequate steps have been taken to preserve the severed finger. It is more frequent in males. round. Educational Objective: It is important to recognize the presence of a melanoma. firm. Malignant melanoma E. C. It is a low-grade malignancy that pathologically resembles squamous cell carcinoma. and usually more than 5 mm in diameter. it should be sealed in a plastic bag and placed on ice in a container. The severed part should never be placed directly on ice. Seborrheic keratosis D.

Observation and repeat follow-up in six weeks. Physical examination reveals swelling and mild hyperemia of the right knee and left ankle. however. Microscopic examination of the joint fluid E. (Choice A) Synovial fluid culture alone yields positive results in less than 50% of patients with gonococcal arthritis. cervical. and protein. He has no known allergies. including the urethral. E. a reduction in glucose concentration and elevation of LDH are consistent with a bacterial infection. He has tried over-the-counter acetaminophen and ibuprofen. He has never had such symptoms before. The range of movements is restricted in these joints due to pain. cell counts below 10. especially if a history of unprotected sexual relationships is present. His past medical history is insignificant. an excisional biopsy is essential for confirmation of the diagnosis and staging of the lesion. Confirmation of the suspected diagnosis is usually done by culturing the joint fluid and the mucosal surfaces. but it lacks sufficient sensitivity and specificity to establish the microbiological diagnosis in most cases. Start therapy with interferon alfa-2b. but are not diagnostic or highly sensitive. (Choice E) Chemistry studies of the joint fluid include the concentrations of glucose. and he uses condoms occasionally. He admits smoking marijuana occasionally but denies any injectable drug use. He smokes one pack of cigarettes daily and consumes 2-3 bottles of beer on weekends.and oligoarthritis in young healthy adults. He has been sexually active with two partners over the last six months. No rash is present. but these gave only little pain relief. Arthrocentesis shows turbid yellow fluid and a leukocyte count of 9. The typical synovial fluid leukocyte count in gonococcal arthritis is around 50. He has not traveled outside the country recently.000/mm3. Due to the significant amount of false negatives reported. It should be strongly suspected in patients with symptoms like those described in this scenario. . More than 80% of patients with disseminated gonococcal infection have positive cultures from at least one of the mucosal sites. however. lactate dehydrogenase. Chemistry studies of the joint fluid Explanation: Gonococcal arthritis is probably the most common cause of acute non-traumatic mono.000 cells/mm3. He denies any fever or chills. rectum. 86% of people answered this question correctly. rectal and oral mucosa. Joint fluid Gram stain C. Complete excision is the treatment of choice.000 cells/mm3 can be present in occasional cases. Joint fluid culture B.D. (Choice B) Joint fluid Gram stain is a reasonable initial approach in patients with suspected infectious arthritis. Culture from joint fluid. Item 1 of 2 What is the best test to confirm the diagnosis? A. Explanation: The sensitivity of a melanoma diagnosis by a dermatologist based on the history and physical examination is approximately 85%. Educational Objective: An excisional biopsy is the next best step in patients with a suspected malignant melanoma. urethra and oral cavity D. (Choice E) Interferon alfa-2b is used as an adjuvant therapy in patients with a high risk of developing metastatic disease. These have only limited value. Case 106 A 27-year-old Caucasian male presents to the office with several days history of joint pain. false negatives have been reported in 15% of the time.

tenosynovitis is a unique finding in patients with disseminated gonococcal infection. and toes. a number of unique. Several tendons are usually simultaneously inflamed. these allow gonococcal infection to be distinguished from other forms of infectious arthritis. ankle. (Choice E) Urticarial skin rash is not specific. Subcutaneous nodules E. (Choices A and B) Sausage digits and back pain may be present in patients with reactive arthritis (e.Educational Objective: In patients with suspected disseminated gonococcal infection.or oligoarthritis. For example. Another characteristic feature is pustular or vesiculo-pustular skin rash that is often transient and disappears spontaneously in several days. Urticarial skin rash Explanation: Although disseminated gonococcal infection may manifest only as mono. Involvement of the respiratory system D. you suspect an infectious cause of arthritis. particularly at the wrist. Item 2 of 2 After running all the appropriate tests. Which of the following additional findings is most helpful in determining the cause of the infection? A. Case 107 A newborn baby girl is found to have a bulging sac covered with membranes in her lower back. 35% of people answered this question correctly. The mother is concerned about the future development of complications secondary to her baby's disease. it is very unusual for other forms of infection. Involvement of the GI tract C. Educational Objective: Tenosynovitis is a unique finding in patients with disseminated gonococcal infection. rectal and oral mucosa. (Choice D) Subcutaneous nodules are typical for patients with rheumatoid arthritis. cervical. it has been described in patients with hepatitis B who may present with symmetric polyarthritis-like symptoms but have non-inflammatory synovial fluid changes. Fractures of the lower extremities Explanation: . it is very unusual for other forms of infection. fingers. Painful tendons along the ankle and toe joints D. Back pain and restriction of movements C. What is the most common extraneural complication of myelomeningocele? A.g. Sausage digits B.. including the urethral. characteristic clinical features is sometimes present. should be done. Involvement of the cardiovascular system E. She is diagnosed with myelomeningocele. Reiter’s syndrome). Involvement of the genitourinary system B. culturing the joint fluid and the mucosal surfaces.

pulse is 80/min. (Choice B) Carbon monoxide poisoning does not cause an increase in methemoglobin levels. and is specifically associated with S2-S3 involvement. followed by lower GI tract dysfunction and fractures of the lower extremities. (Choices C and D) Involvement of the respiratory and cardiovascular system is not associated with lumbosacral myelomeningocele. Educational Objective: Bladder dysfunction is a universal complication of lumbosacral myelomeningocele (excluding neurological deficits). . His temperature is 36. Carboxyhemoglobin levels are measured by co-oximetry of a blood gas sample. Pulse oximetry B. (Choice E) Lower extremity fractures occur in approximately 30% of myelomeningocele patients without a known history of trauma. therefore the PO2 of arterial or venous blood is unaffected. Measurement of methemoglobin levels C.7 C (98 F). and hypothyroidism. Which of the following is most helpful in diagnosing his underlying condition? A. These fractures may be associated with vigorous physical therapy. (Choices C and D) In carbon monoxide poisoning. there is no effect on the amount of oxygen dissolved in the blood. (Choice B) Children with S2-S3 involvement can have external anal sphincter dysfunction that can lead to fecal incontinence. as it does not differentiate oxyhemoglobin from carboxyhemoglobin. Case 108 A 77-year-old Caucasian male is rescued from a house fire and is brought to the emergency department with altered nausea. which can ultimately lead to upper urinary tract involvement and renal dysfunction. Educational Objective: Co-oximetry is used for the diagnosis of carbon monoxide poisoning. His past medical history is significant for hypertension. the lumbar region is involved. and altered mental status. headache. The diagnosis is based on the history and increased carboxyhemoglobin levels. except for identifying the metabolic acidosis from hypoxia. and respirations are 16/min. (Choice A) Pulse oximetry reveals normal oxygen saturation levels in patients with carbon monoxide poisoning. hypercholesterolemia. This spectrophotometric laboratory method can distinguish normal hemoglobin from carboxyhemoglobin. He is a non-smoker and nonalcoholic.In 80% of myelomeningocele cases. Measurement of arterial PO2 D. This is a much less common complication than bladder involvement. an arterial blood gas is not useful for diagnosing CO poisoning. blood pressure is 110/70 mmHg. Almost all these patients will have bladder dysfunction. Measurement of venous PO2 E. Furthermore. Co-oximetry Explanation: The above patient is most likely suffering from carbon monoxide (CO) poisoning.

the alarm is activated. He lives with his wife. all elderly patients must be asked annually about any episode of falls. Head CT scan without contrast C. Explanation: First line management for primary nocturnal enuresis for children less than seven years of age is to reassure the patient’ parents that the child usually outgrows this phase and spontaneously recovers. Case 110 An 81-year-old Caucasian man is brought to the physician because he had a recent fall. and there are no bruises or other superficial lesions.Case 109 A mother brings her healthy 5-year-old Caucasian son to your clinic because "he frequently wets his bed at night. In this test. C. the former is still more effective in preventing relapses. Other options for treatment. Head computerized tomography (CT) scan with contrast B. ‘Get up and go’ test Explanation: According to the guidelines published by the American Geriatric Society (AGS). waking up the child so that he could go to the toilet before he continues to empty his bladder. Although alarms have been shown to be less immediately effective than desmopressin use. Examination shows no abnormalities. Ambulatory cardiac monitoring (Holter monitor) D. What should you tell her? A. along with behavioral therapy. He denies any dizziness or loss of consciousness prior to the event. In the alarm method." She is asking you to comment about an article she had read recently on the internet stating that alarms are more effective than medication. B. His other medical problems include hypertension and a history of stroke ten years ago. There is no motor deficit due to the stroke. Desmopressin and tricyclics are as effective as alarms. Both alarms and medications are equally effective. who is five years younger and has no major medical problems. however. He thinks that he only slipped. (Choice D) Desmopressin and tricyclics are less effective than alarms. British Geriatric Society (BGS) and American Academy of Orthopedic Surgeons. such as limiting the child’s fluid intake before bedtime. His vital signs are within normal limits. but his wife is concerned about the possibility of him falling again. Although desmopressin has a fast induction. chemistry panel and complete blood count (CBC) E. a sensor is placed in the child’s underwear or in the bed padding. He fell to the floor in the living room two days ago. Studies have shown that some types of alarms are better than others. Relapse rates might be higher after stopping alarms than medications. Alarms are more effective if augmented by other behavioral approaches. the physician instructs the patient to stand up from a . If a patient reports a single episode of fall. E. Once the child voids and moisture is detected. alarms are most effective in inducing remission and preventing relapses. Among different treatment modalities. Assessment of gait and balance is important because this determines the need for further evaluation. Which of the following is the most appropriate screening test for this patient? A. (Choice B) Alarms are equally effective. Educational Objective: First line management for primary nocturnal enuresis for children less than seven years of age is reassurance the patient’s parents. The success rate is higher if this method is combined with complex behavioral intervention. Blood electrolytes. he should be evaluated with at least one postural stability test. The "Get up and go" test is most commonly used to assess postural stability. D. (Choice A) The relapse rate of enuresis after treatment with alarms is lower than treatment with desmopressin and tricyclics. it is less effective in preventing relapses. are the use of alarms. Alarms are more effective than treatment with tricyclics during and after treatment.

and his serum parathyroid hormone levels are also elevated. Educational Objective: . unless there is evidence of a specific problem. Physical examination reveals facial asymmetry. which fail to respond to low calcium levels following surgery.. possible cardiac syncope. Hungry bone syndrome D. and sit down again. and pleuritis. Hypercalcemia C. when parathyroid hormone levels fall. What is the likely cause of his new symptoms? A. serum calcium levels can fall (see below) and produce symptoms of hypocalcemia such as perioral numbness. electrocardiogram or echocardiogram are only recommended if a cardiac cause (e. Severe hypocalcemia can cause mental status changes and seizures. Preoperative risk factors for hungry bone syndrome are severe hyperparathyroidism. myocardial ischemia) is suspected. Metoprolol B. and subsequently underwent removal of the parathyroid adenoma. therefore. the patient is stabilized and is taken to the OR for parathyroidectomy. Complication of the anesthetic agent E. The suppression is transient and most patients recover in few days. arrhythmias." If the patient successfully performs the test. walk a short distance. Relative hypoparathyroidism results from the suppression of normal parathyroid glands by high calcium levels. Those who have recurrent falls may need a more extensive work-up. his gait and balance must be initially evaluated using the "get up and go test. Postoperatively. Educational Objective: All elderly patients must be asked annually if they had any history of falls. A single parathyroid adenoma is removed. no further evaluation is needed. positive Chvostek sign (ipsilateral contraction of facial muscles on tapping the angle of the jaw) and positive Trousseau's sign (rapid development of carpopedal spasm on occlusion of blood supply to the upper extremity). the signs of hypocalcemia are bilaterally symmetrical. Following parathyroidectomy. polyuria. turn around. After the initial resuscitation. serum calcium can fall by relative hypoparathyroidism or hungry bone syndrome. Hungry bone syndrome is caused by the sudden withdrawal of parathyroid hormone in patients with severe hyperparathyroidism. If there is evidence of significant head trauma. muscle cramps. vomiting. Hemifacial involvement is not typically seen. (Choice C) Following parathyroidectomy (adenoma removal or removal of 3? parathyroid glands). He had a history of upper respiratory infection two weeks ago. further evaluation is necessary. All these conditions have a very high bone turnover. the serum calcium typically falls to its nadir between 2 to 4 days following surgery. constipation. severe bone disease and vitamin D deficiency. (Choice D) Blood chemistry or CBC are only indicated when a systemic condition is suspected. the most likely diagnosis of this patient is Bell’s palsy (lower motor nuclear involvement of the facial nerve). causing an increased influx of calcium from the circulation into the bone. Mental status changes can occur with severely high calcium levels. Eight hours after the surgery. the dynamics of bone turnover shifts from net efflux of calcium from bone to net influx of calcium into the bone.g. carpopedal spasm. (Choices A and B) Head MRI or CT scans are only needed when a neurologic problem is suggested by the history or physical exam. a head CT scan without contrast should be done. with a preceding history of upper respiratory infection and facial asymmetry. (Choice C) Holter monitoring. Case 111 A 30-year-old male with seizure-like activities is admitted to the intensive care unit. (Choice B) Typical features of hypercalcemia include nausea.chair without assistance. Eight hours following surgery is too early to get symptomatic hungry bone syndrome. Typically. ‘Get up and go’ test Explanation: This patient had hypercalcemia secondary to primary hyperparathyroidism. He is hypercalcemic. If a patient reports a fall. the nurse reports that he has developed facial asymmetry. If the patient is unsteady or has difficulties during the test. return. In hungry bone syndrome.

Unilateral signs may suggest an alternative diagnosis.Hypocalcemia following parathyroidectomy is caused by relative hypoparathyroidism or hungry bone syndrome. *Extremely important question for USMLE step-3 . The signs of hypocalcemia are typically bilateral. Hungry bone syndrome usually develops 2 to 4 days following surgery.

What is the most appropriate response on the behalf of the physician? A. Most cases of drug-induced pancreatitis are mild. Inform the girl that her parent(s) will be informed because they pay for her health insurance . Thiazide C.8C (100F). pentamidine Patient on antibiotics .500/cmm Segmented neutrophils 79% Bands 1% Lymphocytes 20% Alkaline phosphatase 150 U/L Amylase 355 U/L Lipase 523 U/L (N=1-160) Which of the following is the most likely cause of his symptoms? A. Ramipril E. The patient’s labs reveal: Hb 13. tetracycline Educational Objective: Furosemide and thiazide diuretics can cause acute pancreatitis.valproic acid AIDS patient . hypercholesterolemia and gastroesophageal reflux disease.furosemide. and an elective abortion performed one year ago. He denies the use of tobacco. 65% of people answered this question correctly. As the visit comes to a close. His other medical problems include hypertension. 5-ASA Patient on immunosuppressive agents . Case 113 A 15-year-old female presents to clinic for a routine examination. she informs you that she has recently become sexually active with a male classmate and would like a prescription for oral contraception. Prazosin D. alcohol. Inform the girl that her parent(s) will not be informed because the visit is regarding contraception C.induced pancreatitis accounts for 5% of cases of pancreatitis. His temperature is 37. The common conditions which involve the use of drugs (important for USMLE) that can cause pancreatitis are: Patient on diuretics .Case 112 A 53-year-old Caucasian man comes to the emergency department because of a sudden onset of nausea.think about didanosine. or illicit drugs. which is reasonably well managed with methylphenidate. vomiting. She asks that the physician not inform her mother about her use of birth control. She is currently a sophomore in high school and has won many awards for her athletic accomplishments. diarrhea and black stools. Metoprolol B.sulfasalazine.000/cmm Leukocyte count 12. thiazides Patient with inflammatory bowel disease . and severe epigastric abdominal pain radiating to the back.5g/dL Platelet count 180. Inform the girl that her parent(s) will not be informed because she is an emancipated minor B. L-asparaginase Patient with history of seizures or bipolar disorder . Inform the girl that her parent(s) will be informed because she is a minor D. Amlodipine Explanation: Drug. Her medical history is significant for a diagnosis of attention deficit hyperactivity disorder. pulse is 118/min and respirations are 20/min. He denies constipation. Inform the girl that her parent(s) will be informed because she has had an abortion E. blood pressure is 130/80mm Hg.azathioprine.metronidazole.

and emotional illness. Since it is possible that health insurance bills will include descriptions of the services rendered. contraception. blood pressure is 120/76 mm Hg. this does not automatically entitle them to all information regarding the child?s medical care. and continues to smoke one pack of cigarettes a day. If the teenager in this situation were an emancipated minor. she would not need to obtain parental consent for any aspect of her health care. His lung disease has been under good control. substance use. sexually transmitted disease. it would be illogical to presume that a history of abortion has any bearing upon a request for contraceptives (Choice D). idiopathic thrombocytopenic purpura. and emotional illness. His medications include hydrochlorothiazide. surgical repair of a torn ligament). These laws are typically limited to the management of certain issues. it can be difficult to balance the adolescent?s right to confidentiality against the parental right to oversee the child?s health. degenerative joint disease. most states have implemented laws that allow for a physician to provide care to adolescents without parental consent. then her parents would be contacted because she is a minor (Choice C). He has a 40-pack-year history of smoking. Educational Objective: Most states have implemented laws that allow for a physician to provide certain types of medical care to adolescents without parental consent. Oxygen saturation is 94% on room air. However. including the lung exam. However. No other tests are indicated. Therefore. contraception. In most circumstances. including pregnancy. Obtain an arterial blood gas analysis. B. no evidence was presented to suggest that she is an emancipated minor (Choice A). she can be prescribed oral contraceptives without parental involvement. Which of the following should be done next before clearing the patient for the planned surgery? A. Explanation: . Obtain a pulmonary function test and an arterial blood gas analysis. To address this conflict. E. is unremarkable. pulse is 80/min. He has a past medical history of hypertension. parents pay for the health care insurance for their children. if the visit is regarding contraception. Advair Diskus (fluticasone and salmeterol). and respirations are 16/min. substance use. Most often. D.Explanation: As a physician. C. If a teenager requires non-urgent treatment of any condition that is not exempt from parental consent laws (eg. and albuterol inhaler. Case 114 A 60-year-old male comes to see you in the office for a physical evaluation prior to undergoing right total knee replacement. and he has not had any flare-ups of COPD in the last nine months. He does not have any complaints. His temperature is 36. except for the pain in his right knee. Obtain a pulmonary function test. celecoxib. a special independent status legally equivalent to adulthood. sexually transmitted diseases. Since elective abortion is usually exempt from parental notification/consent laws. emancipated minors are teenagers who have successfully presented evidence to the court that they deserve emancipation. Common examples include teenagers who are completely self-sufficient and no longer living with their parents and teenagers who are parents to one or more children. physicians should make every effort to preserve confidentiality when submitting insurance claims while still charting and billing correctly (Choice E). His general physical examination. Obtain a pulmonary consultation. However. a teenaged patient is normally entitled to confidentiality regarding his or her use of contraceptives (Choice B). as needed. Exempted areas typically include pregnancy. and chronic obstructive pulmonary disease (COPD).7C(98F).

After an unremarkable labor she vaginally delivered a son weighing 3440 grams (7 lbs. Item 1 of 2 What is the most likely diagnosis? A. Physical examination of the child reveals a palpably distended bladder and is otherwise unremarkable. Hypospadias C. They should only be obtained in patients with chronic obstructive pulmonary disease or asthma if the clinical examination reveals airflow limitation. Prune belly syndrome Explanation: . In a patient with a known. Ultrasound evaluation demonstrates bladder distention and bladder wall thickening. It is done to specifically look for the known risk factors for postoperative pulmonary complications. or suggests that the patients are not at their normal baseline lung functions. Educational Objective: A detailed history and physical examination aimed at detecting known risk factors for postoperative pulmonary complications is the first step in the preoperative evaluation of all patients who will be undergoing major surgical procedures. An arterial blood gas analysis in other situations does not provide any additional information than what is already available from the clinical evaluation. and in patients with a history of tobacco use or unexplained dyspnea who will be undergoing coronary artery bypass surgery or upper abdominal surgery. stable. routine testing with arterial blood gas analysis. (Choices D and E) Pulmonary function testing should not be done routinely in all patients with chronic obstructive pulmonary disease who will be undergoing abdominal or lower extremity surgeries. Dehydration B. para 2 Caucasian woman at 40 weeks of gestation was admitted to the labor and delivery unit after the spontaneous rupture of membranes. The boy?s urinary stream is very weak.It is important to perform preoperative pulmonary risk assessment in all patients who will be undergoing major surgical procedures. pulmonary function testing. Case 115 The following vignette applies to the next 2 items A 32-year-old gravida 3. respectively. A detailed history and physical examination is the first step in the evaluation of these patients. (Choice B) A preoperative arterial blood gas analysis is recommended in patients who will be undergoing lung resection. Apgar scores were 8 and 9. (Choice A) Pulmonary consultation is not indicated in a patient with stable chronic obstructive pulmonary disease. 9 oz). 22% of people answered this question correctly. chronic obstructive pulmonary disease and no evidence of exercise intolerance. She had regular prenatal care and a normal ultrasonogram at 20 weeks of gestation. Nephrolithiasis D. and helps in reducing postoperative pulmonary complications and length of stay in the hospital. but he is able to pass stool. Risk stratification identifies potential moderate to high risk patients. Posterior urethral valves E. or spirometry is not indicated.

Posterior urethral valves (Choice D) are predominantly found in males and are the most common cause of severe obstructive uropathy in children. The abnormal development of the valves in utero can obstruct urinary flow, leading to detrusor hypertrophy and, eventually, vesicoureteral reflux and hydronephrosis. Hallmarks of PUV include a distended bladder and a weak urine stream. Dehydration (Choice A) in children is characterized by a prolonged capillary refill time, poor skin turgor, tachycardia and tachypnea. This child?s physical examination was normal aside from the distended bladder. Hypospadias (Choice B) is an abnormality of urethral development in which the opening of the urethra is located on the ventrum of the penis proximal to the tip of the glans. The urinary stream may be deflected downward, but the quantity of urine output is usually normal. Nephrolithiasis (Choice C) occurs most often young and middle-aged adult males. Symptoms may include severe pain, cramping, nausea, and hematuria. Prune belly syndrome (Choice E) is characterized by a multitude of renal, ureteral, and urethral abnormalities in the neonate. Obstruction and upper urinary tract dilatation are often observed. Abdominal musculature is underdeveloped, which leads to constipation and a weak cough. Educational Objective: Posterior urethral valves are predominantly found in males and are the most common cause of severe obstructive uropathy in children. Hallmarks of PUV include a distended bladder and a weak urine stream. 90% of people answered this question correctly. Item 2 of 2 Which of the following postnatal procedures is most commonly used to definitively diagnose this condition? A. Voiding cystourethrogram B. Radiograph of kidneys, ureter, bladder C. Abdominal CT scan D. Laboratory evaluation of electrolytes E. Karyotyping Explanation: Voiding cystourethrogram (VCUG) (Choice A) is a radiographic examination of the bladder and lower urinary tract. The bladder is filled with contrast material by catheter and multiple radiographic images of the bladder and urethra are obtained as the patient empties the bladder. VCUG is especially helpful in evaluating young children for vesicoureteral reflux and posterior urethral valves. Radiograph of the kidneys, ureter, and bladder (Choice B) are often used to make the diagnosis of prune belly syndrome based on the classic appearance of the bowels hanging over the lateral edge of the abdominal wall. Evaluation of electrolytes (Choice C) could provide some evidence of dehydration if that was a concern in this child. Karyotyping (Choice D) evaluates for conditions such as Klinefelter or Turner syndrome. Abdominal CT scan (Choice E) would be the appropriate imaging modality for evaluating nephrolithiasis.

Educational Objective: Voiding cystourethrogram (VCUG) is a radiographic examination of the bladder and lower urinary tract that is especially helpful in evaluating young children for vesicoureteral reflux and posterior urethral valves. 91% of people answered this question correctly. Case 116 The following vignette applies to the next 2 items You are working in the emergency department (ED) on New Year?s Eve, when the paramedics bring in a homeless man. They found him lying on the side of a street. He was minimally responsive in the ambulance. In the ED, his core body temperature is 32?C(90F), systolic blood pressure is 70 mmHg, heart rate is 40/min and respiratory rate is 6/min. His oxygen saturation is 90% on 5 liters of oxygen. On examination, he remains unresponsive to all verbal stimuli, but he withdraws his limbs on painful stimuli. His breath smells of alcohol. His pupils are equal, round, normal in size, and have a sluggish reaction to light. His lung examination is unremarkable. Cardiovascular examination reveals bradycardia with an irregular pulse rate. Neurological examination is difficult to perform, but reveals marked hyporeflexia throughout. An initial electrocardiogram reveals sinus bradycardia with frequent premature ventricular complexes. Item 1 of 2 Which of the following is the most appropriate initial step in the management of this patient? A. Lidocaine B. Atropine C. Bretylium D. Intravenous fluids E. Endotracheal intubation Explanation: The patient in the above vignette is suffering from moderate hypothermia. Some factors associated with a higher risk of hypothermia include an older age, homelessness, alcohol abuse, and certain medical conditions such as hypothyroidism, adrenal insufficiency, sepsis, and malnutrition. Most patients with mild hypothermia (core body temperature between 32?C to 35?C) present with confusion, ataxia, slurred speech, tachycardia, and tachypnea. Patients with moderate hypothermia (core temperature between 28?C to 32?C) have marked central nervous system depression, hypoventilation, hypotension, bradycardia, hyporeflexia, and cardiac conduction abnormalities. Severe hypothermia (core temperature less than 28?C) can cause marked hypotension, areflexia, coma, malignant ventricular arrhythmias (ventricular fibrillation), and asystole. The first step in the resuscitation of such patients is to protect and secure the airway with immediate or early endotracheal intubation. The patient in the above vignette has marked hypoventilation and altered mental status. An early endotracheal intubation should be performed to prevent aspiration and respiratory arrest. (Choices A and C) Antiarrhythmic drugs are not indicated in patients with frequent PVCs. They occur as a response to hypothermia and usually resolve with active rewarming of the patient. (Choice B) Bradycardia is also due to a physiologic response to hypothermia and resolves with active rewarming. Atropine or cardiac pacing is not required unless the bradycardia persists despite specific treatment. (Choice D) An adequate airway should be established in all patients before performing any other resuscitative measures.

Educational Objective: Airway control should remain the first priority in all patients during resuscitative efforts. remember the "ABC's" (Airway, Breathing and Circulation) in any resuscitation effort. 71% of people answered this question correctly. Item 2 of 2

Always

The appropriate step was taken for the patient. His clinical status remains unchanged. His blood pressure is 72/42 mmHg and heart rate is 42/min. An EKG monitor reveals persistent sinus bradycardia with frequent PVCs. Which of the following is the most appropriate next step in the management of this patient? A. Lidocaine B. Intravenous fluids C. Active rewarming D. Bretylium E. Endotracheal intubation Explanation: The next important step in the management of this patient is to support and improve his blood pressure with aggressive intravenous hydration. Administration of intravenous fluids (and inotropic agents, if required) will help improve his cardiac output, blood pressure, and perfusion to various organs. After the initial aggressive intravenous hydration, warm intravenous fluids can be used to support blood pressure and provide active internal rewarming. (Choices A and D) There is no evidence of any malignant ventricular arrhythmia (ventricular fibrillation) in this patient. Antiarrhythmic drugs are not indicated for the treatment of frequent PVCs. (Choice C) Active rewarming reverses the physiologic and metabolic responses to hypothermia, and is the specific treatment for patients with moderate to severe hypothermia; however, the initial management of patients should be aimed towards resuscitation and support of airway, breathing, and circulation. Educational Objective: Aggressive intravenous hydration should be used to support low blood pressure in patients with hypothermia and hypotension. 37% of people answered this question correctly. Case 117 A 56-year-old female was found to have a TSH level of 0.2 mU/ml on routine lab testing. She denies symptoms suggestive of thyrotoxicosis. She reports good energy level and no change in body weight. She has mild hypertension, for which she is on hydrochlorothiazide. Her family history is negative for any thyroid disorder. She denies smoking or alcohol use. She does not have allergies to any medications. She had her menopause about three years ago. She has never received hormone replacement therapy. She takes adequate amounts of calcium and vitamin D supplementation. Bone mineral density using dual photon absorptiometry was within normal range about six months ago. Examination is unremarkable, including examination of the thyroid gland. Free T4 levels and free T3 are well within normal limits. What is the next best step in this patient?s care? A. Radioactive iodine uptake B. Start methimazole C. Start propylthiouracil

D. Recheck thyroid functions test in 6-8 weeks E. Subtotal thyroidectomy Explanation: The patient has subclinical thyrotoxicosis, which is defined as suppressed TSH levels along with normal thyroid hormone levels. The most common causes of subclinical thyrotoxicosis are treatment with levothyroxine, nodular thyroid disease, Graves' disease, and thyroiditis. Subclinical thyrotoxicosis induced by levothyroxine is simply treated by reducing the dose. In some cases, the etiology cannot be determined, and TSH becomes normal if repeated in a few weeks. Patients who have mildly suppressed TSH, no symptoms, normal heart rhythm, and normal bone density are not intensively investigated because no treatment is necessary, and there is a high chance of normalization of TSH levels. Repeating TSH after 6-8 weeks is generally performed. (Choices A, B, C, and E) The above patient did not have any indication for aggressive intervention. In symptomatic patients (e.g. persistent fatigue), an antithyroid drug in a small dose (methimazole 5-10 mg/d) is generally started after performing a radioactive iodine uptake and scan. If the symptoms improve with antithyroid drugs, radioactive iodine ablation is usually performed. Patients with multinodular goiter have a 5-10%/year chance of becoming overtly thyrotoxic; therefore, treatment in such patients is warranted. Patients with atrial fibrillation and low bone densities also require treatment. Educational Objective: Patients who have mildly suppressed TSH but normal T4 and T3, no symptoms, normal heart rhythm, and normal bone density are not intensively investigated because no treatment is necessary and there is a high chance of normalization of TSH levels. 79% of people answered this question correctly.

Case 118 A relatively healthy 71-year-old Asian man comes to the office for a routine follow-up visit after a recent discharge from the hospital. During the last visit, he was diagnosed with benign prostatic hypertrophy with a slight elevation of PSA. He subsequently underwent TURP (transurethral resection of the prostate), and his prostatic specimen histopathology results came back as prostate adenocarcinoma in situ. He has a history of mild COPD and hypertension. He has smoked one pack of cigarettes daily for 38 years. Which of the following is the most appropriate next step in his care? A. Radical, suprapubic prostatic resection with lymph node exploration B. Pelvic radiation and bilateral orchiectomy C. Pelvic radiation and estrogen therapy D. Chemotherapy E. Anti-androgen therapy Explanation: Suprapubic resection of the prostate is the currently accepted therapy for patients whose prostate cancer was diagnosed through TURP, needle biopsy, or cytology. This procedure is accompanied by lymph node resection, which can be preceded by sentinel lymph node identification through technetium radio labeling for a higher yield. (Choices B and C) Pelvic radiation can cause serious local lesions (such as strictures) and bowel or rectal damage. It is reserved for more advanced stages of the disease.

(Choices D and E) Anti-androgen agents and chemotherapy have not increased survival when used as adjuvants in this type of patient. Hormonal therapy with bicalutamide is promising (and is being used already in Europe) but is not yet FDA-approved. These are usually reserved for advanced stages of the disease. Educational Objective: Patients with an incidental finding of prostate cancer in situ through TURP or biopsy need further surgical resection of the gland through a suprapubic approach. Radiotherapy, estrogens, and chemotherapy are measures reserved for more advanced stages of the disease. 42% of people answered this question correctly. Case 119 A 68-year-old Caucasian man is brought to the emergency department by her daughter because of altered mental status. The daughter reports that he lives alone and has a history of diabetes mellitus type 2 and hypertension. He takes aspirin, enalapril and glipizide. His blood pressure is 100/60 mm Hg, pulse is 100/min and respirations are 20/min. He is not febrile. Physical examination reveals dry mucus membranes, no jugular venous distension, clear lung fields and normal first and second heart sounds. The abdomen is soft, non-tender, and non-distended. Neurologic examination reveals a drowsy patient who is disoriented to time and space. He is barely communicative. There are no meningeal or focal signs. His laboratory tests reveal: CBC Ht: 44% Platelet count: 300,000/cmm Segmented neutrophils: 70% Monocytes: 8% Serum chemistry Serum Na: 150 mEq/L Chloride: 120 mEq/L BUN: 36 mg/dL Calcium: 9.7 mg/dL Serum ketones: Negative MCV: 90fl Leukocyte count: 10,000/cmm Lymphocytes: 22%

Serum K: 4.6 mEq/L Bicarbonate: 20 mEq/L Serum creatinine: 1.5 mg/dL Blood glucose: 800 mg/dL

The electrocardiogram reveals sinus tachycardia. He is started on insulin therapy. Which of the following is the most appropriate fluid solution to provide adequate hydration to this patient? A. 0.9% sodium chloride solution (normal saline) B. 0.45% sodium chloride solution (half normal saline) C. Hypertonic solution D. Ringer?s lactate E. Free water Explanation: Hyperosmolar, hyperglycemic state (HHS) is a complication usually experienced by poorly controlled type 2 diabetics. It is characterized by altered mental status, glycemic levels over 800 mg/dL, bicarbonate levels higher than 15 mEq/L, effective osmolality higher than 320 mOsm/kg, and the presence of minimal amount of serum ketones. Hydration and insulin therapy aim to correct the electrolyte imbalances and hyperglycemia. Hyperglycemia can cause either hyponatremia or hypernatremia in uncontrolled diabetes mellitus. Hyperglycemia increases serum osmolality, which results in osmotic water movement out of the cells; therefore dilutional hyponatremia (pseudohyponatremia) is usually seen. On the other hand, glucosuria-induced osmotic diuresis results in water loss in excess of sodium and potassium; this may raise the plasma sodium concentration and plasma osmolality, unless there is a compensatory increase in water intake.

In order to adequately correct the hypo/hypernatremia in HHS, the corrected value of serum sodium must be calculated. This is done by adding 1.6 mEq/L for every 100 mg/dL of glucose over the baseline (100 mg/dL) to the total sodium value. The patient?s sodium level is 150 mEq/L, while his glucose level is 800 mg/dL. Using the abovementioned concepts, the calculation for the patient?s corrected serum sodium value is as follows: (1.6 x 7) + 150 = 161.2 mEq/L The corrected sodium level indicates severe hypernatremia, which should be treated with hydration therapy using half-normal saline solution. (Choices A and C) Hyponatremia is treated with normal saline solution or hypertonic solution (for severe cases). (Choice D) Ringers lactate has a similar osmolality and sodium content as normal saline solution. (Choice E) Free (oral) water may be used in the treatment of mild hypernatremia. This patient?s severe hypernatremia warrants urgent treatment with intravenous half-normal saline solution. In addition, although intravenous D5W (free water with dextrose) can be used in patients who need correction of severe hypernatremia, it cannot be used in hyperglycemic patients (such as in this case). Educational Objective: The treatment of hyperosmolar hyperglycemic state involves hydration and insulin therapy. To adequately hydrate the patient, the corrected level of serum sodium must be calculated. Only those patients with hyponatremia or hypovolemic shock should receive normal saline. Those with normal sodium levels or hypernatremia must be hydrated with half-saline solution. Most studies show that the usual water deficit is approximately 9 liters. 35% of people answered this question correctly. Case 120 The following vignette applies to the next 2 items A 47-year-old Caucasian man is brought to the emergency department of a small rural clinic. He was hunting in the woods with a group of friends 45 minutes ago, when he was accidentally shot by another hunter. He complains of abdominal pain, shortness of breath and palpitations. The symptoms are progressively getting worse. He does not use tobacco, alcohol, or illicit drugs. His temperature is 36.1 C (97 F), blood pressure is 90/60 mm Hg, pulse is 118/min and respirations are 26/min. His pulse oximetry reading is 94% at room air. The abdomen is mildly distended. Bowel sounds are absent. Rigidity and rebound tenderness are present. There is a gunshot wound in the left upper quadrant, with no exit orifice. A bedside chest x-ray reveals clear lung fields. Item 1 of 2 Which of the following is the most appropriate course of action? A. Perform a Diagnostic Peritoneal lavage (DPL) B. Perform a Focused abdominal sonogram (FAST) C. Order an Abdominal CT Scan with oral contrast D. Call the nearest surgical reference center to prepare for laparotomy E. Perform laparoscopy Explanation: Approximately 85% of abdominal wall gunshot wounds (GSWs) penetrate the abdominal cavity, and approximately 95% will require surgery. This patient was injured with a long arm bullet (probably a

rifle). The force of the impact is enough to assume penetration through the abdominal wall, unless there is evidence of only a superficial or tangential laceration during the physical examination. Furthermore, the presence of peritoneal signs in the patient is an absolute indication for an urgent laparotomy. Every effort must be made to transfer him immediately to the operating room. Other absolute indications for an urgent laparotomy in patients with acute abdominal trauma are: major vascular injury, hollow viscus perforation, hemodynamic compromise, hemo- or pneumoperitoneum, diaphragmatic lesions, and spinal cord injury. (Choices A, B, and C) There is no need to perform further ancillary procedures to investigate the extent of intra abdominal injuries in this patient because he already has an absolute indication for an urgent laparotomy. (Choice E) Laparoscopy is used to assess tangential abdominal GSWs. It is not recommended in the management of patients with abdominal GSWs with absolute indications for an urgent laparotomy. Educational Objective: Most abdominal gunshot wounds will require laparotomy for further exploration and immediate management of intra abdominal injuries, unless the wounds are only superficial or tangential to the skin. The absolute indications for an urgent laparotomy are: presence of peritoneal signs, spinal cord damage, intra abdominal vessels or bladder damage, and hollow viscus perforation. If the patient is hemodynamically unstable or has lost a great amount of blood, the procedure must be done immediately. 67% of people answered this question correctly. Item 2 of 2 The patient is reevaluated 20 minutes later. His abdominal symptoms are stable. His shortness of breath has improved after nebulizations, but he continues to have palpitations. He has received one and a half liters of normal saline solution. His blood pressure remains at 90/60 mm Hg, pulse is 100/min and respirations are 22/min. His pulse oximetry reading is 97% at room air. Examination reveals clear lung fields. Abdominal findings have not changed. Which of the following is the most appropriate immediate step in the management of this patient? A. Cross type at least 2 units of packed red blood cells B. Perform an abdominal CT scan with oral contrast C. Transfer the patient to the nearest surgical facility, which is 20 minutes apart by helicopter D. Observe and reevaluate clinically every two to four hours E. Explore the abdominal wound under local anesthesia Explanation: Even though the patient remains stable, he still needs an urgent laparotomy. If the procedure cannot be done because of lack of resources or an experienced surgeon, the patient must be transferred immediately to another facility. Most rural areas accomplish immediate patient transfers through air transportation. (Choice A) Although the patient may need a blood transfusion as indicated by the failure of his blood pressure to increase despite adequate intravenous hydration, the transfusion should not delay his transfer. Furthermore, most surgical centers consider blood transfusion in trauma patients when the systolic blood pressure is less or equal to 70 mmHg, because transfusing at higher levels of blood pressure has been shown to increase the rate of bleeding. For these reasons, the transfusion may be given to the patient in the operating room. (Choices B and D) There is no need to periodically observe the patient or perform further ancillary tests/procedures. He requires an urgent laparotomy.

(Choice E) Exploration of the abdominal wound under local anesthesia is done when a superficial injury is suspected, and when the case of penetrating abdominal trauma is due to stabbing. Educational Objective: Early transportation can be life-saving for patients with penetrating abdominal trauma secondary to gunshots. Transfer to a regional trauma center is required if there is no surgeon or operating room available, if the patient has multiple injuries, or if he needs procedures that are not available (e.g., hemodialysis, organ transplantation, neurosurgery, etc.). Air transport (life flight) is recommended for patients who are potentially unstable, or who are in rural areas or places where ground transportation may take more than 20 minutes. 48% of people answered this question correctly. Case 121 A healthy 26-year-old Caucasian male comes to the office for a routine health maintenance examination. He recently got married, and he is currently planning to have children. His younger brother was recently diagnosed with cystic fibrosis, and he wants to know his chances of carrying the abnormal allele. Which of the following is the best response? A. Proceed with treatment B. He has 1/4 chance of being a carrier C. He has 3/4 chance of being a carrier D. He has 4/4 chance of being a carrier E. Explore the abdominal wound under local anesthesia Explanation: Cystic fibrosis is an autosomal recessive disease, and it is manifested when a person carries two mutant alleles. Parents of affected children are heterozygous carriers. The chance of being a carrier (i.e., the chance of carrying one mutant allele) is 1/2, the chance of having the disease (i.e., the chance of having two mutant alleles) is 1/4, and the chance of having both normal alleles is 1/4. Overall, 1/4 offspring will be phenotypically abnormal and 3/4 will be phenotypically normal. Educational Objective: A sibling of a cystic fibrosis patient has a 1/2 (50%) chance of being a carrier. 54% of people answered this question correctly. Case 122 An 8-year-old boy is brought to the pediatrician because he is complaining of a subjective fever, sore throat, headache, and stomach upset. His symptoms began yesterday. His grandmother, who cares for him after school while his mother works, accompanies him. Physical examination reveals temperature of 39.3C (102.8F), erythema and edema of the pharynx and uvula, pharyngeal exudate, and anterior cervical lymphadenopathy. Rapid strep test is positive. The grandmother indicates that the boy has great difficulty swallowing pills, and that an injection of penicillin would be preferred. When asked if she has the authority to permit treatment, the grandmother appears confused and replies that she has never been asked such a question before. What is the most appropriate means of handling this situation? A. Proceed with treatment B. Ask boy for consent to treat C. Ask grandmother for consent to treat D. Call mother at work for consent to treat

E. Petition court for consent to treat Explanation: Unless the grandmother has legally adopted the child or has been designated as his legal guardian, she does not automatically have the authority to permit his treatment. Therefore the mother must be called at work (Choice D) to obtain permission to treat. In the future, the mother can submit a signed statement to the pediatrician authorizing the grandmother to consent to medical care. This statement should be kept with the child?s medical records. Although some physicians would simply proceed with the injection (Choice A), this course of action is risky since consent has not been given. Failing to obtain informed consent before performing a test or procedure is technically considered battery, a form of assault. Since the boy is a minor, he is not able to authorize treatment (Choice B). Were he an adolescent, he could give consent for treatment of sexually transmitted diseases, substance use, and emotional illness. Since there is no paperwork stating that grandmother has permission to treat, her consent (Choice C) would be of no legal benefit. Petitioning the court for consent to treat (Choice E) is only appropriate in serious situations in which the child?s parent or legal guardian refuses to allow a treatment (e.g., blood transfusions) that the physician considers medically necessary. Educational Objective: Permission to treat a child can only be granted by the parent or legal guardian. As an exception to this rule, adolescents are typically allowed to give consent for their own care in regards to pregnancy, contraception, sexually transmitted diseases, substance use, and emotional illness. 58% of people answered this question correctly. Case 123 A 45-year-old Caucasian man comes to the office with complaints of low-grade fever and abdominal distention for the past five days. He denies any history of cough, shortness of breath, nausea, vomiting or any change in his bowel habits. He denies any past medical history. He is an IV drug abuser. He has a history of multiple sexual partners with unprotected sexual intercourse in the past. His temperature is 38.5?C (101.4F), blood pressure is 126/82 mmHg, pulse rate is 96/min, and respiratory rate is 16/min. The general physical examination reveals a thin cachectic man with a distended abdomen and mild icteric sclerae. His lungs are clear on auscultation, with slightly decreased breath sounds at both lungs bases. The cardiovascular examination is within normal limits. He has a distended abdomen with a vague, generalized tenderness and hepatosplenomegaly. Shifting dullness and fluid thrill are elicited during the abdominal examination. There is no guarding or rebound tenderness; the bowel sounds are normoactive on auscultation. Further workup of the patient in the hospital reveals a chronic hepatitis C infection. What is the next best step in the management of this patient? A. Interferon therapy B. Hepatitis B vaccination C. HIV testing D. Abdominal paracentesis E. Ultrasound of the abdomen

Explanation: The patient in the above vignette has ascites due to chronic hepatitis C and cirrhosis of the liver. The presence of fever, generalized abdominal tenderness and distention in such a patient is highly suspicious for the presence of spontaneous bacterial peritonitis. Spontaneous bacterial peritonitis (SBP) is defined as an ascitic fluid infection in the absence of an evident intra-abdominal source. It is almost always seen in patients with advanced cirrhosis and clinically apparent ascites. The most common symptom in patients with suspected SBP includes fever, abdominal pain and/or tenderness, altered mental status or worsening of the underlying hepatic encephalopathy; however, the clinical presentation of SBP can be very subtle, and early diagnosis and treatment is important to prevent major morbidity and mortality in such patients. Abdominal paracentesis and ascitic fluid analysis is required in all patients for the diagnosis of SBP. Ascitic fluid should be sent for cell count and differential, protein and albumin concentration, glucose and LDH concentration, Gram staining and cultures. The diagnosis of SBP is usually made by a polymorphonuclear leukocyte count of greater than 250 cells/cubic mm or with positive ascitic fluid cultures. (Choice A) Treatment with interferon can be used to prevent the development of cirrhosis and its complications in patients with chronic hepatitis C. The patient appears to have advanced cirrhosis from underlying hepatitis C infection at presentation. Therapy with interferon would probably not be helpful at this point. (Choices B and C) The patient should eventually receive hepatitis B vaccination and also should be tested for co-infection with HIV; however, his clinical presentation warrants an initial abdominal paracentesis to rule out spontaneous bacterial peritonitis. (Choice E) Ultrasound of the abdomen is not necessary for the management of this patient at this point. Educational Objective: Abdominal paracentesis should be performed in all patients with new-onset ascites, or with signs of clinical deterioration in patients with ascites and liver cirrhosis. 57% of people answered this question correctly. Case 124 A 66-year-old male comes to the emergency department because of bright red blood per rectum. He says he feels weak and dizzy. The bleeding started this morning and was painless. He denies the use of any medications, trauma, or recent surgery. The physical exam is unremarkable, except for an ejection systolic murmur radiating to the carotids in the second right intercostal space. His blood work reveals a hemoglobin level of 9.7 g/dL. His hemoglobin level three months ago was 13 g/dL. What is the most likely diagnosis? A. Colon cancer B. Diverticulitis C. Ulcerative colitis D. Angiodysplasia E. Hemorrhoids Explanation: Massive colonic bleeding classically has been attributed to diverticulosis, but recent evidence suggests that angiodysplasia, also known as vascular ectasia, is also common. These two entities

angiodysplasia was not recognized as a source of colonic bleeding. (Choice E) Hemorrhoids can cause mild bleeding per rectum. (Choice A) Cancer of the colon usually causes occult rather than massive gastrointestinal bleeding. and mild bleeding. At that time. Diverticulitis can also cause bleeding as a result of superficial mucosal ulcerations. The rest of the boy's examination is unchanged. C. The bleeding is generally painless. but still bulging and immobile. 68% of people answered this question correctly. and pain in the left ear for eight hours. A change to a diet rich in fiber is recommended to prevent recurrences. According to the mother. but may be related to degenerative changes associated with aging and to intramuscular hypertrophy that obstructs submucosal veins. (Choice C) Ulcerative colitis is an inflammatory bowel disorder which can present with lower gastrointestinal bleeding.5C (101.8C (102F). Hemorrhoids may be visible externally and may present with painless or painful rectal bleeding. His temperature is 38. and states that he still has an earache and fever. A colonoscopy is contraindicated in the acute condition. D. Colon cancers of both the right and left side can cause a trace amount of bleeding and are often present with anemia. . colon cancer must be ruled out. Discontinue amoxicillin. The bleeding is generally painless and can be massive. Continue amoxicillin and refer the patient to an otolaryngologist for urgent tympanostomy and tubing. but usually the bleeding is mild. It usually presents with a fever. A guaiac stool test may be the first indication of an underlying colon cancer. which did not move with insufflation. However. The patient had not received any antibiotics for 30 days.frequently coexist. Complications of untreated ulcerative colitis include toxic megacolon. you prescribed amoxicillin 40-mg/kg po qd for 7 days. fever for 24 hours. What is the best next step in this patient's management? A. Case 125 A 4-year-old boy complaining of an earache was brought by his mother to your clinic three days ago. Surgery is the definitive treatment for ulcerative colitis. tympanic membrane (TM). There has been an association between aortic stenosis and angiodysplasia. Diagnosis can be made by colonoscopy. The cause of angiodysplasia is not known. The bloody diarrhea may be associated with mucus and mild abdominal cramping. you observed a bulging. red. and cancer. B. Educational Objective: The most common cause of massive lower gastrointestinal bleeding in elderly patients is angiodysplasia or diverticulosis. The boy was extremely irritable and difficult to examine during that visit. The condition is diagnosed with a CT scan and is readily treated with antibiotics. Continue the current treatment and reassure the mother that her son will improve within 7 days. Before the advent of angiography. Discontinue amoxicillin and start amoxicillin/clavulanate for 7 days. and this has been attributed to ruptured vasa recta either at the apex or neck of a diverticulum. The mother returns with her son today. and exact identification of the bleeding source may require a combination of endoscopic and radiographic methods. In the elderly population who present with a lower gastrointestinal bleed. begin IM ceftriaxone. abdominal pain. The diagnosis is made by endoscopy and barium enema. and refer the boy to an otolaryngologist for urgent tympanocentesis.3F). The left TM is now pink. His temperature was 38. Remember the association between aortic stenosis and angiodysplasia. diverticulitis is an inflammatory condition of the left colon and is usually seen in the elderly. the child has had a cold for a week. The right TM and the rest of the physical examination was normal. (Choice B) Diverticulosis is also a common cause of massive colonic bleeding. colonic perforation. even if hemorrhoids are present. On otoscopy.

(Choice D) Tympanostomy and tubing is generally reserved for chronic otitis media (COM) with effusion persisting for more than 3 months. Moreover. Discontinue amoxicillin 40-mg/kg po qd and start amoxicillin 90-mg/kg po qd for 7 days. IM ceftriaxone is even more effective against DRSP. Educational Objective: AOM patients with an initial clinical treatment failure (failure of acute otitis media to respond clinically to amoxicillin by day 3 of treatment) and who have not received antibiotics in the preceding month require a change to high dose amoxicillin/clavulanate or to other antimicrobials active against drug resistant Streptococcus Pneumoniae strains. or recurrent AOM (greater than six episodes in 6 months) which is not prevented by prophylactic antibiotics (half of normal dose amoxicillin or sulfisoxazole). Gastric alkalinity E. earache. Her ECG and chest x-ray are normal. Reduced total body water . immediate tympanocentesis allows culture and sensitivity testing which can provide invaluable guidance in selected difficult cases not responding to empiric treatment. pneumoniae (drug resistant S. the patient would also have been initially treated with high dose amoxicillin. It might be considered in AOM if the TM bulging. (Choice A) This would be an appropriate choice if the patient has an initial clinical treatment failure and has received antibiotics in the month prior to beginning the current treatment. vomiting. A meta-analysis of studies conducted from 1966 to 1992 concluded that the overall rate of spontaneous resolution of acute otitis media was close to 80 percent. These regimens are reported to be more effective against DRSP than the usual dose of amoxicillin. however. Multiple medications C. 42% of people answered this question correctly. since acute otitis media has a favorable natural history regardless of antibiotic use. The rationale is to enhance activity against penicillin-resistant S. bulging TM.E. this approach is not recommended because of the more recent rising prevalence of DRSP. She denies any fevers. What is the most important factor in perioperative adverse drug reaction in the elderly population? A. or otorrhea three days after therapy. chills. characterized by: persistent ear pain. She is scheduled to undergo elective surgery for right hip replacement. or shortness of breath. fever. high dose amoxicillin/clavulanate. Reduced renal function D. Current recommendations for treatment failure in an AOM patient who has not received antibiotics in the month prior to the initiation of treatment are high doses of amoxicillin/clavulanate or certain second or third generation cephalosporins. which may not be eradicated by simply increasing the dose of amoxicillin.) Under these conditions. pneumoniae or DRSP) found in an increasing percentage (30-60%) of cases of pneumococcal AOM in the US. chest pain. however. Case 126 A 76-year-old female is seen in the clinic with numerous medical complaints. (Choice C) This approach might be successful. Explanation: This patient has been appropriately treated for acute otitis media (AOM) with the usual dose of amoxicillin. (Choice E) Initial acute otitis media clinical treatment failures are in large part attributable to DRSP. (Prior antibiotics in the month preceding AOM increases the likelihood that AOM is due to DRSP. She cannot remember which medications she takes. and does not sleep well at night. or certain second or third generation cephalosporins. he currently presents with an initial clinical treatment failure. Age B. has a very poor appetite. She says she is tired. fever. and/or diarrhea were unusually severe or persistent.

and states he never uses protection. thereby adding to the circulating levels of antagonistic compounds. Educational Objective: Multiple medications are a major cause of adverse drug reactions in the elderly. . which tends to increase the absorption of drugs. diuretics. he reports a weight loss of more then 30 lbs in the past three months. Do not test the patient?s HIV status E. (Choice E) Even with poor decision-making capacity. but the patient refuses to have his blood drawn for the test. Obtain a court order to have the test done D. even if there are concerns for the health risks and welfare of his sexual partners. In this case. with associated fever and night sweats. and digoxin. blood test for HIV requires a formal consent from the patient. (Choice B) The hospital?s ethics committee need not be involved in this case. While other lab tests do not require any formal consent. and during your interview. Go ahead and get the patient tested B. (Choices C and E) The gradual reduction in the glomerular filtration rate in the elderly also adds to the circulating drug levels. corticosteroids. NSAIDs. Discuss with the attending and assess the patient?s competency to make a decision Explanation: A patient's right to refuse treatment can be overruled if there are potential risks to others due to the patient's refusal to treatment. patients cannot be tested for HIV without obtaining their consent. since the patient is clearly refusing the HIV test. which of the following is the most appropriate step at this point? A. patients have a right to refuse HIV testing. The most common medications associated with adverse drug reactions include anti-psychotics. These patients are at an increased risk preoperatively for anesthetic and operative drug reactions. 39% of people answered this question correctly. This is further compounded by the fact that elderly patients have reduced levels of total body water. You are the senior resident on-call. itself. Case 127 A 28-year-old male with a known history of bipolar disorder is admitted to the floor due to an acute manic episode. Educational Objective: Do not test a patient?s HIV status without obtaining a formal consent. (Choice A) It is unethical and inappropriate to conduct HIV testing without obtaining formal consent from the patient. However. 50% of people answered this question correctly. Contact the hospital?s ethics committee C. anti-hypertensives. sedatives. He admits to having multiple sexual partners. (Choice D) Most elderly patients have an increased gastric pH. the physician must respect the patient's decision to not proceed with HIV testing. With concerns about the potential risk to his sexual partners.Explanation: Multiple medications are the most common factor in predisposing elderly patients to an increased incidence of adverse drug reactions. Patients over age 65 take an average of two to six prescribed drugs and one to three non-prescription drugs daily. There is a strong suspicion for HIV. does not increase the risk of a perioperative adverse drug reaction. (Choice A) Age.

If immediate medical care is necessary to prevent serious harm or death. consent is always assumed. has unstable vital signs. on the clinical course of portal hypertension. the parents or legal guardian of a minor must provide voluntary. However. Randomization B. Secondary outcomes are minor gastrointestinal hemorrhage and the number of hospitalizations. Since an exception to the informed consent rule is provided in case of emergency. Petition the court for consent E. Restriction E. there are exceptions to this rule. treatment should proceed. if immediate medical care is necessary to prevent serious harm or death. 70% of people answered this question correctly. propranolol. the parents or legal guardian of a minor must provide voluntary. Therefore the emergency department personnel should provide treatment for this boy without seeking consent (Choice A). However. He is unconscious. informed consent for treatment and most medical tests or procedures. Case 129 A large-scale clinical trial is being planned to evaluate the effect of a non-selective beta-blocker. What is the next best step in managing this boy?s care? A. The primary outcomes of the study are allcause mortality and major gastrointestinal hemorrhage. Withhold treatment until consent cannot be obtained from parents Explanation: Normally. Matching D. They are simply unavailable to provide explicit consent. the parents have not refused treatment. including the allowance that is made in case of emergency.Case 128 A 16-year-old Caucasian boy with Down syndrome is brought into the emergency department by ambulance after being in a serious motor vehicle accident. having witnessed the accident. Seek consent from the grandparents D. Stratified analysis . and has sustained multiple lacerations to his face. Petitioning the court for consent (Choice D) would take far too long in an emergency setting. Moreover. consent is always assumed. since they are not the legal guardians of the boy. the court is asked to intervene primarily when the parents are refusing treatment recommended by physicians. Consent from the sister (Choice B) or grandparents (Choice C) is unnecessary and not of legal benefit. and abdomen. Provide treatment without seeking consent B. In this case. She mentions that their parents are on a cruise and cannot be contacted. Which of the following is the most useful technique to reduce this possibility? A. Withholding treatment until consent cannot be obtained from parents (Choice E) may lead to the death of the boy. informed consent for treatment and most medical tests or procedures. Blinding C. arms. The investigators are concerned about the possibility that major gastrointestinal hemorrhage events could be over-reported in the placebo group. Seek consent from the sister C. His adult sister is present. Educational Objective: Normally.

(Choice A) Randomization helps to balance numerous known and unknown extraneous factors (confounders) evenly between the treatment and placebo groups. stones greater . B. Which of the following is the most appropriate next step in the management of this patient? A. The pain waxes and wanes in intensity. Case 130 A 56-year-old Caucasian female comes to the emergency department with complaints of a sudden onset of severe pain in the left side of her abdomen. Initial management is usually conservative. Most of the patients present with a sudden onset of pain and hematuria. Continue observation and treatment. 60% of people answered this question correctly. She is admitted to the hospital and is treated with intravenous hydration and pain control. D. It is accompanied by nausea and two episodes of vomiting. The location of the pain can sometimes give clues to the site of the stone. she continues to have severe pain. In this clinical scenario. and ?minor? if a patient belongs to the treatment group. Upper ureteral or renal stones usually cause pain in the flank. (Choice E) Stratified analysis is a statistical tool used to control confounding on the analysis stage of a study. Explanation: Renal or ureteral stones are a common presenting problem in the emergency department. Refer her for extracorporeal shockwave lithotripsy. The other listed techniques are used to control confounding variables. physicians may tend to classify hemorrhagic episodes as ? major? if a patient belongs to placebo group. Blinding the physician to the treatment status of a patient can balance this effect.Explanation: Observer?s bias is defined as a misclassification of events that can result from knowing the exposure status of a patient.g. It is commonly used in clinical trials. whereas a lower or distal ureteral stone causes pain which radiates to the ipsilateral groin area. Refer her for percutaneous ureterolithotomy. On the other hand. After 30 hours of conservative management. Educational Objective: Observer?s bias can be effectively reduced by using the blinding technique. and she has been unable to find a comfortable position. Start her on intravenous antibiotics. and includes intravenous hydration and pain control. Her kidney function is within normal limits. The pain is usually colicky in nature (waxing and waning) and can vary from a mild ache to severe discomfort requiring narcotic analgesics. C. Refer her for flexible ureteroscopic removal of the stone. An initial CT scan of the abdomen reveals a 5 mm stone present in the left upper ureter. (Choices C and D) Matching and restriction are typically employed in other study designs (e. Stones that are less than 5 mm in size usually pass spontaneously. cohort studies).. E.

Acute pulmonary edema Explanation: This patient probably has Marfan syndrome (MFS). (Choice B) There is no indication for using intravenous antibiotics in this patient with an uncomplicated ureteral stone. These include extracorporeal shockwave lithotripsy (ESWL). There are three common techniques that have been employed to facilitate stone removal or passage from the ureters. (Choice E) A percutaneous approach for stone removal is only used when shockwave lithotripsy and ureteroscopic removal fail to remove the ureteral stones. Pulmonary embolism E. or signs of urosepsis. Stone removal is indicated in patients with stones greater than 8 to 10 mm (since these are unlikely to pass spontaneously). The patient has particularly long and slender fingers. and ectopia lentis. This is a genetic disease that is characterized by arachnodactyly. acute renal failure. Her father died of an aortic dissection when he was 39. Acute aortic dissection D. Shockwave lithotripsy is the treatment of choice for small symptomatic proximal ureteral calculi (less than 5 ? 10 mm in size). flexible ureteroscopy. and percutaneous ureterolithotomy. and nontender.than 8 to 10 mm are unlikely to pass spontaneously and require removal. Sudden cardiac death C. It is also useful in the management of ureteral calculi after failed therapy with shockwave lithotripsy. This clinical finding needs to be confirmed by echocardiography. She is at greatest risk for which of the following complications? A. For large (more than 10 mm) proximal ureteral stones. (Choice A) Constant or persistent pain after conservative treatment is an indication for stone removal. The abdomen is soft. (Choice D) Ureteroscopic removable of calculi is performed in patients with large and proximal (more than 10 mm) ureteral calculi and/or distal ureteral stones. flexible ureteroscopy combined with laser lithotripsy is the preferred initial therapy. acute renal failure. Lungs are clear to auscultation. persistent pain. Bowel sounds are present. Stroke B. The girl?s mental and physical development is adequate for her age. 49% of people answered this question correctly. Educational Objective: Stones that are less than 5 mm in size usually pass spontaneously. an arm span greater than the height. Stone removal is also indicated in patients with persistent pain. or signs of urosepsis. Shockwave lithotripsy is the preferred initial therapy for small symptomatic proximal ureteral calculi (less than 5 to 10 mm). Case 131 A healthy 15-year-old African-American woman is brought to the office by her mother for a routine evaluation. The patient has no complaints. aortic root dilation. Examination shows a diastolic murmur at the left third intercostal space. The patient?s murmur is characteristic of aortic insufficiency due to aortic root dilation. . The choice of procedure usually depends on the location of the ureteral stone. since it could potentially increase the risk for developing an acute aortic dissection at a young age.

(Choice E) About 80% of MFS patients have mitral valve prolapse. These patients have a higher risk of acute pulmonary edema and congestive heart failure (CHF). The only surgical modality . She had a screening mammography done about a month ago. and will develop mitral valve insufficiency. as compared to Lobular carcinoma in situ is not considered to be the direct precursor of invasive breast cancer. just as any other patient with an increased risk of developing breast cancer. however. Wide surgical excision of the lesion C. Close observation with regular examinations and annual mammograms is appropriate for most women with LCIS. but it is much lower than the risk of aortic dissection or cardiac disease . The risk is increased in both the ipsilateral and contralateral breast. which identified an area of microcalcifications that was suspicious for malignancy in her left breast. its presence is one of the most important risk factors for the subsequent development of invasive breast cancer. usually detected as an incidental finding on microscopic from the lobules and terminal ducts of the breast. (Choice D) There is no increased risk of PE in patients with Marfan syndrome. The biopsy results revealed the presence of lobular carcinoma in situ in the left breast. It arises a multicentric (present at multiple sites in younger premenopausal women. tamoxifen therapy. Patients can be followed regularly. Studies have shown that there is no significant statistical difference in the mortality of women managed by close observation as compared to those managed by a surgical intervention or mastectomy. Regular examination and mammogram B. It is usually in the breast) and bilateral disease. Case 132 A 46-year-old Caucasian female comes to see you in the office to follow-up her breast biopsy results. Educational Objective: The risk of aortic dissection is high in patients with MFS. Perform an open biopsy of the lesion E. It is more commonly seen incidence being much higher in white women. (Choice B) Surgical excision of the lesion with or without radiation therapy is generally not recommended because LCIS is usually a multicentric and bilateral disease. About 80% of the patients will have mitral insufficiency. She subsequently underwent fine needle aspiration biopsy of the lesion. These patients will benefit from mitral valve replacement. corrective surgery is recommended when the aortic root reaches 45 mm. (Choice A) Because of the aortic insufficiency and dilatation of intracranial arteries. Excisional biopsy with radiation therapy D. Which of the following is the most appropriate next step in the management of this patient? A. there can be an increased risk of stroke in patients with MFS. For this reason. The various available options to manage patients with LCIS include close observation. (Choice B) MFS patients with CHF have a higher risk of sudden cardiac death . the African-American women. which can lead to CHF. Wide surgical excision of the lesion with chemotherapy Explanation: Lobular carcinoma in situ (LCIS) is examinations of breast tissue. and prophylactic bilateral mastectomy. 82% of people answered this question correctly. She does not have any family history of breast cancer. regardless of the side where LCIS is present.

e. Neurological examination reveals motor weakness and hypoesthesia of the distal right leg. Physical examination reveals a tense swelling around the right calf region. Case 133 The following vignette applies to the next 4 items A 24-year-old female is admitted to the hospital after a motor vehicle accident. heart rate is 96/min. and drug overdose. Sensory nerves are usually affected earlier than the motor nerves.2?C(99F). Patients usually present with a triad of hypoxemia. Educational Objective: The three possible options for the management of patient with LCIS include close observation. or axilla). (Choice E) Chemotherapy has no present role in the management of patients with LCIS. Late features include extremity paralysis and absent distal pulsation (pulseless paralysis).. Deep venous thrombosis C. a nurse calls to inform you that she is complaining of severe pain in her right lower leg. (Choice D) Open breast biopsy of the lesion is usually not necessary. numbness or hypoesthesia. decreased two-point discrimination. 11% of people answered this question correctly. Fat embolism B. tamoxifen therapy.that can be considered after extensive discussions with the patient is bilateral prophylactic mastectomy. Acute compartment syndrome D. . however. neurological abnormalities (i. and a petechial rash (involving the head. Surgical excision of the lesion. and blood pressure is 140/82 mmHg. the resulting diminished tissue perfusion and compromised blood flow to the muscles and nerves inevitably lead to ischemic tissue necrosis. Acute vascular occlusion E. anterior chest wall. Her temperature is 37. Patients usually present with severe pain which is out of proportion to the extent of injury. a tight cast or dressing after trauma. When the tissue pressure in an enclosed compartment exceeds the perfusion pressure. Neural compression Explanation: Acute compartment syndrome refers to ischemic tissue damage secondary to elevated pressures in the enclosed compartments of the lower legs or forearm. and the neurologic deficit presents as decreased vibration sense. respiratory rate is 18/min. The next morning. neck. The pain is worsened on palpation and passive movements of the foot. where she sustained a right humerus fracture. Item 1 of 4 Which of the following is the most likely diagnosis? A. most commonly tibial fractures. chemotherapy and radiation therapy have no role in the management of patients with LCIS. tamoxifen has been shown to reduce the risk of development of invasive cancer and should be strongly considered in these patients. Other causes include a crush injury or other long bone fractures in a motor vehicle accident. The pain is typically worsened by passive movements of the involved muscles. Majority of the cases involving the lower extremities are due to a traumatic event. and bilateral prophylactic mastectomy. (Choice A) Fat embolism is infrequently seen in patients with long bone or pelvic fractures. multiple rib fractures and a contusion over her right lower leg. confusion).

24% of people answered this question correctly. causing tissue necrosis. Pulmonary embolism D. Laboratory studies typically reveal markedly elevated creatinine kinase levels and the presence of myoglobin in the urine (positive dipstick for blood in the absence of RBC?s in the urine). Rhabdomyolysis and renal failure C.(Choice B) Deep venous thrombosis usually does not present acutely in a setting of motor vehicle accident in an otherwise healthy young patient. Order venous Doppler ultrasonography D. Check the tissue pressure E. it does not lead to blood flow compromise and muscle necrosis (pain with passive movements of the involved muscles). Educational Objective: Acute compartment syndrome usually occurs after a traumatic event and causes pain. Myoglobin is directly toxic to the renal tubules. Administer oxygen B. and rhabdomyolysis. hypoesthesia. disseminated intravascular coagulation. paresis. It is a rare cause of compartment syndrome and does not compromise blood circulation and neuromuscular function. Educational Objective: Rhabdomyolysis and subsequent development of acute renal failure is one of the most common and severe life-threatening complications of acute compartment syndrome. 87% of people answered this question correctly. Item 3 of 4 Which of the following is the most appropriate next step in the management of this patient? A. Thrombocytopenia Explanation: Acute compartment syndrome results in markedly diminished to absent tissue perfusion within hours of the inciting event. C. D. and diminished to absent pulses in the involved limb. and gangrene of the limb are not usually seen in patients with acute compartment syndrome. pulmonary embolism. Acute compartment syndrome usually has a lag period of a few hours before irreversible nerve injury and muscle necrosis occurs. Gangrene of the limb E. (Choice E) Nerve compression may occur in a patient after a motor vehicle accident and possible bone fracture. Acute renal failure and its complications (electrolyte disturbances) are one of the most common life-threatening complications of acute compartment syndrome. (Choices A. E) Thrombocytopenia. Disseminated intravascular coagulation B. which releases myoglobin into the peripheral circulation. muscle infarction. Item 2 of 4 Which of the following is the most common life-threatening complication of the above condition? A. Order a nerve conduction study . and subsequently causes acute tubular necrosis and acute renal failure. (Choice D) Vascular occlusion secondary to a motor vehicle accident usually presents more suddenly and dramatically. however. Start the patient on anticoagulation C.

(Choice C) A consultation with a vascular surgeon is necessary in patients with vascular injury or occlusion. (Choice B) Obtaining a hypercoagulable panel may be useful in patients with idiopathic deep venous thrombosis. It is not helpful for the diagnosis of compartment syndrome. Which of the following is the best next step in management? A. Any delay in treatment leads to irreversible muscle and nerve damage. Some patients may develop a persistent sensory or motor deficit after an episode of acute compartment syndrome despite early fasciotomy. Item 4 of 4 The appropriate step was taken for the patient. It is not indicated in patients with acute compartment syndrome. Educational Objective: Direct measurement of the compartment or tissue pressure is the diagnostic procedure of choice for patients with suspected acute compartment syndrome. 80% of people answered this question correctly. Review the results of venous Doppler ultrasonography Explanation: Acute compartment syndrome is a surgical emergency. and this eventually leads to tissue and muscle necrosis. Obtain a hypercoagulable panel C. the capillaries collapse. (Choice A) Oxygen is usually used in the supportive treatment of patients with fat or cholesterol emboli. (Choice E) Nerve conduction studies are helpful in the diagnosis and localization of the site of nerve damage. (Choice A) Oxygen therapy has no role in the management of patients with acute compartment syndrome. . Continue with oxygen therapy B. especially if the diagnosis is in question. The exact value for the tissue pressure at which blood flows to the muscle and nerve tissue stops is controversial. Consult a vascular surgeon D. Perform urgent fasciotomy E.Explanation: Compartment syndrome is characterized by an increase in the tissue pressure in the enclosed myofascial compartments of the extremities. (Choice B) Anticoagulation is usually required for patients with deep venous thrombosis. A compartment pressure of 30 mmHg or greater warrants an emergent fasciotomy (also known as compartment release). (Choice C) Venous Doppler ultrasonography is useful for the diagnosis of deep venous thrombosis. The current general consensus for the threshold value is greater than 30 mmHg. It is therefore important to measure the tissue or compartment pressure early in the course of management. When the elevated tissue or compartment pressure reaches its threshold level. Surgical decompression aims to relieve the pressure within the enclosed compartment and to restore the blood flow to muscles and other tissues within 6-10 hours of the initial symptoms.

Intravenous hydration C. Intravenous calcium gluconate E. Her medications include aspirin. Which of the following is the most immediate step in the management of this patient? A. 86% of people answered this question correctly. the first thing to do is to administer intravenous calcium gluconate to stabilize the . dysuria. She lives alone at home. nausea. Her abdomen is soft. clear lung fields. lisinopril. and normal first and second heart sounds. peaked T-waves in all leads. and no changes in the ST segments. Physical examination shows dry mucus membranes.8 mg/dL Urine Specific gravity: 1. and frequency.(Choice E) Venous Doppler ultrasonography is useful to diagnose deep venous thrombosis. Intravenous insulin D. acute renal failure. Case 134 A 74-year-old Caucasian woman comes to the emergency department because of fever. alcohol. dehydration. Her blood pressure is 130/80 mmHg and pulse is 98/min. or drugs. potassium is higher than 7 mEq/L. Intravenous bicarbonate Explanation: The patient has a urinary tract infection and is developing high anion gap metabolic acidosis.020 Blood: Trace Leukocyte esterase: Positive Nitrites : Positive WBC: 20-30/hpf RBC: 1-2/hpf The electrocardiogram shows sinus tachycardia. This latter condition is especially serious because there are EKG changes. and ibuprofen. and the process seems to be acute. It has no role in the diagnosis or management of patients with acute compartment syndrome. mildly tender. and nondistended.8 g/dL Ht: 38% Leukocyte count: 13. Surgical decompression aims to restore the capillary blood flow and tissue perfusion. Intravenous antibiotics B. In such a situation.000/cmm Segmented neutrophils: 90% Lymphocytes: 10% Serum Chemistry Serum Na:148 mEq/L Serum K: 7. She also complains of loss of appetite and abdominal pain. and hyperkalemia. She does not use tobacco. Her laboratory tests reveal the following: CBC Hb: 12. Educational Objective: An emergent fasciotomy is the definitive treatment in patients with acute compartment syndrome.1 mEq/L Chloride: 112 mEq/L Bicarbonate: 17 mEq/L BUN: 78 mg/dL Serum Creatinine: 2. She has not been eating or drinking well for the past two weeks.

or there is simultaneous metabolic acidosis. What is the most appropriate response on the behalf of the physician? A. She is currently a sophomore in high school and has won many awards for her athletic accomplishments. Since elective abortion is usually exempt from parental notification/consent laws. administration of calcium gluconate is the first thing to do. If a teenager requires non-urgent treatment of any condition that is not exempt from parental consent laws (eg. As the visit comes to a close. . These laws are typically limited to the management of certain issues. surgical repair of a torn ligament). She asks that the physician not inform her mother about her use of birth control. If the teenager in this situation were an emancipated minor. (Choices A and B) Hydration and antibiotic treatment are not as urgent as the management of significant hyperkalemia. Case 135 A 15-year-old female presents to clinic for a routine examination. However. Inform the girl that her parent(s) will be informed because they pay for her health insurance Explanation: As a physician. if the visit is regarding contraception. In such situations. the potassium is higher than 7. Inform the girl that her parent(s) will not be informed because she is an emancipated minor B. emancipated minors are teenagers who have successfully presented evidence to the court that they deserve emancipation.membrane of the cardiac conduction tissue and prevent the development of life-threatening arrhythmias. she can be prescribed oral contraceptives without parental involvement. Educational Objective: Significant hyperkalemia can be life threatening and needs to be managed immediately. it would be illogical to presume that a history of abortion has any bearing upon a request for contraceptives (Choice D). Inform the girl that her parent(s) will be informed because she is a minor D. However. no evidence was presented to suggest that she is an emancipated minor (Choice A). 77% of people answered this question correctly. Hyperkalemia is considered a medical emergency when there is an acute increase in the serum potassium level. most states have implemented laws that allow for a physician to provide care to adolescents without parental consent. then her parents would be contacted because she is a minor (Choice C). Her medical history is significant for a diagnosis of attention deficit hyperactivity disorder. but these will take some time to act. she would not need to obtain parental consent for any aspect of her health care. including pregnancy. Most often. a teenaged patient is normally entitled to confidentiality regarding his or her use of contraceptives (Choice B). she informs you that she has recently become sexually active with a male classmate and would like a prescription for oral contraception. contraception. a special independent status legally equivalent to adulthood. Therefore. Inform the girl that her parent(s) will not be informed because the visit is regarding contraception C. Common examples include teenagers who are completely self-sufficient and no longer living with their parents and teenagers who are parents to one or more children. (Choices C and E) Insulin and bicarbonate are also part of the therapy. it can be difficult to balance the adolescent?s right to confidentiality against the parental right to oversee the child?s health. which is reasonably well managed with methylphenidate. To address this conflict. substance use. and emotional illness. sexually transmitted diseases. Inform the girl that her parent(s) will be informed because she has had an abortion E. and an elective abortion performed one year ago.

Physical examination is unremarkable. and ibuprofen. Item 1 of 2 Which of the following studies is most appropriate to order? A. and tension headaches. allergic rhinitis. The diagnosis of RLS is based on the clinical history. sexually transmitted disease. She does not smoke or use recreational drugs. . B. and E) should be ordered if there is any indication of their necessity in the history or physical examination. C.In most circumstances. substance use. Erythrocyte sedimentation rate Explanation: Restless legs syndrome (RLS) occurs in 5-15% of the population and is more common in older people. Liver function tests D. 84% of people answered this question correctly. since iron deficiency is frequently present in the absence of an anemia the iron studies should be performed. Her medical history is significant for well-controlled hypertension. Case 136 The following vignette applies to the next 2 items A 53-year-old African American woman presents to clinic at the insistence of her husband. Serum electrolytes C. physicians should make every effort to preserve confidentiality when submitting insurance claims while still charting and billing correctly (Choice E). resting. and emotional illness. liver function tests. Iron studies E. gastroesophageal reflux disease. No other laboratory tests are routinely indicated. 10% of people answered this question correctly. Educational Objective: RLS may be a symptom of iron deficiency. She has trouble falling asleep in bed. Educational Objective: Most states have implemented laws that allow for a physician to provide certain types of medical care to adolescents without parental consent. contraception. It is characterized by spontaneous. RLS may be a symptom of iron deficiency. and is worse when she is feeling particularly anxious or fatigued. which in turn keeps him awake. serum electrolytes. In this woman. However. or lying down at night. Urinalysis. Movement provides relief. and erythrocyte sedimentation rate (Choices A. his wife has been extremely restless when she is sitting. Exempted areas typically include pregnancy. The woman adds that the restlessness comes about every night when she feels a strange sensation that she compares to an "internal itch that creeps up the lower legs. Since it is possible that health insurance bills will include descriptions of the services rendered." The sensation compels her to get up and pace the floor. parents pay for the health care insurance for their children. since iron deficiency is frequently present in the absence of an anemia the iron studies should be performed. iron studies (Choice D) should be checked. this does not automatically entitle them to all information regarding the child?s medical care. She is currently taking hydrochlorothiazide. Urinalysis B. but consumes 1-2 alcoholic drinks on the weekends. Her husband accompanies her and reports that for quite some time. There is no family history of similar problems. omeprazole. repeated leg movements in association with unpleasant sensations that occur at rest.

or use any illicit drugs. Mechanical ventilation that delivers lower tidal volumes and limits plateau pressure . Prostacyclins E. Educational Objective: First-line treatment for daily restless legs syndrome includes dopamine agonists such as pramipexole or ropinirole. A chest x-ray shows diffuse bilateral pulmonary infiltrates. alcohol. including iron replacement therapy. and the avoidance of exacerbating factors (eg. and may work especially well in patients with intermittent RLS. L-dopa is therefore primarily recommended for usage with intermittent RLS because it is thought that sporadic usage of the drug may decrease the likelihood a patient will develop augmentation or rebound. Gabapentin D. crossword puzzles). Clonazepam B. 9% of people answered this question correctly. When prescription medication is warranted for treatment of daily RLS. Which among the following is the most useful strategy to decrease mortality in ARDS patients? A. Codeine (Choice B) is one such possibility. prescription of narcotics is typically restricted to those patients with severe symptoms who have failed therapy with dopaminergic drugs or benzodiazepines. His family history is not significant. You strongly suspect ARDS. Clonazepam (Choice A) may be of help in milder cases of RLS. and is being maintained on 100% oxygen. Gabapentin (Choice C) is more commonly used in patients who have less intense or painful symptoms. Benzodiazepines are recommended for intermittent RLS. also called L-dopa (Choice D). mentally stimulating activities (eg. including rib fractures. caffeine). He is developing progressive shortness of breath. Early administration of methyl prednisone C. It can also cause rebound. Codeine C. which is the worsening of symptoms the morning after a nighttime dose. drink alcohol. He has no previous medical history or any known lung abnormalities. Pramipexole Explanation: Restless legs syndrome (RLS) can be classified as intermittent. Administration of surfactant B. Case 136 A 35-year-old male has been hospitalized for two days after being involved in a motor vehicle accident where he sustained multiple severe injuries. Which of the following medications should be prescribed at this time? A. dopamine agonists such as pramipexole (Choice E) or ropinirole are usually the most effective. nicotine. daily. It is also a good choice when used in the setting of neurodegenerative disorders such as Parkinson?s disease or dementia. and short-acting agents are helpful in patients with sleep-onset insomnia secondary to RLS. Levodopa. Intermittent or daily RLS is sometimes treated with nonpharmacologic methods. has been shown to cause augmentation in RLS patients. which is the recurrence of RLS symptoms early in the morning. Inhaled nitric oxide (NO) D. Levodopa E.Item 2 of 2 The appropriate study was ordered and its results were within normal limits. and refractory. especially in younger patients. He does not smoke. Although opioid abuse potential is thought to be low in patients with RLS.

Item 1 of 2 Which of the following is the most likely explanation for her findings? A. Anterior cruciate ligament tear B. however.Explanation: Development of pulmonary contusions secondary to chest wall trauma is an important etiological factor of ARDS. 40%). McMurray?s maneuver on the left knee does not reveal a popping sensation with external rotation and passive extension of the lower leg. (Choice A) Theoretically. Among the different strategies. (Choice B) Although steroids are frequently used in clinical practice in such situations. however. studies have not shown any beneficial effect on the acute phase. controlled studies have shown that the effect of NO compared to placebo. ARDS is associated with a mortality rate of 35-40%. mechanical ventilation that delivers lower tidal volumes (< 6 ml/kg) and limits plateau pressure (< 30 CmH2O) has been shown to be relatively more effective than other strategies such as NO inhalation. The girl was playing soccer when she fell and injured her left knee after being tackled by one of the players. she is unable to maintain extension of the left knee against gravity. Passive extension and flexion of her left knee are normal. studies have also failed to demonstrate significant effects of prostacyclins on mortality. Among the different strategies. however. She immediately felt a tearing sensation and excruciating pain in the front of her left knee. exogenous surfactant. Educational Objective: ARDS is associated with a mortality rate of 35-40%. Medial collateral ligament tear . surfactant decreases the alveolar surface tension and reduces the chances of atelectasis. On physical examination. Some studies have even demonstrated increased infections in patients using steroids. large multicenter. She has a significant joint effusion. Studies comparing the effects of low tidal volume and limited plateau pressure to that of high tidal volume and plateau pressure have shown a significant reduction in mortality in the first group (32% vs. 79% of people answered this question correctly. It facilitates the mucous clearance and helps to suppress inflammation. She is presently having a great deal of pain and difficulty in rising and bearing weight on her left leg. The valgus and varus stress to the left knee does not reveal an increased laxity or instability on the medial or lateral side. mechanical ventilation that delivers lower tidal volumes (< 6 ml/kg) and limits plateau pressure (< 30 CmH2O) has been shown to be relatively more effective. use of prostacyclins. Case 137 The following vignette applies to the next 2 items A 14-year-old girl comes to the emergency department with her mother for the evaluation of left knee pain. however. studies have failed to demonstrate any significant positive outcome on 30 days mortality in these patients. was modest and inconsistent. Steroids are helpful. The anterior and posterior drawer signs are normal. (Choice C) NO is a vasodilator which should theoretically improve V/Q mismatch. in reducing the intensity of the fibro-proliferative phase of ARDS in later stages. (Choice D) Prostacyclins have similar effects as NO since it increases oxygenation and decreases pulmonary pressures. Unfortunately. and steroids. double blind. there is diffuse swelling and tenderness on the anterior aspect of her left knee. There was no significant difference found in 28 days mortality in both arms of these studies.

Item 2 of 2 Which of the following is the most appropriate next step in the management of this patient? A. medial and lateral meniscus. Its rupture is usually due to traumatic athletic injury. Patellar tendon tear or rupture usually occurs at the osseotendinous junction and results in excruciating pain. the knees bent at 90 degrees.C. The common mechanism of meniscal injury is a twisting force with the foot fixed on the ground. and a popping sensation or sound at the time of injury. and an inability to maintain passive extension of the knee against gravity. and an abnormal opening of the knee as compared to the opposite side on valgus or varus stress is suggestive of ligament injury or disruption. Patellar tendon tear E. (Choices B and C) The valgus and varus stress tests are used to determine the integrity of the medial and lateral collateral ligaments. The test is positive if there is an audible or palpable click or popping sensation during extension of the involved knee. local tenderness on the medial or lateral joint lines. and the knee is extended slowly. Physical examination generally reveals swelling and tenderness in the anterior part of the knee. The patient is placed in the supine position with the hip flexed at 45 degrees. Medial meniscal tear Explanation: Soft tissue knee injuries are extremely common in adolescent and young adults who engage in various contact sports. and joint capsule. It is important to establish the correct anatomic diagnosis of these injuries in order to institute an early and specific intervention. Most patients complain of an immediate. The tibia is then externally rotated. The anterior drawer test is commonly used to evaluate the integrity of the anterior cruciate ligament. Complete bed rest for two weeks with gradual return to baseline activity in six weeks . McMurray?s maneuver is used to detect the presence of meniscal tears. With both hands behind the affected knee. Lateral collateral ligament tear D. 73% of people answered this question correctly. and with the knee in partial flexion during the injury. This is commonly seen during football and basketball games. One hand of the examiner is placed on the posteromedial margin of the involved knee and the other hand supports the foot. Inquire if there is a family history of seizures B. and difficulty in bearing weight. A history of knee injury. medial and lateral collateral ligaments. swelling. The patellar tendon is the distal extension of the quadriceps insertion. the patient is put in a supine position with the knee in maximum flexion. Most patients complain of profound pain. the examiner tries to displace the lower leg anteriorly. Educational Objective: Patellar tendon rupture presents with excruciating pain. The patient in the above vignette has a patellar tendon tear. The most common mechanism is a sudden and unusual quadriceps contraction with the foot firmly planted. inability to ambulate. A detailed history and physical examination (including specific maneuvers) can help in differentiating between the damage to various possible knee structures. With a complete tendon rupture. (Choice A) Anterior cruciate ligament tears are one of the most serious forms of knee injuries. profound pain and difficulty or inability to bear weight on the same leg. A difference of 1 cm compared with the opposite side suggests a complete tear of the anterior cruciate ligament. (Choice E) Menisci are the fibrocartilaginous pads located between the femoral condyles and tibial surfaces. respectively. To detect a medial meniscal injury. the patients are unable to perform active extension of the leg and are unable to maintain the passively extended knee against gravity. swelling in the anterior part of the knee. The most common vulnerable structures in the knee include the anterior and posterior cruciate ligaments. and the patient?s foot firmly planted on the examination table.

and significant disability. Complete patellar tendon tears are ideally managed by early surgical intervention.C. Educational Objective: Early surgical repair of the ruptured patellar tendon is recommended to promote the recovery of normal knee motion and prevent long-term disability. . Medial meniscal tear Explanation: Based on the clinical presentation. he developed a fever of 39.1C (102. He is scheduled to receive the measles-mumps-rubella (MMR) vaccine today. Inquire if the boy has a history of allergy to mercury D. a history of anaphylaxis to egg products is not a contraindication to measles immunization. His mother mentions that the last time he was given this vaccine. She asks if he should still receive the MMR vaccine. Brace immobilization and ice packs in the local area for four weeks E. In all such patients. thereby causing early fatigue. Case 138 A 5-year-old boy with an unremarkable medical history is brought to the office by his mother for his annual wellness exam. Allergies: A history of anaphylaxis after either ingestion of gelatin or contact with neomycin is considered a contraindication. Inquire if there is a family history of anaphylaxis C. (Choices A and B) Non-operative treatment (conservative treatment with bed rest and pain control) has a very limited role in the management of patients with acute patellar tendon rupture. the patient appears to have a complete disruption of the patellar tendon and dysfunction of the knee extensor mechanism. Delayed treatment can lead to quadriceps muscle atrophy. pain. Which of the following is the most appropriate response? A. It can lead to a significant dysfunction of the knee extensor mechanism and long-term disability. (Choice D) A cast or brace immobilization in full extension is used very occasionally in patients with partial patellar tendon tear. Assure her the boy appears to have no contraindications to the MMR vaccine Explanation: Vaccination against measles-mumps-rubella in children/adults is contraindicated if any of the following situations apply: Current moderate or severe febrile illness Anaphylaxis to neomycin or gelatin Severe immunodeficiency Thrombocytopenia after the first dose of MMR Recent administration of immunoglobulins Pregnancy Current moderate or severe febrile illness: In patients with moderate to severe febrile illnesses vaccine administration should be delayed until the acute phase of the illness is resolved. early surgical intervention and repair of the patellar tendon is the treatment of choice. however. Early diagnosis and surgical repair usually lead to excellent recovery of knee function and prevent long-term disability. and limited range of motion of the knee.4F). Complete rupture of the patellar tendon causes significant damage to the knee extensor mechanism. Consult orthopedic surgery for early surgical intervention D. Inquire if the boy has a history of allergy to eggs E. Inquire if there is a family history of seizures B. contracture formation.

. (Choice C) An allergy to mercury is extremely rare. this issue is not of importance in this child. but recent studies have suggested that this is an unnecessary precaution. On the other hand. MMR). (Choice B) A family history of anaphylaxis is not considered relevant in this situation. therefore. but this does occur. (Choice A) A family history of seizures was formerly considered a contraindication to receipt of DTP vaccine. The only allergic contraindication would be a personal history of anaphylaxis associated with ingestion of gelatin or exposure to neomycin. Recent administration of immunoglobulins can diminish the efficacy of MMR. Asymptomatic HIVinfected patients without severe immunosuppression should be vaccinated with MMR. as the current MMR vaccine does not contain a significant amount of egg proteins.Thrombocytopenia: A patient with a history of thrombocytopenia is at risk of developing severe thrombocytopenia following measles vaccination. severe HIV infection. It is advisable not to give a second dose of MMR in patients who developed thrombocytopenia following the first dose. vaccination should be delayed for a period of time (varies from 3-11 months) depending on the strength of antibody in the preparation. whether or not to vaccinate these patients depends on the degree of immunosuppression and the risk of natural measles infection. Please read the explanation at least twice. as these are ingredients in the MMR vaccine. therefore. (Choice D) A history of anaphylaxis after egg ingestion is not considered a contraindication to MMR vaccination. hematologic or solid tumors and long term immunosuppressive therapy) should not receive MMR. Educational Objective: MMR vaccination is contraindicated in patients with: Current moderate or severe febrile illness Anaphylaxis to neomycin or gelatin Severe immunodeficiency Thrombocytopenia after the first dose of MMR Recent administration of immunoglobulins Pregnancy The following are not considered as contraindications for MMR: Tuberculosis or positive PPD Breastfeeding Immunodeficient family member or household contact Asymptomatic HIV-infected patients without severe immunosuppression Anaphylaxis to eggs *Extremely important question for USMLE step-3. Since the MMR vaccine does not contain thimerosal (mercury). The consensus is that patients who are severely immunocompromised (congenital immunodeficiency. Immunocompromised state: An immunocompromised state is considered a contraindication to administer live vaccines because of the risk of vaccine associated fatal infections (eg. the immunocompromised patients are also at high risk of developing natural measles infection. The following are not considered as contraindications for MMR: Tuberculosis or positive PPD Breastfeeding Immunodeficient family member or household contact Asymptomatic HIV-infected patients without severe immunosuppression The boy?s history of a mild febrile reaction to the MMR vaccine is not considered a contraindication. 59% of people answered this question correctly.

Desmoid tumors are locally aggressive neoplasms arising from fibroplastic elements within the muscle or fascial planes. However. What is the most appropriate next step? A. these only cause local complications. although these may occur at all body sites. does not have any risk factors for the development of aortic aneurysm. He denies any other medical problems. The diagnosis is generally confirmed with a tissue biopsy. even after surgical excision. As her labor progresses. Abdominal examination reveals the presence of multiple scars from previous surgical procedures around the epigastric area. A 3 x 5 cm oblong-shaped mass is palpable in the epigastric area. (Choice A) Abdominal aortic aneurysms usually present as a painless pulsatile mass. An oral glucose tolerance test was administered at 29 weeks of gestation and while her fasting plasma glucose was elevated. Her previous pregnancies were unremarkable except for asymptomatic bacteriuria that developed when she was pregnant with her first and third children and a cesarean delivery for her fourth child because of breech positioning. The discomfort is not associated with eating or performing any activities. and hip-buttock area. para 5 Caucasian woman at 41 weeks of gestation is admitted to the labor and delivery unit after experiencing regular uterine contractions every 10 minutes and the spontaneous rupture of membranes. His vital signs are unremarkable. the cervix thins and completely dilates. 6% of people answered this question correctly. Surgical excision with a wide margin of resection is the treatment of choice for patients with an easily approachable and resectable mass. The woman?s fundal height was 42 cm the day prior to admission. There is no tenderness on direct palpation of the mass and the surrounding epigastric area. The patient tells you that he previously had a similar mass in the same area "but it was taken out". but has never been severe enough to make him seek immediate medical attention. This current pregnancy had been uncomplicated except for obesity. There is a high rate of local recurrence. This patient (Choice B) Ventral or incisional hernia can develop at the site of previous surgical scars. slowgrowing masses over the extremities. The vertex of the fetus appears after 15 minutes of second stage labor. the other glucose levels were considered normal. Educational Objective: Desmoid tumors are slow growing and locally aggressive benign neoplasms with a high rate of local recurrence. The pain has been present most of the time for the past three weeks. and pain is an unusual symptom of ventral hernia. even after adequate resection. the fetal anterior shoulder is now proving undeliverable by gentle traction. Tell mother to push with the next contraction B. Since these are locally invasive and slowly infiltrate the surrounding tissues and structures. Ventral hernia C. and she weighed 272 lbs at admission. this is generally reducible. Which of the following is the most likely explanation for the mass? A. Tell mother to push with the next contraction . shoulder girdle. unless it is strangulated. Assure her the boy appears to have no contraindications to the MMR vaccine Explanation: The patient's clinical presentation is consistent with a diagnosis of desmoid tumor. however.Case 139 A 59-year-old African-American man comes to the office and complains of a vague upper abdominal discomfort. Muscle growth D. Case 140 A 36-year-old gravida 6. These usually present as painless or minimally painful. Abdominal wall neuroma E.

Perform McRoberts maneuver D. The Zavanelli maneuver (Choice D) replaces the fetal head in the pelvis before performing a cesarean section. pediatrics) should be summoned. appropriate support staff (eg. The mother should be told not to push (Choice B) while attempts are made to reposition the fetus. Telling the mother to push with the next contraction (Choice A) is incorrect. His past medical history is otherwise insignificant. This maneuver has been shown to relieve the shoulder dystocia in 42% of patients. It is generally accepted that the physician has up to seven minutes to deliver a previously well-oxygenated infant before there is an increase in the risk of damage due to asphyxia. shoulder dystocias in previous deliveries. as it will only exacerbate the problem. Suprapubic pressure directed downward and laterally should then be applied by an assistant. maternal diabetes mellitus. However. alcohol consumption. delivery of posterior arm). He says. He is currently not taking any medications and has no known allergies. the mother should be told to stop pushing until everything is in place. 9% of people answered this question correctly. more than 50% of cases of shoulder dystocia are not associated with any known risk factors. Woods screw maneuver. downward pressure. then typically the McRoberts maneuver is attempted. though many other techniques work as well (eg. ?I frequently explore caves and bats do not always seem to like me. Risk factors for the development of shoulder dystocia include macrosomia. Case 140 A 26-year-old anthropology student presents to the emergency department 10 hours after his right arm was scratched by a bat. then typically the McRoberts maneuver is attempted.? He had a similar scratch one year ago and received complete anti-rabies vaccination. The McRoberts maneuver (Choice C) requires that two assistants grasp both of the mother?s legs and flex the thighs back against her abdomen. He denies smoking. It is diagnosed when the anterior shoulder cannot be delivered with mild. The mother should be told not to push while attempts are made to reposition the fetus. though many other techniques work as well (eg. What is the best management strategy for this patient? A. Woods screw maneuver. When shoulder dystocia occurs. If that fails to deliver the anterior shoulder. and disproportion between the fetal shoulders and maternal pelvis. Rubin maneuver. Therefore. Breaking the fetal clavicle (Choice E) is occasionally done. All his vaccinations are up-to-date. postdate pregnancies. operative vaginal delivery. obstetrics. Tell mother not to push C. Rabies vaccine . Break fetal clavicle to deliver anterior shoulder Explanation: Shoulder dystocia is commonly defined as a failure of the fetal shoulders to pass through the maternal pelvis once the fetal head has been delivered. Perform Zavanelli maneuver E. delivery of posterior arm). appropriate support staff should be summoned. If suprapubic pressure fails to deliver the anterior shoulder. Educational Objective: When shoulder dystocia occurs. Rubin maneuver. obesity and excessive weight gain.B. though it is difficult to perform and obviously not a preferred means of resolving the problem unless other alternatives are unsuccessful. the Zavanelli maneuver is normally employed when other methods have failed and the "safe" period of seven minutes is dwindling. male fetal gender. Before the maneuver is implemented. nursing. advanced maternal age. however. and any illicit drug use. anesthesia.

. Reassurance and routine discharge Explanation: Rabies is an invariably fatal viral disease primarily acquired from a bite or exposure to saliva of a rabid animal.B. Educational Objective: Patients with PSA levels greater than 4 ng/ml should be referred to a urologist for biopsy. Hospitalization and observation E. He does not drink alcohol. There are two types of rabies prophylaxis products: rabies immune globulin for passive immunization and rabies vaccines (several are available) for active immunization. Rabies immune globulin C. He is a software engineer. Refer to urologist for biopsy C. The digital rectal examination is normal. The physical examination shows no abnormalities. (Choice C) Previously unvaccinated individuals who are exposed to a potential source of rabies should receive both active and passive immunization. He has smoked one pack of cigarettes daily for 10 years. He has no medications. The cutoff value has been reduced to 4 ng/dL to increase the sensitivity for diagnosing early prostate cancer. Bats represent a potential source of the infection. Reassurance D. (Choices A and C) Only a biopsy can confirm or rule out a diagnosis of prostate cancer. This can be prevented with proper postexposure prophylaxis. Radical prostatectomy E. Pretreatment tests include biopsy of the tumor and a CT scan. Educational Objective: Previously vaccinated persons who are potentially re-exposed to rabies should receive only active immunization with a rabies vaccine. 42% of people answered this question correctly. Reassurance and routine discharge Explanation: The normal range of serum PSA is 0 to 4 ng/mL. His vital signs are within normal limits. Previously vaccinated persons who are potentially re-exposed to rabies should receive only active immunization with a rabies vaccine. Case 141 An asymptomatic 60-year-old Caucasian man comes to the physician for a routine health maintenance examination. His family history is not significant. Patients with PSA levels greater than 4 ng/mL should be referred to a urologist for a biopsy. Rabies immune globulin and vaccine D. His serum PSA level is 6 ng/mL. prophylaxis is standardly given to patients who have bat bites. Suggest it is unlikely that the daughter will quit smoking unless her mother quits first B. He has no other medical problems. therefore. Reassurance or repeating the measurement of PSA levels in six months is not the appropriate choice because more than 20% of patients with PSA levels greater than 20 ng/mL have cancer on biopsy. Which of the following is the most appropriate next step in the management of this patient? A. 9% of people answered this question correctly. (Choice D) Radical prostatectomy is a treatment option for early prostate cancer.

Suggest that the daughter?s friend?s mother be informed of the situation E. which of the following is the most appropriate next step? A. nicotine gum) should be offered to those smokers interested in quitting. Suggest that the mother lock her cigarettes away C. (Choice B) Locking up the cigarettes may prevent the daughter from using her mother?s cigarettes. she should take on the responsibility of addressing the problem in its entirety herself. Case 143 A 16-year-old gravida 1. Recommend cesarean section and obtain consent from hospital ethics committee E. If the mother is genuinely interested in helping her daughter stop smoking.g. Increase Pitocin drip and re-evaluate cervix in one hour Explanation: . Studies have shown that smokers who attempt to quit while working or living with people who continue to smoke are much more likely to relapse. After five hours of labor.Case 142 A 14-year-old girl presents to the pediatrician for an annual wellness exam. who expresses dismay that the daughter started smoking six months ago. Suggest that the school principal be asked to punish the daughter for smoking on campus Explanation: Nicotine is a highly addictive drug. edema. The decision is made to induce labor. Recommend cesarean section and obtain consent from patient D. Accompanying her is her mother and her boyfriend. the father of the baby. Recommend cesarean section and obtain consent from patient?s boyfriend C. Recommend cesarean section and obtain consent from patient?s mother B. and pitocin is infused intravenously. without accomplishing the goal of smoking cessation. she may well have other friends who also smoke. Suggest it is unlikely that the daughter will quit smoking unless her mother quits first B. and proteinuria. Prescriptions for nicotine replacement (e. Her uterine contraction pattern varies from 200-220 Montevideo units. however. including friends and unscrupulous merchants. Suggest that the daughter be forbidden to socialize with her best friend D. para 0 Caucasian girl at 36 weeks of gestation is admitted to the hospital immediately after developing severe hypertension. It is difficult to control the daughter?s actions while she is away from the house and family. What is the next best step in managing this girl?s care? A. the patient?s cervix remains at four centimeters. she should quit smoking herself. She is accompanied by her distraught mother. She may secretly continue to see her best friend and smoke cigarettes. the patient?s cervix dilates to four centimeters. including friends and family who continue to smoke. In addressing this issue. (Choices D and E) Placing the responsibility onto another adult is inappropriate. Even if the daughter were to stop spending time with this particular friend. (Choice C) Forbidding the daughter to socialize with her best friend may backfire and strain the daughter?s relationship with her mother. She complains of headache and nausea. the daughter may still continue to smoke by obtaining cigarettes from other avenues. Parents who want their children to stop smoking should quit themselves. Numerous factors may elicit the urge to smoke. the daughter now regularly takes cigarettes from her mother?s purse to smoke with a best friend at school. It is extremely difficult for even the highly motivated to stop smoking. If the mother is concerned about the issue of her daughter?s smoking. After another two hours. nicotine patch. Apparently. Educational Objective: Smoking cessation is difficult to accomplish if the smoker remains subject to environmental triggers..

substance use. Which of the following is the best treatment option for this patient? A. She hit her head over the steering wheel. including pregnancy. Educational Objective: Expectant teenage mothers are legally entitled to give consent for procedures related to the management of their pregnancies. However. Her current medications are warfarin. The patient?s boyfriend (Choice B) does not have any legal authority in this circumstance and should not be consulted. since this patient's cervix has not dilated beyond four centimeters in the past two hours. No focal neurologic deficit is evident on physical examination. 75% of people answered this question correctly. a condition occurring after 20 weeks of gestation that is characterized by hypertension. contraception. and proteinuria. Her hemoglobin is 11. including the performing of cesarean sections. and had two episodes of vomiting in the ambulance. Her most recent INR value was 2. Her past medical history is significant for chronic atrial fibrillation and hypertension. D. Therefore. Infuse fresh frozen plasma. Since this girl is at 36 weeks of gestation. the appropriate management of this situation entails recommending a cesarean section and seeking consent from the patient (Choice C). She is complaining of a severe headache. In this life-threatening situation. edema. The hospital ethics committee (Choice D) does not need to be consulted in this case because consent can be obtained from the appropriate individual. her blood pressure is 160/100 mmHg. her fetus should be sufficiently mature to warrant delivery. Those women who develop severe preeclampsia should be delivered once they reach 32-34 weeks of gestation. Continue warfarin and provide routine care. most states have legislated that a physician can provide care for adolescents without parental consent when it comes to certain issues. sexually transmitted diseases. Head CT scan findings are consistent with subarachnoid hemorrhage.The girl in this question is suffering from preeclampsia. Her coagulation status should be improved as quickly as possible. it is important to implement immediate measures to stop the hemorrhage. and emotional illness. Case 144 A 63-year-old Caucasian female is brought to the emergency department after a car accident. Her heart rate is 70/min. enalapril and metoprolol. vaginal delivery is normally successful and results in a good outcome for both mother and child. In such circumstances. but did not lose consciousness. Failure to progress is an indication to perform a cesarean section.6 gm/dL. E. Stop warfarin and provide routine care. she is diagnosed with a failure to progress. irregular.1. but oriented to place and time. Administer parenteral vitamin K . Consider whole blood transfusion. She is lethargic. Fresh frozen . C. B. Increasing the Pitocin and re-evaluating the cervix in one hour (Choice E) does not address the key issue of the girl?s failure to progress. The patient?s mother (Choice A) would need to give consent for surgical procedures unrelated to this pregnancy. Although this girl is a minor at age 16. Explanation: This patient presents with traumatic subarachnoid hemorrhage associated with chronic intake of warfarin.

it was a common belief that Alzheimer?s and multi-infarct dementia damage cortical and subcortical inhibitory structures. (Choice B) Urinary incontinence has a strong epidemiologic association with dementia. (Choice B) Although warfarin is an antagonist of vitamin K. He also has frequency. Careful assessment of an individual patient and revealing predisposing urinary tract and non-urinary tract conditions are important because many of these conditions may be treatable. (Choice C) Simply discontinuing warfarin will not rapidly and adequately correct the coagulation abnormality. Mild pressure on the abdomen results in urine dripping. Physical examination reveals an enlarged rubbery prostate. Urinary incontinence associated with dementia is untreatable Explanation: Dementia-associated urinary incontinence is a multi-factorial disorder that may not be etiologically related to dementia itself. 46% of people answered this question correctly. Enlarged prostate seems to be the main cause of this patient?s condition E. careful assessment of an individual patient and revealing predisposing urinary tract and non-urinary tract conditions are important because many of these conditions may be treatable. several studies have proven that even severely demented patients may stay continent. Therefore. and terminal dribbling while voiding. Which of the following is the best statement about this patient?s condition? A. Bladder atony results from the damage of subcortical structures D. In this case.plasma infusion is the best therapeutic choice because it rapidly provides the necessary clotting factors for coagulation to proceed. Educational Objective: Life-threatening hemorrhage in patients on warfarin therapy should be treated with fresh frozen plasma transfusion. thereby causing an uninhibited bladder and creating a pathophysiological basis for urinary incontinence. supplementation of the vitamin will not work quickly because it takes some time for clotting factors to be synthesized in the liver. however. (Choice C) Until recently. overflow incontinence due to bladder outflow obstruction is likely. hesitancy. (Choice E) There is no indication for whole blood transfusion in this patient. (Choice A) The presence of urinary incontinence does not always imply that NPH is present. Urinary incontinence indicates that normal pressure hydrocephalus (NPH) is present B. . No epidemiologic association is present between dementia and urinary incontinence C. because urinary incontinence is also strongly associated with other types of dementia. Educational Objective: Dementia-associated urinary incontinence is a multi-factorial disorder that may not be etiologically related to dementia itself. Case 145 A 70-year-old man with moderately severe dementia who is placed in a nursing home is noted to soil his bed with urine.

conjunctival hyperemia. Other common pathogens include Streptococcus. and Pseudomonas. Other common pathogens include Streptococcus. Staphylococcus C. sphagnum moss. erythromycin. Pseudomonas (Choice A) is a common cause of bacterial infection in contact lens wearers. Sporothrix E. The eye began to water profusely and he was unable to open it sufficiently to examine the cornea.. and corneal abrasion. and Pseudomonas.g. It typically manifests as nodules on the skin that ulcerate and are slow to heal. irrigation with saline was successful in removing all debris. Studies have shown that the most common pathogen isolated from these cultures is coagulase negative Staphylococcus (Choice B). Neisseria gonorrhoeae (Choice C) can penetrate intact corneal epithelium and cause bacterial keratitis. the treatment for all foreign-body associated corneal abrasions should include empiric broad-spectrum antibiotic eye drops or ointments (e.82% of people answered this question correctly. Neisseria D. ofloxacin). This is one of many possible manifestations of gonorrheal infection resulting from sexual transmission or passage through the birth canal. Immediately after he dropped the crate. Haemophilus. Candida Explanation: Although rarely sent for culture in practice. Pseudomonas B. Haemophilus. diffuse corneal inflammation. sulfacetamide. Physical examination of the left eye reveals edema of the upper eyelid. Candidal (Choice E) infection of the eye is most often found in immunosuppressed patients or those with chronic diseases of the ocular surface. he felt one or more small foreign objects enter his left eye. What organism is most commonly cultured from corneal foreign bodies? A. After a topical anesthetic was applied to the injured eye. corneal foreign bodies are known to frequently test positive for pathogens. or baled hay. Therefore. Earlier that afternoon he was working on his boat when he dropped a heavy metal crate onto the boat?s wooden deck. 46% of people answered this question correctly. Educational Objective: The most common pathogen isolated from cultures of corneal foreign bodies is coagulase negative Staphylococcus. ciprofloxacin. . Case 146 A 35-year-old Caucasian male with no significant past medical history presents to the emergency department complaining of severe pain in his left eye. He states that he does not wear contact lenses. Sporotrichosis (Choice D) is a fungal infection most often found in persons handling thorny plants.

On auscultation of the heart. an early. and decreases with Valsalva) is characteristic of mitral regurgitation. a decreased first heart sound. this patient does not have evidence of ischemia in the EKG. however. there is no evidence of left ventricular hypertrophy in the electrocardiogram or the chest xray. increases with the grip maneuver. Pulmonary embolism D. non-tender and non-distended. there are no signs of ischemia or ventricular hypertrophy. The four common causes of acute heart failure are papillary muscle rupture. He has no other medical problems. The initial EKG shows sinus tachycardia with occasional premature ventricular complexes. radiates to the axilla. (Choice D) The patient does not have fever or risk factors for bacterial endocarditis. The neurologic examination reveals no abnormalities. the second heart sound is normal. His EKG findings reveal occasional premature ventricular complexes (PVC). Acute mitral regurgitation is usually characterized by a soft. and chest wall trauma with compromise of the valvular apparatus. He does not use tobacco. The abdomen is soft. His blood pressure is 110/60 mm Hg. in such a setting. alcohol or illicit drugs. infective endocarditis. (Choice A) Myocardial infarction can be complicated by acute mitral regurgitation when there is rupture of the papillary muscle. None of these are present here. Acute myocardial infarction B. (Choice C) Patients with pulmonary embolism can develop acute cor pulmonale. The above patient clearly has acute pulmonary edema. A fourth heart sound is also present. The diagnosis is confirmed by echocardiography. the EKG will show right axis deviation. rupture of chordae tendineae. Rupture of chordae tendineae C. radiating to the axilla. right bundle branch block or both. however. His pathologic murmur (systolic murmur that is heard in the apex. Due to the acute nature of this condition. the murmur decreases with Valsalva maneuver. His skin is velvety and has multiple scars. . cough or abdominal pain. Papillary muscle rupture Explanation: The patient presents with signs and symptoms of acute heart failure. Jugular venous distention and hepatojugular reflux are present. and the presence of a fourth heart sound. chills. (Choice E) Spontaneous papillary muscle rupture usually presents in elderly people who have acute chest pain or as a complication of myocardial infarction. pulse is 116/min and respirations are 28/min. He takes no medication and has no known drug allergies. He is in marked respiratory distress. and increases with the grip maneuver. which may lead to acute heart failure. decrescendo systolic murmur (can be early. The chest x-ray reveals no cardiomegaly. He had surgery for bilateral inguinal hernia when he was 16. He denies fever. The most common cause of isolated. but bilateral alveolar infiltrates and hilar prominence are present. There are bilateral crackles in both lungs. Pallor and diaphoresis are noted. systolic murmur at the cardiac apex is heard. Item 1 of 2 Which of the following is the most likely cause of his condition? A. Infective endocarditis E. severe acute mitral regurgitation in adults is rupture of chordae tendineae with or without associated myxomatous disease. midsystolic or holosystolic). decrescendo.Case 147 The following vignette applies to the next 2 items A 38-year-old healthy Caucasian man is brought to the emergency department because of sudden onset of shortness of breath and diaphoresis. The first sound is barely audible.

and is usually covered with multiple characteristic "cigarette-paper" scars. progressive mitral regurgitation. A more detailed physical examination reveals the presence of scoliosis and pes planus. Skin changes of thyrotoxicosis can be confounded with those found in EhlersDanlos. (Choice A) There is no evidence of ischemic heart disease. The differential diagnosis of this condition includes infective endocarditis. Educational Objective: Marfan or Ehlers-Danlos syndrome must be suspected in patients with connective tissue abnormalities and an acute mitral regurgitation secondary to chordae tendineae rupture. and mitral valve rupture secondary to trauma. 41% of people answered this question correctly. but other characteristic signs and symptoms are lacking. 46% of people answered this question correctly. (Choice C) Marfan syndrome can affect the valvular apparatus. high-output. due to its frailty and easy bruisability. loose joints or increased arm span. which are characteristic of Marfan syndrome. although a primary. the course of the disease is chronic. Rheumatic fever C. papillary muscle rupture secondary to ischemia. A past history of hernias and mitral valve prolapse is not uncommon. heart failure. leading to acute rupture of chordae tendineae. Case 148 . Ehlers-Danlos syndrome E. The presentation is usually chronic.Educational Objective: Rupture of chordae tendineae should be suspected in healthy individuals who develop flash pulmonary edema (heart failure) associated with an acute mitral regurgitation. Marfan syndrome D. The EKG shows no ischemic changes. Complete blood cell count and serum chemistry results are unremarkable. Item 2 of 2 The patient is feeling better after receiving the appropriate therapy. causing degeneration of the mitral and aortic valves. though not specific findings. Troponins and CK-MB are normal. acute regurgitation due to ruptured chordae tendineae. and the patients usually have evidence of left ventricular and atrial hypertrophy in the EKG. (Choice B) Rheumatic fever is a common cause of mitral regurgitation in young individuals. Coronary artery disease B. (Choice E) Thyrotoxicosis can lead to acute. however. Blood gas analysis reveals respiratory alkalosis. The patient is scheduled for echocardiography. but an etiology can be found in most occasions. however. The skin can be velvety or thin. This patient does not have arachnodactyly. Joint hypermobility and skin hyperextensibility ("rubber man syndrome") can be dramatic in severe cases. preexisting mitral valve prolapse (MVP) is the most common cause. The cardiac enzymes were negative. Thyrotoxicosis Explanation: The patient has features compatible with Ehlers-Danlos syndrome. Which of the following is the most probable diagnosis? A. and rarely. Pes planus and scoliosis are frequent. this will not explain the mitral regurgitation. This condition can cause a myxomatous degeneration of the mitral valve. Some cases may be idiopathic (individuals who experience rupture of the chordae tendineae without previous MVP or connective tissue disease).

she already noticed a small mole on her left cheek. Although this patient is asymptomatic. the primary care physician. Educational Objective: The most common cause of heart failure (CHF) is ischemic heart disease. C and D) Hypertension. Case 149 The following vignette applies to the next 2 items A healthy 24-year-old Japanese woman comes to the physician because of a lesion on her left cheek. Other known etiologies are: hypertension (13%). Her social history is not significant. Explanation: Ischemic heart disease is the most common cause of congestive heart failure (CHF). renovascular disease. but this lesion has recently grown in size. The next step in the management of this patient is to identify the etiology of his CHF. Two years ago. Vital signs are within normal limits. alcohol or cocaine abuse. Which of the following is the most appropriate next step in diagnosis? A. D. C. Item 1 of 2 Which of the following is the most likely diagnosis? A. The objective here is to quickly identify the presence of ischemia to address the need for coronary angiography (for possible revascularization). E. such as obstructive sleep apnea. and sleep apnea are less common causes of CHF. myocarditis. efforts must first be made to rule out the presence of coronary lesions which may be corrected by an angioplasty. Refer the patient for cardiac stress test. 53% of people answered this question correctly. Approximately 50 to 75% of the patients with heart failure (HF) have coronary disease as the etiology. etc. He currently has no complaints. and very rare causes. and advised a follow-up appointment with you. which ceased spontaneously three weeks ago. (Choices A. his echocardiogram results (cardiac dilatation and low ejection fraction) are very suggestive of CHF. Examination shows a 4 cm dark brown. A 2D-Echocardiogram is ordered. The ED doctor gave him a prescription for metoprolol. B. He takes no other medications. Refer the patient for polysomnography. Physical examination revealed no abnormalities. in the United States. a cardiac stress test should be done first. Refer the patient for ambulatory monitoring of blood pressure (AMBP). This is also true for BNP (b-natriuretic peptide). Refer the patient for renal artery Doppler ultrasound. renovascular disease. valvular disease (10-to12%). Troponins can be elevated in any type of heart failure or coronary ischemia. (Choice E) Troponin and BNP level determination is not useful in this setting. slightly elevated macule with slightly irregular borders on the left cheek. Pigmented basal cell carcinoma . EKG showed normal sinus rhythm. which revealed cardiac dilatation and an ejection fraction of 45%. She does not have any other complaints.A 64-year-old healthy male comes to your office after a local emergency department (ED) visit for an episode of paroxysmal atrial fibrillation. In a new case of CHF with unknown etiology. Other important causes of CHF are hypertension. Keratoacanthoma B. Check BNP (B-Natriuretic peptide) and troponins. especially dilated cardiomyopathy. Since ischemic heart disease is the most common etiology. valvular and renovascular disease. which is mainly used to distinguish cardiogenic pulmonary edema from primary pulmonary conditions.

D. firm. with a "warty" form. C. It can be confused with an atypical melanocytic nevus. Seborrheic keratosis D. round. Malignant melanoma E. Educational Objective: An excisional biopsy is the next best step in patients with a suspected malignant melanoma. B. Due to the significant amount of false negatives reported. and is a welldemarcated lesion. (Choice E) Interferon alfa-2b is used as an adjuvant therapy in patients with a high risk of developing metastatic disease. false negatives have been reported in 15% of the time. It appears as a solitary. however. skin-colored or reddish plaque that develops into a nodule with a central keratin plug. Explanation: The sensitivity of a melanoma diagnosis by a dermatologist based on the history and physical examination is approximately 85%. and usually more than 5 mm in diameter. and it rarely appears before the age of 40. Educational Objective: It is important to recognize the presence of a melanoma. Item 2 of 2 Which of the following is the most appropriate statement in this patient?s management? A. because excision can be curative if the lesion is identified early. Case 150 .C. (Choice A) Keratoacanthoma is common on the cheek. It is more frequent in males. 69% of people answered this question correctly. E. an excisional biopsy is essential for confirmation of the diagnosis and staging of the lesion. with color variegation. 86% of people answered this question correctly. however. An excisional biopsy is the next best step. (Choice C) Seborrheic keratosis is rare before the age of 30. Start therapy with interferon alfa-2b. A biopsy is not required since the clinical presentation is so classic. (Choice B) Basal cell carcinoma is usually pink or red in color. this disease is infrequent in the Asian population. Verruca vulgaris Explanation: Malignant melanoma is a concern if a nevus increases in size and develops irregular borders. These lesions can appear spontaneously or develop over a previously atypical nevus. Observation and repeat follow-up in six weeks. Melanoma lesions are usually asymmetric. Administer intralesional corticosteroids. It is a low-grade malignancy that pathologically resembles squamous cell carcinoma. (Choice E) Verruca vulgaris has the same warty appearance as seborrheic keratosis. It also has a "stuck on" appearance. Complete excision is the treatment of choice.

however. the patient's medication should be changed to PTU. . Radioactive iodine is contraindicated during pregnancy. (During pregnancy. Besides methimazole. does not use any form of contraception. She does not smoke or drink alcohol. and her total T4 is elevated. but usually normal in the majority of cases. (Choices C and D) Total T4 is elevated during pregnancy. thyroid binding globulin and total T4 are increased. (Choice A) Methimazole is known to cause a scalp defect (aplasia cutis) in the fetus. she does not take any other medications. She opted for treatment with antithyroid drugs instead of radioactive iodine ablation because she thought of becoming pregnant in the near future. Propylthiouracil is the drug of choice. 49% of people answered this question correctly. on the other hand. increasing methimazole is still not indicated because her TSH level is normal and she is euthyroid .35 mU/ml-5. Her prior menstrual cycles were regular. Increase the dose of methimazole B. She is sexually active. She is married and has no children. Physical examination is unremarkable. and propylthiouracil should be started. Check free T4 D.0 mU/ml) and total T4 of 15. Her mother has hypothyroidism. Even if the patient is not pregnant. It is very likely that she is pregnant. She has nausea. TSH is the most sensitive indicator of primary thyroid dysfunction. She complains of nausea for the past two weeks. Check total T3 E. Her last menstrual period was two months ago. Free T4. (Choice E) Continuing methimazole in the same dose is a reasonable option if the patient is not pregnant. free T4 and total T3 will not add to existing information.2 mg/dl (normal 4 to 12 mg/dl).7 mU/ml (normal 0. Her clinical symptoms have markedly improved after she started taking methimazole. and does not use any form of contraception. Educational Objective: Methimazole is discontinued during pregnancy because it is known to cause a scalp defect (aplasia cutis) in the fetus. and has missed her period. may be normal to high. She was diagnosed with Graves' disease approximately six months ago. Change to propylthiouracil C. She denies allergies to medications. since pregnancy is highly suspected in this case.) Methimazole should be discontinued. Aside from ordering a pregnancy test. what is the next best step in this patient?s management? A. Thyroid function tests performed five days before this visit revealed a TSH of 0. therefore.A 24-year-old female who is on methimazole 10 mg twice daily for the treatment of Graves' disease comes to your office for a follow-up. Continue same dose of methimazole Explanation: The patient is sexually active. Thyrotoxicosis during pregnancy can also be treated with a thyroidectomy during the second trimester (safest) if the patient is intolerant to propylthiouracil. but does not have any other symptoms.

intubation. Violation of patient?s living will directive against intubation C. and is on the 26th week of her first pregnancy. and malaise. however. The patient has no medical problems. Shortly after admission she develops respiratory distress that requires sedation. including an oncologist. In the days leading up to her admission she had complained of fever. She is asymptomatic and takes prenatal vitamins. Each physician meets separately with the patient?s adult children every day to discuss his assessment and treatment recommendations. the family members become increasingly irritable when discussing their mother?s health problems. pulmonologist. Poor nursing care D. it is crucial that they communicate regularly so that family members are provided with a clear and cohesive picture of the medical team? s assessment and plan. (81 kg). She denies any over-the-counter medication use. She lives with her husband and works as a research assistant in a pharmaceutical company. No mention was made of a living will. shortness of breath. There is no evidence that nursing care or the cost of hospital admission is of concern for the family members (Choices C and D). The patient?s condition moderately improves but all attempts to wean her from the ventilator fail. The rest of the . She is escorted by ambulance to the hospital. it is crucial that they communicate regularly about key treatment objectives and the preferred means of accomplishing those objectives. productive cough. malignant ascites. and ventilatory support. On physical examination. and her diuretic dosage is increased. When such communication is present.A 78-year-old Caucasian woman with a history of metastatic colon cancer. If such communication is absent. If multiple physicians are responsible for a patient?s medical care. Since the patient is sedated and there is no reference made to her experiencing any pain or discomfort since her arrival at the hospital. Lack of communication between physicians involved in patient care Explanation: The issues of greatest concern for families of patients with cancer include pain management and the establishment of excellent communication with the health professionals involved. and it is unlikely that the family members would express concern about intubation several days after it was performed (Choice B). Widespectrum intravenous antibiotics are begun to treat suspected pneumonia. As each day passes. Which of the following is most likely responsible for the family?s negative attitude? A. it is unlikely that her family feels her pain management is inadequate (Choice A). cardiologist. Responsible for her care are a number of specialists. where she is admitted to the intensive care unit. Concern that health care insurance will not cover cost of hospital admission E. all physicians involved are well equipped to provide family members with a clear and cohesive picture of the medical team?s assessment and plan. and congestive heart failure collapses at her son?s home. she is five feet (150 cm) tall and weighs 180 lbs. Inadequate pain management B. 80% of people answered this question correctly. family members are left feeling that care is being provided in a haphazard or ineffective fashion (Choice E). Her family history is positive for type-2 diabetes on her father's side. Educational Objective: If multiple physicians are responsible for a patient?s medical care. She does not smoke or drink. and critical care hospitalist. and finally accuse you of suggesting unnecessary procedures and treatments. The following Vignette applies to the next 2 items A 29-year-old female who emigrated from India about five years ago comes to your office for a routine visit.

. Her one-hour blood glucose level after ingesting 50-gm glucose is 160 mg/dL.examination is unremarkable.

59% of people answered this question correctly. Start NPH insulin E. and postprandial blood glucose should be less than 120 mg/dL. D. Start glimepiride C. Measure HBA1c. 165 and 145 mg/dL at 0. She checks her fasting and post-lunch blood glucose values daily. a diagnosis of gestational diabetes is made. The patient has a normal 50-gm glucose tolerance test. Two or more blood glucose values greater than 105. Start Glargine insulin Explanation: The recommended fasting blood glucose values in pregnant diabetic patients should range between 60-90 mg/dL. there is no need to repeat a glucose tolerance test. 190. and is not repeated once the results are abnormal. 2 and 3 hours. however. are diagnostic of gestational diabetes. Some workers have proposed lower cutoff values for the diagnosis of gestational diabetes. This patient should be . The American Diabetes Association is recommending the use of a 75-gm glucose tolerance test. its role in the diagnosis of diabetes is not very clear. Perform 75-gm oral glucose tolerance test with blood glucose measurements for 3 hours. Start metformin D. 1. Her weight gain and blood pressure during pregnancy are within normal limits. for use in non-pregnant women and for diagnosing gestational diabetes. Explanation: All pregnant patients are generally screened for gestational diabetes between the 24th and 28th weeks of pregnancy using the 50 gm glucose tolerance test. Normal values for blood glucose levels one hour after the ingestion of 50-gm glucose should be less than 140 mg/dL. On the third week of dietary restriction. with different cut-off values. Blood glucose levels are checked one hour after the ingestion of 50 gm of glucose. respectively. (Choice D) The patient is at a high risk for developing gestational diabetes since her screening 50-gm glucose tolerance test is abnormal. (Choice C) The 50-gm glucose tolerance test is used for screening. (Choice E) HbA1c is an excellent test for monitoring glycemic control.Item 1 of 2 What is the next best step in the management of this patient? A. Patients with blood glucose values of 140 mg/dL or higher should be subjected to a 3-hour glucose tolerance test after the ingestion of 100 gm of glucose on a fasting state. A diet and exercise regimen is started. Perform 100-gm glucose tolerance test with blood glucose measurements for 3 hours. Continue dietary restriction B. What is the most appropriate way to manage this patient? A. E. her fasting blood glucose values range from 90 and 110 mg/dL. Educational Objective: Understand the screening and diagnostic glucose tolerance test for gestational diabetes mellitus. Item 2 of 2 After the appropriate evaluation. This test does not require fasting. A 50-gm oral glucose challenge with blood glucose values of 140 mg/dL or higher is generally followed by a 100-gm oral glucose tolerance test with hourly blood glucose measurement for 3 hours. B. but she occasionally overeats. C. and her 2 hour post-lunch glucose values range from 120-140 mg/dL. Repeat 50-gm glucose tolerance test in 3 months. The patient says that she is usually compliant with her diet.

and donepezil. hyponatremia. cognitive and perceptual disturbances including memory loss. easy distractibility.. You know her very well from your recent nursing home visit. and Alzheimer?s dementia. This patient is an 82-year-old female who has been in the nursing home for the last two years. NPH in combination with regular or lispro insulin is generally recommended if diet and exercise are not able to adequately control the blood sugar. The factors that precipitate delirium include multiple medication use (polypharmacy). The nurse reports that one patient has been acting strangely for the last few hours and is agitated at times. The most common factors that increase the patient?s susceptibility to delirium include advanced age and an underlying brain disorder (i. urinary tract infections and pneumonia). It typically develops over hours to days. Her daily medications are amlodipine. Parkinson?s disease. and this acute onset distinguishes it from dementia. It manifests as a change in the level of awareness. or hypernatremia).. Delirium is extremely common in old nursing home patients. and postprandial blood glucose values should be less than 120 mg/dL. disorientation. Give diazepam for sedation E. Transfer the patient to a nearby hospital B. calcium vitamin D. The following Vignette applies to the next 3 items You are the current "on call physician" for your group. The use of glargine insulin is not considered safe during pregnancy. fluid and electrolyte disturbances (dehydration.e. The insulin dose and frequency is then adjusted. immobility (including the use of restraints). You are concerned that something is not right with the patient. Simply continuing the dietary restrictions will not control her blood glucose values. Give a dose of haloperidol C. diabetes mellitus. She has a past medical history of hypertension. malnutrition. Oral hypoglycemics are not indicated in pregnant patients. Ask the nurse to use physical restraints as necessary to prevent falls and injury Explanation: This patient is suffering from an acute confusional state. In fact. (Choice A) The patient?s glycemic control is suboptimal.e. and even agitation. delirium may be the only presenting complaint . Item 1 of 3 Which of the following is the most appropriate next step in the management of this patient? A. Dementia is a multifactorial disorder. when you receive a call regarding one of your nursing home patients. osteoporosis. and history of prior stroke). Educational Objective: The recommended fasting blood glucose values in pregnant diabetic patients should range between 60-90 mg/dL. (Choice E) Glargine is a long acting insulin. 25% of people answered this question correctly. and a wide variety of other medical conditions. (Choices B and C) Glimepiride and metformin are not used during pregnancy to obtain glycemic control. also known as delirium. infections (i. metformin.started on NPH insulin (usually as a single dose at bedtime). dementia. Ask the nurse to check vital signs and pulse oximetry D. depending upon her glycemic control. Rapid acting insulin (regular or lispro) may be added for persistent postprandial sub-optimal blood glucose levels. and is not indicated during pregnancy because of the teratogenic effects observed in experimental animals. The factors that increase the risk of delirium are subdivided into those that increase the susceptibility to delirium and those that precipitate delirium. and has always been very pleasant. use of bladder catheters.

especially the reversible causes.7 C (98 F). Constant observation. environmental. and she is now disoriented to place and person. Order a head CT scan E. virtually any acute medical condition can precipitate delirium in an older demented patient. What is the most appropriate next step in the management of her condition? A. therefore. and liver failure. therefore. Educational Objective: Delirium can be the only finding of an acute medical condition in older demented individuals. and should therefore be avoided. As described above. and she is having visual and auditory hallucinations.in an older demented patient suffering from an acute medical illness. (Choice E) As explained above. (Choices B and D) Misuse of antipsychotics and benzodiazepines is very common in managing behavioral problems in demented nursing home patients. (Choice A) Transferring this patient to a hospital may be necessary for further evaluation of the cause of the delirium. She arranged an ambulance to transfer the patient to a nearby hospital. (Choice E) Physical restraints should be used only as a last resort in an agitated and delirious patient. (Choices A and B) The use of psychotropic medications to calm this patient is not recommended at this time. Order a stat psychiatry consult C. Give haloperidol to calm the patient B. It is prudent to rule out the reversible medical causes of delirium before prescribing psychotropic medications or obtaining a psychiatric consultation. a head CT scan is not indicated at this point. They frequently increase confusion and agitation. it is important to rule out any medical. hypo/hypernatremia. Use of psychotropic medications as a first line therapy for behavioral problems is not recommended. infections. or psychosocial causes before prescribing any psychotropic medications. blood pressure is 116/78 mmHg. the use of physical restraints can precipitate and even worsen the delirium. 65% of people answered this question correctly. . In the hospital. Item 2 of 3 The nurse calls you back in tweny minutes. her physical examination is unremarkable. therefore. She states that she gave a dose of prn (as needed) medication which was ordered by a nursing physician before. (Choice D) There is no history of head trauma or any focal neurological signs and symptoms. hypercalcemia. this should not be the first step in the management of this patient. It leads to frequent adverse effects and worsening of the cognitive status. preferably by someone familiar to the patient. however. checking this patient? s vital signs should be the first step to rule out early infections and fluid and electrolyte disturbances. pulse rate is 76/min. is more helpful in such situations. hypoglycemia. and respiratory rate is 18/min. It is important to perform a complete physical examination and obtain basic laboratory studies to identify or rule out the potential causes of delirium. Her temperature is 36. She gets easily distracted. She is still agitated. Order physical restraints to prevent injury to patient and nursing staff Explanation: This patient is still exhibiting the classic signs and symptoms of delirium. Cognitive and perceptual disturbances including hallucinations are very common in delirious patients. uremia. which include: dehydration. Order urine analysis and complete metabolic panel D.

They frequently lead to worsening of confusion. Give low dose haloperidol B. They can be used as an adjunct to antipsychotics to reduce extrapyramidal side effects. (Choice D) Sitters are helpful in providing orientation and constant supervision for a confused patient. altered mental status. The sitter reports that the patient is very combative now. They are used when medications fail to act. physical examination and basic laboratory work-up should be performed early in the initial evaluation of delirium in any patient. and extrapyramidal symptoms. Frequent orientation and reassurance has not improved her behavior.Educational Objective: Focused history. (Choice E) Performing a lumbar puncture is only indicated if the patient has unexplained fever. and having constant supervision has not been successful in managing her disruptive behavior. These help prevent injuries and falls. Educational Objective: Physical and chemical restraints should be used judiciously in a combative and disruptive patient. She has been trying to get out of bed and has twice attempted to pull her IV line out. Perform lumbar puncture Explanation: The patient is exhibiting behavior that could harm herself and the healthcare staff. and allow for the continuation of medical therapy. You start the patient on empiric antibiotic therapy and intravenous fluids. orthostatic hypotension. Which of the following is the most appropriate next step in the management of this patient? A. however. Change in mental status alone is not an indication for lumbar puncture. Thus. Give low dose lorazepam C. the patient should be started at lower doses and the dose is then titrated upwards to achieve the desired effects. preventing harm. Order physical restraints to prevent injury anyway D. Low-dose haloperidol may be useful in controlling her symptoms. Once a patient becomes combative. other modalities including chemical and physical restraints are frequently necessary. orienting her to the environment. and allowing for the safe continuation of her treatment. Always give haloperidol (antipsychotics) before you apply restraints. Initial lab studies reveal the presence of a urinary tract infection with mild prerenal azotemia. and nuchal rigidity. Provide another sitter for the patient E. (Choice C) Physical restraints should be only used as a last resort in a combative patient. These include sedation. the patient?s mental status remains unchanged. . Item 3 of 3 A CT scan of the patient's head is normal. Initial supportive measures such as reassurance. anticholinergic side effects. 63% of people answered this question correctly. She resisted the physical restraints that the nurse was trying to apply. tardive dyskinesia. You provide a bedside sitter for the patient for constant supervision. (Choice B) Benzodiazepines have a more rapid onset of action. but these can worsen confusion and sedation. and the patient remains a significant threat to his/her and the healthcare staff's safety. Antipsychotics are associated with a variety of side effects.

out-of-hospital cardiac arrest two days ago. . and relies on full ventilator support. He was intubated and successfully resuscitated after a prolonged CPR in the field. The patient had an unwitnessed. He is unresponsive to verbal and tactile stimuli.56% of people answered this question correctly. His temperature is 37. he remains intubated. After a lengthy discussion with the patient?s family. and pulse is 70/min. blood pressure is 110/70 mmHg. The following Vignette applies to the next 2 items You are taking care of a 65-year-old male patient in the intensive care unit.2 C (99 F). Two days later. you all agree to have the patient's life-sustaining support withdrawn.

One relative then walks into the patient?s room and notices some movements in the patient's legs. (Choice A) The presence of limb movements is not inconsistent with the diagnosis of brain death . Absence of respiratory drive (apnea) off the ventilator for a duration that is sufficient to produce hypercarbic drive (usually 10 to 20 minutes to achieve pCO2 of 50 to 60 mmHg) (Choice A). corneal. EEG with nonspecific waveforms D. Educational Objective: . gag. Arrange for further testing to confirm your diagnosis C. 4. Irreversible absence of cerebral and brainstem reflexes Explanation: Brain death is defined as the cessation of cerebral and brain stem function. gag. Explaining this in a calm manner should be the appropriate response to dissipate the anger and anxiety among the family members. (Choices B and C) Any further testing or consultations based on limb movements alone is not indicated if the criteria for brain death have been fulfilled earlier. 2. Tell the family that leg movements are inconsistent with the diagnosis of brain death B. swallowing. plantar reflexes. Obtain a neurology consultation D. Item 2 of 2 Using the above criteria. Body temperature above 34 C (93. Purely spinal reflexes. sucking. Tell the family that the relative is probably hallucinating E. corneal. Some of the other criteria for determination of brain death include: 1. Everyone in the family appears to understand the situation and agrees to proceed with the withdrawal of ventilatory support. and extensor posturing. A person is considered legally dead in the United States when criteria for brain death have been demonstrated. EEG isoelectric for 30 minutes at maximal gain (Choice C). you are able to document that the patient is brain dead. 5.2 F) (Choice B). You discuss these findings with his family and recommend that mechanical ventilator support be withdrawn. Explain calmly that limb movements can be seen normally even in a brain dead person Explanation: Brain death is defined as the irreversible absence of cerebral and brainstem reflexes including pupillary. oculocephalic. Which of the following is the most appropriate response to the relative?s reaction at this time? A.Item 1 of 2 Which of the following will you document to determine that the patient meets the criteria for brain death? A. including tendon reflexes. oculovestibular (caloric). oculovestibular (caloric). One of the criteria to determine brain death is the irreversible absence of cerebral and brainstem reflexes including pupillary. He gets angry with you and claims that the patient is not dead. 68% of people answered this question correctly. Absence of respiratory drive for 5 minutes off the ventilator B. swallowing. Absence of cerebral circulation by Doppler or magnetic resonance angiography (Choice D). oculocephalic. Intermittent cerebral circulation on cerebral doppler scanning E. There are no spontaneous breaths regardless of hypercarbia or hypoxemia. 3. Body temperature below 35 C C. and extensor posturing. At least 24 hours of observation in adults with anoxic-ischemic brain damage with a negative drug screen Educational Objective: Brain death is the irreversible absence of all cerebral and brainstem reflexes. and limb movements to painful stimuli can be present in these patients. sucking.

Intravenous cefoxitin and intravenous doxycycline C. as well as nausea and vomiting. For this reason. 46% of people answered this question correctly. Intravenous ceftriaxone and intravenous metronidazole Explanation: This patient has acute pelvic inflammatory disease (PID). Oral azithromycin and intravenous doxycycline D. If a tubo-ovarian abscess is diagnosed. Which of the following is the most appropriate pharmacotherapy? A. . Her temperature is 38.000/cmm Segmented neutrophils: 80% Bands: 7% Eosinophils: 0% Lymphocytes: 12% Monocytes: 1% The urinalysis results are unremarkable. and frequency for the past five days. blood pressure is 120/70 mmHg. There is no splenomegaly and no costovertebral angle tenderness. There is no rebound tenderness or rigidity. Educational Objective: Treatment of severe PID is aimed at obtaining high blood concentrations of the antibiotics as soon as possible. alcohol. Test of the stool for occult blood is negative. She is sexually active and uses oral contraception. She does not use tobacco. tender.9 C (102 F). and nondistended. Her last menstrual period was one week ago. and respirations are 14/min. as well as tenderness on lateralization of the cervix. C. She vomited twice today. pulse is 100/min. A healthy. chills. yellowish vaginal discharge is noted. 78% of people answered this question correctly. 31-year-old African-American woman is brought to the emergency department because of fever. indicates that the infection is severe. leukocytosis. but should not be accompanied by metronidazole. or drugs. The presence of fever.It is not unusual to see purely spinal reflexes manifesting as isolated limb movements in a brain dead person. and D) Intramuscular ceftriaxone. Gynecologic exam revealed some fullness and tenderness on palpation of both adnexa. oral azithromycin or oral doxycycline can be used if there is mild or moderate infection. Combinations that can be used are: cefoxitin + doxycycline or ceftriaxone + doxycycline.6 g/dL Ht: 38% MCV: 90 fl Leukocyte count: 15. PID can be a serious condition that needs to be treated immediately. Intravenous administration of cefoxitin and doxycycline is the best combination of all the given options. but not in this case. Intravenous amikacin and intramuscular ceftriaxone B. A mild. She has abdominal pain and tenderness on palpation of the adnexae and lateralization of the cervix. There is no tenderness to palpation of the lower back. Her symptoms are progressively getting worse. all therapy should be intravenous. The abdomen is soft. (Choices A. bandemia. abdominal pain. chills. surgical evaluation is immediately needed. The patient?s laboratory tests reveal: CBC Hb: 12. She has no known drug allergies. (Choice E) Intravenous ceftriaxone is a good choice. Oral doxycycline and intramuscular ceftriaxone E. Bowel sounds are increased.

but the difference between the two groups in the occurrence of this side effect was not statistically significant (p = 0. because the side effect can occur in susceptible individuals relatively early after starting the therapy. mid-thoracic back pain. Observer?s bias Explanation: Power is the probability to detect a difference in the outcome of interest between two groups. A bigger sample size will increase the power of the study. Inappropriate selection of the patients D. the results are not statistically significant. acute myositis was reported in several small clinical trials of the drug. (Choice B) Increasing the follow-up period may not increase the power. Ascertainment bias B. The rest of the physical examination is unremarkable. is unremarkable. in this study. and the p value will reach statistical significance. the p value is marginal approaching.09). (Choice C) No information is given on how the patients were selected for the study. A 26-year-old white female presents ten weeks after delivery with acute. Her family history is unremarkable. What is the next best step in the management of this patient? A. and long follow-up would not increase the number of events. (Choice A) Diagnosing severe acute myositis is not a big clinical challenge using appropriate diagnostic techniques.A randomized. 37% of people answered this question correctly. double-blinded clinical trial was conducted to evaluate the effect of a new hypolipidemic drug on the survival of patients after PTCA. 1000 patients undergoing PTCA were randomly assigned to the drug or placebo group. if such a difference exists. Her past medical history. Educational Objective: Power is the ability to detect a difference in the outcome of interest between two groups. but not reaching statistical significance. and 25-hydroxyvitamin D levels are normal. The same side effect was reported in several small clinical trials of this drug. (the ability to detect the difference). Xray of the thoracic spine revealed a compression fracture of the T8 vertebra. Double the dose of calcium and vitamin D B. Short follow-up period C. Her pregnancy was complicated by extensive deep venous thrombosis (DVT). Severe acute myositis was reported as a rare side effect of the drug therapy. phosphorus. She has not had any menstrual periods since her delivery. The serum calcium. for which she was on subcutaneous heparin for the last 20 weeks of her pregnancy. (Choice E) Double-blinding techniques decrease the potential for observer?s bias. Check serum PTH levels . Interestingly. She takes a daily supplement of 1200 mg of elemental calcium and 800 international units of vitamin D. The two groups were then followed for three years for the development of acute coronary syndromes. Well-organized clinical trials have little potential for ascertainment bias for such events. 500 patients were in each group. Which of the following is the most likely cause for the failure to detect a significant statistical difference in the occurrence of acute myositis between the treatment and placebo groups? A. if such a difference exists. Small sample size E. Tenderness over the mid-thoracic spine is noted. She is currently breast-feeding her baby. aside from her history of DVT. Increasing the sample size increases the power of a study. Because this side effect is rare and few patients experienced it.

Checking the serum PTH level is not indicated. but no other lesions. Discontinue breast-feeding E. Start on hormone replacement therapy D. This patient presents with an exaggerated bone loss. temperature is 37. coronary artery disease. The reasons for the improvement of bone density after cessation of breast-feeding are decreased calcium loss and decrease in the levels of parathyroid hormone related peptide (PTHrP). His blood pressure is 130/80 mmHg. Bone mineral density can also be significantly reduced by long-term heparin use. (Choice A) Unfortunately. Nasogastric tube aspiration showed a clear aspirate. hypercholesterolemia. and its levels are increased during nursing. The patient appears to be vitamin D sufficient. He has hypertension. 8% of people answered this question correctly. increasing the dose of vitamin D will not be helpful. which of the following is the most likely diagnosis? A. Educational Objective: Some patients during the postpartum state may lose significant bone mass. (Choice C) As the patient has a history of DVT.C. An upright abdominal x-ray showed no free air. Acute diverticulitis D. (Choice B) The patient has normal serum calcium and phosphorus levels. Increased levels of PTHrP can cause increased bone resorption. and respirations are 16/min. but most will regain all this lost mass afterwards. Acute ischemic colitis C. Discontinuation of breast-feeding in the postpartum state has been shown to preserve or improve bone mineral density. Pseudomembranous colitis E. hypercholesterolemia. increasing calcium intake has not been shown to be effective in the restoration of bone loss during the postpartum period. The patient describes the pain as severe and predominantly at the left upper quadrant. Discontinuation of breast-feeding helps prevent further loss of bone mass in these patients. and her clinical features are not suggestive of hyperparathyroidism. but edematous and dilated transverse colon was seen. The diarrhea started a few hours after developing the abdominal pain. An 80-year-old white male with a history of hypertension. Based on the above presentation. PTHrP is possibly important for calcium transfer into the breast milk. and will most likely be helpful in this patient. which can be explained by the combined effects of heparin use during pregnancy and increased bone loss during the postpartum state. His initial labs showed slightly elevated amylase levels. Acute pancreatitis B. hormone replacement therapy is contraindicated. and is not indicated as the next best step. The most . and coronary artery disease suggestive of atherosclerotic disease. predisposing them to fragility fractures. pulse rate is 98/minute. Gastric ulcer Explanation: This patient has all the risk factors for acute ischemic colitis. therefore. (Choice E) Alendronate has not been adequately studied in premenopausal patients with bone loss. and coronary artery bypass graft comes to the emergency department because of a two-day history of abdominal pain and bloody diarrhea. Sigmoidoscopy showed mucosal edema. Acute ischemic colitis typically presents with abdominal pain followed by bloody diarrhea. Start alendronate Explanation: Normal females can lose up to 4-6% of their bone mass during the first 4-6 months of the postpartum period.2?C (98?F).

produce (Choice A) Enalapril can decrease renal and retinal damage. Educational Objective: Acute ischemic colitis is seen in patients who have evidence of atherosclerotic disease. especially in diabetic patients. which include the splenic flexure and rectosigmoid junction. Alpha-1-blockers are also used in diabetic patients because they increase insulin sensitivity. fever. (Choice D) Pseudomembranous colitis is usually seen in elderly patients who reside in nursing homes and other long-term care facilities. Educational Objective: . Stop ipratropium bromide E. and an elevated white count. a beta-blocker. They can have an elevated white count. prazosin. (Choice D) Stopping ipratropium bromide will probably improve the prostatic symptoms. Patients usually have an elevated white count. Acute pancreatitis does not usually cause bloody diarrhea. He does not use alcohol or drugs. Which of the following is the most appropriate pharmacotherapy? A. (Choice B) Amlodipine will only help in the blood pressure control of this patient. and nonbloody diarrhea. upper GI bleeding can present with severe bloody diarrhea. and moderately enlarged prostate. but will not be of any benefit to the blood pressure control and COPD management of this patient. nasogastric tube aspiration will reveal either blood or coffee-ground aspirate. and is usually manifested by acute abdominal pain followed by bloody diarrhea. (Choice B) Metoprolol. but does not improve prostatic symptoms. Add metoprolol C. His blood pressure is 160/90 mmHg. smooth. fever. His medications include hydrochlorothiazide. Add amlodipine D. detection. most of the times. decrease LDL. and increase HDL cholesterol. Amylase can be elevated in various conditions. bronchoconstriction. which could cause damage to the bowel wall.vulnerable areas are watershed areas. Prior history of antibiotic use is also present in majority of the patients. Patients usually present with abdominal pain. and treatment of high blood pressure (JNC VII) states that alpha-1-blockers (i. Add prazosin Explanation: The seventh report of the Joint National Committee on prevention. hypercholesterolemia. can worsen prostatic symptomatology. lovastatin. (Choice C) Acute diverticulitis usually presents with left lower quadrant abdominal pain. decrease insulin sensitivity. terazosin) are indicated for the management of patients with both hypertension and benign prostatic hypertrophy (BPH). (Choice A) Acute pancreatitis is very unlikely to cause bloody diarrhea.e. and ipratropium metered-dose inhaler. however. Add enalapril B. A 62-year-old Chinese-American man comes to the physician for a general medical evaluation. X-rays and sigmoidoscopies usually show mucosal edema and mucosal ulcerations. Evidence of diverticula is almost always found on sigmoidoscopy. and chronic obstructive pulmonary disease (COPD). Rectal examination shows a diffuse. He quit smoking a few years ago when he was diagnosed with COPD. and mask hypoglycemic symptoms. (Choice E) In 10-15% of the patients. 84% of people answered this question correctly. His other medical problems include hypertension. Stool Clostridium difficile toxin assay is positive. evaluation. He has been having intermittent urinary frequency for the past two months.

The study showed that the use of the pain reliever during pregnancy increases the risk of a neural tube defect. Observer bias E.03. although this is not always possible and durable protection is reached in less than 50% of patients. He has been meeting all the developmental milestones appropriately. Confounding . A study was conducted to assess the relationship between the use of an over-the-counter pain reliever during pregnancy and the development of a neural tube defect in the offspring. The odds ratio (OR) is 1. therefore. Varicella vaccine can be administered and the child monitored for the appearance of a rash. The child had an upper respiratory infection and otitis media one month ago that was treated with antibiotics and subsided quickly. Varicella vaccine should not be administered to this patient. D. 31% of people answered this question correctly. A 14-month-old Caucasian boy is brought to your office for routine check-up. Otherwise.5. E. his past medical history is insignificant. p is 0. except for some cases when post-vaccination rash appears. B. 89% of people answered this question correctly. It is advisable for all patients to receive pre-transplantation immunization. Selection bias B. All his vaccinations are up-to-date. Educational Objective: Varicella vaccination of household contacts of transplant recipients is relatively safe and is currently recommended. Alpha-1 blockers are also beneficial in patients with type-2 diabetes mellitus because they increase insulin sensitivity. this child should be monitored for the appearance of a rash and isolated if a rash appears (Choice D). Which of the following is the best statement concerning varicella vaccination in this patient? A. His older sister was diagnosed with polycystic kidneys.The seventh JNC report recognizes BPH as a clear indication for alpha-1-blocker use in hypertension management. Transmission of vaccine-associated VZV is not typical. Mothers whose children have neural tube defects. Which should be the major concern while interpreting the results of this study? A. and increase HDL cholesterol. Explanation: Varicella vaccination of household contacts of transplant recipients is relatively safe and is currently recommended by the American Association of Pediatrics (AAP). were interviewed using a standard questionnaire. family history of congenital abnormalities. He does not have any known allergies. (Choice A) The varicella vaccine is a live virus vaccine. Varicella vaccine should be administered with varicella immune globulin (VZIG). Recall bias D. and serum folate levels. unless the patient has congestive heart failure or develops persistent dizziness. Varicella vaccine is a killed vaccine and can be safely administered. even after adjusting for race. infantile type and underwent kidney transplantation two months ago. as well as age-matched controls (mothers whose children do not have such abnormalities). (Choice E) Varicella immune globulin should be administered to varicella seronegative transplant recipients exposed to varicella or zoster. decrease LDL cholesterol. C. other medication use. Interviewer bias C. Varicella vaccine can be administered and the child isolated for several weeks.

Explanation: Recall bias should always be considered as a potential problem in case-control studies because it can cause an overestimation of the effect of an exposure. (Choice D) Observer bias results in misclassification of the outcome (e. In this scenario. diagnosis of the congenital abnormality was made at birth. the women whose children have neural tube defects are more likely to report use of the drug than the women whose children are healthy. there is little potential for observer bias. This over-report is generally due to psychological trauma induced by the birth of the baby with a congenital abnormality and the search for potential explanations of the problem.g. labeling a healthy baby as having an abnormality and vice versa). Educational Objective: Recall bias is a potential problem in case-control studies. (Choice E) Two techniques were used to control the potential confounders in this study: matching and adjustment during the data analysis. It is explained by the knowledge of the exposure status of the patients by the physician who makes the diagnosis.. 57% of people answered this question correctly. therefore. (Choice B) Using a standard questionnaire minimizes the potential for interviewer bias. Other typical scenarios that may illustrate recall bias are: women whose husbands are diagnosed with lung cancer tend to over-report the number of the cigarettes smoked daily by the patient. . patients with melanoma tend to over-report low tanning ability. (Choice A) No information is given on how the patients were selected for the study. It results in over-reporting of the exposure by the cases. In this scenario.

Ultrasonogram of the abdomen shows multiple cysts in both kidneys. ACE inhibitors are considered as the drugs of choice for controlling hypertension and preventing progression of renal failure in these patients. male sex. In this case. He has mild hypertension. since his blood pressure is controlled with diuretics. Colonic diverticula . The ideal goal for blood pressure control in any patient with chronic kidney disease. including ADPKD. if a patient presents with acute abdominal pain. *Extremely important question for USMLE step-3 37% of people answered this question correctly. and accounts for 10% of ESRD patients in the United States. imaging is performed to differentiate acute urinary obstruction (by clot or stone) from hemorrhage into a cyst. Splenic cysts B. A diagnosis of autosomal dominant polycystic kidney disease (ADPKD) is made. Physical examination shows palpable kidneys. (Choice B) The ideal goal for blood pressure control in any patient with chronic kidney disease. Yearly CT scan of the abdomen E. is less than 130/80mm Hg. all he requires are regular follow-up visits to ensure that his blood pressure is maintained within normal limits. including ADPKD. (Choice E) Approximately 10% of patients with ADPKD have intracranial berry aneurysms. early age of diagnosis. Item 2 of 3 What is the most common extrarenal manifestation of ADPKD? A. (Choice C & D) Yearly CT scan and ultrasonography of the kidneys are not recommended. Regular blood pressure checks B. His BUN and serum creatinine levels are mildly elevated. MRI of brain with contrast Explanation: ADPKD has a prevalence rate of approximately 1:500. Poor prognostic factors for a rapid decline in renal function include severe hypertension. Educational Objective: Most patients with ADPKD have a progressive decline in renal function. which is being controlled with diuretics. Routine screening of these berry aneurysms is restricted to patients with a positive family history of subarachnoid hemorrhage. Keep diastolic blood pressure less than 95 mmHg C. and early development of renal dysfunction. Furthermore. and the course of this decline is variable.The following vignette applies to the next 3 items A 60-year-old male comes to your office for a regular physical examination. The risk for cardiovascular and cerebrovascular events increase with a blood pressure over 140/90 mmHg. the patient is at low risk for progression of renal failure. Good blood pressure control is also helpful in preventing rupture of the berry aneurysm and subsequent intracranial bleeding. A progressive decline in renal function commonly occurs with this disease. Item 1 of 3 What is the ideal follow-up plan for this patient? A. A diastolic blood pressure less than 95 mmHg appears to be suboptimal. is less than 130/80mm Hg. However. Yearly ultrasonography of the kidneys D.

C. Hepatic cysts D. Hypertension E. Cyst formation in brain Explanation: The most common extrarenal manifestation of ADPKD is hepatic cysts. Their incidence increases in the second through fifth decades of life; by 50 years of age, approximately 70-80% of patients with ADPKD will have hepatic cysts. Females occasionally develop massive enlargement of these cysts. (Choices A and C) Splenic cysts can be found in patients with ADPKD. Other locations where cysts could be present are the pancreas and ovaries. However, these cysts are less common extrarenal manifestations of ADPKD. (Choice B) Patients with ADPKD also have an increased incidence of diverticular disease; however, these usually develop in patients who are undergoing dialysis secondary to end stage renal disease (ESRD). Patients with ADPKD have a higher risk of rupture of the colonic diverticula, when compared to other patients with colonic diverticula. (Choice D) Hypertension is not an extrarenal manifestation of ADPKD. Hypertension is caused by compression of the intrarenal vasculature, thereby leading to renal ischemia and subsequent activation of the renin-angiotensin system. (Choice E) Although berry aneurysms have an increased frequency (10-15%) in patients with ADPKD, cyst formation in the brain is rare. Educational Objective: The most common extrarenal manifestation of ADPKD is hepatic cysts. A higher incidence of colonic diverticula is seen in ESRD patients who are on dialysis. Hypertension is not an extrarenal manifestation of ADPKD. Although berry aneurysms are common (present in approximately10-15% of patients), cyst formation in the brain is rare. *Extremely important question for USMLE step-3; 26% of people answered this question correctly. Item 3 of 3 After learning about the patient's disease, the family members become concerned and request that they be screened for possible kidney disease. Which of the following is the most appropriate next step? A. Regular blood pressure check B. Ultrasonogram of the abdomen C. CT scan of the abdomen D. Yearly measurement of BUN and serum creatinine E. Genetic studies for PKD1 and PKD2 Explanation: Ultrasonography is the most cost-effective screening procedure for asymptomatic family members of a patient with ADPKD. The presence of at least three to five cysts in each kidney is required to make a diagnosis of ADPKD. (Choice C) Although computed tomography (CT) scan is more sensitive than ultrasonography in the detection of small cysts, it is not used for screening purposes due to its high cost.

(Choice E) Genetic linkage analysis is available for the diagnosis of ADPKD; however, it is reserved for cases wherein the ultrasound is negative and the need for definitive diagnosis is critical (e.g., screening an individual who is a potential renal transplant donor). Educational Objective: Ultrasonography is the procedure of choice for screening the asymptomatic family members of a patient with ADPKD. *Extremely important question for USMLE step-3 49% of people answered this question correctly. A 79-year-old Caucasian female is brought to the emergency department (ED) by her daughter because of bloody stools. For the past three days, the patient had been occasionally passing blood with her stools, but this morning, she completely filled up the toilet bowl with bloody stools. She denies any associated symptoms such as nausea, vomiting or abdominal pain. Her temperature is 36.7C (98F), heart rate is 92/min, blood pressure is 106/62 mmHg, and respiratory rate is 16/min. She appears very pale. Her general physical examination, including her abdominal examination, is unremarkable. Rectal examination revealed bright red blood in the rectal vault; there is no tenderness. As you are walking out of the room, she has another episode of large amount of bleeding per rectum. You start the patient on generous intravenous fluids and send out blood samples for laboratory evaluation. Which of the following is the most appropriate next step in the management of this patient? A. Start the patient on intravenous infusion of vasopressin B. Start the patient on octreotide C. Refer the patient for urgent colectomy D. Obtain a radionuclide scan E. Obtain a stat barium enema Explanation: The patient is most likely suffering from lower GI bleeding, which is defined as gastrointestinal blood loss from a site distal to the ligament of Treitz. Although rare, upper GI bleeding in the form of a briskly bleeding peptic ulcer can also present as bright red blood per rectum. Regardless of the origin, the initial management of acute GI blood loss is hemodynamic stabilization. This includes rapid establishment of intravenous access and administration of generous amounts of intravenous fluids. The next step is to search for the cause of bleeding to institute specific therapy. An urgent colonoscopy is the initial procedure of choice due to its diagnostic and therapeutic advantages. If a colonoscopy is unavailable or if there is poor visualization due to active bleeding in the colon, radionuclide imaging with technetium-99 labeled autologous red blood cells is the next procedure of choice for localizing the bleeding site. Radionuclide scan requires that the rate of active bleeding be 0.1 to 0.5 mL/min. It is more sensitive than angiography, but only localizes the bleeding to an area of the abdomen. (Choice A) Intraarterial infusion of vasopressin is mainly used to control the bleeding by intraarterial administration during an angiography, although it has also been used to control active variceal hemorrhage. Vasopressin causes constriction of the mesenteric blood vessels and reduces the blood flow to the bleeding site. Adverse effects are arrhythmias and ischemic damage to the organs, and there is a high incidence of recurrence of bleeding once the infusion is discontinued. (Choice B) Octreotide is a long-acting somatostatin analog that is used to control bleeding esophageal varices. (Choice C) Urgent colectomy is sometimes indicated in patients with life-threatening lower GI bleeding; however, all efforts should be made to localize the bleeding site prior to surgical intervention. Surgical treatment without prior localization of the bleeding site has been associated

with higher mortality rates, when compared to that of patients who undergo surgical treatment after the identification/localization of the bleeding site. (Choice E) Barium enema has no role in the localization of lower GI bleeding. It is an insensitive study for visualization of superficial mucosal lesions and makes subsequent colonoscopy difficult to perform. Educational Objective: Radionuclide scan with technetium-99 labeled red blood cells is a very sensitive study to localize active lower GI bleeding. 47% of people answered this question correctly.

A 36-year-old African American man with a medical history significant for hypertension and hypercholesterolemia presents to his primary care physician for an annual exam. He has no complaints at this time. His physical exam is significant for obesity (BMI=31.4). His current medications include verapamil and simvastatin. He mentions that his father recently died of prostate cancer at age 60. Because of this family history, the patient is now concerned about his own risk for developing prostate cancer. At what age would you commence prostate cancer screening in this patient? A. 40 B. 45 C. 50 D. 55 E. 60 Explanation: Men considered to be at high risk for developing prostate cancer are (1)African-Americans, and (2) those with two or more first-degree relatives with prostate cancer. Although this patient only has one first-degree relative with prostate cancer, his ethnic background places him at high risk for developing the disease. According to the American Cancer Society?s guidelines released in 2001, it is recommended that digital rectal exams and PSA testing be performed annually, beginning at age 45 in those men at high risk for developing prostate cancer, and at age 50 for those men not at high risk and with a life expectancy of at least 10 years (Choice C). (Choices A, D, and E) The American Cancer Society (ACS) guidelines recommend that men at high risk for developing prostate cancer be screened starting at age 45, not ages 40, 55, or 60. Educational Objective: Screening for prostate cancer should be started at age 45 in high-risk males (African-Americans and those with two or more first-degree relatives with the disease) and at age 50 in all other men. 18% of people answered this question correctly. The following vignette applies to the next 2 items A 60-year-old Caucasian man is admitted to the hospital with an episode of bacterial pneumonia. Upon review of his past medical history, you notice that he has had three recent admissions within the past seven months for bacterial pneumonia. All the episodes were successfully treated with intravenous antibiotics. Previous chest x-ray comparisons reveal that the infiltrate always occurs at the right middle lobe and leaves a persistent scar. The scar was not noted on the chest x-ray prior to the episodes of pneumonia. He has a 50-pack year history of smoking. He quit smoking 10 years ago. Item 1 of 2 Which of the following is the most likely cause of the patient's recurrent pneumonia? A. Tuberculosis B. Recurrent alveolar hemorrhage C. Endobronchial obstruction D. Congenital immunodeficiency disorder E. Recurrent pulmonary embolism Explanation: The patient in the above vignette has multiple/recurrent episodes of bacterial pneumonia, which respond to antibiotics. This is most likely due to a partial obstruction of the bronchus or a branch of the bronchus supplying the right middle lobe. The most likely cause of endobronchial obstruction in this elderly male with an extensive smoking history is bronchogenic carcinoma. A carcinoid tumor is

another cause of endobronchial obstruction, especially in younger and non-smoking patients. Endobronchial lesions cause compression of the airway lumen and prevent adequate clearance of secretions. This causes stasis of secretions and recurrent pneumonias, even after successful treatment of previous episodes. Other causes of nonresolving pneumonia or pulmonary infiltrates are bronchoalveolar cell carcinoma, lymphoma, eosinophilic pneumonia, bronchiolitis obliterans organizing pneumonia (BOOP), systemic vasculitis, pulmonary alveolar proteinosis, and drugs (amiodarone). (Choice A) Patients with tuberculosis usually do not respond to antibiotic therapy, unless there is a superimposed bacterial infection. They also present with symptoms of chronic tubercular infections, such as a chronic cough, weight loss and night sweats. (Choice B) Patients with recurrent alveolar hemorrhage usually present with recurrent episodes of hemoptysis. These episodes do not respond to antibiotic therapy. (Choice D) Acquired immunodeficiency (AIDS) is a possibility. immunodeficiency to present at this age. It is unusual for a congenital

(Choice E) Recurrent pulmonary embolism can rarely present as nonresolving pneumonia. Patients classically have symptoms of pleuritic chest pain with hypoxia and do not respond to antibiotics. Educational Objective: Recurrent pneumonia in an elderly smoker may be the first manifestation of bronchogenic carcinoma. 86% of people answered this question correctly. Item 2 of 2 Which of the following is the most useful test to confirm the diagnosis in this patient? A. Sputum for cytology and AFB staining B. Bronchoalveolar lavage for hemosiderin laden macrophages C. Flexible bronchoscopy D. Immunoglobulin levels E. High resolution CT scan Explanation: This patient would benefit the most from a flexible bronchoscopy for the confirmation of the diagnosis. Flexible bronchoscopy is a simple, invasive test that will definitely diagnose the cause of this patient's recurrent pneumonia, since it will enable the physician to visualize the actual endobronchial lesion, and take a tissue biopsy at the same time. It is relatively easy to perform, and has a low risk of complications, thus making it the procedure of choice for obtaining tissue samples and lavage fluid to confirm the diagnosis. It also has a better yield for diagnosing certain other infections, such as fungal infections or tuberculosis. (Choice A) Obtaining sputum samples for AFB staining and cytology has a low yield, and is not very helpful in patients suspected of having endobronchial obstruction. (Choice B) Hemosiderin laden macrophages are seen in diffuse alveolar hemorrhage syndromes (Wegner?s granulomatosis, Goodpasture?s syndrome and other systemic vasculitis). (Choice D) Checking for immunoglobulin deficiencies would not be helpful in this patient. (Choice E) High resolution CT scan (HRCT) can diagnose recurrent pulmonary embolism, and can also help in characterizing the persistent "scar" seen on chest x-ray. It will not provide a definite cause of the lesions and recurrent pneumonia.

Educational Objective: Flexible bronchoscopy is a primary diagnostic tool to evaluate patients with persistent or nonresolving pneumonia or pulmonary infiltrates (HRCT scan is an alternative, but it does not provide confirmatory information). *The best diagnostic test for endobronchial obstructive lesions is flexible bronchoscopy. If the question had asked for the next best step in management, then the answer would have been CT scan. 63% of people answered this question correctly.

Case reports indicate that the exposure to manganese in miners may lead to central nervous system damage, particularly Parkinson-like syndrome. A group of investigators wanted to investigate this problem further to define the potential association between the exposure and increased mortality in miners. They calculated standardized mortality ratio (SMR), which is equal to 1.75. Which of the following is the best statement concerning the result of the study? A. SMR is an unadjusted measure of the overall mortality. B. SMR is not generally applicable to occupational studies. C. The observed number of death is higher than expected. D. The crude rate of death is high. E. The effect of exposure seems to vary by age. Explanation: The standardized mortality ratio (SMR) represents an adjusted measure of the overall mortality (Choice A), and is typically used in occupational epidemiology (Choice B). Mortality is typically adjusted for age (less commonly for gender, race and other factors). The standard population is used for comparison. The SMR is calculated using the following formula: SMR = observed number of deaths/expected number of deaths The expected number of deaths is calculated using age-specific rates of death in the standard population (e.g. total US population). The observed number of deaths in the population of interest (e.g. miners) is then divided by the expected number to obtain the SMR. An SMR of 1.75 indicates that the observed number of death in miners is 1.75 higher than in the standard population (e.g. total US population). (Choice D) The crude (unadjusted) rate of death in miners may be higher than the crude rate of the standard population; however, it may also be lower (if the proportion of younger people is high in the population of interest). (Choice E) SMR is a measure of overall mortality adjusted for age (or other factor); age-specific mortality rates are not mentioned in the scenario. Educational Objective: SMR represents an adjusted measure of overall mortality, and is calculated by dividing the observed number of deaths in the population of interest (e.g. miners) by the expected number derived from the reference population (?standard?). 39% of people answered this question correctly. A 59-year-old African-American man comes to the office and complains of a vague upper abdominal discomfort. The pain has been present most of the time for the past three weeks, but has never been severe enough to make him seek immediate medical attention. The discomfort is not associated with eating or performing any activities. He denies any other medical problems. His vital signs are unremarkable. Abdominal examination reveals the presence of multiple scars from previous surgical procedures around the epigastric area. A 3 x 5 cm oblong-shaped mass is palpable in the epigastric area. There is no tenderness on direct palpation of the mass and the surrounding epigastric area. The patient tells you that he previously had a similar mass in the same area "but it was taken out". Which of the following is the most likely explanation for the mass? A. Primary hyperparathyroidism B. Ventral hernia C. Muscle growth

D. Abdominal wall neuroma E. The effect of exposure seems to vary by age.

Explanation: The patient's clinical presentation is consistent with a diagnosis of desmoid tumor. Desmoid tumors are locally aggressive neoplasms arising from fibroplastic elements within the muscle or fascial planes. Since these are locally invasive and slowly infiltrate the surrounding tissues and structures, these only cause local complications. These usually present as painless or minimally painful, slowgrowing masses over the extremities, shoulder girdle, and hip-buttock area, although these may occur at all body sites. The diagnosis is generally confirmed with a tissue biopsy. Surgical excision with a wide margin of resection is the treatment of choice for patients with an easily approachable and resectable mass. There is a high rate of local recurrence, even after adequate resection. (Choice A) Abdominal aortic aneurysms usually present as a painless pulsatile mass. does not have any risk factors for the development of aortic aneurysm. This patient

(Choice B) Ventral or incisional hernia can develop at the site of previous surgical scars; however, this is generally reducible, and pain is an unusual symptom of ventral hernia, unless it is strangulated. Educational Objective: Desmoid tumors are slow growing and locally aggressive benign neoplasms with a high rate of local recurrence, even after surgical excision. 6% of people answered this question correctly. You receive a call from the surgical ICU to evaluate a 20-year-old male professional football player who was admitted three weeks ago following a motor vehicle accident. The patient sustained a C5-C6 translocation, which resulted in quadriplegia. Presently, he has a tracheostomy tube and is on a ventilator. He is being fed by a PEG tube. Investigations reveal a serum calcium level of 12.8 mg/dL (albumin 2.5 g/dL), a PTH level of 10 pg/mL (normal 10-65 pg/mL), a 25-hydroxyvitamin D level of 20 mcg/L (normal 18-68 mcg/L), and a 12,5-dihydroxyvitamin D level of 15 ng/L (normal 15-60 ng/L). A repeat serum calcium level is 13.1 mg/dL, along with a phosphorus level of 3.2 mg/dL, and ionized calcium level of 6.6 mg/dL (normal 4-5.6 mg/dL). What is the most likely cause of this patient?s hypercalcemia? A. Primary hyperparathyroidism B. Vitamin D toxicity C. Paraproteinemia D. Lab error E. Immobilization Explanation: This patient has a characteristic presentation of hypercalcemia caused by immobilization. This is usually seen in patients with a very high bone turnover (e.g., adolescent patients and older patients with Paget?s disease). When these patients are immobilized, bone resorption is increased and bone formation is decreased (uncoupling of bone turnover). The mechanism of this uncoupling is not clearly known. Excessive bone resorption after immobilization leads to hypercalcemia. It happens in days to weeks following immobilization. High serum calcium levels suppress PTH secretion, as seen in this patient. Vitamin D (25-OH D and 1,25-OH2 D) levels are usually normal, although 1,25dihydroxyvitamin D levels may be lower due to the suppressed PTH secretion (PTH stimulates 1-alphahydroxylase activity in the kidneys, an enzyme responsible for formation of 1,25-dihydroxy vitamin D). Management of hypercalcemia due to immobilization is similar to other hypercalcemic states. Bisphosphonates are particularly useful in decreasing the bone resorption. Their use may preserve the bone mass in patients who are immobilized for very long periods. In this patient, the level of albumin-corrected total calcium is 14.3 mg/dL (For every decrease of 1 g/dL serum albumin level below 4 g/dL, add 0.8 mg to the total calcium level. For instance, if the calcium level is 9.0 mg/dl, and the corresponding albumin level is 3 g/dL then the corrected calcium level is 9.8 mg/dL).

(Choices A and B) PTH levels are suppressed, and vitamin D levels (both 25-OH D and 1,25-OH2 D) are within normal limits; therefore, this patient is unlikely to have primary hyperparathyroidism or vitamin D toxicity. (Choices C and D) The patient has an increase in both total and ionized calcium; therefore, the chances of a lab error or paraproteinemia are unlikely. High protein levels in patients with paraproteinemia can avidly bind to calcium, leading to spuriously elevated total calcium levels. Patients with multiple myeloma can have true hypercalcemia. Educational Objective: Excessive bone resorption after immobilization leads to hypercalcemia. This is usually seen in patients with a very high bone turnover (e.g., adolescent patients and older patients with Paget?s disease). 76% of people answered this question correctly. The following vignette applies to the next 2 items A 62-year-old Caucasian female comes to the emergency department with a complaint of severe upper abdominal pain. She has had episodes of nausea and upper abdominal pain over the past three months, but the pain was tolerable and only lasted for 1 to 2 hours. Last night, she had a similar episode one hour after dinner, but the pain progressed in severity, and was accompanited by three episodes of vomiting. The pain is now maximally located in the right upper quadrant and radiates to her back. She denies any diarrhea or constipation. She is a moderately obese female who is in marked distress due to the pain. Her temperature is 38.3C (101F), blood pressure is 118/87 mmHg, heart rate is 112/min and respirations are 20/min. Her lung and cardiovascular examination is unremarkable. Her abdominal examination reveals the presence of hypoactive bowel sounds. There is marked tenderness on deep palpation of the right upper quadrant. She has voluntary and involuntary abdominal guarding. Murphy?s sign is positive. The initial blood work reveals the presence of marked leukocytosis with a left shift. The results of the liver function tests are pending. Item 1 of 2 What is the next best step in the management of this patient? A. Plain x-ray of the abdomen B. Order a right upper quadrant ultrasound C. Obtain a CT scan of the abdomen with IV contrast D. Wait for the liver function tests E. Consult GI for an endoscopic retrograde cholangiopancreatography Explanation: The clinical presentation of this patient is consistent with acute cholecystitis. Acute cholecystitis is defined as gallbladder inflammation characterized by steady right upper quadrant pain, fever and leukocytosis. It is generally caused by gallstone disease; however, acalculus cholecystitis can also occur especially in elderly and critically ill patients. Patients with acute cholecystitis typically complain of a steady and severe upper abdominal or right upper quadrant pain. The pain may radiate to the back or right shoulder, and is generally associated with fever, nausea, vomiting and anorexia. The patient may give a history of intolerance to fatty foods or history of prior episodes of intermittent pain with fatty food ingestion. The physical examination usually reveals an ill-looking patient with significant right upper quadrant tenderness, voluntary and involuntary abdominal guarding and a positive Murphy?s sign (discomfort and inspiratory arrest on palpation of the gallbladder fossa during deep inspiration).

All patients with acute cholecystitis should therefore be admitted to the hospital and managed with supportive care in the first 24 . enterococcus. Empiric antibiotic therapy is usually directed against the most commonly recovered organisms (Escherichia coli. and positive sonographic Murphy?s sign. The ultrasonographic findings which support the diagnosis include the presence of stones in the gall bladder or cystic duct. no clinical or laboratory findings is sufficiently accurate to confirm or refute the diagnosis of acute cholecystitis. It can easily distinguish the gallbladder wall edema or thickening as the cause of upper abdominal pain. their empiric treatment is not necessary.Although patients have a typical presentation. All patients with acute cholecystitis should be treated with intravenous antibiotics. if left untreated. there is a high risk of complications. appropriate intravenous hydration. NPO (nil per os. gallbladder wall thickening. HIDA scan is useful in excluding cystic duct obstruction in patients with clinical features suggestive of acute cholecystitis. laboratory studies and radiographic imaging studies. A commonly used empiric antibiotic regimen is intravenous ampicillin + gentamicin (for coverage against gram-negative bacilli and synergistic action with ampicillin against enterococcus). the symptoms generally subside in 7 to 10 days. The most common complication in patients with acute cholecystitis include gall bladder gangrene and perforation. placement of nasogastric tube if necessary. Ultrasonography is the initial best test to establish the diagnosis. what is the most appropriate next step in her management? A. Klebsiella.48 hours. and Enterobacter). right upper quadrant ultrasound remains as the initial test of choice for the diagnosis of acute cholecystitis. development of cholecystoenteric fistula and emphysematous cholecystitis. 85% of people answered this question correctly. Educational Objective: Ultrasonography is the initial test of choice to establish the diagnosis of acute cholecystitis. Emergent laparotomy or laparoscopic cholecystectomy is only considered for . Emergent T tube placement and biliary tree decompression C. This includes adequate analgesia. (Choices A and D) All low-risk patients should receive 24 . Begin intravenous antibiotics D. these will not help to rule in or rule out the diagnosis. (Choices A) Plain abdominal x-rays have no role in the diagnosis of acute cholecystitis.48 hours of supportive therapy prior to cholecystectomy. pericholecystic fluid collection. therefore. (Choice E) ERCP should be done in patients with suspected common bile duct stones. In the meantime. Patients with a typical clinical presentation should undergo imaging studies to confirm the diagnosis. Since anaerobic organisms are rarely recovered from patients with acute cholecystitis. (Choice C) Abdominal CT scan is usually not necessary for the diagnosis of acute cholecystitis. however. (Choice D) Liver function tests are usually normal or slightly elevated in patients with acute cholecystitis. Perform an endoscopic retrograde cholangiopancreatography Explanation: In patients with uncomplicated acute cholecystitis. "nothing by mouth"). Item 2 of 2 The appropriate test is ordered and the results are pending at this point. however. Emergent laparoscopic cholecystectomy E. and correction of any associated electrolyte abnormalities. Emergent exploratory laparotomy B. Confirmation of the diagnosis is generally made using the physical findings. It has no role in the management of patients with acute cholecystitis.

Sensitivity ? 85%. These tests have different specificities and sensitivities for the early stage of breast cancer. This high sensitivity helps to ?RULE IN? the disease. (Choice B) Choosing a highly specific test with low sensitivity would give more false-negative results. He is diagnosed with varicocele and advised to undergo surgical removal. Sensitivity ? 65%. Educational Objective: A screening test must have a high sensitivity. but he became concerned as the mass increased in size over the past few weeks. The physical examination is normal. specificity ? 94% D." His scrotum feels heavy. thus. Sensitivity ? 80%. many diseased people would be labeled healthy. he ignored it. specificity ? 97% C. non-fluctuant. and for patients who fail to respond or have progressive symptoms while on supportive therapy. the high sensitivity increases the negative predictive value (NPV) of the test: NPV = True negatives / (True negatives + False Negatives) In this case. This high sensitivity helps to ?RULE IN? the disease by decreasing the number of false-negative results. He describes this mass as "many worms in a bag. The mass is warm. and it does feel like a bag of worms. Item 1 of 2 . The left testicle is difficult to palpate.patients with gallbladder gangrene or perforation. and by increasing the negative predictive value. Which of the following tests could be the best screening test for the early detection of breast carcinoma if applied to a population with a stable incidence of the disease? A. His vital signs are within normal limits. 81% of people answered this question correctly. Sensitivity ? 75%. except for left scrotal enlargement. Educational Objective: All hospitalized patients with acute cholecystitis should be treated empirically with intravenous antibiotics to reduce the risk of secondary infection. specificity ? 92% E. At first. (Choice E) ERCP has no role in the management of patients with acute cholecystitis. 81% of people answered this question correctly. and is sometimes itchy. He first noticed this mass three months ago while taking a bath. Several tests have been developed to measure the serologic markers of breast cancer. Furthermore. specificity ? 90% Explanation: A screening test must have a high sensitivity. (Choice B) T tube placement (percutaneous cholecystostomy) is generally considered only for high risk surgical patients (advanced pulmonary or cardiac disease) who continue to have severe symptoms and fail to improve with conservative therapy. The following vignette applies to the next 2 items A 27-year-old male comes to the office with a scrotal mass. nontender. The patient is anxious and afraid of surgery. specificity ? 90% B. giving as few false-negative results as possible. the test with the highest sensitivity and good specificity is the best choice. Sensitivity ? 70%.

The physical findings suggest a diagnosis of right varicocele. Doppler examination of bilateral lower extremities B. hypoandrogenism does not commonly occur with this disease. 39% of people answered this question correctly. which are responsible for keeping the temperature of the scrotal sacs below the normal body temperature. Infection D. specificity ? 90% Explanation: The testes embryologically develop intra-abdominally. Educational Objective: Venous drainage of the testes involves a complex network of veins called the pampiniform plexus. right . which leads to a rise in intrascrotal temperature. trauma. CT scan of the abdomen D. Item 2 of 2 Six months later. Just before birth. clot.g. This plexus is responsible for maintaining the appropriate temperature for the scrotal sacs (i. therefore. orchitis. Development of hydrocele E. The right spermatic vein drains at a more obtuse angle directly into the inferior vena cava. Embolization of right testicle vein C. (Choice C) Intrascrotal infection is unlikely in patients with varicocele. This explains why the testicular arterial supply and venous drainage come from the abdomen. Impotence C.. Surgical removal of varicocele B. Sensitivity ? 85%. Sensitivity ? 85%. specificity ? 90% Explanation: The testes are located outside the abdomen. tumor) should be ruled out in patients who have bilateral varicocele. Acquired causes include: epididymitis.. Varicoceles are more common on the left side because the left spermatic vein enters the left renal vein at a 90-degree angle. (Choice B) Androgen-secreting Leydig cells are more resistant to an increase in temperature caused by varicoceles. There is no increased incidence of varicocele in patients with hydrocele. Scrotal ultrasonography E. Processes that cause inferior vena caval obstruction (e.Which of the following is the most likely complication of untreated varicocele? A. testicular torsion and tumor. and can be congenital (patent processus vaginalis) or acquired. Patients with varicocele have dilatation of the pampiniform plexus. Dilatation of the pampiniform plexus (varicocele) results in an increased temperature of the scrotal sacs. the patient comes back to your office with a right scrotal mass.e. and venous drainage involves a complex network of venous channels called the pampiniform plexus. (Choice D) Hydrocele is a collection of fluid within the potential space in the tunica vaginalis. and are very sensitive to an increase in temperature. Which of the following is the most appropriate intervention? A. thereby facilitating a more continuous flow. the testes descend down to the scrotal sacs. approximately 2 degrees lower than body temperature). thereby causing the seminiferous tubules to atrophy. Seminiferous tubules make up most of the testicular mass. thereby causing testicular atrophy.

or (3) direct trauma to the involved artery. The neurological examination is within normal limits. Echocardiogram D. The sudden onset of symptoms in a previously asymptomatic patient is most likely due to an embolus. (Choice D) Scrotal ultrasonography might show a dilated venous plexus. right varicocele or varicocele that does not disappear in the supine position. femoral pulses. the popliteal and dorsalis pedis pulses are absent. His temperature is 37. 40% of people answered this question correctly. paresthesias and paralysis. Occasionally. pulselessness. nontender and without any palpable masses. Most of the emboli are from a cardiac source. Acute arterial occlusion is usually the result of (1) an embolus from a distal source. Doppler examination of bilateral lower extremities B. (Choices A and B) Surgical removal of the varicocele or embolization is not the most appropriate intervention at this time. The vascular surgeons are immediately called. The left foot also appears pale and cooler than the right foot. The following vignette applies to the next 2 items A 25-year-old Hispanic college student comes to the emergency department with complaints of sudden onset of left foot pain for the past hour. Hypercoagulation workup Explanation: The patient has a classic presentation of acute arterial occlusion. the heart rhythm is regular. Histologic examination of the embolus E. There is no tenderness on palpation of the lower left leg or foot. tumor) should be ruled out in patients who have bilateral varicocele. pallor.varicocele or varicocele that does not disappear in the supine position. The pain started suddenly when he was sitting at his desk at college and has progressed gradually. it is not very likely to show a cause of varicocele. Examination of the extremities reveal adequate. Educational Objective: Processes that cause inferior vena caval obstruction (e. and a diastolic murmur is heard over the cardiac apex. while a history of gradually progressive symptoms in a previously symptomatic patient is consistent with thrombosis. and the pulses are greatly reduced to absent. The lungs are clear on auscultation.g. Angiographic examination of the left lower extremity C. with a few coming from the . The skin of the lower extremities is cool and pale. bilateral. The onset of symptoms can help in differentiating the etiology of arterial occlusion. pain. therefore abdominal computed tomography (CT) is warranted to look for causes of inferior venacaval obstruction.2?C(99F). however. (2) acute thrombosis due to a previously diseased vessel. This patient has bilateral varicocele. Acute ischemia of the limb due to acute arterial occlusion usually presents with five Ps. clot. where an embolus obstructing the entire lumen of the left popliteal artery is removed. usually in the distal extremity. heart rate is 86/min. On the left side. He denies any history of similar episodes in the past or recent trauma to his left leg. The abdomen is soft. and the patient is taken to the operating room for urgent embolectomy. testicular masses can cause varicocele by metastasis into the abdominal lymph nodes. and respiratory rate is 14/min. Item 1 of 2 Which of the following is the most appropriate next step in the management of this patient? A. Almost all the patients present with a gradually progressive pain. On cardiovascular examination. The sudden onset of dramatic symptoms in this patient is most consistent with an embolic source of acute arterial occlusion. The sensations on the left foot are intact and he is able to make voluntary movements. blood pressure is 120/80 mmHg..

the hypercoagulation workup is not indicated at this point. Some of the well-recognized causes of cardiac emboli include atrial fibrillation. however. Histologic examination is therefore more important since this can differentiate a cardiac source from a peripheral one. Educational Objective: Histopathologic examination of the embolectomy specimen is extremely useful in locating the origin of the embolus which caused the acute arterial occlusion. Since this patient appears to have acute arterial occlusion from a cardiac embolic source. . (Choice E) Hypercoagulation workup is important to look for inherited thrombophilias causing venous thrombosis.arterial aneurysms or atherosclerotic plaques. and the presence of a prosthetic aortic valve. valvular disease. These are not helpful in locating the source of the emboli. endocarditis. approximately 20% of the emboli can arise from a peripheral arterial source. (Choices A and B) Doppler or angiographic examination of the lower extremities is used for the diagnosis of acute arterial occlusion. a prior history of myocardial infarction and ventricular dysfunction. the surgical specimen should be sent for histopathologic examination to ascertain the exact source of the emboli. After an embolectomy. (Choice D) An echocardiogram is an important part of the diagnostic workup since this may identify a source of emboli. It is important to find the exact cause of cardiac emboli to prevent future recurrences. atrial myxoma. 5% of people answered this question correctly.

These can also present with systemic embolization. she already noticed a small mole on her left cheek. along with other underlying risk factors. resulting in embolization of the part of the myxoma to the systemic circulation. it should be excised as soon as possible to reduce the risk of recurrent embolization. thereby causing acute arterial occlusion in otherwise healthy patients. Educational Objective: Left atrial myxomas can present with signs and symptoms of mitral valve obstruction (diastolic murmur or "tumor plop"). rapidly worsening heart failure in otherwise young healthy individuals. Prolonged immobilization B. It does not cause acute arterial occlusion. Atherosclerosis of the abdominal aorta D. She does not have any other complaints. Atrial myxomas are the most common primary cardiac tumors. Left atrial myxoma C. and the remaining arise from the right atrium and left ventricle. Item 1 of 2 Which of the following is the most likely diagnosis? A. There is no such history in this patient. Examination shows a 4 cm dark brown. (Choices C & D) Thromboangiitis obliterans or atheroemboli is an unlikely cause of acute arterial occlusion in a young and otherwise previously healthy patient. Two years ago. Vital signs are within normal limits. or new onset atrial fibrillation. Keratoacanthoma B.Item 2 of 2 Which of the following is the most likely cause of the patient?s condition? A. slightly elevated macule with slightly irregular borders on the left cheek. Pigmented basal cell carcinoma C. with a stalk arising from the atrial septum. (Choice E) A left ventricular thrombus is usually seen in patients with a prior history of myocardial infarction or severely reduced LV function. 54% of people answered this question correctly. Thromboangiitis obliterans E. but this lesion has recently grown in size. or new onset atrial fibrillation. Malignant melanoma E. The diagnosis is usually made by echocardiography (either transthoracic or transesophageal echocardiography). Her social history is not significant. the most likely cause of acute embolic arterial occlusion in this 25year-old previously asymptomatic male is left atrial myxoma. Left ventricular thrombus Explanation: Based on the clinical presentation. rapidly worsening heart failure in otherwise young healthy individuals. Some large tumors may initially present with signs and symptoms of mitral valve obstruction (diastolic murmur or "tumor plop"). Seborrheic keratosis D. Verruca vulgaris . Most of these arise from the left atrium. The tumors are typically pedunculated. Once the diagnosis of atrial myxoma is made. can cause deep venous thrombosis. These can be extremely friable. (Choice A) Prolonged immobilization. The following vignette applies to the next 2 items A healthy 24-year-old Japanese woman comes to the physician because of a lesion on her left cheek.

.

Complete excision is the treatment of choice. (Choice B) Basal cell carcinoma is usually pink or red in color. skin-colored or reddish plaque that develops into a nodule with a central keratin plug. firm. E. however. Observation and repeat follow-up in six weeks. with a "warty" form. (Choice E) Interferon alfa-2b is used as an adjuvant therapy in patients with a high risk of developing metastatic disease. with color variegation. false negatives have been reported in 15% of the time. D. . It is more frequent in males. B. It also has a "stuck on" appearance. 69% of people answered this question correctly. (Choice C) Seborrheic keratosis is rare before the age of 30. It can be confused with an atypical melanocytic nevus. 86% of people answered this question correctly. Due to the significant amount of false negatives reported. These lesions can appear spontaneously or develop over a previously atypical nevus. this disease is infrequent in the Asian population. and is a welldemarcated lesion. C. It appears as a solitary. Educational Objective: It is important to recognize the presence of a melanoma. because excision can be curative if the lesion is identified early. Start therapy with interferon alfa-2b. (Choice E) Verruca vulgaris has the same warty appearance as seborrheic keratosis. Melanoma lesions are usually asymmetric. round. Administer intralesional corticosteroids. A biopsy is not required since the clinical presentation is so classic. It is a low-grade malignancy that pathologically resembles squamous cell carcinoma. Explanation: The sensitivity of a melanoma diagnosis by a dermatologist based on the history and physical examination is approximately 85%. Educational Objective: An excisional biopsy is the next best step in patients with a suspected malignant melanoma.Explanation: Malignant melanoma is a concern if a nevus increases in size and develops irregular borders. and usually more than 5 mm in diameter. Item 2 of 2 Which of the following is the most appropriate statement in this patient?s management? A. An excisional biopsy is the next best step. and it rarely appears before the age of 40. (Choice A) Keratoacanthoma is common on the cheek. however. an excisional biopsy is essential for confirmation of the diagnosis and staging of the lesion.

A person with an intact and normal thyroid gland may compensate for these changes by increasing thyroid hormone production. Combination OCPs with ethinyl estradiol less than 50 mcg per tablet are called low-estrogen pills. D. therefore. and the dose of levothyroxine should be adjusted accordingly. pulse is 120/min. You receive a call from the laboratory staff. B. and the dosage of levothyroxine should be adjusted accordingly. Examination shows pharyngeal erythema and exudates that are forming membranes and tender cervical lymphadenopathy. dry cough. A decision is made to start the patient on diphtheria antitoxin to avoid further cardiac or neurologic complications. which normalizes the free T4 levels. Her most recent serum TSH and free T4 levels were well within normal limits. C. and nausea. (Choice A) There is no increased risk of side effects with the use of combined oral contraceptive pills in patients with primary hypothyroidism.A 24-year-old female with primary hypothyroidism for the last four years comes to you for advice regarding the use of oral contraceptive pills. E. (Choice C) Levothyroxine dosages are either unchanged or increased with concurrent use of combined oral contraceptive pills. headaches. Her temperature is 38. loss of appetite. The dose of levothyroxine may need to be increased. Progesterone-only pills should be prescribed. (Choice D) The dose of estrogen in the combined OCP has substantially decreased in the recent years. total T4.3 C (101 F). the use of these hormonal drugs may affect a person's TBG. blood pressure is 120/70 mmHg. The levothyroxine dose might be increased. Her hypothyroidism has been adequately controlled on 125 mcg per day of levothyroxine. hoarseness. chills. On the other hand. The dosage of levothyroxine may therefore be increased in hypothyroid patients who are taking OCPs to compensate for the mentioned physiologic responses. sore throat. these are not contraindicated in such patients. (Choice E) The use of progesterone-only pills (also called as Mini-Pills) is associated with a high risk of breakthrough bleeding. 62% of people answered this question correctly. The estrogen component of the combination pill increases Thyroxine Binding Globulin (TBG) levels. These pills are mainly used in lactating women. which may result in an increase in the total T4 levels and decrease in free T4 levels. Examination of the lung is normal. a hypothyroid patient cannot compensate for these possible physiologic changes since she is unable to produce sufficient amounts of thyroid hormone and is dependent on levothyroxine therapy. The patient is treated with penicillin G and admitted because of poor oral intake. She has no other medical problems and takes no other medications. The dose of estrogen in the combined oral contraceptive pills should be higher. A healthy 42-year-old Caucasian woman comes to the clinic with fever. The levothyroxine dose might be decreased. and respirations are 20/min. Oral contraceptive pills are contraindicated in hypothyroidism because of the increased risk of side effects. This treatment puts the patient in a greater risk for which of the following complications? . It is not necessary to use a higher dose of estrogens in the combined contraceptive pills. What would be the most appropriate response to this patient? A. She is a paramedic. who reports that the throat culture is positive for Corynebacterium diphtheriae. Explanation: Combination oral contraceptive pills (OCPs) are the most reliable form of reversible contraception. however. and free T4 levels. Educational Objective: TSH levels should be checked 12 weeks after patients with primary hypothyroidism are started on combined oral contraceptive pills. After starting combination OCPs in well-controlled patients with hypothyroidism. TSH levels should be checked in 12 weeks.

this is not the next best step. cervical adenopathy. Its prompt recognition in patients with pharyngitis. and her mother has ovarian cancer. Furthermore. Duplex of the lower extremities C. the history of recent hospitalization and prolonged bed rest puts the patient at high risk for PE. She denies cough and hemoptysis. 55% of people answered this question correctly. Anaphylaxis D. She stayed for one month in the hospital. thus. . and palpitations. Hepatotoxicity E. Cardiac enzymes D. Her father has lung cancer. EKG reveals sinus tachycardia. (Choices A. Even though cardiac enzymes are needed to rule out myocardial infarction. There is also a lesser risk of anaphylaxis. Erythema multiforme C. thus.A. She does not drink alcohol. the risk of hypersensitivity or serum sickness is approximately 10%. tachypnea. diphtheria antitoxin should be administered as soon as possible to avoid complications such as myocarditis. which she developed during her previous hospitalization. chest pain. Diphtheria antitoxin is made with horse serum. The following Vignette applies to the next 4 items A healthy 55-year-old Caucasian woman was brought to the emergency department because of sudden onset of shortness of breath. and E) There are no reports of neurotoxicity. Her blood pressure is 110/70 mmHg. She was discharged from the hospital after a prolonged ICU course for sepsis one week ago. B. Sudden onset of shortness of breath with clear lung sounds should always raise the suspicion for PE. Ventilation perfusion scan B. pulse is 112/min. Educational Objective: Diphtheria antitoxin is made with horse serum. and respirations are 28/min. Other suggestive clinical findings are tachycardia. Bleeding diathesis Explanation: Diphtheria is a serious condition that can be life threatening. or bleeding complications . neuritis. the risk of hypersensitivity or serum sickness is approximately 10%. (Choice C) Coronary artery disease usually causes shortness of breath by causing pulmonary congestion. Item 1 of 4 Which of the following is the most appropriate next step in the management of this patient? A. Initiate coumadin therapy Explanation: The most likely diagnosis in this case is pulmonary embolus (PE). and low-grade fever is extremely important. Her chest x-ray is clear. This patient?s chest x-ray is clear. Physical examination shows no abnormalities except bilateral foot drop. erythema multiforme. The best initial diagnostic test in the above setting is a V/Q scan. For these reasons. nephritis. and hypoxia. She has smoked one-and-a-half packs of cigarettes daily for 15 years. epinephrine must be always available. Her pulse oximetry is 89% at room air. If there is a high suspicion. Thrombolytic therapy E. rarely. D. There is also a lesser risk of anaphylaxis. hepatotoxicity. or. Neurotoxicity B. and was subsequently transferred (after discharge) to a rehabilitation facility for physical therapy.

CT angiogram of the chest C. Coronary angiography . If the results reveal the classic pattern of mismatched perfusion. this invasive procedure is only employed if venous ultrasonography or CT angiogram is negative. A diagnosis of DVT makes the probability of pulmonary thromboembolism very high. however. ventilation/perfusion scanning results are inconclusive in a substantial number of patients. and warrants immediate treatment. Educational Objective: The next best step in a patient with intermediate probability V/Q scan is venous ultrasonography to reveal DVT or CT angiogram of the chest. Echocardiography E. Chest CT angiogram is also frequently used in indeterminate cases of pulmonary embolism. and usually requires the combination of several diagnostic modalities. It is also indicated in acute ST elevation myocardial infarction. significant pulmonary thromboembolism should be ruled out. The first test that is usually employed is ventilation/perfusion scanning.(Choice D) Thrombolytics are used in patients with hemodynamic instability or if there is worsening after IVC filter placement. (Choice A) Although pulmonary angiography is the ?gold standard? for diagnosing pulmonary thromboembolism. 42% of people answered this question correctly. Duplex of the lower extremities B. small emboli are usually missed. the next best step in this case is venous ultrasonography to reveal DVT or CT angiogram of the chest. Explain and initiate warfarin therapy D. Item 3 of 4 Which of the following is considered the gold standard for the diagnosis of the above patient?s condition? A. 75% of people answered this question correctly. Since the usual source of emboli causing this condition is deep venous thrombosis (DVT) of the lower extremities. Coumadin is used once good therapeutic anticoagulation is achieved with heparin. Pulmonary angiography E. Ventilation perfusion scan D. and its use has been associated with skin necrosis in some individuals if given without prior heparin infusion. (Choice E) PE is initially treated with heparin. Elevated D-dimer levels B. The patient does not want to be treated until the appropriate diagnosis is made. Pulmonary angiography C. The reason for this chronologic order is that coumadin takes time to start acting. but this ancillary procedure can only detect large emboli. Item 2 of 4 Further evaluation shows normal cardiac enzymes and intermediate probability ventilation perfusion scan. What is the best next step in the management of this patient? A. Educational Objective: A V/Q scan is the most helpful investigation in the evaluation of PE. Coronary angiography Explanation: Pulmonary thromboembolism is difficult to diagnose. it is advisable to proceed directly with treatment. It is therefore important to know the order in which to order these diagnostic tests. If the scan is normal.

Low molecular weight heparin C. and then adding warfarin (Coumadin) after 24-48 hours. as indicated below: Occurrence of PE in the setting of reversible risk factors (e. Lorazepam. this procedure is rarely being performed since it is invasive and CT angiogram is readily available. Viral exanthema C. Patients with a first episode of idiopathic thromboembolism should be treated for at least six months with warfarin.g.8C (100F). Coronary angiography Explanation: Pulmonary embolism (PE) is generally treated by starting the patient on heparin first. He is sexually active with one partner and uses condoms for contraception. the patient should be treated with at least 12 months of warfarin therapy. He does not smoke or consume alcohol. Item 1 of 2 Which of the following is the most likely mechanism of rash development in this patient? A. the patient should continue pharmacotherapy for a minimum of three months. He went to the doctor three days ago and got an antibiotic prescription. blood pressure is 110/76 mm Hg. and respirations are 16/min. Family predisposition B. however. or surgery) should be treated with 3-6 months of warfarin therapy. The following vignette applies to the next 2 items A 17-year-old Caucasian boy presents to the emergency department (ED) with a generalized rash. He seems scared. Family predisposition B. If the first episode of thromboembolism occurs in a setting that involves an underlying malignancy. immobilization. His past medical history is insignificant.Explanation: Pulmonary angiogram is the gold standard test for the diagnosis of pulmonary embolism (PE). Patients with recurrent thromboembolism or a continuing risk factor should be treated indefinitely. Immediate hypersensitivity . use of oral contraceptive pills. Educational Objective: Pulmonary embolism (PE) is generally treated by starting the patient on heparin first. His temperature is 37. and antithrombin deficiency. and says that he never had such a rash before. and he denies any recreational drug use. In this case. Warfarin (Coumadin) D. as needed E. and then adding warfarin (Coumadin) after 24-48 hours. He has had fever and throat pain for the past week.. 80% of people answered this question correctly. pulse is 88/min. three months of therapy is inadequate in this patient group. The recommended duration of pharmacotherapy depends on the setting in which the PE occurred. Item 4 of 4 What is the best long-term treatment for this patient? A. The recommended duration of pharmacotherapy depends on the setting in which the PE occurred. Physical examination reveals generalized maculopapular rash and posterior cervical lymphadenopathy. anticardiolipin antibody.

as well as adequate nutrition. or aplastic anemia. A healthy. It is believed that this vasculitic rash is immune-mediated. and rest. 27-year-old Guatemalan-American woman comes to the physician because of weight loss. nausea. and is caused by circulating IgG and IgM antibodies toward penicillin derivatives. Supportive treatment includes acetaminophen and NSAIDs for fever. Educational Objective: Supportive treatment and observation are the mainstays of treatment for individuals with infectious mononucleosis.D. (Choice C) Corticosteroids are reserved for patients with severe complications such as impeding airway obstruction. (Choices C and E) The rash does not represent immediate or delayed hypersensitivity to ampicillin. Discontinue the antibiotic and prescribe corticosteroids D. She is a vegetarian. Such antibodies have actually been demonstrated in patients with EBVassociated infectious mononucleosis. Delayed hypersensitivity Explanation: Ampicillin-associated maculopapular rash is a well-known phenomenon in patients with infectious mononucleosis. The reported incidence of this reaction is as high as 80%. Item 2 of 2 Which of the following is the best treatment for this patient? A. She does not use tobacco. (Choice A) There is no indication for antibiotic treatment in this patient. Discontinue the antibiotic and prescribe acyclovir E. alcohol. Circulating immune complexes E. Her family history is not significant. it has not been shown to have significant clinical benefits in patients with infectious mononucleosis. liver failure. (Choice E) The antibiotic should be discontinued. Reassure and continue the antibiotic treatment Explanation: Supportive treatment and observation are the mainstays of treatment for individuals with infectious mononucleosis. (Choice D) Although acyclovir is effective in inhibiting EBV replication. and has lived in America for ten years. 30% of people answered this question correctly. throat pain and malaise. fluids. abdominal distention. and diarrhea. Switch to another antibiotic B. 67% of people answered this question correctly. Discontinue the antibiotic and observe C. or drugs. She has no other medical problems. Educational Objective: It is believed that ampicillin-associated rash in patients with infectious mononucleosis is immunemediated. abdominal pain. She has just received a visit from her relatives who came from . She takes no medication. (Choice B) The pathogenesis of ampicillin-associated rash seems to be different from viral exanthema which are commonly observed during viral infections. and is caused by circulating IgG and IgM antibodies toward penicillin derivatives. The patient is a schoolteacher. She has no known drug allergies. which can be used safely when the infection subsides.

Fasciola hepatica (sheep liver fluke). The following vignette applies to the next 4 items A 24-year-old female is admitted to the hospital after a motor vehicle accident.2?C(99F). if left untreated. Trichuris trichiura (whipworm). which are infections caused by Nematodes such as Ascaris lumbricoides (roundworm). with increased bowel sounds. All of these conditions can be treated with albendazole. mildly tender. Her vital signs are within normal limits. eosinophilic gastroenteritis.000/cmm Leukocyte count: 8. Metronidazole D. Physical examination reveals a tense swelling around the right calf region. heart rate is 96/min. (Choice A) Ciprofloxacin or TMP-SMX are used in Gram-negative infections or traveler?s diarrhea. and also because hookworms can cause anemia through indolent intestinal bleeding. Treatment of parasitic infections by roundworms. Trimethoprim-sulfamethoxazole B. or pinworms can be achieved with albendazole or mebendazole. Neurological examination reveals motor weakness and hypoesthesia of the distal right leg. respiratory rate is 18/min.Guatemala four months ago. Albendazole E. Educational Objective: The presence of diarrhea and eosinophilia can be seen in certain conditions (such as intestinal parasitosis) due to Helminths. There is no rebound tenderness or rigidity. Examination shows that the abdomen is soft. and who are now living in her home. however. and distended. whipworms. Eosinophilia associated with diarrhea points to the presence of helminthiasis. The next morning. The pain is worsened on palpation and passive movements of the foot. such infections are not associated with eosinophilia. 40% of people answered this question correctly. but it is highly prevalent in other regions of the world. multiple rib fractures and a contusion over her right lower leg. and blood pressure is 140/82 mmHg. The patient?s labs reveal: CBC Hb: 10 g/dL Ht: 38% Platelet count: 200. . or Addison?s disease. a nurse calls to inform you that she is complaining of severe pain in her right lower leg.000/cmm Segmented neutrophils: 70% Bands: 3% Eosinophils: 10% Lymphocytes: 14% Monocytes: 3% Which of the following is the most appropriate pharmacotherapy? A. No antibiotic needed Explanation: Intestinal parasitosis is not common in the United States. hookworms. Her temperature is 37. Ciprofloxacin C. (Choice E) Parasitosis must be treated because of the risk of transmission to other persons. where she sustained a right humerus fracture. (Choice C) Metronidazole is used to manage parasitosis such as Giardia or amoeba infections. such as Central America. There is no hepatomegaly or splenomegaly. Necator americanus or Ancylostoma duodenale (hookworms).

Gangrene of the limb E. hypoesthesia. Disseminated intravascular coagulation B. numbness or hypoesthesia. decreased two-point discrimination. (Choice D) Vascular occlusion secondary to a motor vehicle accident usually presents more suddenly and dramatically. Other causes include a crush injury or other long bone fractures in a motor vehicle accident. most commonly tibial fractures. 87% of people answered this question correctly.. When the tissue pressure in an enclosed compartment exceeds the perfusion pressure. Deep venous thrombosis C. The pain is typically worsened by passive movements of the involved muscles. Thrombocytopenia . and drug overdose. neck. anterior chest wall. Majority of the cases involving the lower extremities are due to a traumatic event. It is a rare cause of compartment syndrome and does not compromise blood circulation and neuromuscular function. (Choice E) Nerve compression may occur in a patient after a motor vehicle accident and possible bone fracture. it does not lead to blood flow compromise and muscle necrosis (pain with passive movements of the involved muscles). (Choice A) Fat embolism is infrequently seen in patients with long bone or pelvic fractures. Sensory nerves are usually affected earlier than the motor nerves. Fat embolism B. Patients usually present with a triad of hypoxemia. Patients usually present with severe pain which is out of proportion to the extent of injury. however. Neural compression Explanation: Acute compartment syndrome refers to ischemic tissue damage secondary to elevated pressures in the enclosed compartments of the lower legs or forearm. a tight cast or dressing after trauma.e. and diminished to absent pulses in the involved limb. Rhabdomyolysis and renal failure C. the resulting diminished tissue perfusion and compromised blood flow to the muscles and nerves inevitably lead to ischemic tissue necrosis. Pulmonary embolism D. Late features include extremity paralysis and absent distal pulsation (pulseless paralysis). Acute compartment syndrome usually has a lag period of a few hours before irreversible nerve injury and muscle necrosis occurs.Item 1 of 4 Which of the following is the most likely diagnosis? A. and a petechial rash (involving the head. Educational Objective: Acute compartment syndrome usually occurs after a traumatic event and causes pain. Acute compartment syndrome D. paresis. confusion). Item 2 of 4 Which of the following is the most common life-threatening complication of the above condition? A. Acute vascular occlusion E. neurological abnormalities (i. and the neurologic deficit presents as decreased vibration sense. (Choice B) Deep venous thrombosis usually does not present acutely in a setting of motor vehicle accident in an otherwise healthy young patient. or axilla).

disseminated intravascular coagulation. and subsequently causes acute tubular necrosis and acute renal failure. and this eventually leads to tissue and muscle necrosis. and rhabdomyolysis. E) Thrombocytopenia. (Choices A. (Choice A) Oxygen is usually used in the supportive treatment of patients with fat or cholesterol emboli. Acute renal failure and its complications (electrolyte disturbances) are one of the most common life-threatening complications of acute compartment syndrome. C. the capillaries collapse. pulmonary embolism.Explanation: Acute compartment syndrome results in markedly diminished to absent tissue perfusion within hours of the inciting event. (Choice B) Anticoagulation is usually required for patients with deep venous thrombosis. (Choice E) Nerve conduction studies are helpful in the diagnosis and localization of the site of nerve damage. Check the tissue pressure E. Item 3 of 4 Which of the following is the most appropriate next step in the management of this patient? A. The current general consensus for the threshold value is greater than 30 mmHg. Order venous Doppler ultrasonography D. D. which releases myoglobin into the peripheral circulation. especially if the diagnosis is in question. When the elevated tissue or compartment pressure reaches its threshold level. The exact value for the tissue pressure at which blood flows to the muscle and nerve tissue stops is controversial. Laboratory studies typically reveal markedly elevated creatinine kinase levels and the presence of myoglobin in the urine (positive dipstick for blood in the absence of RBC?s in the urine). Educational Objective: Direct measurement of the compartment or tissue pressure is the diagnostic procedure of choice for patients with suspected acute compartment syndrome. Educational Objective: Rhabdomyolysis and subsequent development of acute renal failure is one of the most common and severe life-threatening complications of acute compartment syndrome. 24% of people answered this question correctly. It is not helpful for the diagnosis of compartment syndrome. (Choice C) Venous Doppler ultrasonography is useful for the diagnosis of deep venous thrombosis. 80% of people answered this question correctly. Myoglobin is directly toxic to the renal tubules. Start the patient on anticoagulation C. Item 4 of 4 . It is therefore important to measure the tissue or compartment pressure early in the course of management. and gangrene of the limb are not usually seen in patients with acute compartment syndrome. Order a nerve conduction study Explanation: Compartment syndrome is characterized by an increase in the tissue pressure in the enclosed myofascial compartments of the extremities. muscle infarction. causing tissue necrosis. Administer oxygen B.

Acute stress disorder C. steam. The ensuing inflammatory response results in edema of surrounding soft tissues and significant narrowing of the airway. 86% of people answered this question correctly. (Choice E) Venous Doppler ultrasonography is useful to diagnose deep venous thrombosis. Supraglottic edema E. (Choice C) A consultation with a vascular surgeon is necessary in patients with vascular injury or occlusion. On physical exam. and the values are as follows: pH: 7. An arterial blood gas is obtained.The appropriate step was taken for the patient. It is not indicated in patients with acute compartment syndrome. Obtain a hypercoagulable panel C. there is no visible evidence of burns. (Choice A) Oxygen therapy has no role in the management of patients with acute compartment syndrome. Supraglottic damage is one of the most alarming types of inhalation injuries and stems from inhaling hot air. Consult a vascular surgeon D. Cardiac arrhythmias Explanation: The majority of burn center deaths are due to inhalation injuries. Surgical decompression aims to restore the capillary blood flow and tissue perfusion. and while there is some singing of her facial hair. Some patients may develop a persistent sensory or motor deficit after an episode of acute compartment syndrome despite early fasciotomy. or smoke. Which of the following is the best next step in management? A.39 PaCO2: 42 mm Hg PaO2: 91 mm Hg HCO3-: 24 mEq/L What potential development is of most concern in this woman over the next 24 hours? A. The woman was trapped in a smoke-filled back bedroom of the apartment. Review the results of venous Doppler ultrasonography Explanation: Acute compartment syndrome is a surgical emergency. Sepsis D. A compartment pressure of 30 mmHg or greater warrants an emergent fasciotomy (also known as compartment release). Continue with oxygen therapy B. A 48-year-old Hispanic woman with no past medical history is brought to the emergency department by an ambulance after being rescued from a burning apartment building. It has no role in the diagnosis or management of patients with acute compartment syndrome. Surgical decompression aims to relieve the pressure within the enclosed compartment and to restore the blood flow to muscles and other tissues within 6-10 hours of the initial symptoms. her vital signs are stable. Fiberoptic laryngoscopy or bronchoscopy may be necessary to properly assess the . Any delay in treatment leads to irreversible muscle and nerve damage. Educational Objective: An emergent fasciotomy is the definitive treatment in patients with acute compartment syndrome. Perform urgent fasciotomy E. (Choice B) Obtaining a hypercoagulable panel may be useful in patients with idiopathic deep venous thrombosis. Night terrors B.

(Choice A) Night terrors are episodes of sleep disturbance that are typically found in children aged 312 years. (Choice B) Acute stress disorder is a psychiatric condition that occurs when an individual feels intense fear. but continues to be functionally impaired by re-experiencing the traumatic event. it appears unlikely that her tissues were subjected to hypoxic stress great enough to induce life-threatening arrhythmias in the next 24 hours.extent of airway involvement. the individual exhibits dissociative symptoms. however. horror. Educational Objective: Suspect airway injury and edema in any individual who has been exposed to smoke or superheated air. (Choice C) Sepsis would be of grave concern if this woman had experienced substantial burns to her body that disrupted the skin?s protective barrier. neither condition would put her in immediate danger within the next 24 hours. In patients such as this woman. or serious injury. the potential consequences of inhalation injury are much more ominous. breathing. (Choice E) The development of cardiac arrhythmias is indeed potentially lethal in any individual deprived of oxygen for a lengthy period. While this woman is certainly at risk for developing either acute stress disorder or posttraumatic stress disorder. Since no such burns are evident in her physical examination. and are not of concern in this woman. . the clinician must maintain a high index of suspicion for airway injury and a correspondingly low threshold for intubation. Remember the ABCs (airway. acute stress disorder lasts a maximum of 4 weeks after the traumatic event. since this woman has normal vital signs and normal arterial blood gas values. circulation) and intubate early if the airway is in danger. Subsequently. or helplessness during a traumatic event that involves actual or threatened death. Unlike the more chronic posttraumatic stress disorder. 71% of people answered this question correctly.

Her past medical history is insignificant. normal sensation is somewhat restored. (Choices A and E) Repeating the cytology in 6 or 12 months is not correct because invasive cervical cancer can be missed. She reports that periodically her fingers "feel numb. (Choice C) HPV testing may be indicated if cytologic examination reveals atypical squamous cells of undetermined significance (ASCUS). and the results indicate that the sample is satisfactory. Nerve conduction studies Explanation: . The following Vignette applies to the next 3 items A 50-year-old Caucasian bookkeeper presents to clinic with complaints of weakness in the fingers of both hands. Radiographs of both wrists D. Physical examination is notable for mild atrophy of the thenar eminences bilaterally. Reassure and repeat Pap smear in 12 months Explanation: HGSIL revealed on Pap smear indicates a 1-2% probability of already having invasive cervical cancer and a 20% probability of acquiring invasive cervical cancer if left untreated. Proceed with colposcopy C. She currently takes atenolol and a fiber supplement. Do excisional biopsy E. She is concerned about the possibility of cervical cancer. Do HPV testing D. sort of like they fell asleep. She has no abnormalities of sensation on the dorsal surfaces of her hands. You perform a Pap smear. Repeat cytology in 6 months B. Educational Objective: If a Pap smear reveals a high-grade squamous intraepithelial lesion (HGSIL). Eliciting pain or paresthesia upon compressing the wrist joint C. There is no history of injury to the upper extremities. The results of HPV testing may influence the decision to proceed with a colposcopy in such cases. immediate referral for a colposcopy is indicated.A 36-year-old Caucasian nulligravida presents to your office for a routine check-up. The symptoms are more often present in the evening and at night but are occasionally experienced during the daytime as well. and mitral valve prolapse. Item 1 of 3 What is the next best step in establishing the diagnosis? A. Her medical history is significant for irritable bowel syndrome. with her right hand more symptomatic than the left. (Choice D) If colposcopy suggests HGSIL. with some tingling." When she shakes her hands. Immediate referral for colposcopy and endocervical curettage is indicated. a diagnostic excisional procedure should be performed. because a friend of hers was recently diagnosed with invasive cervical cancer. 79% of people answered this question correctly. Eliciting a positive Trousseau?s sign B. Which of the following is the next best step in the management of this patient? A. She cannot recall when she first noticed the tingling sensations. and a high-grade squamous intraepithelial lesion (HGSIL) is present. Magnetic resonance imaging of both wrists E. but reports it has become slightly more difficult to sign her name to paperwork over the past several weeks. well-controlled hypertension.

such as pain or paresthesias after compression of the median nerve at the wrist (Choice B) or secondary to tapping of the median nerve (Hoffman-Tinel test) or after 30-60 seconds of acute wrist flexion (Phalen maneuver). which often results in litigation). Because the study is somewhat painful and expensive. Evaluation of thyroid function (Choice A) and the erythrocyte sedimentation rate (Choice B) would be indicated if carpal tunnel syndrome persists despite therapy or if symptoms recur. the combination of suggestive history and physical examination findings indicates the diagnosis of carpal tunnel syndrome is likely. Physical examination should be performed first. Refer for electrodiagnostic testing D. it is recommended only for three groups of patients: those with an unclear diagnosis after history and physical examination. Biopsy of the median nerve (Choice D) is not typically recommended as a means of diagnosing carpal tunnel syndrome. hypesthesia. The diagnosis is suspected when: 1) the patient complains of paresthesias. Magnetic resonance imaging (Choice D) should be obtained if there is reason to suspect a lesion in the carpal tunnel or if the patient has failed initial treatment attempts. Eventually. not with carpal tunnel syndrome. those who have not responded to therapy. It is thought that her condition is secondary to repetitive wrist movements at her place of employment. 65% of people answered this question correctly. or numbness in an area of the hand served by the median nerve. Nerve conduction studies (Choice E) can establish the diagnosis of carpal tunnel syndrome. Obtain erythrocyte sedimentation rate C. This neuromuscular hyperexcitability is associated with hypocalcemia. Refer for biopsy of the median nerve E. and pain of the thumb and first three fingers. The positive Trousseau?s sign (Choice A) occurs when compression of the forearm produces spasm in the hand and wrist. Educational Objective: Obtaining findings of median nerve compression on physical examination is the first step in diagnosing carpal tunnel syndrome. and those with evidence of motor dysfunction or atrophy of the thenar eminence. Refer for ultrasonography of the carpal tunnel Explanation: Slowed median nerve conduction velocity during electrodiagnostic testing (Choice C) serves as a more definitive method of diagnosing carpal tunnel syndrome. Although the sensitivity and specificity of these tests is rather low. her diagnosis invites further scrutiny. and the findings suggest the most likely diagnosis. pain.Carpal tunnel syndrome is the most common nerve entrapment disorder and is characterized by numbness. Radiographs of the wrists (Choice C) are not indicated unless trauma or bony alterations are suspected. What is the next best step in confirming the diagnosis? A. as well as localize the area of irritation. and 2) there are physical findings of median nerve compression. . Item 2 of 3 The appropriate action is taken. atrophy of the hand musculature can develop. Since this patient has experienced bilateral atrophy of the thenar eminence (and appears to have developed the condition in her workplace. however. Obtain thyroid function tests B. tingling.

recurrent pancreatitis. Item 3 of 3 Which of the following is the best initial treatment for this condition? A. Two days later. making a fist. It can be of help in detecting synovitis. a recent review of studies showed limited evidence of the benefit of exercise for carpal tunnel syndrome.Ultrasonography of the carpal tunnel (Choice E) is highly operator dependent and is less often used. However. A short-term course of oral corticosteroids (Choice C) can provide rapid pain relief. he complains of nausea and has two episodes of coffee-ground emesis. Surgical release (Choice A) is indicated only in those patients who have repeatedly failed conservative measures (approximately one-third of those with carpal tunnel syndrome). A 55-year-old Caucasian male comes to the emergency department with complaints of a sudden onset of upper abdominal pain. An upper GI endoscopy reveals the presence of varices in the fundus of the stomach. intravenous hydration. However. Educational Objective: Nighttime splinting of the wrist is one of the more effective initial treatment options for carpal tunnel syndrome. Splinting the wrist at night E. He is admitted to the hospital for observation. Actions that require wrist flexion and extension (eg. a finding sometimes indicative of inflammatory processes such as rheumatoid arthritis. which prevents wrist flexion by keeping the wrists in a neutral position. Unfortunately. holding objects. One of the most helpful and cost-effective conservative therapies is nighttime usage of a cockup splint (Choice D). Which of the following is the most likely cause of the above findings? . followed by 10 mg daily for 7 days. Surgical carpal tunnel release B. and bowel rest. Most patients will fare well with only conservative treatment. Corticosteroid injection (Choice B) of the carpal tunnel is most often performed in patients whose pain persists despite usage of more conservative measures. It is not normally a firstline treatment. It is important to first identify and eliminate those factors that appear to exacerbate the condition. 72% of people answered this question correctly. which uses nerve conduction velocity without electromyography. Educational Objective: Electrodiagnostic testing. can be used to confirm the clinical diagnosis of carpal tunnel syndrome. without any evidence of esophageal varices. the benefits tend to dissipate over several weeks. keyboard work) often cause a significant rise in pressure within the carpal tunnel and should be minimized or avoided. Physical therapy Explanation: Timely treatment of carpal tunnel syndrome can halt the progression of the condition and prevent the development of permanent disability. the procedure is dangerous and can cause nerve atrophy or necrosis if the steroid directly enters the median nerve sheath. Injected corticosteroids C. Physical therapy (Choice E) in the form of wrist strength and mobilization exercises is often prescribed. He has a history of alcoholism and chronic. Commonly prescribed is 20 mg of prednisone daily for 7 days. pain control. in part due to its inherent inconsistency. His physical examination and laboratory evaluation confirm another attack of pancreatitis. Oral corticosteroids D.

Refer her for surgical intervention. Apart from gastric varices. ascites. Insert an estrogen-coated pessary to hold the uterus and cervix.A. and ascites. Hepatic venoocclusive disease D. and can get directly inflamed and thrombosed due to recurrent pancreatic inflammation. patients with chronic splenic vein thrombosis may develop noncirrhotic portal hypertension. Obtain an endometrial biopsy at this time. She had three full-term vaginal deliveries at 30. hepatomegaly. The sensation is worse in the evening and with prolonged standing. (Choice C) Hepatic venoocclusive disease is due to the occlusion of terminal hepatic venules and causes postsinusoidal portal hypertension. you notice an ulcerated. Budd-Chiari syndrome E. B. recurrent pancreatitis is suggestive of splenic vein thrombosis. The splenic vein runs along the posterior surface of the pancreas. (Choice D) Budd-Chiari syndrome is due to the thrombosis of hepatic veins or intra/suprahepatic inferior vena cava. and portal hypertension (gastroesophageal varices and splenomegaly). She denies any past history of smoking. Acutely. it presents with right upper quadrant pain. and leukopenia). recurrent pancreatitis is suggestive of splenic vein thrombosis. thrombocytopenia. which is one of the less frequent complications of chronic pancreatitis. Physical therapy Explanation: The presence of isolated gastric varices in a patient with a history of chronic. Physical therapy Explanation: The presence of isolated gastric varices in a patient with a history of chronic. degenerative joint disease of both knees. A 58-year-old Hispanic woman comes to the emergency department and complains of vaginal bleeding. Portal vein thrombosis C. which is one of the less frequent complications of chronic pancreatitis. It presents as tender hepatomegaly. Apart from gastric varices. Chronic Budd-Chiari syndrome usually presents with ascites. 60% of people answered this question correctly. On pelvic examination. and is relieved by lying flat on her back. 32. She also describes a feeling of heaviness in her lower pelvic area. D. and borderline hypertension. The splenic vein runs along the posterior surface of the pancreas. and can get directly inflamed and thrombosed due to recurrent pancreatic inflammation. . Refer her for surgical intervention. jaundice. and 36 years of age. The mass protrudes through the vaginal orifice upon bearing down. however. and massive splenomegaly with associated features of hypersplenism (anemia. C. E. and rapidly developing ascites. Push the mass back into the vaginal cavity manually. B. Which of the following is the most appropriate next step in the management of this patient? A. She had her menopause six years ago. Educational Objective: Isolated gastric varices (without evidence of esophageal varices) due to splenic vein thrombosis can be seen as a complication of chronic recurrent pancreatitis. patients with portal vein thrombosis have both gastric and esophageal varices. (Choice B) Portal vein thrombosis is one of the causes of prehepatic/noncirrhotic portal hypertension. bleeding mass at the introitus. Her other medical problems include a history of osteoporosis. jaundice. patients with chronic splenic vein thrombosis may develop noncirrhotic portal hypertension. The clinical consequences of portal vein thrombosis are similar to that of splenic vein thrombosis. cirrhosis. ascites.

jaundice. Chronic Budd-Chiari syndrome usually presents with ascites. (Choice B) Portal vein thrombosis is one of the causes of prehepatic/noncirrhotic portal hypertension. On pelvic examination. hepatomegaly. jaundice. She denies any past history of smoking. and rapidly developing ascites. Insert an estrogen-coated pessary to hold the uterus and cervix. you notice an ulcerated. She also describes a feeling of heaviness in her lower pelvic area. and ascites. jaundice. recurrent pancreatitis is suggestive of splenic vein thrombosis. The clinical consequences of portal vein thrombosis are similar to that of splenic vein thrombosis. it presents with right upper quadrant pain. It presents as tender hepatomegaly. Push the mass back into the vaginal cavity manually. Her other medical problems include a history of osteoporosis. it presents with right upper quadrant pain. and massive splenomegaly with associated features of hypersplenism (anemia. The mass protrudes through the vaginal orifice upon bearing down. thrombocytopenia. (Choice B) Portal vein thrombosis is one of the causes of prehepatic/noncirrhotic portal hypertension. D. Educational Objective: Isolated gastric varices (without evidence of esophageal varices) due to splenic vein thrombosis can be seen as a complication of chronic recurrent pancreatitis. and leukopenia). cirrhosis. which is one of the less frequent complications of chronic pancreatitis. Refer her for surgical intervention. A 58-year-old Hispanic woman comes to the emergency department and complains of vaginal bleeding. The sensation is worse in the evening and with prolonged standing. It presents as tender hepatomegaly. cirrhosis.and massive splenomegaly with associated features of hypersplenism (anemia. 32. jaundice. Acutely. Chronic Budd-Chiari syndrome usually presents with ascites. and borderline hypertension. (Choice C) Hepatic venoocclusive disease is due to the occlusion of terminal hepatic venules and causes postsinusoidal portal hypertension. however. ascites. She had three full-term vaginal deliveries at 30. and rapidly developing ascites. (Choice C) Hepatic venoocclusive disease is due to the occlusion of terminal hepatic venules and causes postsinusoidal portal hypertension. patients with chronic splenic vein thrombosis may develop noncirrhotic portal hypertension. and is relieved by lying flat on her back. Physical therapy Explanation: The presence of isolated gastric varices in a patient with a history of chronic. and portal hypertension (gastroesophageal varices and splenomegaly). patients with portal vein thrombosis have both gastric and esophageal varices. Acutely. Apart from gastric varices. and can get directly inflamed and thrombosed due to recurrent pancreatic inflammation. and portal hypertension (gastroesophageal varices and splenomegaly). however. patients with portal vein thrombosis have both gastric and esophageal varices. Obtain an endometrial biopsy at this time. and ascites. (Choice D) Budd-Chiari syndrome is due to the thrombosis of hepatic veins or intra/suprahepatic inferior vena cava. thrombocytopenia. B. The splenic vein runs along the posterior surface of the pancreas. The clinical consequences of portal vein thrombosis are similar to that of splenic vein thrombosis. and 36 years of age. Educational Objective: . Which of the following is the most appropriate next step in the management of this patient? A. bleeding mass at the introitus. She had her menopause six years ago. degenerative joint disease of both knees. and leukopenia). E. hepatomegaly. C. (Choice D) Budd-Chiari syndrome is due to the thrombosis of hepatic veins or intra/suprahepatic inferior vena cava.

or drugs. straight-leg raising to 90 degrees is negative. The following Vignette applies to the next 2 items A healthy 75-year-old African-American man comes to the physician because of persistent lower back pain for the past six months. His medications include aspirin. he had a sudden onset of intense pain radiating from his back to his thighs. gastroesophageal reflux disease and rheumatoid arthritis. lansoprazole. His other medical problems include hypertension. The pain disappears when he sits down. He lives in a house with his wife. and gets worse when he extends his back. when he was walking.Isolated gastric varices (without evidence of esophageal varices) due to splenic vein thrombosis can be seen as a complication of chronic recurrent pancreatitis. He has no known drug allergies. A couple of times before. improves when he bends over his knees. On physical examination. atenolol. He does not use tobacco. alcohol. . 60% of people answered this question correctly. Hyperextension of the lumbar spine produces lumbar pain radiating to the gluteal region. and naproxen. His pedal pulses are palpable and full.

It usually appears during the sixth decade of life. This characteristic pain is not found in spondyloarthrosis or vertebral fracture cases. and is very unusual before that age. when using a grocery cart). MRI of the spine D. Lumbar spinal stenosis E. 62% of people answered this question correctly. X-ray of the lumbar spine B.Item 1 of 2 Which of the following is the most likely diagnosis? A. In some patients. gait disturbance is so prominent that they complain of having "spaghetti legs" or walking "like a drunken sailor. however. The associated pain characteristically disappears/decreases upon sitting down. Surgical decompression through a laminectomy is an option when other therapies fail. HLA-B27 levels Explanation: The diagnosis of spinal stenosis in a patient with symptoms is best confirmed by using MRI of the spine. the patient's history is not suggestive of this disease. Educational Objective: MRI is the investigative procedure of choice for suspected lumbar spinal stenosis. The encroaching of osteophytes at the facet joints. (Choice B) Disc herniation worsens with lumbar flexion. (Choice F) The preservation of pedal pulses helps distinguish the disease from vascular claudication. Therapy can be conservative or can include a lumbar epidural block. Spondyloarthrosis B. increases with spine extension. Item 2 of 2 Which of the following is the most helpful in establishing the patient's diagnosis? A. and decreases with flexion. Duplex arterial study C. Educational Objective: Lumbar spinal stenosis is frequently seen in elderly patients.g. (Choice A) X-ray will not be useful for the diagnosis of spinal stenosis. It is characterized by increased lumbar pain on extension of the spine. and the pain lasts for approximately two months. The pain usually improves when the patient sits down or when he bends forward (e. hypertrophy of the ligamentum flavum. Electromyography E." The preservation of pedal pulses helps distinguish this disease from vascular claudication. Romberg?s sign can be found on examination. and protrusion of intervertebral disks results in a narrowing of the spinal canal. . Lumbago Explanation: Lumbar spinal stenosis is a degenerative disease that affects the elderly population. Vertebral fracture D. Disc herniation C. (Choice E) Lumbago is usually self-limited. (Choice E) HLA-B27 is positive in more than 90% of patients with ankylosing spondylitis.. (Choices A and C) Disappearance of the pain when the patient sits is highly specific for lumbar spinal stenosis.

Educational Objective: An HIV-positive patient should be persuaded to tell his spouse about his HIV status. however. a physician should never deceive his patient about his intentions (Choice B). the physician should also offer to help in conveying the difficult news to the patient?s wife. Agree to maintain confidentiality regarding his HIV status B. . In addressing an issue of such import as HIV status. However. Regents of the University of California established that when a physician finds an identifiable third party to be foreseeably endangered due to a patient?s conduct. He claims to eat an otherwise nutritious diet and drinks a glass of wine before retiring to bed at night. Upon further inquiry. The patient should be given sufficient opportunity to tell his wife about his HIV status before a third party intervenes (Choices C and D). Physical examination is normal. If the patient refuses to inform his wife despite the physician?s best efforts. The patient indicates an interest in beginning antiretroviral therapy. Lately he finds himself drinking four to six cups of coffee per day just to stay focused on the tasks at hand. He insists. that his wife not be informed about his diagnosis because he suspects the news would compel her to seek a divorce. Agreeing to maintain the patient?s confidentiality (Choice A) puts the wife at great risk of contracting HIV and is therefore inappropriate.73% of people answered this question correctly. then. even if such a revelation results in divorce. He says he is "stressed out" at his job. The case of Tarasoff v. If he refuses despite the physician?s best efforts. Submit information regarding his HIV status to a state agency so that his wife will be contacted by an official third party E. he hesitantly reveals that he has frequently visited prostitutes while on business trips to foreign countries. Persuade him to tell his wife about his HIV status Explanation: Patient confidentiality has been a sacred and fundamental principle of medicine since the writing of the Hippocratic Oath. An ELISA test for HIV antibodies returns with a positive result and is confirmed with the Western blot. To ease the patient?s burden. Many medical ethicists argue that this legal precedent applies to the potential transmission of HIV as well. While it is ethical to ensure that the wife is informed about her risk of contracting HIV. Agree to maintain confidentiality regarding his HIV status. that physician has a duty to warn the third party. most states allow for the physician to then convey the information to the at-risk spouse. most states allow for the physician to then convey the information to the at-risk spouse. the physician in this case should make every effort to convince the patient to inform his wife about his HIV status (Choice E). Therefore. A 41-year-old executive presents to clinic complaining of generalized lethargy and weakness. Which of the following is the most appropriate response to his request? A. most states also acknowledge the necessity of notifying individuals (such as the spouse in this case) who are known to be at risk for contracting HIV. it is extremely important to honor the patient?s right to privacy and confidentiality to the greatest extent possible. State that you must inform his wife about his HIV status because you are her primary care physician too D. but then contact his wife to inform her once he leaves the office C. 84% of people answered this question correctly.

A 22-year-old African-American man comes to the emergency department because he sustained an animal bite in the local zoo. He has had these symptoms for the past six years. His last tetanus injection was approximately two years ago. His brother has similar symptoms. which is well tolerated in lactose-intolerant patients. All the above queries are important in the initial history. The kind of animal involved in the incident C. however. He has no known drug allergies. He claims that he was playing with the animal with a few other friends. Chocolate milk C. His vital signs are within normal limits. the animal may not have been vaccinated. therefore. however. as studies have shown that the fermented milk and live cultures in yogurt contain beta-galactosidase. alcohol. or illicit drugs. and has noted that the symptoms usually occur after eating or drinking dairy products. 15% of people answered this question correctly. The presence of any endemic diseases in the zoo Explanation: An animal bite is an extremely common problem encountered in the emergency department. Educational Objective: The animal involved in the bite should be traced and ideally kept under observation to look for the development of symptoms in the animal. He has a small 1 x 1 cm laceration on the dorsum of his right hand. flatulence. Stop amiodarone B. He has no other medical problems. Which of the following is the most appropriate dietary recommendation for the patient? A. The involved animal could just have been within the surroundings. there is no loss or limitation of function. The bite in the zoo should not be presumed to be from the animals kept under observation. when the animal suddenly attacked him. Yogurt is a good alternative source of calcium for this patient. the most important piece of information is the exact location of the animal in the zoo. since a more aggressive approach will be warranted in such a situation. He denies the use of tobacco. since milk or milk products are sometimes added back after the fermentation process of these products. This can change the whole management strategy. bloating. The time lapse between the bite and his presentation to the emergency room E. and is not taking any medications. to advise the patient to be careful when choosing commercially available yogurt products. Yogurt with live activated cultures E. The duration of the bite D. and are unprovoked. abdominal pain accompanied by abdominal distention. It is necessary. It is important to obtain an accurate and complete history from the patient for appropriate management. Ice cream D. and not kept under observation. The presence of any endemic diseases in the zoo Explanation: The patient?s history is very typical of lactose intolerance. Most of the bites involve an animal known to the victim. crampy. Which of the following is the most important information to obtain before proceeding with the management of this patient? A. the bites can be from stray and wild animals as well. Sometimes. and diarrhea. Physical examination reveals no abnormalities. Abdominal x-ray and ultrasound did not reveal any abnormalities. . A healthy 22-year-old Asian man comes to your clinic because of mild. The exact location of the animal in the zoo B.

the patient may be instructed to gradually add lactose-containing products to his diet as long as he is able to tolerate it. Once the patient is symptom-free. . Complete restriction of these and other lactose-containing products is necessary in order to confirm the diagnosis and rid the patient of his symptoms. and can be used initially in small quantities after a lactose-free interval.(Choices A. Ice cream has a high concentration of sugar and fat. and C) Milk and ice cream have high concentrations of lactose. Educational Objective: Yogurt is a good alternative source of calcium for patients with lactose intolerance. B. 73% of people answered this question correctly. which is well tolerated in these patients. as studies have shown that the fermented milk and live cultures in yogurt contain beta-galactosidase.

In this case. the positioning and heart rate of the second twin should be assessed with ultrasound. Moreover. What is the most appropriate advice to this patient? A. it is important to be prepared for urgent cesarean section (Choice E). If labor has halted. Forceps delivery (Choice B) is contraindicated if the amniotic sac is intact. Forceps delivery C. An epidural anesthetic is administered in preparation for attempted vaginal delivery of both twins. Observation B.2?C (99F). Abdominal ultrasound reveals a 5 cm abdominal aortic aneurysm. His medical history is significant for hypertension controlled with thiazides.g. the second twin does not have to be delivered within a fixed time frame after the first twin. oxytocin should be administered. version is not necessary. Physical examination reveals a palpable abdominal mass. Stop statin two days prior to the procedure C. A CT scan with IV contrast is suggested. Observation (Choice A) may ultimately be without harm. The second twin is in cephalic position and at +1 station with reassuring fetal heart tones and an intact amniotic sac. and hypercholesterolemia controlled with atorvastatin. Stop thiazide one day prior to the procedure B. 7 oz). What is the next best step in managing this situation? A. His temperature is 37. Educational Objective: Once the first twin is delivered. Expectant management suffices for the spontaneous deliveries of most twins. Her prenatal care was regular and unremarkable. oxytocin (Choice C) is then administered. but electronic fetal monitoring and ultrasound are of significant help in promptly recognizing fetal distress when it does occur. diabetes mellitus controlled with metformin. Cesarean section Explanation: Recent studies have indicated that if the fetal heart rate is reassuring. and pulse is 80/min. The sonologist?s note also mentions the possibility of aneurysmal extension to the renal arteries. para 0 African-American woman at 37 weeks of gestation presented to the labor and delivery unit complaining of uterine contractions spaced eight minutes apart. Internal podalic version E. If labor has halted. but accepted practice is to initiate oxytocin administration if labor has halted. once the first twin is delivered. Twelve hours after admission. respirations are 12/min. Studies have indicated that emergency cesarean section is necessary in 10-30% of twin deliveries. The patient agrees to receive further management. Internal podalic version (Choice D) is a procedure in which the physician manipulates the fetus inside the uterine cavity from the breech to cephalic position.A 28-year-old gravida 1. blood pressure is 140/90 mmHg. as there are a multitude of complications that can arise (e. prolapsed umbilical cord. so cesarean section is not indicated at this time. A 55-year-old man comes to the clinic for a routine physical examination. the positioning and heart rate of the second twin must be assessed with ultrasound.. immediate delivery is not necessary. When vaginal birth is attempted in the delivery of twins. 55% of people answered this question correctly. Ultrasonogram at 16 weeks revealed twin gestations. Stop metformin one day prior to the procedure . Thus in this case. Auscultation reveals a bruit below his umbilicus. Since the second twin in this case is in cephalic position. the second twin is in cephalic position and fetal heart tones are reassuring. since the second twin is in no distress. Labor does not resume. fetal distress). Intravenous oxytocin D. the woman delivers a girl weighing 2480 grams (5 lbs.

Educational Objective: Metformin should be held temporarily in patients who will undergo radiologic procedures using radiocontrast agents. temperature is 38.. and respiratory rate is 26/min.5 or more in males and 1. 57% of people answered this question correctly.000 IU/L LDH: 360 IU/L AST: 270 IU/L Blood sugar: 200 mg/dl Serum calcium: 10.g.6 C (101. The risk for lactic acidosis is increased with all these conditions. admitted patients.5 F). A 55-year-old chronic alcoholic Mexican male presents to your office in the early morning with complaints of severe abdominal pain and vomiting after he had been binge drinking last night. before starting metformin. significant liver disease. Start copious fluid intake the night before the procedure E.0 mg/dl Serum lipase: 1. (Choice E) The patient needs discontinuation of metformin before the procedure. pulse rate is 110/min. (Choice D) The efficacy of oral hydration in the prevention of contrast-induced nephropathy is unclear. decreased creatinine clearance (below 50 mL/min). His blood pressure is 110/70 mmHg. Patients who are at risk for the development of acute renal failure following the administration of contrast agents should be given sodium bicarbonate or normal saline infusion before and after the administration of radio-contrast agents. and no change in his current therapy is likely to result in significant complications. No change in present management Explanation: Metformin is a very useful agent for the treatment of type 2 diabetes.000/cmm Total bilirubin: 1. He describes the pain as very severe and radiating to the back. metformin should be discontinued in any situation where a decrease in creatinine clearance is expected (e. Start the patient on ranitidine .500 IU/L Serum amylase: 2. careful consideration should be given regarding any contraindications to its use. and alcohol abuse. Similarly. congestive heart failure. N-Acetylcysteine (Mucomyst) can also be used.D. before the administration of contrast agents for radiologic procedures).0 g/dl BUN: 20 mg/dl A CT scan of the abdomen shows a fluid collection around the pancreas. Important contraindications include renal failure (creatinine 1. Which of the following is the next best step in the management of this patient? A. as long as the patient?s hydration is maintained.4 or more in females). nasogastric tube suction and is kept on "nothing by mouth" (NPO) order. He is started on intravenous fluids. analgesics. (Choice A) Thiazide need not be discontinued for the procedure. (Choice B) There is no need to discontinue statin before the administration of iodinated contrast agents. Furthermore. High-risk patients should be treated with sodium bicarbonate or normal saline infusion and acetylcysteine to prevent contrast-induced acute renal failure. metformin should also be discontinued in sick. Other drugs which should not be used prior to intravenous contrast administration are NSAIDs. however. His laboratory test results are as follows: WBC count: 22.

B. Do a laparotomy E. Do an endoscopic pancreaticography D. Start the patient on imipenem C. Start the patient on pancreatic protease inhibitors .

drug and sexual history. Factitious disorder Explanation: A thorough history (including a detailed travel history. She is sexually active in a monogamous relationship with her husband. immunization history. acute pancreatitis. therefore. large fluid collections. She visited her parents two months ago in Missouri. which she has taken several times to relieve the fever.Explanation: This patient has an acute episode of alcoholic pancreatitis with poor prognosis. Infectious disease B. and Enterococcus. Educational Objective: Evidence from current experimental studies favors the use of prophylactic antibiotics in patient with severe acute pancreatitis. Preliminary investigations fail to establish the cause of fever. (Choice D) Surgery should be considered in patients with severe pancreatic necrosis. Fever of unknown origin (FUO) is said to occur when a patient presents with a temperature exceeding 38. and no diagnosis can be established after one week of . or for the treatment of specific complications. occupation. A 33-year-old female with a 4-week history of fever and periodic chills is hospitalized. Which of the following is the most likely etiology of this patient?s condition? A. the fever lasts more than 3 weeks. 49% of people answered this question correctly. etc. biliary pancreatitis. however. diarrhea. or sterile pancreatic necrosis involving more than 30% of the gland. She denies any history of close contact with tuberculosis patients.) and comprehensive physical examination is very important in the evaluation of a patient who presents with fever and no localizing signs. In these conditions. lack of response to nonoperative therapy. (Choice C) ERCP can be used in patients with acute pancreatitis when there is concurrent dilatation of the biliary system and/or elevation of liver function tests. abdominal pain or rash.3C (101F) on several occasions. (Choice E) Protease inhibitors can prevent or suppress AP if given before the insult. She denies recreational drug use. Physical examination is insignificant. Neoplastic disease C. family history. as assessed with Ranson?s criteria. cough. Her past medical history is significant for an uncomplicated appendectomy performed five years ago. She is currently not taking any medications. prophylactic antibiotics should be used for at least 4-6 weeks. She denies any associated headache. these are particularly useful in preventing ERCP-induced acute pancreatitis. and does not remember any mosquito or tick bites. (Choice A) Studies have shown that H2 receptor antagonists have no effect on the course of acute pancreatitis. Adult Still?s disease E. or sterile pancreatic necrosis involving more than 30% of the gland. all patients are routinely managed with either H2 blockers or proton pump inhibitors to prevent stress-induced gastritis. Earlier studies have shown that the use of prophylactic antibiotics had no beneficial effect on morbidity and mortality rates. Pseudomonas. The carbapenem group of antibiotics (including imipenem) penetrates well into the pancreatic tissue and has a very broad spectrum including Staphylococcus. evidence from current experimental studies favors the use of prophylactic antibiotics in patients with severe. The next best step in this patient's care would be to start prophylactic antibiotics such as imipenem or cefuroxime. Her fever exceeds 38. however. Collagen vascular disease D. except for acetaminophen.3C (101F) during the day and has no consistent pattern. large fluid collections.

Albumin < 3. LDH levels > 350 IU/L 4. (Choice B) Neoplastic diseases account for 20-30% of cases of FUO. Age > 55 years 2. these account for 30-40% of cases. infectious conditions are the most common cause of FUO. AST > 250 IU/L B. Educational Objective: Infectious conditions are the most common cause of FUO. the Ranson?s scoring system is the most widely adopted. WBC count and serum calcium levels E.inpatient investigation. After 48 hours: 1. Glucose levels > 200 mg/dl 5. BUN increase > 5 mg/dl 4. Hematocrit decrease > 10% 5.500 IU/L Serum amylase: 1. she is in severe distress and has mild epigastric tenderness. Serum calcium and serum albumin B. A 42-year-old chronic alcoholic African-American female comes to the emergency department and complains of severe abdominal pain of acute onset (three hours ago). are less common. Among these.000/cmm 3. (Choice C) Collagen vascular diseases account for 10-20% of cases of FUO. On examination. Within first 48 hours: 1. Ranson?s criteria are as follows: A. (Choices D and E) Other causes. . According to the literature.0 mg/dl AST: 45 IU/L ALT: 40 IU/L Serum lipase: 1. Calcium < 8 mg/dl 3.2 mg/dl 6. WBC count and LDH levels D.800 IU/L A diagnosis of acute pancreatitis is made. WBC count > 16. such as adult Still?s disease and factitious disorder. 48% of people answered this question correctly. Hematocrit and LDH levels Explanation: A number of scoring systems have been developed for determining the prognosis in patients with acute pancreatitis. Estimated fluid deficit > 4 L The presence of three or more of these criteria is associated with a grave prognosis in acute pancreatitis. Which of the following set of laboratory data will help assess the prognosis of her pancreatitis at this point in time? A. Blood urea nitrogen and hematocrit C. Her laboratory test results reveal the following: Total bilirubin: 1. Po2 < 60 mmHg 2. these account for 30-40% of cases.

accuracy. pulse. and excision can be done using knife conization. Otherwise.e. Physical examination of the man is unremarkable. Cryosurgery C. She has a history of migraine headaches. and three raw eggs. Which of the following is the most appropriate next step in the management of this patient? A. urea and electrolytes). Expectant management B. abdominal cramping. and when colposcopy is satisfactory. She has been smoking one pack of cigarettes daily for the last three years. C and D) Ablation is done when a histologic diagnosis is accurate. Ablation can be done using cryosurgery or laser. Loop Electrosurgical Excision Procedure (LEEP) is the treatment of choice for high-grade squamous intraepithelial lesion. High-grade squamous intraepithelial lesions are more likely to be progressive than low-grade lesions. and renal and pulmonary function parameters. Her father died of colon cancer at the age of 50. (Choice A) Expectant management is not the appropriate choice for high-grade lesions. What is the best means of managing this patient?s care? A. and easiness to perform. It is a very successful procedure and can be performed in an office setting.3C (100. LEEP is preferred because of its low cost. Examination shows no abnormalities. and these should always be treated with ablation or excision. The APACHE II score is based on the evaluation of clinical data (i. when there is no evidence of invasion. blood pressure. Salmonella enteritidis is subsequently isolated from his stool culture. She is currently taking no medications. Laser ablation D. She drinks alcohol only on weekends. Educational Objective: Know the Ranson?s criteria used to assess the prognosis in patients with acute pancreatitis. D and E) These are important predictors of prognosis after the first 48 hours of acute pancreatitis. and her mother is diabetic. Cold knife conization E. vomiting. 29-year-old African-American woman comes to the physician for a routine health maintenance examination. diarrhea. and fever to 38. B.. A healthy. moderate and severe dysplasia. powdered protein. (Choices A. LEEP Explanation: High-grade squamous intraepithelial lesions include CIN II. Her vital signs are within normal limits.9F). The symptoms started 12 hours after the man consumed a beverage that contained pureed fruit.e.Another scoring system entitled "Acute Physiology and Chronic Health Evaluation (APACHE II) score" is gaining popularity. 42% of people answered this question correctly. and carcinoma in situ. temperature). Treatment with ampicillin . excision is preferred. and glandular lesion.. Her annual pap smear shows high-grade squamous intraepithelial lesion (LSIL). Satisfactory colposcopy examination confirms CIN II. 50% of people answered this question correctly. A 30-year-old Caucasian man with no significant past medical history presents to his primary care physician complaining of nausea. CIN III. laser conization or Loop Electrosurgical Excision Procedure (LEEP). Educational Objective: LEEP is the treatment of choice for high-grade squamous intraepithelial lesions. biochemical data (i. (Choices B.

Hyponatremia D. A severe form causes loss of the deep tendon reflexes and muscle paralysis. as they are more prone to developing bacteremia and endovascular infection. prolonged nasogastric suction or diarrhea. She sustained a hip fracture. A 22-year-old Caucasian female is hospitalized after a car accident. Hypermagnesemia Explanation: Hypocalcemia is the most probable diagnosis in this patient. however. convulsions. ampicillin would be a poor choice. Preemptive therapy is warranted in patient groups at greater risk for complications. Educational Objective: Salmonellosis does not need to be treated with antibiotics in immunocompetent individuals age 12 months or older. Treatment with ceftriaxone E. Treatment with trimethoprim/sulfamethoxazole D. sometimes it may manifest as hyperactive deep tendon reflexes. Hypocalcemia E. (Choice E) Mild hypermagnesemia results in decreased deep tendon reflexes. These groups include children younger than twelve months of age (with special attention paid to neonates) and immunocompromised adults. Hypocalcemia can occur during or immediately after surgery. Salmonella enteritidis is becoming increasingly resistant to ampicillin (Choice A). Hypomagnesemia may mimic hypocalcemia. The laparotomy revealed a liver laceration and extensive hemoperitoneum. . 48% of people answered this question correctly. Even if antibiotic therapy were indicated. fracture of several ribs. Usually. decreased respiration. trimethoprim/sulfamethoxazole (Choice C). but is associated with alcoholism. and a blunt abdominal injury that required a laparotomy. In the United States. Therapy may be considered for adults at least 50 years old with known atherosclerotic disease. muscle cramps and. and ceftriaxone (Choice D). and diuretic use. Treatment with ciprofloxacin C. The latter antibiotic is only available intravenously. the patient is noted to have hyperactive deep tendon reflexes. Supportive therapy and observation Explanation: Symptomatic individuals found to be infected with Salmonella enteritidis should be given replacement fluid and electrolytes.B. thereby leading to flaccid quadriplegia. Since the gastroenteritis is usually self-limited and antibiotic use has not been shown to hasten the resolution of symptoms or improve the rate of Salmonella clearance from stool. supportive therapy and observation (Choice E) would be most appropriate. rarely. Therefore. Which of the following electrolyte abnormalities may be responsible for this condition? A. so its usage is restricted. as they are at risk for becoming dehydrated. hypocalcemia occurs due to volume expansion and hypoalbuminemia. Effective antibiotics include ciprofloxacin (Choice B). especially in patients undergoing major surgery and requiring extensive transfusions. antibiotic usage is not recommended for immunocompetent adults or children older than one year of age. and is therefore asymptomatic. Hyperkalemia C. In the early postoperative period. and eventual apnea. Hypokalemia B.

vomiting. Intravenous mannitol D. and there is evidence of bleeding from the right side of her head.(Choice B) Hyperkalemia typically results in gastrointestinal disturbances (nausea. It has no role in the lowering of an elevated intracranial pressure. Hyperventilation to achieve a PaCO2 of 25-30 mmHg E. Physical examination reveals a right pupillary size of 7 mm with minimal response to light. patients complain of headaches. hemiparesis. Further elevation in the intracranial pressure leads to transtentorial herniation of brain tissue. (Choice A) Intravenous thiamine is useful in alcoholic patients with severe malnutrition to prevent the development of Wernicke's encephalopathy. with adduction and pronation of her upper extremities. The most important next step in the management is to rapidly intubate the patient to protect and maintain her airway. on the other hand. Hypermagnesemia. however. CNS neoplasm. and asystole. the patient?s airway should be secured before sending her for neuroimaging. There is bilateral papilledema on funduscopic examination. results in loss of the deep tendon reflexes. Which of the following is the most appropriate next step in the management of this patient? A. decerebrate posturing. The left pupil is 3 mm with normal pupillary light reflex. and eventually. In the early stages. especially in patients undergoing major surgery and requiring extensive transfusions. . she is minimally responsive. Her oxygen saturation is 96% on two liters of oxygen. Educational Objective: Hypocalcemia can occur during or immediately after surgery. Her breath smells of alcohol. (Choice B) CT scan of the brain should be done urgently to look for an intracranial hemorrhage or any other potentially reversible causes of elevated intracranial pressure. 45% of people answered this question correctly. There is no evidence of any thoracic or abdominal injuries. crush injuries. bleeding AV malformations.6?C (99. vomiting). and renal insufficiency. While in the ER. Intravenous thiamine B. CNS infections. dilation of the ipsilateral pupil. respiratory arrest. hypertension and respiratory depression (Cushing's triad). and have papilledema on funduscopic examination. The right eye is deviated outwards and downwards. heart rate 52 per minute and respiratory rate 6 per minute. An 18-year-old high school sophomore is brought to the emergency room after she was involved in a motor vehicle accident. It may be associated with severe burns. if severe. causing altered levels of consciousness (stupor progressing to coma). Upon her arrival to the emergency room. blurred vision. The patient in the above vignette has signs of marked respiratory depression and intracranial hypertension. Her vital signs are as follows: temperature 37. in case of a respiratory arrest. blood pressure 182/98 mmHg. Other causes of elevated intracranial pressure include an intracranial hemorrhage from ruptured aneurysms. most likely secondary to an intracranial hemorrhage from head trauma sustained in the motor vehicle accident. and hydrocephalus. Endotracheal intubation Explanation: The above patient has the typical clinical features of elevated intracranial pressure (ICP). Hyperactive deep tendon reflexes may be the initial manifestation.6F). the patient had an episode of generalized body extension. (Choices A and C) Hypokalemia and hyponatremia are unlikely to manifest as hyperactive deep tendon reflexes. ECG changes. CT scan of the brain C. third cranial nerve palsy. Patients with intracranial hypertension have been classically described to have bradycardia.

She works as a secretary in the local law firm. 73% of people answered this question correctly. Which of the following is the most appropriate response to this patient's request for vaccination? . She smokes approximately one pack of cigarettes a week and drinks alcohol occasionally. (Choice D) Lowering the PaCO2 by hyperventilating the patient causes cerebral vasoconstriction. She is married and has two sons. Her husband and sons are all in good health. Educational Objective: Securing and maintaining a patent airway is the first priority in the management of trauma patients with symptomatic intracranial hypertension. Her mother and father both had diabetes mellitus. She does not have a history of any chronic medical illness. Hyperventilation is therefore used to decrease the PaCO2 to 25-30 mmHg and to rapidly lower intracranial pressure in emergent situations. and reduces intracranial pressure. It can be used to acutely lower elevated intracranial pressures in emergent situations. She denies any active medical problems.(Choice C) Intravenous mannitol is an osmotic diuretic which reduces brain volume by drawing water out of the cells. She tells you that she had a "really bad" episode of flu last year and had to take a week off from work. who are 8 and 11 years old. it is contraindicated in patients with traumatic brain injury and an acute stroke. securing and maintaining a patent airway should still remain the first priority in the management of such patients. This is due to the fact that a significant decrease in cerebral blood flow caused by vasoconstriction can lead to worsening of neurological injury in these patients. and do not have any medical problems. her father also had significant coronary artery disease. She is also requesting for an influenza vaccination for this year. A 41-year-old woman comes to see you in the office for the first time. however. however. She has recently moved to your town and wants to establish her medical care with a primary care physician. which decreases the cerebral blood flow.

You should be fine because you have antibodies from last year's infection. His laboratory findings in the hospital reveal a serum sodium level of 120 mEq/L. A 72-year-old. nursing home patient is admitted to the hospital with a three-day history of nausea. HIV/AIDS. Educational Objective: Influenza vaccination is generally recommended only for those people who are at high risk for influenza-related complications. so vaccination is not advisable. vomiting. etc). diabetes. You do not have any risk factors. and chlorpromazine. Since this patient?s husband and two sons do not have any chronic medical illness. You have two young kids at home. Children and young kids 6 months to 18 years of age on long-term aspirin treatment. usually in the winter season. she is unlikely to have the associated complications. asthma. It is responsible for a substantial morbidity in the general population. A chest x-ray showed a 3 cm mass . and then return for vaccination. 38% of people answered this question correctly. and urine osmolality of 400 milliosmoles/kg. Mortality occurs due to an associated influenza pneumonia and occurs mainly in patients with chronic underlying cardiac. serum osmolality of 258 milliosmoles/kg. COPD. metoprolol. diabetes mellitus. hypertension. therefore. You should wait for the influenza epidemic to start. insulin. Certain groups of people at high risk include the following: Persons 50 years of age or older (age limit has been increased to 65 or older for 2004-2005 season secondary to vaccine shortage). vaccination is not recommended. kidney disease. B. (Choices C and D) Vaccination of a patient without any known risk factors is not recommended. All residents of nursing homes and long-term care facilities. and other medical illnesses. I agree. therefore. Household members of persons at high risk of developing influenza and its complications. coronary artery disease. Children between 6 and 23 months of age. (Choice E) Household members of children or adults with chronic medical illnesses should receive an influenza vaccine annually. diarrhea. and schizophrenia. His medications include aspirin. The nurses at the nursing home tell you that he has been drinking a lot of water for the past three days. prior infection or vaccinations are not helpful in preventing future infections. male. Explanation: Influenza is an acute viral respiratory illness caused by influenza A and B virus. You should get the vaccine now and every year. He has a history of tobacco abuse. multiple myeloma. pulmonary. it is not advisable to vaccinate her at this point. Vaccination of the high-risk groups is the major means of preventing influenza and its associated mortality. The woman in the above vignette does not have any risk factors or any high-risk contacts at home or work. urine sodium concentration of 80 mEq/L. Healthcare workers or workers at long-term care facilities who may transmit influenza to high-risk persons. D. and confusion. C. Women who will be in second or third trimester of pregnancy in the influenza season. The United States Preventive Health Services and Center for Disease Control and Prevention (CDC) have devised guidelines for the vaccination of people who are at high risk of developing complications from influenza. All adults and children with a chronic health condition (heart disease. Out-of-home caregivers and household contacts of children less than 6 months of age. Lets give you the vaccine. (Choice A) The influenza virus (influenza A virus in particular) undergoes periodic changes in its antigenic characteristics. It occurs in epidemics nearly every year.A. E. Although she may contract influenza. and malignancy.

the urinary sodium concentration is typically less than 20 mEq/L in these patients. He has been on all these medications for one year. It is caused by excessive free water intake (primary polydipsia). small cell carcinoma of the lung). however. The patient?s medication includes aspirin. Volume depletion from excessive vomiting and diarrhea E.. tumors (i. and occasional swelling in his feet for the last three months. SIADH can be seen in a variety of CNS disorders. diet-controlled type-2 diabetes mellitus. adrenal insufficiency and hypothyroidism). except for a 10-lbs. urinary sodium concentration of more than 40 mEq/L and normal renal. and cyclophosphamide. cyclophosphamide and selective serotonin re-uptake inhibitors. or dizziness. (The urinary sodium concentration is usually more than 40 mEq/L in patients with SIADH. Which of the following is most likely cause of the patient's laboratory findings? A. Hyperproteinemia secondary to multiple myeloma D. HIV infection. and multivitamins.e. Chlorpromazine is an anti-psychotic agent and is not associated with SIADH. (Choice C) Pseudohyponatremia secondary to hyperlipidemia or hyperproteinemia from any cause is usually associated with a normal or elevated plasma osmolality. Syndrome of inappropriate ADH secretion B. Physical examination is unremarkable. Excessive water ingestion Explanation: Hyponatremia is characterized by an excess of water in relation to the total body sodium concentration. use of drugs such as carbamazepine. (Choice D) True volume depletion due to gastrointestinal (vomiting. coronary artery disease. diarrhea) or renal causes can cause hyponatremia with a low plasma osmolality and elevated urine osmolality. 89% of people answered this question correctly.-weight gain since his last visit six months ago. He denies chest pain. cirrhosis or overuse of diuretics) and syndrome of inappropriate ADH secretion (SIADH). metoprolol. Which of the following is the most appropriate next step in the management of this patient? ..) (Choice E) Patients with hyponatremia secondary to primary polydipsia or excessive water ingestion excrete a very dilute urine and have a urine osmolality of less than 100 milliosmoles/kg. carbamazepine. endocrine disorders (i. elevated urine osmolality. Patients with hyponatremia secondary to SIADH usually have a decreased plasma or serum osmolality. weight gain. elevated urinary osmolality (due to excessive fluid retention). He complains of tiredness. and in postoperative patients. adrenal and thyroid functions. warfarin.around the right hilar region. chlorpropamide. or impaired water excretion from advanced renal failure and excessive antidiuretic hormone (ADH) release. A 76-year-old male with a history of hypertension. Chlorpromazine toxicity C. Excessive ADH secretion can be due to decreased effective circulating volume (true volume depletion secondary to vomiting and diarrhea. Educational Objective: The patients with hyponatremia secondary to SIADH typically have a low plasma osmolality.e. dyspnea. most likely small cell carcinoma of the lung. hydrochlorothiazide. pulmonary diseases. orthopnea. and a high urinary sodium concentration. amiodarone. congestive heart failure. (Choice B) The drugs that can cause excessive ADH release include selective serotonin re-uptake inhibitors (fluoxetine and sertraline). The patient in the above vignette appears to have SIADH secretion secondary to lung cancer. and atrial fibrillation comes to the office for a follow-up.

Discontinue hydrochlorothiazide and add furosemide B. Add digoxin . Check thyroid-stimulating hormone level D.A. Decrease the dose of metoprolol C. Discontinue amiodarone E.

(Choice B) Fatigue could be a side effect of a beta-blocker. therefore. corneal deposits. but does not have any focal neurological abnormality. He was involved in a fight. There is slow bleeding through one of the two penetrating wounds in his right thigh. and decreased heart sounds. Educational Objective: Amiodarone can cause thyroid dysfunction. skin discoloration. in this case. He is extremely pale. A 29-year-old Caucasian man is brought to the emergency department after he was found lying on the street. (Choice D) It is not necessary to discontinue amiodarone if a patient becomes hypothyroid . On arrival. 74% of people answered this question correctly. It is prudent to start with a lower dose in elderly patients or those who have significant coronary artery disease.Explanation: The next best step in the management of this patient is to check serum TSH levels. His temperature is 35C (95F). pulmonary fibrosis (lipoid pneumonitis). no JVD. superficial breathing effort. starting a stronger diuretic or adding digoxin would not help. Two mechanisms by which amiodarone-induced-thyrotoxicosis may occur are: activation of Graves? disease (type-1 thyrotoxicosis) and destructive thyroiditis (type-2 thyrotoxicosis). His body is covered with warm blankets. Examination shows decreased bilateral pulses.8 mEq/L Chloride: 100 mEq/L Bicarbonate: 14 mEq/L BUN: 15 mg/dL Serum Creatinine: 0. patients who have amiodarone-induced hypothyroidism required a higher dose of levothyroxine to bring their TSH within normal range because amiodarone inhibits conversion of T4 to its active form T3.3 g/dL Ht: 19% MCV: 92 fl Platelet count: 150.7 mg/dL . unconscious. Hypothyroidism (85%) is more common than thyrotoxicosis (10-15%). fatigue is more likely due to amiodarone-induced hypothyroidism. and normal lung exam). and liver toxicity. Generally. and was stabbed twice in the right thigh. (Choices A and E). no SOB. The hypothyroidism is treated with levothyroxine. which may be attributed to amiodarone use. Steroids are generally required for treating type-2 thyrotoxicosis. and bleeding from his right leg. his clothes are partially covered with snow. The patient is experiencing symptoms of hypothyroidism. and his extremities are cold. The patient?s laboratory tests reveal: CBC Hb: 6. Amiodarone causes thyroid dysfunction due to its high iodine content. Thyroid functions are monitored every six months in euthyroid patients on amiodarone. however. clear lungs on auscultation. The patient is stuporous. Perchlorate can be used to decrease further iodine uptake by the thyroid gland. He is emergently intubated and infused with warm fluids. Graves' disease induced by amiodarone is generally treated with high-dose thioamides (methimazole or propylthiouracil). The patient does not have congestive heart failure (no orthopnea.000/cmm Leukocyte count: 4. pulse is 120/min and respirations are 12/min. blood pressure is 90/60 mm Hg.500/cmm Segmented neutrophils: 65% Lymphocytes: 29% Monocytes: 6% Serum chemistry Serum Na: 134 mEq/L Serum K: 3.

which may cause paradoxical acidification of the central nervous system. hepatic failure. Prophylactic administration of at least 10 cc of 10% calcium gluconate is therefore recommended for every 500 ml of packed red blood cells transfused. (Choice D) There is no need for transfusion of fresh frozen plasma because there is no evidence of coagulopathy. however. He is given intravenous lorazepam. as he recovers from the metabolic acidosis induced by hypothermia. Fundoscopy reveals papilledema. Start bicarbonate infusion B. generalized tonic-clonic seizures. the patient receives a transfusion of packed red blood cells. hepatic failure. symptomatic hypocalcemia resulting from transfusion of citrated blood is rare. diaphoresis. which temporarily controls the abnormal movements. Some of the excess bicarbonate will also be transformed into carbon dioxide in the brain. there will be a rebound or increase in the concentration of alkali. and this leads to hypocalcemia. In these patients (renal failure. He soon develops involuntary. The conversion of citrate into lactate is impaired. (Choice E) The patient?s seizures and new neurologic findings are due to a metabolic problem. He then has another seizure episode. however. an urgent potassium replacement is not necessary. As the patient?s circulation improves. (Choice B) Patients with hypothermia usually develop hypokalemia. lactic acidosis) prophylactic administration of at least 10 cc of 10% calcium gluconate is recommended for every 500 ml of packed red blood cells transfused. This may be aggravated by exogenous administration. shock. This patient is currently normokalemic. which leads to an excess amount of citrate in the blood.8 mg/dL Blood Glucose: 52 mg/dL Because of the acute anemia. (Choice A) Sodium bicarbonate is only indicated if the patient?s serum bicarbonate levels are extremely low (5 mEq/L or less). and bilateral hand contracture. because normal individuals rapidly metabolize citrate in the liver and kidney. patients with renal failure. Start potassium replacement C.Calcium: 9. repetitive. Start fresh frozen plasma infusion E. The excess citrate then binds calcium. Start calcium replacement D. there is no urgent need for a head CT scan. Educational Objective: Patients with hypothermia or shock who receive blood transfusions are predisposed to hypocalcemia because of their impaired ability to metabolize citrate into lactate. This is due to their inability to metabolize citrate. . because the deficit of ionized calcium is not reflected in the total calcium levels. The measured serum calcium levels may remain normal despite this occurrence. and his mental status slightly improves. Unless there is strong evidence or suspicion of head trauma. his potassium level may become slightly low. Transient papilledema is a usual finding in significant hypocalcemia that leads to seizures. Which of the following is the most appropriate immediate step in the management of this patient? A. which is concomitantly transfused with every blood transfusion. Order a head CT scan Explanation: In general. He also receives parenteral glucose and thiamine. 33% of people answered this question correctly. hypothermia or shock who receive blood transfusions have a high risk of hypocalcemia. He suddenly develops muscle spasms of the face and upper extremities. At this point.

calcium . Her past medical history is significant for preterm labor at 28 weeks gestation. despite the use of over-the-counter analgesics. Fluticasone E. Hydrocortisone D. Prednisone B. basic metabolic panel. 79% of people answered this question correctly. The pain has not improved. Betamethasone (and sometimes dexamethasone) is used for antenatal corticosteroid therapy. She had menopause when she was 48 years old. (Choice D) Fluticasone is an inhalational agent used for the treatment of allergic and inflammatory disorders. it should be given to any pregnant woman from 24 to 34 weeks of gestation with intact membranes at high risk for preterm delivery. Fludrocortisone Explanation: Antenatal corticosteroid therapy has been proven to be effective in reducing perinatal morbidity and mortality associated with preterm labor. presents to the emergency department at 32 weeks gestation with regular menstrual-like cramping and low back pain. The pain is described as deep-seated. Seven days ago. she slipped over ice. as well as oral lisinopril and hydrochlorothiazide. and ipratropium inhalations. and without any aggravating or relieving factors. Two regimens of therapy are available: betamethasone and dexamethasone (some authors believe that betamethasone is preferred over dexamethasone). (Choice C) Hydrocortisone is not considered effective because it is extensively metabolized in the placenta and only a little proportion reaches the fetus. The following vignette applies to the next 2 items A 65-year-old female is seen for acute mid-thoracic back pain. salmeterol. Which of the following steroids is preferred for antenatal corticosteroid therapy? A. but quit approximately five years ago. She denies prolonged use of oral glucocorticoids. is not used for antenatal therapy. In addition. the most popular agent for corticosteroid therapy. Her mother and two sisters have osteoporosis. No evidence of membrane rupture is present. antenatal corticosteroid therapy appears to reduce the risk of intraventricular hemorrhage in infants. and has had the back pain ever since. Physical examination shows regular uterine contractions and cervical dilation (3 cm). The contraction stress test is negative.A 23-year-old African-American woman. Examination reveals tenderness over the mid-thoracic vertebrae. not glucocorticoid agent. (Choice A) Prednisone. Her past medical history is significant for chronic obstructive pulmonary disease and hypertension. nonradiating. gravida 2 para 1. You decide to proceed with adequate hydration and tocolysis. Her mammogram and Pap smear were negative six months ago. It reduces the risk of infant respiratory distress syndrome by stimulating phospholipids (surfactant!) synthesis and accelerating morphologic lung development. when she was diagnosed with chronic obstructive pulmonary disease. For these reasons. (Choice E) Fludrocortisone is a synthetic mineralocorticoid. The complete blood count. boring in quality. which resulted in infant death in the early postnatal period. Betamethasone C. The rest of the examination is unremarkable. She is currently on fluticasone. Educational Objective: Antenatal corticosteroid therapy has been proven to be effective in reducing perinatal morbidity and mortality associated with preterm labor. She has a 30-pack-year history of smoking.

.and phosphorus are within normal limits. Plain radiographs of the thoracic spine reveal a compression fracture in the 10th and the 11th vertebrae.

scores are routinely used to report BMD. Calcium and vitamin D supplementation with hormone replacement therapy Explanation: Once osteoporosis is suspected. baseline DEXA will still be useful for monitoring her response to osteoporosis treatment.0 at the hip. In this patient.Item 1 of 2 What is the next best step in the management of this patient? A. It can be useful in differentiating old from new vertebral fractures (an increased uptake is only seen in new compressive fractures. (Choice E) Bone scan is a sensitive but very nonspecific test for a variety of bone diseases. Item 2 of 2 Her 25-hydroxyvitamin D level is 25 mcg/L (normal 18 to 68 mcg/L). bone mineral density (BMD) should be measured. Check bone mineral density of the hip and spine using dual energy X-ray absorptiometry (DEXA) B.and Z. monitoring the patient's response to treatment using a peripheral device is not advocated. T. Measurement of the PTH levels are not required. Even if low bone mass is documented by a peripheral device. The T-score is the BMD score of a patient in comparison to young healthy adults around 25-30 years of age.1 microunits/mL (normal 0. Start calcium and vitamin D supplementation B. . Bone density at the spine and hip shows a T-score of ?2. a bone scan is likely to show an increased uptake in the region of the compressive fracture. Subcutaneous parathyroid hormone injections E. baseline bone mineral density by DEXA will still be necessary for monitoring. family history of osteoporosis. The Z-score is the BMD score of a patient compared to age-matched normal controls. These factors are: Caucasian race. Perform a technetium bone scan Explanation: The patient has multiple risk factors for bone loss.7 at the lumbar spine and ?2.). (Choice B) Peripheral devices such as heel ultrasounds can predict fracture risks. 88% of people answered this question correctly. but this will not be very useful in managing the patient. Calcium and vitamin D supplementation with alendronate C. Calcium and vitamin D supplementation with daily nasal calcitonin D. Although she qualifies for treatment irrespective of her bone mineral status due to her compression fracture. and postmenopausal status. poor lifestyle. (Choice C) Bone biopsy is almost never required for the diagnosis of primary osteoporosis. (Choice D) This patient has normal calcium and phosphorous levels. Bone biopsy D. and TSH level is 2.35 to 5 microunits/mL). Directly proceeding with measurement of central bone mineral density is therefore advised. Educational Objective: The evaluation of patients with suspected osteoporosis is best performed by performing central bone density measurement (hip and lumbar spine) using DEXA. What is the best way to treat this patient? A. She does not have any clinical features that suggest primary hyperparathyroidism. It can also be useful if metastatic disease is suspected. Check parathyroid hormone levels E. however. Measure the heel bone mineral density by using ultrasound C. Measurement of her bone density using a central device (preferably DEXA) is recommended.

The report was published in 2002. teriparatide) is very effective in increasing bone mineral density at the lumbar spine. More thorough investigations may also be done. Supplementation of calcium and vitamin D alone would be suboptimal. particularly at the hip and lumbar spine. it is not the preferred first-line agent for osteoporosis.5 or less with risk factors for fragility fractures. Optimal calcium and vitamin D intake is necessary in all patients.0 or less.5) (T-score <-2. and these include urinary calcium. and in significantly reducing the incidence of vertebral fractures. It is used in patients with a very high risk for fragility fractures.0) (T-score between ?1. and breast cancer. . and possibly in patients who fail therapy with bisphosphonate. current smoking. deep venous thrombosis. It has a slight analgesic effect which may reduce the pain from a spinal fracture. The problem lies with the drug being expensive. This basic workup includes a complete blood count and routine chemistry profile with calcium and phosphorous levels. and bone turnover markers (N-telopeptide for bone resorption and alkaline phosphatase for bone formation). and in those with T-scores of ?1. and improvement in bone density and fracture risk has not been not consistently documented. the fracture risk increases without any threshold effect. The major risk factors for fragility fractures are low bone density. In addition to measuring bone mineral density (BMD). It causes a mild improvement in vertebral bone mineral density. and a body weight less than 127 lbs. This patient has a T-score of -2 and less at the hip and spine. it is a weak anti-resorptive agent. TSH. and is similar to bisphosphonates. pulmonary embolism. This agent is similar to alendronate. and showed that patients on a combination of conjugated equine estrogen and medroxyprogesterone have a significantly higher risk of myocardial infarction. and can still be used in postmenopausal patients with moderate to several hypoestrogenic symptoms. family history of osteoporosis. respectively. history of fragility fractures. The best treatment (Choice A) Because of the patient?s T-score.0 and 2. serum protein electrophoresis. regimen for her is calcium and vitamin D supplementation with alendronate. Antiresorptive therapy is indicated in all patients with fragility fractures. irrespective of the bone mineral density. Alendronate is a bisphosphonate which improves bone mineral density by decreasing bone resorption.5) As the T-score decreases. These tests are usually decided on the basis of clinical features and initial laboratory values. stroke. The National Osteoporosis Foundation recommends bone-specific drug treatment for low bone density in all postmenopausal females with a T-score of ?2. and reduces the incidence of vertebral fractures. Because of the aforementioned. Short-term use of estrogen may not be harmful. (Choice D) Subcutaneous injections of parathyroid hormone fragment (PTH 1-34.The World Health Organization categorizes BMD in postmenopausal Caucasian women (WHO criteria) according to the T-score (BMD score in comparison to young white females). (Choice C) Calcitonin also inhibits bone resorption. Risedronate is another bisphosphonate which is approved for the treatment of osteoporosis. and its only difference is a slight decrease in its gastrointestinal side effects. some basic chemical workup is also required to look for secondary causes of osteoporosis. thereby significantly reducing the incidence of fragility fractures at these areas. It has been associated with an increase in bone mineral density. The diagnosis of osteoporosis in men and young premenopausal females by bone densitometry criteria is not clear. however. as well as its required daily injections. (Choice E) Hormone replacement therapy fell out of favor as the treatment for postmenopausal osteoporosis following the report of the Women?s Health Initiative. as follows: normal osteopenic osteoporosis (T-score > 1. PTH. treatment with a bisphosphonate (alendronate or risedronate) is necessary.

She meets the three cardinal criteria for a clinical diagnosis of brain death.2F).0 and 2. Obtain a technetium radionuclide brain perfusion scan. absent deep central pain response and absent brainstem reflexes) of a neurological examination that was performed approximately six hours earlier. the patient does not meet all the prerequisites required for a definite clinical diagnosis of brain death. Her daily medications included levothryoxine. B. An apnea test at 10 hours after admission did not induce breathing. Electrocardiogram revealed inferior Q waves. No drug intoxication or poisoning .4 ng/dl (normal 0. Wait six hours and repeat an apnea test. diffuse low density. and cough reflexes were absent. Her blood pressure was 98/60 and core temperature was 34C (93. deep coma with unresponsiveness to deep central pain stimulation (i. however. amlodipine. namely: 1. D. and had no motor response to firm supraorbital pressure. The electrocardiogram revealed asystole. after which. A second neurological examination again revealed coma. C. and metoprolol. Document whether or not the patient still has deep tendon reflexes and a Babinski reflex..5) osteoporosis (T score <-2.Educational Objective: Bone mineral density in postmenopausal Caucasian women is classified (WHO criteria) according to the T-score (BMD score in comparison to young white females) as follows: normal (T score > 1.8 ? 1.. forceful twisting of nipples) 2. oculocephalic. a positive apnea test. She was in a comatose state. Make a clinical diagnosis of brain death and inform the patient's relatives. which should replicate the findings (i. such as severe electrolyte.38 uU/mL. Free T4 level was low at 0. irrespective of the bone mineral density. and right bundle branch block. Abnormal lab values included a TSH level of 67. The patient was admitted in the intensive care unit.0) osteopenic (T score between ?1. she was still comatose. Clinical or neuroimaging evidence of an acute CNS catastrophe that is compatible with brain death 2. a brain CT scan demonstrated loss of the gray/white junction. loss of sulci. with no response to deep pain stimulation and absent brainstem reflexes. These prerequisites are: 1. first-degree atrioventricular block. Her pupils were dilated and fixed at 8mm. and found no respirations or pulse in the patient. lisinopril. and four hours later. lasix. Explanation: This patient has suffered from severe ischemic-hypoxic encephalopathy secondary to cardiac arrest.8). A 62-year-old female collapsed at home after a period of shortness of breath and "foaming at the mouth. or endocrine disorder 3. Atropine and epinephrine were then administered. Watch for spontaneous movements of the limbs other than decorticate flexion or decerebrate extension. The patient was intubated and transferred to the emergency department.e. absence of brainstem reflexes 3. supraorbital pressure. defined as no spontaneous ventilation in response to an increase in PaCO2 >= 20 mm Hg above baseline in the presence of adequate oxygenation The patient also fulfills the requirement for a final diagnosis of brain death of a second neurological examination. acid-base. and obliterated ventricles. E.e. Antiresorptive therapy is indicated in all patients with fragility fractures. gag. What is the most appropriate next step in the management of this patient? A. a pulse was restored. Corneal. Caloric testing produced no conjugate eye deviation." An advanced cardiac life support team arrived 30 minutes later. Seven hours after admission. digoxin.5) Optimal calcium and vitamin D intake is necessary in all patients. Exclusion of complicating medical conditions.

although unlikely to account by itself for her comatose state. an additional confirmatory test is necessary. is recommended before venturing a clinical diagnosis of brain death. Educational Objective: The three cardinal criteria for a clinical diagnosis of brain death are: 1.4. which duplicates motor unresponsiveness to deep pain stimulation and absent brainstem reflexes. toxic. however. An interval of six hours between the first and second completely abnormal examinations is a reasonable standard. but should be performed once the core T is > 32C. a positive apnea test If the patient has any concurrent endocrine. (Choice E) According to the American Academy of Neurology (AAN) guidelines and the diagnostic criteria for brain death. The same holds true for deep tendon reflexes and the Babinski reflex. or toxic factors and/or hypothermia which could be contributing to coma are present in the patient. technetium-99m hexamethylpropyleneamineoxime brain scan (showing no isotope uptake in brain parenchyma) 5. he admits to some concerns about his genitalia. A confirmatory test is required whenever a presumed braindead patient does not meet all the prerequisites or does not meet all of the three cardinal criteria. He appears quiet and reserved. absence of a somatosensory evoked potiential in response to median nerve stimulation This patient had a technetium brain perfusion scan. this designation of six hours is currently "arbitrary?. A 22-year-old man presents to the university health clinic for a wellness exam. include: 1. deep coma with unresponsiveness to deep central pain stimulation 2. 9% of people answered this question correctly. Current medicolegal guidelines require performance of an additional confirmatory test to establish brain death if endocrine. which. He is not sexually active at this time and last had sexual intercourse eight months ago. transcranial Doppler ultrasound (showing small systolic peaks in early systole without diastolic or reverberating flow) 4. according to the AAN. cerebral angiography (showing no intracerebral filling above the circle of Willis) 2. When pressed. revealing absent intracranial blood flow. Once you enter the examination room. cortical EEG (no activity during at least 30 minutes) 3. He has been masturbating twice per day for the past few months. absence of brainstem reflexes 3. metabolic. In contrast. or hypothermic (core T < 32C) condition which could cause coma. He worries that he recently acquired a disease through masturbation. metabolic. in approximate order of decreasing sensitivity. Core temperature > 32C (90F) This patient failed the second prerequisite because she has evidence of significant hypothyroidism. The papules are located on the sulcus and corona of . he informs the nurse that he has some nonspecific aches and pains. a repeat neurological examination. which may or may not be observed for some time after brainstem functions have been irreversibly lost. Such movements provide no reliable evidence for or against a clinical diagnosis of brain death. a second apnea test is not required to establish a clinical diagnosis of brain death after a first apnea test has been positive. Such repetition is optional. (Choice B) This would be the correct next step if the patient had no simultaneous medical disorders confounding the diagnosis of brain death. thereby confirming a clinical diagnosis of brain death. does not allow a definite diagnosis of brain death without the perfomance of a confirmatory test. (Choice A) Limb movements may be occasionally observed due to spinal mechanisms in a patient who has lost all brain stem function. Physical examination reveals an uncircumcised penis and multiple dome-shaped skincolored papules measuring 1-2 mm in diameter. Confirmatory tests.

Condyloma acuminata B. herpes simplex virus infection (Choice D) presents with herpetic vesicles on the glans penis. pulse is 68/min. and occasionally on the scrotum or thighs. They typically appear as one or multiple rows of small. Gonococcal urethritis D. Prescribe phenazopyridine . Mild suprapubic tenderness is apparent on palpation. Current medications include oral contraceptives and she reports an allergy to sulfa. blood pressure is 124/78 mm Hg. Past medical history is noncontributory. The lesions are typically skin-colored or pink and vary in appearance from smooth flattened papules to verrucous. vesicles. cleaning products). or tenderness. Contact dermatitis (Choice B) is an inflammation of the skin that results from exposure to specific exogenous agents (eg. These asymptomatic papules are more common in uncircumcised males and typically appear as one or multiple rows of small.7C (98F). dome-topped or filiform papules positioned circumferentially around the corona or sulcus of the glans penis. or anogenital warts. Gonococcal urethritis (Choice C) typically causes urethral discharge and dysuria within 2-7 days of exposure to an infected partner. flesh-colored. The discharge may be scant at symptom onset but typically becomes profuse within the next day or two. An increase in urinary urgency or frequency is inconsistently reported.the glans penis and are arranged circumferentially in a row. In men. Urethritis is a common complaint and is associated with severe dysuria and mucoid discharge. flesh-colored. and harbor no malignant potential. the prepuce. 44% of people answered this question correctly. She is requesting the most cost effective treatment. bleeding. Which of the following is the most likely diagnosis? A. papilliform growths. nocturia. and respirations are 13/min. Normal variant Explanation: Pearly penile papules are considered a normal variant (Choice E). Herpes simplex infection E. Treatment is not necessary. The irritated area is usually clearly demarcated and the lesions range from minimal skin erythema to significant edema. burning. Temperature is 36. These symptoms began yesterday shortly after she had intercourse with her partner of three months. What is the next best step in managing this woman?s condition? A. The condition is caused by infection with human papilloma virus. Educational Objective: Pearly penile papules are a normal variant and are not spread by sexual contact or activity. is the most common viral sexually transmitted disease in the United States. fragrances. and ulcers. the shaft of the penis. A 19-year-old Caucasian woman without health insurance presents to the gynecologist?s office complaining of mild dysuria. Contact dermatitis C. The lesions may progress to pustules and painful ulcers that crust over after 4-15 days. are not spread by sexual contact or activity. dome-topped or filiform papules positioned circumferentially around the corona or sulcus of the glans penis. Patients may be asymptomatic or may complain of pruritus. Urinalysis is positive for leukocyte esterase and nitrites and demonstrates moderate pyuria. Condyloma acuminata (Choice A). and increased urinary frequency. nickel. These asymptomatic lesions are more common in uncircumcised males and are thought to occur in a substantial proportion of the male population.

Trimethoprim alone has a similar efficacy. (Choices D and E) Adnexal mass and pelvic cellulitis rarely develop after LEEP. Adnexal mass E. Educational Objective: Uncomplicated UTIs are typically treated with a three-day course of trimethoprim-sulfamethoxazole. Urinalysis demonstrating pyuria and bacteriuria confirms the diagnosis. The reported incidence of bleeding after LEEP is 2 to 10%. hematuria. as can wiping from posterior to anterior after a bowel movement. Bleeding B. but is not indicated in this situation. A 40-year-old African-American nulligravida is undergoing an evaluation after the cytologic detection of high-grade intraepithelial cervical lesion. Escherichia coli causes over 80% of uncomplicated UTIs. In a woman with limited financial resources and a sulfa allergy. Prescribe metronidazole Explanation: Urinary tract infections (UTIs) are extremely common in women and may be characterized by dysuria. three-day treatment with trimethoprim (Choice C) is appropriate. Which of the following is the most likely short-term complication of this procedure? A. it is particularly expensive. Usually. Prescribe trimethoprim D. However. which is contraindicated in a patient with sulfa allergy. Dyspareunia D. 12% of people answered this question correctly. Prescribe ciprofloxacin E. Prescribe trimethoprim/sulfamethoxazole C. Ciprofloxacin (Choice D) is a wide-spectrum antibiotic that is extremely effective in treating UTI. it is not an antimicrobial agent and will not cure the infection. Typically. both cold knife conization and LEEP. nocturia. and Klebsiella and Proteus mirabilis accounting for the remainder. The following colposcopy does not confirm the cytologic diagnosis. and you decide to proceed with a cone biopsy using the loop electrosurgical excision procedure (LEEP). Pelvic cellulitis Explanation: Bleeding is the most common short-term complication after cervical conization (cone biopsy). the bleeding can be easily controlled by conservative measures. increased urinary frequency and urgency. . The causes of bleeding include inadequate intraoperative hemostasis and vasodilatation after the effect of the local vasoconstrictor wears off. and should therefore not be first-line treatment for an uninsured patient with an uncomplicated UTI. Phenazopyridine (Choice A) is a reasonably inexpensive medication that provides topical analgesia of the genitourinary tract. Cost-conscious patients with sulfa allergies can be given trimethoprim alone. (Choice B) Perforation is uncommon. Metronidazole (Choice E) is commonly prescribed for the treatment of bacterial vaginosis in women.B. Sexual intercourse can increase the risk of UTI. Surgical hemostasis is rarely required. UTIs are treated with a three-day course of trimethoprim/sulfamethoxazole (Choice B). with Staphylococcus saprophyticus causing another 5-15%. Perforation C. However. and suprapubic tenderness.

and antiretroviral therapy was started. pneumoniae D. Orthomyxovirus infection Explanation: This patient presents with community-acquired pneumonia that is most likely caused by a pyogenic organism (e. chills. Mycoplasma. He is known to be HIV-positive.000/cmm. who is also HIVpositive. He took several tablets of acetaminophen today to relieve his fever. and hypercholesterolemia controlled with simvastatin. The entire clinical picture must be considered. cough.(Choice C) Dyspareunia may develop after gynecologic surgery or procedures.g. but very few. Which of the following is the most appropriate next step? . He is sexually active with one partner. (Choices A. She does not want to live in her daughter's house or in a nursing home. Chlamydia. She fractured her right hip after falling down the steps in her home. and viral infections. Although the patient is homosexual and HIV-positive. You advise the patient to consider an alternate living arrangement. usually operations leading to distortions of vulvovaginal anatomy or fibrosis with decreased tissue mobility. He does not smoke or consume alcohol. if any. and neurologic findings (headache. exertional dyspnea and interstitial infiltrates on chest x-ray. She has a 50-year-old daughter who lives near her house. confusion). Breath sounds are decreased over the right middle lobe. nausea. vomiting. The clinical picture of ?typical? pneumonia is described: acute onset of symptoms. It is characterized by gradual onset. B. his CD4 cell count was 600 cells/microL two months ago. organisms. and E) ?Atypical? pneumonia can be caused by Pneumocystis carinii. S. hypertension controlled with thiazide diuretics and metoprolol. His blood pressure is 120/70 mmHg and heart rate is 90/min. Chest x-ray shows right middle lobe infiltrate. she clearly expresses her desire to live by herself in her own home. purulent sputum. Legionella E. the diagnosis of PCP infection should not be assumed. pneumoniae). Sputum analysis reveals many neutrophils. 84% of people answered this question correctly. and characteristic physical findings. Mycoplasma C. (Choice D) Legionella infection causes community-acquired pneumonia that is commonly accompanied by extra-pulmonary symptoms such as diarrhea. She suffered from an acute myocardial infarction six years ago. however. Educational Objective: Bleeding is the most common short-term complication after cervical conization (cone biopsy). She has a past history of osteoporosis. The entire clinical picture must be considered. but she has not had any complications or recurrence of symptoms. S. Educational Objective: Diagnosis of PCP infection should not be assumed in HIV-positive patients. with a left shift. and rusty sputum. WBC count is 13. His partner was hospitalized one month ago because of pneumonia. Pneumocystis carinii B. An 80-year-old Caucasian female is being discharged from the hospital after surgical repair of the right hip fracture. A 32-year-old homosexual man presents to the emergency department with two days history of fever. 70% of people answered this question correctly. diabetes mellitus treated with metformin. non-productive cough. Which of the following is the most likely cause of this patient?s condition? A.

ambulation. and there have been no ill contacts. The intrinsic factors include any acute illness or an age-related decline in balance. proprioception. the patient in the above vignette should have a total assessment and modification of her home environment to reduce the risk of subsequent falls. Therefore. or symptoms suggestive of upper respiratory tract infection. Ask her to live with her daughter for a few weeks C. Get home assessment by a nurse E. he has started to "spit up a whole lot real forcefully. The following vignette applies to the next 3 items A concerned mother brings in her 4-week-old Caucasian son to the pediatrician. and home hazard evaluation and modification by a trained professional. and home hazard evaluation and modification by a trained professional. Inform her that nursing home is the only available option for her B. He has no history of fever. psychotropic medications. His abdomen is slightly distended and there are active bowel sounds. musculoskeletal or cardiovascular function. The mother thinks he may be producing less stool and urine than normal. The family has not traveled recently. 89% of people answered this question correctly. She says that over the past several days. Ask the daughter to convince her mother to stay with her Explanation: Falls are a common cause of morbidity and mortality in the elderly population. and an unsafe home environment. These are associated with injuries and fractures. cognitive impairment. Some of the extrinsic stressors that can lead to an increased risk of falls include the use of multiple medications. Serum electrolytes Sodium: 133 mEq/L Potassium: 3.A. Physical examination shows a mildly dehydrated child in no apparent distress.3 mEq/L Bicarbonate: 31 mEq/L Chloride: 90 mEq/L BUN: 20 mg/dL Creatinine: 1. Ask the patient to prepare advanced directives D. vision. withdrawal of psychotropic medications. Falls in the elderly population occur as a result of a mixture of intrinsic and extrinsic factors. Educational Objective: Some interventions that have been proven to be useful in the prevention of falls in elderly patients include muscle strength and balance training. (Choices A. Prevention of recurrent falls and the associated complications is important in patients with a history of prior falls. diarrhea. No hepatosplenomegaly is present. significant decline in functional status. withdrawal of psychotropic medications. B & E) The patient appears competent and does not wish to live in the nursing home or with her daughter.2 mg/dL Item 1 of 3 . right after a feeding and then he?s hungry again!" She describes the vomitus as white milk with little curdling. Some interventions that have been proven to be useful in the prevention of falls include muscle strength and balance training. and subsequent greater chance of nursing home placement. She should not be forced by the physician or her daughter to move to the nursing home or her daughter?s house.

Abdominal Radiograph E. The imaging modality used most commonly to diagnose IHPS is ultrasound (Choice E). 79% of people answered this question correctly. or appendicitis in young children. Abdominal ultrasound Explanation: Classically. and the child is immediately hungry after vomiting. Upper endoscopy (Choice C) may be used in infants with suspected IHPS when other imaging modalities do not clarify the situation.Which imaging modality should be ordered to confirm the diagnosis? A. Upper GI endoscopy D. Barium enema (Choice A) is often used to diagnose intussusception. Abdominal CT Scan C. though an upper gastrointestinal (UGI) contrast study is preferred in some medical centers. and peristaltic waves are sometimes seen traveling from left to right in the upper abdomen immediately before vomiting. . Barium enema B. Educational Objective: Ultrasound is the most commonly used imaging modality in the diagnosis of infantile hypertrophic pyloric stenosis. There is usually no blood or bile in the vomit. infantile hypertrophic pyloric stenosis (IHPS) presents in a male infant aged three to six weeks who develops postprandial projectile vomiting. although electrolyte imbalances are seen less often now that the diagnosis is made earlier. Abdominal radiograph (Choice D) is helpful in diagnosing conditions such as duodenal atresia or malrotation. metabolic alkalosis secondary to the loss of gastric hydrochloric acid. An abdominal CT scan (Choice B) may be used to diagnose tumors. laboratory evaluation will show hypokalemia and a hypochloremic. though an upper gastrointestinal (UGI) contrast study is preferred in some medical centers. infections. Physical examination often reveals a palpable olive-shaped mass in the right upper quadrant of the abdomen. Historically.

Cephalexin C. Immediate pyloromyotomy E. 65% of people answered this question correctly. Tetracycline Explanation: Studies have documented an association between the development of infantile hypertrophic pyloric stenosis and the usage of oral erythromycin (Choice D). Although rarely used. especially in infant girls. Ampicillin B. which is typically given as postexposure prophylaxis for pertussis. The provision of continuous nasoduodenal feedings (Choice A) for a lengthy period is a conservative treatment that can be used in infants who are not good surgical candidates. Item 3 of 3 The mother of this boy mentions that he was given an antibiotic as prophylaxis after an outbreak of a particular respiratory illness. Erythromycin E. Correction of electrolyte imbalances C. but is not often used because of inconsistent success in opening the muscular ring of the pylorus. Endoscopically guided balloon dilation (Choice E) has been studied. there is some indication that the usage of macrolides in breastfeeding women is linked to the development of infantile hypertrophic pyloric stenosis. The oral or intravenous administration of atropine (Choice C) may be used to relax the pyloric musculature. his dehydration and electrolyte derangements should be corrected (Choice B) before proceeding to surgery. Which of the following antibiotics is associated with the development of his condition? A. As the infant gains weight. Studies have shown that children who undergo surgery without first correcting the electrolyte imbalances are at increased risk for postoperative apnea. Administration of atropine D. pyloromyotomy (Choice D) may be performed immediately. If the child diagnosed with infantile hypertrophic pyloric stenosis is well hydrated and has normal electrolytes. In addition. . This approach is typically reserved for patients who are not otherwise good surgical candidates. what is the next best step in the management of this child?s condition? A. Ciprofloxacin D. Educational Objective: Electrolyte derangements and dehydration must be corrected before proceeding with surgical correction of infantile hypertrophic pyloric stenosis.Item 2 of 3 Once the diagnosis is confirmed. this is another conservative alternative for infants who are not good surgical candidates. hypochloremic metabolic alkalosis. Referral for balloon dilation Explanation: Since this child with infantile hypertrophic pyloric stenosis is dehydrated and suffering from a hypokalemic. Provision of continuous nasoduodenal feedings B. the pyloric stenosis is thought to pose less of an impediment to the digestive process.

(Choice B) Oral contraceptives are sometimes given to control mastodynia. however. movable mass is palpated in the upper outer quadrant of the left breast. The following vignette applies to the next 2 items A 60-year-old Caucasian woman is intubated in the intensive care unit for respiratory failure. Ultrasound E. she develops a fever. for this patient. the mastodynia is expected to resolve after FNA. does not need any further evaluation other than observation. greenish fluid. The chest x-ray is suggestive of new infiltrate in the right lung. A 37-year-old woman has had left breast discomfort for several months. The vital signs and the rest of the exam are normal. B. Educational Objective: A breast mass that produces non-bloody aspirate and disappears completely on aspiration. Observation D. normal breast tissue (seen especially in young women). and possess a characteristic diffuse nodularity. Fine-needle aspiration (FNA) of the mass reveals a thin. (Choice E) The patient doesn?t have signs of infection. a hemorrhagic bulla develops in the center of this patch. she noted a lump. The breast has also been painful before menses. purulent fluid sticky to the touch. contain non-bloody fluid. Antibiotics are not necessary. or if its content was bloody. soft. Her past medical history and family history are unremarkable for breast and gynecologic diseases. Ultrasound is also useful for the evaluation of cystic lesions. Mammogram B. The mass disappeared completely after FNA. She has a history of chronic asthma and is being treated for an acute exacerbation.The usage of other antibiotics (Choices A. Thick. Some diffuse nodularity is present bilaterally. but this cyst has already been drained. Oral contraceptives C. Yesterday. The physical examination reveals a well-circumscribed erythematous patch measuring 10 cm x 8 cm on the lower abdomen. could be pus. and E) is not linked with infantile hypertrophic pyloric stenosis. Antibiotics Explanation: Cysts that disappear completely. She had a baseline mammogram at the age of 36 that was normal. are most likely due to fibrocystic disease. What should the patient's follow-up therapy include? A. C. The most recent vital signs include a temperature . On her fourth day of hospitalization. not thin greenish fluid. One day later. A smooth. Careful observation for recurrence of the mass is the standard follow-up therapy. (Choice D) An ultrasound is indicated if the mass cannot be visualized using a mammogram because of dense. The ulcer exudes a yellow-green. (Choice A) A mammogram would be indicated if the mass didn?t disappear completely. and within hours the bulla evolves into a black necrotic ulcer with an erythematous rim. Educational Objective: The usage of erythromycin is associated with the development of infantile hypertrophic pyloric stenosis. 64% of people answered this question correctly.

9C (102F). blood pressure of 124/76. what is the most likely diagnosis? A. Cellulitis B. Item 1 of 2 Given the clinical presentation. An urgent Gram stain of the fluid is positive for gram-negative rods. pulse of 90/min. and a sample is obtained for culture. Erythema migrans D. Impetigo C. Ecthyma gangrenosum .of 38. Pyoderma gangrenosum E. and respirations of 21/min.

Erythema migrans frequently occurs at or near the site of the tick bite. Popular two-drug regimens include an aminoglycoside (e.Explanation: Pseudomonas aeruginosa is a gram-negative aerobic bacillus commonly responsible for severe nosocomial infections. ulceration. and necrosis. Surgical debridement E. delays of 1-2 days reduced the cure rate from 74 to 46% in these patients. Intravenous antibiotics C. especially in the immunocompromised. Oral antibiotic B. ulceration. Classical pyoderma gangrenosum is most commonly found on the legs and is characterized by deep ulcers with violaceous borders. (Choice B) Impetigo is a highly contagious. Educational Objective: Ecthyma gangrenosum is associated with lesion(s) of the skin or mucous membrane that rapidly worsen and evolve into nodular patches marked by hemorrhage. Streptococcus pyogenes. In immunocompetent patients. pyogenic skin infection most commonly found in children. aeruginosa bacteremia is most often seen in patients with indwelling urinary or central venous catheters. Empiric treatment is frequently employed because the timely administration of antibiotics has a significant impact on cure rate. (Choice D) Pyoderma gangrenosum occurs in two forms. Bullous impetigo is primarily caused by Staphylococcus aureus. This condition is caused by perivascular bacterial invasion of the media and adventitia of arteries and veins.g. (Choice A) Cellulitis is an inflammation of the skin most commonly caused by an infection with Streptococcus pyogenes or Staphylococcus aureus. or a combination of the two.g. aeruginosa bacteremia frequently develop ecthyma gangrenosum. Intravenous steroids Explanation: Pseudomonas aeruginosa bacteremia is usually treated with a two-drug regimen to limit the emergence of antibiotic resistance. piperacillin) or an antipseudomonal cephalosporin (e. its presence increases the likelihood of Pseudomonas as the causative agent.. Although ecthyma gangrenosum is not pathognomonic of P. Characteristic findings are lesion(s) of the skin or mucous membrane that rapidly worsen and evolve into nodular patches marked by hemorrhage. in one study. tobramycin or amikacin) and an extended-spectrum antipseudomonal penicillin (e. Of particular relevance in this case is the observation that mortality is higher in patients with Pseudomonas bacteremia and concurrent pulmonary infection. Patients with P. ceftazidime . while nonbullous impetigo is caused by Staphylococcus aureus. aeruginosa. Which of the following treatments is most appropriate given this woman?s condition? A. Item 2 of 2 The correct diagnosis is made. Lesions of atypical pyoderma gangrenosum appear on the hands. although some experts recommend monotherapy with ceftazidime or ciprofloxacin when susceptibility data are available... erythema migrans is an erythematous lesion that gradually increases in size over a few days. 35% of people answered this question correctly. its presence increases the likelihood of Pseudomonas as the causative agent. P. or following infection of traumatic or surgical wounds. Intravenous antibiotics and surgical debridement D. classical and atypical.g. aeruginosa. Although ecthyma gangrenosum is not pathognomonic of infection with P. (Choice C) Found in patients with Lyme disease. and necrosis. or face and are superficial ulcerations that have vesiculopustular borders. arms. followed by ischemic necrosis.

non-tender. The possibility of serotonin syndrome is extremely high.3?C (101. Serotonin syndrome D. agitation and muscular rigidity.g. Her abdomen is soft. cardiac and pulmonary exams reveal no abnormalities. e.g..0?F). and non-distended. A 45-year-old Caucasian woman is brought to the emergency department by her daughter. tranylcypromine and phenelzine) are used with selective serotonin reuptake inhibitors (SSRIs.or cefepime). pulse is 116/min and respirations are 24/min. (Choice E) Intravenous steroids would not be an appropriate means of treating this patient?s Pseudomonas infection. . (Choices C and D) Surgical debridement is not indicated in the treatment of ecthyma gangrenosum. The patient is taking an SSRI (fluoxetine) and a MAOI (tranylcypromine). (Choice E) Psychosis will not explain the profound alteration of vital signs and neuromuscular changes.g. and fever. In neutropenic patients. tachycardia. Such regimens typically include an aminoglycoside (e. and could in fact worsen her condition by suppressing her immune response. paroxetine. tobramycin or amikacin) and an extended-spectrum antipseudomonal penicillin (e. but the patient has no history of taking any neuroleptics. Deep tendon reflexes are increased. citalopram. but has smoked one pack of cigarettes daily for the past 25 years. The muscular tone is increased. Muscular strength is preserved. Surgical debridement is not indicated in the treatment of ecthyma gangrenosum. Which of the following is the most probable diagnosis? A. diaphoresis. therapy should be stopped after 7-10 days once the catheter has been removed and the patient has significantly improved.g. piperacillin) or an antipseudomonal cephalosporin (e. blood pressure is 120/80 mmHg. In patients with bacteremia secondary to catheter infection. leading to "serotonin syndrome". Her temperature is 38.. but there is some muscular rigidity. profuse sweating. Educational Objective: Pseudomonas aeruginosa bacteremia is usually treated with a two-drug regimen to limit the emergence of antibiotic resistance. She has depression.. This syndrome is characterized by hyperthermia. Examination reveals a diaphoretic and agitated patient. She was started on fluoxetine one month ago. Moreover. sertraline.g. Viral meningitis C. 16% of people answered this question correctly. fluoxetine. and has been taking tranylcypromine for the past nine months. e. therapy is continued for 14 days or longer until the neutrophil count returns to baseline..) there is a possibility of an excessive increase in serotonin levels in the brain. etc.. (Choice A) The presentation of malignant neuroleptic syndrome is similar. Acute psychotic reaction Explanation: When monoamine oxidase inhibitors (MAOIs. some of the newer or more effective antibiotics are available only in parenteral form. She does not use alcohol or illicit drugs. Tetanus E. and is complaining of muscular cramps. and presents with the characteristic signs and symptoms. (Choice A) Intravenous antibiotics are preferred to oral antibiotics in particularly ill patients because of their ease of administration and rapidity of distribution. Malignant neuroleptic syndrome B. ceftazidime or cefepime). She has been agitated since yesterday. Oropharyngeal.

. a board-like rigid abdomen. Her fever can be explained by multiple causes. because the most probable diagnosis is serotonin syndrome. however. (Choice B) Serotonin syndrome may be mimicked by central nervous system (CNS) infections. A work-up to rule out an infection may be necessary. opisthotonus. periods of apnea. but is not a priority at this point. and dysphagia. there is no evidence of infection in this patient.(Choice D) Tetanus usually presents with stiff neck. risus sardonicus (sardonic smile).

paroxetine.g.3?C (101. tachycardia. This syndrome is characterized by hyperthermia. fluoxetine. e. citalopram. Her temperature is 38. The patient is taking an SSRI (fluoxetine) and a MAOI (tranylcypromine). but has smoked one pack of cigarettes daily for the past 25 years. which is a potentially lethal condition that is characterized by fever. diaphoresis. Examination reveals a diaphoretic and agitated patient. Deep tendon reflexes are increased. The muscular tone is increased.. and presents with the characteristic signs and symptoms. Oropharyngeal. diaphoresis. Serotonin syndrome D. Viral meningitis C. Her abdomen is soft. and is complaining of muscular cramps.g. (Choice A) The presentation of malignant neuroleptic syndrome is similar. . there is no evidence of infection in this patient. a board-like rigid abdomen. because the most probable diagnosis is serotonin syndrome. blood pressure is 120/80 mmHg. agitation and muscular rigidity. etc. A 45-year-old Caucasian woman is brought to the emergency department by her daughter. which is a potentially lethal condition that is characterized by fever. She was started on fluoxetine one month ago. risus sardonicus (sardonic smile). Acute psychotic reaction Explanation: When monoamine oxidase inhibitors (MAOIs. and non-distended. tranylcypromine and phenelzine) are used with selective serotonin reuptake inhibitors (SSRIs. The possibility of serotonin syndrome is extremely high. (Choice D) Tetanus usually presents with stiff neck. She does not use alcohol or illicit drugs. diaphoresis. but is not a priority at this point. e. non-tender. Her fever can be explained by multiple causes. She has been agitated since yesterday. but the patient has no history of taking any neuroleptics. sertraline. 69% of people answered this question correctly. tachycardia. Tetanus E. A work-up to rule out an infection may be necessary. leading to "serotonin syndrome". and fever. Educational Objective: SSRIs and MAOIs should not be taken together because of the high risk of "serotonin syndrome". cardiac and pulmonary exams reveal no abnormalities. (Choice B) Serotonin syndrome may be mimicked by central nervous system (CNS) infections.. opisthotonus. 69% of people answered this question correctly. Malignant neuroleptic syndrome B. but there is some muscular rigidity. Muscular strength is preserved. (Choice E) Psychosis will not explain the profound alteration of vital signs and neuromuscular changes. tachycardia. periods of apnea. She has depression. profuse sweating. and has been taking tranylcypromine for the past nine months. and dysphagia. agitation and muscular rigidity.) there is a possibility of an excessive increase in serotonin levels in the brain.0?F). however. agitation and muscular rigidity.Educational Objective: SSRIs and MAOIs should not be taken together because of the high risk of "serotonin syndrome". pulse is 116/min and respirations are 24/min. Which of the following is the most probable diagnosis? A.

Her husband does not know this. Tell him that this happened because his wife had conceived in the past. Positive predictive value D. 61% of people answered this question correctly. You reply that the probability of the breast cancer is low in her case because FNA has a high: A. Explain to him that sensitization can sometimes occur during the first pregnancy due to unclear reasons. Tell him that more tests need to be done to address his question. Sensitivity B. She is currently pregnant and is also being regularly seen by a hematologist because of a probable Rh sensitization. The results of FNA came back as negative. then the NPV is low. In this case. HIV. B. Another good example is as follows: the NPV is . D and E) The physician must not give false information or refer the patient to another physician to address this delicate topic. Explanation: Patient confidentiality is paramount in medical practice and has recently been enforced by the new HIPAA (Health Insurance Portability and Accountability Act) regulations. that is. or STD infection). Her Coomb?s test is currently positive. Specificity C. the best thing to do is to tell the husband to talk to his wife about that particular topic. A 35-year-old Caucasian female presents to your office with a self-palpated breast mass. Which of the following is the best answer? A. On the other hand. Educational Objective: A patient?s confidentiality is paramount in medical practice. She is Rh negative. For example. NPV depends on the pretest probability of a disease. E. and the patient is mentally competent. Negative predictive value E. you decide to proceed with fine-needle aspiration (FNA). the physician is talking about negative predictive value (NPV). (Choice C) If the husband?s health or safety is not jeopardized by his wife?s condition. Validity Explanation: In this scenario. After the appropriate work-up. homicidal intentions. C. and the FNA result is negative. If these cases occur. the physician has no obligation to disclose any confidential information about her to him. NPV is the probability of being free of a disease if the test results are negative. but the patient is still concerned about the possibility of the breast cancer. Refer him to the hematologist for a better explanation. She discloses to you that she has been pregnant in the past from another man and she had an abortion. as he or she is the primary care physician. if the probability of the breast cancer is high after initial work-up in this patient. unless a situation jeopardizes the third party?s (spouse or relative) health or safety (e. 26-year-old Caucasian woman comes to the clinic with her husband for a routine health maintenance examination.g. and the FNA result is negative. and he got some medical information about cases similar to his wife?s condition. if the probability of the breast cancer is low after initial work-up. (Choices B. Tell him that he may need to talk to his wife about this. and this is currently a matter of research. and she does not want it to be revealed to him.A healthy. the probability that the patient is free of disease is high. Her husband asks you how this is possible considering that this is their first child. A friend of her husband happens to be a physician. then the NPV is high. and her husband is Rh positive. It should be honored in most circumstances. the physician should encourage her to disclose the truth to her partner before he/she is obliged to do it him/herself. D. You are her primary care physician.

unlike sensitivity and specificity (which are fixed values). Proceed with cerebral angiogram B. (Choice E) Validity represents the appropriateness of the test (a test measures what it is supposed to measure). 26% of people answered this question correctly. Because the circulating phagocytes usually are quite effective in removing these bacteria.higher in a woman with a negative HIV test who belongs to the low-risk group than in a woman with a negative HIV test who belongs to the high-risk group. blood cultures should be obtained one hour prior to the spiking of a temperature. (Choice C) Positive predictive value follows the same concept. type 2. because the pre-test probability of having HIV is higher in the latter. During the febrile period B. and consumes alcohol occasionally. it does not depend on the pretest probability of the disease. Educational Objective: NPV is the probability of being free of a disease if the test returns negative. Administer mannitol C. usually occur 30-90 minutes after bacteria enter the blood stream. If there is a time pattern to the chill and fever pattern. He smokes 1 ? packs a day. or convulsions. Physical examination reveals left hemiplegia with hemi-sensory loss. Administer IV corticosteroids . At random E. no meningeal signs are present. which include abrupt temperature elevations and chills. One hour after the return of the temperature to normal D. Review of a patient?s clinical course reveals that at approximately 2:00 pm. as one may develop heat stroke. Educational Objective: If possible. but applies if the test returns positive. cooling blankets and antipyretics are often used. the patient developed an abrupt temperature elevation to 39 C (102. Which of the following times would be the best to draw blood cultures from this patient? A. Initially. His current medications include hydrochlorothiazide. A 56-year-old Caucasian male is brought to the emergency department because of a 7-hour history of weakness of the left extremities. In the morning Explanation: Systemic manifestations of bacteremia.2 F) and a shaking chill. the likelihood of obtaining a positive blood culture increases if it is obtained approximately one hour before the anticipated fever. CT scan of the head reveals no blood. enalapril and glyburide. It is high if the pre-test probability of the disease is low. but a locus of brain swelling in the right hemisphere is present. (Choices A and B) NPVdepends on the pretest probability of a disease. 30% of people answered this question correctly. Extremely high fevers should be aggressively treated. blood cultures drawn during the chill are frequently negative. One hour before the anticipated temperature elevation and chill C. His past medical history is significant for hypertension and diabetes mellitus. His blood pressure is 190/110 mmHg and heart rate is 90/min. delirium. ECG shows left ventricular hypertrophy with secondary repolarization changes. Which of the following is the best next step in the management of this patient? A.

Hypotensive agents are not indicated . Consider t-PA E.D.

4 to 16. unstable angina. the woman adopted a vigorous exercise regimen that lasted between three and five hours every day. etc). diastolic blood pressure > 120 mmHg) or causes end-organ damage (pulmonary edema. and her menses last three to five days with moderate flow. Pregnancy test is negative. breast atrophy. (Choice D) Thrombolytic agents are generally considered in patients who presents within three hours from the onset of the symptoms. This condition primarily occurs in children upon weaning from the breast. her BMI has declined from 23. Kwashiorkor B. resulting in an estrogen deficiency (Choice C). These amenorrheic women are therefore at increased risk for all conditions associated with estrogen deficiency. vaginal atrophy. Women athletes with this condition have been shown to have decreased levels of luteinizing hormone (LH) and gonadotropin-releasing hormone (GnRH). (Choices B and C) Local brain swelling is present in up to 40% of the patients with acute ischemic stroke. A deficiency in this hormone is not the cause of amenorrhea in this woman. and is associated with a worse prognosis. mannitol and IV corticosteroids are not indicated in this setting. Progesterone deficiency E. Physical examination reveals a thin woman with well-defined musculature but is otherwise unremarkable. It is not the cause of amenorrhea in this woman. Testosterone deficiency C.Explanation: Hypertension during an acute ischemic stroke should not be treated unless it is very severe (systolic blood pressure > 220 mmHg. Estrogen deficiency D. and is not the cause of amenorrhea in this woman. Her cycles are normally 28 days long. but would like to address the issue of her amenorrhea first. Several studies demonstrated that decreasing the blood pressure in the setting of an acute ischemic stoke is associated with clinical deterioration and a worsened prognosis. Progesterone (Choice D) is an important hormone in the middle to late luteal phase of the menstrual cycle and also serves in the maintenance of pregnancy. Educational Objective: Hypertension during an acute ischemic stroke should not be treated unless it is very severe or causes end-organ damage. Prolactin excess Explanation: Amenorrhea is thought to occur in female athletes when there is a relative caloric deficiency secondary to inadequate nutritional intake as compared to the amount of energy expended. Testosterone deficiency (Choice B) occurs in disorders such as Klinefelter?s syndrome and cryptorchidism. She has been winning many local races and is considering increasing the difficulty of her exercise regimen. Kwashiorkor (Choice A) is a malnutrition disease caused by severe protein deficiency. Most authors consider the elevated blood pressure during an ischemic stroke to be a protective reaction that is intended to preserve the circulation in the underperfused areas of the brain. Since then. A 35-year-old African-American marathon runner presents to the gynecologist complaining of secondary amenorrhea that developed three months ago. One year ago. What is the most likely etiology of her amenorrhea? A. 20% of people answered this question correctly. including infertility.5. . and osteopenia.

This patttern. Autosomal recessive C. A 23-year-old African American male who presents with fatigue and progressive dyspnea is hospitalized.5g/dL MCV: 82 fl Platelet count: 180. A 22-year-old Caucasian woman presents to your office complaining of progressive and bilateral visual problems. it is clear that the grandmother of the patient had the disease and transmitted it to all her children. Educational Objective: Mitochondrial diseases are characterized by a mother-to-offspring inheritance pattern. 47% of people answered this question correctly. There is no jaundice. Males can acquire the disease from their mothers. C and D) Such a pattern is not consistent with either autosomal or X-linked inheritance. Physical examination shows pallor. Stop transfusion and give IV furosemide Males can . The lungs are clear on auscultation. 67% of people answered this question correctly. Stop transfusion and give IV methyl prednisolone C. Bilateral wheezing is heard on lung auscultation. along with the history. Mitochondrial Explanation: The pattern of transmission is consistent with a mitochondrial disease. Other mitochondrial diseases include mitochondrial encephalopathies and myopathies (e. His urine is dark. You draw a diagram showing the following pattern. blood pressure is 80/60 mm Hg and pulse rate is 120/min. makes Leber hereditary optic neuropathy (LHON) the most probable diagnosis in this case. He has received several blood transfusions in the past. In the diagram given above.000/cmm Leukocyte count: 7. but all of them were uncomplicated. (Choices A. His initial lab test results are as follows: CBC Hb: 7. Autosomal dominant B.g.3C(101F).High serum levels of prolactin (Choice E) can occur in pregnant or breastfeeding women or as the result of a prolactinoma. What is the most probable mode of inheritance of the disorder that is present in this family? A. acquire the disease from their mothers. but only the daughters transmitted the disease further. which is characterized by a mother-to-offspring inheritance. X-linked recessive E. Detailed questioning revealed that other family members also have this problem. B. but do not transmit it further. Educational Objective: Secondary amenorrhea is relatively common in elite female athletes and results from estrogen deficiency. The abdominal examination reveals no abnormalities. but do not transmit it further. MELAS).. It is an extremely unlikely cause of amenorrhea in this woman. Which of the following is the best next step in the management of this patient? A. LHON is a bilateral optic atrophy occurring at age 15-30.500/cmm Packed red blood cell transfusion is started. X-linked dominant D. He becomes agitated and complains of severe bilateral flank pain while undergoing blood transfusion. His temperature is 38. Stop transfusion and hydrate with IV normal saline B.

T3 can be used for a short period to prevent symptoms of hypothyroidism in preparation for total radioactive iodine uptake and scan in patients with thyroid cancer. She is currently on 125 mg of levothyroxine everyday.9 mU/mL (normal 0. African-American patients with sickle cell anemia) may form multiple antibodies to common Rh. If undetected. Increase the dose of levothyroxine to bring the TSH to within normal range E. She denies any symptoms. Educational Objective: Patients with acute hemolytic transfusion reaction should be managed by immediately stopping the transfusion and vigorously hydrating the patient with normal saline (not Ringer's or dextrose) to treat the hypotension and to prevent renal failure.8 ng/dL). A 26-year-old female comes to your office for a routine visit.. The dose of levothyroxine for this patient should therefore be increased to bring the TSH to within the goal range. For patients with distant metastasis. Ask her to take levothyroxine after meals Explanation: The patient has a history of papillary thyroid cancer. Patients who require chronic red cell transfusions (e.D. . She has a history of papillary thyroid cancer for which a near total thyroidectomy was performed without complications three years ago.0 mU/mL). and free T4 of 1. and vigorous hydration should be started to treat the hypotension and to prevent renal failure.1 and 0. Increase the dose of levothyroxine to suppress the TSH below 0. She received an ablative dose of radioactive iodine following her thyroid surgery. which appears to be in remission. which she takes on an empty stomach every morning. these red cell antibodies may cause hemolysis.g. What is the next best step in the management of this patient? A. It is also important to remember that patients being treated with suppressive doses of levothyroxine are at an increased risk for bone loss and atrial fibrillation. the dose of levothyroxine is adjusted to suppress the TSH below normal range. Low dose dopamine infusion and osmotic diuresis may also be employed. (Choice B) IV corticosteroids are used to treat allergic reactions. (Choice C) Loop diuretics are commonly administered to treat volume overload.3 mU/mL. the transfusion should be stopped immediately. In patients with thyroid cancer in remission. usually between 0. TSH of 5. (Choice E) Continuing the transfusion may cause further complications such as hemolysis. or other blood group antigens.35-5.35 mU/mL B.8-1. Physical examination is unremarkable. In this case. Continue the same dose of levothyroxine C. The presence of such antibodies may increase the time required for a transfusion service to supply serologically compatible red cells. Add liothyronine (T3) D. Stop transfusion and administer IV antibiotics E. Continue transfusion and give supplemental oxygen Explanation: Acute hemolytic transfusion reaction is a medical emergency that is usually caused by ABO incompatibility. Kell. but severe hemolytic reactions are uncommon.3 ng/dL (normal 0. (Choice C) T3 is not warranted for chronic treatment of hypothyroidism. (Choice D) IV antibiotics are used in patients with septic reaction. even lower levels of TSH (complete suppression) are required. Laboratory investigations show undetectable thyroglobulin.

.3 mU/mL. The correct way to administer levothyroxine is to take it on an empty stomach and separately from other medications. The patient is taking levothyroxine correctly.1 and 0.(Choice E). the dose of levothyroxine is adjusted to suppress the TSH below normal range. Educational Objective: In patients with thyroid cancer in remission. Taking levothyroxine with meals or other medication could significantly impair its absorption. 18% of people answered this question correctly. usually between 0.

His vital signs are stable. A valgus stress test is generally performed with the knee flexed at 20-30 degrees. He complains of right knee pain and swelling. Which of the following is the most appropriate screening test for this patient? A. He has no medical problems. and is often not significantly bloody. Locking of the knee joint on extension is generally seen. B. An isolated injury may occur after hyperextension of the knee. with tenderness over the medial aspect of the knee. On examination. unlike ACL or osteochondral injuries. Medial meniscus D. The rapid onset of a knee effusion and an unstable knee are common. An abduction injury with a torsional component causes a medial collateral ligament tear in most of the instances. A bucket handle tear is the most common type of medial meniscus tear. The medial meniscus is more commonly injured. as compared to the lateral meniscus. His vital signs are within normal limits. He drinks 1-2 beers daily. the knee joint is swollen due to the effusion. and may not have an unstable knee. there is mild swelling and stiffness. Posterior cruciate ligament C. (Choice A) ACL injuries are common in athletic activities. wherein a posteriorly directed force is placed on the anterior aspect of the proximal tibia. and a popping sensation at the time of injury. Educational Objective: The classic dashboard injury results from a posteriorly directed force on the anterior aspect of the proximal tibia with the knee in a flexed position. Unlike patients with ACL injury. On examination. Medial collateral ligament E. (Choices E and F) Medial and lateral collateral ligaments are injured when the line of force strikes from the side of the joint. A similar injury can be seen in an athlete who falls on a flexed knee with the foot in plantar flexion. tenderness is generally felt along the medial side of the knee. Perform colonoscopy at the age of 50 and repeat in 10 years.A healthy 27-year-old Caucasian man is brought to the emergency department after being involved in a motor vehicle accident. while the other hand stabilizes the femur. one hand pulls the proximal tibia. In medial meniscus injuries.g. It is done with the patient's knee flexed at 20 degrees. Perform colonoscopy now and repeat in 10 years. He was sitting in the front seat without a seat belt. McMurray?s sign is snapping felt with tibial torsion and the knee flexed at 90 degrees. Anterior cruciate ligament B. Lateral collateral ligament Explanation: This patient has a classic ?dashboard? injury. As the medial collateral ligament resists valgus angulations at the knee. His father was diagnosed with colon cancer at the age of 63. He has no complaints. Examination shows no abnormalities. Effusion with meniscus injuries takes about 24 hours to form. This results in disruption of the posterior cruciate ligament (PCL). injury to this ligament leads to increased angulation of the affected knee on valgus stress. He has smoked one pack of cigarettes daily for twenty years. Which of the following was most likely injured in this patient's knee joint? A. His knees hit the front dashboard. 47% of people answered this question correctly. with sudden turning while running). these patients do not complain of a typical ?popping? sound. (Choices C and D) Meniscal injuries principally occur after a twisting injury to the knee with one foot fixed to the ground (e. A healthy 43-year-old Caucasian man comes to the physician for a routine health maintenance examination. Patients generally complain of pain and swelling of the knee. . with the knee in a flexed position. Lachman's test is a very sensitive physical test for acute anterior cruciate ligament tear. This results in disruption of the posterior cruciate ligament (PCL). Up to 33% to 90% of patients with an ACL tear experience a ?popping? sensation.

She has no other medical problems. (Choice E) Sigmoidoscopy may also be used for screening purposes. These include fecal occult blood testing (FOBT). how many patients will need to be treated in order to prevent one relapse during the first six months of therapy? A. Eight patients C. 5 more patients showed improvement. Five patients Explanation: The number needed to treat (NNT) is a useful measure to evaluate the efficacy of a therapy and the risk of adverse events. She refused to take medications before. There is a new treatment A available that is apparently highly effective to prevent multiple sclerosis relapses. and 40 for the high-risk patient. The age at which screening for colorectal cancer should be started is 50 for the average-risk patient.C.20=0. Educational Objective: Patients with a history of colorectal cancer in first-generation relatives should start having screening colonoscopy at 40 years of age. but it should be repeated after five years. Obtain genetic testing. which can sometimes outweigh the benefits. (Choice D) Genetic testing is indicated in patients with a family history of FAP or HNPCC. colonoscopy. There are various options for colorectal cancer screening. sigmoidoscopy. Patients managed with placebo had an incidence of 25% during the same time period.20) for treatment A. D. but she is now willing to do so. Four patients B. Explanation: The above patient has a high risk of colorectal cancer (based on his family history).05 (or 5% of ARR). alcohol or tobacco. FOBT + sigmoidoscopy. and screening should be repeated every 10 years. Educational Objective: . This means that 20 patients need to be treated in order to prevent one multiple sclerosis (MS) relapse during the first six months of therapy. Perform sigmoidoscopy now and repeat in 10 years. A 42-year-old Caucasian woman comes to the office for a routine follow-up. All such patients should be screened earlier. Perform colonoscopy now and repeat in 5 years. Colonoscopy is the recommended screening test by the American College of Gastroenterologists. and double contrast barium enema.25) for placebo and 20% (0. She does not use drugs. Twenty patients D. Considering this information. E. the relative risk reduction (RRR) and absolute risk reduction (ARR) must first be determined. Examination shows no abnormalities. The ARR can be obtained by subtracting the RRR of the treatment group from the placebo group: 0. This means that for every 100 patients that used Treatment A.25-0.05=20. A medicine journal shows that treatment A reduced the incidence of relapses to 20% after 6 months of treatment. and has had no relapses ever since. 23% of people answered this question correctly. Ten patients E. In order to calculate the NNT. A normal colonoscopy result is followed by a repeat colonoscopy after ten years. The NNT is equal to 1/ARR. She was diagnosed with multiple sclerosis three months ago. 1/0. The relative risk reduction (RRR) values are 25% (0.

It is calculated by getting the inverse of the ARR (1/ARR). The ARR is calculated by subtracting the relative risk reduction (RRR) of the therapy group from that of the placebo group. NNT is a useful measure to evaluate the efficacy of a given therapy. . 50% of people answered this question correctly.The NNT is the number of patients that need to be treated in order to prevent or cure one disease or medical condition.

Physical examination shows a thin boy in apparent distress. In a patient with sickle cell disease. cold. Ibuprofen (Choice B) is not typically administered to patients in sickle cell crisis. The first step in management of patients (especially children) presenting with an acute painful episode is the administration of fluids orally or intravenously to ensure optimal hydration (Choice A). blood pressure of 110/70 mm Hg. Although most of these crises have no identifiable cause.5 g/dL to be a major risk factor for the development of an acute painful episode. alcohol consumption. stress. the peripheral blood smear (Choice E) usually reveals irreversible sickling of 5-50% of red blood cells. the presence of sickled cells is not diagnostic of an acute pain episode. Urinalysis and 24-hour measurement of urinary output E. Item 1 of 2 What is the next best step in the management of this patient? A. His medical history is otherwise unremarkable. events such as dehydration. Intravenous morphine is the most commonly prescribed analgesic in sickle cell patients. as it does not provide adequate pain relief. which provides pain relief superior to meperidine. and abdomen. infection. Urinalysis and the measurement of urinary output (Choice D) would be particularly helpful if urinary tract infection or dehydration were suspected in a patient with sickle cell crisis. . and respirations of 24/min. 64% of people answered this question correctly. Some studies have also shown hemoglobin >8. Various areas of the body can be affected. Objective clinical signs such as fever or tachypnea are seen approximately half the time. Chest auscultation is unremarkable and heart sounds are normal. Educational Objective: The first step in the management of patients (especially children) presenting with sickle cell crisis is the intravenous administration of fluids. and nocturnal hypoxemia are known triggers. However. ordering these tests would not be the very first step in management of sickle cell crisis. However. His vital signs include a temperature of 38C (100. He has a history of sickle cell disease and experienced an episode of sickle cell crisis six months ago. there are no laboratory tests that can be used to differentiate this type of crisis from baseline condition. pulse of 92/min. His tympanic membranes are pearly gray and the light reflex is present. Peripheral blood smear to evaluate for sickled cells Explanation: The sickle cell crisis is an episode of acute pain that can range in severity from minimal to agonizing. whimpering. Ketorolac IV for pain relief D. However.4F). He is clutching his abdomen. He does not allow you to palpate his abdomen. Intravenous fluids B. No exudates or lesions are visible in the oropharynx.The following vignette applies to the next 2 items A 6-year-old African American boy presents to the emergency department complaining of abdominal pain. fluid resuscitation should be performed first. and lying uncomfortably on the examination table. menses. Unfortunately. It is the most common type of vasocclusive event in patients with sickle cell disease. with the most common locations including the back. chest. extremities. Another option used (especially in patients stricken with bone pain) is the non-steroidal anti-inflammatory drug ketorolac (Choice C). Ibuprofen PO for pain relief C.

Therefore this child would be well advised to avoid contact sports until the splenomegaly resolves (Choice E). Her family history is not significant. Patients with SCC who do not receive blood transfusions in time have a mortality rate of 10-15%. splenic sequestration crisis is of greater concern in this patient. Refer for colposcopy B. She has no complaints. Examination shows no abnormalities. 48% of people answered this question correctly. She does not use tobacco. Educational Objective: A complete blood count should be obtained immediately in sickle cell disease patients who present with abdominal pain and splenomegaly. Schedule repeat Pap smear in 3 months . Hospitalization and administration of intravenous antibiotics (Choice D) is recommended for those sickle cell disease patients in pain who are febrile (>40. Blood and urine cultures B. Warn the boy?s parents that he should avoid contact sports until the splenomegaly resolves Explanation: Young children with sickle cell disease have a 30% risk of developing splenic sequestration crisis (SCC) and are more susceptible because their spleens have not yet become fibrotic. a dramatic fall in hemoglobin concentration occurs secondary to vaso-occlusion within the spleen and splenic pooling of red blood cells. What is the next best step in management of this patient? A. or are not receiving prophylactic penicillin. In SCC. Her vital signs are within normal limits. reveals "atypical squamous cells of unknown significance" (ASCUS). and the patient can go on to experience hypovolemic shock. Patients with splenomegaly are at increased risk for splenic rupture. intraperitoneal bleeding. She takes no medication. Therefore. She has no medical problems. A healthy 23-year-old Caucasian woman comes to the physician for a routine health maintenance examination. However. Intravenous antibiotics E. especially those with signs or symptoms of pulmonary involvement. it can be delayed until discharge. Chest x-ray C. and death can result. which is significant for splenomegaly. alcohol. Although the rupture itself may be painless. Obtain HPV testing on the sample C. however. performed three days ago. Complete blood count D. Blood and urine cultures (Choice A) are appropriate inclusions in the workup of febrile sickle cell patients and should ideally be obtained before antibiotics are administered. However. or drugs. a complete blood count (Choice C) should be ordered next for this child with splenomegaly.Item 2 of 2 The first step in the management of this acute pain crisis is undertaken.0C). Treat with doxycycline and repeat Pap smear in 6 weeks D. Since this warning is not immediately relevant. Typically the spleen rapidly enlarges. The child now allows for a brief physical examination of his abdomen. appear toxic. as this patient group is at risk for developing splenic sequestration crisis. Her Pap smear. splenic sequestration crisis is of greater concern in this patient. either from trauma or infiltrative disease that breaks the splenic capsule. shock. Chest x-ray (Choice B) is an appropriate inclusion in the workup of febrile sickle cell patients. Which of the following is the most appropriate next step in the management of this patient? A.

E. Reassurance and repeat Pap smear in one year .

acetaminophen. the sample for HPV DNA is discarded. peptic ulcer disease. Closed-angle glaucoma C. a colposcopy is performed. On examination. but this will result in a high percentage of false positive cases. headache. The prevalence of cataracts in this age group is almost 40%. an immediate colposcopy is performed. it is still less than 10%. Open-angle glaucoma B. His other medical problems include Alzheimer?s dementia. and degenerative joint disease. he has decreased vision in both eyes. or vertigo. as they may not benefit from cataract surgery. and if this test is positive for high-risk HPV type. (Choice E) Patients with ASCUS on cervical cytology possess a high risk of an underlying high-grade dysplasia. . HPV DNA testing is performed. Macular degeneration E. A 78-year-old white male who lives in a nursing home was sent to the physician?s office because he is having recurrent falls. and if cytology results are negative. If a second Pap smear is still abnormal. omeprazole. Retinal detachment Explanation: The common causes of decreased vision in elderly patients (especially above 75 years of age) are cortical cataracts and associated macular degeneration. nausea. (Choice A) An immediate colposcopy may be done to evaluate ASCUS. (Choice E) Retinal detachment usually presents with a sudden onset of unilateral loss of vision. (Choices C and D) Obtaining accelerated (every four to six months) serial Pap smears is another approach for the evaluation of ASCUS. (Choice C) Proliferative retinopathy is usually seen in diabetic patients. further diagnostic testing is recommended. If the test is negative for high-risk HPV type. and multivitamin tablets. The nursing home staff noticed that he has a progressive decrease in vision. His vital signs are stable. (Choices A and B) Even though the prevalence rates of glaucoma increase with age. In this method. In this method. Which of the following associated conditions is most likely contributing to his decreased vision? A. Without the history of diabetes. and bilateral anterior cortical cataracts. 22% of people answered this question correctly. therefore. the Pap smear is repeated after one year. The patient denies double vision. Among the above choices. and that of associated macular degeneration is 20%. Proliferative retinopathy D. Educational Objective: HPV DNA testing is the best way to evaluate atypical squamous cells of unknown significance. diverticulosis. HPV DNA testing is the most important next step in management. If cytology results are positive. This approach is less favored because of the greater number of follow-up visits and delays in the diagnosis. dizziness. He has been taking donepezil. serial Pap smear testing is done until two consecutive Pap smears are normal. samples are collected both for cytology and HPV DNA. These patients should be thoroughly evaluated for the severity of macular degeneration.Explanation: There are different approaches for the evaluation of ASCUS. vomiting. this diagnosis is very unlikely.

Continuing the intensive phototherapy (Choice B) is inadvisable. After an unremarkable labor she vaginally delivered a son weighing 3720 grams (8 lbs. Elderly patients should be thoroughly evaluated for the severity of macular degeneration. it is appropriate for the clinician to seek approval from the courts to proceed with treatments deemed medically necessary. as they may not benefit from cataract surgery. Intensive phototherapy has not adequately reduced the bilirubin concentration in the infant?s blood. The infant?s serum total bilirubin concentrations then rose rapidly and now.Educational Objective: Cataracts and associated macular degeneration are extremely common in the elderly population and often result in visual impairment. medical practitioners must seek to balance the autonomy of the family with the welfare of the child. Once alloimmunization to the Rh (D) antigen has been established. If the child?s life is endangered. A 27-year-old gravida 2. after clinical procedures or trauma that can cause fetomaternal hemorrhage. What is the next best step in managing this boy?s care? A. RhoGAM (anti-D immune globulin) must be given as a prophylactic measure at 28 weeks of gestation. 23% of people answered this question correctly. at 24 hours after delivery. Transfer infant to another hospital Explanation: In difficult ethical situations such as this one. Moreover. . specific blood-sparing techniques or erythropoietin may allow for excellent outcomes. which was not implied in this case. Continue intensive phototherapy for additional 72 hours C. Transferring the infant to another hospital (Choice E) irresponsibly evades the ethical conflict by placing the child?s care in the hands of physicians who do not know his history. phototherapy will result in a decrease in the bilirubin within 4-6 hours. clinicians must seek to balance the autonomy of the family with the welfare of the child. RhoGAM administration (Choice A) is no longer effective. and at the conclusion of any pregnancy. Typically. however. For instance. para 1 Caucasian woman at 38 weeks of gestation was admitted to the labor and delivery unit after the spontaneous rupture of membranes. Consult with the hospital?s ethics committee about seeking court injunction to mandate exchange transfusion E. in circumstances in which an infant?s survival is at stake. Administer RhoGAM to mother and infant B. it is appropriate for the medical team to seek approval from the courts to proceed with a blood transfusion (Choice D). when surgeries are performed on Jehovah?s Witness adherents (be they adults or children). Proceed immediately with exchange transfusion to prevent kernicterus D. In a R (D)-negative woman carrying a fetus that is or may be R (D)-positive. Waiting another 72 hours puts the child at serious risk for developing kernicterus. Transfers should only be initiated if the hospital currently caring for the boy is unable to properly address his medical issues. It therefore should not be administered to the mother in this case. but invites litigation if done without first obtaining the approval of the court. Without the transfusion. Proceeding with the exchange transfusion (Choice C) may save the infant?s life. Shortly after birth. Parental wishes should be honored within certain parameters. the infant was found to have hemolytic disease of the newborn secondary to Rh incompatibility. are measured at 22. the infant will likely suffer severe brain damage or death. 3 oz). Educational Objective: In providing medical care.8 mg/dL. including those with hemolytic disease of the newborn. The parents of this child are Jehovah?s Witness adherents and refuse the proposed exchange transfusion. However. there is no current indication for the administration of RhoGAM to children.

multiple myeloma. The best response is seen in patients with radiosensitive tumors such as lymphoma. radiation therapy should be started.A 55-year-old Caucasian female presents to the emergency department with complaints of severe back pain and difficulty walking. (Choices A and B) High-dose corticosteroids are considered a part of standard therapy for ESCC. Corticosteroids exert their effect by decreasing the edema and swelling around the tumor tissue. She describes the back pain at the mid-thoracic level. nonHodgkin?s lymphoma. These should always be used along with radiation therapy. This patient presents with a classic thoracic radicular pain (wraps around the abdomen) and neurological symptoms of ESCC. Her neurological examination reveals a motor strength of 3/5 in both lower extremities. and the treatment should be instituted as soon as possible. severe migraine headaches. and prostrate cancer. Give low-dose corticosteroids and consult radiation oncologist B. the physician for a routine health maintenance for oral contraceptive pills because she has a new hypertension. Which of the following is the most appropriate next step in the management of this patient? A. Give high-dose corticosteroids and order MRI of the spine C. and renal cell carcinoma. High-dose corticosteroids (especially dexamethasone) should be administered immediately. MRI is the investigative procedure of choice. Once the MRI confirms the diagnosis. Her symptoms started approximately two weeks ago and are progressively getting worse. bronchial She does not use tobacco. in studies. Her . thereby decreasing the compression. She denies any difficulty with bowel or bladder function. 68% of people answered this question correctly. A 36-year-old Caucasian woman comes to examination. posterior decompression with a laminectomy with or without radiotherapy has not been shown to be superior to radiotherapy alone. due to tumors other than lymphoma. breast and lung cancer. which wraps around her upper abdomen in a band-like fashion bilaterally. which was appropriately treated eight months ago with chemotherapy and radiation therapy. and MRI of the spine should be obtained to confirm the diagnosis. Radiation therapy is the definitive treatment of choice for most patients. A metastatic tumor from any primary site can cause ESCC. Get MRI of the spine and call the surgeon for emergent surgical decompression E. Moreover. Educational Objective: Symptomatic epidural spinal cord compression should be treated emergently with a combination of high-dose corticosteroids and radiation therapy. and a positive Babinski?s sign bilaterally. numbness. There is hyperreflexia of the knee and ankle reflexes. Some of the common cancers with a tendency to metastasize to the spinal column are: prostrate. and it is sometimes the initial presentation of cancer. (Choices C and D) Lymphoma is extremely radiosensitive and should be treated with radiation therapy. Call the radiation oncologist for therapy Explanation: Epidural spinal cord compression (ESCC) is a common complication of cancers. She also complains of weakness. It is a medical emergency. She is requesting a prescription boyfriend. It frequently causes pain and some degree of neurological dysfunction. Her other medical problems include asthma and gastroesophageal reflux disease. alcohol. breast. She has a past history of non-Hodgkin?s lymphoma. Radical surgical resection with tumor debulking has shown to improve outcomes if done early and should be considered in patients with ESCC. Emergent surgical decompression with posterior laminectomy D. and tingling in both her lower extremities. or drugs.

albuterol metered dose inhalers. Her medications include hydrochlorothiazide. Strong family history of ovarian cancer E. The presence of which of the following makes this patient an unsuitable candidate for oral contraceptive pills? A. Her blood pressure is 120/80mm Hg and pulse is 76/min. and famotidine. Examination shows no abnormalities. Her father has diabetes mellitus. Her age and nonsmoking history B. Her history of migraine headaches . Her maternal grandmother was diagnosed with ovarian cancer at the age of 56 years. and her paternal grandfather was diagnosed with prostate cancer at the age of 70 years. Her well controlled hypertension D.mother has ovarian cancer. Her history of bronchial asthma C.

35 ? 5. which is characterized by very low radioiodine uptake (generally less than 5% at 24 hours). this may normalize after treatment. and a family history of malignancies are not contraindications to the use of oral contraceptives. sweating. Increased diffuse uptake C. She also has pain in front of her neck. poorly controlled hypertension 3. heavy smokers who are older than 35 7. history of thromboembolic event or stroke 2. Her temperature is 38. postpartum thyroiditis.0 mU/mL) Item 1 of 2 The erythrocyte sedimentation rate is 90 mm/hr. Radioactive iodine uptake is generally increased. Other systems are essentially unremarkable. Viral infections have been implicated as a cause of subacute thyroiditis. Thyrotoxicosis in subacute thyroiditis is due to the release of stored thyroid hormones by inflammatory damage. The following vignette applies to the next 2 items A 26-year-old Caucasian female comes to your office because of fever. pregnancy 5. bronchial asthma. and shortness of breath. Thyrotoxicosis with low radioactive iodine uptake is also seen in painless thyroiditis. A radioactive iodine uptake scan is mostly likely to reveal: A. 61% of people answered this question correctly. The thyroid gland is slightly enlarged and tender. and D) Increased diffuse uptake is seen in toxic multinodular goiter. hypertriglyceridemia Relative contraindications are the following: 1.Explanation: The absolute contraindications to the use of oral contraceptives are the following: 1. Normal uptake Explanation: This patient has classical clinical manifestations of subacute thyroiditis.3 C (101 F). heat intolerance.01 mU/mL (normal 0. blood pressure is 156/60 mmHg. All these diseases have an overproduction of thyroid hormones. Educational Objective: Migraine headache is a relative contraindication to the use of oral contraceptive pills. Extremities are warm and moist. however. migraine headaches 2. anticonvulsant drug therapy (Choice F) Diabetes mellitus. . and iodine-induced thyroiditis. Hot nodule E. (Choices B. abnormal uterine bleeding 6. pulse is 110/min. and respirations are 22/min. surreptitious thyroid hormone administration. C. history of estrogen dependent tumor 4. and increased patchy uptake is seen in toxic adenoma. Decreased uptake B. Thyroid function tests are as follows: T3: T4: TSH: 256 ng/dL (normal 80-180 ng/dL) 15 mg/dL (normal 4-12 mg/dL) < 0. Increased patchy uptake D. active liver disease 3.

Propylthiouracil B. Rarely. Standard therapy for subacute thyroiditis consists of a NSAID usually combined with beta-blockers (Choice E). NSAID and beta-blocker Explanation: As explained before. Her cervix is 70% effaced and dilated to 3 centimeters. Bacterial thyroid infections are treated with systemic antibiotics. (Choice D) Occasionally. Patients with bacterial infections of the thyroid gland are usually not thyrotoxic because the involvemement in the thyroid gland is central. para 1 Caucasian woman at 38 weeks of gestation is admitted to the labor and delivery unit after complaining of uterine contractions spaced ten minutes apart. The majority of patients with subacute thyroiditis become euthyroid. During her initial pelvic examination. In suppurative thyroiditis. HPV is . which work by decreasing the synthesis of thyroid hormones. the left thyroid lobe is commonly involved (85%) and skin overlying the thyroid gland is erythematous. Administer acyclovir intravenously E. suppurative infection of the thyroid gland is difficult to differentiate from subacute thyroiditis. 62% of people answered this question correctly. hyperkeratotic papules are discovered on her posterior introitus. a systemic glucocorticoid (like prednisone) is required for short period in patients who are very sick and do not respond to standard therapy. several flesh-colored. Treatment with thyroxine may be temporarily required during the hypothyroid phase in severely symptomatic patients. Perform cesarean section Explanation: Condyloma acuminata is the dermatologic manifestation of an infection with the human papilloma virus.Educational Objective: Thyrotoxicosis with low radioactive iodine uptake is seen in subacute thyroiditis. have a smooth surface. Her medical records are not currently available. Radioactive Iodine D. thyrotoxicosis in patients with subacute thyroiditis is due to the release of preformed thyroid hormones. radioactive iodine (Choice C) is incorrect. but the patient states she had a normal pregnancy without any complications. Administer Pitocin to accelerate labor C. The papules range from 1-2 centimeters in diameter. Methimazole C. and are sessile. A 32-year-old gravida 3. and surgical drainage is required in more than 60% of the patients. Thyroid ultrasound may reveal an abscess formation. What is the next best step in managing this situation? A. Systemic antibiotics E. and labia minora. labia major. Administer magnesium sulfate for tocolysis D. are ineffective. Item 2 of 2 What is the best treatment option for this patient? A. with over 90% of such condylomas arising from HPV subtypes 6 and 11 specifically. Educational Objective: Standard therapy for subacute thyroiditis consists of a NSAID usually combined with beta-blockers. The thyrotoxic phase lasts for a few weeks and is then usually followed by a phase of hypothyroidism that can last for a few months. Allow labor to continue without any intervention B. therefore. Due to the same reason. antithyroid drugs (Choices A and B). The patient denies any awareness of the lesions and says she has no history of sexually transmitted diseases.

but always relapsed within the first week. perineum. no intervention is usually undertaken (Choice A). cervix. and dopamine reuptake. Citalopram Explanation: Because nicotine is so highly addictive. Cesarean section (Choice E) was often done in previous decades as a preventive measure to avoid HPV transmission. not human papilloma virus (HPV). larynx. and fluorouracil are used in treating HPV. Another typically well-tolerated option is sustained release bupropion.g. vagina. They are not typically prescribed for smoking cessation. One relatively common benign laryngeal tumor in children. Some individuals find nicotine replacement therapy (e. HPV may be found in the oropharynx. Which of the following medications is commonly prescribed for smoking cessation? A. nicotine gum. serotonin. Bupropion E. 44% of people answered this question correctly. Less frequently. and the areas affected include the penis.primarily transmitted through sexual contact. prescribed for smoking cessation. vulva. recurrent respiratory papillomatosis. Tocolysis with magnesium sulfate (Choice C) is not necessary as this woman is at 38 weeks of gestation and is expected to have a normal vaginal delivery. Topical medications such as trichloroacetic acid. or trachea secondary to oral-genital contact or secondary to vertical transmission from mother to infant during childbirth. It is now only done for HPV infection if the condylomas are thought to be so large that they might bleed excessively during a vaginal childbirth. Her husband was just diagnosed with lung cancer. She is now inquiring about other available options. (Choice C) Trazodone is an antidepressant that inhibits serotonin reuptake. Educational Objective: Condyloma acuminata is a manifestation of infection with HPV and is not considered a contraindication to vaginal delivery in the pregnant woman. she attempted to stop smoking by using the nicotine patch or nicotine gum. and she is now extremely concerned about her own risk of developing lung cancer. and dopamine. (Choices A and E) Fluoxetine and citalopram are antidepressants categorized as selective serotonin reuptake inhibitors. It is not typically . Fluoxetine B. She has smoked 1/2 pack of cigarettes daily for the past 20 years. podophyllin. It is not typically prescribed for smoking cessation. A 41-year-old Hispanic woman comes to a family practice clinic to discuss her desire to stop smoking. serotonin. is caused by the acquisition of HPV during passage through the vaginal canal. Trazodone D. The combination of bupropion and nicotine replacement therapy is particularly effective. However. and perianal region. (Choice B) Venlafaxine is an antidepressant that inhibits norepinephrine. Pitocin (Choice B) is not indicated since the woman was just admitted and her labor is progressing satisfactorily at this time. Acyclovir (Choice D) is a popular and effective medication for the treatment of herpes simplex virus (HSV). since HPV is thought to be contracted by the infant in less than 1% of all childbirths to women who have condylomas. Venlafaxine C. nicotine inhaler) helpful in the quest to stop smoking. an antidepressant that inhibits neuronal uptake of norepinephrine. smoking cessation is a difficult undertaking for many patients. nicotine patch. On several occasions..

95% of people answered this question correctly. .Educational Objective: Bupropion is a drug prescribed both as an antidepressant and for smoking cessation.

7 C (98 F). The patient eats a high-fiber vegetarian diet. Item 1 of 4 Which of the following is the most effective strategy to decrease this patient's risk for developing further complications? A. Past medical history is significant for mitral valve prolapse and fibromyalgia. bilateral exaggeration of deep tendon reflexes with clonus. High fiber diet Explanation: Several studies have suggested a strong correlation between alcohol intake (Choice A) and the development of colon cancer. consumes 3-4 alcoholic beverages per day. and pain in the right upper quadrant of the abdomen. NSAID intake C. Medications include hormone replacement therapy and ibuprofen.A 57-year-old Caucasian female presents to the primary care physician for a follow-up visit after undergoing a routine colonoscopy. The colonoscopy revealed adenocarcinoma of the ascending colon and two well-differentiated sessile adenomatous polyps of the sigmoid colon. Fibrous diets rich in fruit and vegetables. blood pressure is 220/110 mmHg. Family history is negative for cancer. The pelvic exam shows 50% effacement. It is thought that the mechanism responsible may involve interference of folate absorption or decreased folate intake. The following vignette applies to the next 4 items A 22-year-old primigravida is hospitalized at 34 weeks gestation because of blurred vision. Educational Objective: Colon cancer has been associated with significant alcohol intake and cigarette smoking. The patient is very concerned about being diagnosed with colon cancer. While you are obtaining IV access. An airway is secured. Speed vaginal delivery D. Urinalysis reveals proteinuria of 3+. Which of the following factors placed her at greatest risk for developing the disease? A. Start parenteral clonidine . Regular NSAID intake (Choice B). and a diet high in fruits in vegetables (Choice E) are all thought to offer some protection against the development of colon cancer. the amount of alcohol in a 12 oz beer is 13 grams). and has a remote 10-pack-year history of smoking tobacco. and breathing is present. hormone replacement therapy in postmenopausal women (Choice D). headache. and a positive Babinski. and respirations are 20/min. the patient starts to have generalized tonic-clonic seizures. Past surgical history is significant for hysterectomy. Start magnesium sulfate infusion C. hormone replacement therapy. The fundoscopic exam is normal. there is swelling of her face and both her hands. Hormone replacement therapy E. regular NSAID use. especially given her heavy alcohol consumption. However. She rarely exercises. Tobacco use D. Check vital signs every four hours B. On examination. especially in those individuals consuming 45 grams or more of alcohol per day (for sake of comparison. and 3 cm dilation of the cervix. this woman?s remote 10-pack-year history of smoking is likely not the most significant factor in the development of her colon cancer. and regular exercise have been identified as protective factors. Her temperature is 36. Tobacco use (Choice C) has been linked to an increase in both incidence and mortality of colon cancer. Alcohol intake B. pulse is 80/min. 22% of people answered this question correctly.

Start phenytoin infusion .E.

termination of pregnancy is advised in order to stop the pathologic process. Eclampsia can cause several other complications besides seizures. Methyldopa B. This would have been a correct choice if the question had asked about the best next step in the management of this patient. the most effective treatment to prevent further complications is to accelerate delivery. there are some reports of impaired fetal growth. Speeding up the delivery is the most important. Patients with severe preeclampsia are at greater risk of developing eclampsia. it is not as effective as pregnancy termination. Atenolol Explanation: In pregnant patients with a hypertensive antihypertensive drugs of choice. Furthermore. (Choice B) Although magnesium sulfate is beneficial. . antihypertensive drugs of choice. Anticonvulsant medications can be administered after placing two largebore needles in the patient. such as disseminated intravascular coagulopathy. Item 2 of 4 Which of the following is the most effective agent to treat this patient's hypertension? A. especially with atenolol if used in the early part of a pregnancy. etc. (Choice A) Frequent monitoring of vital signs is part of the management. crisis. If the patient is in the third trimester. seizures are not the only complication of eclampsia. either hydralazine or labetalol are the (Choice C) ACE inhibitors are contraindicated in pregnancy.Explanation: This patient was admitted to the hospital because she has a severe preeclampsia. (Choice A) Methyldopa is the preferred agent for oral therapy in mild to moderate hypertension. (Choice D) Clonidine is not indicated in this setting. especially in the last six weeks. acute renal failure. Either hydralazine or labetalol are the (Choice E) Phenytoin or diazepam is not as effective as magnesium sulfate in controlling seizures. as mentioned above. Labetalol C. intracerebral hemorrhage. Magnesium sulfate prevents seizures. hepatocellular injury. 40% of people answered this question correctly. Enalapril D. Educational Objective: Eclampsia is a serious complication of pregnancy. Although betablockers are considered to be safe. but it will not prevent the patient from developing further complications. There is no pharmacologic therapy more effective than this intervention. The first priority in patients with eclampsia or postictal coma is respiratory and cardiovascular resuscitation. Amlodipine E. because hemodynamic stability and seizure control are important to attain before attempting delivery. which was later complicated with eclampsia. (Choice E) Atenolol is an oral agent (in USA) and is not indicated in the acute setting. but it will not stop the pathologic process. Although the most effective agent for hemodynamic and seizure control is magnesium sulfate. (Choice D) Calcium channel blockers are added to methyldopa as second line agents. liver rupture.

some studies have confirmed that magnesium sulfate is not only the best anticonvulsant medication for patients with eclampsia.Educational Objective: Either hydralazine or labetalol are the drugs of choice for the acute management of hypertension during pregnancy. Retinal vasospasm can also be seen in preeclampsia. the patient has another seizure. Subcapsular hematoma of the liver Explanation: This patient has preeclampsia complicated by eclampsia. Increased PGI 2 and Thromboxane A 2 ratio B. Educational Objective: The best medication to prevent further seizures in a patient with eclampsia is magnesium sulfate. Item 3 of 4 During labor. despite the use of magnesium sulfate. Magnesium sulfate has been proven to be more effective and to have a low neonatal morbidity. thereby leading to the clinical symptoms and complications of preeclampsia and eclampsia. Recently. although the use of diazepam should be limited due to its depressant effects on the fetus. This change results in an increase in peripheral resistance. Diazepam E. and does not increase. Diazepam or phenytoin can be added to the therapy if seizures persist. Phenytoin B. (Choice D) With diazepam.. the PGI 2 to Thromboxane A 2 ratio decreases. because it reflects the vascular damage that has occurred in other organs. diazepam. Retinal hemorrhages C. Which of the following is the most appropriate pharmacotherapy in order to avoid seizure recurrence in this patient? A. Glomerular capillary endotheliosis D. Retinal hemorrhage is considered to be an extremely ominous sign. Valproic acid Explanation: Anti-seizure prophylaxis in a patient with eclampsia has been a topic of prolonged debate.g. (Choice E) Valproic acid is not part of the therapy of eclampsia. myasthenia gravis). or phenytoin. Diazepam is more useful in the setting of status epilepticus. but it is also the more effective agent to prevent further seizures. Item 4 of 4 Which of the following is considered an extremely ominous sign/feature of this condition? A. as . Phenobarbital D. there is a greater risk of respiratory depression. Microangiopathic hemolytic anemia E. (Choice A) Phenytoin is also useful. (Choice C) Phenobarbital is reserved only for those cases in which seizures persist. or if the patient has contraindications to use magnesium sulfate (e. but it is not as effective as magnesium sulfate. and can be visualized on ophthalmoscopic examination. Methyldopa is preferred for oral therapy in mild to moderate hypertension during pregnancy. A deficiency in nitric oxide. (Choice A) Opposite to normal pregnancy. Magnesium sulfate C. 73% of people answered this question correctly.

Blood cultures D. low back pain. this can be the first manifestation of sickle cell disease. Most bony vaso-occlusive events occur primarily within the bone marrow cavity.well as an increase in Endothelin-I. (Choices B and C) Chest x-ray and blood cultures are frequently used as part of the work-up in patients with painful crises to reveal the precipitating factor. His blood pressure is 100/70 mmHg.7C (98F) and respirations are 30/min.m. these episodes occur primarily in the joints. Hemoglobin electrophoresis is employed to establish the diagnosis. with endothelial and mesangial cell swelling. All his immunizations are up-to-date. He has been developing normally and has met all the developmental milestones appropriately. On light microscopy. It results from the injury of RBC by the damaged endothelium that is usually associated with the condition. temperature is 36. Aspirin trial Explanation: The classical clinical scenario of a vaso-occlusive painful crisis of sickle cell disease is described.the former being a vasodilator and the latter a potent vasoconstrictor. She is a patient of your physician friend who is away for the weekend. Which of the following would be most helpful in establishing the cause of this patient?s problem? A. have also been incriminated -. (Choice E) Vasoconstriction of the hepatic vasculature can result in necrosis and hemorrhage of the periportal spaces and ultimately. Chest x-ray C. (Choice D) Microangiopathic hemolytic anemia can occur in preeclampsia and eclampsia. A 16-month-old African American boy is brought to the emergency department (ED) by his mother with several hours history of unlocalized pain and crying. (Choice C) Glomerular capillary endotheliosis is the typical glomerular lesion of preeclampsia/eclampsia. Digital systolic pressure E. pulse is 130/min. the glomerular diameter is increased. and her physician usually prescribes . She tells you that she has had low back pain for many years. and can be the first manifestation of sickle cell disease. His physical examination is significant for peripheral cyanosis and symmetric swelling of the hands and feet. She is very upset and angry because she had to call multiple times and was put on hold before she finally got in touch with you. Most are multifocal and associated with mild tenderness and localized edema. (Choice D) Digital systolic pressure in response to cooling is occasionally used to confirm the diagnosis of Raynaud phenomenon. His past medical history is insignificant. except for a runny nose that his mother noticed yesterday. In older children and adults. Educational Objective: Retinal hemorrhage is an extremely ominous sign of preeclampsia/eclampsia. Hemoglobin electrophoresis B. subcapsular hematoma. This presents in infants as painful swelling of the hands and feet (dactylitis or hand-foot syndrome). on a Saturday due to severe. back and chest. Educational Objective: Vaso-occlusive painful crisis presents in infants as painful swelling of the hands and feet (dactylitis or hand-foot syndrome). but it is not considered an ominous sign. A 52-year-old Caucasian woman calls you at 1:00 a. It involves a marked swelling of the glomerular capillary endothelium and deposits of fibrinoid material in and beneath the endothelial cells.

Ask her politely to calm down and call you back in the morning. C. B. and she is unable to sleep at all. Give her long-acting morphine for pain relief. You do not have any records available with you at this time. D. but she does not appear to be drug-seeking. .oxycodone for the pain. Ask the patient to take an extra dose of her pain medication. based on the history. E. Her pain is much worse. so that she can sleep through the night. What is the most appropriate reaction to the patient's request? A. She wants you to prescribe something stronger. Inquire about her pain in detail. Ask her to call her primary care physician on Monday.

the dosage required to attain a therapeutic INR (International Normalized Ratio) is individualized for each patient. Switch him to Coumadin C. He has a vague and generalized pain in his left leg. he has been taking 2. A 50-year-old African-American man comes to the emergency department (ED) because his left leg has been bothering him a lot. to recognize any change in the pain character or severity. Increasing the dose of her current medications or prescribing a more potent narcotic analgesic is not appropriate without further investigation into the cause of her worsening symptoms.Explanation: Chronic. (Choices A and D) Asking the patient to call back while she is having acute pain is unethical and inappropriate. IX. VII. It becomes even difficult in the absence of a long-term relationship with the patient (as in the above vignette). 87% of people answered this question correctly. This is most likely due to inadequate anticoagulation with warfarin. Her worsening pain should not be automatically assumed to be from her chronic back pain. The primary goal and challenge in the management of such patients is to recognize and treat the pain adequately and appropriately. Since his discharge from the hospital. Educational Objective: Any change in the character or intensity of pain in a patient with chronic pain syndrome should be thoroughly investigated. Warfarin is metabolized in the liver by the hepatic cytochrome P450 2C9 isoenzyme. low back pain is a common problem encountered in the primary care setting. It is difficult to recognize the pattern of drug use or abuse in patients who have an underlying chronic disorder that causes pain. It is important. The dosage of warfarin is mainly determined by the difference in the genetically determined rate of drug metabolism and the patient?s vitamin K status. patients on a vitamin . At this point. A venogram reveals recurrent acute venous thrombosis extending into the internal iliac vein and inferior vena cava. Although long-term therapy with warfarin is highly effective and causes a significant reduction in the frequency of recurrent venous thromboembolism. There is also marked swelling of the left leg as compared to the right lower extremity. Furthermore. (Choices B and E) The patient should be inquired regarding her pain complaints and triage based on her response. He does not have any other medical illnesses and is not taking any medications. It is not unusual to see a lot of patients being treated with long-term narcotic analgesics. and X. He was recently discharged from the hospital one month ago ago after being diagnosed and treated for deep venous thrombosis of the left leg. His INR (International Normalized Ratio) in the ED is 1.5 mg of warfarin daily in the morning. and to avoid drug abuse and dependency at the same time. The patient in the above vignette should be inquired about her current symptoms in detail and should be managed accordingly. Discontinue warfarin and begin thrombolytic therapy Explanation: This patient has recurrent deep venous thrombosis with a more proximal extension into the inferior vena cava. which exhibits multiple genetic polymorphisms that are responsible for the individualized dose requirements of patients. which of the following would you recommend for this patient? A. however. The anticoagulant effect of warfarin is mediated by the inhibition of vitamin K dependent gamma-carboxylation of factors II. and this is present both at rest and with activity. Increase the dose of warfarin to bring INR within therapeutic range B. Interrupt the inferior vena cava with a filter D.4. which should not be assumed to be due to underlying medical condition and should be thoroughly investigated. Ask him to take the warfarin dose at bedtime E.

Epinephrine is the drug of choice for anaphylaxis because it can reverse associated hypotension and bronchospasm. Complete physical examination looking for a tick B. (Choice E) The use of thrombolytic therapy in the treatment of acute deep venous thrombosis is controversial and is associated with a higher complication rate. and myocardial depression. IV diphenhydramine and furosemide Explanation: The clinical scenario described is consistent with an anaphylactic reaction. alterations in peripheral vascular resistance. thus. Epinephrine subcutaneously C. Educational Objective: The dosage required to attain a therapeutic INR (International Normalized Ratio) is individualized for each patient. The patient does not recall any bite or injury. Insertion of an IVC filter is usually indicated only in patients with acute venous thromboembolism who have a contraindication to anticoagulant therapy or who continue to have recurrent venous thromboembolism despite adequate anticoagulation. The physical examination reveals widespread wheals all over the body. he returned to the field and complained of shortness of breath and itching. In this case. Respiratory failure usually results from airway obstruction due to bronchospasm and/or laryngeal edema. Due to the potentially life-threatening nature of anaphylaxis. Switching from warfarin to a different agent or brand name is not indicated at this point. The following vignette applies to the next 2 items A 17-year-old Caucasian male is brought to the emergency department by his friend due to acute shortness of breath. He is apparently in acute distress and speaks in broken sentences. It is only considered if there is significant swelling which may compromise the arterial circulation to the extremity. or acute respiratory distress syndrome. and he should be followed closely with serial measurements of PT/INR. the patient's dosage of warfarin should be increased . Epinephrine IV followed by IV fluids D. Item 1 of 2 What is the best next step in the management of this patient? A. (Choice C) Insertion of an IVC filter is usually indicated only in patients with acute venous thromboembolism who have a contraindication to anticoagulant therapy or who continue to have recurrent venous thromboembolism despite adequate anticoagulation. . IV hydrocortisone and fluids E. His friend says that they were playing soccer and he went to the bushes to retrieve the ball. (Choice D) Changing the dose schedule does not affect the bioavailability of the drug and is therefore not required. Soon after. The two most typical causes of death in patients with anaphylactic reaction are respiratory failure and cardiovascular collapse. other complications that lead to respiratory failure are cardiogenic or noncardiogenic pulmonary edema. This patient seems to be in acute distress (broken speech indicates high degree of respiratory compromise) and should be given epinephrine IV. prompt treatment is required. (Choice B) Warfarin is the generic form of Coumadin. 43% of people answered this question correctly. they require higher doses of warfarin to achieve the desired INR. Cardiovascular collapse results from increased vascular permeability and hypovolemia.K-rich diet (green leafy vegetables) can have difficulty attaining a therapeutic INR.

the patient should be observed for as long as 24 hours in severe episodes of anaphylaxis. It should be given immediately because fatality rates are highest in patients whose treatment with epinephrine is delayed. fluid support should also be given to compensate for the relative hypovolemia due to the increased vascular permeability. The injector is administered by taking off the cap and pushing the opposite end firmly into the upper lateral thigh. Prescribe a daily antihistamine drug D. which scared him. Instruct how to use EpiPen injector E.In addition. EpiPen is an epinephrine automatic injector which should always be immediately available in case of recurrence. The most recent physical examination reveals minimal rash and clear lungs on auscultation. This information can expedite diagnosis and appropriate treatment. (Choice A) Because of the potential for biphasic reactions. Immediate discharge B. Such a device may be lifesaving if patients are inadvertently re-exposed to the offending agent. What is the most important step in the management of this patient? A. Advice not to play on that playground Explanation: The most important intervention from the list is instructing the patient about the proper use of EpiPen. Educational Objective: Epinephrine is the drug of choice for anaphylaxis because it can reverse the associated hypotension and bronchospasm. (Choices E and D) Antihistamine drugs and corticosteroids are usually given to patients with anaphylactic reactions. Advise to wear a sign that indicates his allergy C. but he wants to go home now. (Choice C) Daily antihistamines are prescribed to patients with frequent anaphylactic reactions if the allergen can not be determined or avoided. He states that he has never had such symptoms before. The EpiPen for adults delivers 0. Item 2 of 2 The patient is appropriately treated.3 mg). The patient should count to 10 before removing the pen to insure complete delivery of the medication.3 mL of 1:1000 epinephrine (0. (Choice B) Subcutaneous epinephrine can be used in patients without significant respiratory or cardiovascular symptoms. (Choice A) Epinephrine should be given immediately because fatality rates are highest in patients whose treatment with epinephrine is delayed. but these are less important in reversing acute life-threatening complications than epinephrine. Educational Objective: The most important intervention following an episode of anaphylaxis is instructing the patient about the proper use of EpiPen. 38% of people answered this question correctly. (Choice B) Another important measure would be wearing a Medic Alert bracelet or similar device at all times. . The patient should also be instructed to obtain immediate medical care after the injection of the drug. (Choice E) The patients should be instructed to avoid the exposure if the allergen that caused the reaction is identified. The needle is delivered into the thigh automatically.

The reason that many physicians still order this test." The infant?s vomiting has increased in the past month. In . but his weight has been stable. The infant had a decrease in appetite. this test should therefore not be ordered. Examination shows no abnormalities. however positive ANA test results are commonly found in around 20-25% of the normal population. however. an elevated ANA titer has no significance. It typically requires no intervention if the child is otherwise healthy and developing appropriately (the "happy spitter"). Which of the following is the most appropriate course of action? A. In the absence of any SLE symptoms. A mother brings in her 3-month-old son to the office because she is concerned about his "spitting up. Start her on low-dose hydroxychloroquine. and above 1:320 in three percent. She has no other medical problems. Prone positioning at night B. elevated ANA in low titers has no significance. Order anti-Smith and anti-dsDNA antibody levels. B. D. functional gastroesophageal reflux is considered the most likely diagnosis. Based on this presentation. is that they can reassure the patient if the test is negative. She has smoked one pack of cigarettes daily for five years. and occurs primarily at night. Explanation: ANA tests are highly sensitive (>95%) for SLE and are positive in almost all patients with SLE. if the test becomes positive. Explain to her that she does not require further testing. Other labs are unremarkable. C. Prescription of ranitidine to protect esophageal lining D. many will end up having further rheumatologic workup. Her mother has colon cancer. She has no complaints. Her vital signs are within normal limits. A study conducted on 125 normal individuals found an ANA titer above 1:40 in 32 percent. above 1:80 in 13 percent. She is requesting you to do a blood test to diagnose it early. and it came back positive at 1:80 titers (Normal is less than 1:40). In the absence of any SLE symptoms. You order a serum antinuclear antibody test. and is not bilious or projectile. His mother reports that the infant is mildly irritable after feedings. Prescription of cisapride as prokinetic therapy E. Order anti-dsDNA antibody levels. In the absence of SLE symptoms. She says her sister was recently diagnosed with systemic lupus erythematosus and has had several complications. but does not appear to experience significant pain. despite knowing the fact that it can yield false positive results. however. Reassurance should be offered to the mother that the "spitting up" is a normal occurrence in infants up to 24 months old. The vomit is typically composed of curdled formula. Order serum complement and ESR. A healthy 24-year-old Caucasian woman comes to the physician for a routine health maintenance examination. What should you recommend to the mother as the next best step? A. E. Surgical repair with Nissen fundoplication Explanation: Gastroesophageal reflux (GER) is a clinical diagnosis. She does not drink alcohol. positive ANA test results are commonly found in around 20-25% of the normal population. If the ANA test result is negative and the clinical picture is not highly suggestive of SLE. Educational Objective: ANA tests are highly sensitive (>95%) for SLE and are positive in almost all patients with SLE.75% of people answered this question correctly. Thicken formula with cereal C. no further workup for SLE is indicated.

and has been treated with pravastatin. (Choice C) H2 receptor antagonists such as ranitidine are appropriate in those infants with a more severe GER presentation and who have failed conservative treatment. He undergoes left carotid endarterectomy. the tongue deviates to the left. The episode lasted 15 minutes and resolved spontaneously. however. its availability is heavily restricted in the United States. He had a similar episode of right arm weakness two days ago. Formula thickening should be attempted first. (Choice E) The ansa hypoglossus nerve innervates the strap muscles of the neck. The surgery goes well and he recovers from the anesthesia without any complications. decreased cry. Left recurrent laryngeal nerve D. Which of the following structures is most likely damaged? A. Its marginal mandibular branch (which supplies the orbicularis oris muscle) is most commonly injured. however. Doppler studies shows 89% stenosis in his left carotid artery and 40% stenosis in his right carotid artery. (Choice E) Surgery is reserved for cases of GER that do not respond to medical management. this nerve may be sacrificed with impunity. Prescription medication and surgery are reserved for more severe cases of GER which have failed conservative treatment. as observed in this patient. Inadvertent retraction or transection of the hypoglossal nerve causes tongue deviation to the site of injury. His blood pressure is 140/90 mmHg and his heart rate is 70/min. upon protrusion of the tongue. and better weight gain. because cisapride can cause cardiac arrhythmias in some individuals. A 70-year-old Caucasian male presents to the emergency department due to right-sided arm and leg weakness that occurred several hours ago. with a resultant asymmetric smile. (Choice A) Prone positioning is another conservative treatment that may alleviate symptoms. (Choice D) The facial nerve can be damaged after it exits from the stylomastoid foramen and courses along the inferior portion of the ear. *Extremely important question for USMLE step-3 . In the recovery room. and is highly effective in increasing gastrointestinal motility. (Choice C) Recurrent laryngeal nerve injury leads to unilateral vocal cord paralysis. Inadvertent retraction or transection of the hypoglossal nerve causes tongue deviation to the site of injury. the mainstay of conservative treatment is thickening of formula with cereal. This nerve lies distal to the area of carotid dissection . He does not smoke or consume alcohol. Right facial nerve E.children with mild GER symptoms. Ansa hypoglossus nerve Explanation: A number of nerve injuries can occur during carotid endarterectomy. He was diagnosed with hypercholesterolemia on routine check-up three months ago. this treatment method is of some concern. Educational Objective: A number of nerve injuries can occur during carotid endarterectomy. and should be initially addressed with reassurance and formula thickening. which usually results in decreased emesis. (Choice A) The vagus nerve lies posterolaterally in the carotid sheath and is also at risk for injury during the procedure. because of the correlation between prone positioning and SIDS. Educational Objective: Functional GER is extremely common in infants. unlike the other nerves. with a resultant change in voice quality. Left hypoglossal nerve C. Left vagus nerve B. (Choice D) Cisapride enhances myenteric plexus acetylcholine release.

Her TSH level is 9 mU/ml (0. She has four siblings.antithyroid antibodies .ovulatory and menstrual dysfunction 29% of people answered this question correctly. However. Her menstrual cycles are regular. there is a high chance for a patient to become overtly hypothyroid. Routine screening of thyroid functions is controversial. She denies use of tobacco. A patient with a TSH level > 10 mU/ml is also generally treated with levothyroxine. Radioactive iodine uptake and scan E. and E) T3 measurement. the downside of the treatment in asymptomatic patients is the risk of overtreatment. You recommend esophagogastroscopy. but he replies that the procedure would give him a lot of discomfort. (Choice C) Thyroid ultrasound could be useful if thyroid enlargement is present. The American College of Physicians recommends screening women over 50 years with findings suggestive of thyroid disease.35 to 5. His occult fecal blood test is positive.A 50-year-old female was found to have abnormal thyroid function on routine blood testing. His past medical history is insignificant. Thyroid ultrasound D. No such pills exist. ?I gained some weight recently. When antithyroid antibodies are present with elevated TSH.? He complains of frequent heartburns that is relieved with food intake and over-the-counter antacids. Educational Objective: Asymptomatic subclinical hypothyroidism does not require treatment. which is defined as a mild elevation in TSH levels (5 to 10) accompanied by normal free T4 levels. therefore. You must be misinformed . (Choices A. She is currently asymptomatic and is taking no medications. thyroid ultrasound in the above case will not help in making management decisions. radioactive iodine uptake. all are alive and well. He has heard of ?video pills? that he can swallow and ?these would show the stomach. Thyroglobulin measurement Explanation: The patient has subclinical hypothyroidism.8 to 1.symptoms of hypothyroidism . He consumes 1-2 bottles of beer on weekends. Which of the following will be most useful in guiding her therapy? A. and thyroglobulin measurement play no role in the management of subclinical hypothyroidism. in order to monitor any change in size and look for dominant nodules (> 1 cm in diameter).3 ng/dl (normal 0. Family history is positive for a mother with hypothyroidism.? He requests for such a pill.an abnormal lipid profile . leading to increased bone loss and atrial fibrillation. His blood pressure is 150/90 mmHg and heart rate is 85/min. T3 measurement B. Her CBC. alcohol. but he used to smoke 1-2 packs of cigarettes daily for 25 years.8 ng/dl). Treatment is warranted in the presence of: . and I know I should give up fast food. and drugs. Treatment is warranted in the presence of (1) antithyroid antibodies. and (4) ovulatory and menstrual dysfunction. Antithyroid peroxidase (anti-TPO) measurement C. What is the best response to this patient?s request? A.0 mU/ml is normal) and free T4 is 1. The patient's physical exam is normal. Examination is unremarkable. serum chemistries. A 50-year-old Caucasian male presents to your office for routine check-up. The American Thyroid Association (ATA) recommends all individuals over the age of 40 to be screened for thyroid dysfunction. D. (3) symptoms of hypothyroidism. He says. (2) an abnormal lipid profile. He does not smoke currently. and lipid profile are within normal limits.

a novel technique that is gaining popularity in gastroenterology. Video pills have limited view and endoscopy is clearly preferred D. tumors. A video capsule is taken by the patient and video recording is traced by the outside sensors. A 77-year-old Caucasian man is brought to the office by his daughter because of hematuria. He denies frequency.009 Blood: Gross Leukocyte esterase: Negative Nitrites: Negative WBC: 1-2/hpf RBC: many/hpf Serum Chemistry: Serum Na: 141 mEq/L Serum K: 4. Cystoscopy B.5 mg/dL Ultrasonogram of the kidneys shows bilateral cortical atrophy but no other lesions. and hydrochlorothiazide. amlodipine.B. ulceration and inflammatory conditions. painless hematuria for the past week. or dribbling. chronic low back pain. Prostate-specific antigen D. Urine cytology . Retention of the capsule happens in less than 1% of patients. Video pills may be associated with high rates of GI perforation E. His other medical problems include hypertension. Currently. Endoscopy is preferred for the diagnosis of esophageal and stomach disease. He has smoked one pack of cigarettes daily for 46 years. His medications include an acetaminophen and codeine combination. Video pills have low resolution and are therefore inferior to endoscopy C. It can be helpful to identify the source of small bowel hemorrhage. Rectal examination shows no abnormalities. hesitancy. Intravenous pyelography C. Educational Objective: Wireless video endoscopy is an effective tool to diagnose some small bowel disease because visualization of the majority of the small bowel mucosa is not possible with push endoscopy. and chronic renal insufficiency. stomach and cecum are obtained by this technique. urgency. it has been proven to be an effective tool to diagnose some small bowel disease because visualization of the majority of the small bowel mucosa is not possible with push endoscopy.3 mEq/L Chloride: 105 mEq/L Bicarbonate: 20 mEq/L BUN: 53 mg/dL Serum Creatinine: 2. in no way can it currently replace endoscopy for the diagnosis of esophageal and stomach disease. therefore. (Choice B) The images acquired are of excellent resolution and have an 8:1 magnification. (Choice D) Complications of wireless video endoscopy are rare. The patient?s labs reveal the following: Urine: Specific gravity: 1. which is higher than that of conventional endoscopes. Video pills are a good alternative to endoscopy in your case Explanation: The patient is most probably talking about wireless video endoscopy. He complains of gross. (Choice E) Limited views of the esophagus. Which of the following is the most appropriate next step in the management of this patient? A.

Kidney cancers are best evaluated with USG or CT scan. Cystoscopy is the gold standard in the detection of bladder malignancy. especially bladder or prostate cancer. and cystoscopy is negative. evaluation for upper tract and the prostatic urethra tumors should be sought . a retrograde pyelogram at the time of cystoscopy is an alternative approach in these patients.E. This muscle weakness is exemplified by an inability to extend the knee against resistance. passive movements are within normal limits. (Choice C) An elevated PSA level will suggest the presence of prostate malignancy. This is why it is often performed during cystoscopy. This possibility has to be kept in mind in any elderly patient with painless hematuria. This sensory loss extends down the medial shin to the arch of the foot due to dysfunction of the saphenous nerve (branch of the femoral nerve). The likelihood of bladder carcinoma in this patient is higher than that of prostate cancer. which is an uncommon lower extremity nerve injury due to the nerve's location within the pelvis and anterior thigh. . he is unable to extend his right knee against resistance. with sparing of leg adduction (which is a function of the obturator nerve). USG is used if there is any suspected kidney mass. To look for ureteral tumors. (Choice E) An abdominal CT scan would have been the first option if the patient was young. He complains of severe pain in his right groin and is unable to extend his right knee. however. He has no other past medical problems. If the cytology is positive. The knee jerk is markedly decreased on the right side. Cystoscopy can reveal malignancies of the bladder and prostate. patients with significant femoral neuropathies exhibit weakness involving the quadriceps muscle group. Exposure to aniline dyes and a significant smoking history increase the patient's risk. (Choice B) IVP is not advisable because the patient has renal failure. The knee jerk also decreases in amplitude or becomes absent. and if kidney stones were being sought. Abdominal CT scan Explanation: This patient has a high risk of urinary tract malignancy. but it will not detect bladder carcinoma. especially if an elderly patient presents with painless hematuria. He is an avid athlete and runs five miles every day. Repeat Pap in 6 months B. however. Sciatic nerve injury C. A 35-year-old man comes to the emergency department after being involved in a snowmobile accident. Peroneal nerve injury E. There is a sensory loss over the anterior and medial thigh. On physical examination. it can sometimes identify bladder malignancy when cystoscopy is negative. Which of the following nerve injuries can most likely explain the physical findings? A. Obturator nerve injury D. and it is also a very useful test to detect prostate cancer. (Choice D) Urine cytology has a lower diagnostic yield than cystoscopy. Since he has renal insufficiency. On examination. sensory loss over the anterior aspect and most of the medial aspect of the thigh is typical. its use is contraindicated in renal failure. In addition. IVP is superior in the detection of malignancies of the upper urinary tract. giving contrast for CT scan may worsen his condition. medial shin. Urine cytology alone has a false negative rate of 65-80%. Educational Objective: The presence of hematuria should always be a matter of concern. Prepare for extubation Explanation: This patient is most likely suffering from a traumatic femoral nerve injury. and the arch of the right foot.

She does not use tobacco. Educational Objective: Femoral nerve injury is characterized by the following physical findings: inability to extend the knee. When the colposcopic exam is unsatisfactory. A colposcopic examination is satisfactory when an entire lesion and a transformation zone are visualized. but the ankle jerk is unobtainable. extension. C. Which of the following is the most appropriate next step in the management of this patient? A. the next step is always excision as this allows for histological examination. prolonged bed rest). The injury is usually located at the knee. or Loop Electrosurgical Excision Procedure (LEEP). In the above patient. weakness in leg adduction. fracture. Satisfactory colposcopy examination confirms CIN 1. She has no medications. 21-year-old Caucasian woman comes to the physician for a routine health maintenance examination. and knee extension are usually normal. The most common cause of compression or injury to the sciatic nerve in this region is trauma. There is sensory loss involving the lower leg. Laser ablation D. expectant management is preferred for biopsy proven CIN 1 with satisfactory colposcopic examination. (Choice C) A patient with an obturator nerve injury will present with pain. or HPV DNA testing at 12 months. the patient may also complain of paresthesias and/or sensory loss over the dorsum of the foot and lateral shin (superficial peroneal nerve territory). therefore. Cryosurgery C. Obturator neuropathy is often secondary to pelvic trauma or surgery. loss of knee jerk reflex. and E) All other choices would have been appropriate if colposcopic examination was unsatisfactory. (Choices B. treatment is indicated.g. She has no other medical problems. therefore. An asymptomatic. or if she seems to be non-compliant with followup.g. medial aspect of shin. LEEP Explanation: Most of the low-grade squamous intraepithelial lesions (LSIL) or low-grade cervical intraepithelial neoplasia (CIN I) regress spontaneously. Her annual pap smear reveals low-grade squamous intraepithelial lesions (LSIL).. Hip flexion. In contrast to a femoral nerve injury. and arch of the foot. Furthemore. laser conization. on the lateral aspect of the fibular head. Cold knife conization E. Ablation can be done with cryosurgery or laser. The knee jerk is normal. treatment may be indicated if the patient is anxious about her disease. and any deep-seated mass in the pelvis (e. Her family history is not significant. which includes hip dislocation. and excision can be done with knife conization.. including the hamstrings. (Choice D) A patient with a common peroneal nerve injury will usually present with an acute foot drop accompanied by weakness in foot dorsiflexion and eversion. Her vital signs are within normal limits. Expectant management includes repeat cytology at 6 and 12 months. In addition. colposcopy examination is satisfactory. abduction. If there is progression during the follow-up. or lesions are persistent after one year. available modalities are either ablation or excision. and sensory loss over a small area in the medial thigh. or replacement. D. sensation is spared above the knee. If the patient opts for treatment. both anteriorly and posteriorly. compression by external sources (e. hematoma). . Repeat Pap in 6 months B. Even if colposcopic examination is satisfactory. and sensory loss over the anterior and medial aspects of the thigh. Examination shows no abnormalities.(Choice B) A patient with a significant sciatic nerve injury will complain of weakness affecting most of the lower leg musculature. Other etiologies include wayward buttock injections. the next best step should be expectant management. the medial calf and arch of the foot may be spared secondary to the preserved innervation by the saphenous nerve (a branch of the femoral nerve). adduction. She does not drink alcohol.

CT scan of the head B. The patient shows a preference for peritoneal dialysis. 43% of people answered this question correctly. 34% of people answered this question correctly. and D) Other investigations may help detect other extra-renal manifestations of adult polycystic kidney disease. Intravenous pyelography E. and coronary revascularization procedures. splenic. C. pancreatic. Colonic diverticula 5. Chest x-ray D. Inappropriate selection of the study subjects may be present C. it is important to rule out diverticulosis. This can be done by performing a total colonoscopy. Multi-vitamin use seems to be ineffective in preventing cardiovascular events B. He asks the patient which modality (hemodialysis or peritoneal dialysis) she would choose if the need arises in the future. (Choices A. Mitral valve prolapse 6.30. favoring the treatment group. Educational Objective: Before considering peritoneal dialysis as a treatment option in patients with adult polycystic kidney disease. According to the study results. which can potentially complicate peritoneal dialysis. but began to separate in the third year. the overall relative risk of having the cardiovascular outcomes for the placebo group compared to the treatment group was 1. p = 0. but none of these will affect the decision to forego peritoneal dialysis. although the relative risk for only the fifth year of follow-up was 2. Which of the following investigations is needed before the patient can be considered as a candidate for peritoneal dialysis? A. it is important to rule out diverticulosis. While explaining the long-term management of the disease.5. and pulmonary cysts 2. Hepatic. Echocardiography C. Inguinal and abdominal hernias Before considering peritoneal dialysis as a treatment option in patients with adult polycystic kidney disease. non-fatal myocardial infarction.01. p = 0. A 43-year-old African female is recently diagnosed with adult polycystic kidney disease.Educational Objective: Expectant management is the preferred option for biopsy proven CIN 1 with satisfactory colposcopic examination. Aortic aneurysm 4. Which of the following statements is true concerning the study results given above? A. Cerebral aneurysms 3.05. Total colonoscopy Explanation: Patients with adult polycystic kidney disease are predisposed to the following extra-renal manifestations: 1. The outcomes of the study were cardiovascular mortality. B. A large-scale clinical trial was conducted to assess the effect of a multi-vitamin supplement on the risk of future cardiovascular events. Survival curves for the two groups were parallel during the first three years of observation. Latent period can be demonstrated on the survival plot . her physician addresses the issue of different modalities of dialysis therapy.

and NSAIDs (as needed) for the last several years. prednisone (7. His blood pressure is 90/70 mm Hg. (Choice E) The sample size is large enough to demonstrate the efficacy of therapy. His oxygen saturation by pulse oximetry is 92% on 2 liters of intranasal oxygen. Laboratory investigations reveal an increase in the total WBC count with a left shift. and the measure of outcome is unstable Explanation: The concept of latent period is demonstrated in this case. the RR for only the fifth year of follow-up clearly demonstrates the beneficiary effect of the therapy. however. The exposure must be continuous for a certain period of time (called latent period) in order to influence the outcome. The other systems are normal. favoring the treatment group.9C) and respirations are 24/min. He has been taking methotrexate (5 mg/wk). On the other hand. (Choice A) Overall. Educational Objective: The concept of latent period is an important issue in chronic disease epidemiology. . He has had rheumatoid arthritis for the past twelve years. There is no pallor or icterus. (Choice D) An extended period of continuous exposure may be necessary to affect the outcome of this study.D. Latency assumption is a very important issue to consider in chronic disease epidemiology. In this case.. heart rate is 110/min. On the survival plot. The follow-up period is too long for such a study E. EKG reveals sinus tachycardia with nonspecific ST-T wave changes. cancer or coronary artery disease) may have a very long latent period. and does not imply selection bias. The following vignette applies to the next 2 items A 66-year-old male with chronic rheumatoid arthritis comes to the emergency department with fever and cough productive of yellow sputum for the past ten hours. Lung examination reveals crackles on the left base. His mucous membranes are moist. The latent period from getting exposed to developing an outcome is relatively short in infectious diseases. The sample size is not large enough. (Choice B) The latent period demonstrated in this study is a natural phenomenon. 50% of people answered this question correctly.g. the relative risk (RR) is not statistically significant. you can clearly see that the survival curves run parallel to each other (latent period) and then begin to separate at the third year of followup. chronic diseases (e. Chest xray reveals a left lower lobe infiltrate.5 mg/d). temperature is 102 F(38. because it is ?diluted? by the earlier years of latency. His basic serum chemistry profile is normal. Physical examination reveals a sick-appearing male with cushingoid features. at least three years of continuous exposure to multivitamins were required to reveal a protective effect of the exposure on the cardiovascular outcomes. except for a serum sodium level of 131 mEq/L and BUN level of 27 mg/dL.

D. these patients can develop vascular collapse under stressful situations such as an infection due to a decrease in cortisol. Prompt administration of . Start fludrocortisone. Administer intravenous methylprednisone. Place arterial line and start dopamine. The hypotension in this patient should respond to fluid repletion and a stress dose of corticosteroids. Item 2 of 2 Intravenous fluids and antibiotics were administered after drawing blood cultures. Since ACTH does not control the secretion of mineralocorticoids from the zona glomerulosa of the adrenal glands. Sepsis B. cortisoldeficient patients are unable to mount a good pressor response during stress. and replace cortisol. sepsis should be considered. Educational Objective: Patients with chronic suppression of hypothalamic-pituitary-adrenal axis can have hypotension during acute infections. patients have normal plasma aldosterone levels and are normotensive. since cortisol promotes the synthesis of catecholamines in the adrenal medulla. B. (Choice A) Although this patient may have sepsis. (Choice E) This clinical picture and insignificant EKG changes make the diagnosis of cardiogenic shock unlikely. (Choice B) The secretion of aldosterone is not altered in patients with secondary or tertiary adrenal failure because aldosterone is not primarily regulated by ACTH. Perform dexamethasone suppression test. (Choice D) ACTH doesn?t have any direct effects on blood pressure or the vessel tone. 27% of people answered this question correctly. Furthermore. In secondary and tertiary adrenal failure. there are no significant abnormal mineralocorticoid levels. ACTH deficiency E. Aldosterone deficiency C. ACTH mainly works through the release of cortisol from the adrenal gland. C. When his blood pressure does not respond to adequate hydration and a stress dose of glucocorticoids. however. which may result in secondary or tertiary adrenal insufficiency due to the decrease in the plasma ACTH and cortisol levels. E. Cortisol deficiency D. which is the hormone responsible for the maintenance of vascular tone. Explanation: The primary goals of therapy in patients with acute adrenal insufficiency are to reverse the hypotension. Cardiogenic shock Explanation: This patient's history of long-term exposure to a glucocorticoid drug makes him likely to have chronic suppression of the hypothalamic-pituitary-adrenal (HPA) axis. Administer dexamethasone and perform cosyntropin stimulation test. he is more likely to have hypotension secondary to a suppressed HPA axis. Hypotension in these patients usually responds to administration of a stress dose of glucocorticoids and hydration.Item 1 of 2 What is the most likely cause of hypotension in this patient? A. correct the electrolyte abnormalities. What is the most appropriate next step in management? A. respectively.

(Choice D) Mineralocorticoid treatment is not necessary since it takes a long time to show its sodiumretaining effects. False negative occurs when a patient who really has the disease obtains a negative test result. positive predictive value . A 38-year-old Caucasian primigravida presents to the physician's office at 20 weeks gestation for prenatal counseling. she gives birth to a child with Down syndrome. Increase in positive predictive value D. true negative. (Choices A and B) Based on the above values. if triple screening turned out to be positive you should discuss the probability of having a given chromosome abnormality given positive test result. True negative occurs when a patient who really does not have the disease obtains a negative test result.intravenous steroids is indicated without waiting for the confirmation of the diagnosis. Intravenous dexamathasone is preferred because it is long-acting and does not interfere with the measurement of serum or urinary steroids during subsequent cosyntropin (ACTH) stimulation test. which of the following did he emphasize? A. for example. the physician explained to the patient in layman?s terms that triple screening has a sensitivity of 50% in detecting chromosome abnormalities. amniocentesis gives less false negatives and more true positives. Increase in sensitivity Explanation: Before expounding on the characteristics of a diagnostic test. false positive. and false negative. It is obtained by dividing the number of true positives by the number of people who have the disease (true positives + false negatives). (Choice C) The predictive value of a test gives the probability of a disease after running a test and getting the results. (Choice E) Dexamethasone suppression test is used for Cushing?s syndrome. The same effect can be achieved with normal saline very quickly.. True positive occurs when a patient who really has the disease obtains a positive test result (using the diagnostic test). It is obtained by dividing the number of true negatives by the number of people who obtained a negative result (true negatives + false negatives). She is concerned about the risk of Down syndrome. In this case.e. Eighteen weeks later. and that amniocentesis may detect approximately 90% of the cases. Increase in negative predictive value E. The physician explains that triple screening may detect up to 50% of the cases of chromosomal abnormalities. Educational Objective: Prompt administration of dexamethasone followed by ACTH stimulation test are indicated in patients with suspected acute adrenal insufficiency. . She decides not to undergo any test. The sensitivity of a test determines the capacity of the test to correctly diagnose a patient with the disease. The most commonly discussed characteristic of a diagnostic test is its sensitivity. When the physician compared amniocentesis to triple screening. Increase in false positives C. while amniocentesis has a sensitivity of 90%. Increase in false negatives B. and asks about the measures to diagnose it early. 20% of people answered this question correctly. False positive occurs when a patient who really does not have the disease obtains a positive test result. it is important to correctly define the following terms: true positive. (Choice D) The negative predictive value of the test determines the capacity of the test to correctly give a negative result. i.

Educational Objective: Sensitivity of a test is the probability of detecting the disease if it is present. .

weight change. (Choice D) Pituitary radiation is almost never the first choice in the treatment of pituitary tumors due to its delayed effect and risk of hypopituitarism. and increased a-subunits. acts on somatostatin receptors on the nonfunctioning pituitary adenomas. and is possibly due to compression of the pituitary stalk by the tumor. Her hormone profile reveals a prolactin level of 50 ng/mL (normal 5-20 ng/ml). but generally overproduce the a-subunit. dyspareunia. compressive symptoms. or loss of secondary sexual characters. which usually arises from the gonadotropinsecreting cells (gonadotrophs) in the pituitary gland. (Choice B) Treatment with estrogen and progesterone will improve her amenorrhea. they do not usually overproduce intact LH and FSH. LH overproduction is exceedingly rare. galactorrhea. intact FSH is overproduced by these tumors. Patients usually present with hypogonadism and low gonadotropin levels. MRI of the pituitary shows a 2 cm pituitary tumor with suprasellar extension. Bromocriptine orally D. (Choice C) Bromocriptine. a dopaminergic receptor agonist. which are dimeric glycoprotein hormones. (Choice E) Octreotide. . The physical examination is unrevealing. Her routine labs are within normal limits. which have common a and hormone-specific beta sub-units. The first-line therapy for most nonsecretory pituitary adenomas is transphenoidal surgery. She denies the use of tobacco. Large tumors can have local. Pituitary radiation E. It is not the preferred primary therapy because the decrease in tumor size with octreotide is usually minimal. Octreotide Explanation: The patient has hypogonadism with suppressed LH and FSH levels. The level of serum a-subunits is markedly increased. TSH and Beta-HCG are also dimeric glycoprotein hormones similar to LH and FSH. Her LH is undetectable. The increase in prolactin level in this patient is small. but will not have any effect on the large tumor. She is not on any medications. Occasionally. The serum asubunit levels are characteristically increased. Although these tumors arise from the gonadotrophs. hot flashes. What is the most appropriate management of this patient? A. a somatostatin analogue. Gonadotrophs secrete both LH and FSH. Estrogen-progesterone cyclically C. This is classically seen in a nonfunctioning pituitary adenoma. and FSH is low normal. Her pregnancy tests have been negative during this period. alcohol or intravenous drugs. including over-the-counter medications. The primary modality for the treatment is transphenoidal surgery. They are composed of a common a-subunit and hormone-specific b-subunit. She denies headaches. Her past medical history and family history are unremarkable. Patients might regain their normal gonadal functions after resection. Educational Objective: Nonfunctioning pituitary adenomas generally arise from gonadotropin-secreting cells of the pituitary glands.A 41-year-old female is seen for amenorrhea of eight months duration. 34% of people answered this question correctly. Transphenoidal pituitary surgery B. Her serum IGF1 levels are normal. visual change. has minimal effects on pituitary tumors other than prolactin and growth hormone-secreting tumors.

hot flashes. 34% of people answered this question correctly. Patients usually present with hypogonadism and low gonadotropin levels. The level of serum a-subunits is markedly increased. which have common a and hormone-specific beta sub-units. The physical examination is unrevealing. The primary modality for the treatment is transphenoidal surgery. and FSH is low normal. MRI of the pituitary shows a 2 cm pituitary tumor with suprasellar extension. The first-line therapy for most nonsecretory pituitary adenomas is transphenoidal surgery. The serum asubunit levels are characteristically increased. Large tumors can have local. Octreotide Explanation: The patient has hypogonadism with suppressed LH and FSH levels. .A 41-year-old female is seen for amenorrhea of eight months duration. Patients might regain their normal gonadal functions after resection. visual change. but will not have any effect on the large tumor. or loss of secondary sexual characters. Her routine labs are within normal limits. weight change. Her past medical history and family history are unremarkable. She is not on any medications. She denies headaches. TSH and Beta-HCG are also dimeric glycoprotein hormones similar to LH and FSH. Occasionally. including over-the-counter medications. It is not the preferred primary therapy because the decrease in tumor size with octreotide is usually minimal. She denies the use of tobacco. Educational Objective: Nonfunctioning pituitary adenomas generally arise from gonadotropin-secreting cells of the pituitary glands. has minimal effects on pituitary tumors other than prolactin and growth hormone-secreting tumors. Her LH is undetectable. This is classically seen in a nonfunctioning pituitary adenoma. which are dimeric glycoprotein hormones. and increased a-subunits. Her hormone profile reveals a prolactin level of 50 ng/mL (normal 5-20 ng/ml). LH overproduction is exceedingly rare. a dopaminergic receptor agonist. Estrogen-progesterone cyclically C. (Choice E) Octreotide. but generally overproduce the a-subunit. dyspareunia. They are composed of a common a-subunit and hormone-specific b-subunit. Gonadotrophs secrete both LH and FSH. compressive symptoms. Pituitary radiation E. which usually arises from the gonadotropinsecreting cells (gonadotrophs) in the pituitary gland. Her pregnancy tests have been negative during this period. a somatostatin analogue. (Choice B) Treatment with estrogen and progesterone will improve her amenorrhea. galactorrhea. alcohol or intravenous drugs. The increase in prolactin level in this patient is small. and is possibly due to compression of the pituitary stalk by the tumor. Transphenoidal pituitary surgery B. they do not usually overproduce intact LH and FSH. Bromocriptine orally D. (Choice D) Pituitary radiation is almost never the first choice in the treatment of pituitary tumors due to its delayed effect and risk of hypopituitarism. Although these tumors arise from the gonadotrophs. intact FSH is overproduced by these tumors. (Choice C) Bromocriptine. Her serum IGF1 levels are normal. acts on somatostatin receptors on the nonfunctioning pituitary adenomas. What is the most appropriate management of this patient? A.

Her pregnancy tests have been negative during this period. Transphenoidal pituitary surgery B. Her past medical history and family history are unremarkable. Bromocriptine orally D. intact FSH is overproduced by these tumors. The physical examination is unrevealing. She denies headaches. hot flashes. 34% of people answered this question correctly. (Choice D) Pituitary radiation is almost never the first choice in the treatment of pituitary tumors due to its delayed effect and risk of hypopituitarism. (Choice C) Bromocriptine. Her hormone profile reveals a prolactin level of 50 ng/mL (normal 5-20 ng/ml). She is not on any medications. The level of serum a-subunits is markedly increased. and FSH is low normal. (Choice E) Octreotide. Occasionally. galactorrhea. (Choice B) Treatment with estrogen and progesterone will improve her amenorrhea. acts on somatostatin receptors on the nonfunctioning pituitary adenomas. . TSH and Beta-HCG are also dimeric glycoprotein hormones similar to LH and FSH. but generally overproduce the a-subunit. Her LH is undetectable. alcohol or intravenous drugs. Educational Objective: Nonfunctioning pituitary adenomas generally arise from gonadotropin-secreting cells of the pituitary glands. but will not have any effect on the large tumor. The serum asubunit levels are characteristically increased. a somatostatin analogue. Octreotide Explanation: The patient has hypogonadism with suppressed LH and FSH levels. She denies the use of tobacco. Gonadotrophs secrete both LH and FSH. which have common a and hormone-specific beta sub-units. Estrogen-progesterone cyclically C. which usually arises from the gonadotropinsecreting cells (gonadotrophs) in the pituitary gland. This is classically seen in a nonfunctioning pituitary adenoma. including over-the-counter medications. which are dimeric glycoprotein hormones. MRI of the pituitary shows a 2 cm pituitary tumor with suprasellar extension. Pituitary radiation E. and increased a-subunits. Although these tumors arise from the gonadotrophs. dyspareunia. and is possibly due to compression of the pituitary stalk by the tumor. compressive symptoms. Large tumors can have local. weight change. LH overproduction is exceedingly rare. Her serum IGF1 levels are normal. The increase in prolactin level in this patient is small.A 41-year-old female is seen for amenorrhea of eight months duration. Patients might regain their normal gonadal functions after resection. Patients usually present with hypogonadism and low gonadotropin levels. They are composed of a common a-subunit and hormone-specific b-subunit. The primary modality for the treatment is transphenoidal surgery. What is the most appropriate management of this patient? A. has minimal effects on pituitary tumors other than prolactin and growth hormone-secreting tumors. Her routine labs are within normal limits. The first-line therapy for most nonsecretory pituitary adenomas is transphenoidal surgery. or loss of secondary sexual characters. It is not the preferred primary therapy because the decrease in tumor size with octreotide is usually minimal. they do not usually overproduce intact LH and FSH. visual change. a dopaminergic receptor agonist.

peptic ulcer disease and achalasia. syncope and black stool. sclerotherapy and band ligation) to stop active bleeding. Observation and supportive care B. He does not smoke or consume alcohol. (Choices C. . Educational Objective: In patients with Mallory-Weiss tear who are not actively bleeding. The physical examination is within normal limits. Thermal coagulation C. coughing. and D) Endoscopy also allows for therapeutic interventions (i. The "classic" presentation of hematemesis preceded by a bout of retching/vomiting only occurs in 30% of patients. Endoscopy reveals a single small longitudinal tear at the gastro-esophageal junction that is not actively bleeding. blunt abdominal trauma. His blood pressure is 120/72 mmHg while supine and 122/70 mmHg while standing. Sclerotherapy D. This procedure typically reveals a single longitudinal tear at the gastro-esophageal junction. endoscopy). and angiographic arterial embolization have been used occasionally to control severe or refractory hemorrhage. Item 2 of 2 Which of the following is the most likely associated finding in this type of patient? A. He denies ever having such symptoms in the past. observation and supportive care are typically necessary. (Choices B. and diagnostic or therapeutic manipulation (e. Peptic ulcer disease E. Gastric atrophy D.. Other precipitating factors include retching. (Choice E) IV infusion of vasopressin.The following vignette applies to the next 2 items A 33-year-old Caucasian male presents to the emergency department with two episodes of coffeeground colored vomiting. cardiopulmonary resuscitation. D. observation and supportive care are typically necessary. Item 1 of 2 Which of the following is the best management for this patient? A. thereby making this location the most likely to sustain a tear. According to different sources. Increased lower esophageal sphincter (LES) tone B. Endoscopy is the gold standard in establishing the diagnosis. hiccuping. IV infusion of vasopressin Explanation: This patient presents with upper GI hemorrhage caused by a Mallory-Weiss tear. Esophageal varicosities Explanation: Hiatal hernia is the most well known anatomical predisposing factor for Mallory-Weiss syndrome. but these are not predisposing factors to tears per se. Hiatal hernia C. straining. In patients with Mallory-Weiss tear who are not actively bleeding (such as the patient in this case).e.g. it is present in 40-100% of patients with this syndrome. vomiting. He also denies any abdominal pain. Band ligation E. and A) No significant association is present with gastric atrophy. (Choice E) Esophageal varicosities may be revealed in chronic alcoholics who present with this syndrome. esophageal balloon tamponade.. the transmural pressure gradient is greater within the hernia than the rest of the stomach. C. His past medical history is insignificant. primal scream therapy. dizziness. thermal coagulation. During retching or vomiting. His heart rate is 90/min.

He has a history of intravenous drug abuse in the past. His extremities and face appear to be thinned out. he showed a significant improvement in his CD4 lymphocyte count and a decrease in his viral titers. The rest of the physical examination is unremarkable. His past medical history. this presentation is classic and therefore more suggestive of HIV lipodystrophy. B. including those with HIV lipodystrophy. He has smoked one pack of cigarettes daily for the last 28 years. Although it decreases triglycerides levels and increases HDL levels. C. impaired glucose tolerance). this patient has severe triglyceride elevation. triglyceride level of 530 mg/dL. One of the important differences between Cushing?s syndrome . A 54-year-old Hispanic male comes for a routine follow-up visit and states that he might be losing weight. His main lipid abnormality appears to be hypertriglyceridemia. is unremarkable. (Choice E) Although central deposition of fat. he weighs 168 pounds (his weight one year ago was 160 pounds). for which he has been receiving highly active antiretroviral therapy (HAART) for one year. however. drug therapy is also indicated because of severe hyperlipidemia (triglycerides 530 mg/dL) and the presence of risk factors for a coronary event (male sex. He has fat tissue depositions on the back of his neck and on his abdomen. He does not drink alcohol. Although the mechanism of HIV lipodystrophy is unclear. It is preferred over other fibric acid derivatives because it has been extensively studied in patients with HIV infection. smoker. but he is currently not using any recreational drugs. Elevated liver enzymes are most likely due to steatosis. His increased total cholesterol is most likely due to an increase in VLDL (rather than LDL) cholesterol. (Choice A) Nicotinic acid is also likely to improve his lipid profile. the decrease in triglyceride levels is mainly seen in patients who have elevated LDL levels. protease inhibitors are most likely responsible. and high-density lipoprotein level of 29 mg/dL. except for minimally palpable hepatomegaly. and is therefore not preferred over gemfibrozil for this patient. His height is 5?9?? (175cm). Lab investigations reveal a normal complete blood count and routine basic chemistry. In this patient. treatment with atorvastatin will not be beneficial. His father had coronary artery disease and died of a heart attack at the age of 55 years. Start gemfibrozil therapy. particularly from his extremities. The drug interactions with gemfibrozil are less than those with other fibric acid derivatives.Educational Objective: Hiatal hernia is present in 40-100% of patients with Mallory-Weiss syndrome. Gemfibrozil is a fibric acid derivative which is mainly used for hypertriglyceridemia but can also cause a modest reduction of LDL cholesterol levels. His fasting blood sugar is 140 mg/dL and LFTs shows mild elevations of AST and ALT levels. It primarily reduces serum LDL cholesterol levels by inhibiting HMG-CoA reductase. Start nicotinic acid therapy. however. Drug therapy is necessary in addition to dietary and lifestyle modifications. In all patients with hyperlipidemia. Since the increase in total cholesterol in this patient is most likely due to the elevation of VLDL cholesterol. His lipid profile revealed a total cholesterol level of 280 mg/dL. it will not help to treat the glucose intolerance. (Choice C) Atorvastatin is not the first line therapy for patients with hypertriglyceridemia. He does not have hepatitis C or hepatitis B. and impaired glucose tolerance could suggest a diagnosis of Cushing?s syndrome in this patient. On examination. D. He has HIV infection. Following his HAART treatment. positive family history. E. a buffalo hump . Start atorvastatin therapy. Suggest NCEP ATP III dietary restrictions with other lifestyle modifications. (Choice D) Dietary modifications alone usually lead to an improvement in the lipid profile. What is the next best step in the management of this patient? A. Measure 24-hour urinary cortisol levels. dietary restrictions and lifestyle modifications are necessary. Explanation: This is a classic presentation of HIV lipodystrophy occurring after HAART. aside from his HIV infection.

and chorioretinitis. but can include papilledema. On funduscopic examination. broad-spectrum antibiotic therapy. night sweats. photophobia. which has been effective in slowing the deterioration of his immune function. The presence of candida endophthalmitis is a marker for widespread disseminated candidiasis and should not be taken lightly. back pain. The condition is frequently characterized by ocular pain. prior abdominal surgery. malaise. total parenteral nutrition. and lymphadenopathy. cough. The following Vignette applies to the next 2 items A 43-year-old HIV-positive Caucasian male with a history of intravenous drug abuse was admitted to the hospital for nausea and vomiting and severe pain in the mouth. Since his diagnosis he has been on prophylactic antibiotics and highly active antiretroviral therapy. Pulmonary cryptococcosis (Choice C) is characterized by fever. scotomas. anorexia. When he then became increasingly febrile. Risk factors that place patients at greatest risk for developing candida endophthalmitis include central venous catheters. and vomiting. Ocular manifestations are not expected. He had been diagnosed with AIDS four years ago after presenting with pneumocystis carinii pneumonia. Visual acuity is decreased. including the eye. and fever. off-white lesions with indistinct borders are seen. weight loss. and weight loss. Cryptococcosis D. Infective endocarditis C. dyspnea. Cushing?s syndrome presents with rounding of the face. optic neuritis. Infective endocarditis (Choice B) is often subtle and nonspecific in presentation. diarrhea. Gemfibrozil is the treatment of choice for hypertriglyceridemia seen in patients with HIV lipodystrophy. Ocular manifestations of CNS cryptococcosis are uncommon. which resolved with treatment. A vitreous haze is present. tachycardic. Candidiasis E. several large. corticosteroid therapy. fatigue. After admission. neutropenia. One rarely seen ocular manifestation of infective endocarditis is the Roth spot. the face is thinned out. CNS cryptococcosis is characterized by headache. Educational Objective: HAART can lead to lipodystrophic syndrome (redistribution of fat and insulin resistance) and significant hyperlipidemia. It may be characterized by fever. it proved necessary to begin total parenteral nutrition via a central venous catheter because of his inability to take in food or liquid by mouth. and is found in 10-28% of patients with candidiasis. which is a retinal hemorrhage with a pale center. accompanied by facial flushing called "moon facies". shortness of breath. altered mental status. Endogenous candida endophthalmitis (Choice D) is caused by hematogenous seeding of the eye with Candida species (especially C. fatigue. Aspergillosis Explanation: Oropharyngeal and esophageal candidiasis arises commonly in HIV-positive patients and can disseminate widely to multiple organs.and HIV lipodystrophy is the absence or loss of fat from the face. albicans). hypotensive. The lesions are three-dimensional and appear to extend from the chorioretinal surface into the vitreous. he was transferred to the intensive care unit. glistening. Measurement of 24-hour urinary cortisol will be normal in patients with HIV lipodystrophy and will be elevated in patients with Cushing?s syndrome. and pleuritic pain. Mycobacterium avium complex B. nausea. . and tachypneic. In patients with HIV lipodystrophy. Mycobacterium avium complex (Choice A) is characterized by fever. and injection drug abuse. throat. While there he began to complain of significant pain and sensitivity to light in his right eye. Item 1 of 2 What is the most likely cause of his ocular pain? A. and epigastric region. abdominal pain.

prior abdominal surgery. neutropenia. Prompt diagnosis and treatment of candida endophthalmitis is essential. and chronic stable angina. Systemic amphotericin B only E. Although ketoconazole (Choices A) can treat candidiasis. cough. hydrochlorothiazide. and occasionally hemoptysis. and this is completely resolved by sublingual nitrates. dyspnea. metoprolol and atorvastatin. Patients who have candida endophthalmitis with vitreal involvement will therefore require vitrectomy in conjunction with systemic antifungal treatment. which of the following treatment options is likely to be of greatest benefit? A. and injection drug abuse. pleuritic chest pain. Intravenous vancomycin and gentamycin D. broad-spectrum antibiotic therapy. (Choice C) Combination of vancomycin and gentamycin is used in patients with infective endocarditis (in IV drug users) as empirical therapy. Vitrectomy and systemic ketoconazole B. corticosteroid therapy. which did not change the character and severity of the . An early vitrectomy improves the likelihood of a positive outcome. During this episode. Clarithromycin and rifabutin Explanation: Patients with candida endophthalmitis who have chorioretinitis with vitreal involvement should be treated with vitrectomy and systemic antifungal therapy with amphotericin B (Choice B) and/or fluconazole. Systemic amphotericin B (Choice D) attains sufficient concentration within the choroid and retina. it does not attain sufficient concentration within the eye and is therefore not an ideal choice in this case. 45% of people answered this question correctly. He has a history of longstanding hypertension. Item 2 of 2 Given the patient?s condition. and intravitreal injection of amphotericin B may be of help. gastroesophageal reflux disease. but not within the vitreous body. Educational Objective: Candida endophthalmitis with vitreal involvement should be treated with vitrectomy and systemic antifungal therapy (amphotericin B and/or fluconazole). hyperlipidemia. Aspergillus endophthalmitis results from hematogenous spread and can cause eye pain and visual changes. 41% of people answered this question correctly. as the condition can worsen quickly. Educational Objective: Risk factors that place patients at greatest risk for developing candida endophthalmitis include central venous catheters. He occasionally gets substernal chest pressure with brisk walking and running. he took four sublingual nitroglycerine tablets in the first 10 minutes. total parenteral nutrition. The pain started while he was in a meeting with some of his clients. Vitrectomy and systemic amphotericin B C. His other medications include aspirin.Invasive aspergillosis (Choice E) can occur in immunosuppressed patients and is characterized by fever. He is a lifelong smoker and currently smokes two packs of cigarettes a day. A 56-year-old male accountant is brought to the emergency department by paramedics because of a sudden onset of severe crushing chest pain and dizziness.

hypertension. D. E. an early diastolic murmur (reflecting aortic insufficiency). (Choice A) The patient certainly has risk factors and a history of coronary artery disease based on his symptoms of exertional angina. (Choice B) Peptic ulcer perforation is an unlikely diagnosis in the absence of any abnormal abdominal exam findings. You may be having an acute myocardial infarction. What is the best next action? A. absent airflow. The diagnosis of aortic dissection is usually based on the history and the physical examination findings. It has the same predisposing risk factors as an acute coronary syndrome (unstable angina and myocardial infarction). (Choice E) Tension pneumothorax presents as a sudden onset of shortness of breath. and respirations are 16/min. and hyperresonance to percussion on the affected side. Other clinical clues favoring the diagnosis of an aortic dissection include the blood pressure difference in the two arms.pain. The patient’s chest x-ray and examination findings are not consistent with tension pneumothorax. pulse is 80/min. You may have a pulmonary embolism. Furthermore. freely mobile round mass is palpated in the upper. You may have an aortic dissection. however. Oxygen saturation is 94% on room air. Inspection of her breasts is normal. C. and is associated with shortness of breath and hypoxia. Ultrasonography C. A 35-year-old woman comes to her physician after she palpated a lump in her right breast. Educational Objective: Aortic dissection is a catastrophic condition. B. Explanation: Aortic dissection is an uncommon but potentially life threatening cause of severe and sudden chest pain. hypoxia. She doesn?t have any other complaints. A sudden onset of severe chest pain. Which of the following is the most appropriate statement to tell the patient? A. The pain is usually not relieved by sublingual nitroglycerine. She hasn?t seen a doctor for ten years. can be due to an acute myocardial infarction. it would be unusual to have a normal EKG in a patient with acute MI while he is having active chest pain. Her mother died of breast cancer at the age of 40. unrelieved by nitrates. A 1 x 1cm rubbery. His temperature is 36. You may have a perforated peptic ulcer. No axillary lymph nodes are palpated. Observation B. Fine needle aspiration E. An initial EKG and chest x-ray done in the emergency department are normal. and should be suspected from the initial history and physical examination findings. including age greater than 55 years. Her past medical history is unremarkable. a chest-x ray/erect abdominal-x ray usually shows air under the diaphragm. and chronic smoking. Patients with acute aortic dissection typically present with a sudden onset of severe or "tearing" chest pain radiating to the back. Mammography Explanation: . Excisional biopsy D.7C(98F). You may have a tension pneumothorax. She states that she regularly performs a self-breast exam after menses. blood pressure is 160/86 mm Hg. (Choice D) Pulmonary embolism usually presents with pleuritic chest pain that is less severe in intensity. firm. hyperlipidemia. and the presence of mediastinal widening on chest x-ray. outer quadrant.

All patients with breast lumps after the age of 35 should be evaluated using mammography. especially if they have a family history of breast cancer. and D) Although the remaining choices are also appropriate for the management of breast masses. Educational Objective: All patients with breast lumps after the age of 35 should be evaluated with mammography. mammography is the best initial step for this patient. 32% of people answered this question correctly. especially if they have a family history of breast cancer. Apart from the fibroadenoma. which is more superior for this purpose than an ultrasound (Choice B).A baseline mammogram at age 35 is recommended for any woman who has an increased risk for breast cancer. this patient might have other anomalies imperceptible on physical exam that might be seen on the mammogram. C. . (Choices A. It is best to make further decisions for this patient?s management after the mammogram is obtained. The findings on the physical exam are consistent with a fibroadenoma.

alcoholism. He has no other medical problems. He is extremely non-compliant and drug-seeking. this does not provide sufficient grounds for withdrawal in the middle of the treatment. and has slapped one of the nurses in the endoscopy lab for not giving him enough pain medications. and chronic pancreatitis. 29% of people answered this question correctly. the patient feels nauseous and has one episode of hematemesis. they should not neglect the patient." You have been the patient?s primary care provider for the past 12 years and know that the patient can be difficult at times.A 46-year-old man is admitted to the hospital with complaints of constant mid-abdominal pain for the past five days. He looks pale and frightened. and bowel sounds are present. He does not use tobacco or illicit drugs. There is moderate tenderness on palpation of the upper half of the abdomen. Tell him that he can withdraw from the case but he will not be consulted again for any of your patients in the future. (Choice D) As described above. In the above vignette. A 39-year-old Caucasian man is brought to the emergency department because of epigastric pain and melena. (Choices A and B) Asking the physician to withdraw without securing another gastroenterologist for the patient is not appropriate. the physician can withdraw from the case if another gastroenterologist is willing to assume the patient care responsibility. E. His medications include omeprazole and antacids. he can do so if he provides the patient or the caregivers a notice long in advance so as to sufficiently permit the transfer of medical care to another physician. You consult a gastroenterologist. he calls and tells you. A rectal exam reveals dark blood. but drinks alcohol occasionally. B. D. Tell him that he cannot withdraw from the case once he is involved in patient care. the gastroenterologist is already involved with the patient's care since he has already performed the procedure. During the examination. He has also known the patient from his previous admissions. He underwent highly selective vagotomy with antral ulcer resection due to persistent gastrointestinal bleeding one year later. Ask him to withdraw from the patient?s case if he wishes. a close friend of yours. He can opt to withdraw from the patient?s case only if there is another gastroenterologist willing to assume patient care responsibility. Educational Objective: Physicians can terminate the physician-patient relationship by providing a notice long in advance to sufficiently permit the transfer of care to another healthcare provider. once they are involved in a case. There is no rebound tenderness. C. however. He is a real estate agent. After the procedure. He has had three recent admissions for pancreatitis in the past four months. Ask him to document the patient?s behavior in the chart and then withdraw from patient?s case. Which of the following is the most appropriate next step in the management of this patient? A. It is not appropriate to withdraw or discontinue patient care in the middle of a hospitalization or during an acute ongoing medical treatment. He continues to drink heavily. (Choice C) The patient?s behavior should certainly be documented in the chart. however. pulse is 120/min. He receives . Examination shows a midline scar in the epigastrium. He has a history of intravenous drug abuse. and respirations are 18/min. Explanation: All physicians have a moral obligation to provide continuity of care for their patients. His blood pressure is 130/80 mm Hg. "I do not want to get involved in this patient?s care. Some muscular guarding can be appreciated. Tell him that he can withdraw from the case if some other gastroenterologist is willing to take care of this patient. for a possible endoscopic retrograde cholangiopancreatography. He was diagnosed of peptic ulcer disease five years ago. All physicians have the option to choose who they want to serve. If a physician wishes to withdraw from a case.

Upper gastrointestinal (GI) endoscopy E. (Choice C) Abdominal CT scan is not regularly used to evaluate GI bleeding because endoscopy is superior to it.9 mEq/L Chloride: 110 mEq/L Bicarbonate: 25 mEq/L BUN: 28 mg/dL Serum creatinine: 1. it does not offer therapeutic advantages.6 g/dL Ht: 23% Platelet count: 450. For instance. early endoscopy has been associated with a significant decrease in mortality and hospitalization time. (Choice B) Although a contrast study of the esophagus and the stomach can certainly show the presence of ulcerated lesions. Abdominal computerized tomography (CT) with contrast D. Some laboratory tests are done. including crosstyping for a possible transfusion. Abdominal ultrasound B. truncal vagotomy with partial antrectomy has a recurrence rate of 5 % to 10% after a mean follow-up of 3.intravenous hydration and parenteral pantoprazole. Radionuclide imaging Explanation: There is a significant rate of rebleeding after gastric surgery for peptic ulcer treatment.9 mg/dL Glucose: 77 mg/dL Which of the following is the most appropriate test to confirm the diagnosis? A.2 mg/dL Calcium: 9.5 years. because it also has therapeutic applications such as photocoagulation or local injection of vasoconstrictor agents.000/cmm Leukocyte count: 8. Educational Objective: . (Choice A) Abdominal ultrasound is not adequate for the evaluation of gastrointestinal bleeding because it cannot identify intraluminal lesions. The results show the following: CBC Hb: 7. In addition.000/cmm Segmented neutrophils: 72% Bands: 3% Lymphocytes: 25% Serum chemistry Serum Na: 145 mEq/L Serum K: 3. such as those who are actively bleeding. The preferred method to confirm the source of bleeding is upper gastrointestinal (GI) endoscopy. This is why it is not recommended for a patient who needs immediate evaluation. values may be as low as 24% or as high as 91%. (Choice E) Radionuclide scanning is less specific than upper GI endoscopy. Upper gastrointestinal (GI) radiology series C. Its accuracy depends on the experience of the operator and the type of clinical center. Abdominal CT scan with contrast can sometimes localize the source of bleeding of lower gastrointestinal hemorrhages.

. The most common reason for bleeding in a patient with a history of previous gastric lesion is the development of a new ulcerated lesion or the recurrence of the previous one. 84% of people answered this question correctly. These lesions are readily diagnosed and managed through endoscopy.Upper GI endoscopy is the preferred method to evaluate upper gastrointestinal bleeding because it also has therapeutic applications.

therefore. odds ratio) becomes tighter. the confidence interval of study B includes 1. The lack of statistical significance of the results in study B is most probably due to a smaller sample size. A 58-year-old female with a history of diabetes mellitus presents to the family physician for diarrhea. P value in study B is less than 0. Increasing the sample size increases the power of a study. Bentiromide test D. The result in study A is not valid D.0. (Choice A) The 95% confidence interval in study A does not include the ?null? value for the odds ratio (that is 1. Both studies reached the same conclusion. but because of a smaller sample size of study B. The other group conducted study B.Two groups of investigators are interested in the problem of esophageal cancer in a population that has a high prevalence of hot beverage consumption. Xylose is a pentose sugar that is .0). Which of the following is the best test to diagnose bacterial overgrowth in this patient? A. and excess flatulence. Quantitative fecal fat Explanation: The demonstration of excessive bacterial concentrations in a jejunal aspirate is the gold standard for the diagnosis of bacterial overgrowth. which showed that hot beverage consumption is associated with esophageal cancer. bloating. its estimated odds ratio does not reach statistical significance.81.97. (Choice E) The P value of statistically insignificant results should be greater than 0. The patient's bacterial overgrowth is most likely due to her diabetic enteropathy. which demonstrated an OR of 1. The sample in study B is poorly selected C. One group conducted study A. 25% of people answered this question correctly. the confidence interval of the point estimate (e. The sample size in study B is small E. The result of study A is not statistically significant B. [14C]-d-xylose breath test C. the odds ratio achieves statistical significance. which resulted in insufficient power to detect the difference between the exposed and unexposed subjects. with an odds ratio (OR) of 1. (Choice B) The Clinical Efficacy Committee of the American College of Physicians also advocates alternate use of one-gram [14C]-d-xylose in routine clinical practice.95 to 1. As a result..5). Educational Objective: The power of a study is the ability to detect the difference between two groups (treated vs nontreated. Quantitative jejunal cultures B.46 and 95% confidence interval of 0. Laboratory examinations show anemia with MCV of 101 fl. it is not statistically significant. She was diagnosed with diabetic enteropathy last year. Breath hydrogen analysis E. Which of the following is the best statement concerning the results of these two studies? A.05 Explanation: Although both studies have almost the same point estimate of association (OR of about 1.05. therefore. Increasing the sample size of study B will make the confidence interval tighter. exposed vs non-exposed). study B has a wider confidence interval than study A. weight loss.g. (Choices B and C) The accuracy or validity of the studies cannot be evaluated without any information on how the studies were designed and conducted. Furthermore.19 to 1. It can be performed during endoscopy or by fluoroscopy with jejunal intubation.51 and 95% confidence interval of 1.

Which of the following is important to maximize the viability of donor organs? A. and they wish to proceed with the withdrawal of life support. (Choice C) A bentiromide test is a test for pancreatic insufficiency and not bacterial overgrowth. His family is informed of his status. (Choice E) Quantitative fecal fat is a test for fat malabsorption. normothermia should be maintained passively in all brain dead patients using blankets. His fianc?nforms you that he had always wanted to donate his organs in case of an unexpected death. blood pressure is 120/70 mmHg. Adequate volume resuscitation is the first step in correcting hypotension and ensuring donor viability. In contrast. pressors and inotropic agents may be used to improve the blood pressure. it is important to learn the basic principles of management of these patients. His temperature is 36. Anti-hypertensive medications to keep systolic blood pressure less than 100 mmHg B. He is declared braindead by the ICU team. Maintain body temperature to less than 35 C (95 F) E. which is detectable in breath samples. but is not specific for bacterial overgrowth. Hypotension is very common in brain dead patients. Low-dose beta blockers to keep heart rate less than 60/minute C. The paramedics intubated him at the scene of the accident. 25% of people answered this question correctly. He is on full ventilator support. If the body temperature is less than 35 C (95 F). The successful recovery of viable organs for transplantation depends on the appropriate medical care of brain dead patients. The goal of management is to provide optimal ventilator support to prevent hypoxia and hypercapnia. and may be due to the loss of sympathetic tone. euvolemic state. Lower the ventilator rate to induce hypercapnia D. and can be even damaging to the tissues and organs. Educational Objective: The gold standard for the diagnosis of bacterial overgrowth is the demonstration of excessive bacterial concentrations in a jejunal aspirate. and diabetes insipidus. he remains unresponsive to all stimuli and has no spontaneous respiratory drive. On the third day of hospitalization. and pulse is 76/min. (Choice D) Breath hydrogen testing is performed by the administration of a test dose of carbohydrate.catabolized by gram-negative aerobes present in the intestine. The primary aim is to achieve hemodynamic stability and to maintain physiologic homeostasis to maximize the viability of organs. (Choices A and B) It is critical to achieve and maintain a normotensive. Maintain normothermia with blankets Explanation: Organ transplantation from cadaveric donors has become increasingly common in the last few years. Educational Objective: . He was involved in a motor vehicle accident two days ago. (Choice C) Hypercapnia has not been shown to improve organ viability. If systemic blood pressure still remains low. Most of the organs are obtained from brain dead donors. You are managing the care of a 32-year-old football player in the intensive care unit. and had sustained severe head injuries. active rewarming should be attempted with warm air blankets and warm intravenous fluids.7 C (98 F). A common misconception is that the body temperature should be kept low to improve the viability of organs. systemic infections. which would be associated with a rise in breath hydrogen levels in patients with bacterial overgrowth. volume depletion secondary to losses. releasing the radioactive isotope 14CO2. therefore.

and respirations are 12/min. and normothermic state. 25-hydroxy vitamin D levels E. B. E. Educational Objective: Hypoglycemia can lead to protean central nervous system manifestations which include focal neurological deficits. Apart from measuring the patient's serum calcium levels. Serum glucose levels should therefore be measured in all patients presenting with central nervous system dysfunction. She does not have any medical problems. phosphorous. and she has always had regular cycles. normotensive. She uses condoms infrequently. She is a non-smoker and non-alcoholic. therefore a change in the serum albumin levels can result in a change of the total calcium levels without a change in the ionized fraction.The primary goal of medical management of a brain dead organ donor is to maintain a euvolemic. and coma. Approximately 50% of calcium is bound to albumin. 45% of people answered this question correctly. alerted mental status. D. The PTH level is low in patients with hypoparathyroidism. and increased in patients with pseudohypoparathyroidism and vitamin D deficiency. (Choices A. Physical examination shows tetany and cramping of muscles. Total serum calcium levels should always be corrected for corresponding serum albumin level. Aside from measurement of the serum calcium level. It can present with protean signs and symptoms. C & D) Measurement of the serum parathyroid hormone. Chvostek and Trousseau signs are positive. His blood pressure is 100/70 mmHg. Hypocalcemia is suspected.7C (98F). however. Advise her to use barrier methods in addition to oral contraceptives. Advise her to use barrier methods instead of oral contraceptives. A 30-year-old male is brought to the emergency department (ED) by his relatives following a generalized tonic-clonic seizure. B. Serum phosphorus levels C. One remote possibility of the association of hypocalcemia and hypoglycemia is autoimmune polyglandular failure. Prescribe her oral contraceptives and inform the parents later. She recently started having sex with her boyfriend. measurement of the serum glucose levels should be done right away by doing a fingerstick. Serum parathyroid levels B. Educate about teenage sex and do not give contraception. Explanation: . seizures. C. Which of following is the most appropriate next step in the management of this patient? A. pulse is 67/min. Serum albumin levels D. which of the following is the most important laboratory investigation to conduct? A. where hypoparathyroidism (decreased calcium levels) is associated with primary adrenocortical insufficiency (decreased glucose levels). who is 16 years old. The EKG tracing shows prolongation of QT intervals. The serum phosphorus level is increased in patients with hypoparathyroidism and low in vitamin D deficiency. Hypovitaminosis D is a very important cause of hypocalcemia and can be assessed by measuring the 25-hydroxy vitamin D levels. temperature is 36. A healthy 14-year-old Caucasian girl comes to your office and asks for a prescription for oral contraceptive pills. albumin and vitamin D levels are also required in evaluation of patients with hypocalcemia. measurement of the serum glucose level is also very important. Call the parents from the office and prescribe if they are okay. She started menstruating at the age of 13. Hypoglycemia is the greatest mimmicker of central nervous system diseases. Serum glucose levels Explanation: This patient has clinical features suggestive of hypocalcemia.

His past medical history is significant for hypertension and diabetes. His blood pressure is 170/100 mmHg and heart rate is 80/min. In addition. however. He also takes ibuprofen for muscle cramps and antacids for heartburns occasionally. She can become pregnant. He had two episodes of extremity weakness and numbness within the last three months that lasted 15-20 minutes and resolved spontaneously. high palate. in patients with Turner syndrome. webbed neck. Such patients may become pregnant without medical assistance before developing secondary amenorrhea. nausea. but there still remains a very small chance. and present with primary amenorrhea. 42% of people answered this question correctly. regular. however. most women are infertile. A 16-year-old Caucasian girl is being worked up for primary amenorrhea. confidentiality should always be maintained. The CT scan of his head is negative for intracranial hemorrhage. and a short fourth metacarpal. XO. C. lisinopril and metformin. She has the same chances of pregnancy as the general population. Her mother is concerned about the patient's chances to conceive. Educational Objective: Pregnancy is almost impossible. Which of the following is the best response? A. barrier methods should be offered to reduce her risk for STDs. (Choice C) Turner syndrome is not a contraindication for pregnancy. In one retrospective study of 522 patients. therefore.This patient does not have any absolute or relative contraindication to the use of oral contraceptive pills (OCPs) and has a personal preference for this mode of contraception. The biggest reason for failure of adolescents to obtain contraceptive services is the concern about confidentiality. Some patients may develop normally and undergo spontaneous menarche. IV labetalol B. The following vignette applies to the next 2 items A 65-year-old Caucasian male presents to the emergency department six hours after the onset of leftsided weakness in his arm and leg. Pregnancy is absolutely impossible. His current medications are hydrochlorothiazide. Item 1 of 2 What is the best next step in the management of this patient? . His family history is insignificant. (Choices A and B) Adolescents do not need consent from their parents for the use of oral contraceptives. therefore. He denies headache. vomiting and swallowing difficulty. E. D. Educational Objective: Adolescents do not need consent from their parents for contraceptive services. patients should undergo a complete medical evaluation. She has short stature. Barrier methods should be used by all sexually active adolescents even if an additional method of contraception is being used. but secondary amenorrhea may occur after some time. Educate about teenage sex and do not give contraception. Most patients do not undergo puberty. but pregnancy is contraindicated in her condition. Explanation: Ovarian function and morphology is highly variable in patients with Turner syndrome. she should be prescribed OCPs. Her karyotype analysis showed 45. He does not smoke or consume alcohol. three women became pregnant spontaneously.

especially if carotid studies are negative. Item 2 of 2 The patient receives the appropriate therapy. (Choice A) Some interventions that sometimes seem intuitively appropriate can be harmful. large-scale studies demonstrated no improvement in the outcome of patients with thrombotic stroke receiving nimodipine.? Despite very intensive clinical research in this field. labetalol is the drug of choice. Discharge the patient B. Educational Objective: The reduction of blood pressure in patients with acute ischemic stroke can deteriorate their condition. and should be used only if the blood pressure is extremely high (>220/120). IV isotonic D5W and oral metoprolol C. large-scale studies demonstrated no improvement in the outcome of patients with thrombotic stroke receiving nimodipine. (Choice D) Despite initial encouraging evidence. and should be used only if the blood pressure is extremely high (>220/120). and carotid duplex scanning is normal. IV isotonic saline and aspirin D. What is the best next step in the management of this patient? A. Cautious IV hydration with isotonic saline is generally indicated. For example. Echocardiography is indicated in patients with suspected embolic stroke and in patients in whom the mechanism of stroke is not clear. Repeat CT scan D. Left ventricular systolic dysfunction appears to be more common in patients who present with stroke than in the general population. he does not show any progression of neurological deficit. Thrombotic. and many patients with stroke have asymptomatic left ventricular dysfunction that can be detected on echocardiography. If blood pressure reduction is required. IV isotonic saline and nimodipine E. Schedule carotid angiography E. and is recommended in all patients with ischemic stroke who do not receive thrombolytics or anticoagulants. Two days after the event. The EKG shows no rhythm abnormalities. the reduction of blood pressure in patients with acute ischemic stroke can deteriorate their condition. (Choice E) Lumbar puncture is indicated when a patient has a negative CT scan and the clinical suspicion of subarachnoid hemorrhage remains high. (Choice B) Overzealous hydration and D5W solution are usually avoided. Lumbar puncture Explanation: The acute management of ischemic stroke emphasizes the concept of ?first. do no harm. very few interventions have been proved to be beneficial. Despite initial encouraging evidence.A. embolic and lacunar strokes may require different management approaches that underscore the importance of the underlying pathophysiology. Cardiac evaluation should be performed in almost all patients with brain ischemia. Aspirin has been shown to be effective in improving prognosis in two large-scale clinical trials. 48% of people answered this question correctly. . Order echocardiography C. IV labetalol B. Obtain EEG Explanation: Determining the stroke subtype is important in patients with ischemic stroke in terms of short-term as well as long-term treatment decisions.

. as well as patients undergoing preoperative evaluation of carotid artery disease. especially if carotid studies are negative. Educational Objective: Echocardiography is indicated in patients with suspected embolic stroke and in patients in whom the mechanism of stroke is not clear. It may be helpful in patients with fibromuscular dysplasia and carotid dissection. (Choice D) Conventional angiography is rarely performed nowadays. 42% of people answered this question correctly. repeat CT scan has little diagnostic significance.(Choice C) In stable patients with no progression of neurological deficits.

and bilateral hemianopsia on visual field testing would most probably indicate the presence of an intracranial mass lesion in this patient. and she continues to take this drug with periodic ?blood tests?. (Choice C) A low INR value on routine coagulation studies indicates inadequate anti-coagulation. hypertension and diabetes mellitus controlled with atorvastatin. such as renal insufficiency or effective volume depletion (e. Manifestations of lithium toxicity are diverse: gastrointestinal. endocrine. The mortality is 25% in patients with acute lithium poisoning and 8% in patients on maintenance dose.2 mg/dL and an albumin level of 4. A significant number of patients suffers irreversible neurological damage. dermal. She is oriented to person. These symptoms started several days ago and gradually progressed. confusion. Lab investigations reveal a serum calcium level of 14. renal. as well as neurological abnormalities have been described. One month ago. cardiovascular. which of the following is the most likely additional finding? A. diabetes mellitus type 2 and hypertension comes to the office because of constipation. Any factor that decreases renal excretion. It has a low therapeutic index. Colonoscopy performed one year ago was normal. Hydrochlorothiazide for hypertension treatment C. (Choices D and E) Right-sided hemiparesis would suggest a stroke. tremors. Typical neurological symptoms include lethargy. An overdose may result due to intentional poisoning or other factors. If medication toxicity is responsible for this patient?s current symptoms. Educational Objective: Any factor that decreases renal excretion may be responsible for the increase of serum lithium levels. The following vignette applies to the next 2 items A 61-year-old male with hypercholesterolemia.g. hematological. hydrochlorothiazide and rosiglitazone..A 55-year-old Caucasian female is brought to the emergency department by her son because of slurred speech and confusion. He has hyperlipidemia. Low INR value on routine coagulation studies D. Her son says that the ?mood disorder? runs in the family because his grandmother had the same problem. and deep vein thrombosis. This scenario demonstrates how various factors can affect serum lithium levels and precipitate lithium toxicity. fasciculations and ataxia. respectively. She takes lithium. Item 1 of 2 What is the most likely cause of this patient?s hypercalcemia? A. Bilateral hemianopsia on visual field testing Explanation: Lithium is widely used as an effective agent to treat bipolar disorder. Warfarin treatment was started at the hospital. Hormone replacement therapy (HRT) for hot flushes B. but not to time and space. but admits smoking two packs of cigarettes daily for the last several years. Primary hyperparathyroidism . The physical examination reveals a mild tremor of her hands and an unstable gait. (Choice A) HRT may be responsible for deep vein thrombosis in this patient. Right-sided hemiparesis with slight motor aphasia E. bipolar disorder. which seems to control her symptoms well. but the question asked about the current neurological symptoms.0 gm/dL. diuretics or congestive heart failure) may be responsible. He denies alcohol intake. 25% of people answered this question correctly. Her past medical history is significant for hypertension. she was diagnosed with deep vein thrombosis and hospitalized.

Patients with squamous cell carcinoma of the lung can produce parathyroid hormone related protein (PTHrP). Chest x-ray E. Parathyroid independent causes include malignancies. vitamin D toxicity. (Choice A) Primary hyperparathyroidism is one of the most common causes of hypercalcemia in an outpatient setting. Secondary hyperparathyroidism C. (Choice E) Diabetic nephropathy per se is not associated with hypercalcemia. Item 2 of 2 The physical examination of the patient is essentially unremarkable. Calcium levels above 12mg/dL are rare. Drug-induced D. Bone scan C. Educational objectives: The three most common causes of hypercalcemia include primary hyperparathyroidism. he has higher chances of developing lung cancer. and is most likely due to a malignancy. Malignancy E. which can cause hypercalcemia. Examples of parathyroid dependent hypercalcemia include primary or tertiary hyperparathyroidism. As stated above. (Choice C) HCTZ can cause hypercalcemia. the serum calcium levels are generally very high. but the elevations in serum calcium levels are usually minimal. CT scan of the chest D. the level of serum calcium is lower in patients with primary hyperparathyroidism compared to patients with malignancy-induced hypercalcemia. (Choice B) Secondary hyperparathyroidism due to renal failure or vitamin D deficiency is not typically associated with hypercalcemia. Serum PTH measurement B. Diabetic nephropathy Explanation: This patient has a longstanding history of smoking. In hypercalcemia secondary to malignancy. What is the most appropriate next step in management? A.2 mg/dL. malignancyinduced hypercalcemia and vitamin D-induced hypercalcemia. .B. and familial hypocalciuric hypercalcemia. but other mechanisms have also been described. and milk-alkali syndrome. lithium-induced hypercalcemia. 34% of people answered this question correctly. This patient?s serum calcium level is 14. therefore. the serum calcium level in patients with malignant lung tumors is much higher than those with primary hyperparathyroidism. particularly in hematological malignancies. It is sometimes difficult to differentiate primary hyperparathyroidism from hypercalcemia seen during malignancy. Renal biopsy Explanation: Hypercalcemia can be divided in to two broad categories: (1) parathyroid dependent and (2) parathyroid independent. which is then called tertiary hyperparathyroidism. Patients with secondary hyperparathyroidism can sometimes develop autonomously functioning nodules of the parathyroid gland. granulomatous disease. Hypercalcemia can occur in the presence of very high serum PTH levels in tertiary hyperparathyroidism. Typically. Malignancy-induced hypercalcemia is generally due to the secretion of PTHrP.

He has no known drug allergies.e. He is admitted and started on clindamycin and gatifloxacin. therefore. (Choice D) Prophylactic therapy with INH is not needed at this point. Specific PTHrP assays are commercially available and are usually ordered with PTH if malignancy is highly being considered in the differential diagnosis. The most appropriate next step in management is to do a parathyroid estimation. and respirations are 22/min. . His pulse oximetry is 92% at room air. Place a PPD in three weeks and evaluate B. unless the HCW has specific respiratory symptoms. D and E) Bone scan. three weeks after. Educational Objective: Hypercalcemia can be divided in to two broad categories: (1) parathyroid dependent and (2) parathyroid independent. and renal biopsy are not indicated at this point. He is unemployed and homeless. Take a chest x-ray and place a PPD in three weeks Explanation: The Center for Disease Control (CDC) recommends immediately giving a PPD test to all health care workers (HCW) exposed to a contagious patient with tuberculosis. C. In majority of endocrinological disorders. the most appropriate next step in this case is to do a parathyroid estimation to help classify this patient's hypercalcemia as parathyroid dependent or independent. Place a PPD now and repeat it in three weeks C. and shortness of breath.9 C (102 F). as it is not known if the HCWs were infected or not. chills. Which of the following is the most appropriate course of action? A. he is breathing better and has more appetite. If the result is negative.. the PPD test will be repeated after three weeks to check for any changes that could have been induced by the recent exposure to the bacteria. He has no other medical problems. He also has night sweats.These categories can be distinguished by measuring the serum parathyroid hormone levels. bronchial. productive cough. He has no medications. and he is started on anti-tuberculosis (TB) therapy. biochemical confirmation is required before any imaging is performed. He drinks 6-8 bottles of beer daily. chest x-ray. A 36-year-old African-American man was brought to the hospital because of fever. CT scan. pulse is 104/min. (Choices B. PPD retesting will be given to check for any changes due to the recent TB exposure. loss of appetite. (Choices C and E) PPD test must be given before ordering a chest x-ray. Educational Objective: When a HCW is exposed to a patient with a contagious form of tuberculosis (i. Start prophylactic therapy with isoniazid (INH) for those who attended him for more than two consecutive days without using a mask E. (Choice A) The initial PPD must always be given immediately because the HCW can be PPD positive from before. he was found in the street and brought to the hospital by some concerned policemen. His temperature is 38. laryngeal. and not due to the most recent exposure. They want you to tell them what they can do about it. the CDC recommends immediate PPD testing to determine the baseline immunologic status. Take a chest x-ray in three weeks D. On his fourth hospital day. or pulmonary). His laboratory results reveal that one of his sputum samples is positive for acid-fast bacilli (AFB). The nurses that were taking care of him in the unit approach you to ask about their risk of acquiring tuberculosis (TB). but he continues to be febrile. His family history is not significant. and weight loss. His chest x-rays show a left upper lobe alveolar infiltrate.

Prescribe oral analgesics. He went home after the incident because his hand did not look too swollen and the pain was tolerable. There is severe tenderness on palpation of the anatomical snuffbox. rest for two weeks. and tenderness on palpation of the scaphoid within the anatomic snuffbox is diagnostic of scaphoid fracture until proven otherwise. Five hours ago. He has no other medical problems. He denies the use of tobacco. minimal tenderness on palpation of the lunate and scaphoid (navicular) bones. (Choice A) Patients with Colles? fracture have tenderness in the region located 2 cm below the radioulnar joint. normal range of motion of the wrist joint. Which of the following is the most appropriate next step in the management of this patient? A. Physical examination reveals tenderness on palpation of the scaphoid within the anatomic snuffbox. severe pain. he fell to the ground and landed on his outstretched right hand. Wrist sprain D. (Choice B) Chondral fracture is characterized by moderate pain. Order a magnetic resonance imaging (MRI) study of the right wrist D. severe pain. Chondral fracture C. alcohol or drugs. Examination shows mild swelling in the dorsum of the right hand. and decided to come to the hospital. Item 2 of 3 An x-ray of the wrist reveals no evidence of dislocation or fracture. the ulnar styloid separates from the rest of the bone. Place a cast brace with the hand on dorsal hyperextension . In almost half of the cases. (Choice E) Triangular cartilage injury is characterized by tenderness of the region distal to the ulnar styloid. Scaphoid fracture E. he noticed that he was unable to move his hand. stiffness. It is most commonly seen in young adults between the ages of 15 and 30 years. and stiffness. and lateral view of the wrist reveals a dinner fork deformity. Accompanying symptoms are complete (or greater than 50%) loss in range of motion of the wrist joint. It results from a fall on the outstretched hand. which increases in severity with forced ulnar deviation. and mild swelling of the dorsum. Order a computerized tomography (CT) scan of the right wrist C. A few hours later. After receiving analgesic therapy. complete (or greater than 50%) loss in range of motion of the wrist joint. (Choice C) Wrist sprain is characterized by mild pain. Item 1 of 3 Which of the following is the most likely diagnosis? A. the patient reports that the pain in his wrist has improved. stiffness. resulting in severe hyperextension and slight radial deviation of the wrist.The following Vignette applies to the next 3 items A 25-year-old Caucasian man comes to the emergency department because of persistent pain and limited range in motion of the right wrist. The hand cannot be fully flexed. and approximately 20% loss in range of motion of the wrist joint. and discharge the patient home B. Triangular cartilage injury Explanation: A history of falling on an outstretched hand is characteristic of a scaphoid fracture. Colles? fracture B. and can be extended only by passive motion due to pain. Educational Objective: A history of falling on an outstretched hand. while playing football.

Avascular necrosis B. . Nonunion C. Place a cast brace with the hand on dorsal flexion Explanation: Patients with a non-displaced scaphoid fracture can have normal radiographs for up to two weeks after a traumatic incident. bone scan). (Choice D) Cast placement with the hand in a hyperextended position is not beneficial for both Colles? and scaphoid fractures. CT scan of the hand.e. in the normal volar tilt position. Overlooking this lesion may lead to complications such as traumatic arthritis (which results from nonunion of the fracture) and avascular necrosis of the scaphoid bone.E. Which of the following is the most common complication of his injury? A. its higher cost makes it less appealing than a CT scan. Educational Objective: Although displaced fractures of the scaphoid can be identified in x-rays immediately after trauma. even if the initial x-ray results are negative. Proximal fractures of the scaphoid therefore require longer immobilization (up to 12 weeks) to ensure adequate healing.e. 9% of people answered this question correctly. bone scan).. Educational Objective: The most common complication of scaphoid fracture is nonunion. undisplaced scaphoid fractures are treated with immobilization in a long or short arm thumb spica cast with the wrist in slight radial deviation and in neutral flexion. which is enough to make the diagnosis. The other important complication is avascular necrosis. (Choice C) MRI studies are used in the diagnosis of triangular cartilage injury. some scaphoid fractures can take one or two weeks before it becomes apparent in x-rays. (Choice A) Analgesic therapy and resting the affected hand are indicated in the management of wrist sprain.. Although it may also be used in this case. CT scan of the hand. undisplaced scaphoid fractures are treated with immobilization in a long or short arm thumb spica cast with the wrist in slight radial deviation and in neutral flexion. Item 3 of 3 The patient is concerned about the complications that he might develop. Malunion D. even if the initial x-ray results are negative. The uncomplicated. These two complications often result because the blood flows from the distal to proximal portion of the scaphoid bone. (Choice E) Cast placement in the management of a patient with uncomplicated Colles? fracture involves immobilization of the hand in the neutral position. and this proximal portion is completely dependent on the distal blood supply. A high clinical suspicion for scaphoid fracture warrants the use of further diagnostic studies (i. or ideally. No complications Explanation: The most common complication of scaphoid fractures is nonunion. Infection E. The uncomplicated. A high clinical suspicion for scaphoid fracture therefore warrants the use of further diagnostic studies (i.

and the rate in circumcised males was 6/1000. and denies any recreational drug use. not the practical aspects of treatment efficacy). according to the study results. 500 males should be circumcised in order to prevent one case of penile carcinoma. He says that he noticed it in the spring season.9% of people answered this question correctly. but the rash may also involve the upper arms. 5000 Explanation: The "number needed to treat" (NNT) is the number of patients who need to be treated in order to prevent one additional bad outcome.002 = 500 Therefore. 500 D. The calculation of NNT is easy: it is actually the inverse of absolute risk reduction (ARR). ARR = Control group event rate ? Experimental group event rate = 8/1000 ? 6/1000 = 2/1000 NNT = 1/ARR = 1/0. Secondary syphilis D. The rate in uncircumcised males was 8/1000. The clinical picture is usually very characteristic: multiple small circular maculae are observed that may vary in color (white. how many patients should be circumcised to prevent one case of penile carcinoma? A. Item 1 of 2 Which of the following is the most likely diagnosis in this patient? A. it is more convenient for practitioners to use NNT than measures of association (which represents the strength of association. The investigators concluded that circumcision may be markedly effective in reducing the incidence of the disease in the population. it is actually the inverse of absolute risk reduction. According to the study results. Educational Objective: NNT is the number of patients who need to be treated in order to prevent one additional bad outcome. He has been sexually active with two partners during the last year. Sometimes. pink or brown). neck and abdomen. . Pityriasis rosea B. A large cohort was investigated. A follow-up study was conducted to assess the effect of circumcision on the incidence of penile carcinoma. Eczema E. back and upper arms. 1000 E. His past medical history is insignificant. and he uses condoms occasionally. 250 C. 100 B. The typical location of the lesions is the upper trunk. The rash is typically more prominent in the summer time because the yeast inhibits pigment transfer to keratinocytes and makes the affected skin more demarcated from unaffected tanned skin. and it got worse during the summer. Tinea versicolor C. Rocky mountain spotted fever Explanation: Tinea versicolor is a fungal infection of the skin that is caused by the dimorphic yeast Pityrosporum orbiculare (also known as Malassezia Furfur). although mild pruritus may be present. The following vignette applies to the next 2 items A 21-year-old Caucasian male presents to your office with a non-pruritic rash. It is an important way to present the results of a study or assess the usefulness of treatment or prophylaxis. The physical examination reveals multiple circular hypopigmented macules on the chest. He does not smoke or consume alcohol. The lesions are usually asymptomatic.

including terbinafine. Physical examination reveals pallor. Her blood pressure is 120/70 mmHg and heart rate is 95/min. (Choice D) Topical corticosteroids can be used in patients with eczema. The success rate with topical anti-fungal agents exceeds 80%. Oral doxycycline Explanation: The treatment of choice for patients with tinea versicolor is topical anti-fungal therapy. multiple small circular maculae are observed which may vary in color (white. confinement of the lesions to the central trunk. A 65-year-old Caucasian female presents to the emergency department with progressive shortness of breath on minimal exertion and fatigue. (Choice E) Doxycycline is used in the treatment of patients with RMSF. Any anti-yeast topical agent can be used. 75% of people answered this question correctly. Penicillin IM D. She experienced an episode of severe pneumonia one year ago that required hospitalization and IV antibiotic therapy. pink or brown). Educational Objective: In patients with tinea versicolor. clotrimazole and ketoconazole. (Choices C) Penicillin is used for the treatment of syphilis. oral antifungals are preferred (ketoconazole. but the blood bank is unable to find suitable blood. Oral erythromycin B. Laboratory findings are significant for hematocrit of 24% and hemoglobin level of 5.(Choice A) Pityriasis rosea is characterized by the presence of a herald patch. (Choice C) Secondary syphilis commonly involves the hands and feet. (Choice D) Eczema typically affects the extremities and produces scaling and severe pruritus. orientation of the lesion along the lines of cleavage of the skin. With extensive disease or recalcitrant infection. What is the most likely reason for this incompatibility? . (Choice A) Oral erythromycin is effective in patients with pityriasis rosea. itraconazole or fluconazole). Systolic murmur with intensity of II/VI is heard over the cardiac apex. Topical corticosteroids E. You consider RBC transfusion in this patient. Educational Objective: The treatment of choice for patients with tinea versicolor is topical anti-fungal therapy.7 mg/dL. Topical terbinafine C. This is the first time such an incompatibility has occurred. She was diagnosed with myelodysplasia two years ago. and a typical pink color of the lesions. Item 2 of 2 Which of the following is the best treatment for this patient? A. (Choice E) RMSF is an infectious disease that is characterized by an acute onset and severe systemic symptoms. She is taking no medications currently and has no known allergies. Her last transfusion was 3 months ago. Blood grouping and cross-matching are done. and has been receiving supportive therapy with frequent RBC transfusions. 70% of people answered this question correctly.

If positive. Anti-HLA antibodies E.g. Anti-Rh (D) antibodies D. Moreover. a procedure called pretransfusion antibody screening. Alloantibodies C. Pretransfusion antibody screening is intended to detect any of all clinically significant RBC antibodies. Remember that RBCs do not express HLA antigens. these patients tend to develop multiple alloantibodies that make finding compatible blood even more difficult. The major problem that leads to difficulties finding cross-matched blood in patients with a history of multiple transfusions is alloantibodies (e. (Choices C and E) Finding ABO and Rh-compatible blood is usually not a big challenge. in patients with sickle cell anemia or myelodysplasia). the following compatibility testing is usually performed.. ABO incompatibility Explanation: After blood is ordered for transfusion.A. (Choice A) Autoantibodies are less likely to cause difficulties in cross-matching in this patient. . the patient?s ABO and Rh types are determined. Educational Objective: The major problem that leads to difficulties finding cross-matched blood in patients with a history of multiple transfusions is alloantibodies. (Choice D) HLA allosensitization increases risk of graft rejection in patients awaiting organ or bone marrow transplantation and platelet refractoriness in those requiring subsequent platelet transfusion support. further investigation is usually warranted to evaluate the identity of the antibody. The most commonly implicated RBC antigens in that case are E. L and K. methyldopa and procainamide). First. Autoantibodies B. 52% of people answered this question correctly. the patient can be safely transfused. they are commonly implicated as a cause of the incompatible cross-match in patients with autoimmune anemia and taking certain drugs (e. If negative.. the patient's serum is screened for unexpected antibodies. After this.g.

(Choice E) Spermicides. with osteoporosis or osteopenia confirmed through bone densitometry. Which of the following is the most appropriate method of contraception for this patient? A. Physical examination shows no abnormality. but this is not a problem for her as she does not want to get pregnant "at least in the next five years. ballet dancers. (Choices C and D) Barrier methods of contraception such as diaphragms. A 26-year-old white woman who is a long distance runner comes to your office. and respirations are 14/min. and male condoms are moderately effective due to inconsistent or incorrect use. (Choice A) Oral contraceptives are also very effective. Early menopause D. You alert the patient that her amenorrhea poses her in risk of another condition. if used alone. Treatment consists of improving . Oral contraceptives B. Her blood pressure is 100/60 mmHg. Spontaneous fractures have been reported in these types of patients. including implantable levonorgestrel and depot medroxyprogesterone acetate. She wants the most effective method of contraception. 62% of people answered this question correctly. She is 168 cm (5?6??) tall and weighs 50 kg (110 lbs). but the actual pregnancy rate is higher than with implantable and injectable contraceptives due to inconsistent or incorrect use. but does not want it to be "permanent". pulse is 58/min. Her last menstrual period was three years ago. They are at special risk of developing osteopenia. Which of the following conditions are you referring to? A. Spermicides Explanation: Implantable and injectable contraceptives. Hyperprolactinemia C.A 31-year-old multigravid woman presents to your office for counseling on the various methods of contraception. have the lowest rate of pregnancy (does not exceed 2-3%). Implantable or injectable contraceptives C. The actual pregnancy rate may be as low as 0. Osteoporosis E. She denies smoking or alcohol drinking. and had three elective abortions in the past. gymnasts. Hypocholesterolemia Explanation: Females who maintain a lower weight or body mass index (BMI) due to the sport or activity that they regularly engage in (e. and says that she follows a healthy. Diaphragms/cervical caps D. She has four children. have the lowest rate of pregnancies among nonpermanent methods of contraception. Male condoms E.g. Educational Objective: Implantable and injectable contraceptives. The actual pregnancy rate is 12-14%.3%. have a high failure rate. Thyroid disease B." After an extensive work-up. her amenorrhea was attributed to exercise. cervical caps. including implantable levonorgestrel and depot medroxyprogesterone acetate. Her past medical history is insignificant. low-fat diet. She trains daily and participates frequently in marathons and other long-distance competitive events all around the country. and even osteoporosis. and runners) may become hypoestrogenic and present with exercise-induced amenorrhea.

is normal. mild hypercholesterolemia. but exercise-induced amenorrhea can mimic early menopause because of estrogen deficiency. usually first evident distally in one of the limbs. On further questioning.g. Involvement of the bulbar muscles leads to difficulty with chewing and swallowing. Weakness is associated with progressive wasting. The physical examination reveals weakness in his right lower leg. These cramps are most prominent in the morning. and tongue fasciculations. Vascular dementia C. but it ultimately causes progressive loss of both upper and lower motor neurons. (Choices A and B) Exercise-induced amenorrhea is a diagnosis of exclusion. He also has difficulty with swallowing and chewing. Patients may disclose a history of recent development of cramping with volitional movements that typically occur in the early morning hours (e. His vital signs are within normal limits. atrophy and fasciculation of the thigh and calf muscles. as well as fasciculations of the face and tongue. His other medical problems include hypertension and hypercholesterolemia. Multiple sclerosis D. which leads to a decline in estrogen production. breast and vaginal atrophy. while stretching in bed). ALS may involve selective loss of function of only upper or lower motor neurons. . he tells you that he has been having frequent leg cramps in the right leg. 72% of people answered this question correctly. and infertility.caloric intake. At its onset. and spontaneous twitching or fasciculations of motor units. if this is not possible. The rest of his neurological examination. The following vignette applies to the next 2 items A 62-year-old Caucasian man comes to the physician because of progressive weight loss and right lower extremity weakness for the last two months. It can lead to osteopenia. there is a tendency toward hypercholesterolemia. (Choice C) There is no risk of early menopause. Binswanger?s disease B. His family history is not significant. Brain stem glioma Explanation: Amyotrophic lateral sclerosis (ALS) is the most common form of progressive motor neuron disease. He denies any problems with bowel or bladder function. Thyroid hormone and prolactin level determinations are necessary in the evaluation of this patient because one/both of these may be the underlying cause (but not a complication or aftermath) of the amenorrhea. patients are started on hormonal replacement with oral contraceptives and supplementation with calcium and vitamin D. after he wakes up. He does not use tobacco. atrophy of muscles. a hyperactive knee jerk. It is a relentlessly progressive disorder that involves both the lower motor neurons (consisting of anterior horn cells in the spinal cord and brainstem neurons innervating the bulbar muscles) and upper or corticospinal motor neurons. Amyotrophic lateral sclerosis E. not the opposite. Educational Objective: Exercise-induced amenorrhea is due to a decrease in the pulsatile secretion of LH. (Choice E) Paradoxically. osteoporosis. including the sensory examination. The initial sign of the disease with lower motor neuron involvement is an insidiously developing asymmetric weakness. Item 1 of 2 Which of the following is the most likely diagnosis? A.

agitation. The presentation may closely resemble ALS. She has a history of hypertension. and osteoporosis. it may prolong survival and delay the need for a tracheostomy. sensory.ALS with prominent corticospinal involvement is characterized by hyperactivity of muscle-stretch reflexes (tendon jerks) and frequent spastic resistance to passive movements of the affected limbs. (Choice C) Multiple sclerosis is usually seen in younger females with two or more clinically distinct episodes of CNS dysfunction. Surgery Explanation: Riluzole is a glutamate inhibitor that is currently approved for the management of amyotrophic lateral sclerosis. and cognitive functions are preserved. and cyclophosphamide. Plasmapheresis E. (Choice E) Brain stem tumors may compress the cervical cord and produce weakness. bladder. intravenous immunoglobulins. Riluzole B. 79% of people answered this question correctly. fasciculations in the upper limbs. and cognitive functions are preserved. and D) Amyotrophic lateral sclerosis is a neurodegenerative disease. Corticosteroids C. Patients with this disease usually present with apathy. Ocular motility. have no role in its management. Agents such as corticosteroids.) Educational Objective: Riluzole is a glutamate inhibitor that is currently approved for the management of amyotrophic lateral sclerosis. (Corticosteroids are used to treat acute exacerbations of multiple sclerosis. Educational Objective: ALS should be suspected in patients who present with progressive weakness accompanied by both upper and lower motor neuron deficits. bowel. A 65-year-old female is admitted to the intensive care unit because of unstable angina. Ocular motility. The decline in the level of cognition is relatively abrupt and progresses in a stepwise fashion. diabetes. bowel. C. hyperlipidemia. and bilateral corticospinal or bulbar signs. or bladder and bowel dysfunction. bladder. sensory. (Choice A) Binswanger?s disease is a type of vascular dementia that involves white matter infarcts. and spasticity in the legs. (Choice B) Vascular dementia is characterized by the presence of behavioral disturbances and cognitive deficits associated with clinical or radiographic evidence of a stroke. These agents may be useful in immunologically-mediated neurological diseases such as multiple sclerosis and Guillain-Barr 頳 yndrome. (Choices B. Patients typically have sensory. visual. Cardiac catheterization is . IV immunoglobulins D. Although it cannot arrest the underlying pathological process. however. while plasmapheresis and intravenous immunoglobulins are the main treatment modalities of Guillain-Barr 頳 yndrome. Item 2 of 2 Which of the following treatment has been shown to be beneficial in these patients? A. 42% of people answered this question correctly. even with advanced disease. absence of pain or sensory changes and normal bowel and bladder function in the patient favor ALS. even with advanced disease.

She has had recurrent angina while in the hospital.0 mU/mL is normal). Which of the following is the most appropriate next step in the management of this patient? A. triple-vessel.35 ?5.performed and shows severe. Your intern reported to you that her thyroid-stimulating hormone level in a blood sample drawn in the emergency department is 36 mU/mL (0. Start liothyronine (T3) intravenously and proceed with cardiac surgery E. coronary artery disease. A coronary artery bypass graft procedure is planned. Proceed with cardiac surgery C. Start her on liothyronine (T3) orally and postpone surgery D. Call the cardiac surgeon to cancel the surgery B. Start her on a usual dose of levothyroxine (T4) and perform surgery when euthyroid .

Associated symptoms and signs E. due to this patient's age and significant coronary artery disease. (Choice E) Levothyroxine (T4) is the treatment of choice in patients with hypothyroidism. History of cigarette smoking C. (Choice A) There is no need to cancel the scheduled surgery. are at a slightly higher risk for developing postoperative ileus and hyponatremia. Postoperative mortality rate is not increased in patients with hypothyroidism undergoing major surgeries. He has no other medical problems. 73% of people answered this question correctly. Type of diet D. (Choice B and E) Both alcohol use and cigarette smoking have been associated with an increased risk of colon cancer. . or if colon cancer develops at an age younger than 55. Hypothyroidism. early development of colon cancer in a first-generation relative is a more important risk factor. His father had colon cancer. A 27-year-old Caucasian man comes to the physician for a routine health maintenance examination. The dose is then gradually increased to achieve euthyroidism. 40% of people answered this question correctly. (Choice D) Associated signs and symptoms give little information regarding the risk of colon cancer in the above patient. In such cases. and are more prone to oversedation with narcotic medications. Higher doses of levothyroxine in elderly patients or in patients with significant coronary artery disease will increase myocardial oxygen demand and can precipitate myocardial infarction. Colon cancer occurs at an earlier age in patients with familial adenomatous polyposis and familial nonpolyposis colorectal cancer. (Choice C) A diet rich in fiber. His vital signs are within normal limits. is not a contraindication to emergency surgical procedures. even if severe. levothyroxine should be started on a lower dose. folate. Educational Objective: Hypothyroidism. Examination shows no abnormalities. however. even if it is severe. lower doses of levothyroxine should be started postoperatively when the coronary blood flow improves. however. and calcium has a protective effect against colon cancer. however. Age of onset of colon cancer in his father B. which are very important risk factors for colon cancer. Educational Objective: Early development of colon cancer in a first-generation relative is a very important risk factor for evaluating a patient for colon cancer prevention. These hypothyroid patients.Explanation: The patient needs to undergo cardiac surgery on an emergent basis. is not a contraindication to an emergency surgical procedure. Which of the following information is the most important to determine the patient's risk for colon cancer? A. (Choices C and D) Liothyronine is not indicated in the treatment of hypothyroidism . History of alcohol use Explanation: The history of colon cancer in a first-generation relative is the most important risk factor. This risk is further increased if more than one first-generation relatives are affected.

He works as an assistant to a lawyer. (Choice E) Antireflux surgery is too invasive. or gastrointestinal bleeding. calcium. She does not smoke or drink alcohol. glipizide. diabetes mellitus.8C(100F). Endoscopy should be considered early in the course if patients present with symptoms of dysphagia. odynophagia. and vitamin D supplementation. and respiratory rate is 14/min. Item 1 of 2 . His symptoms are progressively getting worse. She has no known drug allergies. weight loss. her temperature is 37. ciprofloxacin. and ranitidine earlier. but these have not significantly relieved his symptoms. On physical examination. Her medications include aspirin. blood pressure is 124/72 mmHg. Start him on a trial of a proton pump inhibitor B. and GI bleeding. odynophagia. Educational Objective: A trial of proton pump inhibitors should be used in patients who have failed other conservative therapies. which involves a trial of proton pump inhibitors for at least eight weeks. over-the-counter antacids. and a recent hospital admission for urosepsis. levothyroxine. alendronate. Examination of the rash reveals the presence of multiple small vesicles over an erythematous base in the thoracic 9-10 nerve root distribution. He has no other medical problems. Endoscopy should be done early if the patient complains of dysphagia. heart rate is 92/min. weight loss. He smokes a pack of cigarettes daily and drinks 6 to 8 cups of coffee daily. antacids. Patients with more severe and prolonged symptoms. and should not be recommended unless all other modalities have failed. Which of the following is the most appropriate next step in the management of this patient? A. or gastrointestinal bleeding. This results from a combination of excessive gastric acid reflux and impaired clearance of the acid by the esophagus. significant weight loss. odynophagia. osteoporosis.A 42-year-old Caucasian man comes to see you in the office with symptoms of dyspepsia and heartburn for the last two years. low-dose prednisone. Ambulatory pH monitoring helps to confirm the diagnosis in patients with persistent symptoms without the endoscopic evidence of mucosal damage. rheumatoid arthritis. It also helps to evaluate refluxassociated pulmonary and upper respiratory symptoms. His physical examination is unremarkable. 61% of people answered this question correctly. and non-prescription H2 blockers. Mild symptoms can usually be managed by simple lifestyle and dietary modifications. Obtain esophageal manometry C. The following vignette applies to the next 2 items An 82-year-old Caucasian female comes to the office for the evaluation of a low-grade fever and rash on her left flank area for the past two days. and those who fail initial management usually require more aggressive therapy. Manometry is used to facilitate the placement of ambulatory pH probes and to guide antireflux surgery. Refer to a surgeon for antireflux surgery Explanation: The patient has symptoms consistent with gastroesophageal reflux disease. He denies any history of dysphagia. He has tried lifestyle changes. She has a past medical history of hypothyroidism. (Choice D) The patient should be referred to a gastroenterologist for an upper endoscopy if he fails a trial of proton pump inhibitors. All the available agents in this class have similar efficacy when used in equivalent doses. Schedule him for an ambulatory pH monitoring D. (Choices B and C) Esophageal manometry and pH monitoring have very limited and specific roles. Refer to a gastroenterologist E.

Explanation: All major organizations. C. meningoencephalitis. The goal of antiviral treatment is to promote early healing. Obtain blood for varicella-zoster virus serology. and localized pain. Explanation: The presentation and physical findings of the patient are classic for herpes zoster. skin biopsy or serologies is not necessary. Item 2 of 2 The appropriate step was taken for the patient. Most patients have a prodromal phase consisting of fever. patients on cancer chemotherapy or chronic steroid therapy. she was admitted to the hospital. cerebellar ataxia. Isolate the patient only if she has extensive or disseminated herpes zoster. which occurs as a result of reactivation of latent varicella-zoster virus (VZV) infection in the sensory or dorsal nerve root ganglion. followed by the development of a vesicular eruption several days later. Over the next 24 hours. Perform a Tzanck smear. The disease is characterized by the development of a painful vesicular rash in the distribution of specific nerve roots. The vesicles typically appear along the thoracic or lumbar dermatomes. Which of the following is the most appropriate next step in the management of this patient? A. and immunocompromised patients. Educational Objective: Antiviral therapy with acyclovir is the mainstay of treatment for herpes zoster. and HIV-infected patients). Due to severe pain. Isolate the patient only if varicella-zoster virus serology is positive. D and E) Herpes zoster is a clinical diagnosis. Infection in pregnant woman may lead to the development of congenital varicella syndrome in newborn infants. E.Which of the following is the most appropriate step in the management of this patient? A. D. healthcare workers. she developed a similar rash in other parts of her body. and death. E. The risk of transmission and development of varicella is extremely high in susceptible patients. B. have a history of varicella and have immunity against the infection. Most people. This can result in severe disease and complications such as bacterial superinfection of the lesions. 70% of people answered this question correctly. . Obtain a skin biopsy to confirm the diagnosis. Obtain a complete blood count with differential count. malaise. D.e. Treatment should be started based on the typical signs and symptoms. Isolate the patient until the lesions are crusted. (Choices A. B. If started within 48 hours of the onset of rash. There is no need to isolate the patient. Isolate the patient until the pain resolves. Start the patient on acyclovir. B. and to prevent or reduce the duration and severity of complications. and these evolve into pustules before crusting in about 7-10 days. C. The pain is the most consistent symptom. including healthcare workers. varicella pneumonia. however. including the Center for Disease Control and Prevention (CDC) have recommended guidelines regarding the isolation of patients with varicella-zoster virus (chicken pox) infections. nosocomial transmission of the infection can occur in all susceptible adults. The population at greatest risk of developing herpes zoster includes the elderly and immunosuppressed patients (i.. transplant recipients. acyclovir has been shown to improve acute pain and prevent the development of postherpetic neuralgia in a significant number of patients. headache. Varicella-zoster virus is a highly contagious virus that is transmitted from person to person by droplets and close contact. The treatment of choice is oral acyclovir. Diagnostic workup such as Tzanck smear. and can persist for days to months after the rash resolves. Treatment should be initiated based on clinical suspicion within 48 hours of the onset of rash for maximum efficacy.

He denies any history of trauma to his flank. Contact precautions are indicated in hospitalized patients with localized herpes zoster. (Choice E) All hospitalized patients with localized dermatomal herpes zoster should be isolated to prevent nosocomial spread. He is complaining of a severe. Studies have shown the superior sensitivity and specificity of non-contrast helical CT scan over other diagnostic modalities in the diagnosis of nephrolithiasis.Herpes zoster is also considered infectious. His past medical history is not significant. An added advantage is that this modality is fast. and bladder (KUB) C. Murphy?s sign is negative. important next step in the management of this patient? A. and has been gradually worsening. but these are not currently recommended in a community setting. (Choice C) All patients with herpes zoster should be isolated to prevent nosocomial spread to susceptible healthcare workers. Order a CT scan of the abdomen and pelvis E. According to the current recommendations. Urinalysis results are as follows: Blood: moderate RBC: 25-30/HPF WBC: 0-2/HPF Nitrite: negative Leukocyte esterase: negative After relieving the patient?s pain with intravenous hydromorphone (Dilaudid). particularly if abdominal tenderness is absent. (Choice B) The pain of herpes zoster may persist for weeks to months after all the lesions have resolved. all patients with disseminated herpes zoster should be maintained on contact and airborne isolation until all skin lesions are dry and crusted. 53% of people answered this question correctly. The patient feels nauseated. but has not actually vomited. The standard procedure is to obtain 8 mm slices using the CT scan. Order an intravenous pyelogram (IVP) D. and urinalysis shows hematuria. His family history is significant for three first-degree relatives with kidney stones. It is not necessary to isolate the patient until that point. Order x-ray of kidney. A 35-year-old white male comes to the emergency department. although the risk of transmission is not as high as that of varicella. The history of the patient is very suggestive of nephrolithiasis. he has very mild tenderness on the right lumbar region. Order a urine culture and sensitivity Explanation: Nephrolithiasis should strongly be suspected in any patient who presents with atraumatic flank pain. however decreasing the size to 3-5 mm slices will further increase sensitivity and specificity. rightsided abdominal pain that started two hours ago. Order ultrasonogram B. widely available. The pain now radiates to his groin. and enables doctors to search for other what is the most . All healthcare workers without a history of varicella-zoster virus infection are strongly encouraged to avoid contact with patients with varicella or herpes zoster infection. ureter. and is described as 10/10 in intensity and sharp in nature. (Choice D) There is no need to check VZV serology in patients with herpes zoster. On examination. Educational Objective: Airborne and contact isolation should be maintained for all patients with disseminated herpes zoster infection until all their lesions are dry and crusted.

cardiac. Administer tetanus toxoid and influenza vaccine D. and tetanus toxoid.possible etiologies of the pain without unnecessary delay. Provide reassurance but do not vaccinate today B. Administer influenza vaccine and pneumococcal vaccine today E. To address this issue. healthcare workers and people in prolonged contact with adults in these high-risk categories . However. followed by an IVP.e. along with the possible risk for allergic reactions occurring secondary to the dye. The indications for influenza vaccination in adults include the following: 1. He reports some improvement in his symptoms of mild headache. (Choice E) The rapid onset of symptoms and urinalysis results (negative for WBC. 30% of people answered this question correctly. and may add an unnecessary delay to the treatment of this patient. one of his close friends suggested he seek out any recommended vaccinations at this visit. A 65-year-old Caucasian male comes to the clinic in September for a follow-up visit regarding an episode of acute sinusitis he developed after a lingering cold. Given his recent susceptibility to illness. if the CT scan results turn out to be negative. immunosuppressed state 4. He attributes this improvement in symptoms to his usage of over-the-counter decongestants and the amoxicillin prescribed a few days ago. choose the USG as the procedure of choice. Ordering a urine culture and sensitivity at this point is not needed. however. leukocyte esterase and nitrites) has made this case unlikely to be a urinary tract infection. (Choice C) IVP is a very sensitive and specific procedure. Administer influenza vaccine today and pneumococcal vaccine next week Explanation: The three most commonly administered vaccinations for adults include the influenza vaccine. He received his last dose of tetanus toxoid 5 years ago. IVP is relatively more time-consuming. or in individuals where you want to avoid the radiation exposure. Influenza season includes the winter months (with a peak incidence in January). nasal congestion. and increased sinus drainage. These reasons. Since 20% of kidney stones do not contain calcium. which of the following is the most appropriate next step? A. pregnant women 6. and is only slightly less expensive than CT scan. 50 years of age and older 2. residents of long-term care facilities 5. Educational Objective: Non-contrast helical CT scan is the gold standard for the diagnosis of nephrolithiasis. Administer tetanus toxoid C. or metabolic conditions 3. (Choice A) USG of the kidneys. it may miss small stones. chronic respiratory. In pregnant patients. the pneumococcal vaccine. and the vaccine is only effective for the year in which it is given. cough. it has a few disadvantages compared to CT scan. have resulted to IVP being used as a second line investigation after CT scan. ureters and bladder (KUB) is the procedure of choice for cases wherein IVP or CT scan cannot be obtained or is contraindicated (i. failure to visualize these types of stones makes this procedure unfavorable. (Choice B) X-Ray of KUB without IVP detects calcium-containing stones only. pregnant patients). and sometimes miss even ureteral stones.

The cough is productive of greenish-yellow sputum. Which of the following is the best treatment option for this patient? A. feces. (Choice A) If methicillin-resistant S. (Choices B and C) Tetanus toxoid should be administered to the following individuals: 1. The patient was diagnosed with cystic fibrosis after three episodes of severe pneumonia two years ago. vancomycin is employed. there is no need to postpone administration of the pneumococcal vaccine until next week. pulse is 130/min. healthcare workers. pneumococcal pneumonia is a known common complication of influenza infection. the selection of antibiotics should be done according to the results of the sputum culture. and it usually includes at least two drugs. and all his immunizations are up-to-date. or saliva) and who received their last dose more than five years ago 2. Chest x-ray shows an infiltrate in the lower left lobe. chills. A 7-year-old Caucasian boy is brought to the emergency department due to a two-day history of fever. he does not need to receive tetanus toxoid. a pathogen responsible for a substantial proportion of community-acquired pneumonias and subsequent hospitalizations. He is currently not taking any medications. a third generation cephalosporin or a carbapenem is used. The most popular combination is an aminoglycoside (e. aureus infection is diagnosed. His blood pressure is 110/60 mmHg.g...g.g. since this patient is clearly prone to upper respiratory tract infections. Educational Objective: Pneumococcal vaccine should be administered to adults 65 years of age and older. Influenza vaccine should be administered to adults 50 years of age and older. Ampicillin plus clindamycin E..On the other hand. . Physical examination reveals decreased breath sounds over the left lower lobe and scattered wheezing bilaterally. Ideally. temperature is 38. and is in the recommended age group for both influenza and pneumococcal vaccinations. pneumococcal vaccination is recommended for all adults 65 years of age and older. cough and progressive shortness of breath. Vancomycin B.g. those who have serious or dirty wounds (e. Adults who were vaccinated more than five years ago (while younger than 65 years of age) are eligible for one additional re-vaccination. pregnant women. (Choice E) Resolving sinusitis and antibiotic usage are not contraindications to vaccination.. Piperacillin plus tobramycin D. piperacillin or ticarcillin). this patient should receive both vaccines. therefore. Dicloxacillin Explanation: Severe exacerbations of pulmonary disease in patients with cystic fibrosis usually require IV antibiotic therapy. Concurrent administration of the pneumococcal and influenza vaccines is safe and effective. He has no known allergies. those who have clean minor wounds and who received their last dose more than ten years ago Since this patient has not incurred a wound recently. the immunosuppressed or chronically ill). as well as those adults in various high-risk categories (e. tobramycin) with an anti-pseudomonal semi-synthetic penicillin (e. the pneumococcal vaccine provides protection against Streptococcus pneumoniae. Empirical therapy should cover Pseudomonas aeruginosa as a common pathogen. puncture wounds or wounds contaminated with soil. For these reasons. Moreover. (Choice A) Providing only reassurance is not advisable. Azithromycin C. therefore. Sometimes.9C(102F) and respirations are 32/min. 72% of people answered this question correctly.

His blood pressure is 110/60 mmHg. He has no known allergies. Educational Objective: The most commonly used empiric antibiotic therapy in cystic fibrosis patients with severe exacerbations of pulmonary disease is an aminoglycoside with anti-pseudomonal semi-synthetic penicillin. pulse is 112/min. Empirical therapy should cover Pseudomonas aeruginosa as a common pathogen. (Choice D) Ampicillin plus clindamycin is not a good option for empirical therapy in this patient. male taxi driver had a motor vehicle accident.9C(102F) and respirations are 32/min. Which of the following is the best treatment option for this patient? A. The cough is productive of greenish-yellow sputum. The most popular combination is an aminoglycoside (e. He is currently not taking any medications. and it usually includes at least two drugs. along with the paramedics. (Choice D) Ampicillin plus clindamycin is not a good option for empirical therapy in this patient. vancomycin is employed. Sometimes. 44-year-old. and all his immunizations are up-to-date. piperacillin or ticarcillin). Dicloxacillin Explanation: Severe exacerbations of pulmonary disease in patients with cystic fibrosis usually require IV antibiotic therapy. A 7-year-old Caucasian boy is brought to the emergency department due to a two-day history of fever. temperature is 38. Azithromycin C. He could not . pulse is 130/min.. the selection of antibiotics should be done according to the results of the sputum culture. His blood pressure is 100/60 mmHg. You come to help him. chills.g. (Choices B and E) Azithromycin or dicloxacillin can be used as oral agents in less severe cases in patients with susceptible flora. a third generation cephalosporin or a carbapenem is used. Middle-eastern. aureus infection is diagnosed. Azithromycin may be a useful long-term agent to prevent acute exacerbations. He was a restrained driver. 78% of people answered this question correctly. Chest x-ray shows an infiltrate in the lower left lobe. A healthy..(Choices B and E) Azithromycin or dicloxacillin can be used as oral agents in less severe cases in patients with susceptible flora. The patient was diagnosed with cystic fibrosis after three episodes of severe pneumonia two years ago. Piperacillin plus tobramycin D. Physical examination reveals decreased breath sounds over the left lower lobe and scattered wheezing bilaterally. and find him unresponsive with spontaneous respirations. tobramycin) with an anti-pseudomonal semi-synthetic penicillin (e. cough and progressive shortness of breath. and respirations are 12/min. Educational Objective: The most commonly used empiric antibiotic therapy in cystic fibrosis patients with severe exacerbations of pulmonary disease is an aminoglycoside with anti-pseudomonal semi-synthetic penicillin. Vancomycin B. Examination shows clear lung fields and normal first and second heart sounds. Ampicillin plus clindamycin E. Ideally. 78% of people answered this question correctly.g. Azithromycin may be a useful long-term agent to prevent acute exacerbations. (Choice A) If methicillin-resistant S.

it is advisable to use the jaw lift maneuver to avoid further complications if there is any neck injury. he or she will need to be intubated. . the paramedics can proceed to suction the mouth to prevent any possible aspiration. Intubate immediately B. the airway must be secured through the jaw lift maneuver to avoid further strain in the neck area. There is no indication for immediate intubation or cricothyrotomy at this point. (Choices A and C) The patient has spontaneous respirations. (Choice B) After securing the airway. Whenever the airway needs to be protected. Do cricothyrotomy D. Which of the following is the most appropriate course of action? A. Cricothyrotomy may be necessary if there is complete obstruction of the airway. Stabilize the spine first Explanation: There is a considerable risk of neck trauma during most motor vehicle accidents. (Choice E) Stabilization of the spine is also done after securing the airway. 20% of people answered this question correctly.be extricated from the car. he starts to cough and spit some blood. completely unresponsive. The first thing to always do in such trauma cases is to secure the airway. Educational Objective: Whenever there is an accident with possible neck trauma. If the patient is unconscious. unable to protect the airway. Do the jaw lift maneuver E. Suction the mouth C. Suddenly. not breathing or coughing.

Which of the following is the best statement concerning the results of the study? A. (Choice E) Because both the incidence of CHD and cigarette sales declined progressively. His mother is worried and asks if such development is normal. it is clear that the incidence of CHD. Reassurance B. His past medical history is unremarkable. Other candidates for hearing evaluation . Educational Objective: It is important to remember that ecologic studies give population-level information. Screening for TORCH organisms E. A 2-year-old child is supposed to know a 50+ word vocabulary. Discordant changes in cigarette sales and incidence of CHD are present. Which of the following is the most appropriate next step in the boy's management? A. not individuallevel information! 35% of people answered this question correctly. Watchful waiting C. however. He was delivered vaginally at 39 weeks? gestation. E. According to his mother. Explanation: No individual-level conclusions can be ascertained from the given plot. Cigarette sales were stable over time in the population. It is important to remember that ecologic studies give population-level information. D." He runs well and walks up and down stairs without assistance. except for language which is delayed. and follow two step commands.to 3-word phrases. therefore. steadily declined over time in the population. The relationships between the cigarette sales in the population (average number of cigarette packs sold per person per day) and the incidence of CAD (per 1000 people) over time are given on the figure below. They studied several factors in relation to the incidence of the disease. but prenatal visits were not regularly followed. Quitting smoking decreases the risk of CHD for a person living in this population. it also cannot be concluded that personal computer use decreases the risk of CAD. the only words that he says are "mama" and "dada. A 2-year-old boy is brought to the physician because of a delay in language development. his mother's pregnancy was uncomplicated. Hearing test D. as well as cigarette sales. No individual-level conclusions can be ascertained from the given plot . A similar trend could be possibly observed by plotting personal computer usage in this population (increasing over time). not discordant.A group of investigators is exploring trends in the incidence of coronary artery disease (CAD) in a large population. C. the changes over time are concordant. use 2. No stable trend is present in the incidence of CHD over time. (Choice B) It cannot be concluded directly from this plot that quitting smoking decreases the risk of CHD for a person living in this population. CT scan of the head Explanation: This child has normal developmental milestones. (Choices A and C) The given plot illustrates the temporal trends of cigarette sales and incidence of CHD. not individual-level information! Applying population-level information to an individual level may lead to a bias called ecologic fallacy. He builds a tower of seven blocks and turns pages one at a time. such children should be referred for audiologic assessment. The study described is a typical ecologic (correlational) study. B. Delayed speech development may indicate an underlying hearing impairment.

CT scan of the head Explanation: Hospice care is usually provided to terminally ill patients who have a predicted life expectancy of six months or less. The patient's caretaker tells you that he has not been able to eat or drink for the last six weeks. history of recurrent or persistent otitis media with effusion for more than three months. history of recurrent or persistent otitis media with effusion for more than three months. even mild or unilateral. Early identification is thus mandatory for a better prognosis. Educational Objective: Delayed speech development may indicate an underlying hearing impairment and should prompt referral of the patient for audiologic assessment. history of meningitis. hence. documented intrauterine infections. tympanosclerosis. The cancer has spread to his lungs and liver. isolated or in a syndromic association with other anomalies. it may be autosomal dominant or recessive. Postnatal infectious causes include group B streptococcus and bacterial meningitis. When is the most appropriate time to refer this patient to hospice care? A. cholesteatoma. may affect speech and language development. He should be referred to hospice care after he has cleared his hospital bills. and use of ototoxic medications such as aminoglycoside. ossicular discontinuity (infection. you think about offering hospice care to the patient.include children with a family history of hereditary childhood hearing loss. and use of ototoxic medications such as aminoglycoside. Hearing loss can also be genetically determined. He should be referred to hospice care two months before his anticipated death. A 78-year-old Caucasian man with end stage esophageal cancer is admitted to the hospital with severe malnutrition and failure to thrive. at present. The most common cause of conductive hearing loss in children is presence of fluid in the middle ear. C. (Choices D and E) The other diagnostic methods may be more or less useful for evaluation of this child. it may be congenital or acquired. systematic screening is implemented in 32 states only. and trauma). and its type identified by a hearing test. Hearing loss early in life. screening programs have been widely and strongly advocated. The patient expresses his wishes to not receive any further treatment for the cancer. (Choices A and B) Reassurance and watchful waiting are inappropriate because hearing impairment should be identified promptly. and specifies that he does not want any heroic measures or interventions done to keep him alive. and rubella. craniofacial anomalies. B. E. documented intrauterine infections. social and emotional development. The most common infectious cause of congenital SNHL is CMV. D. Tell the patient that you would not be able to treat her if she refuses to sign the consent. The etiology of hearing impairment depends on whether the hearing loss is conductive or sensorineural. however. 61% of people answered this question correctly. syphilis. . The largest population of patients receiving hospice care consists of cancer patients. and academic achievements. Other less common congenital infectious causes include toxoplasmosis. Other candidates for hearing evaluation include children with a family history of hereditary childhood hearing loss. craniofacial anomalies. and congenital anomalies of the external ear canal or middle ear components. hearing impairment should first be confirmed. Keeping his current clinical condition in mind. Although the American Academy of Pediatrics endorses universal screening. history of meningitis. His weight dropped from 160 pounds to 120 pounds during that time. Other causes include tympanic membrane perforation (trauma or infection). He should be referred to hospice care two weeks prior to his anticipated death. As for sensorineural hearing loss (SNHL).

In the above vignette. C. but is not limited to psychological. (Choices A and B) Refusal of admission or treatment of the patient is unethical and inappropriate. and tells you that women in their culture are not allowed to sign any papers if their husbands are alive. It is usually provided at the patient?s own home (home hospice care). Examination reveals that she is in active labor. The patient or surrogate then exercises the right of autonomy and makes the healthcare decision. which includes. and is easily and completely comprehended. The patient should be treated appropriately even if she refuses to sign the consent for treatment herself. She and her husband appear to understand the information completely. and a hospice physician who closely coordinates with the patient?s attending physician. Before arriving at a decision. When you ask the patient to sign the consent sheet for treatment. to make healthcare decisions on her behalf. It is important to ensure that the information provided to the patient is adequate. A 32-year-old pregnant woman who recently migrated from Eastern Asia is brought to the hospital by her husband. You then explain to the patient and her husband the various possible methods of delivery and the complications that can arise from them. This leads to a shorter length of stay in hospice programs. nursing. but it can also be given as an inpatient hospice care for patients who are not functionally independent. She agrees to be admitted for delivery. social. and deprives the patients of the full benefits available to them. . Ask the hospital not to admit the patient if she refuses to sign the consent. or pulmonary fibrosis. Obtain a witness to the above conversation. It is the physician?s obligation to provide all the medical facts accurately to the patient or the surrogate decision maker in accordance with good medical practice. She asks you to have her husband sign the consent sheet for her treatment. D. chaplains. Both the patient and her husband want to proceed with the planned treatment as well. 95% of people answered this question correctly. She is on her 37th week of gestation. Educational Objective: Patients with advanced metastatic cancers or other terminal illnesses with an expected life expectancy of less than six months should be evaluated for hospice care. or as soon as possible. she becomes reluctant. social workers. He should be referred to hospice care program now.Other patients receiving hospice care have terminal medical conditions such as endstage cardiomyopathy. She has been having regular uterine contractions for the last four hours. The patient in the above scenario has advanced esophageal cancer with an expected survival of less than six months. The couple appears to understand everything that you explain. Hospice care is provided by a multidisciplinary team. which includes a registered nurse. the patient and the healthcare professional work must together as a team. the patient was provided with adequate information. If the child does not cry after she finishes feeding him. B. and treat the patient. (Choices B and C) There is a general tendency to delay hospice care to eligible patients by their caregivers or attending physicians. Hospice care is based on the principle of providing compassionate and comprehensive support and care. E. Which of the following is the most appropriate reaction to the patient's request? A. She has a right to choose a surrogate decision maker. and palliative medical care to a dying patient. It also provides support and respite care to the family members or caregivers of the terminally ill patient. CT scan of the head Explanation: Informed consent involves a process whereby a patient or his/her surrogate decision-maker makes a healthcare decision based on the physician?s recommendation. nurse?s aide. such as her husband. endstage chronic obstructive pulmonary disease. Tell her that you would not be responsible for any malpractice claims if her husband signs the paper.

.(Choice C) This statement is not true. and is easily and adequately comprehended by the patient or their surrogate decision maker. 80% of people answered this question correctly. Educational Objective: Informed consent is considered effective when sufficient information is provided by a physician. The physician has to assume responsibility for all actions which directly involves the management of his patient.

Which of the following is the most accurate answer? A. It is recommended that the infant be fed at least every four hours.A healthy 28-year-old Middle-Eastern woman comes to the physician for a routine health maintenance examination. he was prescribed topical retinoid and benzoyl peroxide. like suckling of the hand or fingers or arm movements towards the mouth. On his face are numerous comedones and many inflamed papules and pustules. (Choice E) Newborns cry for many different reasons. 26% of people answered this question correctly. Explanation: Most breastfeeding authorities. as complete emptying of the breast will increase the milk?s nutritional qualities. E. What is the most appropriate means of managing his condition? A. If the child does not cry after she finishes feeding him. This was her first pregnancy. however. Furthermore. Add oral corticosteroids to the regimen C. re-evaluate in three months . The mother should be able to identify early signs of hunger. and the baby has to be fed using artificial formula. She has just delivered a 3. C.7 lb) baby boy three days ago. (Choice C) Some infants may need feeding every two hours. recommend feeding infants at least every four hours. Add topical erythromycin to the regimen B. (Choice B) It is a good practice to feed the newborn using both breasts. He feels that the acne has improved slightly with this treatment regimen. and she asks you what the best way is to know if the baby is being fed properly. Make sure you feed him anytime he cries. Feeding the baby using both breasts will therefore not guarantee the infant?s satiety. She is breastfeeding. Make sure you feed him every 2 hours. as well as the CDC (Center for Disease Control). Examination shows no abnormalities. as preterm or debilitated infants may not be able to cry vigorously or show agitation. Make sure you feed him every 4 hours. which he has been using regularly. sometimes there may be a decreased production of milk. D. She is a housekeeper. Unfortunately. as well as to look for early signs of hunger (like hand or finger suckling or arms movement toward the mouth) to determine proper breastfeeding. Make sure you feed him using both breasts. B. Educational Objectives: Every primary care physician should encourage breastfeeding. Begin treatment with oral isotretinoin only E. If the baby does not cry. She does not use tobacco. there is no scientific evidence to support this method. No change in treatment. or drugs. and not always because they need to be fed. alcohol. and there is some evidence of mild scarring. She has no complaints. it is not advisable to wait until the newborn cries to breastfeed him. this does not mean that he was properly fed.5 Kg (7. At his first visit three months ago for this problem. A 14-year-old Caucasian male presents to the pediatrician for a follow-up visit regarding his acne. (Choice A) Breastfeeding has a soporific effect in the infant. Begin treatment with oral tetracycline only D.

No change in treatment. Corticosteroids (Choice B) are used in patients with excessive adrenal androgen production (e. and he was extremely drowsy. A single intramuscular injection of penicillin G B.. she evaluated him. then oral isotretinoin (Choice D) is indicated. cases of congenital adrenal hyperplasia). refractory forms of acne. including a lumbar puncture for CSF analysis. Treatment regimens usually progress through several stages. based upon how severe the acne is at presentation and how effective the treatment options are in resolving the symptoms. benzoyl peroxide. or 2) systemic antibiotic plus topical retinoid or benzoyl peroxide. More severe acne (or refractory moderate acne) is treated with: 1) topical retinoid. Note that systemic antibiotics (Choice C) are not typically used exclusively. some general principles are observed by most clinicians. His teachers at school C. Paramedics who brought the patient to the emergency room E. The nurse tells you that the boy has not been feeling well for the past two days. She first saw him two days ago when he was complaining of headache and generalized body aches. Item 1 of 2 Which of the following contacts should be offered antibiotic prophylaxis to prevent the development of meningococcal meningitis? A. . so any acne therapy regimen must be continued for at least this length of time before determining its efficacy. and prescribed him acetaminophen for his symptoms. Educational Objective: Topical products (e.g. antibiotics) are first-line treatments for mild to moderate acne. if there is no response after 3-6 months.. 36% of people answered this question correctly. The following vignette applies to the next 2 items A 16-year-old Caucasian boy is brought to the ED via ambulance by his school nurse. re-evaluate in three months Explanation: Neisseria meningitidis is the most common cause of acute bacterial meningitis in children and adolescents from ages 2-18 years. In the ED. Emergency room physicians and other staff members D. it would be unreasonable to ask him to wait another three months (Choice E) before reevaluating the treatment regimen.g. Microcomedones take eight weeks to mature. Subsequent evaluation.Explanation: Although there are no definitive evidence-based guidelines on the treatment of acne. Since this boy has already waited three months. Moderate acne (or refractory mild acne) is treated with topical retinoid and either benzoyl peroxide or a topical antibiotic. Mild acne is initially treated with topical retinoid. benzoyl peroxide. The portal of entry of this bacteria is via the nasopharynx. The most severe cases of acne should be treated with a systemic antibiotic and topical retinoid or benzoyl peroxide. he had two episodes of vomiting while sitting in his classroom. Earlier this morning. reveals that he is suffering from acute meningococcal meningitis. Systemic products such as oral antibiotics are reserved for more significant acne. At that time. and oral isotretinoin is used for the most severe. concluded that he was suffering from a viral prodrome. retinoid. He experiences another episode of emesis and is emergently intubated by the emergency room resident for airway protection. and topical antibiotic (Choice A). he is minimally responsive.

A single intramuscular injection of penicillin G B. and subsequent development of potentially fatal meningitis in predisposed individuals. Antibiotic prophylaxis is not indicated if the exposure to the patient is brief or short.. or during transportation) do not require antibiotic prophylaxis. all healthcare workers (including physicians) who have had direct exposure to the respiratory secretions of the patient (e. close contact with the patient. sulfonamides. In addition. 87% of people answered this question correctly. antibiotic prophylaxis is indicated in all the close contacts of patients with meningococcal meningitis. The mortality rates are even higher in adult patients with meningitis.g. either at school or work. 37% of people answered this question correctly.. It is therefore recommended that antibiotic chemoprophylaxis be used to prevent the spread of meningococcal meningitis. These include people who live in the same household and persons who have had prolonged. Two days of cefazolin Explanation: As described above. cefazolin. C. and minocycline. (Choices A. or intravenous vancomycin is not recommended for chemoprophylaxis to prevent the spread of meningococci. Meningococcal meningitis is a devastating illness and is associated with significant morbidity and mortality. and is effective in preventing the development of meningitis in close contacts. & C) Penicillin G. and if there is no direct exposure to the respiratory or nasopharyngeal secretions. It is only required for persons who have had prolonged contact in a closed environment with the patient. (Choices B. Educational Objective: All persons with prolonged. & D) Those persons with brief exposure to the patient (e. thereby causing systemic bacteremia and subsequent meningitis in predisposed patients. Oral rifampin E. A single dose of intravenous vancomycin D. Antibiotic prophylaxis is used to eliminate the nasopharyngeal colonization of meningococci. . Inhaled tobramycin for two days C. Which of the following is the most appropriate therapy for chemoprophylaxis against meningococcal meningitis? A. close contact or direct exposure to the respiratory secretions of a patient with meningococcal meningitis should receive antibiotic prophylaxis to prevent the spread and development of meningitis.Although colonization of Neisseria meningitidis in the nasopharynx is relatively common and affected patients are usually asymptomatic. Educational Objective: Oral rifampin is the recommended antimicrobial for chemoprophylaxis against the spread of meningococcal meningitis. Oral rifampin (600 mg every 12 hours for a total of four doses) is the recommended regimen for chemoprophylaxis. B. Item 2 of 2 You identify and contact the persons in whom the antibiotic prophylaxis is indicated. Other antimicrobials that can be used for chemophrophylaxis include fluoroquinolone (a single 500 mg dose of ciprofloxacin). while suctioning or intubating the patient) should receive chemoprophylaxis. The other commonly used regimens are single oral dose of ciprofloxacin or single intramuscular injection of ceftriaxone. inhaled tobramycin. seeding of the meninges. All close contacts must receive antibiotic prophylaxis. Neisseria meningitidis tends to colonize the nasopharynx and invade the mucosa. it can cause mucosal invasion with systemic bacteremia. ceftriaxone.g.

and is also due to thick. Most dihydropyridine calcium channel blockers (e. She says. Aspirin E. nifedipine and amlodipine). The following Vignette applies to the next 2 items A 33-year-old Caucasian female presents to your office with a six-month history of cold intolerance. She is sexually active with her husband and uses condoms for contraception. Physical examination findings are within normal limits. but it does not always work?.. Her past medical history is significant for non-ulcer dyspepsia treated with omeprazole. Only males are infertile. When the weather is cold. Item 1of 2 Which of the following medications is the best initial treatment for this patient? A. Calcium antagonists are considered the first-line pharmacological therapy for these patients. She works as a nurse at a local hospital and considers her job moderately stressful. Which of the following statements is true regarding fertility in a patient with cystic fibrosis? A. ?I wear gloves to keep my hands warm. She does not smoke or consume alcohol. an exaggerated vascular response to cold temperature or emotional stress. Many other vasodilator agents have been tried to treat this condition. She has no known drug allergies. There is a 50% chance that you may not become pregnant. (Choice C) Verapamil does not seem to be effective or at least equally effective as calcium antagonists. Verapamil D. Topical nitroglycerin Explanation: This patient presents with symptoms suggestive of Raynaud phenomenon. 27% of people answered this question correctly. Her boyfriend does not have any medical problem. C. This increased risk is due to secondary amenorrhea caused by malnutrition. There is a 20% chance that you may not become pregnant. She is a non-smoker and non-alcoholic. . Educational Objective: Chances of infertility in a female with cystic fibrosis are 20% percent. Prazosin B. and denies any recreational drug use. Prazosin B.g. Chances of infertility in a male with cystic fibrosis are 95%. Spermatogenesis is normal in a patient with cystic fibrosis.A 26-year-old Caucasian woman who is suffering from cystic fibrosis comes to the physician. D. She has recently changed her boyfriend and is trying to conceive these days. E. Chances of infertility in a male with cystic fibrosis are 95%. Nifedipine C. are proven to work well in these patients. you will not have any problem. but sperm transport is impaired because of impaired development of the Wolffian duct. as well as diltiazem. Air pollution Explanation: Chances of infertility in a female with cystic fibrosis are 20% percent. her third and forth fingers on both hands get numb and turn blue. but it should be mentioned that not all calcium antagonists are equally effective. tenacious cervical mucus.

however. (Choice E) Nitroglycerin is usually used as an adjunct agent to calcium antagonist therapy in patients with severe Raynaud phenomenon. however. Educational Objective: Calcium antagonists. aspirin should be used with caution because it can actually worsen vasospasm by blocking the synthesis of vasodilatory prostaglandins. 59% of people answered this question correctly. patients eventually become refractory to these agents after prolonged usage. typically nifedipine or amlodipine. It is not recommended as the first-line agent.(Choice A) Alpha-adrenergic blockers such as prazosin are effective. are considered the first-line pharmacological therapy for patients with Raynaud phenomenon. (Choice D) Some authors recommend adding aspirin to the treatment regimen in patients with severe ischemia and necrosis to prevent platelet aggregation. .

and weight loss) in patients with Raynaud phenomenon warrants further evaluation. blood chemistry. His blood glucose levels during the last two days have ranged from 120?200 mg/dl. Which of the following is the best next step in the management of this patient? A. Itraconazole D. CBC. vibration) should first be excluded. and there was a black discoloration in the antero-inferior aspect. Which of the following is the most effective agent for the treatment of this infection? A. Twenty-four hours after being transferred to the medical floor. Increase the dose of the medication B.. medications. RF. Terbinafine C. he started to have a spiking fever up to 102?F (39? C). Amphotericin B B. and developed foul-smelling nasal discharge and pain in his right paranasal area. the nasal mucosa was inflamed. Order arterial Doppler ultrasonography D. Her husband even gave up smoking because you had warned her that passive smoking may worsen her condition. this may include ANA. fever. urinalysis and measurement of complement levels. she has started to experience periodic joint and muscle pain.? In addition. and is currently on glargine (14 units at bedtime) and lispro (8 units three times a day before meals). this may include ANA. blood chemistry. vascular lesions. On examination. The presence of symptoms suggestive of systemic disease (arthralgias and myalgias) and resistance to treatment (such as in this patient) warrant further evaluation.. arterial Doppler ultrasonography or angiography should be considered. He started tolerating oral feeding yesterday. urinalysis and measurement of complement levels. (Choices A and B) It is not reasonable to change the treatment without first excluding a systemic disease that may be responsible for the condition. frostbite. Flucytosine . He has had type-1 diabetes for the past two years. CBC. myalgias.Item 2 of 2 The patient returns in one month and complains that the treatment ?does not help much. No specialized studies are indicated in these patients.g. When managing patients with Raynaud phenomenon. Add a second agent C. Educational Objective: The presence of symptoms suggestive of systemic disease (arthralgias. RF. (Choice E) Patients are diagnosed with primary Raynaud phenomenon when there are no historic clues to a secondary condition. Obtain ANA and RF E. etc. She says that she has been adherent to the medication and has tried to avoid going out in cold weather as much as possible. Voriconazole E.g. potential precipitating factors such as medications and environmental factors (e. normal physical findings and no ischemic digital lesions. 67% of people answered this question correctly. A 26-year-old male who was initially admitted in the intensive care unit three days ago for diabetic ketoacidosis (DKA) is transferred to the medical floor after getting the appropriate initial treatment. further evaluation with digital plethysmography. (Choice C) In patients who have symptoms suggestive of vascular lesions (e. asymmetric involvement and deficient pulses). Reassure and observe Explanation: Raynaud phenomenon may be idiopathic (also called Raynaud disease) or secondary to other conditions such as connective tissue diseases.

.

(Choices C and E) Short-term use of low-dose estrogen for menopausal symptoms does not appear to be harmful. and does not smoke or drink alcohol. undesirable cardiovascular and other side effects. Treatment consists of debridement of the necrotic tissues and amphotericin B. it may do so in patients with DKA. Start raloxifene Explanation: Most females rapidly lose considerable bone mass following menopause. Tell her to discontinue the exercise program E. including weightbearing exercises and optimum calcium and vitamin D supplementation. and were reported to be normal. Since then. maxillary pain and tenderness. The common clinical features are fever. hormone replacement therapy could be possibly avoided. In such patients. Although this class of fungi does not cause infections in a normal host. Her past medical history is unremarkable. She denies any symptoms. prevents postmenopausal bone mass loss and possibly reduces the risk of fragility fractures. because her symptoms appear to improve with time.Explanation: Patients with DKA are predisposed to get mucormycosis. This can be easily achieved by taking one multivitamin tablet (which contains 400 international units of vitamin D) with two tablets of calcium/vitamin D (containing 600 mg of elemental calcium and 200 international units of vitamin D) everyday. Her physical examination is unremarkable. which are likely to improve with hormone replacement therapy. stressful exercises should be avoided as much as possible. Lifestyle modification. (Choice E) Flucytosine is used in cryptococcal meningitis in combination with amphotericin B. (Choices C and D) Voriconazole and itraconazole are not effective against mucormycosis. There is no history of cancer or osteoporosis in her family. She has not been on any hormone replacement therapy. (Choice D) Exercise with weightbearing leads to improvement in bone mass. since they have a higher risk of fracture. which have been gradually improving during the last two months. 78% of people answered this question correctly. an infection caused by fungi from the class Zygomycetes. It is not used for systemic fungal infections. and should be continued in this patient. except for minimal hot flashes. She exercises regularly. The National Academy of Science recommends daily supplementation of elemental calcium (1200 mg) and vitamin D (400 to 800 international units) in women after 50 years of age. Despite aggressive treatment. This patient has minimal hypoestrogenic symptoms in the form of hot flashes. What is the next best step in the management of this patient? A. She had menopause one year ago. however. and invade the surrounding structures rapidly. Her mammogram and pelvic exam were performed eight months ago. nasal discharge. The diagnosis is suggested by the characteristic clinical picture. the mortality remains high. This patient does not . hormone replacement therapy fell out of favor following a recently published study of the women?s health initiative because of increased. these pathogens can infect the nasal mucosa. she started having some menopausal symptoms. however. Start her on hormone replacement therapy B. facial swelling. Because of the acidic environment and high free iron. exercise should be individualized in patients with significant osteoporosis. Start calcium and vitamin D supplementation C. Her father has premature coronary artery disease. Start low-dose alendronate D. (Choice B) Terbinafine is approved for the treatment of onychomycosis of the fingernails. Educational Objective: Rhinocerebral mucormycosis is best treated with surgical debridement and intravenous amphotericin. however. A 53-year-old African-American female is seen for her annual physical examination. ophthalmoplegia and headache. It is a weak anti-fungal agent on its own. She is currently on no medication. and confirmed by performing a biopsy of the infected tissues.

it is pragmatic to rule out concomitant central adrenal insufficiency before beginning therapy. alendronate. The thyroid gland is normal. Neurological examination reveals hung-up ankle jerks. however. except for postmenopausal stature. but not suspected central hypothyroidism.5 mg/dl (normal 0.8 to 1.have any risk factors for osteoporosis. The chest is clear on auscultation. A cosyntropin stimulation test is the most preferred initial test to screen for adrenal insufficiency. Measurement of cortisol with cosyntropin stimulation E.g. It still haa a role in differentiating isolated pituitary resistance to thyroid hormones (normal response) from TSH secreting pituitary tumors (diminished response).0 mU/ml) and free T4 is 0. . TRH stimulation test C. while the rest of the basic chemistries are normal. RBCs are normochromic and normocytic.35 mU/ml (normal 0. and constipation for the past two months. Serum sodium is 129 mEq/dL . Central hypothyroidism can also have slightly elevated TSH levels. Educational Objective: Calcium and vitamin D supplementation should be recommended in all postmenopausal females to protect bones. What is the next best step in this patient?s care? A. this elevated TSH is not biologically active. raloxifene) is not warranted at this time. Patients with primary adrenal insufficiency (Addison?s disease) can have increased TSH levels without hypothyroidism due to the loss of an inhibitory effect of glucocorticoids on TSH secretion. Her family history is positive for osteoporosis and hypertension. There is no documentation of low bone density (osteopenia or osteoporosis). Heart sounds are normal. There is also no history of fragility fractures. as suggested by borderline TSH and low free T4 levels. a patient on high-dose glucocorticoid treatment will have a transient decrease in TSH levels. When central hypothyroidism is suspected. Treating a patient with central hypothyroidism and concomitant adrenal insufficiency could precipitate adrenal crisis. and a hematocrit of 34%. and in the evaluation of suspected factitious thyrotoxicosis. She denies allergies to drugs. (Choice E) Thyroglobulin level determination is useful in the follow-up management of patients with differentiated thyroid cancers. TRH stimulation test is now rarely performed. Educational Objective: Evaluation of the adrenal status is warranted in patients with suspected central hypothyroidism. (Choice A) Antithyroid antibodies are useful in the evaluation of goiter and primary hypothyroidism. A 56-year-old female presents with lethargy. Serum T3 levels D. Laboratory tests reveal a hemoglobin of 11. She is three years postmenopausal. weight loss. Thyroglobulin levels Explanation: The patient most likely has central hypothyroidism. Conversely. vomiting. (Choice B) After the advent of sensitive TSH assays.8 mg/dl). She does not use tobacco or alcohol. Abdominal examination is unremarkable. She has mild pallor. Measurement of antithyroid antibodies B. TSH is 0. She currently takes no prescription medications. Her heart rate is 64/min and blood pressure is 124/66 mmHg. Treatment with bone-specific antiresorptive therapy (e. and has no long-standing medical problems..35-5. Imaging studies (preferably a MRI) are done to look for a mass lesion in the sellar area. Her height is 5?3" (160cm) and she weighs 138 lbs (63kgs). nausea. (Choice C) T3 level determination has no role in the evaluation of hypothyroid patients. 31% of people answered this question correctly.2 g/dL.

Intestinal obstruction B. Plain abdominal radiographs will show air fluid levels. along with a history of bloody diarrhea or hematochezia. Educational Objective: A sudden onset of severe periumbilical pain that is out of proportion to the physical examination findings. however. The abdominal examination is initially normal. non-distended and non-tender. (Choice D) Acute intermittent porphyria is a rare disease. and occurs in a setting with risk factors such as atrial fibrillation. (Choice A) Patients with intestinal obstruction usually have a history of absolute constipation.0 mEq/L.7C(98F). Embolization usually throws clots into the superior mesenteric artery. Liver function panel is also normal. There is no rebound tenderness or rigidity. and occur in the presence of other manifestations such as neuropathy. She has no complaints.000/microL. and serum creatinine is 0. Acute colonic ischemia D. She is an executive secretary with a sedentary lifestyle. Patients will usually have recurrent episodes of abdominal pain that is precipitated by several factors. The serum lipase is normal. with normal bowel sounds. Patients usually present with a sudden onset of periumbilical abdominal pain. She has a history of 20 pack years of smoking. hypertension. She denies any urinary complaints. blood pressure is 120/76 mm Hg. while the serum amylase is slightly elevated. nausea and vomiting. She had an appendectomy at the age of eighteen. (Choice E) Acute diverticulitis usually causes a more localized pain (LLQ). She is an occasional alcohol drinker. blood glucose is 110mg/dL. This patient also had a recent anterior myocardial infarction. Pelvic examination is within normal limits. Serum sodium is 140 mEq/L. Fecal occult blood test is negative. Acute mesenteric ischemia C. she is concerned about her risk of developing osteoporosis. Acute diverticulitis Explanation: This patient is most likely suffering from acute mesenteric ischemia secondary to embolic phenomenon caused by atrial fibrillation. Her temperature is 36. The symptoms are usually manifested much earlier (usually after puberty).7 mg/dL. She drinks coffee for at least five times daily. etc. congestive heart failure. She denies any fever. hyponatremia. Her past medical history is significant for coronary artery disease. Acute intermittent porphyria E. irregular. Which of the following is the most likely diagnosis of this patient? A. EKG shows atrial fibrillation. and peripheral vascular disease. 90% of people answered this question correctly. Caucasian woman comes to the physician for a routine health maintenance examination. resulting in mesenteric ischemia.A 65-year-old white female presents to the emergency department with a sudden onset of severe periumbilical pain. The abdomen is soft. Her last menstrual period was two years ago. and respirations are 16/min. . This is not because of the obstruction of flow to the colon. Her last menstrual period was fourteen years ago. diarrhea. BUN is 20 mg/dL. This usually results from hypovolemic states or transient ischemia to the bowel. CBC shows a WBC count of 14. and hyperlipidemia. should always raise the suspicion for acute mesenteric ischemia. A 53-year-old asymptomatic. Plain abdominal x-ray fails to show any abnormalities. a recent acute anterior myocardial infarction. serum K is 4. Urinalysis is normal. and the pain felt by the patient is usually out of proportion to the initial examination findings. Patients may also present with diarrhea. and soda at least twice daily. pulse is 120/min. The physical exam would show tenderness in the LLQ. or constipation. (Choice C) Patients with acute colonic ischemia usually have a more lateralized abdominal pain with tenderness.

alcohol. She takes no medication. but there are no secretions. there is an . His vital signs are within normal limits. She drinks 1-2 ounces of alcohol daily. but widespread use is not advisable because of the risk of malignancy or cardiovascular disease. and discontinuation of medications such as heparin or glucocorticoids. and history of previous fractures). (Choices A. Some recent studies even show that it may also increase the risk of cardiovascular disease. the majority of which are non-modifiable. Stop smoking D. For instance. and soda ingestion mildly increase the risk of osteoporosis compared to menopause or smoking. Cataracts E. The conjunctiva of the left eye is also erythematous. it is also necessary to know the modifiable factors in order to provide interventions which can lower a patient's risk for the disease. purulent discharge from his right eye. calcium and vitamin D supplementation. She has no known drug allergies. 39% of people answered this question correctly. Recurrence D. Start hormonal replacement therapy E. Item 1 of 3 Which of the following complications is most likely to occur with his condition? A. Nothing C.. race. The mother is especially concerned about the possible complications of the disease.g. Examination shows no abnormalities. She has smoked one pack of cigarettes daily for 35 years. (Choice D) Although hormonal replacement therapy (HRT) can effectively decrease a patient?s risk of osteoporosis. increased risk of a corneal lesion in the form of keratitis. Stop drinking alcohol B.She is a vegetarian. Endophthalmitis B. B and E) Lack of exercise. but a smoker who consumes one or more packs of cigarettes a day will benefit more from smoking cessation than from any other intervention. The interventions that have proven to offer more benefit are: smoking cessation (if the patient smokes one pack or more of cigarettes a day). coffee. Start an exercise program Explanation: Although the most important risk factors for osteoporosis are the non-modifiable ones (e. Which of the following interventions will be the most beneficial to decrease her risk for osteoporosis? A. Educational Objective: There are multiple risk factors for osteoporosis. Keratitis Explanation: This is a typical presentation of bacterial conjunctivitis. Stop drinking coffee and soda C. smoking half a pack of cigarettes a day has a mild negative effect on osteoporosis. family history. The following vignette applies to the next 3 items A healthy 8-year-old Caucasian boy is brought to the office by his mother because of redness and copious. Her father has hypertension. Her mother had a stroke. The school nurse informed the mother that the boy's disease is very contagious. HRT can unfortunately increase the risk of breast and endometrial cancer. Examination shows conjunctival erythema and yellow exudates in his right eye. The boy denies fever or blurred vision. raloxifene. age. HRT is extremely effective in osteoporosis prevention. When the infection is severe. She does not use drugs.

Erythromycin ointment Explanation: Erythromycin ointment or sulfa drops are the first line agents for the treatment of uncomplicated bacterial conjunctivitis. Ofloxacin eye drops C. What is the best response? A. The mother wants to know when her son can go back to school.(Choice B) Although this is a self-limiting disease in the majority of situations. Item 2 of 3 Which of the following is the most appropriate pharmacotherapy? A. These should not be used as first line agents in uncomplicated bacterial conjunctivitis because of the risk of the emergence of resistance. it must be treated because there is a small but real risk of keratitis. however. Educational Objective: Bacterial conjunctivitis is usually a self-limiting disease. (Choice C) Recurrence is only possible if the patient has bad hygienic habits or if he acquires viral conjunctivitis. Educational Objective: Erythromycin ointment or sulfa drops are the first line antibiotic agents for the empirical treatment of patients with bacterial conjunctivitis. Antihistamine eye drops D. as these cover most organisms. C. Item 3 of 3 The appropriate evaluation was performed. (Choices A and B) Fluoroquinolones are preferred for contact lens wearers and corneal ulcers because of their activity against Pseudomonas. This is not contagious. E. Explanation: . which can lead to visual impairment. B. (Choice A) Endophthalmitis is acquired through an open wound to the eye (post-cataract surgery. He should stay at home until the discharge has cleared. Ciprofloxacin eye drops B. 34% of people answered this question correctly. D. and not usually through conjunctivitis. (Choice D) Primary care physicians should not prescribe corticosteroids. post-traumatic) or a systemic route. With the treatment. as these can cause sightthreatening complications in patients with bacterial conjunctivitis and herpes keratitis. he can go to school tomorrow . 53% of people answered this question correctly. he can go to school tomorrow. (Choice C) Antihistamines are used for allergic conjunctivitis. (Choice D) Cataracts have not been described as complications of this disease. One week from now. Corticosteroid eye drops E. which is characterized by watery discharge and usually involves both eyes. this is not always true. He has to wait at least 2 weeks from now and will have to be reevaluated by me.

at least 24-hours of topical antibiotic therapy should be applied before returning to work. He is admitted to the hospital for observation and further work-up. Disseminated intravascular coagulopathy E. Educational Objective: Bacterial conjunctivitis is very contagious. especially for those with work/demanding occupations. Spontaneous bacterial peritonitis B. If this is not possible. he is appropriately treated.Bacterial conjunctivitis is very contagious. He has a history of alcoholic cirrhosis with ascites for the last two years. this may not be feasible for many patients. Hemolytic uremic syndrome . In those patients. Patients should be advised to stay home until the discharge has cleared. In such cases. patients should have had at least 24 hours of topical antibiotic therapy before returning to work/school. His upper GI endoscopy reveals the presence of esophageal varices with stigmata of recent bleeding. In the emergency room. the best thing to do is to keep the child at home until the discharge has cleared. However. A 55-year-old African-American man is brought to the emergency department because of an episode of hematemesis. and has no new episodes of bleeding. Congestive heart failure D. Which of the following is the most likely complication that he is at risk of developing during his hospitalization? A. Renal failure C.

One controlled trial showed that . or ciprofloxacin) agent for 7-10 days. Her past medical history is insignificant.Explanation: Patients who are admitted to the hospital because of recent variceal bleeding are at an increased risk of developing complications during their hospitalization. aspiration pneumonia or primary bacteremia. and renal failure. these patients should be treated prophylactically with antibiotics. She is concerned about getting pregnant and requests contraception. High dose estrogen B. Reassurance and no intervention Explanation: Levonorgestrel is the recommended method of emergency contraception if used soon enough after an unprotected sexual intercourse. and is not associated with cirrhosis. but her partners used condoms. Hemolytic uremic syndrome (HUS) is associated with Shiga toxin-producing Escherichia coli (E. The principal complications in these patients that lead to increased mortality are: infections. Caucasian. however. The currently preferred regimen is the use of a fluoroquinolone (ofloxacin. The preferred regimen involves the use of a fluoroquinolone (ofloxacin. Levonorgestrel D. The optimal choice of antibiotics and the duration of therapy remain unclear. such as acute tubular necrosis (ischemic or toxic) or precipitation of hepatorenal syndrome. Copper intrauterine device E. (Choice C) Congestive heart failure is uncommonly seen in these patients. hepatic encephalopathy. All these trials have suggested a decreased incidence of infectious complications with the use of prophylactic antibiotics. It has maximal efficacy when used within the first 12 hours after intercourse. Educational Objective: Bacterial infections can develop in up to 50% of patients who are hospitalized for acute variceal bleeding. (Choices B and A) Levonorgestrel seems to be more effective than ethinyl estradiol /levonorgestrel combination or high dose estrogen. (Choice D) Disseminated intravascular coagulopathy occurs rarely in patients with acute variceal hemorrhage. She does not smoke. therefore. good efficacy within 48 hours. 70% of people answered this question correctly. or ciprofloxacin) agent for 7-10 days. She is currently not taking any medications. Which of the following is the best contraception modality for this patient? A. and is usually seen in the presence of underlying infections. college student presents to the student health center on a Monday morning after having unprotected intercourse during a party the last Saturday evening. which usually occurs as a urinary tract infection. but consumes alcohol occasionally. It also has fewer side effects. (Choice B) The development of renal failure in these patients can have multiple etiologies. She has been sexually active with two partners over the last several months. (Choice E) Hepatorenal syndrome is a complication of cirrhosis and a variceal bleed. norfloxacin. Ethinyl estradiol plus levonorgestrel C. The physical examination is insignificant. coli O157:H7). The most common complication is the development of an infection. and appears to work up to 120 hours after intercourse. She confessed that she has tried several recreational drugs. this complication is not as common as the development of an infection. A large number of trials have evaluated the efficacy of prophylactic antibiotics in cirrhotic patients that were hospitalized for variceal bleeding. but does not remember their names. norfloxacin. respiratory infection. female. spontaneous bacterial peritonitis. A 17-year-old.

pregnancies (compared to 57% prevented by (Choice D) The copper intrauterine device is an effective emergency contraception tool that can be used if a patient presents more than 120 hours after unprotected intercourse. Allergen avoidance is traditionally considered the first step in the management. His mother notes that the symptoms usually appear after the child plays with a neighbor?s dog. and appears to work up to 120 hours after intercourse. Nasal corticosteroids D. (Choices D and E) Second-generation antihistamines and cromolyn are less effective than topical steroids. The neighbor?s dog is the most likely allergen trigger for this patient?s condition.7 C (98 F). Even after placental delivery. (Choice B) Nasal decongestive sprays are not recommended because tachyphylaxis usually develops. Second-generation antihistamines E. Cromolyn sodium Explanation: This patient presents with signs and symptoms suggestive of allergic rhinitis.levonorgestrel prevents 85% of expected estrogen/progesterone combination). avoidance of the antigen triggers is typically the first step in the management of allergic disorders. blood pressure is 100/60 mmHg. 30% of people answered this question correctly. 75% of people answered this question correctly. good efficacy within 48 hours. the patient is bleeding continuously. The lungs are clear on auscultation. A 23-year-old Caucasian female has just delivered a 9 lb healthy baby at 37 weeks gestation thirty minutes ago. Which of the following is the most appropriate next step in the management of this patient? . and rebound phenomena may result.5 liters of blood. nasal corticosteroids should be the first-line therapy. IV ringers lactate is administered. Her temperature is 36. pulse is 102/min. A 9-year-old Caucasian boy is brought to your office with a two-month history of periodic clear rhinorrhea. Dog or cat dander is one of the most common identifiable allergen in patients with allergic rhinitis. and dry cough. His past medical history is significant for an episode of severe pneumonia experienced two years ago. Educational Objective: Levonorgestrel is the recommended method of emergency contraception if used soon enough after an unprotected sexual intercourse. the baby and placenta were delivered spontaneously. Which of the following is the next best step in the management of this patient? A. without application of forceps. Educational Objective: When possible. or if the symptoms persist after avoidance measures. (Choice C) If the allergen is not identified. nasal and orbital itching. Avoidance of the dog B. Although the labor was prolonged. and respirations are 18/min. She has lost approximately 1. Physical examination reveals excoriations of the external nares. The copper intrauterine device is an effective emergency contraception tool that can be used if a patient presents more than 120 hours after unprotected intercourse. Nasal decongestant sprays C. It has maximal efficacy when used within the first 12 hours after intercourse.

A. Observation D. Bimanual uterine massage E. Intravenous oxytocin B. Uterine artery ligation . Pelvic examination C.

20% of people answered this question correctly.g. Although these could occur. or tricuspid regurgitation. Uterine massage stimulates the uterus. Carotid bruit Explanation: This patient has developed amaurosis fugax. blood pressure is 160/90 mmHg. Even though aortic stenosis can be related to syncope. and denies any other new symptoms. This condition is sudden and usually reversible. and enalapril. (Choice B) A diastolic heart murmur can be a marker of aortic insufficiency or mitral stenosis.. aortic stenosis. (Choice A) If bimanual uterine massage fails to control bleeding. Observation alone may be fatal. Systolic heart murmur B. . Which of the following signs is most likely to be found during the physical examination? A. (Choice D) If the retained placental products are not identified. hydrochlorothiazide. (Choice E) If bleeding does not stop with medical measures. His medications include aspirin. Papilledema D. His temperature is 36. and the first step in the management of all patients with PPH is to do a pelvic examination to identify any retained placental fragments. (Choice D) Acute retinal vein thrombosis can be diagnosed by fundoscopy. (Choice C) PPH is a serious obstetrical complication. He is currently symptom-free. Educational Objective: Pelvic examination to look for any retained placental products is the first step in the management of PPH. Uterine artery ligation is one of the surgical measures for the treatment of PPH.7 C (98 F). Measures should be taken immediately to stop the bleeding. this elderly patient's transient symptom is more likely to be concurrent with findings suggestive of carotid artery disease. Both conditions are related to ischemic cerebrovascular accidents (CVA). are more related to heart failure symptoms. An 83-year-old Caucasian man comes to the emergency department because of a sudden onset. A carotid bruit on auscultation of the neck is a very frequent finding. manual uterine massage should be started. when extensive hemorrhage is seen in the retina. and the resulting contractions stop the bleeding. surgical measures are taken.Explanation: The most common cause of post partum hemorrhage (PPH) is uterine atony. Hemorrhagia exudates in the retina E. (Choice A) Conditions producing systolic heart murmurs such as mitral regurgitation. Diastolic heart murmur C. and respirations are 12/min. an acute ischemic event involving the retinal artery. His other medical problems include hypertension and peripheral vascular disease. It is a marker of carotid artery atherosclerotic disease. It will not present as amaurosis fugax. transient visual loss in his right eye. this indicates a significant carotid obstruction. IV oxytocin) are used to control the bleeding.. it does not cause amaurosis fugax . pulse is 80/min. uterotonic drugs (e.

Ischemia will manifest as disc paleness. on the other hand. . but not in amaurosis fugax. not papilledema. especially in a transient event.(Choice C) Papilledema is seen as a result of increased intracranial pressure. Pseudopapilledema. may be seen in an established nerve damage or in optic neuritis.

She is extremely anxious and wants you to see her daughter right away. (Choice A) A person exposed to a known tuberculosis patient has the greatest risk of developing tuberculosis within the next two years. especially in children less than 15 years of age and in HIV-positive patients. (Choices C and D) The majority of primary pulmonary tubercular infections are radiographically and clinically silent. 86% of people answered this question correctly. She tells you that her daughter came back two months ago after spending six weeks with her grandmother in a ranch in Texas. (Choice E) Isoniazid therapy for nine months should be recommended for all patients with a positive PPD or recent tuberculin skin test conversion (at least 10 mm increase in the skin reaction within a two-year period). it is a marker of carotid artery atherosclerotic disease that is usually advanced. Educational Objective: Tuberculin skin testing should be initially performed in all persons exposed to patients with tuberculosis. Explanation: Tuberculosis is spread from person to person through airborne droplets. The girl does not have any new symptoms suggestive of active tuberculosis. It is important to document latent tubercular infection with a positive tuberculin skin test before prescribing isoniazid therapy. 85% of people answered this question correctly. Prescribe a weight-based isoniazid therapy for nine months. In most cases. Even though it is reversible. This is why the first step in evaluating an asymptomatic person with recent significant exposure to tuberculosis patients is to obtain a tuberculin skin test. and prescribed six months of antitubercular therapy.Educational Objective: Amaurosis fugax is a sudden and transient monocular blindness. Obtain a plain chest x-ray. Perform a tuberculin skin test on the daughter. Which of the following should be your next step in management? A. The grandmother was recently hospitalized. . This person should receive a tuberculin skin test to document the presence of latent tuberculosis. The mother of a two-year-old girl comes to your office. If the initial test result is negative. and asks for your advice. Carotid Doppler evaluation is necessary to evaluate the extent of the disease and to assess the need for a carotid endarterectomy. a person?s body mounts a cell-mediated immune response which is detected by a tuberculin skin test. a second test should be performed 10 weeks after the last known exposure. E. a positive tuberculin skin test is the only indication that infection with Mycobacterium tuberculosis has occurred. Reassurance is not appropriate at this point. Schedule a serial followup examination of the patient every month. The mother is concerned about her daughter?s risk of contracting the illness. B. C. Tuberculin skin testing detects the presence of latent tubercular infection. Reassure the mother and do nothing at this point. Physical examination will often reveal a carotid bruit. The risk of spread of latent or active tuberculosis is greatest when there is a history of contact with patients who have active (sputum-positive) pulmonary tuberculosis. The treatment of latent tubercular infection should be strongly considered in all patients. in which case she should be treated with a full course of antitubercular therapy. Once infected. D. It is also important to document that the patient does not have active tuberculosis. diagnosed with pulmonary tuberculosis.

She has a 52 pack-year smoking history and occasionally drinks bourbon with her friends. The gynecologic examination demonstrates protrusion of the posterior vaginal wall that is most prominent with bearing down while in the lithotomy position. The physical examination reveals a moderately overweight woman in no apparent distress." His physical . However. these can cause chronic discharge and bleeding secondary to injury of the vaginal tissues.. and constipation. His father and uncles also have "back problems. He works as a chef at a local restaurant. Educational Objective: Women with symptomatic rectoceles who are poor surgical candidates may be treated with pessaries in conjunction with estrogen cream. The pain is worse in the morning and gets better as the day progresses.A 76-year-old gravida 4. there is no indication for oral hormone replacement therapy in the treatment of rectoceles. (Choice D) Surgical repair. Her vital signs are normal. Recommend pelvic exercises C. (Choice E) There is no need to deny this patient further care simply because she does not want to undergo surgery. The patient is diagnosed with rectocele.g. and peptic ulcer disease. Recommend pessary use D. most commonly via a posterior colporrhaphy. These symptoms were gradual in onset and have been present for a period of months. pessaries). Rather. lower back pain. para 4 woman presents to the clinic complaining of pelvic pressure and heaviness. What is the most appropriate response in this situation? A. which are structures designed to support the vaginal wall. The following Vignette applies to the next 5 items A 26-year-old Italian-American man comes to your office for the evaluation of low back pain. 70% of people answered this question correctly. The woman declines to have surgery and remains steadfast on this point. The condition is typically caused by damage to the rectovaginal septum incurred during vaginal childbirth and is exacerbated by periodic increases in intraabdominal pressure (e. it is preferable to avoid elective surgical procedures. Since there is a reasonable alternative available. and it is progressively getting worse. Recommend oral hormone replacement therapy B. He has had this pain for the last eight months.g. Women with symptomatic rectoceles who are poor surgical candidates may be treated with pessaries. (Choice A) Although estrogen creams are useful in conjunction with pessary usage. Convince her to undergo surgical repair E. when laughing or coughing) and the effects of gravity.. without it. Additional recommendations for this patient group include avoidance of activities related to increased intraabdominal pressure and regular usage of intravaginal estrogen to prevent tissue atrophy. Pessaries should only be used in conjunction with vaginal estrogen. Inform the patient she needs to find a new physician Explanation: Rectocele is a relatively common condition in older women and is characterized by the displacement of the rectum through posterior vaginal wall defect(s). (Choice B) Pelvic exercises are appropriate to recommend in women with asymptomatic rectocele. and since she is an elderly woman with numerous serious medical conditions. He denies any history of trauma in the past. is an appropriate recommendation for women with symptomatic rectoceles. Patients who are not good surgical candidates or who prefer not to undergo surgery should not be pressured to proceed. Her past medical history is significant for mild congestive heart failure. and surgical repair is recommended. hypertension. they should be advised about alternative treatment options (e. it is important to advise these patients that correction of the condition does not always provide symptomatic relief. emphysema.

examination reveals a limited range of motion of his lumbosacral spine and markedly reduced chest expansion. The rest of his physical and musculoskeletal examination is unremarkable. .

(Choice D) When ankylosing spondylitis is strongly suspected clinically and radiographic findings of plain x-ray are negative or equivocal. a plain x-ray of the sacroiliac joint is the next step to establish the diagnosis. Limitation of chest expansion relative to the normal values. squaring of the vertebral disease on plain x-ray may also suggest the diagnosis. (Choice B) Testing for ANA and rheumatoid factor is not the next appropriate step when a patient has a history typical of ankylosing spondylitis. a CT scan is indicated to establish the diagnosis. which is the earliest change that is seen radiographically. its absence (negative for HLA B 27) makes the diagnosis of ankylosing spondylitis unlikely. HLA-B 27 levels B. ANA and rheumatoid factor C. A diagnosis of ankylosing spondylitis cannot be made unless there is evidence of sacroiliitis. Therefore. Repeat x-rays after 3 months B. (Choice C) A bone scan has no role in the diagnosis of ankylosing spondylitis. when a patient has typical features of ankylosing spondylitis. what would you do to monitor the disease activity? A. Repeat HLA-B 27 levels in 3 months E. Repeat ANA and rheumatoid factor levels in 3 months Explanation: . Educational Objective: The three important clinical criteria for the diagnosis of ankylosing spondylitis are: Presence of low back pain and stiffness for more than a three month duration that improves with exercise or activity. presence of symptoms for more than three months. but a CT scan is usually recommended in such setting. however. Early in the course of disease. A MRI of the spine E. Item 2 of 5 If the initial evaluation shows mild disease. X-ray of the sacroiliac joint Explanation: The patient has typical features of ankylosing spondylitis.Item 1 of 5 Which of the following is the most appropriate next step in the management of this patient? A. (Choice A) HLA-B 27 is frequently (>90% of the patients) present in patients with ankylosing spondylitis and other spondyloarthropathies. Bone scan D. insidious onset. Limitation of the range of motion of the lumbar spine. ANA and rheumatoid factor are absent in ankylosing spondylitis and other seronegative spondyloarthropathies. Repeat MRI in 3 months C. 63% of people answered this question correctly. Repeat bone scan in 3 months D. Its presence is not specific for the diagnosis of ankylosing spondylitis. and reduced chest expansion. MRI may also be used for this purpose. reduced range of forward flexion of the lumber spine on Schober testing. These include back pain with morning stiffness which improves with exercise. Plain x-ray of the sacroiliac joint is the next best step in the management of a patient who is suspected with ankylosing spondylitis. Other radiographic abnormalities suggesting the diagnosis of ankylosing spondylitis include erosions of the ischial tuberosity and iliac crest.

The following radiographs are used in monitoring the disease progression of patients with ankylosing spondylitis: 1. Anteroposterior and lateral views of the lumbar spine 2. Lateral view of the cervical spine 3. Pelvic radiograph, including the sacroiliac joints and hip Other acute phase reactants such as ESR can also be used. (Choice B) CT scans are almost never used to monitor the disease activity. MRI is also not used to monitor the disease activity, unless the patient develops complications such as cauda equina syndrome. Educational Objective: Radiographs and acute phase reactants (i.e., ESR) are used to monitor the disease progression of patients with ankylosing spondylitis. 59% of people answered this question correctly. Item 3 of 5 Which of the following conditions is associated with the patient?s diagnosis? A. Restrictive lung disease B. Acute narrow angle glaucoma C. Coarctation of aorta D. Early development of testicular cancer E. Sclerosing cholangitis Explanation: Once a diagnosis of ankylosing spondylitis is being considered, it is important to search for concurrent extraarticular manifestations. Although they are usually asymptomatic in the initial stages, many patients have restrictive lung disease due to the limited costovertebral joint motion and development of apical pulmonary fibrosis. It is important to counsel such patients regarding smoking cessation to prevent early deterioration of lung function. (Choice B) Ocular manifestations with AS include acute anterior uveitis, cataracts, and cystoid macular edema. Uveitis presents with acute onset unilateral eye pain, photophobia, and blurring of vision. It is sometimes the initial presentation of ankylosing spondylitis. (Choice C) The most common valvular abnormalities associated with ankylosing spondylitis include aortic regurgitation and mitral valve prolapse. The incidence of coarctation of the aorta and septal defects is not increased in these patients. (Choice D) There is an increased prevalence of varicocele, not testicular cancer, in these patients. (Choice E) The gastrointestinal manifestations are nonspecific ileal and colonic mucosal ulcerations. Some other extraarticular features include atlanto-axial subluxation causing spinal cord compression, cauda equina syndrome, IgA nephropathy, and secondary amyloidosis presenting as nephrotic syndrome. Educational Objective: The most common and important extraarticular manifestations of ankylosing spondylitis are acute anterior uveitis, aortic regurgitation, apical pulmonary fibrosis, IgA nephropathy, and restrictive lung disease. 58% of people answered this question correctly. Item 4 of 5

The patient is given a prescription for non-steroidal anti-inflammatory agents. He returns for a followup visit after two weeks, and says that he feels a lot better. His pain and stiffness have almost resolved with daily intake of medications. He used to swim and exercise regularly before his symptoms developed a few months ago, and he wants to resume these activities, but he is concerned that his disease may get worse if he does so. Which of the following is the most appropriate response? A. Aerobic exercises will accelerate the joint destruction B. Extension exercises of the spine can be harmful C. He should not resume exercise for at least 1 year D. Swimming should be avoided as it increases the strain on back muscles E. Aerobic exercises improve overall functional status without increasing the disease activity

Explanation: Regular aerobic exercises such as swimming, walking, and bicycling improve joint stability, muscle strength, and overall functional status without an increase in the disease activity. These also help to prevent bone loss due to immobility and use of medications. The exercise regimen should be tailored to the individual, depending on the exercise tolerance, extent and severity of joint disease, and other coexisting medical conditions. An initial evaluation by a physical therapist should be a part of therapy for ankylosing spondylitis. (Choice A) Supervised physical therapy and exercises can lead to significant improvement of the range of motion of the spine. It does not lead to acceleration of the joint destruction. (Choice B) In ankylosing spondylitis, postural training and extension exercises help to prevent spine fusion in a flexed position. (Choice C) There is no reason to avoid exercise for a year. The patient should be evaluated by a physical therapist and initiate an exercise program as early as possible. (Choice D) Swimming (hydrotherapy) is a type of aerobic exercise with special benefits for patients with rheumatologic disorders. It is associated with less joint stress and weight bearing and is useful for patients with advanced disease. Educational Objective: Aerobic exercises improve overall functional status of patients with rheumatologic disorders and should be encouraged. 81% of people answered this question correctly. Item 5 of 5 Which of the following is the most appropriate statement regarding the prognosis of this condition? A. Overall mortality is increased in this patient population B. Most patients will have functional and employment disability C. Smoking is surprisingly protective in this population D. Life expectancy is not reduced E. Prolonged standing at the work place is protective Explanation: There are no studies that have demonstrated an increased overall mortality or reduced life expectancy in patients with ankylosing spondylitis. Most patients do well and have no functional or employment disabilities. (Choice C) Smoking cessation should be strongly advised, as this is associated with a very bad prognosis. (Choice E) Prolonged standing at work or exposure to cold conditions are risk factors for disability. Educational Objective: Most patients with ankylosing spondylitis do well and have no functional or employment disabilities. There is no increased overall mortality or reduced life expectancy. 46% of people answered this question correctly.

The following vignette applies to the next 3 items A 45-year-old Caucasian woman comes to the emergency department (ED) with complaints of severe abdominal pain. She started having pain in her upper abdomen approximately twelve hours ago. The pain is sharp and radiates to her back. She had two episodes of vomiting before coming to the ED. She has been hospitalized four times in the past with similar complaints. On review of her previous hospitalizations, you notice that there was never a specific cause found for her symptoms. She has a history of diabetes and hypertension, and both are well controlled by diet and exercise. Her blood pressure is 130/70 mmHg, pulse is 92/min, temperature is 36.7C (98F), and respirations are 16/min. She is moderately obese, and is in distress. Her lungs and cardiovascular examination are within normal limits. There is diffuse tenderness to palpation over the whole abdomen, with maximum tenderness present at the epigastric area. Item 1 of 3 Which of the following is the next step in the diagnosis of the patient?s condition? A. Serial abdominal examination B. CT scan of the abdomen C. LFTs with lipase levels D. No further tests are needed at this point as prior workup was normal E. Ultrasound of the right upper quadrant Explanation: The clinical presentation of the patient is consistent with acute pancreatitis, which is characterized by an acute onset of steady, upper abdominal pain radiating to the back, with associated nausea and vomiting. However, since these symptoms are nonspecific and can be seen in a number of acute abdominal illnesses, confirmation of the diagnosis is necessary with clinical and biochemical markers, as well as radiographic imaging. A variety of biochemical tests have been devised to diagnose acute pancreatitis. Of these, measurement of the serum amylase and lipase levels are the most frequently used. Serum lipase is more sensitive and specific than serum amylase; therefore, measurement of the former is the diagnostic test of choice. (An elevated serum amylase level is nonspecific as it is also elevated in a number of other conditions such as acute parotitis, intestinal disorders, renal failure, cholecystitis, and fallopian tube diseases.) In addition, a liver function test (LFT) is also obtained since an elevated alkaline phosphatase level may point towards gallstone/common bile duct stones as the etiology of the acute pancreatitis. (Choice A) Serial abdominal examination can delay the diagnosis of acute pancreatitis, and may even prove to be potentially fatal in these patients. It is only useful to follow the clinical progress of the patient once the diagnosis has been made. (Choice B) CT scan may be eventually needed to document the severity of pancreatitis and to detect the presence of other intra-abdominal complications. These should only be done if all other biochemical markers fail to provide a diagnosis, or if the patient fails to improve with initial conservative treatment. (Choice D) Her current symptoms should not be assumed to be benign based on her past history of hospitalizations. (Choice E) An ultrasound of the right upper quadrant of the abdomen may provide a clue to the cause of her symptoms; however, up to one-third of patients have bowel or intestinal gas that may obscure the pancreas, and thus, the diagnosis. Educational Objective: The diagnosis of acute pancreatitis is confirmed initially with an elevated level of serum biochemical markers (amylase or lipase).

*Extremely important question for USMLE step-3 56% of people answered this question correctly.

Item 2 of 3 The initial lab results of the patient reveal the following: Total bilirubin: 1.2 mg/dL Direct bilirubin: 1.0 mg/dL Alkaline phosphatase: 382 units/L AST: 40 units/L ALT: 38 units/L Albumin: 4 g/dL Serum calcium: 8.9 mg/dL Amylase: 1026 mg/dL Lipase: 662 mg/dL A right upper quadrant ultrasound reveals an enlarged hypoechoic area in the head of the pancreas with mild dilatation of the common bile duct. A contrast-enhanced CT scan of the abdomen reveals enlargement and inflammation of the pancreatic head without any areas of necrosis. Which of the following is the best next step in the management of this patient? A. Intravenous antibiotics B. CT-guided needle aspiration of the pancreatic tissue C. Daily abdominal CT scans D. IV fluids and nasogastric tube aspiration E. Surgical consult Explanation: Most episodes of acute pancreatitis are mild, and patients usually recover in five to seven days. Treatment is usually conservative (i.e., supportive therapy) and aimed at correcting the underlying predisposing condition and preventing any further damage to the pancreatic tissue. Patients can have a significant amount of third space loss of fluids, thereby causing hypotension, acute renal failure and even worsening of the pancreatitis; therefore, all patients should have early and aggressive fluid resuscitation with close monitoring of the urine output to ensure adequate tissue perfusion. Pain control is also important, and is generally achieved with the use of intravenous narcotics. Lastly, patients are kept off an oral diet (NPO), and their gastric contents are aspirated via a nasogastric tube (NGT) to prevent further pancreatic stimulation. Based on the radiographic imaging, the patient is suffering from a mild, edematous, acute pancreatitis. The next best step in management is nasogastric tube (NGT) aspiration and administration of IV fluids. (Choice A) Intravenous antibiotics are indicated only in patients with severe necrotizing pancreatitis or in patients with clinical or tissue evidence of infection of the necrotic pancreatic tissue. These are not given to patients with mild attacks of acute pancreatitis. (Choice B, C) There is no indication for CT-guided aspiration of the pancreatic tissue or daily CT scans. (Choice E) Surgical d?idement is indicated only in patients with extensive tissue necrosis or localized abscess formation. Educational Objective: Most of the patients with mild acute pancreatitis can be managed conservatively by adequate pain control and intravenous fluid resuscitation. *Extremely important question for USMLE step-3 77% of people answered this question correctly.

Item 3 of 3 While you are making your rounds the next morning, the nurse informs you that the patient has developed a temperature of 39.4C (103?F). The rest of her vital signs are within normal limits. Which of the following is the next best step in the management in this patient? A. Obtain blood cultures B. Obtain blood cultures and start the patient on imipenem C. Obtain urine cultures D. Repeat a stat CT scan E. Start the patient on intravenous ampicillin Explanation: The occurrence of fever in a previously afebrile patient with acute pancreatitis is one of the earliest signs of pancreatic infection. Infection of the pancreatic tissue is the major cause of morbidity and mortality in patients with acute pancreatitis. Most infections are seen late in the clinical course of the disease. There is considerable evidence from several studies that the early use of antibiotics in patients with severe necrotizing pancreatitis or in patients with evidence of pancreatic infection improves the outcome and reduces mortality. It is important to use a broad-spectrum antibiotic that can achieve good penetration in the pancreatic tissue. Examples of such antibiotics are: imipenem, third generation cephalosporins, piperacillin, fluoroquinolones, and metronidazole. If the patient?s condition fails to improve after one week of antibiotic therapy, a CT-guided aspiration of the tissue should be performed to obtain tissue samples for culture and sensitivity. (Choices A and C) It is important to start the patient on antibiotics as soon as the cultures are drawn. Obtaining blood or urine cultures alone is not sufficient. (Choice D) Another CT scan is unlikely to change the treatment at this point. The patient should be started on broad-spectrum antibiotics (imipenem) and followed closely for signs of clinical improvement or deterioration. (Choice E) Ampicillin has a poor tissue penetration into the pancreas, and there is considerable drug resistance against its action by most of the gut bacteria which are associated with pancreatic infection. Educational Objective: All patients with severe necrotizing pancreatitis or suspected pancreatic infection should be started on imipenem to decrease the morbidity and mortality associated with the disease. People rarely use a combination of ampicillin, gentamycin, and metronidazole. *Extremely important question for USMLE step-3 68% of people answered this question correctly. A 26-year-old Caucasian male presents to the emergency department with a three day history of dull back pain, progressive difficulty in walking, and urinary retention. He had a mild upper respiratory infection one week ago, but he is otherwise healthy. He is not taking any medications and denies drug abuse. His temperature is 36.7 C (98 F), blood pressure is 120/76 mmHg, pulse is 80/min, and respirations are 16/min. Neurologic examination reveals a decreased muscle strength (2/5) bilaterally in the lower extremities, hyporeactive knee and ankle reflexes, and decreased pain sensation up to the umbilical level. Which of the following is the most likely diagnosis of this patient? A. Herniated intervertebral disk B. Epidural abscess C. Acute subdural hemorrhage

D. Malignancy E. Transverse myelitis

Explanation: Rapidly progressive weakness of the lower extremities following an upper respiratory infection, accompanied by sensory loss and urinary retention, is characteristic for transverse myelitis. Dull back pain may be present. Neurologic examination initially reveals muscle flaccidity and hyporeflexia, but spasticity and hyperreflexia develop subsequently. In patients presenting with acute transverse myelopathy, other causes (especially compressive lesions) should be ruled out by obtaining a careful history and performing the appropriate imaging procedures. (Choice A) A herniated intervertebral disk is characterized by an abrupt onset of neurologic deficit and may be related to strenuous activity. A straight-leg raising test will be positive. (Choices B and C) Although an epidural abscess or an acute subdural hemorrhage may develop in otherwise healthy individuals, an underlying cause is usually present (e.g., IV drug abuse or treatment with anticoagulants). (Choice D) Spinal cord compression from a metastatic tumor may present acutely, but the history of systemic malignancy is typical. Educational Objective: Rapidly progressive weakness of the lower extremities following an upper respiratory infection, accompanied by sensory loss and urinary retention, is characteristic for transverse myelitis. 78% of people answered this question correctly. A healthy 29-year-old Caucasian woman comes to the physician for contraception counseling. She has had two unplanned pregnancies, and doesn?t want to have more. She has no medical problems. She does not use tobacco, alcohol, or drugs. She takes no medications. Her friend recommended a contraceptive method named "Norplant." The patient is concerned about the risks that this method could pose to her health. Which of the following complications is most likely to occur in a patient who uses this method? A. Vaginal spotting B. Thromboembolism C. Rash D. Menorrhagia E. Breast cancer Explanation: "Norplant" consists of six capsules of levonorgestrel which are placed subdermally, generally in the upper arm. It offers contraceptive protection for about five years. The most common complication is menorrhagia (prolonged vaginal bleeding during each period), which occurs in about 28% of the cases. (Choice A) Vaginal spotting is the second most frequent complication, affecting around 17% of the patients. (Choices B, C, and E) "Norplant" increases the risks of thromboembolism and breast cancer. It can also produce a rash. However, all these three complications are not frequent, and occur in less than 10% of the cases. Educational Objective: The use of "Norplant" is associated with menorrhagia and vaginal spotting. Other possible but less common complications are: venous thromboembolism, myocardial infarction, pulmonary embolism, thrombotic thrombocytopenic purpura (TTP), stroke, and breast cancer. 18% of people answered this question correctly.

zidovudine and lamivudine) be started immediately after exposure and continued for the next .9C (102F) and respirations are 24/min. Recent laboratory testing of the patient demonstrated a CD4 count of 410/?L and HIV load 12. SLE E. Transesophageal echocardiography reveals small vegetations confined to the tricuspid valve. Therapy with one nucleoside reverse transcriptase inhibitor and one protease inhibitor to be initiated immediately and continue for six months C. and a vast majority are IV drug users. Rheumatoid arthritis C. Therapy with one nucleoside reverse transcriptase inhibitor and one protease inhibitor to be initiated immediately and continue for four weeks B. Lung auscultation reveals scattered bilateral rales. Overall. The endocarditis seen in drug users is different from non-drug users in that the tricuspid valve is involved in 30 to 70% of endocarditis cases in injection drug users. a 28-year-old Caucasian female nurse accidentally pricks her finger with the needle. for baseline purposes.. A grade II/VI blowing systolic murmur that increases with respiration is heard over the lower part of the left sternal border.A 24-year-old male presents to your office with a one-week history of night sweats and progressive fatigue. The chest x-ray demonstrates several circumscribed round pulmonary infiltrates on both sides. After drawing blood from an HIV-positive patient. She takes no medications and is not pregnant or breastfeeding. Rheumatic fever B. Congenital valve defect Explanation: The clinical scenario is highly suggestive of infective endocarditis involving the right cardiac chambers.000 copies/mL. pulse is 98/min. Therapy with two nucleoside reverse transcriptase inhibitors to be initiated immediately and continue for four weeks D. Immediate consultation with the hospital?s infectious disease expert is recommended. What is the best approach to handling this situation? A. Illicit drug use D. His past medical history is insignificant. Therapy with two nucleoside reverse transcriptase inhibitors to be initiated immediately and continue for six months E. Two very important clues to the diagnosis are: evidence of right-sided cardiac involvement (systolic murmur with inspiratory accentuation and tricuspid vegetation on echocardiography) and evidence of septic pulmonary emboli (present in 75% of patients with right-sided endocarditis). What is the most likely cause of this patient?s problem? A. (Choices A and D) Rheumatic fever and SLE predominantly involve left cardiac structures. The CDC recommends that two nucleoside reverse transcriptase inhibitors (e. rightsided endocarditis (predominantly involving the tricuspid valve) is far less common than left-sided disease. temperature is 38. Her immunizations are current.g. His blood pressure is 120/80 mmHg. Unless seroconversion is documented. Isolated lesions of right cardiac valves are quite uncommon with these diseases. 94% of people answered this question correctly. no antiviral therapy is necessary Explanation: A prophylactic antiretroviral regimen is always indicated when a healthcare worker is exposed to the bodily fluids of an HIV-positive patient. is found to be HIV-negative. Educational Objective: A vast majority of patients with right-sided endocarditis are IV drug users. Peripheral manifestations and heart failure are uncommon in these patients. He also complains of palpitations and shortness of breath on moderate exertion. The nurse has no significant medical history and.

Criteria observed during the initial 48 hours include a hematocrit fall (>10%). and an estimated fluid sequestration > 6L. however. Admission criteria are age > 55 years. (Choice B) Hypocalcemia. Therefore. not hypercalcemia. Which of the following admission criteria is indicative of a severe attack in this patient? A. His serum lipase level is elevated. Therapy with two nucleoside reverse transcriptase inhibitors (Choice D) is indeed the recommended regimen. indinavir) if viral resistance to the postexposure prophylaxis is known or suspected. Since the criteria were initially designed for pancreatitis not induced by gallstones.four weeks (Choice C). Age B. Elevated ESR Explanation: Ranson?s prognostic criteria gained widespread use in predicting the severity of acute pancreatitis. high serum AST. Treatment should begin within hours of the exposure and be continued for four weeks. this patient is only 44 years old. and high blood glucose level. hypoxemia (PO2 < 60 mmHg). and heart rate is 90/min. Educational Objective: Exposure to the body fluid of an HIV-positive individual requires antiretroviral prophylaxis. (Choice A) The admission criteria includes an age > 55 years. Foregoing antiviral therapy (Choice E) is not advisable. but the therapy should be continued for four weeks. base deficit > 4 mEq/L. Accepted regimens include zidovudine and lamivudine or zidovudine. High blood glucose level D. He had a similar episode one year ago that required hospitalization. BUN elevation. is a part of the Ranson's criteria during the initial 48 hours. there is a brief period in which antiretroviral therapy is thought to limit viral replication. any healthcare worker exposed to the bodily fluids of an HIV-positive individual should be strongly urged to use a prophylactic regimen to minimize the likelihood of becoming HIV-positive. early on. lamivudine. Hypokalemia E. Therapy with one nucleoside reverse transcriptase inhibitor and one protease inhibitor (Choices A and B) is not recommended. and denies any drug abuse. (Choices D and E) Hypokalemia and elevated ESR are not considered significant prognostic factors. He is not taking any medications. and criteria observed during the initial 48 hours. Educational Objective: .. He admits to excessive drinking for the past several weeks. The prognostic factors include admission criteria. high serum LDH. the scoring system was modified so it could also be used in the evaluation of patients with gallstone-induced pancreatitis.g. A 44-year-old Caucasian male presents to the emergency department with a 12 hour history of severe epigastric pain and vomiting. hypocalcemia. His blood pressure is 100/70 mmHg. Some experts have suggested modifying the regimen to also include a protease inhibitor (e. high WBC count. Hypercalcemia C. One study showed that healthcare workers using zidovudine alone as postexposure prophylaxis were 81% less likely to seroconvert as compared to those who used no treatment regimen. and indinavir. not six months. 18% of people answered this question correctly. Systemic infection does not occur immediately after inoculation with HIV.

. 59% of people answered this question correctly.Ranson?s criteria gained widespread use in predicting the severity of acute pancreatitis.

Renal failure D. They are not typically used in the setting of a physician?s office. Order laboratory testing to detect hepatic dysfunction Explanation: The approach to a patient with alcoholism is a stepwise process. She has been playing with a small cat for the past month. He has no significant past medical history and takes no medications. This is useful to distinguish between moderate and heavy drinkers.A 44-year-old Caucasian male presents to his primary care physician for an annual physical exam. Appropriate screening questionnaires include CAGE. Administer a breath test to rule out alcohol intoxication E. and about a family history of alcohol problems. Examination shows tender cervical and right axillary lymphadenopathy. frequency. which of the following complications is most likely? A. She also has a small pet dog. Suppuration of the lymph nodes Explanation: . Myocarditis B. quantity and frequency of alcohol use. and TWEAK. She has had these symptoms for the past five days. and quantity of alcohol use C. A 6-year-old Caucasian girl is brought to the office by her mother because of loss of appetite. Step 1: Inquire about current and past alcohol use. which she feeds personally everyday. (Choice D) Breath tests are administered by law enforcement personnel when evaluating an individual for acute alcohol intoxication. AUDIT. Hepatosplenomegaly E. (Choice A) Although there is a high rate of comorbid psychiatric disorders in individuals with alcohol abuse and dependence. Seizures C. Step 4: Ask more specific questions based upon steps 1 to 3 in patients with suspected alcohol problems. Inquire about the type. Administer a screening questionnaire such as CAGE D. the likelihood of alcohol abuse should be more fully explored before discussing the psychiatric history. malaise. and are more likely to inspire annoyance than compliance. Step 2: Obtain information regarding the type. He admits to drinking socially. and pain in the right arm. * If this question had asked about ?next step? the answer would be choice B. He states that his mother and brother are both recovering alcoholics. and denies recreational drug use. Step 3: Use a standard screening questionnaire such as CAGE. Educational Objective: Studies have shown screening questionnaires to be superior to both laboratory testing and inquiries about quantity or frequency of drinking in evaluating individuals for alcohol abuse or dependence. What is the most effective method of detecting alcohol abuse or dependence in this patient? A. Studies have shown screening questionnaires (Choice C) to be superior to both laboratory testing (Choice E) and inquiries about quantity or frequency of drinking (Choice B) in evaluating individuals for alcohol abuse or dependence. He has a 25 pack-year history of tobacco use. 84% of people answered this question correctly. Over the next week. Inquire about psychiatric history B.

The circulating platelets are rapidly removed by the autoantibodies anyway. differential count. the platelet count drops even further to 10. The most common complication is suppuration of the lymph nodes.Cat-scratch disease is an infection that usually affects the young immunocompetent population. Other complications are: visual loss due to neuroretinitis. She denies any regular medication intake. ITP occurs as a result of platelet destruction by specific autoantibodies. The admitting resident gets concerned with the lab results and orders 6 units of random donor platelet transfusion. (Choices A and B) Myocarditis and seizures are not part of the expected complications. The rest of her physical examination is normal. The labs reveal the following: Hb: 14. 76% of people answered this question correctly.4 g/dL MCV: 90 fl Platelet count: 16. She has a rash over her lower legs and ankles. and it slowly spread up to her knees. and hepatosplenomegaly. Drug induced thrombocytopenia Explanation: A presumptive diagnosis of idiopathic thrombocytopenic purpura (ITP) can be made when the history. She first noticed the rash over her ankles 2 weeks ago.22 ?g/mL Peripheral blood smear is normal. making . Antiplatelet antibodies D. encephalopathy. and peripheral blood smear do not suggest any causes for isolated thrombocytopenia. Platelet transfusions are rarely necessary to maintain the platelet count. The following day. Her vital signs are within normal limits.000/cmm Segmented neutrophils: 60% Bands 3% Eosinophils 6% Lymphocytes 24% Monocytes 6% Prothrombin time: 14 sec Partial thromboplastin time: 30 sec Plasma fibrinogen: 300 mg/dL D-dimer: 0.000/cmm Leukocyte count: 8. It is produced by Bartonella henselae. (Choice C) Renal compromise has not been reported. Physical examination reveals the presence of fine petechiae and purpura around her ankles and lower legs. complete blood count. physical examination. She has no other past medical history. 30-year-old Caucasian female is admitted to the hospital. Disseminated intravascular coagulation B. Thrombotic thrombocytopenic purpura C. The following vignette applies to the next 2 items A previously healthy.000/microliter. Educational Objective: Approximately 10% of patients with cat-scratch disease can develop suppuration of the lymph nodes. Item 1 of 2 Which of the following is the most likely cause of the drop in the platelet count? A. (Choice D) Hepatomegaly and splenomegaly can sometimes be seen. fever of unknown origin. Septicemia E.

Educational Objective: Corticosteroid therapy is the treatment of choice for ITP in adult patients. What is the most appropriate next step in the management of this patient? A. and swelling around the right lower leg for the last five days.000/microliter) should not be treated. Treat the patient for 4-6 weeks for tibial osteomyelitis.platelet transfusions futile. Order a three phase technetium 99m bone scan. Patients with mild and asymptomatic thrombocytopenia (platelet count between 30. In such cases. He has a past medical history of coronary artery disease. ischemic cardiomyopathy with an ejection fraction of 25%. B. (Choice B) Plasmapheresis is the treatment of choice for hemolytic uremic syndrome (HUS) and thrombotic thrombocytopenic purpura (TTP). The patient is started on the appropriate antibiotics. and respiratory rate is 16/minute. Educational Objective: ITP is due to autoimmune phenomena involving the formation of antiplatelet antibodies. the blood culture results are still pending. Intravenous immunoglobulins E. A plain radiograph of the lower extremity is also negative for any acute pathology. Once the patient starts to bleed. blood pressure is 132/76 mmHg. Corticosteroids B. and C) There is no clinical or laboratory evidence of DIC. Item 2 of 2 Which of the following is the most appropriate next step in the management of this patient? A. pacemaker implantation for sick sinus syndrome. Plasmapheresis C. with most patients responding within the first week. Obtain a MRI scan of the lower extremity. corticosteroid therapy is the treatment of choice. C. Most adults respond to steroids within two weeks. Treatment is only necessary in severe or symptomatic thrombocytopenia. heart rate is 86/minute. B. E. A 56-year-old Caucasian man comes to the emergency department with complaints of fever. A splenectomy is rarely performed in refractory cases. Give more platelets Explanation: ITP is acute and self-limiting in children. and he has been having difficulty weight bearing and ambulating for the last two days. D. Low-dose heparin D. He quit smoking 12 years ago. His symptoms are getting worse. pain. He is a manager at a local restaurant.e. Obtain open bone biopsy to confirm the diagnosis. (Choice E) The patient has not been exposed to any drugs which could cause or precipitate thrombocytopenia. TTP or septicemia in this patient. (Choice A. and insulin-dependent diabetes mellitus with diabetic neuropathy. but it usually becomes a chronic disorder in adults. The lower extremity ultrasound is negative for deep vein thrombosis. (Choice C) Heparin is used very cautiously in patients with early disseminated intravascular coagulation (DIC). 43% of people answered this question correctly. IV IG can be used if steroids fail. . Physical examination reveals significant swelling and erythema around the right lower leg. life threatening emergencies such as intracerebral or massive gastrointestinal hemorrhage).000 to 50. His temperature is 38.9 C (101 F). heparin should not be used. Transfusions are only necessary in severe or symptomatic thrombocytopenia (i. Repeat the x-ray in 2 weeks to confirm the diagnosis.

and has a 5-year-old daughter. It uses technetium 99-m bound to phosphorus as a tracer. erythema. For all these reasons. it does not mean that it will happen again. which precludes the use of MRI to evaluate suspected osteomyelitis. but that does not mean it will happen again. abscess or gas formation in the soft tissue). so you have to be very careful. imaging is necessary to rule out the presence of potential complications (e. MRI is not needed in this patient. (Choice D) Empiric treatment for 4?6 weeks is inappropriate in the absence of a specific diagnosis. B. so you must be careful. although it is difficult to diagnose early in its course because the presenting symptoms and signs can be nonspecific. and denies a prior history of miscarriages. A 33-year-old African-American female comes to your clinic.g. It is usually positive 2-3 days after the onset of infection. An acute infection usually presents with fever. it is rare during the second.. (Choice E) Although a bone biopsy is the gold standard for the diagnosis of osteomyelitis. D. Repeating the films is also an insensitive procedure. preeclampsia usually occurs during the first pregnancy. MRI is better for evaluating spine and complicated foot osteomyelitis. This is due to the 2-3 week lag time for the changes of acute osteomyelitis to appear on the plain films. Some other nuclear scans that can be used include indium-labeled white cell scan and gallium citrate scans.Explanation: Osteomyelitis is an infection of the bone which causes bone destruction and necrosis. MRI cannot be used in patients with certain metal hardware and implants. You don?t have to worry about that. You will have preeclampsia for sure again. E. She is using oral contraception. Furthermore. If you had preeclampsia once. What is the most proper statement to tell her? A. She has no significant past medical history. and denies any smoking or use of illegal drugs. Educational Objective: The three-phase technetium 99-m bone scan is the diagnostic test of choice for evaluation of acute uncomplicated osteomyelitis. She works as an executive secretary. it should only be performed if the non-invasive tests are inconclusive and the index of suspicion for osteomyelitis is high. A three-phase technetium bone scan is the diagnostic test of choice for suspected uncomplicated osteomyelitis if the plain films are negative. She wants to get pregnant again. MRI is especially useful in patients with suspected vertebral osteomyelitis and in infected diabetic foot lesions. including diabetic foot ulcers. It is also useful in detecting abscesses around the site of infection. Furthermore. This patient has a pacemaker implant. a technetium bone scan can easily make the diagnosis. Radiologic imaging plays an important role in the evaluation of patients with suspected osteomyelitis. She drinks alcohol occasionally (twice a month). She is married. C. which accumulates in the area of increased osteoblast activity. Explanation: . and swelling over the involved bones. Nobody can predict if it will happen again. chills. She had preeclampsia during her first pregnancy at the 34th week of gestation. and will only serve to delay the diagnosis. (Choice C) Plain films are insensitive for the diagnosis of acute osteomyelitis. You have a higher risk of developing preeclampsia than other women. She was pregnant only once. but she is afraid of having preeclampsia again. However. (Choice A) CT scan and MRI are very accurate in detecting changes of osteomyelitis in the early stages.

Physical examination reveals mild tenderness in the left lower quadrant of his abdomen. although this may provide valuable information in specific situations when a quick diagnosis is imperative. but it can be as high as 15 if the previous preeclampsia presented before 33 weeks of pregnancy. He does not smoke or consume alcohol. difficile colitis. (Choices B and C) Repeating the rapid immunoassay test is more reasonable and cost-effective in this case than proceeding with colonoscopy or abdominal CT. His past medical history is significant for a recent episode of acute sinusitis treated with amoxicillin. He denies any gross blood or black discoloration of the stool. (Choices A and D) It is inappropriate to give the patient false reassurance. and he has tried several over-the-counter anti-diarrheal agents without any success. which is lower than that of the stool cytotoxin test (94-100%). Rapid immunoassays to detect C. The risk is higher if the preeclampsia presented earlier (age of delivery was less than 32-33 weeks). He is sexually active with his wife and uses condoms for contraception. or when the diagnosis is in doubt. difficile toxin B. He works as a programmer at a private firm and does not consider his job stressful. her chances for getting preeclampsia again are uncertain. Educational Objective: A history of preeclampsia in the past increases the risk of developing this complication during a subsequent pregnancy. nor ignore that there are studies which address the topic and supply the patient with an ambiguous answer. difficile toxins are gaining popularity among clinicians because these are less time-consuming and less expensive than the older stool cytotoxin test. These rapid tests have very high specificity (close to 100%). difficile E. but is negative for C. as well as the history of recent antibiotic treatment.A history of preeclampsia in the first pregnancy increases the possibility of a second episode in the following pregnancy. difficile infection is high and an initial test result is negative. are highly suggestive of C. however. Order stool culture for C. She has to be informed that the risk for preeclampsia exists. His stool is positive for occult blood. therefore. difficile toxin by rapid immunoassay. and is therefore ten times more likely to develop preeclampsia than a woman without that history. He denies any recent travel or contact with a patient with similar symptoms. Do colonoscopy C. endoscopy is not generally recommended in patients with a classical scenario of C. one cannot make false assumptions. nausea and vomiting. Furthermore. Item 1 of 3 Which of the following is the best next step in the management of this patient? A. Obtain blood cultures and liver function tests Explanation: The given symptoms and findings in this patient. repeating the test may be necessary in patients in whom the pretest probability of C. Because of this lower sensitivity. Repeat immunoassay for C. . The following Vignette applies to the next 3 items A 34-year-old Caucasian male presents to your office with abdominal cramps. or if the patient has renal disease or chronic hypertension. (Choices B and C) Although the patient is at risk. although he admits that his appetite has decreased a little. their sensitivity is about 70-87%. Order abdominal CT D. His symptoms started two days ago. The patient had preeclampsia between 33 and 36 weeks of pregnancy. The risk is at least seven times higher. difficile colitis. watery stools and mild fever.

Most authors currently recommend metronidazole as the first-line agent over vancomycin because of the following reasons: 1) both agents have been shown to be equally effective. whereas vancomycin should be given only in oral form as it will not be absorbed from the intestine. (Choice C) Oral bacitracin has been tried with success for C. difficile are very labor-intensive and are not helpful because nontoxigenic strains of C. Due to this lower sensitivity. Metronidazole E. difficile-induced diarrhea. Vancomycin B. however. Clindamycin .(Choice D) Stool cultures of C. Metronidazole can be given in either oral or intravenous form because of its biliary secretion. he returns to your office and complains of abdominal cramps and watery diarrhea again. Bacitracin D. but its efficacy is much lower than that of vancomycin and metronidazole. difficile toxin in the stool. (Choice E) Clindamycin is an agent that is often implicated as a cause of C. their sensitivity is about 70-87%. repeating the test may be necessary in patients in whom the pretest probability of C difficile infection is high and an initial test result is negative. difficile exist. Item 3 of 3 Soon after the initiation of therapy. you proceed with treatment. Cholestyramine C. the patient seems to recover completely. Bacitracin D. 3) vancomycin may lead to the selection of vancomycin-resistant enterococci. (Choice D) Cholestyramine has also been proven to be effective for this condition. Educational Objective: Rapid stool tests to detect C. difficile-induced colitis. Which of the following agents is the best initial choice for this patient? A. mainly due to its limited availability. difficile toxins have very high specificity (close to 100%). Item 2 of 3 After running the appropriate tests. Metronidazole E. difficile-induced diarrhea. 2) metronidazole treatment is much more cheaper than vancomycin treatment. but this is not commonly used. One week after the completion of therapy. Cholestyramine C. and this may create a future problem in public health. Clindamycin Explanation: There are several agents available for the treatment of C. Vancomycin and metronidazole are the most popular agents because their efficacy and safety have been tested in many clinical trials. Educational Objective: Most authors currently recommend oral or intravenous metronidazole as the first-line agent over oral vancomycin for the treatment of C. difficile colitis. Vancomycin B. His stool is positive for occult blood and the rapid immunoassay test is positive for C. It is not the agent used for its treatment. Which of the following is the best next step in the treatment of this patient? A.

however. Educational Objective: The most common cause of recurrence of C.500 kg. difficile diarrhea and colitis does not differ substantially from treatment of the initial episode. It is the most common form of obstetrical brachial plexus injury and involves the upper roots (C5. The prognosis of Erb?s palsy is typically good. Palmar grasp reflex is present on b