7313198
182 Pages

7313198

Course Number: MEDICINE 911, Spring 2012

College/University: Eastern Virginia...

Word Count: 82759

Rating:

Document Preview

FREE MCCEE QUESTIONS www.mcceereview.com General Medicine Questions 1) A family physician cares for a family consisting of a 45-year old husband, 43-year-old wife and a 12-year-old daughter. The family reports that recently the 77-year-old maternal grandmother who lived with them died after a prolonged respiratory infection. Autopsy subsequently confirms that she had active pulmonary tuberculosis at the time of...

Unformatted Document Excerpt
Coursehero >> Virginia >> Eastern Virginia Medical School >> MEDICINE 911

Course Hero has millions of student submitted documents similar to the one
below including study guides, practice problems, reference materials, practice exams, textbook help and tutor support.

Course Hero has millions of student submitted documents similar to the one below including study guides, practice problems, reference materials, practice exams, textbook help and tutor support.

MCCEE FREE QUESTIONS www.mcceereview.com General Medicine Questions 1) A family physician cares for a family consisting of a 45-year old husband, 43-year-old wife and a 12-year-old daughter. The family reports that recently the 77-year-old maternal grandmother who lived with them died after a prolonged respiratory infection. Autopsy subsequently confirms that she had active pulmonary tuberculosis at the time of death. The organism tested sensitive to all anti-tuberculosis drugs. In responding to the grandmother's illness, which of the following is the most appropriate step in management? A. Obtain leukocyte counts on all family members B. Obtain sputum cultures for acid fast bacilli C. Obtain chest computerized tomograms on all members D. Place protein purified derivative (PPD) test on all members E. Schedule bronchoscopy lavage for the adults Explanation: The correct answer is D. The immediate step is to screen the family for TB exposure. The most effective manner in which to accomplish this is by placing PPDs on all members and working up those with a positive test. The white cell count may be elevated for a variety of reasons and would not necessarily help in diagnosis or management (choice A). Sputum cultures will take 6 months to grow and may be too cumbersome to obtain (choice B). Chest CT scans may show the tuberculosis lesion but a more effective method would be to place the PPD and perhaps then scan those with a positive test (choice C). A bronchoscopy would be too invasive an option at this point (choice E). 2) A 57-year-old man comes to the emergency department because of excruciating pain in his right big toe. He describes the pain as so severe that it woke him from a deep sleep. He has no chronic medical conditions, does not take any medications, and denies any similar episodes in the past. He admits to a few "drinking binges" over the past 2 weeks. His temperature is 38.1 C (100.5 F), blood pressure is 130/90 mm Hg, and pulse is 80/min. Examination shows an erythematous, warm, swollen, and exquisitely tender right great toe. The skin overlying the first metatarsophalangeal joint is dark red, tense, and shiny. Synovial fluid analysis reveals negatively birefringent, needle-shaped crystals within polymorphonuclear leukocytes (PMNs). Laboratory studies show: Serum Leukocytes........16,000/mm3 Uric acid...........15 mg/dL Calcium.............9 mg/dL Which of the following is the most appropriate pharmacotherapy? A. Allopurinol B. Ceftriaxone C. Indomethacin D. Probenecid E. Sulfinpyrazone Explanation: The correct answer is C. This patient has the classic presentation of a patient with acute gouty arthritis with the sudden onset of severe pain (typically in the middle of the night), swelling, erythema and warmth of a single joint. Low-grade fever and leukocytosis may be seen. It is more common in men and it is associated with hyperuricemia, usually due to decreased renal excretion of uric acid. Common causes are thiazides and alcohol. Diagnosis is made by examination of joint fluid under polarizing light. Negatively birefringent, needle-shaped crystals within polymorphonuclear leukocytes, hyperuricemia, and acute monoarticular arthritis make the definitive diagnosis of gout. Indomethacin or colchicine is the treatment during an acute attack. Allopurinol, probenecid, and sulfinpyrazone are used for prophylaxis against further attacks. Allopurinol (choice A) is a xanthine oxidase inhibitor that is used as an antihyperuricemic agent by individuals with recurrent gouty attacks. Common side effects include rash, headache, and gastrointestinal upset. Ceftriaxone (choice B) is the treatment of acute gonococcal arthritis. It has no role in the treatment of gout. Probenecid (choice D) is a uricosuric agent that increases the rate of urate excretion. It is used to prevent gouty attacks. It may precipitate nephrolithiasis. Sulfinpyrazone (choice E) is another uricosuric agent that increases urate excretion. It is used to prevent gouty attacks. It, too, may precipitate nephrolithiasis. 3) A 35-year-old woman arrives on the floor after an uneventful hysteroscopy to evaluate her long history of uterine fibroids. About 30 minutes after her arrival, she begins to complain of nausea and has two episodes of vomiting. The physician administers 0.625 mg of droperidol and 400 mg of acetaminophen by mouth. On follow-up evaluation, the patient's neck is involuntarily flexed to one side. She is alert, oriented, and conversant and has an otherwise normal neurologic examination. Which of the following is the most likely diagnosis? A. Cerebral vascular accident B. Conversion disorder C. Dystonic reaction to droperidol D. Munchausen syndrome E. Seizure Explanation: The correct answer is C. The most likely diagnosis is a dystonic reaction to the droperidol. Droperidol causes its antiemetic effect by antagonizing dopaminergic receptors in the vomiting center (central chemoreceptor zone) of the brain. This antidopaminergic action can produce torticollis or other dystonias. A cerebral vascular accident (choice A) is unlikely given that the patient is alert and oriented, has no detectable language deficit, and has an otherwise nonfocal neurologic examination. A conversion disorder (choice B) is unlikely since the patient has no prior history of a psychiatric disorder and has a viable medical reason (dystonia from droperidol) for her neuromuscular deficit. Munchausen syndrome (choice D) is also unlikely since the patient had valid medical reasons for her initial admission and your current visit. We are also not informed of any prior history of hospitalizations or seeking of medical attention without appropriate cause. A seizure (choice E) is similarly unlikely since the patient has no history of a seizure disorder and is alert, oriented, and conversant. 4) A 50-year-old nurse consults a physician because of a rash above both her ankles. Physical examination demonstrates marked ankle edema with erythema, mild scaling, and brown discoloration of the overlying skin of the distal lower legs. Varicose veins are also noted. Which of the following is the most likely diagnosis? A. Atopic dermatitis B. Cellulitis C. Lichen simplex chronicus D. Nummular dermatitis E. Stasis dermatitis Explanation: The correct answer is E. This is stasis dermatitis, which is a persistent inflammation of the skin of the lower legs. The condition is often related to varicose veins, although it has been postulated that the true cause may instead be perivascular fibrin deposition and abnormal small vessel vasoconstrictive reflexes. The presentation illustrated is typical. Most patients are relatively asymptomatic and may not seek medical attention until the edema becomes severe or the lesions become complicated by secondary bacterial infection or ulceration. It is important to increase the venous return to the heart by elevating the ankles while resting and use of properly fitted support hose. Local topical tap water compresses can be helpful. Purulent lesions can be treated with hydrocolloid dressings. Ulcers are treated with compresses and bland dressings, such as zinc oxide paste. Atopic dermatitis (choice A) typically involves the antecubital and popliteal fossas, eyelids, neck, and wrists. Cellulitis (choice B) is a bacterial infection of the subcutaneous tissues, and causes local erythema, tenderness, and often lymphangitis. Lichen simplex chronicus (choice C) is a skin rash caused by chronic scratching characterized by dry, scaling, well-demarcated, hyperpigmented plaques. Nummular dermatitis (choice D) causes widespread coin-shaped, crusted skin lesions. 5) An AIDS patient develops symptoms suggestive of a severe, persistent pneumonia with cough, fever, chills, chest pain, weakness, and weight loss. The patient does not respond to penicillin therapy, but goes on to develop very severe headaches. The presence of focal neurologic abnormalities leads the clinician to order a CT scan of the head. This demonstrates several metastatic brain abscesses. Biopsy of one of these lesions demonstrates beaded, branching, filamentous gram-positive bacteria that are weakly acid fast. Which of the following is the most likely causative organism? A. Actinomyces B. Aspergillus C. Burkholderia D. Francisella E. Nocardia Explanation: The correct answer is E.Nocardia asteroides is an aerobic soil saprophyte that can cause acute or chronic infectious disease often characterized by granulomatous-suppurative lesions that may become widely disseminated. Many, but not all, patients have underlying causes for immunodeficiency, including advanced age, lymphoreticular malignancies, organ transplantation, high dose corticosteroid therapy, or (increasingly commonly) AIDS. Disseminated nocardiosis usually starts as a pulmonary infection that can resemble either a severe pneumonia or tuberculosis. Once dissemination occurs, metastatic brain abscesses are particularly common, occurring in as many as 1/3 of patients with nocardiosis. Nocardiosis is treated with sulfa drugs, such as sulfadiazine or trimethoprim-sulfamethoxazole, for periods of months. Actinomyces (choice A) is very similar to Nocardia, but is not acid-fast. Aspergillus(choice B) is a fungus. Burkholderia(choice C)pseudomallei is a gram-negative bacillus that causes melioidosis, which is characterized by lung involvement or disseminated infection. Francisella(choice D)tularensis causes tularemia, which is usually acquired by contact with infected wild rabbits. 6) A 28-year-old patient with end-stage renal disease (ESRD) on continuous ambulatory peritoneal dialysis (CAPD) for two months presents with fever, abdominal pain and cloudy dialysis fluid. There is no diarrhea or vomiting and the pain has been present for about 12 hours. The patient has ESRD secondary to chronic glomerulonephritis, there is no history of diabetes, urinary infections or antibiotic use. Examination reveals a temperature of 38.9 C (102 F), and blood pressure of 110/70 mm Hg. The throat is clear, as are the lungs. Cardiac examination reveals a grade 2/6 systolic murmur. Abdominal examination reveals decreased bowel sounds with diffuse tenderness. There is mild rebound. There is no edema or skin rash. A complete blood count shows a leukocyte count of 14,200/mm3, hemoglobin is 12.5 g/dL. Peritoneal fluid is cloudy with 1,000 white blood cells, 85% of which are polymorphonuclear leukocytes. Gram's stain of fluid is negative. Cultures of blood and peritoneal dialysis fluid are taken. Which of the following is the most appropriate initial step in management? A. Fluconazole B. Immediate removal of dialysis catheter. C. Intravenous vancomycin D. Intravenous gentamicin E. Oral ciprofloxacin Explanation: The correct answer is C. Peritonitis in a patient on CAPD is usually due to gram-positive pathogens such as Staphylococcus aureus or epidermidis. It is usually characterized by abdominal pain and over 100 white blood cells (typically polymorphonuclear leukocytes) in a sample of peritoneal dialysis fluid. Intravenous vancomycin would be a reasonable treatment to cover gram-positive pathogens. Fluconazole (choice A) would be indicated for a fungal infection. Fungal peritonitis is not usually seen until patients have been treated with multiple antibiotics or are further immunosuppressed. Immediate removal of the dialysis catheter (choice B) is usually not needed unless the patient has a peritonitis that has not improved with a trial of antibiotics. Intravenous gentamicin (choice D) has good gram-negative coverage but would not be an ideal drug to cover Staphylococcus. Ciprofloxacin (choice E) would be a very broad spectrum antibiotic that would not be a first choice as a single antibiotic to treat staphylococcal peritonitis. Further, the oral route may not be adequate as patients with peritonitis may have nausea and vomiting. 7) A 54-year-old man presents for a periodic health examination. His family history is significant for his mother who died of a cerebrovascular accident at age 72, his father who died of a myocardial infarction at age 68, and a brother who developed sigmoid cancer at age 60. The patient is on no medications except for aspirin, 81 mg daily. His physical examination is unremarkable. The patient asks for a recommendation regarding current cancer screening. Which of the following is the most appropriate screening test for this patient? A. Annual digital rectal examination and fecal occult blood testing B. Flexible sigmoidoscopy C. Flexible sigmoidoscopy and barium enema D. Colonoscopy E. Genetic testing for the p53 gene Explanation: The correct answer is D. Any patient with a first-degree relative who has developed an adenoma or colorectal cancer should undergo colonoscopy for screening at age 50, or 10 years before the relative developed the adenoma or carcinoma, whichever comes first. This patient has a brother who has a colon cancer at age 60; therefore, a full colonoscopy is warranted. Although there are various opinions regarding appropriate screening in the "average risk individual," there is a consensus that full colonoscopy is required in patients who have an increased risk, e.g., firstdegree relative with a positive history. Annual digital rectal examination and fecal occult blood testing (choice A) are no longer considered a reliable method of screening for colon cancer, since a shift in the demographics of colon cancer has lead to more than half being identified in the first half of the colon. Digital rectal examination also often fails to identify premalignant colonic polyps. Flexible sigmoidoscopy (choice B) is a good initial screening technique for patients older than 50 with no specific known risk factors. If polyps are identified, they can be biopsied, their type established, and subsequent complete colonoscopy performed if adenomas were identified microscopically. Flexible sigmoidoscopy and barium enema (choice C) offers an alternative way of screening the entire colon in patients in whom a complete colonoscopy cannot be performed. Genetic testing for the p53 gene (choice E) is not currently used for colon cancer screening. 8) An AIDS patient under treatment with a nucleoside analog and a protease inhibitor comes to medical attention with complaints of leg weakness and incontinence. His vital signs are within normal limits. Physical examination reveals reduced strength in the lower extremities with accompanying mild spasticity. There is also diminished sensation in the feet and legs bilaterally. Lumbar puncture shows: Opening pressure.....100 mm H20 Cell count................5 lymphocytes/mm3 Glucose...................48 mg/dL Proteins, total..........33 mg/dL Gamma globulin.......8% total protein Additional laboratory investigations show normal hematologic parameters, vitamin B12 within normal values, and negative serology for syphilis. MRI of the head fails to reveal any focal abnormality. Which of the following is the most likely diagnosis? A. AIDS dementia complex B. CMV polyradiculopathy C. Cryptococcal meningoencephalitis D. Vacuolar (HIV) myelopathy E. Zidovudine-related toxicity Explanation: The correct answer is D. This is one of the most common neurologic complications of AIDS. Its pathologic substrate is degeneration of the spinal tracts in the posterior and lateral columns, which have a vacuolated microscopic appearance. Although the morphologic changes and clinical manifestations are similar to those associated with vitamin B12 deficiency, the pathogenetic mechanism is probably not related to dietary deficiencies. Since there is no specific clinical or laboratory test available for the diagnosis of this syndrome, vacuolar myelopathy in AIDS patients remains a diagnosis of exclusion. This implies that other HIV-related neurologic complications must be ruled out (see below). AIDS dementia complex (choice A) manifests with progressive memory loss, alterations in fine motor control, urinary incontinence, and altered mental status. CMV polyradiculopathy (choice B) may simulate HIV myelopathy and is a relatively frequent complication of AIDS. It can be excluded by the results of CSF analysis. CMV infection leads to neutrophilic pleocytosis in the CS F. Cryptococcal meningoencephalitis (choice C) would lead to signs and symptoms of meningitis. The CSF would show the fungal organism, which can be detected by special stains and culture studies. Zidovudine-related toxicity (choice E) would lead to proximal muscle weakness and tenderness due mainly to a myopathic process. 9) A 45-year-old man is involved in an automobile accident and sustains severe injuries with considerable blood loss and hypotension. He is transferred from the emergency department to an intensive care unit, where he develops multiorgan failure. During the first 2 days in the intensive care unit, his plasma phosphate was within normal limits. Subsequently, it began to rise, eventually reaching 6.0 mg/dL. Failure of which of the following organs would most likely have this effect? A. Heart B. Kidneys C. Liver D. Lungs E. Pancreas Explanation: The correct answer is B. The usual cause of hyperphosphatemia is advanced renal insufficiency that destroys the kidneys' ability to excrete phosphate, thereby leading to hyperphosphatemia. Other causes include hypoparathyroidism, pseudohypoparathyroidism, and excessive oral phosphate administration. Acute transcellular shifts of phosphate into the extracellular space can also occur in the settings of diabetic ketoacidosis, crush injuries, rhabdomyolysis, systemic infections, and tumor lysis syndrome. Failure of the heart (choice A), liver (choice C), or lungs (choice D) has no direct effect on phosphate metabolism. Pancreatic failure (choice E) has no direct effect on phosphate metabolism. Diabetic ketoacidosis can cause a transcellular shift of phosphate into the extracellular space. 10) A 28-year-old woman is diagnosed with lupus nephritis, World Health Organization (WHO) type IV. She has a malar rash, diffuse arthritis, and edema. Her blood pressure is 190/110 mm Hg. Her creatinine is 2.1 mg/dL with a blood urea nitrogen of 28 mg/dL. Her urine reveals 25 red blood cells per hpf, and 3+ protein. One red blood cell cast is seen. A 24-hour urine collection reveals a protein of 11 grams with a creatinine of 1 gram. Which of the following would be the most appropriate management? A. Oral azathioprine B. Oral cyclophosphamide C. Oral gold D. Oral prednisone E. Pulse IV cyclophosphamide Explanation: The correct answer is E. The most effective treatment for aggressive systemic lupus erythematosus with nephritis is pulse cyclophosphamide. This has been shown to be the best agent to treat type IV lupus nephritis. Oral cyclophosphamide (choice B) is effective but not as effective as the pulse IV form. Oral gold (choice C) is used to treat rheumatoid arthritis. Oral prednisone (choice D) and oral azathioprine (choice A) are other commonly used agents but are not as effective as cyclophosphamide. 11) A 48-year-old woman is seen by a clinician. She has a bright red, sharply demarcated, oozing and crusting rash involving one breast in the areola area. She has had this lesion for six months and states that it is slowly growing. The lesion does not respond to antibiotic ointment, antifungal ointment, or steroid ointment. This lesion is most likely related to which of the following conditions? A. Breast cancer B. Crohn disease C. Gastric cancer D. Rheumatoid arthritis E. Systemic lupus erythematosus Explanation: The correct answer is A. This is Paget disease of the breast, which actually corresponds microscopically to the presence of individual adenocarcinoma cells in the epidermis. When it involves the nipple area, it usually overlies an area of breast cancer. (Paget disease can also involve the vulva and vagina, where it may be unrelated to bulk cancer.) It is important to recognize the presentation, since focusing on treating the skin lesion empirically can lead to a delay in recognizing the cancer. The clinical description given in the question stem is typical. Mastectomy is a common form of treatment in these cases because of the nipple involvement. Crohn disease (choice B) can cause erythema nodosum (deep subcutaneous nodules on lower legs). Gastric cancer (choice C) can cause supraclavicular node enlargement due to metastasis. Rheumatoid arthritis (choice D) can cause subcutaneous rheumatoid nodules. Systemic lupus erythematosus (choice E) can cause a rash, most commonly seen on the face. 12) A recent article in a prominent medical journal explored the disparity of resource utilization between men and women. More men than women have major cardiac procedures, including catheterization, performed. This is thought to be because of which of the following reasons? A. Fewer outcome studies have studied women with these disease B. The incidence of cardiovascular disease is lower in women C. Men have better health insurance D. Men receive too many cardiovascular procedures E. Provider attitudes has led to this situation Explanation: The correct answer is E. Attitudes of physicians has been shown to have a significant effect on the delivery of health care. Health providers believe men to be more likely to have cardiac disease than women and this has guided practice, leading to a larger amount of cardiac procedures for men, compared with women. Fewer outcome studies have studied women because of the belief that cardiac disease is more common in men (choice A). The incidence of cardiovascular disease in women is similar to that in men (choice B) across the entire life-span. There is a significant disparity between men and women in the use of cardiovascular interventions in the absence of financial (i.e., insurance) barriers (choice C). One study has reported that women receive more appropriate cardiac services than men and that major interventions in men are over-utilized (choice D), but this does not explain the overall disparity. 13) A 43-year-old man presents with a 4-year history of joint pain. The distribution is asymmetric, involving the proximal and distal small joints of the right hand, the left knee, the ankle, and right elbow. Pain and morning stiffness are moderate. Physical examination reveals mild nail pitting, and the distal third interphalangeal joint is partially subluxated. X-rays of the hands show resorption of the distal end of the phalanx. The erythrocyte sedimentation rate (ESR) is elevated to 46 mm/hr, and rheumatoid factor is negative. Which of the following is the most likely diagnosis? A. Primary generalized osteoarthritis B. Pseudogout C. Psoriatic arthritis D. Rheumatoid arthritis Explanation: The correct answer is C. Nail pitting and dystrophy associated with distal destructive asymmetric arthritis are virtually diagnostic of psoriatic arthritis. Skin disease may or may not be severe and obvious. Nail changes occur in 85% of those with psoriatic arthritis, and in only 20% of those with uncomplicated psoriasis. The clinical categories of psoriatic arthritis include distal interphalangeal, asymmetric, symmetric, mutilating, and spinal. Antimalarials should be avoided if disease-modifying therapy is indicated, as they can exacerbate psoriasis. Primary generalized osteoarthritis (choice A) can involve the distal interphalangeal joints; joint erosions do not occur, and osteophytes are seen radiologically. Nail dystrophy does not occur. A variant of pseudogout (choice B) can closely mimic rheumatoid arthritis or a mutilating arthropathy, but nail changes are absent, and there is radiologic evidence of chondrocalcinosis (calcification of articular cartilage). Rheumatoid arthritis (choice D) does not cause distal erosive disease and is generally (but not invariably) symmetric. 14) A 45-year-old man presents to a physician with complaints of weakness, fatigue, and feeling near fainting when he stands up quickly. Screening chemistry studies demonstrate sodium, 128 mEq/L; potassium, 5.2 mEq/L; bicarbonate, 17 mEq/L; and urea nitrogen, 45 mg/dL. The physician is considering Addison disease in his differential diagnosis. Which of the following features on physical examination would be most suggestive of this diagnosis? A. Black freckles on the shoulders B. Large, furrowed tongue C. Many spider angiomas D. Protruding eyeballs E. Small glistening bumps on the lips Explanation: The correct answer is A. While there is some variation in the usage of the term, Addison disease is usually taken to mean adrenocortical insufficiency related to disease that destroys the adrenal gland. Most authors separate out secondary adrenocortical insufficiency due to pituitary failure and recent or current exogenous steroid therapy. True Addison disease, which is not related to inadequate pituitary secretion of ACTH, frequently has stigmata of hyperpigmentation relating to a melanocyte-stimulating hormone (MSH) effect seen with high ACTH levels. The biochemical basis of this is a homology between part of the ACTH molecule and the MSH molecule. Typical hyperpigmentation features include black freckles of the shoulders, head, and neck; bluish-black discoloration of areolas and mucous membranes (both oral and anogenital); and diffuse tanning, specifically including non-sun-exposed skin. The pattern of laboratory screening studies illustrated in the question stem is also very suggestive, with very low serum sodium, high potassium, low bicarbonate, and high serum urea nitrogen. A large, furrowed tongue (choice B) suggests acromegaly. Many spider angiomas (choice C) suggest chronic liver disease. Protruding eyeballs (choice D) suggest Grave's disease. Small glistening bumps on the lips (choice E) suggests the mucosal neuromas of MEN IIb. 15) A 71-year-old man presents to the emergency department with fever and cough. He has known hypercholesterolemia and is status post a right hemicolectomy for colon cancer. The patient states that he has had 3 days of fever to 102 F, cough productive of green sputum, as well as general malaise and weakness. His physical examination is remarkable for decreased breath sounds at the left base, left basilar egophony and dullness to percussion. A complete blood count reveals a leukocyte count of 15000/mm3. A chest radiograph reveals a left lower lobe infiltrate. Which of the following is the most important part of the history to ascertain prior to initiating therapy? A. Influenza immunization status B. Plasma lipid profile C. Stage of the colon cancer D. Social support structure for home therapy E. Recently hospitalizations Explanation: The correct answer is E. This patient clearly has pneumonia. The absolute requirement to diagnose pneumonia is an infiltrate on chest radiograph, coupled with clinical findings suggestive of a pneumonia, which this patient has. The next relevant issue is, what is the likely organism? If this man were living at home, the most common organism is the pneumococcus. However, given his recent hemicolectomy, the possibility of a more virulent organism emerges. This is the most critical factor in dictating his course of therapy. Whether the patient received the annual influenza vaccine (choice A) is important given his age and the morbidity associated with an influenza infection, however, it has no bearing on the course of this pneumonia or its therapy. His lipid status (choice B) is not relevant to therapy of his pneumonia. The stage of his colon cancer (choice C) is important, but not for the treatment of his pneumonia. There is no clinical relationship between pneumonia severity and colon cancer progression until late stage metastases occur and there is a possibility of post-obstructive pneumonia developing. The patients social support structure for home therapy (choice D) is an issue only at the time of discharge when the issue of continued home therapy is important. At this time his ability to have assistance with possible intravenous medications is an issue. 16) A 49-year-old woman presents to the office because of complaints of fatigue. She has had progressive exercise intolerance over the prior 6 months. On physical examination, she is pale and afebrile. Her blood pressure is 112/68 mm Hg, and her pulse is 88/min. Heart and lung examinations are normal except for a I/VI systolic flow murmur at the left sternal border. Routine laboratory results reveal hemoglobin of 8.3 g/dL, a mean corpuscular volume of 118 L/m3, and a B12 of 82 pg/mL (normal >210 pg/mL). She undergoes a Schilling test, which reveals malabsorption of radiolabeled B12. Intrinsic factor is administered and the radiolabeled B12 is subsequently absorbed. Which of the following is the diagnosis? A. Atrophic gastritis B. Bacterial overgrowth C. Chronic pancreatitis D. Crohn disease E. Gastric ulcer Explanation: The correct answer is A. This patient has pernicious anemia, as demonstrated by correction of her deficiency in intrinsic factor production by her parietal cells. This is an autoimmune disease directed against the parietal cells of the stomach, which are the normal producers of the intrinsic factor needed for absorption of vitamin B12. The lack of B12 then causes development of a megaloblastic (with high mean corpuscular volume) anemia. Biopsy of the gastric mucosa in these cases reveals atrophic gastritis. The Schilling test examines the absorption of radioactively labeled vitamin B12 before and after administration of intrinsic factor. A result of poor absorption of B12 before administration of intrinsic factor and good absorption after strongly suggests pernicious anemia as the diagnosis. Patients with pernicious anemia require long-term (probably life-long) parenteral replacement of vitamin B12 and may also have other significant autoantibodies, notably those directed against thyroid antigens. Choices B, C, and D may all produce a B12 deficiency, but they do not correct with intrinsic factor. In patients with bacterial overgrowth (choice B), the excess bacteria will preferentially absorb intraluminal B12. Chronic pancreatitis (choice C) may predispose to a B12 deficiency by failing to secrete the enzymes that are necessary to cleave the salivary R factor from the B12, making it unavailable for binding to intrinsic factor. Crohn disease (choice D) may cause a B12 deficiency if the terminal ileum is severely inflamed or has been resected. Gastric ulcer (choice E) can cause anemia secondary to bleeding, but it would be a normocytic anemia (unless there had been enough blood loss to cause iron deficiency, in which case it would microcytic) and would not be expected to respond to B12. 17) A 65-year-old woman consults a physician because of a 3-month history of weight loss, burning sensation of the tongue, fatigue, anorexia, and poorly localized abdominal pain. The woman appears pale to the physician. Intraoffice hematocrit is 35% with peripheral smear showing large erythrocytes and hypersegmented neutrophils. Serum folate is 2.4 ng/mL (normal greater that 1.9 ng/mL) and serum vitamin B12 is 100 pg/mL (normal 200-800 pg/mL). Stomach biopsy demonstrates chronic gastritis. Autoantibodies to which of the following are most likely involved in this patient's condition? A. Basement membrane B. Insulin receptor C. Intrinsic factor D. SS-B E. TSH receptor Explanation: The correct answer is C. This patient has pernicious anemia, in which autoimmune gastritis causes a lack of the intrinsic factor needed to absorb vitamin B12. Autoantibodies that are often present include those directed against the microsomal fraction of parietal cells and those capable of neutralizing intrinsic factor. The result is that vitamin B12 can no longer be absorbed by the terminal ileum. Since some vitamin B12 is stored in the liver, deficiency tends to develop slowly. Vitamin B12 deficiency can cause megaloblastic anemia; neurologic abnormalities that tend to begin with loss of position and vibration sense; and GI manifestations including anorexia, intermittent constipation or diarrhea, and abdominal pain. Antibodies to basement membrane (choice A) are associated with Goodpasture syndrome. Antibodies to insulin receptors (choice B) are associated with insulin resistance. Antibodies to SS-B (choice D) occur in association with Sjgren syndrome. Antibodies to TSH receptor (choice E) are associated with Graves disease. 18) A previously healthy 50-year-old woman comes to the physician because of double vision for three days. Her temperature is 37 C (98.6 F). The patient denies nausea or vomiting. Examination reveals ptosis and slight divergence of the right eye. Extraocular movements are limited in all directions, except laterally. The right pupil is larger than the left and poorly reactive to light. Examination of the fundus fails to reveal papilledema. Which of the following is the most likely underlying condition? A. Aneurysm of the posterior communicating artery B. Carcinoma of the right pulmonary apex C. Diabetes mellitus D. Giant cell arteritis E. Syphilis F. Systemic hypertension Explanation: The correct answer is A. This patient displays signs of oculomotor palsy, with restriction of the eye movements in all directions (except laterally, due to preservation of the sixth cranial nerve, the abducens), and ptosis. Dilatation of the pupil, which fails to react to light, is a sign of intracranial compression of the third, or oculomotor cranial nerve. This should prompt search for an underlying surgical cause of oculomotor palsy. Uncal herniation and aneurysm of the posterior communicating artery are the two most common surgical conditions leading to oculomotor palsy. In the absence of clinical evidence of increased intracranial pressure, it may be assumed that the patient has an aneurysm of the posterior communicating artery until proven otherwise. Cerebral angiography is the investigation of choice to confirm the diagnosis. All of the most common medical causes of oculomotor nerve palsy result in paresis of extraocular movements and ptosis, but the pupillary light reflex is preserved. These conditions include diabetes mellitus (choice C), giant cell arteritis (choice D), syphilis (choice E) and systemic hypertension (choice F). Carcinoma of the right pulmonary apex (choice B) may result in Horner syndrome (miosis, ptosis, enophthalmos, and loss of sweating on the affected hemiface) due to infiltration of the cervical autonomic ganglia. 19) A patient with a history of chronic bacterial sinusitis presents to the emergency department with a very severe headache. While waiting to be seen, he develops a generalized grand mal seizure. Physical examination, after the seizure is over, demonstrates high fever, exophthalmos, papilledema, and nerve palsies of the VI and III cranial nerves on one side. Which of the following is the most appropriate next step? A. Admit to the medical floor for monitoring of progression of symptoms B. Emergency CT scan C. Emergency exploratory surgery D. Emergency ultrasound E. Keep in emergency department for monitoring of progression of symptoms Explanation: The correct answer is B. This is the way that cavernous sinus thrombosis presents. This condition is due to a septic thrombosis that can complicate chronic bacterial sinusitis. Meningitis is another significant possibility. Lumbar puncture is dangerous in a patient with increased intracranial pressure, as indicated by the papilledema. Emergency CT scan of the cavernous sinus, air sinuses, orbit, and brain is warranted. Additionally, cultures of blood and any nasal discharge are warranted; Gram's stain of the nasal discharge may give a preliminary indication of the causative organism. High dose intravenous antibiotics are started, and then altered, if necessary, when culture results are reported. Cavernous sinus thrombosis has a 30% mortality rate, even when prompt, appropriate medical care is given. Simply monitoring (choices A and E) a patient like this would be very dangerous. Ultrasound (choice D) would probably not adequately visualize the complex structures of the sinuses, orbits, and brain. Surgery (choice C) is not indicated in this setting. 20) A 41-year-old man presents with complaints of mild intermittent heartburn after meals for the past 6 months. He has tried various over-the-counter antacids and H2 receptor antagonists with only minimal relief. He denies any dysphagia or odynophagia, and is otherwise in good health. He is concerned about the risk of developing cancer, because his father died of gastric cancer at age 49. His physical examination is unremarkable. Which of the following would be the most appropriate next step in management? A. Avoidance of a high-protein diet B. Avoidance of aspirin C. Avoidance of acetaminophen D. Elevation of the head of his bed E. Increased consumption of carbohydrates Explanation: The correct answer is D. Before initiating pharmacologic therapy, it is worthwhile to consider lifestyle modifications that may reduce symptoms in patients with gastroesophageal reflux disease (GERD). In this regard, elevating the head of his bed is an important step, since it will reduce the degree of nocturnal acid reflux while the patient is in the supine position. Other nonpharmacologic measures that may be helpful include avoidance of strong stimulants of acid secretion (coffee, alcohol), avoidance of certain drugs (anticholinergics) and foods (fats, chocolates), and cessation of smoking. Although fatty foods may exacerbate GERD by reducing the pressure on the lower esophageal sphincter (LES), high-protein diets (choice A) and carbohydrates (choice E) have no particular effect on the mechanism or symptoms or GERD. Although aspirin (choice B) may be injurious to the gastric and duodenal mucosa, it is not implicated in exacerbations of GERD. Acetaminophen (choice C) has no effect on the symptoms or cause of GERD. 21) A 40-year-old woman is brought to the emergency department following a suicide attempt with imipramine. Her fiancee found her unresponsive, with an empty bottle of the imipramine at her side. The imipramine had been his, and the prescription had been filled that morning. Her past medical history is significant for hypertension, atrial fibrillation, diabetes, and asthma. Her medications include furosemide, procainamide, glyburide, prednisone, and albuterol. She has no known drug allergies. She is afebrile, has a blood pressure of 100/60 mm Hg, pulse of 62/min, and respirations of 22/min. A gastric lavage yields multiple pill fragments. She is confused and somnolent, and has shallow respirations. Her physical examination is otherwise unremarkable. On an ECG, which of the following abnormalities would most likely reflect possible cardiac toxicity? A. Left deviation of the QRS axis B. Prolongation of the QRS interval C. Shortening of the QT interval D. ST segment depression E. T wave inversion Explanation: The correct answer is B. A prolongation of the QRS interval is highly predictive of both cardiac and CNS toxicities from tricyclic antidepressant ingestion. Left deviation of the QRS axis (choice A), which can be seen with conditions such as left ventricular hypertrophy and left bundle branch block, is not typically associated with tricyclic cardiac toxicity. Conversely, right deviation of the QRS axis (greater than 120 degrees) is very predictive of cardiac toxicity from tricyclics. Shortening of the QT interval (choice C) is not seen with tricyclic toxicity, but can be seen with metabolic derangements such as hypercalcemia. Neither ST segment depression (choice D) nor T wave inversion (choice E) is directly associated with cardiac toxicity from tricyclic overdose. These changes may be seen, however, in conjunction with the more classic ECG manifestations of tricyclic toxicity (prolonged QRS interval, right axis deviation) if the resulting cardiac toxicity leads to diminished coronary perfusion and ischemia. 22) A 43-year-old bus driver presents to his gastroenterologist with complaints of difficulty swallowing solid foods. The evaluation demonstrates a smooth, tapered stricture of the distal esophagus, and biopsies reveal changes consistent with chronic esophagitis and fibrosis. The stricture is dilated with an endoscopic balloon dilator, and the patient's symptoms resolve. He reports that although he has had dysphagia for the past 2 months prior to the endoscopy, he rarely has heartburn and uses an over-the-counter antacid only occasionally. Which of the following is the most appropriate future management of this patient? A. Famotidine B. Lansoprazole C. Magnesium hydroxide D. Metoclopramide E. No medication is necessary Explanation: The correct answer is B. Although this patient has rarely been aware of symptoms of gastroesophageal reflux disease (GERD), the development of a peptic stricture clearly indicates longstanding acid reflux into the distal esophagus. This will be a persistent process and, if not treated, will lead to recurrent strictures. He therefore requires chronic treatment with a proton pump inhibitor to suppress acid secretions. Famotidine and antacids, such as magnesium hydroxide (choices A and C), are adjuncts to the mainstay of therapy, which is proton pump inhibition. Even though the patient is not symptomatic, he does require continued acid suppression. Metoclopramide (choice D) reduces the lower esophageal sphincter pressure and is an adjunct to acid suppression in the management of patients with reflux. It is not used as first-line therapy, however. It is nowhere near as effective as proton pump inhibitors and frequently leads to side effects of sedation because of its ability to cross the blood-brain barrier and inhibit dopamine, producing Parkinson-like symptoms. As stated above, this patient will have recurrent strictures if he does not receive treatment. Therefore, choice E is incorrect. 23) A 23-year-old professional basketball player presents to the team physician 3 hours before game time complaining of abdominal pain. The symptoms began approximately 8 hours earlier in a diffuse fashion. Two hours later, he began feeling nauseated and vomited twice. Over the past 4 hours, the abdominal pain has become more severe and well localized in the right lower quadrant. His examination now reveals well-localized pain in the right lower quadrant inferolateral to the umbilicus. Which of the following is the most likely diagnosis? A. Acute obstruction of the appendiceal lumen by a fecalith B. Acute onset of ileocolitis C. Acute onset of ischemic colitis D. Acute Yersinia infection E. Obstruction of the ileocecal valve by a mass Explanation: The correct answer is A. Acute appendicitis is the second most common cause in the U.S., behind hernia, of severe acute abdominal pain that requires abdominal operation. Although it can occur at all ages, many patients, like this man, are teenagers or young adults. This patient's presentation is typical for acute appendicitis, with initially poorly localized pain that is followed by nausea and vomiting. In classic appendicitis, the pain shifts to the right lower quadrant, where it becomes more localized. In most patients, acute obstruction of the appendiceal orifice by a fecalith initiates the acute appendicitis. The acute onset of ileocolitis (choice B) will produce diarrhea or bloody stools. There is no evidence to suggest an etiology for ischemic colitis (choice C), which will typically present with bloody diarrhea and often with left-sided abdominal pain. Acute Yersinia infection (choice D) will produce acute right lower quadrant findings similar to those of acute appendicitis. However, it is accompanied by diarrhea, which is not described in this case. There is no reason to suspect obstruction of the ileocecal area by any mass (choice E) in a 23year-old man. Such an obstruction, should it occur, would typically present with abdominal distention as a result of bowel obstruction. 24) A 31-year-old homeless woman is brought to the emergency department after being found face down on the street. The woman has a long history of admissions to the hospital for alcoholrelated issues, including seizures, withdrawal, and hallucinations. Today, she was seen to fall in the street, have what were described as "convulsions" and then vomit. She remained face down in the street until the paramedics arrived. On physical examination, she has dry mucous membranes, a jugular venous pressure of less than 5 cm, and diffuse ecchymoses on her face, body, and breasts. Which of the following vitamins should be administered prior to volume resuscitation with IV fluids containing glucose? A. Vitamin B1 (Thiamin) B. Vitamin B3 (Niacin) C. Vitamin B12 (Cobalamin) D. Vitamin C E. Vitamin K Explanation: The correct answer is A. Administering glucose to a patient who is deficient in thiamin may precipitate Wernicke-Korsakoff syndrome, which is a combination of confusion, ataxia, ophthalmoplegia, anterograde and retrograde amnesia, and confabulation. It is therefore imperative to administer IV thiamin prior to glucose-containing IV fluids. Niacin (choice B) is an essential component of the coenzymes involved in oxidation-reduction reactions. Profound deficiency in niacin causes the classic triad of pellagra: dermatitis, diarrhea, and dementia. Vitamin B12 deficiency (choice C) may lead to megaloblastic anemia, neurologic complications, and dementia. Vitamin C deficiency (choice D) may lead to difficulty with wound healing and scurvy. Vitamin K (choice E) is essential for the production of selected clotting factors. Although alcoholics may be deficient in all the vitamins mentioned in the answer choices, only deficits in thiamin are associated with harmful effects if glucose is administered without replenishment. 25) A 36-year-old man develops rapid mental status deterioration two days after sustaining a femoral fracture in a skiing accident. Physical examination shows multiple petechiae in the anterior chest and abdomen. On the third day, the patient lapses into coma and dies. Postmortem examination of the brain reveals numerous petechial hemorrhages in the corpus callosum and centrum semiovale. Which of the following is the most likely diagnosis? A. Diffuse axonal injury B. Fat embolism C. Septic embolism D. Systemic thromboembolism E. Watershed infarction Explanation: The correct answer is B. The clinical manifestations are consistent with fat embolism. This complication is frequent, following fractures of long bones, but is usually asymptomatic. Fat embolism mainly affects the lungs and the brain, and the clinical picture consists of dyspnea, tachycardia, and mental status changes. Only rarely, does this condition lead to death. In the lungs, fat emboli can be visualized histologically. In the brain, multifocal petechiae in the white matter represent the most common pathologic change. Diffuse axonal injury (choice A) is one of the most common forms of traumatic brain injury. It involves the central white matter, especially the corpus callosum and cerebral peduncles. It is sometimes associated with small petechiae in these areas. The patient may develop coma a few hours to days after head trauma. Septic embolism (choice C) results from septic emboli lodging in the terminal intraparenchymal arteries of the brain. It leads to multiple cortical infarcts, usually of the hemorrhagic type. The white matter is spared. Systemic thromboembolism (choice D) is usually of cardiac originfor example, in patients with cardiac arrhythmias with thrombi in the right atrium or ventricle. Thromboemboli in the brain cause hemorrhagic infarction in the cortex. Watershed infarction (choice E) is often seen in patients suffering from acute hypotensive episodes, especially if the circle of Willis is already compromised by atherosclerotic change. The cortical regions at the border zone between different vascular territories (e.g., between the distribution of the anterior and middle cerebral arteries) undergo ischemic necrosis. 26) A 45-year-old man consults a physician because of dysuria. The patient is treated with antibiotics, but symptoms recur one week after antibiotic therapy is stopped. A different antibiotic is tried, but symptoms again recur after cessation of the antibiotic. Rectal examination demonstrates an enlarged prostate with areas of tenderness and fluctuance. Which of the following is the most likely diagnosis? A. Benign prostatic hyperplasia B. Chronic nonbacterial prostatitis C. Prostadynia D. Prostatic abscess E. Prostatic carcinoma Explanation: The correct answer is D. The patient has a prostatic abscess. The typical age is 40 to 60 years, and is consequently somewhat younger than the ages at which benign prostatic hyperplasia and prostate cancer become major problems. Infecting organisms include aerobic gram-negative bacilli and Staphylococcus aureus. Prostatic abscess should be suspected when a man develops repeated urinary tract infections that seem to get better with antibiotic therapy, only to recur later. The most important diagnostic clue, if detectable, is the presence of a fluctuant mass in the prostate on rectal exam. Some patients have only prostatic enlargement, or even no positive findings on physical examination. Patients may have normal urine, although it is more usual for an organism to be cultured at some point. Prostatic ultrasound may be helpful if the diagnosis is suspected. A few cases are even picked up at the time of prostatic resection for benign prostatic hyperplasia or other disease. Treatment is with evacuation of the abscess by a transurethral or perineal route followed by appropriate antibiotics. Benign prostatic hyperplasia (choice A) can cause urinary obstruction predisposing for bladder infection, but the prostate would not be fluctuant. Chronic nonbacterial prostatitis (choice B) can cause symptoms resembling urinary tract infection, but would not cause a fluctuant prostate. Prostadynia (choice C) is a noninfectious, noninflammatory condition of younger men that can mimic prostatitis, but would not cause a fluctuant prostate. Prostatic carcinoma (choice E) is usually asymptomatic, and can cause a firm prostatic mass. 27) A 31-year-old woman presents at the hospital for a pre-employment physical examination prior to beginning her year as a medical intern. She is sexually inactive and denies alcohol use. She had infectious mononucleosis while in college and received the recombinant hepatitis B vaccine before starting medical school. Which of the following would describe her hepatitis B serologic profile? A. Hepatitis B surface antigen positive, core antibody positive, and surface antibody negative B. Hepatitis B surface antigen negative, core antibody positive, and surface antibody positive C. Hepatitis B surface antigen positive, core antibody negative, and surface antibody negative D. Hepatitis B surface antigen negative, core antibody negative, and surface antibody positive E. Hepatitis B surface antigen negative, core antibody negative, and surface antibody negative. Explanation: The correct answer is D. Patients who receive the hepatitis vaccine will develop only surface antibodies, since the vaccine contains only epitopes of the surface antigen and NOT of the intact viral particle, which contains the core antibody. These patients will therefore have a negative surface antigen, negative core antibody, and positive surface antibody. Choice A describes a patient who has recent hepatitis B infection and has not yet developed surface antibody B. Choice B describes a patient that has had a past hepatitis B infection and has developed immunity. Choice C refers to a patient who has developed acute hepatitis B and has not yet developed immunity. Choice E describes a patient who has never been exposed to surface antigen and has no immunity. 28) A 57-year-old man presents to his physician for a preoperative evaluation. He has been a long-time patient in this office and has been treated for hypertension and gastritis. He has been scheduled for an elective open cholecystectomy in 2 days. He currently takes omeprazole for his gastritis and thiazide for his hypertension daily. He smokes two packs of cigarettes per day. His home blood pressure log shows that his systolic pressures range from 150 to 190 mm Hg, and his diastolic pressures range from 80 to 105 mm Hg, indicating that his blood pressure may be not adequately controlled for the surgical procedure. Which of the following medications is most appropriate in the perioperative period for added blood pressure control? A. Captopril B. Clonidine C. Metoprolol D. Nifedipine E. Prazosin Explanation: The correct answer is C. There is an extensive body of literature indicating that beta blockers given to non-cardiac surgical patients who are at risk of cardiac events are associated with a more favorable outcome in terms of postoperative cardiovascular morbidity and mortality. This patient has somewhat poorly controlled hypertension, as well as at least three cardiovascular risk factors (hypertension, tobacco, age). Ideally, one would like to have better control of the blood pressure and to reduce any risk for adverse perioperative events. Beta blockers can achieve both of these endpoints. Captopril (choice A) is an ACE inhibitor that has good efficacy in the treatment of hypertension. This class of drugs has also been shown to prolong survival in patients with congestive heart failure. Clonidine (choice B) is a central alpha-2 receptor agonist that works to attenuate sympathetic outflow and thus lower blood pressure. Although it is a reasonably efficacious drug, it is associated with rebound hypertension if abruptly discontinued. It has no role in the perioperative management of blood pressure. Nifedipine (choice D) is a calcium channel blocker that has reasonable efficacy in treating hypertension. There is no benefit to giving this agent in the perioperative period. Prazosin (choice E) is a alpha-1 receptor antagonist that is very efficacious in the treatment of hypertension. This class of drugs is also useful in the treatment of benign prostatic hypertrophy (BPH). 29) A 66-year-old man presents to the clinic complaining of progressively worsening shortness of breath and nonproductive cough over the past 2 years. He retired 1 year ago, after working as a rock miner for more than 30 years. He has no other significant past medical history. On physical examination, he is a thin man who appears tachypneic at rest. His lungs have reduced chest expansion and dry inspiratory rales in the upper lobes bilaterally. The remainder of his examination is normal. A chest x-ray film reveals multiple round opacities in the upper lobes accompanied by hilar lymphadenopathy with lymph node calcification. Which of the following is the most likely diagnosis? A. Asbestosis B. Aspergillosis C. Cystic fibrosis D. Silicosis E. Tuberculosis Explanation: The correct answer is D. This patient's occupational history of working in the mining industry should always prompt the consideration of the diagnosis of silicosis. There is usually bilateral upper lobe involvement associated with hilar lymphadenopathy and "eggshell" calcification of the visualized lymph nodes. There is no description of asbestos exposure (choice A), making this diagnosis unlikely. Bronchopulmonary aspergillosis (choice B) is often seen in farm workers who have been working in silos. Cystic fibrosis (choice C) presents during childhood, and these patients do not survive to this age. There is no evidence of tuberculosis exposure (choice E) by the patient's history. 30) A 55-year-old woman with a long-standing history of atrial fibrillation secondary to mitral regurgitation presents to the emergency department with a painful right foot. The patient reports that, over the past few hours, her foot has become more painful and now is nearly insensate. She describes the pain as burning and states that it is not relieved by any intervention. She takes coumadin, atenolol, digoxin, and aspirin. On physical examination, her pulse is irregularly irregular. Her lungs are clear, and she has a loud holosystolic murmur heard best at the apex. Her right foot is gray and cool to the touch and has poor capillary refill. Dorsalis pedis and posterior tibial pulses are absent on the right. Her prothrombin time is 14.4 seconds (INR 1.4). Which of the following is the most appropriate course of action? A. Arrange for her to be seen by a vascular surgeon in the emergency department now B. Arrange for her to be seen by a neurologist within the next few days C. Arrange for her to undergo an MRI of the head that day D. Ask her to make an appointment to be in seen in your office within 1 week E. Instruct her to soak her leg in warm water and to place a fitted stocking on her affected leg Explanation: The correct answer is A. The symptoms and signs that she is describing, particularly in the context of atrial fibrillation (AF), suggest peripheral embolization, which is a surgical emergency. The treatment of choice involves immediate embolectomy, which is usually performed by a vascular surgeon, followed by anticoagulation. Her subtherapeutic prothrombin time and persistent AF on examination are supportive of this diagnosis. All the other choices (choices B through E) represent actions that would delay surgical care and likely lead to the loss of her limb. Even if the physician has not seen this patient before, it is incumbent on him to direct her to and facilitate immediate surgical intervention. 31) A 50-year-old man is brought to the emergency department complaining of light-headedness. He has a history of lung cancer, which was diagnosed a month ago and found to be widely metastatic to the bone and pericardium. On physical examination, his blood pressure is 70/40 mm Hg, and his pulse is 100/min. His heart sounds are distant and soft. His ECG demonstrates low voltage, and electrical alternans is present. A chest x-ray film shows that the cardiac silhouette has a "water bottle" appearance.Which of the following is the most appropriate intervention in this patient? A. Beta-blockers B. Nonsteroidal anti-inflammatory drugs C. Steroids D. Pericardiocentesis E. Cardiac catheterization Explanation: The correct answer is D. This patient is in pericardial tamponade, most probably as a result of his malignancy. Lung cancer is particularly likely to cause pericardial effusions. Furthermore, since this patient has metastases to the pericardium, he might be bleeding into the pericardial space. This tamponade may be the cause of his significant hypotension and the soft cardiac sounds. Electrical alternans, a phenomenon in which the QRS changes axis, is indicative of pericardial effusion, since the heart is moving freely in the fluid, causing a change in axis noted on the ECG. Emergently, this patient needs decompression of the pericardial space with the aid of pericardiocentesis, whereby a catheter directly drains the fluid in the pericardial sac. Beta-blockers (choice A) would be of no benefit in treating cardiac tamponade. Nonsteroidal anti-inflammatory drugs (NSAIDs) (choice B) can be useful in treating pericarditis, which may cause pericardial effusions. However, this is a longer term option and will have little utility emergently. Steroids (choice C) may similarly be used in pericarditis, after NSAIDs have failed. However, this is an option to be explored after the pericardial fluid has been drained. Cardiac catheterization is often used to confirm the diagnosis of tamponade (choice E). Typically the pressure equalizes across the right atrium and ventricle. However, emergently, this patient should have pericardiocentesis. 32) A 62-year-old man with a 110 pack-year history of smoking presents with chest pain. He states that for the past few months, he has been getting chest "pressure" localized to the substernal region, radiating to the left arm on occasion. The pain occurs with mild exertion, but never at rest. He further states that when he gets the pain, it usually last about 5 minutes but goes away with rest. He reports that his exercise tolerance is moderate, and he gets dyspnea on exertion after a few blocks of walking. On physical examination, he has no chest wall tenderness to palpation, but a carotid bruit is heard, and his dorsalis pedis pulses are decreased. He has no history of coronary disease but his family history is significant for his father having a myocardial infarction at age 56. He denies chest pain at this time. In addition to ascertaining his other coronary risk factors, which of the following is the most appropriate diagnostic intervention? A. Obtain a resting electrocardiogram B. Schedule the patient for a cardiac echocardiogram C. Schedule the patient for an exercise treadmill test D. Schedule the patient for non-urgent coronary angiography E. Schedule the patient for immediate coronary angiography Explanation: The correct answer is C. This is a patient who has 3 clear risk factors for coronary artery disease (tobacco, family history and age) and based on his physical examination, likely has severe peripheral vascular disease. He has, by definition, typical chest pain, so called "new onset angina". He is a prime patient to have significant coronary disease, and thus we suspect ischemia as a cause for his pain. As a surrogate for coronary angiography, which actually shows anatomy, an exercise treadmill test allows us to detect ECG changes of ischemia with activity and thus stratify this patient as requiring intervention (such as percutaneous transluminal coronary angioplasty, or coronary artery bypass grafts), or perhaps angiography to better evaluate his anatomy. A resting ECG (choice A) is appropriate, but not the most appropriate, given that he is pain-free at present and one would not expect to see any ECG changes associated with ischemia. A cardiac echocardiogram (choice B) will likely be performed, given his dyspnea on exertion, but is not an appropriate test in the triaging of suspected ischemic chest pain. In some centers a "stress-echo", specifically a dobutamine echocardiogram, is used to evaluate ischemic potential. A non-urgent coronary angiography (choice D) is also inappropriate since angiography is an invasive procedure reserved for people that have had equivocal results from less invasive diagnostic procedures, or are having signs of crescendo angina. This patient has new angina, but it is "typical" angina in that it is exertional. An immediate coronary angiogram (choice E) is clearly not indicated as the patient is not having active ischemia or a myocardial infarction requiring reperfusion. 33) A 35-year-old man comes to the physician for a health maintenance examination. He received blood transfusions for hypovolemic shock following a gunshot wound 10 years earlier. He is currently in good health, and physical examination is unremarkable. A serum chemistry panel shows: ALT 250 U/L AST 140 U/L Alkaline phosphatase 70 U/L Serologic evaluation for viral hepatitis reveals positive antibodies to hepatitis C virus (HCV). A percutaneous liver biopsy shows marked portal inflammatory infiltrate disrupting the limiting plate of hepatic lobules. Which of the following is the incidence rate of this complication following HCV infection? A. 5% B. 10% C. 20% D. 40% E. 80% Explanation: The correct answer is E. The acute infection due to hepatitis C virus (HCV) is most commonly asymptomatic, but 80% of these cases progress to chronic hepatitis. Of the 80%, 20% will eventually evolve to cirrhosis. The source of infection remains unknown in a substantial number of cases, but 50% are related to IV drug abuse and 4% are attributable to blood transfusion. HCV, on the other hand, is now the most common cause of transfusion-associated hepatitis. The mode of presentation of chronic hepatitis C is often insidious, and patients might well be in good health when elevated aminotransferases are discovered. This laboratory finding prompts additional investigations, usually including a percutaneous liver biopsy. This will demonstrate the typical histologic changes of chronic hepatitis, namely chronic portal inflammation eroding, to varying extents, into the hepatic lobule. The degree of lobular "invasion" by the portal inflammatory infiltrate is the main indicator of the propensity for evolution to cirrhosis. Male sex, infection after age 40, and alcohol consumption are risk factors for evolution of chronic hepatitis C to cirrhosis. Nowadays, HCV is considered the most common cause of chronic hepatitis and one of the most common causes of cirrhosis in industrialized countries. 34) A 71-year-old woman is admitted to the hospital for pneumonia. The patient presented to the hospital 2 days ago for cough and fever. She reported temperatures to 38.9 C (102 F) and a cough productive of green, copious sputum. She also reported pleuritic chest pain with deep inspiration. The initial examination revealed diminished breath sounds in the left lower lobe with dullness to percussion, and a chest radiograph revealed a dense left lower lobe infiltrate. Which of the following organisms is most likely responsible for her pneumonia? A. Bordetella pertussis B. Klebsiella pneumoniae C. Mycoplasma pneumoniae D. Pneumococcus E. Staphylococcus aureus Explanation: The correct answer is D. The etiology of pneumonia is related to both the age of the patient and the particular risk factors that he or she may exhibit. For patients with no specific risk factors, pneumonia is referred to as community-acquired pneumonia (CAP). CAP has a variable etiology depending on the age of the patient. In patients aged 29-55, the pneumococcus (Streptococcus pneumoniae), a gram-positive organism, is the most frequent agent causing so-called typical or bacterial pneumonia. Bordetella pertussis(choice A) causes whooping cough in children. Most adults in the U. S. have been vaccinated against this organism. However, 20 years after the last booster, immunity begins to fade, and it is reasonably common to see patients aged 55 and older presenting with upper and lower respiratory tract infections caused by this organism. Klebsiella pneumoniae(choice B) is a reasonably frequent source of pneumonia in both hospitalized patients and those with chronic aspiration problems, such as post-stroke patients. Mycoplasma pneumoniae(choice C) is the primary agent responsible for so-called atypical pneumonia in the same age bracket. Staphylococcus aureus(choice E) is a gram-positive organism that causes severe cavitating pneumonia. It is most often responsible for pneumonia in diabetic patients. 35) A 69-year-old woman presents to her physician of 3 years with progressive shortness of breath. The dyspnea was initially limited to exertion but has progressed to shortness of breath at rest. She has had intermittent cough but no fever. Her past medical history is significant for mild hypertension and seropositive rheumatoid arthritis. Which of the following aspect of her social history is the most important consideration to review at this point? A. Alcohol history B. Drugs of abuse history C. Marital status D. Occupation E. Tobacco history Explanation: The correct answer is E. In Canada, lung damage from smoking is by far the most important contributor to lung disease, from an epidemiologic standpoint. In addition, smoking can significantly exacerbate the clinical course of other diseases that affect the lungs, such as asthma or cystic fibrosis. Fortunately, smoking behavior can be potentially altered by new pharmacologic approaches. Although the physician may have asked this patient about smoking before, it is now time to review her smoking history in detail. Asking about alcohol (choice A) and drugs of abuse (choice B) is always important, even in the elderly, but reviewing the smoking history should take precedence here. Alcohol use typically does not directly lead to lung pathology or cause dyspnea. Some drugs of abuse, such as marijuana, crack cocaine, and heroin, have deleterious effects when introduced into the lungs. That said, the age of this patient makes it much more likely that she would be using tobacco. Although exploring the marital status (choice C) and key relationships in a patient's life is very important in terms of the patient's overall health, this process has little additional role during this visit. Reviewing the occupational history (choice D) is also an important part in the evaluation of dyspnea. Although smoking usually overshadows occupational-related lung injuries, the occupational history should take a close second to the smoking history. Occupational exposures can exacerbate diseases such as asthma and can cause diseases such asbestosis and silicosis. If the patient had been a 50-year-old brake mechanic or shipyard worker, the occupational history may have been a more important component of the social history on which to concentrate. 36) A 42-year-old man presents for his annual physical examination. He was last seen 2 years ago for a periodic health examination and was in good health. He is on no medications. His past medical history is significant for a cholecystectomy 2 years ago and rheumatic fever at age 15. He has been smoking approximately ten cigarettes daily for the past 23 years. On physical examination, his blood pressure is 154/56 mm Hg, pulse is 68/min, and respirations are 14/min. He is afebrile. A head and neck examination is normal. His lungs are clear. He has a regular heart rhythm, with a II/IV blowing decrescendo diastolic murmur heard at the aortic area. His abdominal and rectal examinations are normal. Complete blood count, electrolytes, and thyroid function tests are normal. Which of the following is the most appropriate advice for this man regarding future preventive health maintenance? A. Antibiotic prophylaxis before dental work B. Annual chest x-ray film C. Annual echocardiogram D. Annual flexible sigmoidoscopy E. Annual prostate specific antigen testing Explanation: The correct answer is A. This patient should have antibiotic prophylaxis before undergoing dental work. The patient's physical examination is consistent with asymptomatic aortic insufficiency, as indicated by his lack of symptoms combined with a characteristic diastolic murmur. This has occurred as a result of his childhood rheumatic fever. Patients with any significant cardiac valvular disease should be instructed to have antibiotic prophylaxis before dental work to reduce the risk of subacute bacterial endocarditis. Although this man is at increased risk for lung cancer given his long history of smoking, chest xray films (choice B) have never been proven effective as early detection. Although he does have underlying valvular heart disease, there is no indication for an annual echocardiogram (choice C) unless specific symptoms develop and warrant evaluation. A sigmoidoscopy (choice D) is one of several choices that are appropriate colorectal cancer screening examinations beginning at age 50. Prostate specific antigen testing (choice E) remains controversial in asymptomatic adults and is certainly not recommended in asymptomatic men younger than 50. 37) A 30-year-old man consults a physician at his wife's insistence because "his eyes are a little yellow all the time now". Screening chemistry studies show modest elevations of liver transaminases and total bilirubin 2.0 mg/dL, almost all of which is conjugated. The patient denies ever using alcohol. Viral hepatitis studies are negative. Liver biopsy shows hepatic fibrosis with normal iron levels and no evidence for alpha-1-antitrypsin deficiency. On further questioning about his general health, the patient reveals that he has had an unusually large number of bacterial pneumonias in his life. He has even had Pneumocystis pneumonia at one point. HIV testing at that time and repeated twice since has always been negative. A doctor at the time had commented that he seemed to have some trouble making neutrophils. T and B cell numbers are within normal limits. Antibody studies reveal the following: IgG total 200 mg/dL [normal 723-1685 mg/dL] IgA 40 mg/dL [normal 81-463 mg/dL] IgM 450 mg/dL [normal 48-271 mg/dL] Which of the following is the most likely diagnosis? A. Adenosine deaminase deficiency B. Bruton's agammaglobulinemia C. IgG subclass deficiency D. Hyper IgM immunodeficiency E. Selective IgA deficiency Explanation: The correct answer is D. Hyper IgM immunodeficiency is a congenital, often X-linked, form of immunodeficiency which is characterized by low IgG and IgA and compensatory high IgM. The immunodeficiency causes increased susceptibility to major gram-positive pathogens and opportunistic infections (such as the patient's Pneumocystis infection). The biochemical basis of the condition appears to be a defect in a receptor on the T cell membrane that helps to trigger B cell switching from IgM to IgA, IgG, and Ig E. Cases, such as in this question, in which the problem is not picked up because of the immunodeficiency may come to medical attention with other features of the syndrome, including lymphadenopathy, autoimmunity (notably Coombs positive hemolytic anemia), or chronic liver disease. Adenosine deaminase deficiency (choice A) is a cause of a form of severe combined immunodeficiency that usually presents (often with thrush) in the first three months of life. Bruton's agammaglobulinemia (choice B), also known as x-linked agammaglobulinemia, is characterized by markedly decreased B cell numbers, and low values of all of the immunoglobulins, particularly IgG. IgG subclass deficiency (choice C) is characterized by markedly decreased levels of a single IgG subclass in the setting of normal total IgG levels. Selective IgA deficiency (choice E) is very mild, and is usually clinically significant only because of a tendency to anaphylaxis if given IgA-containing blood products. 38) A 42-year-old man consults a physician because he has a "lump" on his forearm. Examination of the arm demonstrates a 3-cm diameter nodule protruding above the forearm surface. The lesion is covered with apparently normal skin and is soft and freely movable. It location appears to be subcutaneous. The lesion has been slowly growing over the past 2 years, and the patient has experienced no discomfort. He has consulted a physician at this time because his wife keeps pestering him to get something done about it. Which of the following is the most likely diagnosis? A. Capillary hemangioma B. Dermatofibroma C. Intradermal nevus D. Lipoma E. Seborrheic keratosis Explanation: The correct answer is D. This is probably a lipoma, which is a benign mass lesion composed of mature adipose tissue bound by a limiting membrane. (Another possibility is an epidermoid cyst, which can be indistinguishable clinically from lipoma.) Lipomas are very common, and patients may have more than one lipoma. Common sites include the trunk, nape of the neck, and forearms. The lesions are only rarely malignant, although a rapidly growing lesion should be biopsied to make sure of the diagnosis. They are usually asymptomatic; a small percentage are painful. They can be treated with surgical excision or liposuction. Capillary hemangioma (choice A), also known as strawberry mark, is a bright red, vascular lesion that usually develops shortly after birth and then often involutes by late childhood. Dermatofibroma (choice B) causes a firm, red to brown, small papule or nodule that is most frequently found on the legs. Intradermal nevus (choice C) causes a flesh colored to black, elevated, lesion that is usually 3 to 6 mm in size. Seborrheic keratosis (choice E) causes a pigmented, superficial, usually warty, epithelial lesion. 39) A 45-year-old man undergoes a routine examination. While the physical examination is unrevealing, a hematocrit performed in the physician's office gives a value of 25%. Review of the peripheral smear reveals smaller-than-normal erythrocytes. The cells vary in size, and some have abnormal shapes. The cells do not appear paler than normal. Reticulocytes are decreased. Assuming that this patient has only a single cause for his anemia, which of the following is most likely to be seen on further evaluation? A. Low iron B. Low iron binding capacity C. Low folate D. Low mean corpuscular hemoglobin concentration (MCHC) E. Low vitamin B12 Explanation: The correct choice is A. This patient has a microcytic, normochromic anemia and is not obviously ill on physical examination. The overwhelmingly most likely diagnosis is irondeficiency anemia, which is, in turn, almost always due to bleeding in adults on a typical American diet. Occult GI bleeding is a common source in both men and women. Menstrual disorders are also important causes of iron deficiency in women. Low iron binding capacity (choice B) is seen in the anemia of chronic disease. Low folate (choice C) produces a megaloblastic anemia. Low mean corpuscular hemoglobin concentration (MCHC; choice D) is seen in hypochromic anemias. Low vitamin B12 (choice E) produces a megaloblastic anemia. 40) A 23-year-old African American man with AIDS is sent for work up of the nephrotic syndrome. His blood pressure is 140/82 mm Hg. He has 3+ edema in both legs. His risk factor for AIDS is IV heroin use. His creatinine is 2.0 mg/dL, and his urine reveals +3 protein, no blood. A kidney biopsy would most likely reveal which of the following? A. Diabetic nephropathy B. Focal glomerular sclerosis C. IgA nephropathy D. Membranous nephropathy E. Nil disease Explanation: The correct answer is B. Focal glomerular sclerosis is the type of nephropathy most commonly seen in African American IV drug users with AIDS. It is likely to lead to a very rapid loss of renal function. There is no clinical evidence to indicate that this person has diabetes, making diabetic nephropathy (choice A) unlikely. Nil disease (choice E), IgA nephropathy (choice C) and membranous nephropathy (choice D) are only very rarely associated with AIDS. 41) A 57-year-old woman presents to her physician for follow-up of a fasting serum cholesterol level of 236 mg/dL. She is post-menopausal since age 52, and has been not been on hormone replacement therapy. She has a positive family history for coronary artery disease and she has smoked one-half pack of cigarettes per day for the past 20 years. During her last physical examination, a lipid profile was ordered, and she presents today for evaluation of those results. Which of the following lipid panels would most strongly suggest the need for pharmacologic therapy in this patient? A. Total cholesterol 180 mg/dL, LDL cholesterol 140 mg/dL B. Total cholesterol 184 mg/dL, LDL cholesterol 100 mg/dL C. Total cholesterol 230 mg/dL, LDL cholesterol 100 mg/dL D. Total cholesterol 245 mg/dL, LDL cholesterol 165 mg/dL E. Total cholesterol 285 mg/dL, LDL cholesterol 100 mg/dL Explanation: The correct answer is D. For those patients in whom a fasting panel has been obtained, a stepwise approach to intervention based on the patient's LDL and risk factors may be used. A patient with 2+ risk factors (this patient) and an LDL of greater than 160 mg/dL warrants medical therapy. A total cholesterol of 180 mg/dL, LDL cholesterol of 140 mg/dL (choice A) or a total cholesterol of 184 mg/dL with an LDL cholesterol 100 mg/dL (choice B) in this patient could be managed with a trial of dietary modification and education. For marginally high total cholesterol: total cholesterol 230 mg/dL, LDL cholesterol 100 mg/dL (choice C), there is no indication for drug therapy because the LDL is still not above 130. A total cholesterol of 285 mg/dL with an LDL cholesterol of 100 mg/dL (choice E), although disconcerting, does not require drug therapy. The total cholesterol is elevated, but the LDL is not, suggesting either increased triglycerides or an equally high HDL level. 42) A 47-year-old man presents for follow up of his previous visit 2 weeks ago, when he was seen for evaluation of his duodenal ulcer. At that time, a test for Helicobacter pylori was performed. The patient was otherwise well but had been complaining of epigastric pain that was exacerbated by eating. An esophageal-gastroduodenoscopy revealed the presence of a duodenal ulcer, and biopsies were taken at that time. In addition, the patient was told that he needed to modify his diet, such as decreasing his coffee intake, and cutting his tobacco use. The patient returns today to discuss his test results, which were positive for the H. pylori organism. Which of the following is the most appropriate therapy at this time? A. Amoxicillin orally B. Bismuth, metronidazole, tetracycline, and omeprazole orally C. Metronidazole orally D. Omeprazole orally E. Sucralfate orally Explanation: The correct answer is B.Helicobacter pylori plays a major role in the pathogenesis of peptic ulcer disease. The organism is present in 95% to 100% of patients with duodenal ulcers and in 75% to 85% of those with gastric ulcers. Eradicating the organism generally results in a cure for the disease. Therapy varies, but one of the more common regimens consists of antibiotics and a proton-pump inhibitor. Oral amoxicillin (choice A) and oral metronidazole (choice C) are possible antibiotics used in combination therapy. They are not efficacious when given without the other agents in the combination. The same is true for oral omeprazole (choice D). This proton-pump inhibitor is not efficacious in eradicating the organism when it is given without antibiotics. Oral sucralfate (choice E) has no role in therapy of H. pylori infection. This drug coats preexisting gastric erosions to prevent worsening of ulcers, not to prevent acid secretion. 43) A 33-year-old woman comes to the physician because of palpitations, restlessness, sweating, weight loss, and a tremor for the past 3 weeks. She does not drink coffee, tea, soda, or alcohol, and she does not smoke cigarettes. Her temperature is 37 C (98.6 F), blood pressure is 130/80 mm Hg, and pulse is 90/min. Examination shows a fine tremor, lid lag and stare, and pretibial myxedema. The thyroid gland is diffusely enlarged, asymmetric, and lobular. A bruit is present over the gland. Laboratory studies show an undetectable level of thyroid-stimulating hormone, an increased level of thyroid hormones, and an increased radioactive iodine uptake (RAIU). The diagnosis of Graves' disease is made and the treatment options are discussed. The patient selects radioactive iodine therapy. This patient is at greatest risk for which of the following conditions? A. Cholestasis B. Granulocytopenia C. Hypothyroidism D. Recurrent laryngeal nerve damage E. Thyroid carcinoma Explanation: The correct answer is C. Hypothyroidism is the main complication of radioactive iodine therapy, affecting up to 70% of patients in 10 years. Radioactive iodine therapy is a safe and effective treatment for Graves' disease because it can provide the same ablative effects of surgery without the surgical complications. There is no evidence that this treatment increases the risk for carcinoma (choice E). Cholestasis (choice A) and granulocytopenia (choice B) are side effects of long-term antithyroid therapy (propylthiouracil). Recurrent laryngeal nerve damage (choice D) is a complication of subtotal thyroidectomy. Subtotal thyroidectomies provide rapid control of the disease but can lead to nerve damage, hemorrhage, hypothyroidism, and hypoparathyroidism. 44) A 65-year-old man complains of increasing urinary frequency and dribbling at night. He has no past medical history and is on no medications. On physical examination, a digital rectal exam reveals a normal-sized prostate. The prostate-specific antigen (PSA) level is elevated at 15.4 ng/mL. Ultrasonography reveals a small hypoechoic area on the prostate measuring 6 8 mm in the right lobe. Which of the following is the most appropriate next step? A. Administer leuprolide B. Biopsy prostate lesion C. Perform bone scan D. Repeat PSA in 3 months E. Scan pelvis and retroperitoneum Explanation: The correct answer is B. Measurement of serum levels of prostate-specific antigen (PSA) can be used to screen for prostate cancer. However, this substance can also be elevated in prostate hypertrophy. A transrectal ultrasound can identify lesions not palpable on rectal examination, and the area can be biopsied under ultrasound guidance. Metastatic prostate cancer can be treated with leuprolide (choice A). This is a luteinizing hormone releasing hormone (LH-RH) agonist that suppresses testicular testosterone production. This is equivalent to orchiectomy or estrogen therapy. Patients with prostate cancer will undergo a metastatic work-up as well, including a bone scan (choice C) to rule out bony metastases. However, the diagnosis of cancer must first be made. Repeat PSA analysis would be helpful in following response to therapy (choice D). However, the PSA is high enough to warrant immediate work-up. Imaging of the pelvis and retroperitoneum (choice E) would be part of the standard metastatic work-up as well. 45) The day after hunting and skinning wild rabbits, a hunter develops an inflamed papule on one finger. The papule rapidly enlarges and then bursts, releasing pus and forming a clean ulcer cavity productive of thin, colorless exudate. Several days later, the patient develops severe illness with atypical pneumonia and delirium. It is at this point that the patient seeks medical care. The regional lymph nodes of the axilla of the affected arm are enlarged. Reduced breath sounds and occasional rales are heard. Splenomegaly is noted. Blood studies show a mild leukocytosis. Which of the following is the most likely diagnosis? A. Actinomycosis B. Brucellosis C. Melioidosis D. Plague E. Tularemia Explanation: The correct answer is E. This is tularemia, the causative organism of which is Francisella tularensis. The classic clue in test questions is exposure to wild rabbits, although wild rodents and their arthropod vectors may also carry the disease. You should also be aware that this highly infectious organism should not be isolated except in special protective hoods. The description in the question stem is typical of the ulceroglandular form; less common forms include disease resembling typhoid fever, an oculoglandular form secondary to eye inoculation, and a glandular form in which the initial site of infection is not obvious. Very severe cases may develop disseminated necrotic lesions of various sizes throughout the body. Agglutination tests can confirm the diagnosis after about the 10th day of illness. Untreated cases tend to last 3 to 4 weeks before resolving. Streptomycin is the antibiotic of choice; gentamicin and chloramphenicol can alternatively be used. Deaths occur in about 6% of untreated cases and are very rare in treated cases. Actinomycosis (choice A) causes multiple draining sinuses. Brucellosis (choice B) causes recurrent fevers. Melioidosis (choice C) causes lung and disseminated infection, usually following contamination of wounds by infected soil or water. Plague (choice D) causes lymph node and lung involvement after exposure to infected rodents and their parasites. 46) A 72-year-old man with a 25-year history of emphysema presents to his physician after he develops the acute onset of fevers, rigors, and a cough productive of green sputum. The symptoms gradually worsen over 36 hours and he presents to the emergency department. He has been taking a beclomethasone inhaler twice daily, an albuterol nebulizer treatment at home four times daily, and has been taking erythromycin for a recent bronchitis. On physical examination he is 183 cm (6 feet) tall and weighs 85 kg. His temperature is 38.3 C (100.9 F), blood pressure is 162/92 mm Hg, pulse is 94/min, and respirations are 32/min. His lung examination reveals diffuse bilateral coarse rhonchi. He uses his sternocleidomastoid muscles with each inspiration. An arterial blood gas reveals a pH of 7.20, a pCO2 of 60 mm Hg, and a pO2 of 52 mm Hg. Over the next 2 hours, he becomes increasingly tachypneic, and his pCO2 rises to 74 mm Hg. The decision is made to intubate him at that point. Which of the following settings would be most appropriate for his tidal volume on the respirator? A. 500 mL/breath B. 600 mL/breath C. 700 mL/breath D. 850 mL/breath E. 1000 mL/breath Explanation: The correct answer is D. The tidal volume for a patient is generally estimated as 10 mL/kg of weight, which for this patient would be 850 mL/breath. Giving a lower tidal volume will yield hypoventilation and be insufficient to eliminate pCO2. Providing a tidal volume greater than 10 mL/kg increases the risk of pneumothorax, particularly in a patient with longstanding emphysema who may have thin-walled alveoli. A low tidal volume with risk of hypoventilation would be produced by choice A (500 mL/breath), choice B (600 mL/breath), and choice C (700 mL/breath). A high tidal volume with risk of pneumothorax would be produced by choice D (1000 mL/breath). 47) A 41-year-old man presents to his physician for a routine physical examination. He is a new to this office and brings his previous medical record with him. He has no significant past medical history but he does have a strong family history of cancer and heart disease. His father and his brother both had myocardial infarctions before age of 55, and his sister, mother, and aunt had breast cancer. He exercises regularly and eats well, with most of his diet being low in saturated fat and cholesterol. He smokes one pack of cigarettes per week. His review of systems is unremarkable. He is very anxious and would like only minimal interventions done because of his good health. Which of the following is an age-appropriate screening test in this patient? A. Fasting lipid profile B. Non-fasting total cholesterol level C. Oral glucose tolerance test D. Prostate examination E. Sigmoidoscopy Explanation: The correct answer is B. The current recommendations for routine, age-appropriate screening are based, in some measure, on data from clinical trials. Depending on the source of the recommendations, there is considerable variability in these recommendations. One of the more agreed on recommendations is that, at least every 5 years, a random cholesterol level should be checked. A fasting lipid profile (choice A) is usually obtained only after a screening cholesterol is shown to be greater than 240 mg/dL. An oral glucose tolerance test (OGTT) (choice C) is given to pregnant women to screen for gestational diabetes. There is no current recommendation for using OGTT in routine screening practice in any age group. The incidence of prostate cancer is age-related and becomes reasonably prevalent after age 50. Therefore, prostate examinations (choice D) are recommended annually after age 50. Like prostate cancer, colon cancer is also age-related and begins to have significant incidence after the 5th decade. Sigmoidoscopy (choice E) is indicated every 3-5 years after age 50 to monitor for lesions up to the splenic flexure. Colonoscopy is necessary to survey the entire colon. 48) Two weeks after receiving an allogeneic bone marrow transplant for treatment of acute myelogenous leukemia, a 45-year-old man develops fever, intractable diarrhea, generalized rash, and non-productive cough. Chest x-ray films show bilateral interstitial infiltrates in the lung. The patient dies of overwhelming sepsis and multiorgan failure. Autopsy investigations reveal cytomegalovirus pneumonia, and extensive single cell necrosis in the intestinal epithelium and skin. This complication of bone marrow transplantation is principally mediated by which of the following cells? A. B-lymphocytes of bone marrow graft B. Leukemic cells C. Natural killer cells of recipient D. T-lymphocytes of bone marrow graft E. T-lymphocytes of recipient Explanation: The correct answer is D. Allogeneic bone marrow transplantation has become a frequent therapeutic approach to a variety of conditions, including leukemic diseases. The patient undergoing bone marrow transplantation is profoundly immunosuppressed and prone to developing opportunistic infections. The clinical picture described in this case is consistent with graft versus host disease (GVHD), in which T cells (both helper and suppressor cells) of the engrafted marrow react against the recipient's antigens, thus triggering inflammation and injury to the host tissues. The most severely affected organs include the immune system, gastrointestinal tract, liver, skin, and lungs. This complication may be acute (this case) or chronic. CMV pneumonia is a frequent fatal complication in the acute stage. The chronic stage is characterized by progressive fibrosis of affected organs. B-lymphocytes of a bone marrow graft (choice A) do not play a significant role in GVH D. Leukemic cells (choice B) may give rise to recurrence of the original disease, which must be distinguished from GVH D. The combination of skin rash and opportunistic infections strongly favor GVH D. In addition, single cell necrosis in the epithelia of skin, GI tract, and liver is highly characteristic of GVHD. Natural killer cells of the recipient (choice C) and T-lymphocytes of the recipient (choice E) play a crucial role in mediating rejection of allogeneic marrow transplants. 49) A 25-year-old woman consults a dermatologist because of scaling skin since childhood. Physical examination demonstrates fine scaling of the back and extensor surfaces of the extremities. Involved areas also show horny plugs in the orifices of hair follicles. The flexor surfaces are uninvolved. Cracking of the skin is prominent on the palms and soles. The patient also has a history of atopy. Which of the following is the most likely diagnosis? A. Epidermolytic hyperkeratosis B. Ichthyosis vulgaris C. Lamellar ichthyosis D. X-linked ichthyosis E. Xeroderma Explanation: The correct answer is B. This is ichthyosis vulgaris, which is the most frequent form of inherited ichthyosis. Ichthyosis vulgaris has autosomal dominant inheritance with a frequency of 1:300 in the general population. The condition usually begins in childhood and has the features illustrated in the question stem. Skin care should involve minimizing bathing with use of soaps only in the intertriginous areas. Bathing limited to 10-minute periods (to hydrate the stratum corneum), followed by immediate application of an emollient such as petrolatum, can help to control the scaling. In addition, 50% propylene glycol in water under occlusion by thin plastic film or bags during the night is helpful in adults, but is not usually used in children. Epidermolytic hyperkeratosis (choice A) is a rare, autosomal dominant form of ichthyosis that is present from birth and is characterized by thick, warty skin all over the body, most prominently in flexural creases. Lamellar ichthyosis (choice C) is a rare, autosomal recessive form of ichthyosis that is present from birth and causes large, coarse scale over most of the body. X-linked ichthyosis (choice D) is a relatively common form of ichthyosis that can present at birth or in childhood and usually causes large, dark scales with a predilection for the neck and trunk; the palms and soles are normal. Xeroderma (choice E) is a mild, acquired form of dry skin, sometimes with cracking or mild scaling. 50) A 32-year-old woman has had a 15-year history of heartburn. Over the past 4 months, she has had difficulty swallowing large bites of solid food. She has no difficulty with soft foods or liquids, and she has not lost weight. Which of the following is the most likely explanation for her symptoms? A. Adenocarcinoma in the lower third of the esophagus B. Barrett's esophagus in the distal esophagus C. Fibrosis and narrowing at the distal esophagus D. Schatzki ring in the distal esophagus E. Squamous carcinoma in the mid-third of the esophagus Explanation: The correct answer is C. This patient has classic symptoms of mechanical dysphagia, as she has difficulty with large solid food but not softer foods or liquids. Mechanical dysphagia frequently follows many years of heartburn and is often indicative of a peptic stricture that has developed as a result of fibrosis after a long period of chronic inflammation due to gastroesophageal reflux disease (GERD). These benign strictures can usually be dilated endoscopically. An intensive regimen of proton-pump inhibitors should then be instituted to reduce the frequency of recurrence. Although chronic acid reflux can predispose for Barrett's esophagus (choice B) and then subsequently adenocarcinoma (choice A), Barrett's esophagus is a mucosal change only that would not cause lumenal narrowing. Furthermore, adenocarcinoma would be very unusual in a patient this young. Schatzki ring (choice D) is unlikely, since it typically produces episodic mechanical dysphagia rather than the progressive mechanical dysphagia described in this question. Squamous carcinoma (choice E) in the mid-third of the esophagus can produce mechanical dysphagia. However, this patient is far younger than the usual patient with squamous carcinoma, and she has no risk factors, such as smoking, drinking, lye ingestion, or upper esophageal web (Plummer-Vinson syndrome). Obstetrics and Gynecology Questions 1) A 20-year-old female comes to the physician because she has never had a period. She has no medical problems, has never had surgery, and takes no medications. Examination shows that she is a tall female with long extremities. She has normal size breasts, although the areolas are pale. She has little axillary hair. Pelvic examination is significant for scant pubic hair and a short, blind-ended vaginal pouch. Which of the following is the most appropriate next step in the management of this patient? A. No intervention is necessary B. Bilateral gonadectomy C. Unilateral gonadectomy D. Bilateral mastectomy E. Unilateral mastectomy Explanation: The correct answer is B. This patient has the findings that are most consistent with androgen insensitivity syndrome (formerly called testicular feminization syndrome). This syndrome results from genetic defects leading to abnormal androgen receptor function. Patients with androgen insensitivity syndrome are genotypically males (46, XY) but phenotypically females-with breasts and no external male genitalia. The reason that breasts develop is that estrogens, which are expressed at puberty and which also result from peripheral conversion of androgens, act upon the breast tissues unopposed by androgens because of the androgen receptor defect. This unopposed estrogen leads to breast growth and the resultant breasts are normal sized, although they have undeveloped nipples and pale areolae. There are no internal female organs, because mullerianinhibiting substance is present during development. There are no external male organs because of the androgen receptor defect. Testicles do exist, but they are intra-abdominal. The gonads have a high rate of malignant degeneration in patients with androgen insensitivity syndrome and therefore, after puberty, they should be removed via bilateral gonadectomy. It is important to wait until after puberty so that full development can take place. To state that no intervention is necessary (choice A) is incorrect. If the gonads are not removed from a patient with androgen insensitivity syndrome there is a significant risk that the patient will develop a gonadal malignancy. To perform a unilateral gonadectomy (choice C) is incorrect. To leave one of the gonads in would still run the risk of malignant degeneration in that gonad. Once puberty has taken place, therefore, both gonads should be removed. To perform a bilateral mastectomy (choice D) or a unilateral mastectomy (choice E) would be incorrect. In patients with androgen insensitivity syndrome (testicular feminization syndrome) the primary concern is for gonadal malignancy and not breast malignancy. 2) A 54-year-old woman comes to the physician for an annual examination. She has no complaints. For the past year, she has been taking tamoxifen for the prevention of breast cancer. She was started on this drug after her physician determined her to be at high risk on the basis of her strong family history, nulliparity, and early age at menarche. She takes no other medications. Examination is within normal limits. Which of the following is this patient most likely to develop while taking tamoxifen? A. Breast cancer B. Elevated LDL cholesterol C. Endometrial changes D. Myocardial infarction E. Osteoporosis Explanation: The correct answer is C. Tamoxifen is a nonsteroidal agent with both pro- and antiestrogenic properties. It was first approved in 1977 by the U.S. Food and Drug Administration for use in postmenopausal women with advanced breast cancer. Since that time, it has been approved for many other uses related to breast cancer: as adjuvant therapy in postmenopausal women with resected node-positive disease, in postmenopausal women with metastatic breast cancer, and as adjuvant therapy in women (pre- and postmenopausal) with resected node-negative disease. Recently, much attention has been focused on its use for breast cancer prevention. There is evidence that women at high risk for the development of breast cancer may reduce their risk by taking tamoxifen. However, although tamoxifen appears to be antiestrogenic at the level of the breast, it appears to act in a proestrogenic fashion at the level of the endometrium. Many women on tamoxifen will develop endometrial changes, including polyp formation, hyperplasia, and frank invasive carcinoma. Thus, women on tamoxifen need to be followed carefully, and prompt evaluation of abnormal vaginal bleeding should be conducted. Tamoxifen is used to prevent breast cancer (choice A). Tamoxifen, like estrogen, has been shown to lower blood levels of LDL cholesterol (choice B). Women on tamoxifen appear to be at no greater risk, and may be at a lower risk, for the development of myocardial infarction (choice D). Tamoxifen, like estrogen, has been shown to increase bone density and to reduce the likelihood of development of osteoporosis (choice E). 3) A 22-year-old woman comes to the physician for an annual examination. She has been sexually active since the age of 15 and has not had regular Pap smears or examinations. She is currently sexually active with multiple partners and intermittently uses condoms. She has no medical problems and takes no medications. Her examination is unremarkable. Her Pap smear is described as satisfactory but limited by the absence of endocervical cells. It is otherwise within normal limits. Which of the following is the most appropriate next step in management? A. Repeat the Pap smear in 1 year B. Repeat the endocervical portion of the Pap test as soon as possible C. Perform colposcopy with colposcopically directed biopsies D. Perform laparoscopy with laparoscopically directed biopsies E. Perform exploratory laparotomy Explanation: The correct answer is B. A Papanicolaou smear should ideally be a sampling of the transformation zone. An adequate sample should show endocervical cells. When endocervical cells are not present, there is some question as to whether the transformation zone was fully sampled. If a woman has no risk factors for cervical dysplasia, has had three normal annual Pap smears in a row, and has a current Pap that shows no abnormality other than the absence of endocervical cells, then the Pap smear can be repeated in 1 year. This patient, however, has significant risk factors for cervical dysplasia, including early initiation of sexual activity, multiple partners, and unprotected intercourse. Therefore, this patient needs the endocervical portion of the Pap test to be repeated as soon as possible. To repeat the Pap smear in 1 year (choice A) would be incorrect management. As noted above, repeating the Pap smear in 1 year is correct only in patients who have no risk factors for cervical dysplasia, three normal annual Pap smears, and a present Pap that is normal except for the lack of endocervical cells. To perform a colposcopy with colposcopically directed biopsies (choice C) would not be correct. This patient has a normal Pap smear overall. The lack of endocervical cells makes the smear incomplete but not abnormal. To perform laparoscopy with laparoscopically directed biopsies (choice D) would not be correct. Laparoscopy does not allow evaluation of the cervix and is not indicated for abnormal or incomplete Pap smears. To perform an exploratory laparotomy (choice E) is not indicated. Again, this patient has a normal but incomplete Pap smear, and major surgery would not be correct management. 4) A 24-year-old woman comes to the physician because of right lower quadrant abdominal pain. She has had the pain off and on for the past month, but it is now increasing. She has no other symptoms and no medical problems. Examination reveals a mildly tender, right adnexal mass. Pelvic ultrasound shows a 7 cm right adnexal complex cyst. Urine hCG is negative. The patient is taken to the operating room for laparotomy and right ovarian cystectomy. Microscopically the cyst has cartilage, adipose tissue, intestinal glands, hair, and a calcification that appears to be a tooth. There is also a large amount of thyroid tissue. Which of the following is the most likely diagnosis? A. Corpus luteum B. Ectopic pregnancy C. Gastric carcinoma D. Struma ovarii E. Thyroid carcinoma Explanation: The correct answer is D. Cystic teratomas, also known as dermoid cysts, are the most common benign ovarian neoplasm. They account for approximately 1/3 of all ovarian neoplasms. They may be composed of a variety of cell types and have a mixture of tissues, as this patient has. When thyroid tissue makes up more than 50% of the teratoma, the dermoid is then referred to as struma ovarii. Approximately 3% of ovarian teratomas fall into this category and there is an association of struma ovarii with carcinoid tumor. Struma ovarii is unilateral in approximately 90% of patients and most (80%) are benign. Rarely struma ovarii is a cause of hyperthyroidism and patients with this manifestation may have symptoms of hyperthyroidism, as well as elevated levels of thyroid hormones and decreased levels of thyroid stimulating hormone (TSH). Treatment of struma ovarii is by surgical removal of the tumor. A corpus luteum (choice A) is a common cause of complex cysts in young women. However, a corpus luteum does not contain thyroid tissue, hair, teeth, and other such tissues. Ectopic pregnancy (choice B) can cause an adnexal mass, and a live ectopic may have various tissues in it when examined microscopically. However, this patient has a negative hCG, which effectively rules out ectopic pregnancy unless there is a laboratory error. Also, this cyst has tissues that are found in struma ovarii. Gastric carcinoma (choice C) can metastasize to the ovary. In fact, 5% of all ovarian malignancies are metastases from other sites. The cancers that most frequently metastasize to the ovary are colon, breast, stomach, and pancreas. When a gastric carcinoma metastasizes to the ovary, it is termed a Krukenberg tumor and has the pathognomonic "signet-ring" cells. Thyroid carcinoma (choice E) rarely metastasizes to the ovary and rarely would be found in combination with the other tissue elements that this patient's cyst has. 5) A 60-year-old woman comes to the physician for an annual examination. She has no complaints. She had her last menstrual period at age 55 and has had no vaginal bleeding since. She has no medical problems and has never had surgery. She takes no medications and has no allergies to medications. The physical examination is unremarkable. She is concerned about cancer and wants to know which type is the major cause of cancer death in women. Which of the following is the correct response? A. Breast cancer B. Cervical cancer C. Endometrial cancer D. Lung cancer E. Ovarian cancer Explanation: The correct answer is D. Breast cancer accounts for the greatest number of new cancer cases in women each year. In 1997, there were 180,200 new breast cancer cases. However, lung cancer is the major cause of cancer death in women. In 1997, lung cancer accounted for 66,000 cancer deaths in women, compared with the 43,900 female deaths caused by breast cancer. There is currently no test used to screen for lung cancer. Smoking cessation is the most effective way to reduce mortality from lung cancer. As stated above, breast cancer (choice A) accounts for the most number of cancer cases in women each year in the U.S., but not the highest number of cancer deaths. Mammography is the screening method used to detect subclinical breast cancerthe stage at which breast cancer is least likely to have spread. Cervical cancer (choice B) is the gynecologic type that causes the fewest number of cancer deaths, partly because of the success of Pap test screening. Pap testing allows preinvasive lesions to be identified and treated, which prevents the progression to invasive disease. Endometrial cancer (choice C) is the most common gynecologic cancer in women older than 45. There is no proven screening test available for endometrial cancer. Ovarian cancer (choice E) is a major cause of cancer death in women. More women die of ovarian cancer than of cervical or endometrial cancer combined. There is no proven screening test available for ovarian cancer. 6) A 19-year-old female comes to the physician because of left lower quadrant pain for 2 months. She states that she first noticed the pain 2 months ago but now it seems to be growing worse. She has had no changes in bowel or bladder function. She has no fevers or chills and no nausea, vomiting, or diarrhea. The pain is intermittent and sometimes feels like a dull pressure. Pelvic examination is significant for a left adnexal mass that is mildly tender. Urine hCG is negative. Pelvic ultrasound shows a 6 cm complex left adnexal mass with features consistent with a benign cystic teratoma (dermoid). Which of the following is the most appropriate next step in management? A. Repeat pelvic examination in 1 year B. Repeat pelvic ultrasound in 6 weeks C. Prescribe the oral contraceptive pill D. Perform hysteroscopy E. Perform laparotomy Explanation: The correct answer is E. This patient has a presentation and findings that are most consistent with a benign cystic teratoma (dermoid). Dermoids are a type of ovarian germ cell tumor. Germ cell tumors are the most common type of ovarian neoplasm in females under the age of 20 and dermoids are the most common benign ovarian neoplasm. Dermoids can range in size from small masses that are noted incidentally on ultrasound and cause no symptoms, to large cysts that cause pain and pressure, as this patient has. Laparotomy is the most appropriate next step in the management of this patient because, as adnexal masses enlarge--especially when they become greater than 5 cm--the risk of ovarian torsion increases. Thus, laparotomy with removal of the dermoid is indicated to prevent torsion. Also, this patient's mass is causing her symptoms of pain and pressure and, on that basis, should be removed. Finally, while the mass most likely is a dermoid, this is not certain without pathologic diagnosis and, therefore, the cyst should be removed and evaluated by a pathologist. At the time of surgery, close examination should be made of the other ovary because dermoids may be found bilaterally in more than 10% of cases. To repeat pelvic examination in 1 year (choice A) would not be correct management. This patient is symptomatic with a 6 cm ovarian mass that is at risk for torsion. She should, therefore, be managed surgically. To repeat pelvic ultrasound in 6 weeks choice B) is appropriate for some adnexal masses. For example, in a young woman with a small complex cyst that appears consistent with a corpus luteum, it may be most prudent to recheck an ultrasound in 6 weeks to see if the cyst has resolved. This patient, however, is symptomatic with a 6 cm cyst that appears to be a dermoid, which will not resolve spontaneously. She, therefore, requires surgery. To prescribe the oral contraceptive pill (choice C) may help to prevent future ovarian cysts but it will not resolve this cyst, which requires surgical management. To perform hysteroscopy (choice D) would not be indicated. Hysteroscopy is used to evaluate the uterine cavity and would not be used for management of an adnexal mass. 7) A 32-year-old woman, gravida 3, para 2, at 37 weeks' gestation comes to the physician for a prenatal visit. She has no current complaints. Her past medical history is significant for hepatitis C infection, which she acquired through a needle stick injury at work as a nurse. She is hepatitis B and HIV negative. She takes no medications and has no allergies to medications. Her prenatal course has been uncomplicated. She wants to know whether she can have contact with the baby or breast-feed given her hepatitis C status. Which of the following is the correct response? A. There is no evidence that breast-feeding increases HCV transmission B. There is strong evidence that breast-feeding increases HCV transmission C. Complete isolation is not needed but breast-feeding is prohibited D. The patient should be completely isolated from the baby E. Casual contact with the baby is prohibited Explanation: The correct answer is A. In the U.S., hepatitis C virus (HCV) is the most common blood-borne infection. HCV is a single-stranded RNA virus that is transmitted by blood-borne transmission or through sexual contact. With the disease being so prevalent-it affects 3.9 million Americans-it is not rare to find a pregnant patient with hepatitis C. In fact, it appears to infect as much as 0.6% of the pregnant population. Studies that have been performed so far show that the rate of infection of infants born to hepatitis C-positive, HIVnegative mothers is about 5%. Hepatitis C transmission through breast milk has not been clearly proven. Breast-fed and bottle-fed infants have a rate of infection that is approximately 4%. Therefore, the patient should be told that casual contact is permitted and that currently there is no evidence that breast-feeding increases HCV transmission to the baby. To state that there is strong evidence that breast-feeding increases HCV transmission to the baby (choice B) is incorrect. As explained above, the available studies do not demonstrate that breast-feeding increases HCV transmission. To state that complete isolation is not needed but breast-feeding is prohibited (choice C) is incorrect for the reasons detailed above. To state that the patient should be completely isolated from the baby (choice D), or that casual contact with the baby is prohibited (choice E) are both incorrect for the reasons detailed above. If patients with hepatitis C were not allowed contact with their infants, they would have to give them up, because hepatitis C is a chronic disease. Fifty percent of patients with HCV develop biochemical evidence of chronic liver disease. Hepatitis C is not like varicella-zoster (chickenpox), where a neonate can be isolated from the mother until she is no longer infectious. 8) A 25-year-old woman, gravida 2, para 1, at 22 weeks' gestation comes to the physician with complaints of burning with urination and frequent urination. Her prenatal course has been uncomplicated except for a urinary tract infection (UTI) with E. coli at 12 weeks' gestation, which was treated at that time. Physical examination is unremarkable. Urine culture demonstrates greater than 100,000 colony-forming units per milliliter of E. coli. After treating this patient for her current infection, which of the following is the most appropriate next step in management? A. No further treatment or diagnostic study is necessary B. Prophylactic antibiotics for the remainder of the pregnancy C. Intravenous antibiotics for the remainder of the pregnancy D. Intravenous pyelogram E. Abdominal CT Scan Explanation: The correct answer is B. The most common medical complication of pregnancy is infection of the urinary tract. Because of the anatomic and physiologic changes that occur during pregnancy, asymptomatic bacteriuria is more likely to become symptomatic and there is also an increased progression to pyelonephritis during pregnancy. Escherichia coli is the causative organism in approximately 80% of cases of UTI while other gram-negative organisms (e.g., Klebsiella, Enterobacter, and Proteus species) and gram-positive cocci (e.g. enterococci and group B streptococci) are responsible for the remainder. UTI in pregnancy can be treated with a 3-day course of antibiotics including trimethoprim-sulfamethoxazole, nitrofurantoin, and cephalexin. It is essential to document successful treatment with a follow-up urine culture 10 days after treatment. All women who are treated for UTI during pregnancy should have periodic rescreening for infection with urine cultures or urine dipstick for nitrites or leukocyte esterase. If a woman develops a second infection, as this patient has, she should be retreated and then placed on chronic suppression with prophylactic antibiotics. The drug of choice for such prophylaxis is nitrofurantoin once a day or sulfisoxazole once a day. To state that no further treatment or diagnostic study is necessary (choice A) is incorrect. Women with bacteriuria during pregnancy are at increased risk of developing pyelonephritis and are at higher risk for low birth weight and preterm deliveries. Therefore, this patient should be placed on prophylactic antibiotics for the remainder of the pregnancy. To place the patient on intravenous antibiotics for the remainder of the pregnancy (choice C) would not be indicated. Once a day oral therapy is usually sufficient to prevent recurrence of the infection. Intravenous pyelogram (choice D) and abdominal CT scan (choice E) result in significant fetal exposure to radiation. They should only be performed when absolutely necessary. This patient has a second UTI, which does not require that either of these studies be performed. 9) A 22-year-old woman in labor progresses to 7 cm dilation, and then has no further progress. She therefore undergoes a primary cesarean section. Examination 2 days after the section shows a temperature of 39.1 C (102.4 F), blood pressure of 110/70 mm Hg, pulse of 90/min, and respirations of 14/min. Lungs are clear to auscultation bilaterally. Her abdomen is moderately tender. The incision is clean, dry, and intact, with no evidence of erythema. Pelvic examination demonstrates uterine tenderness. Which of the following is the most appropriate pharmacotherapy? A. Ampicillin B. Ampicillin-gentamicin C. Clindamycin-gentamicin D. Clindamycin-metronidazole E. Metronidazole Explanation: The correct answer is C. This patient has signs and symptoms that are most consistent with endometritis. Postpartum endometritis is believed to result from organisms ascending from the vagina and causing a polymicrobial infection of the endometrium. Infection may also involve the myometrium and parametrial tissues. Patients with endometritis typically present with fever and chills, lower abdominal pain, a foul-smelling vaginal discharge, and malaise. Examination is significant for fever, abdominal tenderness, and uterine tenderness. Cesarean section is the major risk factor for postpartum endometritis. Patients undergoing cesarean section have a several-fold higher risk of developing endometritis compared with those having a vaginal delivery. The treatment of choice for endometritis following a cesarean section must include anaerobic coverage, along with gram-positive and gram-negative coverage. Therefore, the treatment of choice is clindamycin and gentamicin. Ampicillin (choice A) and ampicillin-gentamicin (choice B) fail to cover the anaerobic organisms that play an important role in the pathophysiology of post-cesarean section endometritis. Clindamycin-metronidazole (choice D) and metronidazole (choice E) have good activity against anaerobic organisms, but fail to cover gram-negative organisms. 10) A 64-year-old woman undergoes a total abdominal hysterectomy and bilateral salpingooophorectomy for uterine prolapse. On postoperative day 1, a complete blood count shows the following: Leukocytes.......5500/mm3 Hematocrit.......36% Platelets...........245,000/mm3 By postoperative day 2, the patient is alert and able to ambulate without difficulty. She has no complaints. She has not taken in nutrition orally but is receiving IV fluids. She is voiding without difficulty and has passed flatus. Her temperature is 37 C (98.6 F), blood pressure is 124/72 mm Hg, pulse is 86/min, and respirations are 12/min. Examination shows her abdomen to be soft, nontender, and non-distended. The incision is clean, dry, and intact. The rest of the examination is unremarkable. Which of the following is a reason for keeping this patient hospitalized for a longer period of time? A. Absent oral intake B. Evidence of infection C. Hematocrit D. Urinary tract function E. Vital signs Explanation: The correct answer is A. In the current era of medical cost containment, postoperative hospital stays tend to be significantly shorter than they were in the past. Therefore, it is more essential than ever to make sure that patients who are discharged postoperatively are, in fact, ready for discharge. Discharge criteria generally include that the patient should be alert, able to ambulate (if this was her preoperative level of function), able to tolerate adequate oral intake, have stable vital signs, and have satisfactory bowel and urinary tract function. This patient is 2 days status post total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO). Although this is a major procedure, it is not uncommon for patients to be ready for discharge at this time. However, this patient has not had adequate oral intake. Therefore, this patient should not be discharged until she shows evidence of being able to tolerate oral intake. Postoperative infection is frequently seen following TAH-BSO and it is often a reason to delay discharge in order to treat the infection with antibiotics and ensure that there is no abscess formation. This patient, however, shows no evidence of infection (choice B). Therefore, she does not need to be kept hospitalized longer on this basis. Low hematocrit (choice C) is a concern in a postoperative patient because it may make the patient symptomatic and it may be a sign of continued bleeding. This patient, however, has a hematocrit of 36%, which is well within the expected range after TAH-BSO. It is important to make sure that a postoperative patient is able to urinate normally. Many patients have difficulty with urination secondary to general anesthesia, use of the Foley catheter, or bladder denervation. This patient's urinary tract function (choice D), however, is normal. Unstable vital signs are a very good reason to keep a postoperative patient hospitalized for a longer period of time. However, this patient's vital signs (choice E) are normal. 11) A 39-year-old woman, gravida 3, para 2, at 40 weeks' gestation comes to the labor and delivery ward after a gush of fluid with regular, painful contractions every two minutes. She is found to have rupture of the membranes and to have a cervix that is 5 centimeters dilated, a fetus in vertex presentation, and a reassuring fetal heart rate tracing. She is admitted to the labor and delivery ward. Two hours later she states that she feels hot and sweaty. Temperature is 38.3 C (101 F). She has mild uterine tenderness. Her cervix is now 8 centimeters dilated and the fetal heart tracing is reassuring. Which of the following is the most appropriate management of this patient? A. Administer antibiotics to the mother after vaginal delivery B. Administer antibiotics to the mother now and allow vaginal delivery C. Perform cesarean delivery D. Perform cesarean delivery and then administer antibiotics to the mother E. Perform intra-amniotic injection of antibiotics Explanation: The correct answer is B. Chorioamnionitis is an infection that can develop at any time before and during delivery. The most common findings in patients with chorioamnionitis are a fever and uterine tenderness. An elevated fetal heart rate is also often seen. This patient has a temperature elevation and uterine tenderness, which make the diagnosis of chorioamnionitis. It is essential that antibiotics be started immediately because prompt initiation of antibiotics, once the diagnosis of chorioamnionitis is made, results in better maternal and neonatal outcomes than if therapy is delayed. It is also essential that broad-spectrum antibiotic therapy be chosen because a mixture of organisms is usually involved including aerobes and anaerobes. The most frequently used regimen is ampicillin or penicillin with gentamicin. In terms of the mode of delivery, vaginal delivery is acceptable in patients with chorioamnionitis. While it is desirable to have an expeditious delivery, chorioamnionitis is not an indication for cesarean delivery. To wait to administer antibiotics to the mother after vaginal delivery (choice A) would not be correct, as the delay would deprive both the mother and the fetus of the beneficial effects of the antibiotics. To perform cesarean delivery (choice C) or to perform cesarean delivery and then administer antibiotics to the mother (choice D) would not be indicated. As explained above, when a woman has chorioamnionitis, it is desirable to expedite delivery, but cesarean delivery should be performed only for obstetric indications. To perform intra-amniotic injection of antibiotics (choice E) would not be indicated. Intra-amniotic injection of antibiotics during labor is not a therapy used to treat chorioamnionitis during labor. 12) A 43-year-old primigravid woman at 10 weeks' gestation comes to the physician for a prenatal visit. She is feeling well except for some occasional nausea. She has had no bleeding from the vagina, abdominal pain, dysuria, frequency, or urgency. She has asthma for which she occasionally uses an inhaler. Examination is normal for a woman at 10 weeks gestation. Urine dipstick is positive for nitrites and leukocyte esterase and a urine culture shows 50,000 colony forming units per milliliter of Escherichia coli. Which of the following is the most appropriate next step in management? A. Wait to see if symptoms develop B. Resend another urine culture C. Obtain a renal ultrasound D. Treat with oral antibiotics E. Admit for intravenous antibiotics Explanation: The correct answer is D. Asymptomatic bacteriuria is present in 2 to 9% of pregnant women. An association between asymptomatic bacteriuria and preterm delivery/low birth weight has been demonstrated. Therefore, all pregnant women should be screened for asymptomatic bacteriuria early in the pregnancy, and women who demonstrate bacteriuria (defined as a clean-catch, midstream urine specimen with 25,000 to 100,000 colony forming units per milliliter of a single organism) should be treated. E. Coli is the organism that is isolated in roughly 80% of cases while other gram-negative organisms (e.g., Klebsiella, Enterobacter, and Proteus species) and gram-positive cocci (e.g. enterococci and group B streptococci) are responsible for the remainder. Antibiotic sensitivities are often available at the time of diagnosis of the asymptomatic bacteriuria, which will allow for correct choice of medications. A 3-day course of antibiotics may be given. Possible choices include trimethoprim-sulfamethoxazole, nitrofurantoin, and cephalexin. Ampicillin and amoxicillin can also be used, but up to 1/3 of E. Coli isolates will be resistant to these drugs. Therefore, these drugs should be chosen only if the organism is sensitive. 10 days after completing the medication, the patient should have a follow-up urine culture as a test-of-cure. Waiting to see if symptoms develop (choice A) is not appropriate. Bacteriuria, even without symptoms, has been shown to be associated with preterm labor and low birth weight. Asymptomatic bacteriuria should, therefore, be treated. Resending another urine culture (choice B) would not be the most appropriate next step. This patient already has demonstrable bacteriuria and treatment should be instituted. Admitting for intravenous antibiotics (choice E) or obtaining a renal ultrasound (choice C) would not be necessary. This patient has asymptomatic bacteriuria and not pyelonephritis; therefore, a 3-day course of oral antibiotics followed by a repeat culture 10 days later is all that is necessary. 13) A 29-year-old primigravid woman at 34 weeks' gestation comes to the physician for a prenatal visit. At 28 weeks, she failed her 50-g, 1-hour oral glucose-loading test. She also failed her follow-up 100-g, 3-hour oral glucose tolerance test, with a normal fasting glucose, but abnormal 1, 2, and 3-hour values. Over the past several weeks, she has maintained good control of her fasting and 2-hour postprandial glucose levels by adhering to the diet recommendations of her physician. She asks the physician what effect her type of diabetes can have on her or her fetus. Which of the following is the most appropriate response? A. Gestational diabetes is associated with fetal anomalies B. Gestational diabetes is associated with intrauterine growth restriction C. Gestational diabetes is associated with macrosomia D. Gestational diabetes is not associated with future diabetes E. Gestational diabetes with normal fasting glucose is associated with stillbirth Explanation: The correct answer is C. Gestational diabetes is defined as glucose intolerance that either has its onset or its first recognition during pregnancy. Gestational diabetes is usually diagnosed by means of oral glucose tolerance testing. Patients with gestational diabetes and normal fasting glucose levels have two major risks. The first is fetal macrosomia. Women with gestational diabetes are known to have larger babies, and this creates an increased risk of complications of delivery including shoulder dystocia and cesarean delivery. The second risk is of the eventual development of overt diabetes. Fifty percent of women with gestational diabetes will go on to develop overt diabetes within the next 20 years. Patients with gestational diabetes and abnormal fasting glucose levels do have an increased risk of stillbirth. To state that gestational diabetes is associated with fetal anomalies (choice A) is incorrect. However, patients with overt diabetes do have an increased risk of fetal anomalies. To state that gestational diabetes is associated with intrauterine growth restriction (choice B) is not correct. Gestational diabetes is associated with macrosomia. To state that gestational diabetes is not associated with future diabetes is incorrect (choice D), as explained above. To state that gestational diabetes with normal fasting glucose is associated with stillbirth (choice E) is incorrect. However, overt diabetes and gestational diabetes with abnormal fasting glucose levels (class A2) are associated with stillbirth. 14) A 36-year-old primigravid woman at 36 weeks' gestation comes to the physician for a prenatal visit. She is experiencing good fetal movement and has had no loss of fluid, bleeding from the vagina, or contractions. She has no complaints. Her past medical history is significant for mitral stenosis, which she developed after an episode of rheumatic fever as a child. She also has asthma for which she uses an albuterol inhaler daily. She has herpes outbreaks approximately once a year. At her last visit she was found to be positive for Group B Streptococcus colonization. For which of the following disease processes would this patient benefit by having a forceps-assisted vaginal delivery at the time of delivery? A. Asthma B. Group B Streptococcus (GBS) colonization C. Herpes D. Mitral stenosis E. This patient would not benefit from a forceps-assisted vaginal delivery Explanation: The correct answer is D. Mitral valve stenosis is one of the more common valvular lesions seen in pregnancy. The most common cause of mitral stenosis is rheumatic endocarditis. During normal pregnancy there is an increase in the cardiac output and an increase in preload and circulating volume. Patients with mitral stenosis have a fixed, decreased valve area, which places them at risk for the development of pulmonary hypertension and pulmonary edema. Control of arrhythmias is absolutely essential in these patients because they are at increased risk, given the left atrial enlargement that often goes along with their mitral stenosis. Labor and delivery can be a particularly dangerous time for these patients. Therefore, patients with significant mitral stenosis should be monitored invasively using a Swan-Ganz catheter. It is recommended that the second stage of labor be shortened using forceps or vacuum to prevent excess maternal Valsalva efforts and maternal tachycardia. Asthma (choice A) is not an indication for forceps-assisted vaginal delivery. In terms of mode of delivery, asthmatic patients may be managed like any other patient in the second stage of labor. Group B Streptococcus colonization (choice B) is an indication for intravenous penicillin or clindamycin (if the patient has an allergy to penicillin). These antibiotics are given to prevent GBS sepsis in the neonate. GBS colonization is not an indication for forceps-assisted vaginal delivery. Herpes (choice C) can be transmitted to the fetus at the time of delivery. Therefore, when lesions are present in the birth canal, most obstetricians recommend cesarean delivery. A history of herpes outbreaks, as this patient has, is not an indication for forceps. To state that this patient would not benefit from a forceps-assisted vaginal delivery (choice E) is incorrect. As explained above, given this patient's mitral stenosis, forcepsassisted vaginal delivery would be recommended. 15) A 32-year-old, HIV-positive, primigravid woman comes to the physician for a prenatal visit at 30 weeks. Her prenatal course has been notable for her use of zidovudine (ZDV) during the pregnancy. Her viral load has remained greater than 1000 copies per milliliter of plasma throughout the pregnancy. She has no other medical problems and has never had surgery. Examination is appropriate for a 30-week gestation. She wishes to do everything possible to prevent the transmission of HIV to her baby. Which of the following is the most appropriate next step in management? A. Offer elective cesarean section after amniocentesis to determine lung maturity B. Offer elective cesarean section at 38 weeks C. Offer elective cesarean section at 34 weeks D. Recommend forceps-assisted vaginal delivery E. Recommend vaginal delivery Explanation: The correct answer is B. A significant body of evidence has developed that transmission rates of HIV from mother to infant can be decreased through the use of medications and cesarean delivery. The Pediatric AIDS Clinical Trials Group (PACTG) 076 Zidovudine Regimen was shown to decrease the rate of transmission from 25% to 8%. This regimen consisted of ZDV being given antepartum and intrapartum to the mother and postpartum to the infant. More recent evidence is accumulating that the mode of delivery also affects transmission rates. The combination of ZDV therapy and cesarean delivery decreases the risk of transmission to approximately 2%. But, the decrease in transmission with cesarean delivery occurs regardless of whether the patient is receiving antiretroviral therapy. Thus, cesarean delivery should be offered to HIV-positive women to prevent transmission. Delivery at 38 weeks is recommended to reduce the chances that the patient will go into labor or rupture her membranes. Once these occur, the benefit of cesarean delivery is reduced. To offer elective c-section after amniocentesis to determine lung maturity (choice A) is incorrect. Amniocentesis should be avoided, if possible, in the HIV-positive woman. To offer elective c-section at 34 weeks (choice C) is incorrect. To perform a cesarean delivery at 34 weeks risks iatrogenic prematurity in the neonate. Cesarean delivery prior to the onset of labor or rupture of membranes is the preference, and this can be accomplished at 38 weeks with a lower risk of iatrogenic prematurity. To recommend forcepsassisted vaginal delivery (choice D) or vaginal delivery (choice E) is incorrect. The decision of which mode of delivery to choose ultimately belongs to the patient. But, vaginal delivery would not be recommended, as cesarean delivery has been shown to decrease transmission rates. 16) A 14-year-old girl comes to the office for a health maintenance evaluation. She is concerned that she has not yet started her menstrual cycle. Her height has increased by 3 inches since her last visit 1 year ago, and her weight is up by 10 pounds. On physical examination, the physician notes a general enlargement of her breasts and areola. Examination of her genital area reveals pubic hair that is coarse and dark and extends past the medial border of the labia. Which of the following is the most likely diagnosis? A. Constitutional delay B. Dysfunctional uterine bleeding C. Dysmenorrhea D. Primary amenorrhea E. Secondary amenorrhea Explanation: The correct answer is A. Constitutional delay is normal pubertal progression at a delayed rate or onset. The average age at menarche is 12 1/2 years, but it may be delayed until 16 or may begin as early as age 10. Dysfunctional uterine bleeding (choice B) results when the endometrium has proliferated under estrogen stimulation, and then begins to slough and causes irregular painless bleeding. This is common in younger adolescents who have not been menstruating long. Dysmenorrhea (choice C) is pain associated with menstrual cycles, and this adolescent is not menstruating yet. Primary amenorrhea (choice D) is a delay in menarche with no menstrual cycles or secondary sex characteristics by 14 years of age or no menses with secondary sex characteristics by 16 years of age. This adolescent has secondary characteristics but is not yet 16 years of age. Secondary amenorrhea (choice E) is the absence of menses for at least three cycles after regular cycles have been present. 17) A 32-year-old woman comes to the physician because of amenorrhea. She had menarche at age 13 and has had normal periods since then. However, her last menstrual period was 8 months ago. She also complains of an occasional milky nipple discharge. She has no medical problems and takes no medications. She is particularly concerned because she would like to become pregnant as soon as possible. Examination shows a whitish nipple discharge bilaterally, but the rest of the examination is unremarkable. Urine human chorionic gonadotropin (hCG) is negative. Thyroid stimulating hormone (TSH) is normal. Prolactin is elevated. Head MRI scan is unremarkable. Which of the following is the most appropriate pharmacotherapy? A. Bromocriptine B. Dicloxacillin C. Magnesium sulfate D. Oral contraceptive pill (OCP) E. Thyroxine Explanation: The correct answer is A. Hyperprolactinemia is the cause in approximately 10 to 20% of cases of amenorrhea. It is known that elevated prolactin levels alter the hypothalamic-pituitary-ovarian axis such that ovulation is suppressed and menses do not occur. This patient has amenorrhea, galactorrhea (i.e., a milky discharge from the breasts), and an elevated prolactin level. All of these findings are consistent with hyperprolactinemia, likely coming from a pituitary microadenoma. The fact that no mass is seen on the head MRI is also consistent with a pituitary microadenoma, as small microadenomas may not be visualized. The treatment of choice for this patient is with bromocriptine. Bromocriptine is a dopamine agonist that has been shown to decrease prolactin levels and bring about a return of ovulation and menses. The re-establishment of ovulation is especially important for this patient who wishes to conceive. Dicloxacillin (choice B) is often used to treat a breast infection, which can occur in a nursing mother. This patient, however, does not have findings consistent with breast infection. Rather, the nipple discharge is secondary to the patient's elevated prolactin levels. Magnesium sulfate (choice C) is used in obstetrics to prevent seizures in patients with pre-eclampsia and to stop the uterus from contracting in patients with preterm labor. It is not indicated for the treatment of hyperprolactinemia. The oral contraceptive pill (choice D) would not be appropriate as this is a young woman who wishes to become pregnant. If she did not desire pregnancy, the oral contraceptive pill would be appropriate therapy. One of the major concerns in young women with microadenomas is that decreased levels of estrogen will lead to bone loss and the eventual development of osteoporosis. The oral contraceptive pill, by providing daily estrogen and progestin, will help to prevent bone loss. Thyroxine (choice E) is used in patients with hypothyroidism. This patient has a normal TSH and no evidence of hypothyroidism, and would, therefore, not need thyroxine. 18) A 32-year-old woman, gravida 3, para 2, at 14 weeks' gestation comes to the physician for a prenatal visit. She has some mild nausea, but otherwise no complaints. She has no significant medical problems and has never had surgery. She takes no medications and has no known drug allergies. She is concerned for two reasons. First, the "flu season" is coming, and she seems to get sick every year. Second, a child at her son's daycare center recently broke out with welts and was sent home. Which of the following vaccinations should this patient most likely be given? A. Influenza B. Measles C. Mumps D. Rubella E. Varicella Explanation: The correct answer is A. Influenza pneumonia during pregnancy can be a severe illness. Normally "the flu" is a self-limited illness that lasts 3-4 days and produces few major sequelae. However, patients with influenza pneumonia during pregnancy can develop high fever, malaise, cough, and headache. In some cases a bacterial superinfection will occur (often with Staphylococcus aureus), which can lead to peribronchial infiltrates, cavitation, and a pleural effusion. Current recommendations are that pregnant women who will be in the second or third trimester during the flu epidemic season should be given the influenza vaccination. Also, pregnant women with significant medical problems should be given the vaccination before the influenza season, regardless of trimester. The measles (choice B), mumps (choice C), and rubella (choice D) vaccines are live attenuated vaccines. Their use during pregnancy is contraindicated. The varicella (choice E) vaccination is used to prevent chickenpox. It is a live-virus vaccine; therefore, its use during pregnancy is also contraindicated. 19) A 35-year-old woman, gravida 3, para 2, at 39 weeks' gestation, comes to the labor and delivery ward with contractions. Past obstetric history is significant for two normal spontaneous vaginal deliveries at term. Examination shows the cervix to be 4 centimeters dilated and 50% effaced. The patient is contracting every 4 minutes. Over the next 2 hours the patient progresses to 5 centimeters dilation. An epidural is placed. Artificial rupture of membranes is performed, demonstrating copious clear fluid. 2 hours later the patient is still at 5 centimeters dilation and the contractions have spaced out to every 10 minutes. Which of the following is the most appropriate next step in management? A. Expectant management B. Intravenous oxytocin C. Cesarean delivery D. Forceps-assisted vaginal delivery E. Vacuum-assisted vaginal delivery Explanation: The correct answer is B. This patient is demonstrating an abnormal labor pattern with arrest of dilation. The normal pattern of labor is one of continued progression. Whether a patient is in the latent phase or the active phase, there should be a gradual progression with an increase in the amount of cervical dilation. This patient, however, has stopped dilating and has had her contractions space out considerably. An arrest of labor like this can be caused by several reasons: contractions may not be adequate; the fetus may have a malpresentation; or the maternal pelvis may not be able to accommodate the fetus. In this case it appears that the contractions are not adequate, so at this point, it would be reasonable to give intravenous oxytocin in an effort to reestablish a contraction pattern that can effect a vaginal delivery. Expectant management (choice A) would not be the most appropriate next step. The patient is clearly demonstrating a dysfunctional labor pattern at this point. To "watch and wait" in the face of insufficient uterine contractions is to place the patient at risk of an even longer labor and the correspondingly higher risk of infection. Cesarean delivery (choice C) would not be the most appropriate next step in management. This patient may very well need a cesarean delivery if she is truly unable to progress in labor. However, it is worth attempting a vaginal delivery in this multiparous patient who has already had two vaginal deliveries. To attempt a forceps-assisted vaginal delivery (choice D) or a vacuum-assisted vaginal delivery (choice E) would be contraindicated. This patient's cervix is only 5 centimeters dilated. Forceps and vacuum cannot be attempted in patients unless they are fully dilated and at +2 station or lower. 20) A 27-year-old woman, gravida 2, para 1, at 20 weeks' gestation comes to the physician for a prenatal visit. She has no complaints. Her obstetric history is significant for a primary low transverse cesarean delivery because of a non-reassuring fetal tracing 3 years ago. She has no medical problems. She takes prenatal vitamins and has no known drug allergies. She is debating whether to have an elective repeat cesarean delivery or to attempt a vaginal birth after cesarean (VBAC). She wants to know her chances for a successful VBA C. Which of the following most accurately represents the patient's likelihood of having a successful vaginal delivery? A. 0% B. 25% C. 50% D. 70% E. 100% Explanation: The correct answer is D. The cesarean delivery rate in the U.S. is roughly 25%. Much effort has been put into trying to lower this rate. One third of all cesarean births are a result of elective repeat cesarean delivery. Therefore, much attention has been focused on vaginal birth after cesarean (VBAC). A few decades ago, there was an obstetric dictum that "once a cesarean, always a cesarean." This is no longer the case. Some women are allowed to attempt vaginal birth after a prior cesarean delivery. And, in fact, the attempt is often successful. Estimates are that approximately 70% of all women that attempt VBAC will be successful. This patient has had one prior cesarean delivery, and it was through a low transverse uterine hysterotomy. Right now, she has no contraindications to VBA C. Therefore, a VBAC attempt may be tried. If the success rate of VBAC were 0% (choice A) or even 25% (choice B), the topic would be a non-issue. The fact that the success rate of VBAC is so high is what makes the choice between repeat cesarean and VBAC more complicated. 50% (choice C) is approximately the success rate in women who attempt VBAC who had a prior cesarean for dystocia. Women with a prior cesarean delivery for dystocia have a VBAC success rate of approximately 50% to 70%. Although this rate is still good, it is consistently lower than the rate for women with non-recurring indications, such as a non-reassuring fetal tracing. Attempts at vaginal delivery are not 100% (choice E) successful even in women who have never had a cesarean delivery. In fact, the success rate for vaginal delivery in women who have not undergone previous cesarean delivery is about 70%--the same success rate as women attempting VBAC with a non-recurring indication. 21) A 62-year-old woman comes to the physician because of bleeding from the vagina. She states that her last menstrual period came 11 years ago and that she has had no bleeding since that time. She has hypertension and type 2 diabetes mellitus. Examination shows a mildly obese woman in no apparent distress. Pelvic examination is unremarkable. An endometrial biopsy is performed that shows grade I endometrial adenocarcinoma. Which of the following is the most appropriate next step in management? A. Chemotherapy B. Cone biopsy C. Dilation and curettage D. Hysteroscopy E. Hysterectomy Explanation: The correct answer is E. Endometrial cancer is the most common gynecologic cancer in women ages 45 and older. The main factor that predisposes a woman to the development of endometrial cancer is exposure to unopposed estrogen, whether endogenous or exogenous. Endogenous factors include, early menarche, late menopause, chronic anovulation, estrogen-secreting ovarian tumors, and obesity. Exogenous factors include the ingestion of unopposed estrogen (as with estrogen replacement therapy). Hypertension and diabetes have also been associated with endometrial cancer, though this relationship may likely be related to obesity. This patient has endometrial cancer on the basis of her endometrial biopsy result. The correct management for this patient is with total abdominal hysterectomy, bilateral adnexectomy, and possible lymph node sampling. Chemotherapy (choice A) would not be the most appropriate next step in management. If the patient were not a surgical candidate, because of her obesity, for example, then radiation therapy could be administered. Cone biopsy (choice B) is used in the diagnosis and management of cervical cancer. It would not be used for this patient with an endometrial biopsy showing endometrial cancer. Dilation and curettage (choice C) or hysteroscopy (choice D) would not be the most appropriate next step in management. The diagnosis of endometrial cancer has been made on the basis of the endometrial biopsy. Therefore, the most appropriate next step in management is to treat the patient through hysterectomy or, if hysterectomy is not possible because of obesity or medical disease, radiation. 22) A 35-year-old woman, gravida 4, para 3, at 38 weeks' gestation comes to the labor and delivery ward after a gush of clear fluid from the vagina. After the gush, she has had increasing contractions. Sterile speculum examination shows a pool of clear fluid in the vagina that is nitrazine positive. Cervical examination shows that the patient is 5 cm dilated, with the fetal face presenting in a mentum anterior position. External uterine monitoring shows that the patient is contracting every 2 minutes, and external fetal monitoring shows that the fetal heart rate is in the 140s and reactive. Which of the following is the most appropriate next step in management? A. Expectant management B. Oxytocin augmentation C. Forceps delivery D. Vacuum delivery E. Cesarean section Explanation: The correct answer is A. This patient has a face presentation. Typically, a fetus in labor is as an occiput presentation. In certain rare instances (roughly 1 in 500 deliveries), however, the fetus is in a face presentation. Causes of face presentation include an anencephalic fetus, pelvic contraction, and high parity. A vaginal delivery is possible when the fetus is in a mentum anterior position (i.e., the fetal chin is oriented toward the maternal pubic symphysis.) The fetus can flex its head, thereby allowing delivery. This patient is in active labor with contractions every 2 minutes and 5 cm of cervical dilation. The fetus is in mentum anterior position. Therefore, expectant management is the most appropriate next step. Oxytocin augmentation (choice B) is not indicated. This patient is in active labor on her own and therefore does not need oxytocin to augment it. Forceps delivery (choice C) would not be indicated. Forceps are not used prior to full dilation of the cervix. Also, with a non-vertex presentation, forceps would be contraindicated. Vacuum delivery (choice D) is not indicated. As with forceps, vacuum delivery is not performed prior to full dilation of the cervix. With a face presentation, vacuum delivery would be contraindicated. Cesarean section (choice E) would not be indicated. Vaginal delivery is possible with face presentation. 23) A 36-year-old woman, gravida 3, para 2, at 33 weeks' gestation comes to the physician for a prenatal visit. She has some fatigue but no other complaints. Her current pregnancy has been complicated by a Group B Streptococcus urine infection at 16 weeks. Her past obstetric history is significant for a primary, classic cesarean delivery 5 years ago for a non-reassuring fetal tracing. Two years ago, she had a repeat cesarean delivery. Past surgical history is significant for an appendectomy 10 years ago. Which of the following is the major contraindication to a vaginal birth after cesarean (VBAC) in this patient? A. Classic uterine scar B. Group B Streptococcus urine infection C. Previous appendectomy D. Prior cesarean delivery for non-reassuring fetal tracing E. Two prior cesarean deliveries Explanation: The correct answer is A. The presence of a classic uterine scar is an absolute contraindication to a vaginal birth after cesarean (VBAC). A classic uterine scar is a vertical incision into the uterus that extends from the lower uterine segment up into the active myometrial portion toward the fundus of the uterus. Patients with a previous classic cesarean delivery have roughly a 10% risk of uterine rupture. Therefore, these patients should have an elective repeat cesarean delivery when the fetus is mature. Group B Streptococcus (GBS) urine infection (choice B) is not a contraindication to vaginal delivery. Patients with GBS urine infection are allowed to have a vaginal delivery but must receive IV antibiotics during labor to prevent GBS invasive disease of the newborn. Previous appendectomy (choice C), or other intra-abdominal surgery, is not a contraindication to vaginal delivery. Prior cesarean delivery for non-reassuring fetal tracing (choice D) is not a contraindication to vaginal delivery. Patients with this indication for primary cesarean delivery have approximately a 70% rate of success with VBA C. Women with two prior cesarean deliveries (choice E) may undergo a trial of labor (VBAC). This is the case if the two prior cesarean deliveries were low-transverse hysterotomies. However, the patient should be cautioned that the risk of rupture does increase with the number of previous cesarean deliveries. 24) A patient who has been taking tamoxifen to prevent breast cancer for the past 6 months presents complaining of irregular vaginal bleeding. An endometrial biopsy is performed that demonstrates atypical hyperplasia. Which of the following is the most appropriate next step in management? A. Discontinue the tamoxifen B. Increase the tamoxifen dose C. Repeat the endometrial biopsy D. Schedule a pelvic ultrasound E. Switch the patient to estrogen Explanation: The correct answer is A. Tamoxifen is known to act as an estrogen agonist at the level of the endometrium. Numerous studies have shown that women on tamoxifen develop changes in the endometrium including polyps, hyperplasia, and cancer. Hyperplasia runs a continuum from cystic glandular hyperplasia to atypical hyperplasia. Patients with atypical hyperplasia are at significantly increased risk for the eventual development of endometrial cancer. Thus, in a patient who is taking tamoxifen for breast cancer prevention and develops atypical endometrial hyperplasia, the tamoxifen should be stopped. If there is a need to continue the tamoxifen, then hysterectomy should be considered. To increase the tamoxifen dose (choice B) would be contraindicated. This patient has atypical hyperplasia, likely caused by the tamoxifen. Increasing the dose will only exacerbate the problem. To repeat the endometrial biopsy (choice C) would not be the most appropriate next step in management. The next step should be to discontinue the tamoxifen. The patient should then have a repeat endometrial biopsy in several months to ensure that there is no progression of the hyperplasia. To schedule a pelvic ultrasound (choice D) would not be the most appropriate next step in management. This patient has known atypical hyperplasia; thus, the tamoxifen should be stopped first. Pelvic ultrasound can be used to evaluate the endometrium; however, in this case, regardless of what the ultrasound shows, the pathology reveals atypical hyperplasia. To switch the patient to estrogen (choice E) would be absolutely contraindicated. Unopposed estrogen would worsen the endometrial changes. 25) A 18-year-old woman comes to the physician for an annual examination. She has no complaints. She has been sexually active for the past 2 years. She uses the oral contraceptive pill for contraception. She has depression for which she takes fluoxetine. She takes no other medications and has no allergies to medications. Her family history is negative for cancer and cardiac disease. Examination is unremarkable. Which of the following screening tests should this patient most likely have? A. Colonoscopy B. Mammogram C. Pap smear D. Pelvic ultrasound E. Sigmoidoscopy Explanation: The correct answer is C. The Pap smear has been shown to be a highly effective screening test for cervical cancer. The Pap test was introduced in the U.S. roughly 50 years ago, and since that time the mortality rate from cervical cancer has decreased by 70%. The main drawbacks to Pap testing are that many women do not get a regular (or any) Pap smear and that the test has a high false-negative rate. That is, a given Pap smear may be read as negative when, in fact, the woman has abnormal cytology. The reason for this false negative rate is that there may be errors in sampling, preparation, screening, and interpretation, such that abnormal cells are missed. Yet, if a woman has a yearly Pap test, it is assumed that these abnormal cells will eventually be discovered. Because the natural history of most cervical cancers is believed to be a gradual progression over many years, then annual screening (even with a high false-negative rate) will lead to lesions eventually being discovered and appropriate treatment being given. Women should have an annual Pap test when they begin having sexual intercourse or at the age of 18, whichever comes first. Colonoscopy (choice A) is used to screen for colon cancer in some at-risk patients. This patient is not high-risk and therefore, at age 18, does not need to have a colonoscopy. The mammogram (choice B) is used to screen for breast cancer. Women should begin having regular mammograms at age 40. Pelvic ultrasound (choice D) is not used as a screening test. Certain studies have been done to evaluate whether pelvic ultrasound is a good screening test for ovarian cancer. On the basis of these studies, however, pelvic ultrasound is not recommended for this purpose. Sigmoidoscopy (choice E) is also used to screen for colon cancer. As explained above, this patient is not high-risk and therefore does not need a sigmoidoscopy. 26) A 19-year-old primigravid woman at 42 weeks' gestation comes the labor and delivery ward for induction of labor. Her prenatal course was uncomplicated. Examination shows her cervix to be long, thick, closed, and posterior. The fetal heart rate is in the 140s and reactive. The fetus is vertex on ultrasound. Prostaglandin (PGE2) gel is placed intravaginally. One hour later, the patient begins having contractions lasting longer than 2 minutes. The fetal heart rate falls to the 70s. Which of the following is the most appropriate next step in management? A. Administer general anesthesia B. Administer terbutaline C. Perform amnioinfusion D. Start oxytocin E. Perform cesarean delivery Explanation: The correct answer is B. Once patients reach 42 completed weeks of gestation, many physicians will induce labor for post-term pregnancy. This is done to avoid the uncommon but catastrophic outcome of fetal demise and the higher rates of placental insufficiency that develop as patients get further post-term. Prostaglandin (PGE2) gel is an effective agent to use for labor induction. It has been shown to improve the Bishop's score, to shorten the length of labor and delivery, to decrease the amount of oxytocin needed, and to decrease the cesarean delivery rate. The main complication from its use is uterine hyperstimulation. This hyperstimulation is defined as an increased frequency of contractions (greater than 5 every 10 minutes) or an increased length of each contraction (greater than 2 minutes) with evidence of fetal distress. When this hyperstimulation occurs, the patient may be treated with IV or subcutaneous terbutaline. This medication usually has a rapid onset of action in resolving hyperstimulation. IV magnesium sulfate can also be used. To administer general anesthesia (choice A) would be incorrect. There are occasions in which the fetal heart rate tracing rapidly deteriorates and emergency cesarean delivery is needed. On these occasions, it may be necessary to administer general anesthesia to the mother during the cesarean. In this case, however, more conservative measures should be tried prior to cesarean delivery. To perform amnioinfusion (choice C) would be incorrect. Amnioinfusion can be used when a patient has ruptured membranes and decelerations of the fetal heart rate or thickened meconium. It is not used with intact membranes. To start oxytocin (choice D) would be contraindicated. Oxytocin is known to cause uterine hyperstimulation, as is prostaglandin (PGE2) gel. Oxytocin would not be given to a patient in the midst of uterine hyperstimulation. To perform cesarean delivery (choice E) would be incorrect for the reasons detailed above. 27) A 25-year-old primigravid woman comes to the physician for her first prenatal visit. Her last menstrual period was 7 weeks ago. She has had some nausea and vomiting but otherwise has no complaints. Past medical and surgical history are unremarkable. Her family history is significant for cystic fibrosis with an affected aunt. Her husband has an affected cousin. Physical examination is unremarkable. Given her family history, she is concerned about the risks of having a child with cystic fibrosis. She inquires about cystic fibrosis screening. Which of the following is the appropriate response? A. Screening is available B. Screening is inappropriate in her case C. Screening is mandatory D. Screening is not available E. Screening is unnecessary: she has a 1 in 4 chance of having an affected child Explanation: The correct answer is A. Cystic fibrosis (CF) is an autosomal-recessive disease that is common in North American Caucasians of European ancestry. In this population, the frequency of the disease is 1 in 2500 live births. The carrier rate is approximately 1 in 25 individuals. The outcome of patients with CF is highly variable. Some will die in infancy from complications of meconium ileus, whereas others will live beyond the age of 50. The usual clinic manifestations include pulmonary disease with bronchiectasis, pancreatic insufficiency, and failure to thrive. The gene for the disease is known. However, there are more than 500 mutations that can cause C F. The most common mutation, which causes 75% of cases in Caucasians, is referred to as deltaF508. The CF gene has been cloned, and it is possible to perform screening on couples. Genetic techniques can also be used to determine whether the fetus has the relevant mutations. In this patient, with her and her husband's family histories, screening would be available and appropriate. To state that screening is inappropriate in her case (choice B) is incorrect. This patient has relatives with CF and so does her husband. She is concerned about the possibility of having a child with this disease. Screening is available and appropriate in her case. To state that screening is mandatory (choice C) is inappropriate. Whether to undergo screening for a genetic disease is a very personal choice. This patient may not want to know whether she is a carrier or whether her fetus is affected. Many patients with genetic diseases or with family histories of genetic disease feel this way, and screening is certainly not mandatory. To state that screening is not available (choice D) is incorrect. As stated above, CF screening is available. To state that screening is unnecessary because she has a 1 in 4 chance of having an affected child (choice E) is incorrect. If she and her husband were both carriers with the same mutation, the risk would be 1 in 4. However, we do not know this. Although they both have positive family histories, neither may be a carrier. 28) A 52-year-old woman comes to the physician because of hot flashes. Her last menstrual period was 1 year ago. Over the past year, she has noted a persistence of her hot flashes, which come several times each day and are associated with a feeling of heat and flushing. They also awaken her at night and interfere with her sleep. She has no medical problems, takes no medications, and has no known drug allergies. She has a family history of cardiovascular disease and she does not smoke. Physical examination is unremarkable. She is started on estrogen and medroxyprogesterone acetate (Provera). The addition of a progestin is most likely to decrease her risk of which of the following? A. Breast cancer B. Breast pain C. Endometrial cancer D. Mood changes E. Weight gain Explanation: The correct answer is C. Unopposed estrogen is known to cause endometrial hyperplasia and cancer. Estrogen has direct effects on the growth and development of the endometrium. Studies have shown that the addition of a progestin can protect a woman from the development of endometrial hyperplasia and that the addition of a progestin to women with endometrial hyperplasia can lead the endometrium to revert to normal. Thus, any woman with a uterus who is on estrogen therapy should also be on a progestin to protect her endometrium. This is usually done by placing the patient on daily estrogen and progesterone or on cyclic progesterone. Progestins do not protect against the development of breast cancer (choice A). In fact, there is evidence that progestins may stimulate the growth of breast tumors. Breast pain (choice B) is often a result of progestin therapy. Mood changes (choice D) and weight gain (choice E) are well-known side effects of progestins. 29) A 21-year-old woman comes to the physician because of "bumps" on her vulva that she has just recently noticed. These bumps do not cause her symptoms, but she wants to know what they are and wants them removed. She has no medical problems, takes no medications, and has no allergies to medications. She smokes one-half pack of cigarettes per day. She is sexually active with 3 partners. Examination shows 3 cauliflower-like lesions on the right labia majora. Which of the following is the most appropriate next step in management? A. Acyclovir B. Penicillin C. Cone biopsy D. Cryotherapy E. Vulvectomy Explanation: The correct answer is D. This patient has findings that are most consistent with condyloma acuminata, or genital warts. Condyloma acuminata is caused by the human papillomavirus. This virus, of which there are many different subtypes, infects epidermal cells and can cause warty growths. When the virus affects skin cells on the hands, the result is the common warts that are often seen in children. When the virus affects cells on the perineum, the result is condyloma acuminata. Diagnosis is made on the basis of the classic, verrucous (cauliflower-like) appearance of the lesions. Treatment is with local destruction. This local destruction can be achieved in a variety of ways including with cryotherapy (i.e. freezing of the skin), laser therapy, trichloroacetic acid (i.e. chemical destruction of the skin), or imiquimod. However, while the lesions themselves are often successfully treated with these locally destructive agents, the virus is not usually completely eradicated and recurrences of the lesions may occur. Acyclovir (choice A) is used to treat herpes viruses. Condyloma acuminata is caused by the human papillomavirus and, therefore, acyclovir is not used. Penicillin (choice B) is an antibiotic effective against bacteria, and not the human papillomavirus. Cone biopsy (choice C) is performed on the cervix when a patient has high-grade dysplasia or cancer. While there is an association between human papillomavirus infection and cervical dysplasia, cone biopsy would not be indicated for a patient on the basis of the presence of condyloma. Vulvectomy (choice E) is performed on patients for vulvar dysplasia or cancer. It is not indicated for patients with condyloma. 30) A 29-year-old patient comes to the physician for an annual examination. She has normal menstrual periods every 30 days. She was 15 years old when she first began having intercourse. She uses condoms for contraception. Her past medical history is significant for multiple sclerosis. This condition has required her to use a wheelchair for the past 4 years, which makes pelvic examination somewhat difficult for her. She smokes one pack of cigarettes per day. Given her difficulty with the pelvic examination, she inquires as to how often she needs to have a Pap smear performed. Which of the following is the correct Register to View AnswerA Pap smear should be performed every year B. A Pap smear should be performed every 3 years C. A Pap smear should be performed every 5 years D. A Pap smear should be performed only if there are symptoms E. A Pap smear is not necessary Explanation: The correct answer is A. It is essential that physicians who treat women with disabilities do not give them substandard care because of their disability. This woman has two risk factors that place her at greater risk of having cervical dysplasia: early age at first intercourse and smoking. Both of these characteristics have been shown to be associated with patients who develop cervical dysplasia. Current recommendations are that women begin having annual Pap smears at the onset of intercourse or age 18, whichever comes first. Some physicians believe that in certain low-risk women with three annual normal Pap smears, the interval of screening may be increased to every 3 years. Others argue that annual Pap smears should be performed in all women, regardless of risk status. For this patient, given her risk factors, annual Pap smears should be performed. The fact that pelvic examination is difficult for her because of her multiple sclerosis needs to be addressed by taking appropriate measures so that the examination can be made easier for her. She should not receive inadequate screening for cervical cancer because she has a disability. To state that a Pap smear should be performed every 3 years (choice B) is incorrect. This patient, with her early onset of first intercourse and current cigarette smoking, has risk factors for cervical dysplasia and needs annual screening. To state that a Pap smear should be performed every 5 years (choice C) is not correct. Because of the false-negative rate of the Pap smear, screening every 5 years would risk missing many cases of dysplasia or cancer. To state that a Pap smear should be performed only if there are symptoms (choice D) is incorrect. Progressing cervical dysplasia is typically an asymptomatic process, and awaiting symptoms prior to performing the Pap smear would miss most cases. To state that a Pap smear is not necessary (choice E) is not correct. All sexually active women or women older than 18 need to have screening with the Pap smear. Women with disabilities should not receive substandard care because of their disability. 31) A 33-year-old woman comes to the physician for her first prenatal visit. Her last menstrual period was 7 weeks ago. She has had no bleeding or abdominal pain. She has no medical problems and takes no medications. She has no family history of congenital anomalies. Her husband is 55 years old. He is in good health and also has no family history of birth defects. The patient is concerned that her husband's age may place their fetus at increased risk of a chromosomal anomaly. She wishes to know the paternal age above which amniocentesis or chorionic villus sampling should be considered. Which of the following is the correct response? A. Above age 30 B. Above age 35 C. Above age 40 D. Above age 45 E. There is no age cutoff for paternal risk Explanation: The correct answer is E. Increasing maternal age leads to an increased risk of chromosomal anomalies in the fetus. These anomalies include trisomy 13, 18, and 21. Advanced maternal age also leads to increased rates of the sex chromosome aneuploidies 47 XXY and 47 XXX. Because of this relationship between advanced maternal age and chromosomal anomalies, many experts suggest amniocentesis or chorionic villus sampling in women who will be 35 years of age or older at the time of their delivery. Paternal age has not been shown to be related to chromosomal anomalies. There is evidence that advanced paternal age is linked to an increased risk of autosomal dominant mutations, which lead to diseases such as neurofibromatosis, achondroplasia, Apert syndrome, and Marfan syndrome. Increasing paternal age also may be associated with X chromosome mutations that are transmitted through carrier daughters to affected grandsons. However, these risks are exceedingly small, and it is currently not possible to screen prenatally for all the autosomal dominant or X-linked diseases that advanced paternal age may be associated with. Therefore, unlike with women, in whom the age of 35 is usually given as the cutoff for chromosomal evaluation of the fetus, there is no age cutoff for paternal risk. To state that amniocentesis or chorionic villus sampling should be considered for a paternal age above age 30 (choice A), 35 (choice B), 40 (choice C), or 45 (choice D) is incorrect. As explained above, advanced paternal age is associated with autosomal dominant mutations and Xlinked mutations. These mutations are very rare, and we are currently unable to screen for all of these mutations prenatally. 32) A 14-year-old girl comes to the physician for an annual examination. She has no complaints. She became sexually active during the past year and uses condoms occasionally for contraception. She has asthma, for which she occasionally takes an albuterol inhaler. She had an appendectomy at age 9. Physical examination is unremarkable including a normal pelvic examination. When should this patient begin having Pap testing? A. Immediately B. Age 16 C. Age 18 D. Age 20 E. Age 21 Explanation: The correct answer is A. Pap testing is used to screen women for cervical cancer. The development of cervical cancer is believed to be a gradual process in which the cervical cells gradually progress from dysplasia to carcinoma in situ to invasive cancer. Cervical cancer is certainly linked to sexual activity, as the human papillomavirus, which is transmitted through sexual contact, is believed to play a causative role. Sexual intercourse also allows exposure to other infectious diseases and carcinogens that may play a role in the process. Therefore, a patient should begin having Pap testing once she begins to engage in sexual intercourse. If a patient has not had sexual intercourse by the age of 18, Pap testing should begin then. Pap testing should be performed yearly, primarily because a single Pap test has a high false-negative rate (i.e., the Pap test has a low sensitivity). The sensitivity of Pap testing is often quoted as 80%. Therefore, 2 of 10 women with abnormal cervical cells will be missed with Pap testing. However, if the examination is repeated every year, as it should be, then the likelihood of missing the lesion over time is much lower. To start at age 16 (choice B), 18 (choice C), 20 (choice D), or 21 (choice E) is too late for this patient. Although the progression to cervical cancer is believed to be a gradual one, there are more aggressive forms that are more rapidly progressive. Also, if one waits until age 16, 18, 20, or 21, and the patient misses that next appointment or has a false negative on the Pap test, then the disease will be given even further time to progress. Also, to wait until later to do Pap testing with this patient is to miss an opportunity for cervical cancer screening. The patient may not return for follow-up. Therefore, screening should be performed now. 33) A 25-year-old nulliparous woman at 35 weeks' gestation comes to the labor and delivery ward complaining of contractions, a headache, and flashes of light in front of her eyes. Her pregnancy has been uncomplicated except for an episode of first trimester bleeding that completely resolved. She has no medical problems. Her temperature is 37 C (98.6 F), blood pressure is 160/110 mm Hg, pulse is 88/minute, and respirations are 12/minute. Examination shows that her cervix is 2 centimeters dilated and 75% effaced, and that she is contracting every 2 minutes. The fetal heart tracing is in the 140s and reactive. Urinalysis shows 3+ proteinuria. Laboratory values are as follows: leukocytes 9,400/mm3, hematocrit 35%, platelets 101,000/mm3. Aspartate aminotransferase (AST) is 200 U/L, and ALT 300 U/L. Which of the following is the most appropriate next step in management? A. Administer oxytocin B. Discharge the patient C. Encourage ambulation D. Start magnesium sulfate E. Start terbutaline Explanation: The correct answer is D. This patient has severe preeclampsia. Preeclampsia is diagnosed on the basis of hypertension, edema, and proteinuria. Severe preeclampsia may be diagnosed when the patient has one of the following: a headache that does not respond to analgesics, visual changes, seizure, very elevated blood pressures, pulmonary edema, elevated liver function tests, severe proteinuria, oliguria, an elevated creatinine, thrombocytopenia, hemolysis, intrauterine growth restriction, or oligohydramnios. The management of severe preeclampsia after 32 weeks is with delivery. Prior to 32 weeks, consideration may be given to expectant management of the patient depending on the clinical circumstances. This patient is at 35 weeks' with headache, visual changes, elevated blood pressures, thrombocytopenia, and elevated liver function tests. She, therefore, needs to be delivered. She appears to already be in labor as she is contracting every two minutes and her cervix is dilated and effaced. At this point, magnesium sulfate should be started. Magnesium sulfate has consistently been demonstrated to be the most effective medication for seizure prophylaxis in women with preeclampsia. To administer oxytocin (choice A) would not be necessary for this patient. She appears to already be in labor with contractions every two minutes. To discharge the patient (choice B) would absolutely be incorrect. Severe preeclamptics need to be delivered or, at the very least, admitted to the hospital. There is no role for discharging a patient home in the management of severe preeclampsia. To encourage ambulation (choice C) would also be incorrect. Severe preeclamptics should be kept on bed rest. To start terbutaline (choice E) would not be appropriate. Terbutaline is used in obstetrics as a tocolytic agent to treat preterm labor. In this patient, contractions and labor are desirable and no attempt should be made to stop them, as she requires delivery. 34) A 33-year-old primigravid woman at 18 weeks' gestation comes to the physician for a prenatal visit. Her prenatal course has been uncomplicated thus far. She has no complaints. She has had no loss of fluid, bleeding, or contractions. She has hypothyroidism, for which she takes thyroid hormone replacement. The patient states that a friend of hers recently had a preterm delivery. The patient is quite concerned about preterm delivery and wants to know whether home uterine activity monitoring (HUAM) is recommended. Which of the following is the most appropriate response? A. HUAM has been proven to cause preterm birth B. HUAM has been proven to prevent preterm birth C. HUAM has not been proven to prevent preterm birth D. HUAM should be started immediately E. HUAM should be started at 35 weeks Explanation: The correct answer is C. Home uterine activity monitoring (HUAM) became a controversial area of obstetrics during the 1990s. Of all liveborn neonates, approximately 7% will be less than 2500 g (low birth weight). Approximately 1% will be less than 1500 g (very low birth weight). Most of the infant mortality rate comes from these low birth weight and very low birth weight neonates. Preterm labor and delivery is the cause of many of these cases. Thus, strategies to prevent preterm delivery are very much sought after. One such strategy is HUAM. With this technique, women are monitored at home with a tocodynamometer (a way to measure uterine contractions). The theory is that this home monitoring will allow for preterm labor to be recognized and treated in its earliest stages, which may help to prevent preterm births. In practice, however, this has not been proven to be the case. Numerous studies have been performed, and HUAM has not been proven to prevent preterm birth. A possible benefit of HUAM may be the early recognition of preterm labor, which would allow for the administration of corticosteroids to bring about fetal pulmonary maturity, even if a preterm delivery could not be prevented. This question has not been fully answered. At present, therefore, HUAM has not been proven to prevent preterm birth, and its use is not recommended. To state that HUAM has been proven to cause preterm birth (choice A) is not correct. HUAM is a noninvasive technique for monitoring uterine activity, and it is used to try to prevent preterm birth. Side effects and complications are rare. To state that HUAM has been proven to prevent preterm birth (choice B) is incorrect. This is the central area of controversy for this technique, namely that it has not been proven to prevent preterm birth. To state that HUAM should be started immediately (choice D), or that HUAM should be started at 35 weeks (choice E) is incorrect. As explained above, HUAM has not been proven to prevent preterm delivery; therefore, its use is not currently recommended. 35) A 32-year-old nulliparous woman at 38 weeks' gestation comes to the labor and delivery ward with regular painful contractions after a gush of fluid two hours ago. Her temperature is 98.6 F (37 C). She is found to have gross rupture of membranes and to have a cervix that is 6 centimeters dilated. The fetus is in breech position. The patient is then brought to the operating room for cesarean delivery. Which of the following represents the correct procedure for antibiotic administration? A. Administer intravenous antibiotics 30 minutes prior to the procedure B. Administer intravenous antibiotics after the cord is clamped C. Administer intravenous antibiotics immediately after the procedure D. Administer intravenous antibiotics for 24 hours after the procedure E. Administer oral antibiotics for 1 week following the procedure. Explanation: The correct answer is B. One of the major risk factors for developing postpartum endometritis is cesarean delivery. Therefore, prophylactic antibiotics are recommended in all cases of nonscheduled cesarean delivery (i.e., a cesarean delivery that is not anticipated). This patient is having a cesarean delivery because she is a nulliparous woman in labor with a fetus in the breech position. The fact that her membranes broke a few hours ago, and that she has dilated to 6 centimeters puts her at even higher risk for postpartum endometritis because of the possible exposure that has occurred to the vaginal flora. Intravenous antibiotics will help to prevent infection of the mother if they are given before or after the umbilical cord is clamped. Therefore, to minimize fetal exposure to the antibiotics, the medication should be given after the umbilical cord is clamped. This patient has no evidence of chorioamnionitis; therefore there is no indication to give the antibiotics immediately. To administer intravenous antibiotics 30 minutes prior to the procedure (choice A) is proper management in a non-pregnant patient undergoing, for example, a hysterectomy. In the pregnant patient, administering the antibiotic prior to clamping the umbilical cord results in unnecessary fetal exposure. To administer intravenous antibiotics immediately after the procedure (choice C) is incorrect because there is a needless delay. Once the umbilical cord is clamped, there is no further concern regarding unnecessary fetal exposure and the antibiotic may be given immediately. To administer intravenous antibiotics for 24 hours after the procedure (choice D) is indicated when the patient has chorioamnionitis. This patient, however, has no evidence of being infected and the antibiotics are being given for prophylaxis. To administer oral antibiotics for 1 week following the procedure (choice E) is unnecessary. Once the single dose is given at the time of cord clamping, there is no need for further treatment. 36) A previously healthy 21-year-old woman has a profuse, malodorous vaginal discharge. Examination shows a greenish gray "frothy" discharge with a "fishy" odor and petechial lesions on the cervix. There is no cervical motion tenderness. Her temperature is 37.5 C (99.4 F), blood pressure is 120/80 mm Hg, pulse is 60/min, and respirations are 16/min. Microscopic evaluation of the discharge is most likely to show which of the following? A. "Clue cells" B. Gram-negative diplococci C. Gram-positive diplococci D. Motile, flagellated organisms E. Pseudohyphae or hyphae Explanation: The correct answer is D. This patient has trichomoniasis. Trichomoniasis is caused by a motile, flagellated protozoan, Trichomonas vaginalis. The symptoms include a copious, malodorous ("fishy"), greenish-gray, "frothy" discharge. The vulvar and vaginal epithelium may be erythematous and edematous. Colposcopy may reveal petechial cervical lesions ("strawberry cervix"). A wet mount of the discharge often reveals motile trichomonads and polymorphonuclear leukocytes (PMNs). The treatment is metronidazole. Simultaneous treatment of the sexual partner reduces the risk of reinfection. "Clue cells" (choice A), vaginal squamous epithelial cells coated with coccobacillary organisms, are seen in bacterial vaginosis. The symptoms include a moderate amount of malodorous ("fishy"), white to gray, homogeneous vaginal discharge. An amine ("fishy") odor is present after mixing vaginal secretions with KOH. This is often called a positive whiff test. Saline preparations of the discharge reveal the "clue cells". The treatment is metronidazole.Simultaneous treatment of the sexual partner has not been shown to reduce recurrence. Gram-negative diplococci (choice B) are an indication of Neisseria gonorrhoeae. N. gonorrhoeae causes a mucopurulent cervical discharge in acute cervicitis and can lead to pelvic inflammatory disease (PID). PID is characterized by lower abdominal pain, fever, and cervical motion tenderness. Diagnosis is often made by Gram's stain of cervical secretions revealing gram-negative diplococci and polymorphonuclear leukocytes. Treatment is ceftriaxone IM once and doxycycline or azithromycin. The 2 latter drugs are given since concomitant chlamydial infection is common. Sexual partners must be treated. Gram-positive diplococci (choice C) are not a common cause of cervical discharge. Pseudohyphae or hyphae (choice E) is an indication of candidiasis. Vulvar pruritus, irritation, and a thick, white, cottage cheese-like discharge are the predominant symptoms. Diagnosis is made by KOH, saline, or Gram's stain evaluation of the vaginal fluid revealing fungi. Treatment is fluconazole PO or imidazole cream. Routine treatment of sexual partners is usually not indicated. 37) A 21-year-old primigravid woman at 39 weeks' gestation comes to the labor and delivery ward with painful contractions every three minutes. Her prenatal course was unremarkable. Examination shows her cervix to be 3 centimeters dilated and 90% effaced. The fetal heart rate tracing is in the 150s and reactive. 5 hours later cervical examination reveals that the patient is 9 centimeters dilated and at -1 station. The fetal heart rate tracing shows moderate variable decelerations with each contraction and decreased variability. Fetal scalp sampling is performed that yields fetal scalp pHs of 7.04, 7.05, and 7.06. Which of the following is the most appropriate next step in management? A. Expectant management B. Episiotomy C. Forceps-assisted vaginal delivery D. Vacuum-assisted vaginal delivery E. Cesarean delivery Explanation: The correct answer is E. Fetal scalp sampling (FSS) is a method of fetal assessment that is used during labor and delivery to obtain fetal blood for pH assessment. Normal labor and delivery is characterized by a lowering of the fetal pH as the labor progresses. However, most fetuses tolerate labor and delivery without a dangerous drop in pH (i.e. an acidosis that will result in organ damage). When the fetal heart rate tracing is not reassuring, FSS can be used to determine the acid-base status of the fetus, which will help with management of the labor. If the pH is > 7.25 then the patient may be managed expectantly with continued observation of the labor and the fetal heart rate. If the pH is between 7.20 and 7.25, the FSS should be repeated in 15 to 30 minutes. If the pH is < 7.20, steps should be taken to bring about delivery. Acidemia likely to cause damage to the fetus appears to occur at values < 7.00. However, by using a cutoff of 7.20, there is a margin for error to protect the fetus. This fetus has fetal scalp blood pHs of 7.04, 7.05, and 7.06. This level of acidemia is considered an indication for immediate delivery. Because the fetus is at -1 station, far too high for forceps or vacuum-assisted vaginal delivery, a cesarean delivery should be performed. Expectant management (choice A) would be inappropriate. This patient has a fetus at -1 station with scalp pHs consistently less than 7.20. Therefore, cesarean delivery should be performed. Episiotomy (choice B) would not be indicated. Episiotomy is sometimes used when forceps or vacuum-assisted vaginal delivery will be performed. It may also be performed to facilitate an uninstrumented vaginal delivery. In this case, however, the patient requires a cesarean delivery. Forceps-assisted vaginal delivery (choice C) or vacuum-assisted vaginal delivery (choice D) would be incorrect. Forceps and vacuum-assisted vaginal delivery should not be performed at stations higher than +2. Certainly, at -1 station, this fetus is "too high" to attempt an assisted vaginal delivery. 38) A 31-year-old, HIV-positive woman, gravida 3, para 2, at 32-weeks' gestation comes to the physician for a prenatal visit. Her prenatal course is significant for the fact that she has taken zidovudine throughout the pregnancy. Otherwise, her prenatal course has been unremarkable. She has no history of mental illness. She states that she has been weighing the benefits and risks of cesarean delivery in preventing transmission of the virus to her baby. After much deliberation, she has decided that she does not want a cesarean delivery and would like to attempt a vaginal delivery. Which of the following is the most appropriate next step in management? A. Contact psychiatry to evaluate the patient B. Contact the hospital lawyers to get a court order for cesarean delivery C. Perform cesarean delivery at 38 weeks D. Perform cesarean delivery once the patient is in labor E. Respect the patient's decision and perform the vaginal delivery Explanation: The correct answer is E. Cesarean delivery has been shown to decrease the rate of transmission of HIV from an infected mother to her fetus. Some reports have shown that the transmission rate can be decreased to as low as 2% with the combination of antiretroviral medication and elective cesarean delivery prior to labor or rupture of membranes. However, although cesarean delivery benefits the infant by decreasing the risk of transmission, the risks of the surgery accrue to the mother. Risks of cesarean delivery include bleeding, infection, and injury to internal organs. HIV-infected women with low CD4 cell counts are known to have higher rates of postoperative complications. Thus, the decision of whether to have a cesarean ultimately belongs to the mother. This patient's autonomy must be respected and she should have a vaginal delivery if she so chooses. To contact either psychiatry to evaluate the patient (choice A) or the hospital lawyers to get a court order for cesarean delivery (choice B) would be incorrect. Patient autonomy must be respected when it comes to the decision of whether to have a cesarean delivery. This patient has weighed the benefits and risks and has put a great deal of deliberation into her decision. There is no need to involve the psychiatry department or the hospital lawyers in this decision. To perform cesarean delivery at 38 weeks (choice C) or once the patient is in labor (choice D) would not be correct. In HIV-positive women who do want an elective cesarean delivery, the delivery should be performed at 38 weeks to avoid the risk of labor or rupture of membranes. Once labor starts or the membranes are ruptured, the risk of HIV transmission increases. However, this patient does not want a cesarean delivery, so that operation should not be performed. 39) A 26-year-old nulligravid woman comes to the emergency department because of severe right lower quadrant pain. She states that the pain started last night. This morning she was awakened from sleep with severe pain in the same area. During the episode of pain she also had nausea, vomiting, and diaphoresis. On admission to the emergency department she required 5 mg of morphine to control her pain. Examination is significant for right lower quadrant tenderness and a tender right adnexal mass on pelvic examination. Urine hCG is negative. Urinalysis is negative. Transvaginal ultrasound reveals an 8 cm right ovarian mass. Which of the following is the most likely diagnosis? A. Appendicitis B. Ectopic pregnancy C. Nephrolithiasis D. Ovarian torsion E. Pelvic inflammatory disease Explanation: The correct answer is D. This patient's presentation is most consistent with ovarian torsion. Ovarian torsion typically occurs in the setting of an adnexal mass. A mass changes the motion "dynamics" of the adnexae such that a twisting of the adnexa becomes possible. This mass can be a functional ovarian cyst, a dermoid, a paratubal cyst, or any number of other benign or malignant neoplasms. Once a complete torsion has occurred, the arterial supply to the ovary is occluded and necrosis can result. Patients with adnexal torsion can present with a history of intermittent pain that comes and goes as the adnexa twists. The pain is usually severe and often accompanied by episodes of nausea, vomiting, and diaphoresis, as this patient had. They may need narcotics to control the severe pain. A pelvic mass will almost always be found on physical examination or by ultrasound. If there is no adnexal mass, the diagnosis of ovarian torsion is highly unlikely. This is true because most normal ovaries do not have the motion "dynamics" that will allow them to twist. Appendicitis (choice A) should always be a consideration when a patient presents with right lower quadrant pain. However, in this case, the combination of the pain with the ovarian mass makes ovarian torsion, and not appendicitis, the most likely diagnosis. Ectopic pregnancy (choice B) should also be an important consideration when a young woman presents with abdominal pain. Some emergency departments have signs reading "Think Ectopic" to keep staff aware of this possibility. In this case, however, the patient is not pregnant (negative urine hCG) which excludes ectopic from the differential. Nephrolithiasis (choice C) can also cause excruciating pain, as does ovarian torsion. With nephrolithiasis, hematuria will often be present. In this patient, the absence of hematuria and the presence of the right adnexal mass make nephrolithiasis less likely. Pelvic inflammatory disease (choice E) is a diagnosis that merits consideration in a woman with abdominal pain with a negative hCG (it is far less common during pregnancy). However, the ovarian mass in this case makes torsion a more likely diagnosis than PID. 40) An 18-year-old woman comes to the physician for advice regarding birth control. She has been sexually active since the age of 15 and has had numerous sexual partners since that time. She has tried the oral contraceptive pill twice, for approximately two cycles each time, but stopped because of irregular bleeding. She has had gonorrhea once and Chlamydia twice. She does not smoke. Physical examination is unremarkable. Which of the following forms of birth control should be recommended for this patient? A. Condoms B. Diaphragm C. Intrauterine device D. Oral contraceptive pill E. Tubal ligation Explanation: The correct answer is A. All of the above options will provide birth control for this patient. However, another major factor for this patient is the prevention of sexually transmitted disease. Other than abstinence, condoms provide the best protection against the acquisition of sexually transmitted diseases. This patient, with her early onset of intercourse at the age of 15 and her numerous sexual partners, is at high risk for HIV, hepatitis, herpes, chlamydia, gonorrhea, syphilis, human papillomavirus, and the eventual development of cervical cancer. It is absolutely essential that she be counseled regarding condom use and the importance of her protecting herself from sexually transmitted diseases as well as pregnancy. The diaphragm (choice B) is an effective method of birth control for motivated women who are able to use this method with each episode of intercourse. Because it covers the cervix, it provides some protection against disease. However, it does not provide as much protection against sexually transmitted diseases as condoms do. The intrauterine device (choice C) is absolutely contraindicated in a woman with numerous sexual partners and a recent history of sexually transmitted disease. Furthermore, it is highly suboptimal for young women, in whom a pelvic infection could lead to reduced or absent future fertility. The oral contraceptive pill (OCP) (choice D) would provide this patient with protection against pregnancy; however, it would not protect her from sexually transmitted diseases. An ideal approach may be to have her use both the OCP and condoms. However, consistent use of both can be difficult. Tubal ligation (choice E) would provide this patient with no protection against sexually transmitted disease. Furthermore, except in very rare circumstances, it is contraindicated for an 18-year-old. 41) A 44-year-old woman, gravida 4, para 3, at 8 weeks' gestation comes to the physician for her first prenatal visit. She has mild nausea and vomiting but no other complaints. Her obstetric history is significant for three full-term, normal vaginal deliveries of normal infants. She has no medical or surgical history and takes no medications. Physical examination reveals an 8-weeksized uterus, but is otherwise unremarkable. She wishes to have chromosomal testing of the fetus and wants to have chorionic villus sampling performed, as she did with her last pregnancy. Compared with amniocentesis, chorionic villus sampling may place the patient at greater risk for which of the following? A. Fetal Down syndrome B. Fetal limb defects C. Fetal neural tube defects D. Maternal sepsis E. Mid-second-trimester abortion Explanation: The correct answer is B. Chorionic villus sampling (CVS) is a procedure in which the chorionic villi are sampled through either a transabdominal or transcervical approach. Amniocentesis is a procedure in which amniotic fluid is removed. In both procedures, cells are removed and can be analyzed for chromosomal abnormalities. A major advantage of chorionic villus sampling is that it can be performed at 10-12 weeks, as opposed to amniocentesis, which is performed in the second trimester. CVS thus allows a woman to undergo an earlier termination than amniocentesis allows for. In the early 1990s, there were several reports linking chorionic villus sampling to limb reduction defects in the infants. Most of the large studies have shown no overall increased risk of limb deficiencies among infants whose mothers underwent CVS. However, there is some evidence that one subtype of limb defect, called transverse digital deficiency, is more common with CVS. The risk of fetal Down syndrome (choice A) is not increased by the procedure used to detect it. Whether CVS or amniocentesis is used, the fetus has a set risk of Down syndrome. The risk of fetal neural tube defects (choice C) is also not increased by the procedure used to detect them. However, CVS does not allow for the prenatal diagnosis of neural tube defects. Only amniocentesis allows for the evaluation of amniotic fluid alpha-fetoprotein, which is often necessary to make the diagnosis. Maternal sepsis (choice D) is not more likely with CVS compared with amniocentesis. The risk for either procedure is very low. Mid-second-trimester abortion (choice E) is more likely with amniocentesis than with CVS. Amniocentesis is performed later in pregnancy; therefore, termination based on the amniocentesis result is likely to occur later than with CVS (performed at 10-12 weeks). 42) A pharmaceutical company sponsors a physician lecture concerning thrombotic complications of the oral contraceptive pill (OCP). At the start of the presentation, the company's representative makes a short presentation regarding their particular brand of OCP. He then proceeds to announce that his company would like to award a gift to the physician in the group who gives the largest number of prescriptions for this pill. Which of the following is the most appropriate action? A. Acceptance of the gift B. Attempt to get colleagues to prescribe the medication C. Promise to prescribe more of the medication D. Refusal of the gift E. Request for money rather than a gift Explanation: The correct answer is D. Pharmaceutical companies often provide funding for educational opportunities for physicians. This involvement is considered acceptable by some and unacceptable by others. Pharmaceutical company involvement, however, should never place the physician in a situation whereby the interests of the patient are not placed in a primary position. In the above scenario, the physician will be rewarded for giving the most prescriptions for this particular oral contraceptive pill (OCP). This reward system may place the physician's interest against that of the patient. For example, a given patient may benefit more from another OCP, but the physician will feel pressure to prescribe the pill that will bring him the gift. Thus, most specialty societies declare that physicians should not accept gifts if they are given secondary to the physician prescribing certain medications. Acceptance of the gift (choice A) would legitimize the approach of the company of providing gift incentives to physicians that prescribe their medication. This is considered unethical. An attempt to get colleagues to prescribe the medication (choice B) or a promise to prescribe more of the medication (choice C) to please the pharmaceutical company representative would also place the patient's interests in a secondary position. This is considered unethical. A request for money rather than a gift (choice E) is an example of direct conflict of interest behavior. The interest of the patient in this case is not primary. Therefore, schemes of reward such as that presented above are considered unethical. 43) A 24-year old woman comes to the physician because of burning with urination. She states that every time she urinates there is pain and that she has a feeling that she constantly needs to urinate even though only a little comes out. She has never had any similar symptoms before. She has no medical problems and no known drug allergies. Examination is unremarkable. Urinalysis demonstrates that the urine is positive for leukocyte esterase and nitrites. Which of the following is the most appropriate pharmacotherapy? A. Intramuscular ceftriaxone B. Intravenous levofloxacin C. Oral levofloxacin for 7 days D. Oral trimethoprim-sulfamethoxazole for 3 days E. Wait for the culture results to institute therapy Explanation: The correct answer is D. This patient likely has an uncomplicated urinary tract infection (UTI). Patients with UTIs often present with dysuria, frequency, and urgency. Physical examination is often unremarkable, although there may be some suprapubic tenderness if a cystitis is the predominant infection rather than a urethritis. Urine "dip" will often be positive for leukocyte esterase and nitrites. Microscopic urinalysis will often show the presence of white blood cells and red blood cells. Escherichia coli is the offending organism in about 80% of cases with Staphylococcus saprophyticus being the next most likely causative organism. Treatment of an uncomplicated urinary tract infection is with a 3-day course of oral antibiotics. Trimethoprimsulfamethoxazole (Bactrim) has been shown to be safe, effective, and cost-effective in the treatment of uncomplicated UTIs. Intramuscular ceftriaxone (choice A) is used for the treatment of gonorrhea. This patient has findings consistent with urinary tract infection and not gonorrhea, and therefore, a 3-day course of oral antibiotics is indicated, rather than intramuscular ceftriaxone. Intravenous levofloxacin (choice B) can be used in cases of complicated urinary tract infections in patients that cannot take oral medications and oral levofloxacin (choice C) can be used when the patient is tolerating oral intake. Levofloxacin has roughly the same bioavailability when taken orally versus intravenously, so the route depends on the patient's status. However, this medication is used when patients have complicated urinary tract infections (i.e. with Pseudomonas or Proteus species) or when the patient has underlying medical illness. To wait for the culture results to institute therapy (choice E) would not be appropriate. The patient has symptoms and findings consistent with a UTI right now and therefore should be treated now. To wait 2 or more days for the culture results to come back would not be appropriate. 44) A 21-year-old woman comes to the physician because of abdominal pain. She states that the pain is in her right lower quadrant and has been getting worse over the past 3 months. She has no other symptoms and a normal appetite. Examination demonstrates mild right lower quadrant abdominal tenderness. Pelvic examination reveals mild right adnexal enlargement and tenderness. Urine human chorionic gonadotropin (hCG) is negative. A pelvic ultrasound is obtained that shows a 4-centimeter, heterogeneous hyperechoic lesion in the right adnexa with cystic areas. On transvaginal ultrasound, hair and calcifications are demonstrated within the cystic areas. Which of the following is the most likely diagnosis? A. Appendicitis B. Benign cystic teratoma (dermoid) C. Corpus luteum cyst D. Ectopic pregnancy E. Tubo-ovarian abscess Explanation: The correct answer is B. This patient has a presentation and findings that are most consistent with a benign cystic teratoma (dermoid). Cystic teratomas are, by far, the most common type of ovarian neoplasm: cystic teratomas account for 25 to 40% of all ovarian neoplasms. They are a type of ovarian germ cell tumor, which can range in size from small masses that are noted incidentally on ultrasound and cause no symptoms to larger cysts that cause pain and pressure, as this patient has. A single germ cell gives rise to a teratoma. Because the germ cell is totipotential, the dermoid is characterized by all three germ cell layers: ectoderm, mesoderm, and endoderm. Gross examination of a dermoid will often reveal skin, bones, hair, and teeth, which can often be seen on ultrasound. The part of the dermoid that contains the largest number of different tissues is called Rokitansky's protuberance. Laparotomy is usually the most appropriate management of a patient with a dermoid because, as adnexal masses enlarge, the risk of ovarian torsion increases. Also, dermoids may cause symptoms of pain and pressure and, on that basis, should be removed. At the time of surgery, close examination should be made of the other ovary because dermoids may be found bilaterally in more than 10% of cases. Appendicitis (choice A) is usually not a chronic process slowly developing over 3 months. Also, patients with appendicitis typically have anorexia and appear ill. A corpus luteum cyst (choice C) is a common cause of a complex adnexal mass in a young woman. However, this patient has a presentation and a mass with ultrasound characteristics that are classic for dermoid. Ectopic pregnancy (choice D) should always be considered when a woman of childbearing age presents with abdominal pain. A negative urine hCG effectively rules out ectopic pregnancy. Patients with a tubo-ovarian abscess (choice E) usually have fevers, significant abdominal and pelvic tenderness, and appear ill. 45) A 65-year-old woman comes to the physician because of bleeding from the vagina. She states that her last menstrual period was at age 50 and that she has had no bleeding since. She has no medical problems and takes no medications. She is not sexually active. Examination is unremarkable, including a normal pelvic examination. After informed consent is obtained, an endometrial biopsy is performed. The patient complains of discomfort during and after the procedure but feels well enough to go home. Later that night, with her abdominal pain worsening, the patient comes to the emergency department. An ultrasound is performed that shows a normal uterus and adnexae but a complex fluid collection posterior to the uterus. Which of the following is the most likely diagnosis? A. Bowel perforation B. Endometritis C. Endometrial cancer D. Tuboovarian abscess E. Uterine perforation Explanation: The correct answer is E. This patient presents with postmenopausal bleeding. The majority of patients who have postmenopausal bleeding will not have endometrial hyperplasia or cancer. However, because postmenopausal bleeding is the most common presenting complaint of women with endometrial cancer, it is important to rule this out. A common way to evaluate the endometrium is with an endometrial biopsy. This can be performed with a small suction cannula that is introduced through the cervical os and into the uterine cavity to get a sample of the endometrium. The procedure is standard in the practice of gynecology but is not without risks. One of the risks of endometrial biopsy is uterine perforation (i.e. advancing the cannula too far such that it penetrates and perforates through the wall of the uterus). This patient has evidence of uterine perforation. First, she experienced significant pain during the procedure and continuing afterwards. While endometrial biopsy can cause considerable discomfort, it is usually of a crampy nature that should resolve shortly after the procedure. Second, her pelvic ultrasound now shows a complex fluid collection posterior to the uterus, which likely represents a collection of blood in the posterior cul-de-sac. If the patient has stable vital signs and an acceptable hematocrit, uterine perforation can be managed expectantly. If, however, the patient has evidence of hemodynamically significant bleeding, then she will require operative intervention. Bowel perforation (choice A) is a very unlikely complication with an endometrial biopsy. It's rare for the cannula to be advanced far enough to damage the uterus (uterine perforation), let alone damage the bowel. Endometritis (choice B) can be a complication of an endometrial biopsy. Patients undergoing endometrial biopsy should be counseled that infection is one of the risks of the procedure. However, this patient is afebrile and the pelvic fluid collection is more suggestive of a perforation than an endometritis. While it is possible that this patient has endometrial cancer (choice C), it is not likely that endometrial cancer is causing her acute problem. Again, most women with postmenopausal bleeding do not have endometrial cancer. And, this patient's sudden onset of pain and pelvic fluid collection after endometrial biopsy is most suggestive of endometrial cancer. A patient with a tuboovarian abscess (choice D) usually presents with abdominal pain and fevers, and ultrasound will reveal a pelvic mass. In a non-sexually active patient with no adnexal mass, tuboovarian abscess can be effectively ruled out. 46) A 23-year-old female comes to the physician because of a swelling in her vagina. She states that the swelling started about 3 days ago and has been growing larger since. The swelling is not painful, but it is uncomfortable when she jogs. She has asthma for which she uses an albuterol inhaler, but no other medical problems. Examination shows a cystic mass 4 cm in diameter near the hymen by the patient's left labia minora. The mass is nontender and there is no associated erythema. The mass is freely mobile. The rest of the pelvic examination is unremarkable. Which of the following is the most likely diagnosis? A. Bartholin's cyst B. Condyloma lata C. Granuloma inguinale D. Hematocolpos E. Vulvar cancer Explanation: The correct answer is A. This patient has a presentation and findings that are most consistent with a Bartholin's cyst. Bartholin's cysts develop when a Bartholin's gland becomes obstructed. The Bartholin's glands are bilateral structures that are present near the posterior fourchette of the vagina at the 5 and 7 o'clock positions. They secrete mucus, particularly during sexual stimulation, which drains into the posterior vagina.They undergo rapid growth during the process of puberty and they shrink after the menopause. When the duct of the Bartholin's gland becomes obstructed, a Bartholin's cyst results. If the cyst becomes infected, the result is a Bartholin's abscess. These abscesses are usually polymicrobial in nature, although the gonococcus is implicated in about 25% of cases. Treatment of a symptomatic Bartholin's cyst is with placement of a Word catheter. This is a small balloon-tipped catheter device that is placed into a small hole that is punched into the cyst itself. This catheter allows drainage of the cyst and the formation of an epithelialized tract that will allow continued drainage once the catheter is removed. This tract should prevent the cyst from reforming. If Bartholin's cysts continue to form in spite of the use of the Word catheter, a marsupialization procedure may be tried. In this procedure, the cyst walls are sutured open to the surrounding skin to prevent re-closure and re-formation of the cyst. Condyloma lata (choice B) is a manifestation of secondary syphilis. They appear as coalesced, large, pale, flat-topped papules and not as a cystic mass. Granuloma inguinale (choice C) is also known as Donovanosis and is a sexually transmitted disease associated with the gram-negative bacillus Calymmatobacterium granulomatis. The disease is characterized by papules progressing to ulcers and not by a vulvar cyst. Hematocolpos (choice D) describes the condition in which there is blood filling the vagina. This is often seen with an imperforate hymen. Vulvar cancer (choice E) does not usually present as a single cystic mass at the introitus and, in young women, is far less common than Bartholin's cysts 47) A 37-year-old woman, gravida 3, para 2, comes to her physician for follow-up on her ectopic pregnancy. She was diagnosed with an ectopic pregnancy 7 days ago and given methotrexate. She now presents with abdominal pain that started this morning. Examination is significant for moderate left lower quadrant tenderness. Laboratory analysis shows that her beta-hCG value has doubled over the past week. Transvaginal ultrasound shows that the ectopic pregnancy is roughly the same size but there is an increased amount of fluid in the pelvis. Which of the following is the most appropriate next step in management? A. Expectant management B. Repeat methotrexate C. Laparoscopy D. Oophorectomy E. Hysterectomy Explanation: The correct answer is C. An ectopic pregnancy is a pregnancy that is located outside of the normal intrauterine location, most often in the fallopian tube. In a stable patient, an ectopic pregnancy may be treated medically or surgically. Medical management is with methotrexate. When methotrexate is given, it is essential to have the patient return for follow-up to ensure that the beta-hCG value is falling, the indication that the methotrexate is working. This patient not only has a beta-hCG value that is rising, but also has other signs and symptoms consistent with a rupturing ectopic pregnancy. The worsening abdominal pain and left lower quadrant tenderness are concerning for rupture as is the increased amount of fluid in the pelvis on the ultrasound. This fluid likely represents blood. The management for a ruptured ectopic is surgical. In this case laparoscopy could be performed to identify the ectopic pregnancy and either a salpingostomy (i.e. making a hole in the tube to remove the ectopic pregnancy) or a salpingectomy (i.e. removing the entire tube) could be performed. Expectant management (choice A) would be absolutely inappropriate, as this patient has a doubling beta-hCG value in spite of the methotrexate therapy and has findings consistent with a ruptured ectopic. Repeat methotrexate (choice B) can be given to women with an ectopic pregnancy that show persistently high levels of serum beta-hCG on a day 7 evaluation (i.e. 7 days after the first dose of methotrexate). However, this patient would not be a candidate, as she appears to be actively rupturing her ectopic pregnancy. Oophorectomy (choice D) and hysterectomy (choice E) are not the treatments of choice for women with an ectopic pregnancy. All reasonable steps should be taken to preserve the patient's uterus and ovaries during a surgery for ectopic pregnancy. Preferably, only the tube itself should be operated upon, with either a salpingectomy or salpingostomy being performed. 48) A 26-year-old woman comes to the physician because of a lump in her vagina. The lump is nontender but is uncomfortable when she walks. She states that for the last 6 years this lump has appeared about once a year. When it occurs she goes to the doctor who puts a catheter into it, which is taken out in a few weeks. She has no other medical problems. She is sexually active with two partners. Examination shows a cystic mass approximately 4 cm in diameter on the right side of the vagina near the hymeneal ring. The mass feels like a discrete cyst. The rest of the pelvic examination is unremarkable. Which of the following is the most appropriate next step in management? A. Expectant management B. Oral antibiotics C. Intravenous antibiotics D. Incision and drainage E. Bartholin's cyst marsupialization Explanation: The correct answer is E. This patient has a presentation that is most consistent with recurrent Bartholin's cysts. The Bartholin's glands are paired glands that are located in the vulvar tissue on both sides of the fourchette. They secrete mucus into the vagina. Bartholin's cysts occur when the opening to the duct becomes occluded and the gland swells from a buildup of mucus secretions. If the cyst becomes infected, the result is a Bartholin's abscess. These Bartholin's cysts and abscesses are the most common vulvar cysts. Some of these cysts are small and asymptomatic and do not require treatment. This patient, however, is uncomfortable when she walks and she also has continued recurrences. Therefore, surgical intervention is indicated. Often a Word catheter is used to drain the cyst and create an ostium to allow future drainage. However, as in this patient's case, once the catheter is removed the cyst may form once again. Consequently, this patient would be best served with a Bartholin's cyst marsupialization procedure. This is a surgical procedure in which the Bartholin's cyst wall is opened and the cyst itself is sewn open to the vaginal mucosa medially and the skin of the introitus laterally. This should allow free egress of the cyst fluid and prevent re-formation of the cyst. A portion of the cyst wall can be removed at the time of surgery and sent for pathologic evaluation to rule out malignancy, which, while highly unlikely in a young woman, is still a small possibility. Expectant management (choice A) would not be the best choice for this patient. She has had multiple recurrent Bartholin's cysts over the past several years and expectant management is unlikely to lead to resolution of the present cyst or long-term resolution of the problem. Oral antibiotics (choice B) or intravenous antibiotics (choice C) are not the most appropriate next step in the management of this patient. There is no evidence that this is a Bartholin's abscess, which is often characterized by tenderness and erythema of the mass. This appears to be simply a recurrent Bartholin's cyst. And, even if this were an abscess, the definitive management is with incision and drainage. Incision and drainage (choice D) is appropriate management of a Bartholin's abscess, as stated above. However, this patient has a Bartholin's cyst. To simply perform an incision and drainage of this cyst would likely lead to a recurrence of the cyst, as this patient has had several times in the past. The more definitive therapy would therefore be to do a marsupialization procedure. 49) A 25-year-old woman, gravida 2, para 2 is 4 days status post cesarean section and develops a temperature to 100.7 F (38.2 C). She had her cesarean section when she went into unstoppable preterm labor with a breech fetus. She had an uncomplicated postoperative course until this temperature elevation. Her pulse is 100/min, blood pressure is 110/70 mm Hg, and respirations are 16/min. There is discoloration and cyanosis around the incision. The area around the incision is completely numb. There is no uterine tenderness on bimanual exam. Which of the following is of the most concern in this patient? A. Endometritis B. Mastitis C. Necrotizing fasciitis D. Preeclampsia E. Wound infection Explanation: The correct answer is C. Necrotizing fasciitis is a rare but potentially fatal complication of abdominal wound infection. It typically occurs in patients who are immunocompromised or who have diabetes or cancer. It is a clinical diagnosis that is characterized by discoloration and cyanosis around the incision with numbness of the area. It can be polymicrobial in nature, but anaerobes are frequently involved. It is considered to be a potentially fatal condition and aggressive treatment with broad-spectrum antibiotics and surgical debridement is essential. Endometritis (choice A) is characterized by abdominal pain, malaise, foul-smelling lochia, temperature elevation, and uterine tenderness on bimanual examination. This patient does not have uterine tenderness on bimanual examination and her disease process appears focused around the incision site. Therefore, endometritis would not be the process of most concern in this patient. Mastitis (choice B) is an infection of the breast that is characterized by breast pain, elevated temperature, erythema and edema of the breast. This patient's process is not involving the breast; therefore, mastitis would not be of concern here. Preeclampsia (choice D) is characterized by hypertension, edema, and proteinuria. The cure for preeclampsia is delivery of the fetus. This patient has no findings concerning for preeclampsia and is postpartum, which makes the development of preeclampsia much less likely. Wound infection (choice E) is certainly of concern here. However, this patient has features to her presentation that suggest a process that goes beyond simple wound infection. The discoloration of the wound edges and cyanosis, along with the loss of sensation around the wound point toward the more worrisome process of necrotizing fasciitis. 50) A 32-year-old woman, gravida 2, para 2, comes to the physician for follow-up of an abnormal Pap test. One month ago, her Pap test showed a high-grade squamous intraepithelial lesion (HGSIL). Colposcopy demonstrated acetowhite epithelium at 2 o'clock. A biopsy taken of this area demonstrated HGSIL. Endocervical curettage (ECC) was negative. The patient has no other medical problems, has never had cervical dysplasia, and takes no medications. Which of the following is the most appropriate next step in management? A. Repeat Pap test in 1 year B. Repeat Pap test in 6 months C. Repeat colposcopy in 6 months D. Loop electrode excision procedure (LEEP) E. Hysterectomy Explanation: The correct answer is D. There is a significant risk that a high-grade squamous intraepithelial lesion (HGSIL) will progress to invasive cervical cancer. Although only roughly 15% of patients with a low-grade squamous intraepithelial lesion (LGSIL) will have progression of the lesion, a significantly higher proportion of patients with HGSIL will progress to cervical cancer. Therefore, once colposcopically directed biopsy is performed, the diagnosis of HGSIL is confirmed, and the distribution of the lesion is known, removal or destruction of the entire transformation zone should be performed. This can be done with a loop electrode excision procedure (LEEP). In this procedure, a thin-wire loop electrode is used to excise the entire transformation zone. The removed tissue may then be sent to pathology. LEEP can thus be used as both a diagnostic and therapeutic procedure. A repeat Pap in 1 year (choice A) is the recommended follow-up for patients with a normal Pap test. This patient has HGSIL; therefore, follow-up in 1 year with a repeat Pap test would not be appropriate. A repeat Pap test in 6 months (choice B) may be appropriate follow-up for patients with atypical cells of undetermined significance (ASCUS) or LGSIL on their Pap test. It is not appropriate management for patients with HGSIL. Repeat colposcopy in 6 months (choice C) would not be correct. This patient has known, biopsy-proven HGSIL and therefore requires treatment of the lesion. Hysterectomy (choice E) would not be appropriate for this patient. HGSIL can usually be treated adequately without needing to perform hysterectomy. Hysterectomy may be appropriate in some patients with recurrent HGSIL or in those with lesions that cannot be adequately treated with local therapies. However, this patient is a young woman having her first episode of cervical dysplasia. Pediatrics Questions 1) A 16-year-old female presents to the emergency room with severe right-sided abdominal pain. Her last menstrual period was 2 weeks ago and felt to be normal. She displays painful difficulty in positioning herself on the examination table. Her temperature is 38.5 C (101.3 F), blood pressure is 128/75 mm Hg, pulse is 80/min, and respirations are 22/min. Examination of the throat reveals mild pharyngitis. Her abdomen is diffusely tender, especially the lower abdomen. Rectal examination reveals tenderness anteriorly on the right side. Stool guaiac is negative. A pelvic examination is performed, and there is evidence of cervical tenderness and questionable fullness in the right adnexal area. Which of the following is the most likely diagnosis? A. Ovarian cyst B. Pyelonephritis C. Pelvic inflammatory disease D. Constipation E. Endometriosis Explanation: The correct answer is C. Pelvic inflammatory disease (PID) can be a difficult diagnosis to make in a teenage girl. There may be a history of abnormal uterine bleeding and dysmenorrhea. The teenager may not always be forthright with information about sexual activity. Most patients with PID have signs of abdominal pain, lower abdominal tenderness, and the pelvic examination reveals cervical motion tenderness. In addition, the pelvic examination may reveal purulent cervical discharge, and an adnexal mass or tenderness may be present. Fever over 38.0 C is frequently present. Laboratory tests may reveal an elevated white blood cell count and a sedimentation rate greater than 15 mm/hr. The most common pathogens in PID are the gonococcus and Chlamydia. Less frequently, PID is caused by a mixed infection with anaerobic and aerobic bacteria.In this case, the emergency physician was initially concerned the patient might have an ectopic pregnancy, but a serum hCG was performed and the result was negative. An ectopic pregnancy may have been more likely if there had been adnexal fullness and tenderness on one side without pain on cervical motion. An ovarian cyst (choice A) would not cause cervical motion tenderness. Adnexal tenderness would be present, but not fullness.Cervical cultures for gonorrhea and Chlamydia would be negative. A pelvic ultrasound would be helpful in differentiating an ovarian cyst from a tuboovarian abscess. In the absence of back pain or costovertebral tenderness, pyelonephritis (choice B) would be unlikely. There is no mention of the results of a urinalysis or urine culture tests. Constipation (choice D) would be unlikely to result in right lower quadrant pain. In older children and adolescents, constipation may be a cause of left upper quadrant pain or referred pain to the left lower chest area. It is always important in a pediatric cases of abdominal pain to obtain a history of bowel movements. Endometriosis (choice E) usually has a much more chronic history of pain episodes. Frequently there may be intermenstrual bleeding episodes. A family history of endometriosis may be helpful. Importantly, the presence of cervical motion tenderness favors a diagnosis of pelvic inflammatory disease. 2) A 14-year-old boy is evaluated for short stature. He has no significant past medical history and is considered otherwise healthy by his parents. He eats a normal diet and has regular meals. His height and weight have been consistently at the 5th percentile since early childhood. His physical examination is normal, with genitalia at Tanner stage 3. Which of the following is the most likely laboratory finding for this boy? A. Bone age that is equivalent to chronologic age B. Decreased complement C3 level C. Decreased serum albumin concentration D. Decreased thyroid stimulating hormone E. Increased serum creatinine concentration Explanation: The correct answer is A. This boy most likely has familial short stature (FSS). Children with FSS usually have a normal birth weight and length. At the age of 2-3 years, however, their growth begins to decelerate and drops to around the 5th percentile. The onset and progression of puberty in children with FSS are normal. Bone age is typically consistent with the chronologic age. A decreased complement C3 level (choice B) may suggest chronic inflammatory disorders. But, the lack of any signs or symptoms makes any chronic inflammatory disorder unlikely. A decreased serum albumin concentration (choice C) can be secondary to a variety of conditions, such as nephrotic syndrome and malnutrition. But, the lack of supportive history and physical examination data makes these conditions unlikely. Decreased thyroid stimulating hormone (choice D) suggests hyperthyroidism as the etiology of the boy's short stature, but it is highly unlikely in this case. An increased serum creatinine level (choice E) indicates renal failure, but this is inconsistent with the child's history and physical examination. 3) A 1-month old boy is brought to the emergency department by his mother, who states that he has been having what she describes as "projectile vomiting" for the past several days. She states that he vomits every time she feeds him, and the situation seems to be getting worse, although he does not seem to be in pain. She describes the vomitus as non-bilious, and he has had normal stools with no blood in them. On examination, the infant appears to be mildly dehydrated, his abdomen is soft, and there is a palpable, olive-sized, firm moveable mass in the right upper quadrant. Which of the following is the most likely diagnosis? A. Duodenal atresia B. Intussusception C. Hirschsprung disease D. Midgut volvulus E. Pyloric stenosis Explanation: The correct answer is E. Pyloric stenosis develops in the first weeks of life. It is caused by hypertrophy of the pyloric muscle, which obstructs gastric outflow. The incidence is higher in males and first-born infants. The symptoms include progressively worsening vomiting, which becomes projectile and is non-bilious. On examination, peristaltic waves may be seen, and an olive-sized mass is usually palpated in the right upper quadrant. Duodenal atresia (choice A) is usually associated with other congenital anomalies. Symptoms include bilious vomiting, abdominal distention, and failure to pass meconium. Upright abdominal x-ray films show the classic "double-bubble sign." Intussusception (choice B) presents with vomiting, bloody stool, and colicky abdominal pain. As the obstruction progresses, the vomitus becomes bile-stained. On examination, there is usually a sausage-shaped mass in the distribution of the colon. Hirschsprung disease (choice C), or aganglionic megacolon, is associated with failure to pass meconium or constipation and abdominal distention. Diagnosis is made by rectal biopsy. Midgut volvulus (choice D) can occur at any age but is common in infancy. Symptoms include bilious vomiting, abdominal distention, pain, and bloody stools. An upper gastrointestinal series is diagnostic for volvulus showing a "corkscrew" narrowing of the distal duodenum. 4) A 6-day-old girl who was born at home is being evaluated for bruising and gastrointestinal bleeding. Laboratory findings include partial thromboplastin time and prothrombin time, greater than 2 minutes; serum bilirubin, 4.7 mg/dL; alanine aminotransferase, 18 mg/dL; platelet count, 330,000/mm3; and hemoglobin, 16.3 g/dL. Which of the following is the most likely cause of her bleeding? A. Factor VIII deficiency B. Factor IX deficiency C. Idiopathic thrombocytopenic purpura D. Liver disease E. Vitamin K deficiency Explanation: The correct answer is E. The infant in this clinical vignette has hemorrhagic disease of the newborn as a result of vitamin K deficiency. It was a major cause of bleeding in neonates in the past, but it is now uncommon because of the routine administration of vitamin K at birth. However, it is still encountered in situations in which babies are born outside the hospital. The normal newborn has a moderate deficiency of the vitamin Kdependent coagulation factors. The plasma levels of these factors fall even further during the first 2-5 days of life, rise again when the infant is 7-14 days old, and attain normal adult levels at about 3 months of age. This variation usually does not produce any bleeding or bruises. However, in hemorrhagic disease of the newborn, the initial fall is accentuated, and the restoration is delayed and incomplete. As a result, coagulation abnormalities become severe and bleeding may occur. All newborns should receive 0.5-1.0 mg of vitamin K intramuscularly within the first hour after birth. Prematurity has been associated with hemorrhagic disease of the newborn. Delayed feeding, breast-feeding, vomiting, severe diarrhea, and antibiotics also delay the colonization of the gut by bacteria. Bleeding is usually severe and occurs most commonly on the 2nd or 3rd day of life. The most common manifestations are melena, large cephalohematomas, and bleeding from the umbilical stump and after circumcision. Generalized ecchymoses, often without petechiae, intracranial bleeding, and large intramuscular hemorrhages, also may develop in severe cases. In infants with hemorrhagic disease of the newborn, the prothrombin time (PT) is always prolonged. The partial thromboplastin time (PTT) and the thrombin time are also prolonged. Specific factor assays reveal deficiencies of prothrombin; factors VII, IX, and X; and proteins C and S. The bleeding time and the platelet count usually are within normal limits. In the differential diagnosis of hemorrhagic disease of the newborn, virtually all causes of bleeding, particularly thrombocytopenia and disseminated intravascular coagulation (DIC), must be considered. Factor VIII deficiency (choice A), or hemophilia A, is caused by factor VIII deficiency. Factor VIII is the critical cofactor for generation of factor Xa by factor IXa. Significant prolongation of the PT is not found in hemophilia A. Factor IX deficiency (choice B), or hemophilia B, is not associated with significant prolongation of the PT. Idiopathic thrombocytopenic purpura (choice C) is usually characterized by a platelet count of <20,000/mm3. It often follows an acute infection and has spontaneous resolution within 2 months. Liver disease (choice D) would cause prolongation of PT and PTT, as well as liver enzymes. 5) A 7-year-old boy is brought to the clinic for a lifetime history of bedwetting. He has otherwise been completely healthy and has met all development milestones. His parents deny a history of trauma, and the history is not consistent with abuse. The patient has been wetting every night but not during the daytime. He has no incontinence. Which of the following is the most appropriate next step in his evaluation? A. Intravenous pyelogram B. Renal ultrasound C. 24-hour urine collection D. Urinalysis E. CT of pelvis Explanation: The correct answer is D. Given the fact that this patient has had a lifelong history of bedwetting, the initial evaluation will include a urinalysis to rule out infection or bleeding. No neurologic dysfunction exists in this case. An intravenous pyelogram would be needed to evaluate for renal failure or chronic urinary tract infections (choice A). A renal ultrasound would help evaluate structural damage but is not indicated in the initial evaluation (choice B). 24-hour urine collection is commonly done in the evaluation of nephropathy in diabetics (choice C). A CT scan at this time would not be indicated at this stage of evaluation (choice E). 6) A 3-month old infant is brought to a pediatrician's office because of increased lethargy and irritability. The parents state that the child rolled off the couch and fell on the floor one day prior to presentation. His parents report that the child has been previously healthy and is up to date on his vaccinations. He has been meeting his development milestones. His fontanelles are full. While in office the patient develops a tonic clonic seizure. Which of the following is the next appropriate step? A. Obtain a head computerized tomography scan B. Perform a retinoscopic examination C. Check serum levels of ammonia D. Administer intravenous benzodiazepines E. Perform a lumbar puncture Explanation: The correct answer is B. The child's story is worrisome for shaken baby syndrome, in which the symptoms may not correlate with the physical findings. This diagnosis should be considered in any infant presenting with a dissonant history suspicious of child abuse. The child's fontanelles are full, indicative of increased intracranial pressure. A retinoscopic examination will indicate if this is indeed the case, since blurred fundi would suggest increased pressure. A retinoscopic examination can be done faster than a head CT (choice A). The patient may ultimately need a head CT but the eye examination should be done first. Ammonia levels (choice C) should be checked if hepatic encephalopathy is a consideration. This is a possibility if Reye syndrome is on the differential. The increased fontanelle pressure leads to a diagnosis of trauma. Benzodiazepines may be needed (choice D) in the short term to stop the seizure, but it is important to determine the cause of the seizure before intervening. Because the patient has increased intracranial pressure (suggested by the full fontanelles), a lumbar puncture may cause uncal herniation and should be avoided (choice E). 7) A toddler is brought to the emergency department with burns on both of his buttocks. The areas are moist, have blisters, and are exquisitely painful to touch. The parents explain that the child accidentally pulled a pot of boiling water over himself. Which of the following is the most important step in management? A. Application of mafenide acetate to the burned areas B. Early excision and grafting of the burned areas C. Education of the parents on accident prevention D. Prompt administration of fluid resuscitation E. Referral to the proper authorities for suspected child abuse Explanation: The correct answer is E. Scalding burns in children should always raise the possibility of child abuse, and the problem is virtually certain to have occurred when the pattern of the burns does not match the story given by the parents. In this case, had the child indeed pulled a pot of boiling water over himself, the burns would follow the distribution of water running from head to toe. Burns on both buttocks are classic for a child who is held by arms and legs, and dipped into boiling water. Mafenide acetate (choice A) is not the topical agent of choice, unless deep penetration is needed. Silver sulfadiazine would be the proper choice for topical use. In this case, however, the burn itself is less important than the future welfare of the child. Early excision and grafting (choice B) is indicated only in burns that are clearly third degree. In children, those would be deep red and dry. The description here is that of second-degree burns (moist, blisters, painful). Education of the parents (choice C) assumes the injury was accidental. We have reason to believe it was intentionally inflicted. Fluid resuscitation (choice D) would be minimal in a burn of this size. Assuming the entire surface of both buttocks is involved, it would still represent less than 10% of body surface and it is all second degree. 8) A pediatrician examines a 2-month-old infant who had been born at term. The pediatrician hears a continuous murmur at the upper left sternal border. The peripheral pulses in all extremities are full and show widened pulse pressure. Which of the following is the most likely diagnosis? A. Coarctation of the aorta B. Patent ductus arteriosus C. Peripheral pulmonic stenosis D. Persistent truncus arteriosus E. Ventricular septal defect Explanation: The correct answer is B. This is patent ductus arteriosus, which is a failure of closure of the duct between the pulmonary artery and the aorta. As many as 80% of significantly premature (<28 week gestation) infants have patent ductus arteriosus. In term infants, delayed closure is diagnosed if the murmur of the patent ductus (described in the question stem) is still present at 6-8 weeks of age. Infants should be evaluated for other cardiac disease, since a patent ductus arteriosus may be partially compensating for other cardiac anomalies. Infants with heart failure require prompt surgical correction. Infants without heart failure or complicating cardiac defects typically undergo elective surgery at 6 months to 3 years to reduce the risk of infective endarteritis later involving the patent ductus. Coarctation of the aorta (choice A) will cause diminished pulses in the legs and sometimes arms. Peripheral pulmonic stenosis (choice C) causes murmurs heard over the lung fields. Persistent truncus arteriosus (choice D) is a failure of the aorta to separate from the pulmonary artery, and causes heart failure within days to weeks of birth. Ventricular septal defect (choice E) causes a murmur heard best at the lower left sternal border. 9) An 8-month-old infant, who is up-to-date with his immunizations, is brought to the clinic by his mother. The mother states that she overheard other mothers talking about a varicella vaccination that their children have received. She does not want her son to have the chickenpox virus and therefore, wants him to receive the vaccine today. The physician explains that the infant has not yet reached the recommended age for the vaccine. If this visit is in November, when is the earliest that this patient can return for the varicella vaccine? A. February B. March C. April D. May E. June Explanation: The correct answer is B. The varicella vaccine is recommended at any visit on or after the first birthday (12 months) for susceptible children (those who have not had the virus). February (choice A) is incorrect because the infant will be 11 months. April, May, and June (choices C, D, and E) would all be appropriate times to receive the varicella vaccine except that the question asks for the earliest possible date. A general summary of routine immunizations is as follows: Hep B vaccine- At birth, 1 month, and 6 months DTaP- At 2, 4, and 6 months, 15-18 months, and 4-6 years Td booster- 11-12 years, and then every 10 years Hib- At 2, 4, and 6 months, and 12-15 months IPV- At 2 and 4 months, 6-18 months, and 4-6 years MMR- At 12-15 months and 4-6 years Varicella- 12 months 10) An inner city family has been using a neighbor to care for their 3-year-old child while the parents work. The neighbor is diagnosed with pulmonary tuberculosis. PPD test of the 3-year-old is negative. Which of the following is indicated for the 3-year-old? A. Ethambutol chemoprophylaxis B. Isoniazid chemoprophylaxis C. Rifampin chemoprophylaxis D. Streptomycin chemoprophylaxis E. No chemoprophylaxis Explanation: The correct answer is B. You are likely to be tested about the criteria for prophylaxis of tuberculosis. The usual agent chosen, unless a resistant strain of tuberculosis is clinically suspected, is isoniazid. The chemotherapeutic dose is given for 6 to 9 months and is 300 mg/day for adults or 10/mg/kg/day for children. Chemoprophylaxis is indicated in the following groups: 1) persons whose tuberculin skin test has converted from negative to positive within the previous 2 years; all small children (<4 years of age) who are either exposed by known close contact to a person with untreated tuberculosis or who have a positive PPD; all HIV patients with positive PPD; elderly patients with a definite conversion of PPD; PPD positive persons with apical scars; and PPD positive persons with significant risk of recurrence due to diabetes mellitus, prolonged corticosteroid therapy, gastrectomy, end-stage renal disease, or gastric stapling. In young children, such as in this case, it is particularly important not to delay chemoprophylaxis until the PPD test becomes positive, because these children sometimes have very rapid progression of tuberculosis, and may be very ill by the time that the PPD is repeated. Ethambutol (choice A) is usually used in treatment regimens when isoniazid resistance is suspected. Rifampin (choice C) is added to isoniazid for initial treatment of tuberculosis and can also be a component in retreatment regimens. Streptomycin (choice D) is usually used as part of retreatment regimens. No chemoprophylaxis (choice E) would be potentially dangerous in this child, who is in a population that tends to have rapidly progressive tuberculosis. 11) A 20-year-old female is brought to the Emergency Room by her college roommate who states that the patient vomited all night. The patient complains of a sore throat and says she has not eaten for the last two days. She admits to a "sugar problem" and quit taking her medication because she has not been eating. Examination reveals an ill-appearing woman. Her temperature is 37.9 C (100.2 F), blood pressure is 118/78 mm Hg, pulse is 160/min, and respirations are 30/min. The patient's lips and mucous membranes are dry. There is a fruity odor noted to the patient's breath. The lung and cardiac examination are unremarkable except for mild tachypnea and tachycardia. Laboratory analysis shows: Sodium......................130 mEq/L Potassium..................6.1 mEq/L Chloride....................100 mEq/L Bicarbonate...............8 mEq/L Urea nitrogen............10 mg/dL Creatinine.................1.0 mg/dL Glucose....................680 mg/dL pH...........................7.15 pCO2.......................30 mm Hg pO2.........................85 mm Hg Urinalysis is positive for ketones. Which of the following is the most appropriate initial step in management? A. Immediate intubation B. Intravenous insulin C. Intramuscular ceftriaxone D. IV fluid bolus with normal saline and potassium E. Mannitol Explanation: The correct answer is B. Diabetic ketoacidosis (DKA) is a life threatening complication of diabetes mellitus. DKA exists if there is hyperglycemia (glucose >300), ketonemia, acidosis (pH <7.30, HCO3 < 15) with clinical symptoms of diabetes. The mainstay of treatment for DKA is intravenous insulin. Intubation (choice A) is rarely necessary in DKA patients. The patient is alert enough to give some history and appears to be oxygenating well. Intramuscular ceftriaxone (choice C) may be necessary in this case to treat an underlying infection, which may have precipitated this episode of DK A. However, this is certainly not first-line treatment for DK A. Intravenous fluids (choice D) are also vital for DKA patients, as they are severely dehydrated. However, potassium is not initially added to intravenous fluids, especially if the potassium level is greater than 6.0 mEq/L. Mannitol (choice E) is used in suspected cases of cerebral edema, a complication of DK A. Clinical signs include deterioration in mental status, headache, and unequal pupils. 12) An 8-year-old boy is seen in the pediatrician's office for a routine health supervision visit. The mother states that he has Duchenne muscular dystrophy. On examination, he is found to have hip waddle and enlargement of both calves. He is ambulatory, but his muscle strength is diminished symmetrically. Which of the following signs is most consistent with Duchenne muscular dystrophy? A. "Foot drop" gait B. Gower sign C. Increased deep tendon reflex D. Myotonia E. Positive Babinski sign Explanation: The correct answer is B. Duchenne muscular dystrophy is the most common type of muscular dystrophies. It is an X-linked genetic disorder and happens in 1:3600 boys. It is characterized by progressive muscle weakness caused by degeneration of muscle fibers. The disease is rarely symptomatic at birth, but usually develops to a clinically evident stage before the age of 5 years. Weakness is prominent in proximal muscles. Affected children often present with toe-walking and difficulty climbing stairs. The gait is waddling, and patients often fall. The Gower sign is very characteristic of Duchenne muscular dystrophy. It is considered positive if the patient uses his hands to "walk" up the legs when going from a prone to an upright sitting position because he does not have enough proximal muscle power to get up in a normal fashion. Pseudohypertrophy of the calves is also a prominent feature. Many patients die in their 20s because of respiratory failure. In a "foot drop" gait (choice A), the patients must lift their legs high enough to avoid tripping over their drooping feet. It is characteristic of peripheral neuropathy, which typically causes distal muscle weakness rather than proximal muscle weakness. Deep tendon reflex (choice C) is usually not affected in muscle dystrophy. Myotonia (choice D) is used to describe slow relaxation of the muscle after contraction and is characteristic of myotonic muscular dystrophy. The Babinski sign (choice E), also called the extensor plantar reflex, is normal before 18 months of age, but signifies damage of the upper motor neurons in patients older than this. It is also associated with spasticity and increased reflexes. 13) A male infant born at term is found to have bilateral colobomas, choanal atresia, ear anomalies, and cryptorchidism. There is no history maternal drug or alcohol abuse during pregnancy. There is no family history of similar congenital defects. Which of the following is the most appropriate initial test to exclude any associated abnormalities? A. Barium swallow B. Echocardiography C. Fiberoptic bronchoscopy D. Renal ultrasonography E. Skeletal survey Explanation: The correct answer is B. The infant in this clinical vignette likely has the CHARGE syndrome, which includes colobomas, heart defects, choanal atresia, retardation, genitourinary abnormalities, and ear anomalies. With the presence of four anomalies, an echocardiogram is the logical next step to detect any associated heart defect. The etiology of the CHARGE syndrome is unknown, but it may involve altered morphogenesis during the second trimester of pregnancy. It is not genetically transmitted and is not associated with a teratogenic effect of any substance. 14) A 15-year-old girl presents to the emergency department with the sudden onset of watery diarrhea tinged with blood. The girl was previously healthy. Her only medications are topical benzoyl peroxide and oral clindamycin for acne vulgaris. Physical examination reveals a slightly distended abdomen that is diffusely tender. Her temperature is 38.1 C (100.5 F). She has not been exposed to any uncooked meat and has not eaten any unusual foods. Which of the following is the most likely diagnosis? A. Gastroenteritis B. Irritable bowel syndrome C. Pseudomembranous enterocolitis D. Salmonella infection E. Ulcerative colitis Explanation: The correct answer is C. Pseudomembranous enterocolitis is caused by the toxins produced by Clostridium difficile. It occurs in some patients after treatment with antibiotics (especially clindamycin, cephalosporins, and amoxicillin). Patients develop fever and abdominal pain with diarrhea containing leukocytes and blood. Gastroenteritis (choice A) is an acute condition, usually caused by a virus, that presents with vomiting and diarrhea. There is typically no blood in diarrhea associated with gastroenteritis. Irritable bowel syndrome (choice B) is a chronic condition that produces episodic diarrhea with periods of constipation. There often is blood in the diarrhea but it is not associated with a fever. Salmonella infection (choice D) is a common cause of food poisoning. Findings include nausea, vomiting, abdominal pain, and diarrhea, often with blood. Ulcerative colitis (choice E) is a chronic condition that has features of bloody diarrhea, abdominal pain, and weight loss. 15) A 5-year-old boy is brought to an emergency room because of a painful, swollen knee joint. The boy had fallen while playing, and the joint had subsequently begun to swell. The mother reports that the boy was known to have hemophilia B. Replacement of which of the following is indicated? A. Factor C B. Factor S C. Factor VII D. Factor VIII E. Factor IX Explanation: The correct answer is E. Hemophilia B is clinically very similar to hemophilia A, but is due to X-linked deficiency of blood clotting factor IX rather than VIII. This patient needs factor IX replacement to stop his bleeding. The method used for calculating the amount of Factor VIII to give in hemophiliac A patients is to multiply the patient's weight in pounds by 20 and then by the desired plasma level in units. If this algorithm is used in hemophiliac B patients to calculate factor IX levels, it is found that the actual achieved blood levels are only about half that expected, possibly because Factor IX tends to bind to the endothelium of the vessel walls. For this reason, it is important to either monitor the patient for cessation of bleeding or check clotting times before assuming that a calculated dose of Factor IX had its intended effect. Aspiration of blood out of a joint (such as in this case) is usually only attempted after the bleeding process is under control. Factor C (choice A) deficiency and Factor S (choice B) deficiency cause a thrombotic tendency. Factor VII (choice C) deficiency is a rare, autosomal recessive cause of serious bleeding. Factor VIII (choice D) deficiency causes hemophilia A. 16) A 5-month-old male infant has a urine output of less than 0.1 mL/kg/hr shortly after undergoing major surgery. On examination, he has generalized edema. His blood pressure is 94/48 mm Hg, pulse is 140/min, and respirations are 20/min. His blood urea nitrogen is 38 mg/dL, and serum creatinine is 1.4 mg/dL. Initial urinalysis shows a specific gravity of 1.018 and 2+ protein. Microscopic examination of the urine sample reveals 1 WBC per high-power field (HPF), 18 RBCs per HPF, and 5 granular casts per HP F. His fractional excretion of sodium is 3.2 %. Which of the following is the most appropriate next step in diagnosis? A. CT of the abdomen and pelvis B. Cystourethrography C. Intravenous pyelography D. Renal biopsy E. Renal ultrasonography Explanation: The correct answer is E. This infant developed acute renal failure (ARF) in the immediate post-op period, as manifested by the increase in blood urea nitrogen and serum creatinine and the decrease in urine output. ARF can be classified into prerenal, renal, and postrenal. Prerenal causes include hypovolemia secondary to severe dehydration, hemorrhage, and hypotension secondary to shock. Renal causes include acute tubular necrosis (ATN), parenchymal disorders (e.g., glomerulonephritis), and vascular disorders (e.g., renal artery thrombosis or renal vein thrombosis). Postrenal causes include ureteral or urethral obstruction. This infant most likely has ATN, which is caused by ischemic or toxic injury to the nephrons. Ischemia can be caused by hypovolemia, low cardiac output states, or renal vasoconstriction. Toxins include contrast agents, antibiotics, uric acid, and myoglobin. ATN is characterized by mild proteinuria, microscopic hematuria, and the presence of coarse granular casts in the urine. A fractional excretion of sodium greater than 2% (or 2.5% in neonates) is consistent with renal causes of ARF. Renal ultrasonography is the imaging study of choice for this patient because it provides both anatomic and structural information about the kidneys. The study is noninvasive and can be easily done by the bedside. Doppler studies can also be done with ultrasound technology to assess blood flow in the renal vessels, the aorta, and the inferior vena cava. CT of the abdomen and pelvis (choice A) can provide more anatomic details but is not a good initial imaging study, especially in this case. The contrast dye needed for CT can cause further damage to the kidneys and thus worsen renal failure. The same argument applies to intravenous pyelography (choice C). Cystourethrography (choice B) provides structural details of the urinary bladder and the urethra, but it is not indicated in this case. Renal biopsy (choice D) is the gold standard of diagnosing renal disease, but it is not indicated as an initial study. It might be useful in prolonged renal failure with an unidentified cause. 17) A 12-year-old boy presents with a 2-month history of recurrent headache and deteriorating school performance. Neurologic examination is unremarkable except for bitemporal deficits in his visual field. X-ray and MRI of the head are performed. X-ray films show calcifications in the suprasellar region, while MRI images reveal a multicystic tumor displacing the optic chiasm. The patient undergoes neurosurgical operation for excision of the tumor. During the procedure, the surgeon notices that the cystic cavities contain a "machinery oil"-like fluid. Which of the following is the most likely diagnosis? A. Craniopharyngioma B. Cysticercosis C. Ganglioglioma D. Pilocytic astrocytoma E. Pituitary adenoma Explanation: The correct answer is A. Craniopharyngioma is a histologically benign epithelial tumor of odontogenic origin. It is typically located in the suprasellar compartment, extending variably onto the sella, hypothalamus, and optic chiasm. Heavy calcifications, unilocular or multilocular cysts, and a viscous yellow fluid content are the classic features that allow the diagnosis on radiologic and gross examination. Microscopic examination will show a tumor composed of islands of keratinizing epithelium with multifocal calcific deposits, a picture similar to the most common of tooth-related tumors, i.e., adamantinoma (ameloblastoma). Craniopharyngiomas probably originate from misplaced odontogenic epithelium. Location of a neoplasm is often more important than histology with regard to the possibility of definite cure. Craniopharyngioma highlights this rule. Although histologically benign, recurrences are frequent, as the tumor cannot be entirely excised because of its location close to vital structures (hypothalamus, nerves, and blood vessels). Radical surgery is usually accompanied by severe neurologic deficits. Cysticercosis (choice B) is an infestation acquired by eating improperly cooked pork. It leads to formation of (usually multiple) cysticerci, which are cystic structures lined by a characteristic three-layered epithelium and containing a clear fluid. It is often calcified. Ganglioglioma (choice C) is a neuroglial tumor composed of variable admixtures of neoplastic ganglionic (i.e., neuronal) cells and glial cells (either astrocytes or oligodendrocytes). The temporal lobe is the most common location, and seizure is the most frequent clinical manifestation. Grossly, the tumor has cystic and solid components. Pilocytic astrocytoma (choice D) is a well-circumscribed, frequently cystic, low-grade astrocytoma that affects children and young adults. The two most common locations include the cerebellum and the diencephalic/hypothalamic region. It is an important differential to consider in any tumor of the suprasellar region. However, pilocytic astrocytoma is rarely calcified, and the cysts do not contain the "machinery oil" fluid of craniopharyngioma. Pituitary adenoma (choice E) is mainly an intrasellar tumor. A large pituitary adenoma (macroadenoma) may extend into the suprasellar region, but calcifications and cysts are absent. 18) A 6-year-old boy is brought to the pediatrician because of a 3-day history of skin lesions. On physical examination, he has multiple yellow, crusted erosions below the nares and on the cheeks, chin, and upper extremities. The rest of the examination is normal. Which of the following is the most appropriate treatment for this condition? A. Oral acyclovir B. Oral amoxicillin C. Oral cephalexin D. Topical ketoconazole E. Topical 2% hydrocortisone Explanation: The correct answer is C. Bullous impetigo (staphylococcal impetigo) is caused by an epidermolytic toxin produced at the site of infection, most commonly by staphylococci of phage group II. The toxin causes intraepidermal cleavage below or within the stratum granulosum. Bullous impetigo is most common in infants and children. It typically occurs on the face, but it may infect any body surface. There may be a few lesions localized in one area, or the lesions may be numerous and widely scattered. One or more vesicles enlarge rapidly to form bullae in which the contents turn from clear to cloudy. The center of the thin-roofed bulla collapses, and a thin, flat, honey-colored crust may appear in the center with a bright red, inflamed, moist base that oozes serum. In most cases, a tinea-like scaling border replaces the fluid-filled rim as the round lesions enlarge and become contiguous with the others .The border dries and forms a crust. The lesions have little or no surrounding erythema. Regional lymphadenitis is uncommon with pure staphylococcal impetigo. There is some evidence that the responsible staphylococci colonize the nose and then spread to normal skin prior to infection. Serious secondary infections (e.g., osteomyelitis, septic arthritis, and pneumonia) may follow seemingly innocuous superficial infections in infants. The drug of choice for impetigo is oral cephalexin. Cloxacillin, dicloxacillin, and azithromycin are good alteratives. Because some cases of impetigo are due to a mixed staphylococcal/streptococcal infection penicillin and amoxicillin (choice B) are inadequate for treatment. Oral acyclovir (choice A) is used to treat herpes simplex virus infection. Topical ketoconazole (choice D) is to used treat fungal infection of the skin. Topical 2% hydrocortisone (choice E) is ineffective against impetigo. 19) A 2-month-old infant is evaluated by a pediatric cardiologist. The infant was noted at birth to have an upper left sternal border ejection murmur. The infant at that time was not cyanotic, but slowly developed cyanosis over the next two months. At the time of the pediatric cardiologist's examination, an ECG showed right axis deviation and right ventricular hypertrophy. A chest xray film showed a small heart with a concave main pulmonary artery segment and diminished pulmonary blood flow. Which of the following is the most likely diagnosis? A. Complete atrioventricular canal defect B. Hypoplastic left ventricle C. Isolated atrial septal defect D. Tetralogy of Fallot E. Transposition of the great arteries Explanation: The correct answer is D. This is tetralogy of Fallot, in which severe obstruction of right ventricular outflow and a ventricular septal defect allow unoxygenated blood to pass from the right side of the heart to the left. In severe cases, cyanosis presents at birth; in milder cases (such as this baby has), it develops more slowly. The upper left sternal border ejection murmur is due to right ventricle outflow obstruction. The ECG and chest x-ray findings described in the question stem are typical for older babies. Early surgical repair is now recommended for tetralogy of Fallot. Complete atrioventricular canal defect (choice A) characteristically has ECG findings including superior left axis deviation and a counterclockwise loop of electrical impulses. Hypoplastic left ventricle (choice B) causes severe heart failure with loss of peripheral pulses at 2-3 days of life. Isolated atrial septal defect (choice C) could cause a murmur heard at the upper left border of the sternum, but would not show the characteristic x-ray findings illustrated in the question stem. Transposition of the great arteries (choice E) is characterized by severe cyanosis from birth and a normal ECG. 20) A 2 1/2-year-old child is evaluated by a neurologist because of difficulty walking. Neurological examination documents ataxia and mental retardation. The neurologist notes the presence of multiple telangiectasias involving the conjunctiva, ears, and antecubital fossae. The child also has a history of multiple respiratory tract infections. Immunoglobulin studies on the child would most likely demonstrate an absence of which of the following? A. IgA and IgE B. IgA and IgG C. IgE and IgG D. IgE and IgM E. IgM and IgG Explanation: The correct answer is A. The child's condition is the autosomal recessive disease, ataxia-telangiectasia, which is a multisystem disorder of unknown etiology. The ataxia is noticed in early childhood, and with time, progresses to severe disability. Choreoathetoid movements, slurred speech, ophthalmoplegia, and progressive mental retardation characterize the disease at it advances. Telangiectasias, as described in the question stem, are a helpful diagnostic clue. These children also are vulnerable recurrent sinopulmonary infections. Immunologic evaluation may demonstrate a lack of IgA and IgE, cutaneous anergy, and a progressive cellular immune defect. Other features of the syndrome include endocrine disorders and a predisposition for certain cancers (leukemias, brain cancer, and gastric cancer). Most of these patients die of their neurologic deterioration by age 30. IgG (choices B, C, and E) and IgM (choices D and E) are not specifically affected in this condition. 21) A 15-year-old boy with Duchenne muscular dystrophy is brought to the emergency department with increasing respiratory distress and cyanosis. On examination, he is diaphoretic, with gasping respirations, poor air entry, and diminished responsiveness. He is tachycardic at 160 beats/min. His chest x-ray film shows a lingular pneumonia, and he is intubated. He improves over the next 10 days with antibiotics but is not extubated secondary to hypoventilation on weaning because of muscle weakness. Which of the following modalities will most likely help wean him off the ventilator? A. Nasopharyngeal tube B. Pressure controlled ventilation C. Pressure supported ventilation D. Supplemental oxygen E. Tracheostomy Explanation: The correct answer is E. This patient has irreversible muscle weakness, and his tidal volume is diminished, causing impaired alveolar ventilation. The tracheostomy will reduce the dead space and airway resistance. It may allow deep suctioning, helping effect ultimate weaning off the ventilator. The nasopharyngeal tube (choice A) would help only if there were an obstruction between the nose and the posterior nasopharynx. Pressure controlled ventilation is a ventilator mode (choice B) and not an aid to spontaneous ventilation. Pressure supported ventilation (choice C) can improve spontaneous breathing, but the patient would need to remain intubated. Supplemental oxygen will improve oxygenation, but not ventilation (choice D). 22) An 8-year-old male presents to the emergency department with decreased mental status. His mother states that she has noticed he has been drinking and urinating more frequently over the past several weeks. He was hard to wake up this morning and complained of abdominal pain. Physical examination reveals an afebrile drowsy male with clear airways and mild tachycardia. Mucous membranes are dry and his lips are cracked. His abdomen is mildly tender to palpation diffusely, but there is no rebound or guarding. Laboratory evaluation reveals a glucose of 560 mg/dL and potassium of 5.9 mEq/L.An arterial blood gas analysis reveals a pH of 7.18. A urinalysis is positive for ketones and glucose. CT scan of the abdomen is normal. A chest x-ray film is clear. Two hours after initiation of treatment the physician adds potassium to the patient's IV fluids. Which of the following best explains this therapeutic decision? A. Acidosis causes extracellular depletion of potassium B. Hyperglycemia causes potassium to shift to the extracellular space C. Hyperkalemia will protect the patient against dysrhythmias D. Hypokalemia will result as acidosis is corrected E. Potassium should not have been added to the IV fluids Explanation: The correct answer is D. Total body potassium is considerably depleted during diabetic ketoacidosis, even when the serum potassium is normal or elevated. This is due to renal losses from osmotic diuresis cause by hyperglycemia. The intracellular potassium exchanges for extracellular hydrogen ions in an attempt to correct the acidosis. During correction of ketoacidosis, insulin decreases potassium levels. Acidosis (choice A) causes intracellular potassium depletion, as discussed above. Hyperglycemia (choice B) does not cause potassium to shift extracellularly. Hyperkalemia (choice C) does not protect against dysrhythmias. Rather, both hyperkalemia and hypokalemia can induce dysrhythmias. Hyperkalemia is evidenced by peaked T-waves and hypokalemia by U waves on the EKG. Withholding of potassium (choice E) is definitely wrong for this patient. Hypokalemia predisposes the heart to ventricular dysrhythmias. 23) An infant comes to the office for his 1-year check up. His father states that he is worried that his son is smaller than he should be. The child's weight is 8.6 kg (19 lb), and his length is 71 cm (28 in). He appears to be growing appropriately on his growth curve. Which of the following is the most appropriate explanation about growth to be given to the father? A. Infants usually double their birth weight by 1 year B. Infants usually triple their birth weight by 1 year C. Infants usually quadruple their birth weight by 1 year D. Infants usually double their length by 1 year E. Infants usually triple their length by 1 year Explanation: The correct answer is B. Most infants are expected to triple their birth weight by the age of 12 months. Infants usually double their birth weight (choice A) by 6 months, not 1 year. Infants usually quadruple their birth weight (choice C) by 24 months. Infants usually double their length (choice D) by 4 years. Infants do not usually triple their length (choice E) until they are out of infancy and into puberty. 24) A 7-year-old boy arrives at the emergency room in acute distress. Over the past 3 to 4 days he has become progressively ill with generalized fatigue and mild, mid-abdominal pain that have become steadily worse. On physical examination he has a maculopapular rash on his thighs and feet with some spread of the rash to his buttocks. The rash does not blanch and the some lesions near the ankles look petechial or bruised. His temperature is 39.0 C(102.2 F) and he is drawing his knees to his chest for relief of his stomach pains. He is nauseated and vomited once before coming to the hospital. He has semi-soft dark stool, which is guaiac-positive. The boy has not voided since early morning and cannot provide a urine sample. The doctor determines that he is 10% dehydrated and asks the nurse to start intravenous fluids. Which of the following is the most likely diagnosis? A. Pancreatitis B. Rocky Mountain spotted fever C. Nephrotic syndrome D. Henoch-Schnlein Purpura E. Appendicitis Explanation: The correct answer is D. Henoch- Schnlein Purpura (HSP) is the most likely diagnosis. This boy has abdominal pain with guaiac-positive stools, but also has a prominent rash, mostly on his lower extremities. Other characteristic findings of HSP include hematuria and joint pains. The illness may follow an upper respiratory infection or strep throat. The rash starts out as an urticarial rash and progresses to become petechial and purpuric. There may be a history of migratory joint pain and arthritis. Affected joints include ankles, knees, wrists, and elbows. If the abdominal pain were described as epigastric with radiation to the back, pancreatitis (choice A) might have been the likely diagnosis.In children, pancreatitis is frequently associated with viral illnesses (e.g., mumps), drugs (e.g., sulfonamides), or underlying systemic disease (e.g., lupus). Although pancreatitis has been reported in association with HSP, it is not the most likely diagnosis. Rocky Mountain spotted fever (choice B) is one of the most common tick-borne diseases. The typical rash of RMSF appears within a week of the tick bite. It begins on the palms, soles, and extremities and spreads centrally. Severe headache and photophobia are common complaints. This child did not have the typical findings of nephrotic syndrome (choice C) including: proteinuria, edema, and oliguria. Nephrotic syndrome frequently follows an infectious illness. In the classic case of appendicitis (choice E) periumbilical pain progresses with localization to the right lower quadrant.Anorexia, nausea, vomiting and changes in bowel movements may all occur. Fever is typically low-grade and rash is not present. 25) A newborn girl is noted to be drooling saliva, and she chokes violently when she is first fed. On physical examination, she is found to have abdominal distention and an imperforate anus. There is no fistula to the perineum or vagina. Examination of the urine reveals no meconium in it. Echocardiogram and renal sonogram are reported as negative for other congenital defects. Xray films show abundant gas in the gastrointestinal tract. Pictures taken with a metal marker taped to the anus, and the baby hanging upside down, show that there is a significant distance (2.5 cm) between the blind end of the rectum and the anal marker. Before a diverting colostomy is performed, which of the following steps should be taken? A. A soft nasogastric tube passed, and x-rays taken B. Barium injected through the anal dimple C. Barium swallow D. Nasogastric suction for at least 24 hours E. Surgical exploration of the perineum to see whether a primary repair is possible Explanation: The correct answer is A. Although the physical finding of the imperforate anus has given you a diagnosis, the presentation with drooling and choking is classic for esophageal atresia, which is often an associated anomaly (part of the "VACTER" constellation). In fact, the abundance of gas in the gastrointestinal tract is also typical, as the babies get it by way of the distal tracheoesophageal fistula that accompanies the majority of esophageal atresias. The nasogastric tube coiled on itself would confirm the suspected diagnosis, which would significantly alter the surgical plans. Barium injected through the anal dimple (choice B) would probably end up in the tissues, where it would be very irritating. In the absence of a fistula, imperforate anus is not likely to be low. The study would not help define the imperforate anus and would do nothing to diagnose the esophageal problem. Barium swallow (choice C) would demonstrate the esophageal atresia, but at the cost of ending up in the tracheobronchial tree as the baby vomits and aspirates it. Barium is very irritating in that location. If contrast material is needed to demonstrate the atresia, water soluble contrast material would be preferred, and it would have to be promptly sucked out before it also ended up in the lungs. Decompressing the gastrointestinal tract (choice D) would not be possible by nasogastric suction if the esophagus indeed is atretic. If it is patent, the colostomy can be done without prior decompression. If there is a tracheoesophageal fistula, and for some reason it cannot be promptly repaired, a gastrostomy would be required to protect the lungs from aspiration of gastric acid. Attempts to reconnect the anal canal (choice E), when all evidence points to a high blind end, would be pointless and would do nothing to diagnose the other potentially lethal anomaly affecting the esophagus and tracheobronchial tree. 26) A 4-year-old boy presents with severe pains in both of his legs. On physical examination, his temperature is 37.7 C (99.8 F), blood pressure is 108/68 mm Hg, pulse is 96/min, and respirations are 17/min. He is noted to have marked pallor on his lips and palpebral conjunctiva. Numerous purpura and petechiae are noted on his skin. His spleen is palpable 3 cm below his left costal margin. Laboratory evaluation reveals a white blood cell count of 1600/mm3; hemoglobin, 6.1 g/dL; and platelets, 36,000/mm3. Which of the following diagnoses is most consistent with these findings? A. Acute lymphocytic leukemia B. Aplastic anemia C. Henoch-Schnlein purpura D. Immune thrombocytopenic purpura E. Thrombotic thrombocytopenic purpura Explanation: The correct answer is A. This boy most likely has acute lymphocytic leukemia (ALL). The signs and symptoms of ALL result from suppressed marrow function and invasion of organs by leukemic blasts. Anemia is present at diagnosis in most patients and causes fatigue, pallor, headache, angina, or even heart failure. Thrombocytopenia is usually present, and many patients have clinically evident bleeding at diagnosis, usually in the form of petechiae, purpura, ecchymoses, bleeding gums, epistaxis, or hemorrhage. Most patients with ALL are significantly granulocytopenic. In addition to suppressing normal marrow function, leukemic cells can infiltrate normal organs. Enlargement of lymph nodes, liver, and spleen is common at diagnosis. Bone pain, thought to result from leukemic infiltration of the periosteum or expansion of the medullary cavity, is a common complaint. ALL is the most common form of cancer and the second leading cause of death in children younger than 15 years. ALL has a maximal incidence between 2 and 10 years of age, with a second, more gradual rise in frequency later in life. Children with aplastic anemia (choice B) do not usually have bone pain, splenomegaly, and hepatomegaly. Henoch-Schnlein purpura (choice C) is a vasculitis and presents with lower extremity purpura without thrombocytopenia. Immune thrombocytopenic purpura (choice D) is a childhood disease that often follows an acute infection. It is characterized by a decrease in the circulating number of platelets (<100,000/mm3) in the absence of toxic exposure or a disease associated with a low platelet count. It occurs as a secondary effect of peripheral platelet destruction as well as decreased platelet production. It usually resolves spontaneously within 2 months. Thrombotic thrombocytopenic purpura (choice E) is a systemic disorder characterized by occlusion of the microcirculation by platelet clumps. The complete clinical pentad (present in fewer than 30% of cases) includes consumptive thrombocytopenia, microangiopathic hemolytic anemia, fever, renal dysfunction, and fluctuating neurologic deficits. 27) A 13-year-old healthy boy presents to the physician for a routine health maintenance visit. A urinalysis reveals 1+ proteinuria. There is no hematuria or bacteruria. His physical examination is unremarkable, revealing no edema and a normal blood pressure. Which of the following is the most likely diagnosis? A. Acute glomerulonephritis B. IgA nephropathy C. Minimal change disease D. Orthostatic proteinuria E. Urinary tract infection Explanation: The correct answer is D. Orthostatic proteinuria is very common. It occurs when the total urinary protein excretion rate is higher while the child is in an upright position. It is asymptomatic, and there is no associated increase in renal disease. Diagnosis is made by obtaining a "first morning" urine before the child has had much time in an upright position. Acute glomerulonephritis (choice A) usually presents with gross hematuria and may or may not be associated with edema. Severe glomerular injury would be associated with proteinuria. IgA nephropathy (choice B) usually presents with episodic, asymptomatic gross hematuria, with microhematuria occurring between episodes. Proteinuria occurs in more severe, atypical cases. Minimal change disease (choice C) is characterized by proteinuria, hyperlipidemia, edema, and hypoproteinemia. The proteinuria is usually greater than 2+. A urinary tract infection (choice E) may present with 1+ proteinuria but the patient would also more typically have hematuria. The fact that there are no bacteria would make a urinary tract infection less likely. 28) An 8-month-old boy is diagnosed with obstructive hydrocephalus. He was born prematurely after a 26-week gestation to a 25-year-old primigravida and developed seizures and hypoxemia soon after birth. Which of the following is the most likely underlying cause of this clinical course? A. Arnold-Chiari malformation B. Germinal matrix hemorrhage C. Kernicterus D. Periventricular leukomalacia E. Ulegyria Explanation: The correct answer is B. The clinical manifestations are compatible with germinal matrix hemorrhage (GMH). The germinal matrix is a highly vascularized layer of neuroectodermal precursors lining the ventricular cavities, which is most developed between 22 and 30 weeks of intrauterine life. The vessels of the germinal matrix are especially vulnerable to hypoxic insults. Babies born prematurely are thus at high risk of hemorrhage in the germinal matrix region, as they often suffer from poor oxygenation. The pathophysiologic consequences depend on the severity of GMH. Severe forms of GMH extend into the ventricles and result in death, or obstructive hydrocephalus and neurologic deficits later in life. Both types of Arnold-Chiari malformation (choice A) (more frequently type 2) may lead to obstructive hydrocephalus due to compression of the fourth ventricles by the downward displacement of the cerebellar tonsils. Kernicterus (choice C) refers to brain damage due to accumulation of unconjugated bilirubin in the central nervous system. This complication occurs in babies suffering from severe forms of jaundice, e.g., those with erythroblastosis fetalis. Periventricular leukomalacia (choice D) results from ischemic damage to the periventricular white matter in premature babies. In premature infants, the periventricular white matter is more vulnerable to hypoxic injury. Ulegyria (choice E) is a complication related to intrauterine hypoxic injury. The depth of the sulci is more prone to ischemia than the crests of the gyri during intrauterine life. A fetus suffering from early cerebral ischemic damage will thus develop atrophy of the base of the gyri, which then acquire a mushroom-like shape (hence the designation: ulex = mushroom). Germinal matrix hemorrhage, ulegyria, and periventricular leukomalacia are among the causes of perinatal brain injury, which leads to a complex set of neurologic manifestations referred to as cerebral palsy. 29) A young Hispanic couple brings their first child to their physician for a well-child examination. The child is a 3-month-old healthy-appearing infant, whose weight is at the 45th percentile of the normal growth curve. During examination, the physician observes an area of blue-black pigmentation over the buttocks. The parents say that it was present from the time of birth. Which of the following is the most appropriate next step in management? A. Tell parents that this is a normal finding B. Tell parents that this is a bruise caused by trauma C. Order CT/MRI scans to rule out dysraphism D. File a report of suspected child abuse Explanation: The correct answer is A. A Mongolian spot is an area of hyperpigmentation found in 66% of all infants of Hispanic, Asian, and Native American ethnic background. It is sometimes mistaken for a bruise caused by trauma (choice B), and erroneously reported to the authorities as evidence of suspected child abuse (choice D). All physicians, and especially primary care providers, should be aware of this common normal feature in order to avoid such mistakes. An autopsy finding that may be mistakenly attributed to child abuse is postmortem livedo, which is due to blood settling to the dependent parts of the body once circulation stops. CT/MRI studies (choice C) would be useful to rule out the possibility of an underlying neural tube defect (dysraphism) in the presence of a hemangioma in a sacral location. 30) A 14-year-old boy presents with decreased exercise tolerance. He is noted to have a grade III/VI systolic ejection murmur best heard at the left upper sternal border and a grade II/VI middiastolic murmur at the lower left sternal border. The first heart sound is normal. The second heart sound is widely split and fixed. A right ventricular impulse is palpated. On a chest roentgenogram, the pulmonary artery segment is enlarged, and pulmonary vascular markings are increased. An ECG shows right axis deviation. Which of the following congenital heart diseases does this boy most likely have? A. Aortic stenosis B. Atrial septal defect C. Coarctation of the aorta D. Patent ductus arteriosus E. Ventricular septal defect Explanation: The correct answer is B. One of the most common types of structural congenital heart disease to present in adolescence is atrial septal defect (ASD), and the most common presentation is a heart murmur. However, some patients present with arrhythmias, decreased exercise tolerance, or a paradoxic embolus. The physical examination can show classic findings of an ASD; in some cases, however, the findings may be extremely subtle. The murmur associated with the ASD is not caused by blood flow traversing the actual defect but rather by the increased volume of blood flow across the pulmonary valve and, to a lesser extent, across the tricuspid valve. Thus, the murmurs of an ASD are a systolic ejection murmur at the upper left sternal border and a mid-diastolic murmur at the lower left sternal border. The second heart sound is widely split and fixed with regard to respiration. On palpation, a right ventricular impulse is present. The chest radiogram shows evidence of an enlarged pulmonary artery segment in the posteroanterior projection. The superior vena cava shadow may not be visible because of the rotation of the heart secondary to right ventricular volume overload. Pulmonary vascularity is increased, and the heart may be somewhat enlarged. The lateral projection shows the right ventricular enlargement with filling of the retrosternal airspace. The ECG has a normal to rightward axis and a right ventricular volume overload pattern in the precordial leads. An echocardiogram with color Doppler examination can demonstrate the AS D. However, because the atrial septum is a posterior structure, it may not be visualized adequately with a transthoracic echocardiogram; therefore, a transesophageal echocardiogram is frequently necessary for diagnosis. Closure of the defect is recommended for patients with ASD to decrease the risk of pulmonary vascular obstructive disease, stroke, and arrhythmias. Aortic stenosis (choice A) is often associated with bicuspid aortic valve and presents with dyspnea on exertion, chest pain, and syncope. A harsh systolic ejection murmur is typically heard at the right upper sternal border. Coarctation of the aorta (choice C) results in obstruction between the proximal and the distal aorta. On examination, the femoral pulses are weak and delayed relative to the brachial pulses. Turner syndrome must be considered in a girl with coarctation of the aorta. Patent ductus arteriosus (PDA) (choice D) usually presents with a "machinery murmur" that is continuous beginning after S1, peaking at S2, and trailing off during diastole. Indomethacin is often effective in closing the PDA in premature infants. Ventricular septal defect (choice E) is the most common congenital defect of the heart and usually presents with a wide spectrum of symptoms including growth failure, congestive heart failure, and chronic lower respiratory infections. Patients with small defects might be asymptomatic but would have a holosystolic murmur. 31) A 17-year-old girl presents to the emergency department with a 2-day history of a painful and swollen right big toe. She also has had a fever, with temperatures up to 38.9 C (102 F), at home for 2 days. On physical examination, her temperature is 101.8 F (38.8 C). Her first metatarsal joint of the right foot is markedly swollen and very painful to touch. An aspirated fluid from the joint reveals a white blood count of 35,000/ mm3. Which of the following is the most likely diagnosis? A. Juvenile rheumatoid arthritis B. Gout C. Lyme disease D. Pseudogout E. Septic arthritis Explanation: The correct answer is E. Septic arthritis refers to microbial invasion of the synovial space. Pathogens enter the synovial space by either hematogenous spread, local spread from contiguous infection, or a traumatic or surgical infection of the joint space. Accumulating fluid and pus rapidly raise the intraarticular pressure and permanently injure vessels and articular cartilage. More than 90% of cases of septic arthritis affect the joints of the lower extremity, with the knee most commonly involved. Acute septic arthritis is bacterial, with Staphylococcus aureus the most common organism, followed by group A streptococci and Streptococcus pneumoniae. Other organisms to consider vary by age groups. Haemophilus influenzae is common in children younger than 3 years, but the incidence is decreasing with Hib vaccine. Neisseria gonorrhoeae may be isolated in neonates and sexually active adolescents. The teenage girl in this clinical vignette most likely has N. gonorrhoeae. Group B beta-hemolytic streptococci is an important cause in neonates. Sickle cell patients are at risk for Salmonella infection. Most children with septic arthritis appear ill and present with fever, joint pain, joint swelling, and limited movement of the affected joint. The pain is often severe and constant, with increased pain when the infected joint is moved. On physical examination, the joint is typically flexed to limit motion; local erythema, warmth, and swelling may be present. In septic arthritis of the hip, the joint is often flexed, with slight abduction and external rotation, and limitation of internal rotation with passive motion. When septic arthritis is suspected, diagnostic studies should include a complete blood count (CBC), blood cultures, an erythrocyte sedimentation rate (ESR), and plain radiographs. If the patient is febrile with an elevated ESR and CBC, the joint should be aspirated and the fluid sent for analysis. Only one third of cases will have a positive Gram's stain. Up to 80% of joint fluid cultures may be positive, but the yield decreases with antibiotic use. Findings on plain radiographs may include joint space widening, increased opacity of the joint space, local soft tissue swelling, distortion of periarticular fat or muscle shadows, and lateral displacement or dislocation of the femoral head. Treatment of septic arthritis includes surgical drainage of the purulent material from the joint and IV antibiotics. The choice of antibiotic should be based partly on the age of the patient to ensure coverage of the most likely causative organism. Empiric coverage should include an antistaphylococcal agent, either a beta-lactamase-resistant penicillin or a first-generation cephalosporin. Appropriate gram-negative coverage must be provided to neonates and adolescents. Juvenile rheumatoid arthritis (choice A) is characterized by chronic synovitis and systemic inflammatory manifestations. Gout (choice B) is characterized by serum uric acid elevation and urate deposition in the joint. It commonly affects the first metatarsal joint. Lyme disease (choice C) is a tick-borne illness caused by Borrelia burgdorferi. It can present with fever, myalgias, and arthritis. Pseudogout (choice D) refers to the deposition of calcium pyrophosphate dihydrate in the joint. Neither gout nor pseudogout are common disorders in children. 32) A 4-week-old boy is brought to clinic by his mother because of a 1 day history of labored breathing. His birth was uneventful and immunizations have been up to date. His mother reports that the patient developed conjunctivitis on the fourth day of life. On physical examination, he is breathing rapidly at 40 breaths per minute and is afebrile. His chest reveals bilateral inspiratory crackles and a slight wheeze. On chest x-ray, bilateral pneumonia is evident. The leukocyte count is elevated at 15,000 with 40% eosinophils. Which of the following is the most likely pathogen causing the patient's symptoms? A. Ascaris lumbricoides B. Chlamydia trachomatis C. Mycoplasma pneumoniae D. Pneumocystis carinii E. Varicella zoster virus Explanation: The correct answer is B. This patient presents with symptoms consistent with neonatal pneumonia due to Chlamydia trachomatis. This agent is transmitted from the mother's vaginal secretions to the neonate at birth. The conjunctivitis precedes the pneumonitis. Tachypnea, hypoxemia, crackles, wheezing and eosinophilia are seen. Ascaris lumbricoides(choice A) produce visceral larva migrans and can cause pneumonia and eosinophilia. However, this is caused by ingestion of Ascaris eggs passed by dogs and cats. Mycoplasma pneumoniae(choice C) is the etiologic agent in atypical pneumonias in young people, but not in neonates. Pneumocystis carinii(choice D) causes pneumonia in patients with acquired immune deficiency syndrome and other immunocompromised patients. Varicella(choice E) pneumonia is accompanied by skin lesions. Furthermore, eosinophilia is not seen. 33) A 15-year-old girl with type 1 diabetes mellitus presents to her primary care doctor for a routine check up. Perusal of her blood sugar chart indicates that her recorded blood glucose levels are routinely between 120 and 150 mg/dL before breakfast, dinner and bedtime, with the normal being 116 mg/dL. She is on NPH and regular insulin. Which of the following is the next appropriate step? A. Decrease the dosage of NPH B. Decrease the dosage of Regular insulin C. Make no changes and obtain a glycosylated Hb test D. Increase the dosage of NPH E. Decrease the dosage of Regular insulin Explanation: The correct answer is C. The patient has near perfect glycemic control. However, she may be experiencing higher levels with snacks, and compliance is often an issue in adolescents. Her near perfect glucose levels are a bit suspicious, and it is advisable to obtain a glycosylated hemoglobin level. This is an indication of the average glucose level over the past three months, and would give insight into the overall glycemic control in this patient. Decreasing the NPH dose might increase glucose levels 4-6 hours later (choice A) since the time of peak NPH action is around that amount of time. Decreasing the regular dose would lead to an increase in glucose levels 30 minutes later (choice B). Increasing the NPH level would decrease glucose levels 4-6 hours later (choice D). Increasing the regular dosage would decrease glucose levels 30 minutes later (choice E). 34) A newborn infant is noted to have microcephaly after birth. His mother is 38 years old. She also has a 5-year-old son who is mentally retarded and she had one previous second-trimester miscarriage. In addition, she has a genetic disease that required a special diet, but she discontinued the diet many years ago. On physical examination, the infant's weight and length are both below the 10th percentile for his gestational age. He is also noted to have a grade III systolic ejection murmur best heard at the lower left sternal border. Which of the following conditions does the mother most likely have? A. Fragile X syndrome B. Galactosemia C. Hypothyroidism D. Maple syrup urine disease E. Phenylketonuria Explanation: The correct answer is E. The mother had phenylketonuria (PKU) early in her life. Many clinically normal female PKU patients, who were treated with diet early in life, discontinue dietary treatment and have marked hyperphenylalaninemia by the time they reach childbearing age. Most children born to such women are mentally retarded and microcephalic, and 15% have congenital heart disease, even though the infants themselves are heterozygotes. This syndrome, known as maternal PKU, results from the teratogenic effects of phenylalanine or its metabolites (which cross the placenta), affecting specific fetal organs during development. It is very important that maternal dietary restriction of phenylalanine is initiated before conception and continues throughout the pregnancy. The biochemical abnormality in PKU is an inability to convert phenylalanine into tyrosine. With a block in the phenylalanine metabolism secondary to lack of phenylalanine hydroxylase, minor shunt pathways come into play. This produces metabolites, such as phenylpyruvic acid, phenyllactic acid, phenylacetic acid, and -hydroxyphenylacetic acid, which are excreted in large amounts in the urine in PKU. Some of these abnormal metabolites are excreted in the sweat, and phenylacetic acid, in particular, imparts a strong musty or mousy odor to affected infants. It is proposed that excess phenylalanine or its metabolites contribute to the brain damage and mental retardation in PKU. Homozygotes with this autosomal recessive disorder classically have a severe lack of phenylalanine hydroxylase, leading to hyperphenylalaninemia and PKU. Affected infants are normal at birth but, within a few weeks, develop a rising plasma phenylalanine level, which in some way impairs brain development. Usually by 6 months of life, severe mental retardation becomes evident. Seizures, other neurologic abnormalities, decreased pigmentation of hair and skin, and eczema often accompany the mental retardation in untreated children. Hyperphenylalaninemia and the resultant mental retardation can be avoided by restricting phenylalanine intake early in life. Hence, a number of screening procedures are routinely used for detection of PKU in the immediate postnatal period. Fragile X syndrome (choice A) is an X-linked disorder that results in mental retardation of various degrees. Galactosemia (choice B) is an autosomal recessive disorder of galactose metabolism that causes significant damage to the liver, eyes, and brain. Congenital hypothyroidism (choice C) is associated with cretinism and severe mental retardation. It occurs in 1 in 7000 births and is amenable to in utero diagnosis and treatment. Maple syrup urine disease (choice D) is a familial cerebral degenerative disease caused by a defect in branched chain amino acid metabolism and characterized by severe mental and motor retardation and urine with a maple-syrup-like odor. 35) A 5-month-old infant presents with diarrhea and decreased activities for the past 3 days. On physical examination, his pulse is 162/min. His anterior fontanelle is sunken, and he has skin tenting. Laboratory investigation reveals sodium, 165 mEq/L; potassium, 5.8 mEq/L; chloride, 128 mEq/L, bicarbonate, 14 mEq/L; creatinine, 0.9 mg/dL; blood urea nitrogen, 49 mg/dL; and glucose, 154 mg/dL. Eight hours after IV fluid therapy is started, the infant develops a generalized seizure. Which of the following is the most likely etiology of the seizure? A. Hyperglycemia B. Hyperkalemia C. Idiopathic epilepsy D. Rapid correction of hypernatremia E. Rapid correction of metabolic acidosis Explanation: The correct answer is D. The infant in this clinical vignette has developed hypernatremic (Na, 165 mEq/L) dehydration from the diarrhea. Hypovolemic patients who have hypernatremia have a relatively greater loss of water than of sodium. Initial therapy requires administration of normal saline or Ringer's lactate to restore an effective circulating plasma volume. Five percent albumin solution or plasma also can be used. These patients require a hypotonic solution containing salt to restore the Na+ deficit (2-5 mEq/kg of body weight) and to begin the Na+ maintenance (3 mEq/kg of Na+ ) in a solution containing 20-40 mmol/L of KCl and 5% glucose. For a serum Na+ concentration of 150-160 mEq/L, this volume should be given over a 24-hour period. Because extracellular fluid osmolarity may fall more rapidly than the brain can dissipate the idiogenic osmoles generated to protect intracellular osmolarity, an elevated serum Na+ concentration should be corrected by no more than 10 mEq/L per day. For a serum Na+ concentration >160 mEq/L, the rehydration should be spread out over the number of days necessary to lower the Na+ concentration to 150 mEq/L at a rate of 10 mEq/day (e.g., 2 days for a Na+ of 170 mEq/L). Both the daily fraction of the deficit and the daily maintenance requirement should be provided. The degree of hypotonicity of the fluid administered is less important than the rate of correction. If hypernatremia is corrected too rapidly, the brain cells can be swollen beyond the cell volume restored by the osmoles, resulting in seizures. Hyperglycemia (choice A) is not a common case of seizure. Hyperkalemia (choice B) causes arrhythmias. Idiopathic epilepsy (choice C) is much less likely in this clinical vignette. Rapid correction of metabolic acidosis (choice E) does not cause seizures. 36) A 4-year-old girl is found drinking a bottle of liquid drain cleaner and is immediately brought to the emergency department. She appears to be very irritable and is unwilling to swallow any liquid. Examination of her oral cavity reveals no evidence of burns or ulcerations. Which of the following is the most appropriate management of this patient? A. Barium swallow B. CT of the abdomen C. NPO for 12 hours, then clear liquid diet for 3 days D. Indirect laryngoscopy E. Esophagoscopy Explanation: The correct answer is E. Ingestion of corrosive material is a rather common problem in pediatrics. Annual incidence ranges from 5000 to 15,000. The most common corrosive substances ingested by children include household cleaners, detergents, bleaches, disk batteries, and coins. Liquid drain cleaner is a highly alkaline substance, and ingestion can cause severe esophageal necrosis of the liquefaction type. Full-thickness injury is common. In severe cases, it can cause esophageal perforation and mediastinitis. Acid ingestion causes coagulation necrosis and eschar formation. The eschar tends to protect the esophagus from full-thickness injury and corrosive perforation. When a child has a definitive history of ingestion of corrosive substance, he or she needs to be evaluated emergently. Especially in this case, dysphagia further suggests the presence of esophageal injury. Even though there are no ulcerations or burns in the mouth, esophageal ulceration is very likely because oral lesions correlate poorly with esophageal injuries. The child should be stabilized, and flexible esophagoscopy is indicated to directly visualize the esophagus. It might be prudent to perform a chest radiograph first to rule out overt perforation and mediastinitis. If esophagoscopy shows no esophageal injury, no treatment is necessary. For mildto-moderate burns, therapy should include IV hydration, analgesics, and antibiotics. Complications include esophageal stricture. Prevention is better than treatment. When there is young child at home, corrosive substances should always be put in a safe place, out of the child's reach. Pediatricians should also address this issue with the parents and give appropriate anticipatory guidance on routine office visits. Barium swallow (choice A) is not appropriate in the setting of acute corrosive injury of the esophagus. CT of the abdomen (choice B) is not indicated unless there are peritoneal signs that suggest stomach perforation and peritonitis. NPO for 12 hours, then liquid diet for 3 days (choice C) without further evaluation by esophagoscopy is inappropriate. Indirect laryngoscopy (choice D) is not indicated unless there is a burn of the larynx that might result in laryngeal edema. 37) A 4-year-old girl with sickle cell disease presents to the emergency department with a temperature of 39.6 C (103.2 F). Other than irritability, the physical examination is unremarkable. Laboratory evaluations reveal a white blood cell count of 18,200/mm3, with 88% polymorphonuclear neutrophils, 10% lymphocytes, and 2% monocytes, and a hemoglobin of 7.6 g/dL. Which of the following is the most appropriate next step in management? A. Observe the child pending blood culture results B. Administer amoxicillin orally C. Administer ceftazidime and gentamicin intravenously D. Administer ceftriaxone intravenously E. Administer vancomycin and gentamicin intravenously Explanation: The correct answer is D. Children with sickle cell disease are at risk of serious bacterial infection and sepsis because they have impaired splenic function. Sepsis in these children is often caused by encapsulated organisms such as Streptococcus pneumoniae and Haemophilus influenzae type b. The course of the infection, if uncontrolled by appropriate antibiotic treatment, can be overwhelming and results in rapid deterioration and eventual death. Blood cultures, preferably two sets, should be obtained promptly before the initiation of antibiotic therapy. However, antibiotics should not be delayed while waiting for the culture results (choice A). Intravenous ceftriaxone is the most commonly used antibiotic in a febrile child with sickle cell disease. It is effective against both S. pneumoniae and H. influenzae. Orally administered amoxicillin (choice B) is not adequate for bacteremia or sepsis in a child with sickle cell disease and fever. Combined therapy of ceftazidime and gentamicin (choice C) is used against suspected Pseudomonas aeruginosa infection in patients with neutropenia or cystic fibrosis. Although combination therapy with vancomycin and gentamicin (choice E) covers a wide range of gram-positive and gram-negative organisms, it is not indicated in a febrile child with sickle cell disease. 38) A previously healthy 13-year-old girl presents to the emergency department with an acute onset of red urine after she played soccer in the morning. Her physical examination is unremarkable. Urinalysis shows a red color; pH, 6.2; specific gravity, 1.024; glucose, negative; blood, +4; protein, trace; nitrite, negative; leukocyte esterase, negative; white blood cell, 0/hpf; red blood cell, 1/hpf. Which of the following is the most likely explanation of the red urine? A. Glomerulonephritis B. Hematuria C. Ingestion of food coloring D. Myoglobinuria E. Presence of urates F. Trauma G. Urinary tract infection Explanation: The correct answer is D. Red urine can be caused by gross hematuria, hemoglobinuria, myoglobinuria, certain foods or medications (e.g., rifampin, nitrofurantoin, chloroquine, azo dyes, beets, and blackberries), and the presence of urates. The strip-test for blood in a urinalysis does not test directly on red blood cells; rather it tests the presence or absence of hemoglobin. It is sensitive to 5-20 red blood cells per high power field (hpf) in the urine, but it is even more sensitive to free hemoglobin. Because of the structural similarity of myoglobin and hemoglobin, the strip-test reagents also react to myoglobin. Therefore, a positive test for "blood" in a strip test of urinalysis can mean red blood cells, hemoglobin, or myoglobin. It is important to perform microscopic analysis of the urine to distinguish between these possibilities. In this case, the absence of a significant number of red blood cells (1 RBC/hpf) does not qualify for hematuria, and the presence of 4+ blood on the strip test is consistent with myoglobinuria or hemoglobinuria. The fact that it happens abruptly after vigorous exercise further suggests that the red urine might be secondary to myoglobinuria, which happens not uncommonly after exercise. It is important to confirm with a quantitative test of urine myoglobin. The serum creatinine phosphokinase (CK) level should also be tested for possible rhabdomyolysis. If rhabdomyolysis is present with elevated creatinine phosphokinase, the patient should be admitted for aggressive IV hydration and treatment with sodium bicarbonate to alkalinize the urine to prevent precipitation of the myoglobin in the renal tubules. The absence of more than 3-5 RBC/hpf rules out glomerulonephritis (choice A) and hematuria (choice B). Glomerulonephritis would also be characterized by red cell casts upon urinalysis. Ingestion of food coloring (choice C) is possible but less likely without any supporting history, and the urinalysis should be negative for blood in that case. The presence of urates (choice E) in the urine can cause "red diaper syndrome" in infants younger than 6 months. It is due to physiologic high excretion of uric acid in infants. However, the urinalysis should be negative for blood. Trauma (choice F) can cause renal contusion and various degrees of hematuria. Urinary tract infection (choice G) occasionally causes gross hematuria. Urinalysis is usually positive for nitrite, leukocyte esterase, and WBCs. 39) A 4-year-old boy, who has a ventriculoperitoneal shunt for congenital hydrocephalus, develops fever, headache, irritability, lethargy, photophobia, and vomiting. His temperature is 39.6 C (103.2 F). He is noted to have nuchal rigidity, with the presence of both Kernig's and Brudzinski's signs. The shunt tract is erythematous on the surface. A lumbar puncture is performed and shows a WBC of 40,000/mm3 with 85% neutrophils, a glucose concentration of 48 mg/dL, and a protein concentration of 169 mg/dL. Which of the following is the most likely pathogen? A. Haemophilus influenzae B. Neisseria meningitidis C. Pseudomonas aeruginosa D. Staphylococcus epidermidis E. Streptococcus pneumoniae Explanation: The correct answer is D. Unlike meningitis occurring in normal children, ventriculoperitoneal shunt infections are most commonly caused by coagulase-negative Staphylococcus, such as Staphylococcus epidermidis. S. epidermidis causes 40% to 60% of all CSF infections in persons with ventriculoperitoneal shunts. Coagulase-negative Staphylococcus presents a significant threat to people who have indwelling devices or catheters. Most S. epidermidis isolates are resistant to multiple antibiotics, including nafcillin and oxacillin. Vancomycin is the drug of choice to S. epidermidis infection. Removal of the indwelling medical device and parenteral antibiotic treatment are often necessary. Kernig's sign is positive if when the thigh is flexed at a right angle, complete extension of the leg is not possible, or causes exquisite pain. A positive Brudzinski's sign is when bending of the neck causes flexion of the hips. Both signs are used to test nuchal rigidity in evaluating patients for meningitis. Haemophilus influenzae(choice A), Neisseria meningitidis (choice B), and Streptococcus pneumoniae(choice E) are the most common pathogens of meningitis in normal hosts. Pseudomonas aeruginosa(choice C) is a rare cause of meningitis in children, with or without ventriculoperitoneal shunt. 40) A female infant is born by vaginal delivery at 39 weeks' gestational age without any significant complications. There is no history of any genetic diseases in the family. She is noted to have a port-wine stain on the right side of her face that is 4 cm in length and 3 cm in width. Which of the following treatment modalities offers the best palliation for cosmetic purposes? A. Cryosurgery B. Pulsed dye laser C. Radiation therapy with gamma particles D. Skin grafting E. Topical corticosteroid therapy Explanation: The correct answer is B. Port-wine stains are vascular malformations on the skin, and most commonly occur on the face. Over time, port-wine stains darken and pose psychological stress to the affected person because of cosmetic reasons. Port-wine stains rarely disappear on their own, and the most effective therapy is pulsed dye laser. Pulsed dye laser reduces the size of most port-wine stains, and in some cases can eradicate the stain completely. Factors affecting the response to pulsed dye laser include location, timing, and size. Smaller port-wine stains respond better than the bigger ones. The earlier the treatment takes place, the better the response. Cryosurgery (choice A), radiation therapy (choice C), skin grafting (choice D), and topical corticosteroids (choice E) are not appropriate treatment for port-wine stains. 41) A 4-year-old, apparently healthy child is examined by a pediatrician. The pediatrician hears a loud systolic ejection murmur with a prominent systolic ejection click. He also hears a soft, early diastolic murmur. Both murmurs are heard best at the upper right sternal border. ECG shows left ventricular hypertrophy. Which of the following is the most likely diagnosis? A. Aortic valve stenosis B. Atrial septal defect C. Tetralogy of Fallot D. Transposition of great arteries E. Ventricular septal defect Explanation: The correct answer is A. This is aortic valve stenosis, which accounts for 5% of diagnosed cardiac defects, but may actually be the most common congenital anomaly of the heart since many minor cases are never diagnosed. Most cases are due to bicuspid aortic valves, and characteristically produce a systolic ejection murmur. An accompanying aortic insufficiency may produce an early diastolic murmur. The timing of surgical correction depends on the severity of the individual case. Atrial septal defect (choice B) causes a murmur heard best at the left upper sternal border. Tetralogy of Fallot (choice C) and transposition of great arteries (choice D) usually present in infancy. Ventricular septal defect (choice E) causes a murmur heard best at the lower left sternal border. 42) A 6-year-old girl with acute lymphocytic leukemia (ALL) is admitted to the hospital with a generalized vesicular rash and high fever. She has no previous history of chickenpox and has never received immunization for varicella. Her 4-year-old sister recently recovered from chickenpox that started about 10 days ago. On admission, her temperature is 38.4 C (101.1 F), blood pressure is 94/58 mm Hg, pulse is 80/min, and respirations are 20/min. Which of the following is the most serious complication of varicella that might occur in this patient? A. Arthritis B. Cellulitis C. Endocarditis D. Hepatitis E. Pneumonia Explanation: The correct answer is E. Varicella (chickenpox) usually presents with cutaneous infection in immunocompetent hosts. However, in immunocompromised patients, such as this girl with acute lymphocytic leukemia (ALL), varicella can cause serious and life-threatening complications, such as varicella pneumonia. Varicella pneumonia has a very poor prognosis in patients with ALL, reaching a mortality of roughly 25%. The clinical course usually deteriorates rapidly and many patients die within 3 days of the diagnosis. Pneumonia is exceedingly rare in normal children, but it can happen in older adults. IV acyclovir therapy is indicated in immunocompromised patients with varicella infection. Therapy should be initiated early in the disease course to maximize efficacy of the treatment. Varicella-zoster immune globulin (VZIG) may modify the disease course if it is given shortly after the exposure. It is not useful, however, once the disease is established, as in this clinical vignette. Children with varicella also should not be given salicylates because of a theoretically increased risk of subsequent Reye syndrome. Patients should be both contact- and airborneisolated during the entire course of the illness. Other, less common, complications include encephalitis, hepatitis, glomerulonephritis, arthritis, and thrombocytopenia. 43) A 5-year-old boy suddenly begins coughing while eating peanuts. He is choking and gagging. When he is brought to the emergency department, but he is awake and is able to give his name. On physical examination, his vital signs are stable. On examination of the chest, inspiratory stridor and intercostal and suprasternal retractions are apparent. Which of the following is the most appropriate initial step in management? A. Allow patient to clear foreign object by spontaneous coughing B. Clear oropharynx with multiple blind sweeps with finger C. Position patient and perform back blows D. Stand behind patient and perform abdominal thrusts E. Perform emergency tracheostomy and take to surgery Explanation: The correct answer is A. Since the patient can cough and breathe, he should be allowed to clear the foreign object spontaneously, if possible. In the management of foreign object obstruction, if the patient can cough and breathe, it is best to initially observe and allow spontaneous resolution, since intervention may actually be damaging. Often, blind finger sweeps (choice B) may remove the foreign object and resolve the symptoms. Also, this will need to be done if the patient is to be intubated. The next step would be performing back blows if the patient was less than 1 year of age (choice C). If the patient were over 1 year old, abdominal thrusts would be the next management option (choice D). An emergency tracheostomy (choice E) should be the last option and should be undertaken only by a physician trained to perform the procedure. 44) A 9-year-old boy presents with a 3-month history of multiple episodes of sudden awakening at night. His mother states that when he wakes up suddenly, he screams, "Go! Get away! Go!" and does not respond to the parents. His eyes are wide open, and he sweats heavily and looks scared. The parents have had to struggle to awaken him. After the episodes, he has no memory of what happened. Which of the following is the most likely diagnosis? A. Confusional arousals B. Night terrors C. Nightmares D. Obstructive sleep apnea E. Panic disorder Explanation: The correct answer is B. Night terrors are a form of parasomnias. Parasomnias refer to unusual behaviors that occur in the context of sleep, specific sleep stages, or in connection with arousal from sleep. Night terrors are most common in children aged 4-12 years and typically occur within the first several hours of sleep. They are characterized by the child suddenly crying out, sitting up in bed with a terrified look, crying inconsolably, perhaps thrashing about, and exhibiting evidence of increased autonomic arousal with enlarged pupils, tachycardia, rapid breathing, and sweating. These episodes typically last only a few minutes, and the child then returns to sleep, with no memory of the events the next morning. Night terrors are believed to be disorders of arousal from non-REM sleep (stage 3 and 4), in which motor behavior occurs, but conscious awareness and memory of the action are not present. They are more likely to take place during periods of illness, stress, or sleep deprivation, but they can happen without any obvious associated stress. Those subject to night terrors or somnambulistic events should avoid sleep deprivation, which can increase the likelihood of their occurrence. Most children with infrequent night terrors grow out of them with maturity and usually require no specific treatment. Clinicians should thoroughly explain the phenomenon to the parents and reassure them that the child is well. The expected eventual remission of the problem should be emphasized. Parents are encouraged not to awaken the child, but to allow the episode to run its course. If the child is not awakened, he or she will return to normal sleep at the end of the episode. If the child thrashes about wildly during the episode, the parents should provide protection from injury at that time. Confusional arousals (choice A) start gradually (unlike a full sleep terror in older individuals, which begins precipitously), with moaning progressing to crying, sitting, and thrashing. The children are difficult to arouse and do not respond to comforting, but when allowed to return to sleep, they do not typically remember the event the next morning. Nightmares (choice C) are frightening dreams that awaken the child from REM sleep. The child becomes fully awake and is scared. He or she usually can recall details of the dream. Obstructive sleep apnea (choice D) manifests as apneic episodes during sleep in which the patient awakens suddenly. Affected patients usually are obese. Panic disorder (choice E) is characterized by recurrent panic attacks, which initially may occur spontaneously and, over time, may develop in a number of agoraphobic situations. The patient may experience a sense of terror or fear associated with a panic attack, including concerns about dying, going crazy, or losing control. 45) A mentally retarded 10-year-old boy presents with arthritis, nephrolithiasis, and progressive renal failure. Since his first years of life, he manifested peculiar neurologic abnormalities consisting of self-mutilative biting of the lips and fingers, choreoathetosis, and spasticity. Two male relatives on his mother's side presented with a similar condition and died in their teens. Which of the following is the most likely diagnosis? A. Chronic lead intoxication B. Fragile-X syndrome C. Gout D. Huntington disease E. Lesch-Nyhan syndrome Explanation: The correct answer is E. Lesch-Nyhan syndrome was described in 1964 in two brothers who manifested self-mutilative behavior, choreoathetosis, and mental retardation beginning in their first year of life. This X-linked hereditary disorder is due to complete deficiency of hypoxanthine phosphoribosyltransferase (HPRT), an enzyme that catalyzes the "salvage" pathway of purines. A salvage pathway deficiency results in increased "de novo" synthesis of purines, with consequent overproduction of uric acid. This is why patients with deficient HPRT develop hyperuricemia, with secondary uric acid stones, renal impairment, and gouty arthritis. Lesch-Nyhan syndrome is also characterized by self-mutilative behavior, choreoathetosis, and mental retardation, which manifestations are still largely unexplained. Renal failure is the most frequent cause of death. Chronic lead intoxication (choice A) affects the nervous, gastrointestinal, and hematopoietic systems. Behavioral anomalies, hypochromic microcytic anemia, and peripheral neuropathies are the most common manifestations. Children are particularly vulnerable to lead intoxication. Fragile X syndrome (choice B) is the most common cause of mental retardation if Down syndrome is excluded. The condition is due to a triplet repeat expansion in the X chromosome and manifests with mental retardation and macroorchidism, among other, less common anomalies. Gout (choice C) is a systemic condition resulting from hyperuricemia. The joints and the organs are primarily affected, with recurrent attacks of acute arthritis most often involving the first metatarsophalangeal joint, ankle, heel, knee, wrist, fingers, and elbow. A positive family history is frequently present, but most cases are due to unknown metabolic defects resulting in overproduction or decreased excretion of uric acid. Extra-articular manifestations include formation of urate stones in the urinary tract, uric acid nephropathy, and tophi formation. Huntington disease (choice D) is an autosomal dominant neurodegenerative disorder caused by a triplet repeat expansion in a gene encoding a novel protein of unknown function. It manifests in the third or fourth decade with chorea and progressive dementia. Patients frequently present a strong propensity towards suicide. 46) A previously healthy 7-year-old girl comes to the office with complaints of episodic abdominal pain over the past several months. The pain is periumbilical and sharp but does not wake her from sleep or interfere with play. She has no fever, joint complaints, or constipation or diarrhea. Growth and development have been normal. The physical examination is within normal limits. Which of the following is the most likely diagnosis? A. Acute appendicitis B. Acute cholecystitis C. Crohn disease D. Functional abdominal pain E. Irritable bowel syndrome Explanation: The correct answer is D. Functional abdominal pain is pain that lasts for more than 3 months and often interferes with normal activity. The pain is periumbilical and often hard to describe. The pain typically does not awaken patients from sleep or interfere with pleasant activities. The pain is real and is the result of the regulation of gastrointestinal motility in response to either psychological or physical stress. Acute appendicitis (choice A) usually occurs with right lower quadrant pain, fever, and anorexia. The chronic nature described in the question would rule out acute appendicitis. Acute cholecystitis (choice B) presents with right upper quadrant pain and vomiting, and again the history of several months of symptoms would rule out this diagnosis. Crohn disease (choice C) would usually present with abdominal pain, diarrhea (usually loose with blood), and anorexia. Although the abdominal pain lasts several months, such as in this case, it usually causes weight loss and delayed growth. Irritable bowel syndrome (choice E) would cause abdominal pain that could last several months. This condition would also typically cause bouts of diarrhea alternating with constipation. 47) A 1 1/2 -year-old girl is sent to a children's hospital for evaluation following a nosebleed which was so severe as to require nasal packing and transfusion of platelet concentrates. When a blood sample had been drawn in the emergency room for serum chemistry studies, the local hospital laboratory had noted that the clot that formed was unusual in that it failed to retract. Peripheral blood smear obtained by finger puncture showed an appropriate number of normalsized platelets, all of which were individual, without clumping. At the children's hospital, it was noted that the child's parents were cousins. Special platelet studies showed that the child's platelet's failed to aggregate with any physiologic aggregating agent, including a high concentration of exogenous ADP. Which of the following is the most likely diagnosis? A. Bernard-Soulier syndrome B. Chediak-Higashi syndrome C. May-Hegglin anomaly D. Thrombasthenia E. Von Willebrand disease Explanation: The correct answer is D. This patient has thrombasthenia. This rare genetic disorder of platelet function has autosomal recessive inheritance. The biochemical defect appears to be a lack of the platelet membrane glycoprotein GPIIb-IIIa. This protein normally can bind to fibrinogen, and in its absence, platelet aggregation (and the resulting clot retraction) can not occur. The laboratory findings listed in the question stem are typical. Affected individuals have a particular problem with severe bleeding from mucosal surfaces, which commonly undergo minor traumas. Bernard-Soulier syndrome (choice A) is characterized by very large platelets. Chediak-Higashi syndrome (choice B) is an immunodeficiency disease with defective microbicidal activity after phagocytosis and unusually large platelets. May-Hegglin anomaly (choice C) is a thrombocytopenic disease with abnormal neutrophils. Von Willebrand disease (choice E) is due to an abnormality of factor VIII related von Willebrand factor that secondarily affects platelet function. 48) A 2-year-old girl is brought to the clinic with headache, vomiting, and pallor. Her blood pressure is 130/80 mm Hg. On physical examination, she is noted to have aniridia and a large abdominal mass. Abdominal scanning reveals a poorly vascularized tumor in the upper pole of the right kidney. Which of the following is the most likely cause of this presentation? A. Deletion of a gene on chromosome 11 B. Fragile X syndrome C. Translocation of chromosome 9 and 21 D. Trisomy 13 E. Turner syndrome Explanation: The correct answer is A. The blood pressure of this child is significantly elevated for her age. The age, hypertension, abdominal mass, and aniridia suggest Wilms tumor, which arises because of the deletion involving chromosome 11. Fragile X syndrome (choice B) is a common cause of mental retardation. Translocation of chromosomes 9 and 21 (choice C) is called the Philadelphia chromosome and causes leukemia. Trisomy 13 (choice D) causes severe birth defects, including CNS malformations, cleft lip, polydactyly, and mental retardation. Turner syndrome (choice E) is a cause of short stature, infertility, and mild mental retardation. 49) A 6-year-old boy with mental retardation has recently been diagnosed with Fragile X syndrome. His 9-year-old sister appears to be of normal intelligence but has symptoms of attention deficit hyperactivity disorder (ADHD). What is the first test that is indicated in her work-up for ADHD? A. EEG B. Cytogenetic testing C. MRI D. Intelligence quotient (IQ) test E. Urine for metabolic screen Explanation: The correct answer is B. Cytogenetic testing should be performed on all sisters of males with Fragile X. Heterozygous females frequently have developmental and behavioral problems such as ADH D. They may also have borderline or mild mental retardation. An EEG (choice A) is likely to be normal, and unless there are signs or symptoms suggestive of a seizure disorder, it would not be indicated. ADHD is a clinical diagnosis and no neuroimaging tests such as MRI (choice C) will be useful in making the diagnosis of ADHD. IQ testing (choice D) may be helpful in school placement, but it is not the first test to be ordered. Urine for metabolic screening (choice E) is used to detect rare inborn errors of metabolism. It would be indicated in cases of failure to thrive, seizures, and sepsis. Many inborn errors of metabolism are associated with severe mental retardation. 50) A 15-year-old boy comes to the physician for advice about his facial acne. On examination, the patient has mild to moderate acne, mostly consisting of open comedones, some closed comedones, and a few pustules on the forehead and cheeks. Which of the following is the best advice to give this patient? A. Avoidance of chocolate and spicy foods B. Frequent face washing with strong soap C. Topical application of tretinoin or adapalene D. Treatment with oral antibiotic E. Oral treatment with isotretinoin Explanation: The correct answer is C. Acne vulgaris affects the majority of adolescents and is more prevalent in males. Hormonal influences, abnormal keratinization of pilosebaceous units and colonization by bacteria (Propionibacterium acnes) are important pathogenetic elements. Treatment of acne depends on the severity of the condition. Topical application of comedolytic agents such as retinoids (tretinoin, adapalene, and the new yeast-derived agent azaleic acid) is effective for mild to moderate forms of non-inflammatory acne, characterized by open comedones. Daily application of these compounds will result in improvement within several weeks after starting treatment. Mild skin irritation and scaling may be minimized by starting with low-concentration creams, and then progressively increasing the concentration. Another side effect of retinoids is increased photosensitivity. The patient must be instructed to avoid prolonged exposure to the sun and to use a sunscreen. Avoidance of chocolate and spicy foods (choice A) would have no beneficial effects on acne. It is well established that there is no correlation between acne and specific types of foods. Frequent face washing with strong soap (choice B) will probably cause exacerbation of acne. This skin condition is not caused by dirt. Gentle face washing once or twice daily with mild soaps is recommended. Treatment with oral antibiotic (choice D) is aimed at decreasing bacterial colonization It is used for patients who fail to respond to topical treatments or have severe forms of inflammatory acne. The antibiotics of choice include tetracyclines and erythromycin. Oral treatment with isotretinoin (choice E) is used for severe cases of acne not responding to topical comedolytics and antibiotics. This compound acts by decreasing sebum production. In addition to various types of side effects, isotretinoin is teratogenic. Female patients of childbearing age should be required to use effective means of contraception beginning one month before treatment to one month after treatment. Surgery Questions 1) Ten days after undergoing liver transplantation, a patient's levels of gamma-glutamyl transferase (GGT), alkaline phosphatase, and bilirubin begin to rise. Which of the following is the most appropriate next step in diagnosis? A. Measurement of preformed antibody levels B. Ultrasound of biliary tract and Doppler studies of the anastomosed vessels C. Liver biopsy and determination of portal pressures D. Liver biopsy and more detailed liver function tests E. Liver biopsy and trial of steroid boluses Explanation: The correct answer is B. In all other solid organ transplants, deterioration of function 10 days out would suggest an acute rejection episode, and appropriate biopsies would be done to confirm the diagnosis. In the case of the liver, however, antigenic reactions are less common, whereas technical problems with the biliary and vascular anastomosis are the most common cause of early functional deterioration. They are, therefore, the first anomalies to be sought. Preformed antibodies (choice A) are responsible for hyperacute rejection, which would be evident within minutes of establishing blood flow to the graft. Choices C, D, and E are centered on liver biopsy, which would be done only after technical problems have been ruled out. 2) A previously healthy, intoxicated, 19-year-old man is driving a car without using a seat belt. He crashes the car into the back of a parked truck. In the process he slams his abdomen into the steering wheel and ruptures his spleen. Which of the following is the most important problem associated with this type of injury? A. Bacteremia B. Electrolyte abnormalities C. External blood loss D. Internal blood loss E. Peritonitis Explanation: The correct answer is D. The spleen is a highly vascularized organ, and is vulnerable to traumatic rupture. This can occur "spontaneously" (i.e. with minimal trauma such as falling against a table or even overly vigorous palpation during a physical examination) in patients with an enlarged spleen due to disease (e.g., leukemias, autoimmune diseases with red cell sequestration in the spleen, or as a complication of portal hypertension). Alternatively, splenic rupture can occur in previously normal individuals who have severe trauma to the abdomen. In either case, the heavily vascularized spleen is usually unable to stop (often massively) bleeding internally. Emergency splenectomy is indicated to control the bleeding. Bacteremia (choice A) and peritonitis (choice E) are much less of a risk in splenic rupture than in rupture of a hollow viscus such as the colon, since the spleen is usually sterile. Electrolyte abnormalities (choice B) can develop secondarily to the ischemia produced by severe blood loss; these are much less critical than the blood loss itself and will often correct spontaneously with adequate replacement of blood. External blood loss (choice C) is often insignificant in injuries such as this. 3) After suitable calculations have been made using the modified Parkland formula, a 70-kg man with extensive third-degree burns is receiving Ringer's lactate at the calculated rate, which happens to be 750 mL/hr. The infusion was started within 30 minutes of the time when the burn occurred. Over the next 3 hours, his urinary output is recorded as 15 mL, 22 mL, and 18 mL. It is verified that the Foley catheter is open and draining freely. The urine is dark yellow, without blood, and has a specific gravity of 1040 and a sodium concentration of 10 mEq/L. The patient's blood pressure is 100/70 mm Hg, his pulse is 98/min, and his central venous pressure is 2 cm H2O. On the basis of these findings, which of the following is the most appropriate next step in management? A. Diuretics should be given B. Fluid administration should continue at the present rate C. The rate of fluid administration should be decreased D. The rate of fluid administration should be increased E. Treatment is needed for renal failure Explanation: The correct answer is D. The calculations made by standard formulas are only an educated guess. Once fluid administration begins, we judge its adequacy by the information provided by urinary output and central venous pressure, aiming for an output of 1-2 mL/kg/hr, while not exceeding a venous pressure of 10 or 15. In this case, our calculations fell short of the mark, and the patient needs more fluids at a faster rate. Diuretics (choice A) are not the answer when all indicators show fluid need: his venous pressure is low, his blood pressure and pulse rate are marginal, and he has very concentrated urine. He needs fluids! The present rate (choice B) may follow the "formula," but it is clearly inadequate. Decreasing the rate (choice C) is the very opposite of what is needed. And as for renal failure (choice E), it is indeed part of the differential diagnosis whenever urinary output is not as high as it should be. However, the vignette told you that his urine is highly concentrated and has well less than 20 mEq/L of sodium: evidence of superb kidneys trying to conserve fluid to the best of their ability. Don't blame them. 4) A 27-year-old immigrant from El Salvador has a 14 12 9 cm mass in her left breast. It has been present for 7 years and has slowly grown to its present size. The mass is firm, nontender, rubbery, and completely movable, and it is not attached to the overlying skin or the chest wall. There are no palpable axillary nodes or skin ulceration. Which of the following is the most likely diagnosis? A. Breast cancer B. Chronic cystic mastitis C. Cystosarcoma phyllodes D. Intraductal papilloma E. Mammary dysplasia Explanation: The correct answer is C. Cystosarcoma phyllodes occurs in young women, grows to huge size over many years, and yet spares the skin, the nodes, and the underlying chest wall. There is no particular connection with Central America, but often these are seen in immigrants of limited financial circumstances, who have had no access to medical care in their own countries. Breast cancer (choice A) this big and for these many years, would have ulcerated the skin, would be fixed to the chest wall, and would have produced massive axillary metastasis. Chronic cystic mastitis (choice B), also known as mammary dysplasia (choice E), is seen in women of reproductive age, who complain of tender and lumpy breasts related to the menstrual cycle. Large cysts can develop in this disease, but not to the huge size described in the vignette. Intraductal papilloma (choice D) is the most common source of bleeding from the nipple. These tumors are tiny, just a few millimeters in diameter. 5) A 32-year-old woman in the 2nd month of pregnancy is found to have a 5-cm mass in the upper outer quadrant of her left breast. Mammogram shows no other lesions, and core biopsy reveals infiltrating ductal carcinoma. Which of the following would be the best course of action at this time? A. Chemotherapy now, deferring surgery until after delivery B. Radiation therapy now, deferring surgery until after delivery C. Lumpectomy and axillary sampling, followed in 6 weeks by radiotherapy D. Modified radical mastectomy now, deferring systemic therapy until later E. Immediate therapeutic abortion and palliative breast surgery Explanation: The correct answer is D. The treatment of breast cancer in a pregnant woman should be the same as that in a nonpregnant woman, except for two restrictions: no chemotherapy during the first trimester, and no radiation therapy during the pregnancy. It is not necessary to terminate the pregnancy. The preferred treatment for a 5-cm tumor would be mastectomy (too big for lumpectomy). Should axillary nodes be positive, systemic therapy should be done later. Although the appropriate surgery can be done during the pregnancy, neither chemotherapy (choice A) nor radiation therapy (choice B) would be acceptable at this time. Lumpectomy (choice C) is not a good idea for a 5-cm tumor. Furthermore, the radiation therapy that must follow lumpectomy could not be given in 6 weeks, while she is still pregnant. Finally, let's not terminate a pregnancy that is doing no harm. Therapeutic abortion (choice E) does not help with the treatment of breast cancer. Neither is the pregnant woman who gets cancer of the breast automatically incurable, and thus only fit for a palliative procedure. 6) In the course of a robbery, a young woman is stabbed repeatedly. On arrival at the emergency department, she is shivering and asks for a blanket and a drink of water; she is noted to be pale and perspiring. Her blood pressure is 72/50 mm Hg and her pulse is 130/min. Her neck and forehead veins are large and distended. A quick initial survey reveals entry wounds in her left chest and upper abdomen. She has bilateral breath sounds and a scaphoid, nontender abdomen. As IV infusions of Ringer's lactate are started, her systolic blood pressure drops further to 40 mm Hg, no distal pulses can be felt, and she loses consciousness. Her central venous pressure at that time is 28 cm H2O. Which of the following is the most appropriate next step in management? A. Chest x-ray to direct further therapy B. Bilateral chest tubes C. Diagnostic peritoneal lavage D. Evacuation of the pericardial sac E. Crash laparotomy in the emergency department to clamp the aorta Explanation: The correct answer is D. The diagnosis of pericardial tamponade should be obvious. The patient has the type of chest wound that can produce it, and the very high central venous pressure to prove it. Evacuation of the blood that is preventing normal ventricular filling will produce instant improvement. Later, she will need repair of the heart wound that is probably the source of the pericardial blood and may also need exploratory laparotomy. A chest x-ray (choice A) would never be ordered in a dying patient. This patient is in trouble, and she needs instant action based on a clinical diagnosis. She would die while waiting for an x-ray. Chest tubes (choice B) have nothing to offer when there are bilateral breath sounds. In this case, the patient probably does not have a tension pneumothorax to account for the shock and the high venous pressure. Diagnostic peritoneal lavage (choice C) assumes that the reason for the deterioration is intra-abdominal bleeding. With a very high central venous pressure, it is not a reasonable conclusion. Clamping the aorta (choice E) assumes that she is bleeding to death. She may be bleeding, but if that were the cause of her present predicament, her central venous pressure would be zero, or near zero. 7) A 62-year-old man reports an episode of gross, painless hematuria. There is no history of trauma, and further questioning determines that he had total hematuria, rather than initial or terminal hematuria. The man does not smoke and has had no other symptoms referable to the urinary tract. He has no known allergies. Physical examination, including rectal examination, is unremarkable. His serum creatinine is 0.8 mg/dL, and, except for the presence of many red cells, his urinalysis is normal and shows no red cell casts. His hematocrit is 46%. Which of the following is the most appropriate initial step in the workup? A. Coagulation studies and urinary cultures B. Intravenous pyelogram (IVP) and cystoscopy C. PSA determination and prostatic biopsies D. Sonogram and CT scan of both kidneys E. Retrograde cystogram and pyelograms Explanation: The correct answer is B. Although most patients with hematuria have benign disease, silent hematuria can be due to renal, ureteral, or bladder cancer, and these malignant processes must be effectively ruled out. Intravenous pyelogram (IVP) will visualize kidney and ureteral tumors, but is not reliable enough to rule out bladder cancer. Direct visualization of the bladder mucosa by cystoscopy is the only way to rule out bladder cancer. Thus, both procedures are needed. Assuming hematuria to be a manifestation of clotting problems or infection (choice A) is unwarranted as the first diagnostic consideration in the absence of a history suggestive of such problems. Prostatic cancer can produce hematuria when it is advanced, but typically it does not show up that way in a previously asymptomatic patient. At age 62, this man needs a PSA, but this test, along with prostatic biopsies (choice C), would do nothing to find the source of the hematuria. In patients with allergy to the IVP dye, or with a creatinine above 2 mg/dL (neither of which are present here), the IVP cannot be done. In those cases, sonogram or CT scan (choice D) would provide an alternative way to look at the kidneys. The bladder would still remain as a potential site of undiagnosed cancer. Retrograde studies (choice E) are invasive and unwarranted here. A bladder full of dye will not necessarily reveal the presence of a shallow bladder cancer. The collecting system outlined by radiopaque material would not show the renal parenchyma. 8) A 63-year-old man, who weighs 65 kg, is in his 2nd postoperative day after an abdominoperineal resection for cancer of the rectum. An indwelling Foley catheter was left in place after surgery. The nurses are concerned because, even though his vital signs have been stable, his urinary output in the past 2 hours has been zero. In the preceding 3 hours, they had collected 56 mL, 73 mL, and 61 mL. Which of the following is the most likely diagnosis? A. Acute renal failure B. Damage to the bladder during the operation C. Damage to the ureters during the operation D. Dehydration E. Plugged or kinked catheter Explanation: The correct answer is E. In the presence of normal perfusion pressure, biological problems do not suddenly drive the urinary output from normal to zero. Such a change is invariably due to a mechanical problem. Acute renal failure (choice A) does not result in a urinary output of zero. Some urine is still produced, although it is a small volume, on the order of 5 or 10 mL per hour. Intraoperative damage to the bladder (choice B) or the ureters (choice C) would have become obvious immediately after the operation. Dehydration (choice D) would have produced a gradual decline in the urinary volume. The 3 hours preceding the onset of the problem had shown normal values (about 1 mL per kg of body weight per hour), with no downward trend. 9) A 37-year-old woman undergoes a lumpectomy and axillary dissection for a 3-cm infiltrating ductal carcinoma, diagnosed by core biopsies, located on the upper outer quadrant of her left breast. The pathology report of the surgical specimen is received 3 days after the operation. It indicates that all margins around the tumor are clear, and that 4 of 17 axillary lymph nodes have metastatic tumor. The tumor is reported to be estrogen and progesterone receptor negative. Which of the following should further therapy most likely include? A. Antiestrogen medication (tamoxifen) B. Conversion to modified radical mastectomy C. Radiation to the remaining left breast D. Radiation to the remaining left breast and systemic chemotherapy E. Radiation to both breasts and tamoxifen Explanation: The correct answer is D. Lumpectomy alone has an unacceptably high incidence of local recurrence, which can be significantly reduced by radiation therapy. In addition, the presence of metastatic disease in the axillary nodes requires systemic therapy. As a rule, chemotherapy is preferred for premenopausal women, which this woman is, but it is also indicated here because she is not receptor positive. Antiestrogens alone (choice A) would not reduce the likelihood of local recurrence, and it would not help much with systemic disease because she is premenopausal and receptor negative. Conversion to mastectomy (choice B) is not needed because her surgical margins are clear of tumor. Radiation alone (choice C) would not suffice because her positive axillary nodes require the addition of systemic therapy. Radiation to the opposite breast (choice E) is not required in any event, and tamoxifen is the wrong drug for a premenopausal woman who had a receptor negative tumor. 10) A 45-year-old man with alcoholic cirrhosis is bleeding from a duodenal ulcer. He has required 6 units of blood over the past 8 hours, and all conservative measures to stop the bleeding, including irrigation with cold saline, IV vasopressin, and endoscopic use of the laser have failed. He is being considered for surgical intervention. Laboratory studies done at the time of admission, when he had received only one unit of blood, showed a bilirubin of 4.5 mg/dL, a prothrombin time of 22 seconds, and a serum albumin of 1.8 g/dL. He was mentally clear when he came in, but has since then developed encephalopathy and is now in a coma. Which of the following best describes his operative risk? A. Acceptable as he now is B. Amenable to improvement if he receives vitamin K C. Amenable to improvement if he is given albumin D. Prohibitive unless he is dialyzed to normalize his bilirubin E. Prohibitive regardless of attempts to improve his condition Explanation: The correct answer is E. The studies show extremely marginal liver function, which would be tipped into overt liver failure by an anesthetic and an operation. He is not a surgical candidate. Choice A obviously misses the gravity of his situation. Vitamin K (choice B) works only when there is a functioning liver that can use it. In the absence of adequate liver function, it will not correct the prothrombin time. Albumin (choice C) can be given, but it will have a short life span and will not correct the liver dysfunction. The low albumin is not the main problem per se, it is a symptom of how bad his liver is. The same is true of bilirubin (choice D). It is a symptom, not the problem. We can operate on patients with much higher bilirubin if it is not due to intrinsic liver disease. 11) A 55-year-old woman falls in the shower and hurts her right shoulder. She shows up in the emergency department with her arm held close to her body, but the forearm rotated outward as if she were going to shake hands. She is in pain and will not move the arm from that position. Her shoulder looks "square" in comparison with the rounded unhurt opposite side, and there is numbness in a small area of her shoulder over the deltoid muscle. Which of the following is the most likely diagnosis? A. Acromioclavicular separation B. Anterior dislocation of the shoulder C. Fracture of the upper end of the humeral shaft D. Posterior dislocation of the shoulder E. Scapular fracture Explanation: The correct answer is B. Anterior dislocation of the shoulder is the most common dislocation of that joint. The position is classic, as is the lack of the rounded contour of the humeral head. The area of numbness represents injury to the axillary nerve, a common complication of anterior dislocation of the shoulder. Acromioclavicular separation (choice A) would be characterized by very localized pain at that particular spot and none of the other features described here. Fracture of the humeral shaft (choice C) would likewise lack the specific deformity, inasmuch as the humeral head would still be in place to provide the normal rounded contour. Posterior dislocation (choice D) typically occurs following massive uncoordinated muscle contractions (electrical injuries, epileptic seizures), and the arm and forearm are held in a more "normal" protective position, close to the body. Scapular fracture (choice E) happens only with extremely severe chest trauma; it would not happen by falling in the shower. Along with two other injuries (fracture of the sternum or fracture of the first rib), scapular fracture, when present, indicates that very severe trauma has occurred, and it is a useful clinical clue to look for hidden internal injuries. 12) A 22-year-old convenience store clerk is shot once with a .38 caliber revolver. The entry wound is in the left midclavicular line, 2 inches below the nipple. There is no exit wound. He is hemodynamically stable. A chest x-ray film shows a small pneumothorax on the left, and demonstrates the bullet to be lodged in the left paraspinal muscles. In addition to the appropriate treatment for the pneumothorax, which of the following will this patient most likely need? A. Barium swallow B. Bronchoscopy C. Extraction of the bullet via local back exploration D. Extraction of the bullet via left thoracotomy E. Exploratory laparotomy Explanation: The correct answer is E. Although this vignette describes a gunshot wound of the chest, we must remember that the chest and the abdomen are not stacked up like pancakes. There is a dome - the diaphram - that separates them, and thus an area where chest and abdomen overlap. Any gunshot wound below the nipples involves the abdomen, and such is the case here. The management of all gunshot wounds of the abdomen requires exploratory laparotomy. Barium swallow and bronchoscopy (choices A and B) are indicated if there are signs suggestive of injury to those organs (coughing up blood, spitting up blood), or if the anatomic trajectory of the bullet puts the track in their vicinity. Here, we have an entry wound on the left and a bullet lodged on the left: the midline has not been crossed. Taking out the bullet (choices C and D) is unnecessary if the missile is not pressing on some vital structure. A bullet embedded in a muscle can be left there. 13) A 68-year-old man is brought to the emergency department with excruciating back pain that began suddenly 45 minutes ago. The pain is constant and is not exacerbated by sneezing or coughing. He is diaphoretic and has a systolic blood pressure of 90 mm Hg. There is an 8-cm pulsatile mass deep in his epigastrium, above the umbilicus. A chest x-ray film is unremarkable. Two years ago, he was diagnosed with prostatic cancer and was treated with orchiectomy and radiation. At that time, his blood pressure was normal, and he had a 6-cm, asymptomatic abdominal aortic aneurysm for which he declined treatment. Which of the following is the most likely diagnosis? A. Dissecting thoracic aortic aneurysm B. Fracture of lumbar pedicles with cord compression C. Herniated disc D. Metastatic tumor to the lumbar spine E. Rupturing abdominal aortic aneurysm Explanation: The correct answer is E. Abdominal aortic aneurysms have a high incidence of rupture once they reach or exceed a size of 6 cm. Often, the first manifestation is excruciating back pain, as the blood leaks into the retroperitoneal space before the aneurysm blows out into the peritoneal cavity. The combination of a big aneurysm and sudden severe back pain should always lead to this presumptive diagnosis. Looking for orthopedic or neurologic explanations can be a deadly mistake. Dissecting thoracic aortic aneurysm (choice A) could also cause excruciating back pain, but the pain usually starts as retrosternal and later migrates down. The absence of hypertension mitigates against this diagnosis, and one would expect to see a wide mediastinum on the chest xray film. Fracture of the spine with cord compression (choice B) could indeed happen to someone who recently had prostatic cancer, but the symptoms would be primarily neurologic deficits from cord compression. The pain from a herniated disc (choice C) runs down the leg and is exacerbated by sneezing and coughing. Metastatic tumor (choice D) is a good bet in someone with prostatic cancer. However, the pain of bony metastasis is present for weeks or months, and is constant, dull, low grade, and worse at night-not the sudden excruciating pain of this vignette. 14) A middle-aged homeless man is brought to the emergency department because of very severe pain in his forearm. He had passed out after drinking a bottle of cheap wine, and then slept on a park bench for an indeterminate time, probably more than 12 hours. Shortly after he woke up and began to walk, the pain began. There are no signs of trauma, but the muscles in his forearm are very firm and tender to palpation, and passive motion of his fingers and wrist elicits excruciating pain. Pulses at the wrist are normal. Which of the following is the most appropriate next step in management? A. Analgesics and observation B. Immobilization in a sling C. Immobilization in a plaster cast D. Emergency embolectomy E. Emergency fasciotomy Explanation: The correct answer is E. The presentation is classic for compartment syndrome, triggered by prolonged ischemia followed by reperfusion (the arm pressed against the park bench until he woke up and changed position), and located in one of the two most common sites (forearm and lower leg). He has the most reliable physical finding (pain on passive extension), and the diagnosis is not ruled out by normal pulses. Only a fasciotomy will solve his problem. Analgesics and observation (choice A) will result in permanent damage to the compartment muscles. Immobilization, by sling (choice B) or cast (choice C), will allow the high pressure within the compartment to continue to destroy the muscles. Embolectomy (choice D) assumes an arterial occlusion, which his normal pulses rule out. 15) A 54-year-old obese man gives a history of burning retrosternal pain and heartburn that is brought about by bending over, wearing a tight belt, or lying flat in bed at night. He gets symptomatic relief from over-the-counter antiacids or H2 blockers, but has never been formally studied or treated. The problem has been present for many years and seems to be progressing. Which of the following is the most appropriate next step in management? A. Barium swallow B. Cardiac enzymes and ECG C. Proton pump inhibitors D. Endoscopy and biopsies E. Laparoscopic Nissen fundoplication Explanation: The correct answer is D. The clinical picture is fairly convincing for long-standing gastroesophageal reflux. The main concern is the degree of peptic esophagitis that he may have developed, and the possibility of Barrett's esophagus and premalignant changes. Endoscopy and biopsies will provide the answer. Barium swallow (choice A) would provide anatomic evidence of hiatal hernia and evidence of reflux, but would not tell us whether Barrett's esophagus has developed. Cardiac enzymes and ECG (choice B) would be part of the work-up (along with pH monitoring) if we were uncertain as to the genesis of ill-defined low retrosternal and upper epigastric pain. This man gives a classic presentation for reflux. Proton pump inhibitors (choice C) might likewise be indicated for this man, but not until we know the severity and potential premalignant stage of his disease. Nissen fundoplication (choice E) may some day be needed here, but one would not jump to a surgical solution based only on a clinical presentation. 16) A pedestrian is hit by a car and knocked unconscious. Within a few minutes, he starts to move around and moan. When the ambulance arrives, he is moving all four extremities and mumbling that his neck hurts. Shortly thereafter, he lapses again into a deep coma. In the emergency department, it is noted that his left pupil is fixed and dilated, and he has clear fluid dripping from the left ear. The trauma team intubates him nasally over a fiberoptic bronchoscope and does a quick initial survey that reveals no other obvious injuries. He is hemodynamically stable. Which of the following is the most appropriate next step in management? A. Antibiotics and high dose corticosteroids B. Cervical spine and skull x-ray films C. CT scan of the head, extended to include the cervical spine D. Otoscopic examination and laboratory studies of the fluid E. Emergency ear surgery to stop the leak of cerebrospinal fluid Explanation: The correct answer is C. Clinically, this man has a life-threatening head injury, with a high probability that he may have an intracranial hematoma that has to be drained. CT scan is the only study that will show such a hematoma. Furthermore, we know that the head trauma was severe enough to produce a fracture of the base of the skull (cerebrospinal fluid dripping from the ear); thus, it may well have produced injury of the cervical spine as well. This is likely since he was complaining of neck pain, and it is imperative that it be diagnosed to protect his cord, which is probably still intact (when he was last awake he still was moving all four extremities). The most expedient way to do it is to extend the CT scan to include the neck. Antibiotics and steroids (choice A) are not indicated. The former used to be given for cerebrospinal fluid leaks, but is no longer considered appropriate. Steroids are used if the cord is injured, but we have reason to believe that it is still intact. Cervical spine x-ray films (choice B) are a good idea, but skull x-ray films are not. If his only problem were the cervical spine, we would indeed go for the x-rays. But we also have to check his head, for which we need the CT. Let the CT take care of both issues. The same is true of choice D. We do not need to look into the ear or to study the fluid. The CT will show the fracture to the base of the skull, at the same time that it will tell us if an intracranial hematoma has to be drained. Cerebrospinal fluid leaks caused by fractures to the base of the skull typically stop spontaneously. Surgery is rarely needed for them. When it is needed, it is not an emergency and would not be done through the ear. Thus, choice E is wrong on all counts. 17) While working at a bookbinding shop, a young man suffers a traumatic amputation of his index finger. The finger was cleanly severed at its base. The patient and the finger are brought to a first-aid station, from which both are to be transported to a highly specialized medical center for replantation to be done. Which of the following is the correct way to prepare and transport the severed finger? A. Dry the finger of any traces of blood and place it in a cooler filled with crushed ice B. Freeze it as quickly as possible, and transport it immersed in liquid nitrogen C. Immerse it in cold alcohol for the entire trip D. Paint it with antiseptic solution and place it on a bed of dry ice E. Wrap it in a moist gauze, place it on a plastic bag, and place the bag on a bed of ice Explanation: The correct answer is E. The digit must be kept from drying out, must not be injured with any chemical agents, and must not be placed in direct contact with ice or allowed to freeze. Direct contact with ice (choice A) is one of the damaging events to be avoided. Freezing (choice B) is absolutely contraindicated. Alcohol (choice C) would damage the tissues. Antiseptic solutions and direct contact with dry ice (choice D) would damage the finger both chemically and physically. 18) An out-of-shape, recently divorced, 42-year-old man is trying to impress a young woman by challenging her to a game of tennis. In the middle of the game, a loud "pop" (like a gunshot) is heard, and the man falls to the ground clutching his ankle. He limps off the court with pain and swelling in the back of the lower leg. Although he can still weakly plantar-flex his foot, he seeks medical help the next day because of persistent pain, swelling, and limping. He can put weight on that foot with no exacerbation of the pain, but the motion of taking a step is painful. Which of the following would be the most likely finding on physical examination? A. Tapping on the calcaneus is extremely painful B. The ankle joint can be abducted farther out than the normal contralateral side C. The ankle joint can be adducted farther in than the normal contralateral side D. There is a gap in the Achilles tendon easily felt by palpation E. There is crepitation and grating by direct palpation over either malleoli Explanation: The correct answer is D. The clinical description is that of a rupture of the Achilles tendon. The injured structure is so close to the skin that direct palpation of the gap in the tendon is usually possible. A fracture of the calcaneus (implied in choice A) would happen with a fall from a height, landing on one's feet. The ability to bend a joint beyond the normal boundaries (choices B and C) implies damage to the ligaments that keep that joint tight. However, such damage would not produce the loud popping noise so characteristic of rupture of the Achilles tendon. Grating and crepitation (choice E) are findings that indicate bony fracture; if these were present, the patient would not be able to put weight on the injured side. 19) A 66-year-old man with diabetes and generalized arteriosclerotic occlusive disease notices a gradual loss of erectile function over several years. Initially, he can get erections, but they do not last long enough. Later, he notices a decrease in the quality of his erections, and more recently he becomes, by his own criteria, completely impotent. He has occasional, brief nocturnal erections, but "he can never get an erection when he needs one." Which of the following is the most appropriate initial step in management? A. Psychotherapy B. Pharmacologic therapy C. Erectile nerve reconstruction D. Implantable penile prosthesis E. Pudendal artery revascularization Explanation: The correct answer is B. This patient has organic impotence, but it is not related to trauma for which surgical reconstruction would be indicated. His remaining function can be augmented with sildenafil (Viagra). Psychotherapy (choice A) is the thing to do for psychogenic impotence, which has a sudden onset rather than the gradual development described in this case. Nerve damage (as suggested in choice C) is the culprit in impotence following pelvic surgery (not the case here). As of now, there is no effective way to reanastomose those invisible little nerve fibers. Penile prosthesis (choice D) is always the last option, never the first one. Once a prosthesis is inserted, the normal erectile mechanism is destroyed forever. Had the history been that of a young man becoming impotent after a motorcycle accident, a vascular lesion would have been the likely problem, and a reconstruction (choice E) would be the thing to do. 20) A 54-year-old woman has a severe ureteral colic. An intravenous pyelogram shows a 7-mm ureteral stone at the ureteropelvic junction. She has a normal coagulation profile. Which of the following would most likely be the best therapy in this case? A. Plenty of fluids and analgesics and await spontaneous passage B. Extracorporeal shock wave lithotripsy (ESWL) C. Endoscopic retrograde basket extraction D. Endoscopic retrograde laser vaporization of the stone E. Open surgical removal Explanation: The correct answer is B. Extracorporeal shock wave lithotripsy (ESWL) is the most commonly used method to fragment urinary stones and allow their passage. Pregnancy and coagulation problems are contraindications. The first one is ruled out by her age, the second one we have been told she does not have. Waiting for spontaneous passage (choice A) would have been perfect for a much smaller stone (3 mm) that had already negotiated most of the ureter. A 7-mm stone way up at the ureteropelvic junction has a very small chance of spontaneous passage. Retrograde endoscopic approaches (choices C and D) are more invasive than ESWL. They would not be the first choice for this scenario. Open surgical removal (choice E) would have been good for a much bigger stone. A huge target (a stone 3 cm or larger) could indeed be fragmented by ESWL, but then we would be contending with dozens of still very large stones. In those cases, a direct approach to extract the huge intact stone would work better. 21) A 68-year-old woman presents with an obviously incarcerated umbilical hernia. She has gross abdominal distention, is clinically dehydrated, and reports persistent fecaloid vomiting for the past 3 days. Although tired, weak, and thirsty, she is awake and alert and her sensorium is not particularly affected. Laboratory analysis reveals a serum sodium concentration of 118 mEq/L. Which of the following is the most likely physiologic explanation for the serum sodium? A. She has acute water intoxication B. She has been vomiting and trapping hypertonic fluids in the bowel lumen C. She has vomited and sequestered sodium-containing fluids, and has retained endogenous and ingested water D. There must be a laboratory error, because such a serum sodium level would have produced coma E. Volume deprivation leads to renal wasting of sodium Explanation: The correct answer is C. Gastrointestinal tract fluids have a sodium concentration very close to that of plasma; as they are lost (internally or externally), they should be replaced with isotonic, sodium-containing fluids. But that is not what patients typically do at home. Thirsty and unable to eat solid (sodium-containing) foods, they drink water, Coke, and tea, fluids without significant amounts of sodium, which the body avidly retains because of the severe volume depletion. Endogenous water from catabolic activity is also retained. Dilutional hyponatremia eventually develops. She does not have "water intoxication" (choice A). This term denotes abnormal water retention due to excessive water infusion at a time when there is a high level of ADH in the blood. This patient is retaining water because she is desperately volume-depleted, not because high volumes of water are being forced into her. The hyponatremia is not due to the loss of hypertonic fluid (choice B). There are no hypertonic fluids in the gut, or anywhere else for that matter. The only hypertonic fluid that we can lose is highly concentrated urine, but we usually do so as a physiologic response to save water. Yes, we often see comatose and convulsing patients when they have this much hyponatremia (choice D), but that happens when water retention is massive and fast. Slow water retention allows the brain to adapt. One can see even lower serum sodium concentrations in patients with a clear sensorium. Volume deprivation leads to renal wasting of sodium (choice E) is plain wrong. What the kidney does when there is volume depletion is to increase reabsorption of sodium, not to dump it. 22) A 31-year-old woman smashes her car against a bridge abutment. She sustains multiple injuries, including upper and lower extremity fractures. She is fully awake and alert, and she reports that she was not wearing a seat belt and distinctly remembers hitting her abdomen against the steering wheel. Her blood pressure is 135/75 mm Hg, and her pulse is 88/min. Physical examination shows that she has a rigid, tender abdomen, with guarding and rebound in all four quadrants. She has no bowel sounds. Which of the following would be the most appropriate step in evaluating potential intraabdominal injuries? A. Continued clinical observation B. CT scan of the abdomen C. Sonogram of the abdomen D. Diagnostic peritoneal lavage E. Exploratory laparotomy Explanation: The correct answer is E. The presence of an "acute abdomen," which this woman has, is an indication for exploratory surgery and prompt repair of the injuries (probably affecting hollow viscera) that have produced the signs of peritoneal irritation. Continued clinical observation (choice A) would be irresponsible when it is clinically obvious that she already has an acute abdomen. What would one observe for? Development of septic shock? Death? CT scan (choice B) is ideal when the issue is potential intraabdominal bleeding in a hemodynamically stable patient who can be safely sent to the radiology department. CT scan might even be a good idea if the picture of acute abdomen were equivocal. But it is not needed here. Diagnostic peritoneal lavage (choice D) or sonogram done in the emergency department (choice C) are our options when we suspect intraabdominal bleeding and the patient is too unstable to be sent anywhere. As pointed out above, however, when an acute abdomen has clearly developed, it is time to operate. 23) A 27-year-old man sustained penetrating injuries of the chest and abdomen when he was repeatedly stabbed with a long ice-pick. At the time of admission, he had a right pneumothorax, for which a chest tube was placed prior to undergoing a general anesthetic for exploratory laparotomy. The operation revealed no intraabdominal injuries and was terminated sooner than had been anticipated. The patient remained intubated, waiting for the anesthetic to wear off. Because he was not moving enough air, he was placed on a respirator. Then, he suddenly went into cardiac arrest and died. All through this time he had been hemodynamically stable, and never had any signs of hypotension or arrhythmias. Which of the following was the most likely cause of the cardiac arrest? A. Air embolism B. Fat embolism C. Myocardial infarction D. Pulmonary embolus E. Tension pneumothorax Explanation: The correct answer is A. Truly sudden death, with no warnings whatsoever, brings to mind the possibility of air embolism. The mechanism in this case is suggested by the circumstances. The patient had deep penetrating injuries that may have involved a major vein and an adjacent bronchus. When he was placed on the respirator, the air was forced through from the tracheobronchial tree into the vein, and thus into the heart. Fat embolism (choice B) is seen with multiple long bone fractures, and the symptomatology is respiratory failure. Myocardial infarction (choice C) would be extremely unlikely in a young man who was never hypotensive, and never showed arrhythmias. Pulmonary embolus (choice D) is seen late in the postoperative period after several days of reduced mobility. This man would have had no opportunity to develop clots in major veins in such short clinical course. Tension pneumothorax (choice E) would be unlikely to develop with a chest tube in place. However, even if we assume the tube was clogged or kinked and thus not functioning properly, a tension pneumothorax does not cause sudden death: it causes progressive hemodynamic shock and respiratory distress. 24) A 13-year-old, obese boy complains of persistent knee pain for several weeks. The family brings him in because he has been limping. He sits in the examining table with the sole of the foot on the affected side pointing to the other leg. Physical examination is normal for the knee, but shows limited hip motion. As the hip is flexed, the leg goes into external rotation and cannot be rotated internally. Which of the following is the most likely diagnosis? A. Avascular necrosis of the femoral head B. Developmental dysplasia of the hip C. Osteogenic sarcoma of the lower femur D. Slipped capital femoral epiphysis E. Tibial torsion with foot inversion Explanation: The correct answer is D. Slipped capital femoral epiphysis is an orthopedic emergency. The clinical picture is classic: a chubby male in his early teens who is limping and cannot rotate his leg internally. Part of the classic presentation is also the fact that often hip pathology produces knee pain, but the knee is normal on physical examination. Avascular necrosis (choice A) is seen in younger children, around the age of 6 years. Developmental dysplasia (choice B) is typically diagnosed at birth. If it is missed, the affected child develops significant sequelae early in life. Osteogenic sarcoma (choice C) happens in the late teens, but the clinical findings are different, with a bony mass at the area of tenderness and no limitation on the motion of the hip. Tibial torsion and foot inversion (choice E) would not limit hip motion. 25) A 72-year-old man has a 3-mm ureteral stone impacted at the ureterovesical junction. He has been having mild ureteral colicky pain for about 12 hours, and he has been given fluids and analgesics in the expectation that he will spontaneously pass the stone. He then has shaking chills, and spikes a temperature of 40 C (104 F). When seen shortly thereafter, he has flank pain and looks quite ill. Which of the following is the most appropriate next step in management? A. Addition of IV antibiotics to the current therapeutic regimen B. Crushing and extraction of the stone via cystoscopy C. Extracorporeal shock wave lithotripsy and parenteral antibiotics D. Immediate insertion of a suprapubic catheter into the bladder E. IV antibiotics and immediate decompression of the urinary tract above the stone Explanation: The correct answer is E. The combination of obstruction and infection in the urinary tract constitutes a dire emergency that requires, in addition to IV antibiotics, the immediate decompression of the urinary tract above the point of obstruction. Adding antibiotics without decompressing the urinary tract (choice A) is not enough. Rapid destruction of the kidney, and even death from septic shock, will ensue if decompression is not done. It is too late to crush and remove the stone (choice B) once the infection has occurred. Complicated instrumentation should not be done in these circumstances. Such steps should await resolution of the lethal infection-obstruction combination. The same can be said for the use of extracorporeal shock wave lithotripsy (choice C). If it is chosen as the way to manage the stone, it should be done when infection and obstruction are no longer present. Putting a catheter into the bladder (choice D) would provide decompression below the level of obstruction. The drainage of infected urine is needed above the obstructing point. 26) A 14-year-old boy dives into the shallow end of a swimming pool and hits his head against the bottom. When he is rescued, he shows a complete lack of neurologic function below the neck. He is still breathing on his own, but he cannot move or feel his arms and legs. The paramedics carefully immobilize his neck for transportation to the hospital, and they alert the emergency department to his impending arrival. Once there, which of the following would most likely have an immediate benefit for this patient? A. Hyperbaric oxygenation B. IV antibiotics C. IV high-dose corticosteroids D. Massive diuresis induced by loop diuretics. E. Surgical decompression of the cord Explanation: The correct answer is C. There is some evidence that high-dose corticosteroids administered as soon as possible after the injury will result in a better ultimate outcome. Although the true medical value of this observation may be debatable, there is a legal imperative to use the treatment, which offers some hope and has not been shown to be detrimental. Hyperbaric oxygenation (choice A) has no role in the acute management of neurologic injuries. Antibiotics (choice B) are likewise unlikely to affect the course of events in a case like this. Although diuresis (choice D) is part of the therapy used to decrease intracranial pressure, the agent of choice is mannitol, and the indications do not include spinal cord injury. Surgical decompression (choice E) might be done, but the decision is individualized depending on the findings on MRI. Not all patients are automatically and immediately taken to the operating room. 27) A 72-year-old man is scheduled to have elective sigmoid resection for diverticular disease. He has a history of heart disease, and had a documented myocardial infarction 2 years ago. He currently does not have angina, but he lives a sedentary life because "he gets out of breath" if he exerts himself. During the physical examination, it is noted that he has jugular venous distention. He has a hemoglobin of 12 g/dL. If surgery is indeed needed, which of the following should most likely be done prior to the operation? A. Evaluate the patient as a candidate for coronary revascularization B. Place the patient on intensive respiratory therapy C. Order a transfusion to increase the patient's hemoglobin to 14 g/dL D. Treat the patient for congestive heart failure E. If at all possible, wait 6 months before performing surgery Explanation: The correct answer is D. Jugular venous distention in this setting is indicative of congestive heart failure, a condition that would make elective surgery very risky. Medical treatment for congestive heart failure can reduce the risk. Coronary revascularization (choice A) is a preoperative consideration for patients with progressive angina. Preoperative respiratory therapy (choice B) is needed for patients with chronic obstructive pulmonary disease (COPD) who have compromised ventilation. A hemoglobin of 12 g/dL should be sufficient, and bringing it up to 14 g/dL (choice C) by transfusions would aggravate the existing congestive failure. Waiting 6 months (choice E) is imperative before noncardiac surgery is done after a myocardial infarction. In this case, the infarction happened 2 years ago; thus, the waiting period has already taken place. 28) A group of illegal immigrants is smuggled across the border in a closed metal truck in the middle of summer. When apprised by radio that the border patrol is on their trail, the smugglers abandon their charges in the middle of the desert, in the locked truck, with little water to drink. The victims are found and rescued 5 days later. One of them is brought to the emergency department, awake and alert, with obvious clinical signs of severe dehydration and a serum sodium concentration of 155 mEq/L. Which of the following would be the best choice and rate of IV fluid administration? A. 5 L of 5% dextrose in water (D5W) over 2-3 days B. 5 L of D5W over 5-10 hours C. 5 L of 5% dextrose in half normal saline (D5 1/2 NS) over 5-10 hours D. 10 L of D5 1/2 NS over 5-10 hours E. 10 L of normal saline over 2-3 days Explanation: The correct answer is C. A rough guideline to quantify water loss is that every 3 mEq/L that the serum sodium concentration is above normal, represents about 1 L of water deficit. With a value of 155, we can assume a water deficit of about 5 L. There is no advantage to the patient in remaining severely volume contracted for several days, thus the replacement should aim for correction in a matter of 5-10 hours rather than 2 or 3 days. However, because his loses were incurred slowly (over 5 days), his brain has had a chance to adapt to the tonicity change (he is indeed awake and alert). Thus, the tonicity correction should not happen with the same speed with which the volume is going to be corrected. That delay is achieved by choosing a fluid that is not pure water, but one that has some sodium in it to dampen the effect on tonicity. Half normal saline is a good choice. 5 L of D5W over 2 or 3 days (choice A) would be safe from the viewpoint of slowly correcting the tonicity, but it would unnecessarily prolong the state of volume depletion. 5 L of D5W over 5-10 hours (choice B) could well be deadly, because it would revert the tonicity to normal at a rate too fast for the brain to follow. Choices D and E budget a volume replacement well beyond what is needed. Neither would be lethal, because D5W is not used, but neither of them is the best answer. 29) A 72-year-old man comes in complaining of persistent and nagging low back pain that he has had for several weeks. The pain seems to be increasing in intensity, is worse at night, is unrelieved by rest or positional changes, and is not exacerbated by coughing, sneezing, or straining to have a bowel movement. He is a chronic smoker, and for the past 3 months has had persistent cough with occasional bloody streaked sputum, as well as a 20-pound weight loss. On physical examination, he is distinctly tender to palpation at a particular spot over his lower thoracic spine. Which of the following is the most likely diagnosis? A. Ankylosing spondylitis B. Herniated disk C. Metastatic tumor to the thoracic spine D. Multiple myeloma E. Primary malignant bone tumor Explanation: The correct answer is C. The age, nature of the pain, physical findings, and associated symptoms are all highly suggestive of metastatic tumor, and the source is probably the lung. Ankylosing spondylitis (choice A) happens to younger patients (in their early 30s) who have pain and stiffness in the mornings, and relief as they become active during the day. Herniated disc (choice B) can virtually be excluded by the fact that the pain is not exacerbated by coughing, sneezing, or straining. Multiple myeloma (choice D) is also a disease of old men, but they get anemia and multiple lytic lesions throughout the skeleton. Primary malignant bone tumors (choice E) occur in much younger people, and the extremities are a more likely location. 30) The unrestrained front-seat passenger in a car that crashes at high speed is brought to the emergency department by paramedics. At the site of injury, the patient was unconscious and had gurgly respiratory sounds, and the EMTs successfully accomplished blind nasotracheal intubation. The initial survey in the emergency department shows normal vital signs, multiple facial lacerations, and an unresponsive, comatose patient with fixed dilated pupils. Preparations are made to do a CT scan of the head. It is imperative that which of the following should be obtained as well? A. Base of the skull x-ray films B. Extension of the CT to include the entire cervical spine C. Radiographs of all the teeth D. Separate CT scan of the abdomen E. Special views of the maxillary sinuses Explanation: The correct answer is B. Deceleration injury resulting in head trauma of sufficient magnitude to produce coma and multiple facial lacerations may very well have also produced injuries to the cervical spine. Although intubation in the field was very appropriate before the cervical spine was visualized (the patient was comatose and had signs of compromised airway), we need to know the status of the cervical spine before much more is done to the patient. Since CT is needed to evaluate his head injury, the most expeditious way to check his cervical spine is by extending the CT to include the neck. The base of the skull (choice A) will be very well visualized in the CT. No separate x-ray films are needed. Checking the status of the teeth (choice C) or the sinuses (choice E) are hardly the sort of emergencies that need to be addressed now. A separate CT scan of the abdomen (choice D) would have been indicated if he had been hypotensive. So far we have no indication of internal bleeding, and thus do not need to look for a source. 31) A 55-year-old woman has been known for years to have mitral valve prolapse. She has now developed exertional dyspnea, orthopnea, and atrial fibrillation. She has an apical, high-pitched, holosystolic heart murmur that radiates to the axilla and back. Because of her deterioration, surgery has been recommended. Which of the following is the most appropriate procedure? A. Aortic valve replacement B. Mitral commissurotomy C. Mitral valve annuloplasty D. Mitral valve replacement E. Both aortic and mitral valve replacement Explanation: The correct answer is C. The physical findings are classic for mitral valve insufficiency. Whenever possible, repair of the native mitral valve is preferable to replacement. The way to repair an insufficient valve is to tighten the annulus, bringing the leaflets closer to one another. There are no physical findings indicating involvement of the aortic valve; therefore, choices A and E are wrong. Mitral commissurotomy (choice B) is the preferred operation for mitral stenosis. This patient has no signs of stenosis, and no history of rheumatic heart disease to suggest that she might have it. Mitral valve replacement (choice D) is the choice when repair of the native valve cannot be done. 32) A 23-year-old woman seeks help for exquisite pain with defecation and blood streaks on the outside of her stools, which she has been having for several weeks. Because of the pain, she has avoided having bowel movements, and when she finally did the stools were hard and even more painful. When seen, she has no fever or leukocytosis. Physical examination has to be done under spinal anesthesia, because the patient was so afraid of the pain that she initially refused even inspection of the area. The examination confirms the suspected diagnosis, and she is placed on stool softeners and appropriate topical agents, but without success. She is willing to undergo more aggressive treatment. Which of the following is the most appropriate next step? A. Excision of the lesion B. Fistulotomy C. Incision and drainage D. Lateral internal sphincterotomy E. Rubber band ligation Explanation: The correct answer is D. The clinical picture is classic for anal fissure, which is perpetuated by the fact that the anal sphincter is "too tight." Forceful dilatation under anesthesia, lateral sphincterotomy, or botulinum toxin injections are acceptable options to "break the cycle." The only one of those choices given is the sphincterotomy. Excision (choice A) used to be done for this condition, before the role of the "too tight sphincter" was elucidated. Fistulotomy (choice B) is not the answer. She has a fissure, not a fistula. Incision and drainage (choice C) is another option that addresses a wrong diagnosis. We do that for perirectal abscess, which produces severe pain with fever and leukocytosis, but without blood streaks, and drains spontaneously after several days if not diagnosed and treated. Rubber band ligation (choice E) is the answer for internal hemorrhoids. Internal hemorrhoids can bleed, but typically do not hurt. Thrombosed external hemorrhoids can hurt tremendously, but those are not amenable to rubber band ligation. 33) An exploratory laparotomy for multiple intra-abdominal injuries has lasted 3 and a half hours. Multiple blood transfusions have been given, and several liters of Ringer's lactate have been infused. When the surgeons are ready to close the abdomen, they find that the abdominal wall edges cannot be pulled together without undue tension. Both the belly wall and the abdominal contents seem to be swollen. Which of the following is the most appropriate management in this situation? A. Approximate the skin only, using towel clips B. Close the abdomen with heavy retention sutures C. Give diuretics and close the abdomen in the usual way D. Leave the abdomen and its contents open to the air E. Provide temporary bowel coverage with an absorbable mesh Explanation: The correct answer is E. This is a new entity known as the abdominal compartment syndrome, unknown in the days when severely traumatized patients died prior to, or during, surgery. The life-saving massive fluid infusions produce severe edema in the surgical field. Forced closure would compromise ventilation and venous return. A temporary plastic coverage, or a mesh, allows the bowel to be protected without undue pressure. Closing the skin only (choice A) can be life-saving when hypothermia develops during surgery. In this setting, however, the skin will not come together without undue tension. Forced closure (choice B) would compromise ventilation and produce acute renal failure due to pressure on the inferior vena cava. Diuretics (choice C) cannot selectively remove the fluid from the swollen tissues. Leaving the bowel exposed to the air (choice D) is not an option. In the short term, the patient would suffer severe heat loss; later, the bowel would dry out and perforate. 34) A 61-year-old man comes in because of colicky abdominal pain and vomiting of 3 days' duration. On physical examination, he is moderately distended and has high pitched hyperactive bowel sounds and a 5-cm tender groin mass. On direct questioning, he explains that he has had that bulge for many years, but has always been able to "push it back in" when he lies down. For the past 3 days, however, he has been unable to do so. He has a temperature of 38.9 C (102 F) and a white blood cell count of 12,500/mm3. Which of the following is the most appropriate management at this time? A. A sonogram of the mass B. A trial of nasogastric suction and IV fluids for a few days C. Insertion of a long rectal tube via sigmoidoscopy D. Manual reduction of the hernia, followed by a period of observation E. Urgent surgical intervention Explanation: The correct answer is E. The clinical picture is that of a strangulated inguinal hernia. If he only had the tender mass without signs of intestinal obstruction, he might have omentum trapped. If he had the intestinal obstruction without fever, leukocytosis, and the tender mass, he could be obstructed but not strangulated. But, the combination that he has is clearly that of obstruction with strangulation. He needs urgent surgery. A sonogram to make a diagnosis (choice A) might be appropriate for a mass without signs of obstruction, if we could not clinically be sure that it was a hernia. Nasogastric suction and IV fluids (choice B) is the standard approach for obstruction due to adhesions, when there are no signs suggestive of strangulation. We do not operate for adhesions (they form again), but do so only to rescue the bowel that is trapped. In hernias, on the other hand, we want not only to rescue the bowel but also to repair the hernia. A long rectal tube (choice C) is used in Ogilvie's syndrome or volvulus, but not in strangulated hernias. Manual reduction (choice D) would actually be dangerous in this case, as it might force a dead segment of bowel into the abdomen, increasing morbidity and delaying definitive treatment. If he had no fever, no leukocytosis, and no tenderness, such an approach might be justified to gain time for an elective, non-rushed hernia repair. 35) In a rollover car accident, a 42-year-old woman is thrown from the car. The car subsequently lands on her and crushes her. On physical examination in the emergency department, it is determined that she has a pelvic fracture, which is confirmed by portable x-rays done as she is being resuscitated. Her initial blood pressure is 50/30 mm Hg, and her pulse is 160/min and barely perceptible. Thirty minutes later, after 2 L Ringer's lactate and 2 U packed cells have been infused, her pressure is only 70/50 mm Hg, and her pulse is 130/min. A sonogram done in the emergency department shows no intra-abdominal bleeding, and a diagnostic peritoneal lavage confirms that there is no blood in the abdomen (the recovered fluid is pink, but not grossly bloody). Rectal and vaginal exams show no injuries to those organs. There is no blood in her urine. Which of the following is the most appropriate next step in management? A. Packing of the vagina and rectum B. Angiographic embolization of torn veins C. External fixation of the pelvis D. Open reduction and internal fixation of the pelvis E. Exploratory laparotomy with pelvic dissection and hemostasis Explanation: The correct answer is C. This is actually a terrible situation, with no easy way out. Pelvic fractures can bleed massively, and often the source is torn veins that are not easily controlled. Minimizing the motion of the bone fragments by external fixation can be helpful, and it will not make the situation worse. Packing the vagina or rectum (choice A) would help if bleeding originated in those organs, but they cannot reach the source of bleeding in this case. Angiography (choice B) can be very helpful when arteries are torn. It cannot do the same for veins. Opening the fractured area (choice D) would lose the tamponade effect and would not help control the bleeding. And as for the surgeons coming to the rescue (choice E), this is one place in which the high and mighty are routinely humbled. Opening the pelvic hematoma loses the tamponade effect, and once into the thick of things, pelvic veins bleed massively and are not easily controlled. It is best to stay out of these situations. 36) A 52-year-old nurse seeks medical retirement because of a "heart condition." She complains of disabling attacks of tachycardia and palpitations. The physical examination and ECG studies confirm that indeed her pulse is between 100 and 105/min at all times, and she is in and out of atrial fibrillation. It is also noted that she is fidgety and constantly moving, and various examiners remark that she arrives for tests lightly dressed when it is rather cold outside. Thyroid function studies show elevated free thyroxine (T4) and undetectable levels of thyroid stimulating hormone (TSH). Her thyroid gland is not clinically enlarged or tender. Which of the following is the most appropriate next step in diagnosis? A. Fine needle aspiration cytology of the thyroid gland B. MRI of the pituitary area C. Radioactive iodine uptake D. Serum levels of C peptide E. Serum levels of triiodothyronine (T3) Explanation: The correct answer is C. It has been established clinically and by the laboratory that this patient is hyperthyroid, but the thyroid gland does not seem to be abnormal. The circumstances suggest that self-administration of thyroid hormone for secondary gain (e.g., weight loss) is a possibility. Radioactive iodine uptake should be high if her gland is indeed hyperfunctioning, but it will be near zero if it is suppressed by the exogenous hormone. Malignancy is not an issue; thus, fine needle aspiration (choice A) does not have a role. High thyroid function with undetectable levels of TSH excludes the pituitary as the source of the problem. Thus, there is no reason to investigate it as suggested in choice B. C peptide (choice D) is indeed used to ferret out hormonal self-administration, but it distinguishes endogenous from exogenous insulin, not thyroid hormone. T3 (choice E) needs to be determined when clinical signs of hyperthyroidism coexist with normal levels of T4. 37) A 59-year-old man is referred for evaluation because he has been fainting at his job, where he operates heavy machinery. He is pale and gaunt, but otherwise his physical examination is remarkable only for 4+ occult blood in the stool. Laboratory studies show a hemoglobin of 5 gm/dL with microcytosis, as well as decreased levels of serum iron and increased iron binding capacity. Which of the following will most likely establish the diagnosis? A. Upper gastrointestinal series (swallowed barium studies) B. Colonoscopy C. Flexible sigmoidoscopy to 45 cm D. Upper gastrointestinal endoscopy E. Visceral angiogram Explanation: The correct answer is B. Iron deficiency anemia in the adult is always due to chronic blood loss, and the source is obvious in this vignette: the gastrointestinal tract. In turn, the most likely site, in the absence of other symptoms, is a cancer of the right side of the colon, which is best seen by colonoscopy. Upper gastrointestinal series (choice A) would not be likely to reveal the source of this man's anemia, since the cecum or ascending colon is the number one target. Flexible sigmoidoscopy (choice C) would not reach the likely site of the cancer. If the cancer were located in the left colon, he would likely have visible blood in his stools and a change in bowel habits. Upper gastrointestinal endoscopy (choice D) is the first test when someone vomits blood. It often will also reveal the source of occult blood loss (peptic ulcer disease or aspirin-related gastritis) when the colon is found to be normal. In this case, however, the cecum or ascending colon is the number one target. As for visceral angiogram (choice E), it would be great at the time of massive gastrointestinal bleeding (more than 2 mL/min), but in this example it would be a very expensive, invasive, and roundabout way to demonstrate the presence of a tumor (by tumor blush). 38) A 24-year-old woman is admitted to the hospital for a broken femur. The patient was in a motor vehicle accident 20 hours ago and was brought to the hospital by EMS. On the scene, she was found belted in her car in the drivers seat, and her only documented injury was the leg fracture. She had no loss of consciousness or altered mental status. On arrival to the hospital, radiographs confirmed a fracture of her femur. She was stabilized over night and scheduled for surgery the next day. Which of the following is the major surgical risk for this patient? A. Air embolism B. Cerebrovascular accident C. Fat embolism D. Osteomyelitis E. Permanent disability Explanation: The correct answer is C. If a transesophageal echo probe is placed in every patient undergoing femoral reaming for fracture repair, the incidence of fat and particle debris in the right atrium approaches 70%. In fact, a major risk of lower extremity orthopedic procedures is pulmonary embolism due to fat or clots. The intramedullary pressures generated during the repair are greater than 500 psi and are enough to cause venous extrusion of fat and other particulate matter into the circulation. Air embolism (choice A) is common with neurosurgical procedures but is not often seen with orthopedic procedures of the lower extremity. Although cerebrovascular accident (choice B) can occur in the absence of a patent foramen ovale, it is rare. Osteomyelitis (choice D) is a feared complication of orthopedic surgery, and precautions such as sterile preparations and antibiotics are taken to guard against it. Because of this, the complication of pulmonary embolism due to fat is much greater than that of bone infection. Permanent disability (choice E), although a vague term, would rarely be the result of a lower extremity fracture repair. 39) A 42-year-old woman hit her breast with a broom handle while doing housework. She noticed a lump in that area at the time, and 1 week later the lump was still present. She then sought medical advice. On physical examination, she has a 3-cm, hard mass deep inside the affected breast, and some superficial ecchymosis over the area. Which of the following is the most appropriate next step, or steps, in management? A. Reassess in about 2 months, with no specific therapy B. Hot packs, analgesics, and surgical evacuation of the hematoma C. Mammogram, and no further therapy if the report does not identify cancer D. Mammogram and biopsy of the mass E. Mastectomy Explanation: The correct answer is D. Although the history of trauma might suggest a hematoma or fat necrosis, it is well known that trivial trauma sometimes brings to the attention of the patient an area of the body that had not been examined before. A breast mass in a 42-year-old woman requires a mammogram and biopsy. Waiting 2 months (choice A) would be unacceptable for a potential cancer. Hot packs and analgesics (choice B) on the assumption that this is a hematoma would also delay the diagnosis if a cancer is present. Furthermore, if this is indeed a hematoma one would not necessarily want to drain it. Choice C is incorrect because the mammogram is an adjunct to the biopsy of a breast mass, not a substitute for it. The two studies are complementary. Mastectomy (choice E) is too radical a step before a diagnosis has been established. 40) The unrestrained front-seat passenger in a car that crashed at high speed arrives at the emergency department with signs of moderate respiratory distress. Physical examination shows no breath sounds at all on the left hemithorax. Percussion is unremarkable, and his vital signs are normal. A chest x-ray film shows a collapsed left lung and multiple air-fluid levels filling the left pleural cavity. A nasogastric tube that had been placed prior to taking the film shows the tube reaching the upper abdomen and then curling up into the left chest. Which of the following is the most likely diagnosis? A. Blow out of pulmonary blebs B. Esophageal rupture or perforation C. Left diaphragmatic rupture D. Left hemopneumothorax E. Major injury to the tracheobronchial tree Explanation: The correct answer is C. The left diaphragm can blow out with blunt injuries, allowing the bowel to move up into the chest. The multiple air-fluid levels suggest that bowel is indeed there, and the trajectory of the nasogastric tube confirms that the abdominal viscera (including the stomach) have been sucked up into the thoracic cavity. Pulmonary blebs (choice A) produce a pneumothorax when they rupture. The esophagus (choice B) virtually never ruptures with blunt abdominal trauma. You need a penetrating injury, or better yet an endoscopy, to perforate it. When that happens, the outcome is mediastinitis. A hemopneumothorax (choice D) can indeed happen in thoracic injuries, but the x-ray films would show one single large air-fluid level, and the nasogastric tube would be in the stomach, without curling up into the chest. The tracheobronchial tree (choice E) can indeed break as a consequence of deceleration injuries, but the outcome would be a pneumothorax and air in the mediastinum and the subcutaneous tissues. 41) On the 7th postoperative day after the pinning of a broken hip, a 76-year-old man suddenly develops severe pleuritic chest pain and shortness of breath. When examined, he is found to be anxious, diaphoretic, and tachycardic, with a blood pressure of 140/85 mm Hg. He has prominent distended veins in his neck and forehead. Blood gases show hypoxemia and hypocapnia. His chest x-ray film is unremarkable. The nurses have placed him on supplemental oxygen by face mask. Which of the following is the most appropriate next step in management? A. Aortogram and emergency surgical repair B. ECG and cardiac enzymes C. Intubation and respirator, with hyperventilation and PEEP D. Retinal examination looking for fat droplets E. Ventilation-perfusion lung scan, or spiral CT scan of the chest Explanation: The correct answer is E. The clinical picture is that of a pulmonary embolus. Although pulmonary angiogram is the "gold standard" diagnostic test, confirmation is usually obtained with the less invasive ventilation-perfusion scan. In some centers, the high-definition spiral CT scan has been found to be a better diagnostic modality, and it is noninvasive. Aortogram and surgical repair (choice A) assumes the pain is due to a dissecting aortic aneurysm. Had that been the case, the pain would have been more likely to radiate down toward the back, and the patient would have been severely hypertensive. ECG and cardiac enzymes (choice B) would probably be done in this patient, but only to rule out myocardial infarction with greater certainty. Clinically, we should be suspecting a pulmonary embolus, and negative ECG and negative enzymes would not specifically confirm the suspected diagnosis. Hyperventilation (choice C) is not needed on someone who already has hypocapnia. Looking for fat droplets (choice D) is not particularly useful, even when the clinical diagnosis suggests fat embolism. Fat embolism is more likely to be seen with multiple comminuted fractures of long bones (not just a broken hip), and the clinical manifestations are those of respiratory failure. There would be no chest pain. 42) A young man sustains a gunshot wound to the base of his neck. He was shot point blank with a .38 caliber revolver. The entrance wound is above the left clavicle, below the level of the cricoid cartilage, and just lateral to the sternomastoid muscle. The exit wound is just above the spinous process of the right scapula. He has normal breath sounds on both sides, is awake and alert, is talking with a normal tone of voice, is neurologically intact, and is hemodynamically stable. Portable x-ray films of the neck and chest taken in the emergency department show some air in the tissues of the lower neck, but are otherwise non-diagnostic. Which of the following is the most appropriate next step in management? A. Observation for several hours B. CT scan of the lower neck and upper chest C. Angiogram, esophagogram, esophagoscopy, and bronchoscopy prior to surgical exploration D. Immediate surgical exploration of the lower neck through a collar incision E. Immediate surgical exploration of the upper chest through a median sternotomy Explanation: The correct answer is C. Gunshot wounds to the base of the neck need exploratory surgery, but the exact approach and incision are determined by a more accurate knowledge of the location and extent of the injuries. Thus, if time permits, diagnostic studies should precede surgical intervention. The major vessels, the tracheobronchial tree, and the esophagus are the potential targets that have to be investigated. Observation (choice A) might be appropriate for a stab wound in a completely asymptomatic patient. In gunshot wounds, we have to expect that injuries will exist, and they should not be neglected waiting for overt clinical signs. CT scan (choice B) has done wonders for our assessment of closed head injuries and blunt abdominal trauma, but it is not the study that would tell us what has happened to the major vessels, the esophagus, or the tracheobronchial tree in a gunshot wound. Immediate surgical exploration, either through the neck or the chest, or in combination, might be forced by a rapidly deteriorating situation. In the absence of such imperative, a decision to open the neck (choice D) or the chest (choice E) is premature at this point. 43) A 67-year-old man shows up in the emergency department because he has not been able to void for the past 12 hours. He feels the need to, but he cannot do it. He gives a history that, for several years now, he has been getting up four or five times a night to urinate. It would take him a considerable time to get the urinary stream going, and the stream lacked force and often ended in a dribble. Because of a cold, 2 days ago he began taking an antihistamine, taking a decongestant, and drinking plenty of fluids. Physical examination shows a palpable, smooth, round mass arising from the pubis and reaching about half way toward the umbilicus. The mass is dull to percussion, and pushing on it accentuates the feeling of needing to void. Rectal examination reveals a large, boggy, non-tender prostate gland without nodules. This a classic presentation for which of the following acute conditions? A. Bacterial prostatitis B. Cystitis in a patient with bladder cancer C. Renal failure D. Urinary retention in a patient with benign prostatic hypertrophy E. Urinary retention in a patient with prostatic cancer Explanation: The correct answer is D. The history and rectal examination findings are classic for benign prostatic hypertrophy. The use of a decongestant has led to stimulation of alpha adrenergic receptors, which have further closed the bladder neck. A big, palpable bladder has resulted. Bacterial prostatitis (choice A) would produce pain, fever, and a very tender prostate on rectal examination. Cystitis and bladder cancer (choice B) could be expected to produce irritative symptoms and hematuria, but not painless retention. Renal failure (choice C) produces oliguria, not anuria. The bladder would be empty and thus not palpable. The patient would urinate small amounts and feel no need to urinate more. Prostatic cancer (choice E) is usually first felt as a stony hard nodule. It would be unusual for it to grow to a size at which complete obstruction is the first manifestation. If it did, though, the prostate would feel stony hard. 44) Several months after sustaining a crushing injury to his arm, a patient complains bitterly about constant, burning, agonizing pain in that arm, that does not respond to the usual analgesic medications. The pain in his arm is aggravated by the slightest stimulation of the area, such as rubbing from the shirt sleeves. The arm is cold, cyanotic, and moist, but it is not swollen. Pulses at the wrist are normal, and neurologic function of the three major nerves is intact. Which of the following is most appropriate to provide diagnostic confirmation of the nature of the problem and eventual therapy? A. Angiogram and subclavian vein bypass B. Cervical spine x-rays and cervical rib resection C. Doppler studies and arterial reconstruction D. Doppler studies and fasciotomy E. Sympathetic block and surgical sympathectomy Explanation: The correct answer is E. The description is that of causalgia, also known as reflex sympathetic dystrophy. If sympathetic block relieves the symptoms, permanent cure will be obtained with surgical sympathectomy. Venous occlusion (choice A) would produce swelling but not this kind of pain. Cervical ribs (choice B) can produce neurologic and vascular symptoms in the arm, but they are related to activity and position and do not have the nature described here. Normal pulses make arterial insufficiency (choice C) unlikely. Furthermore, there is no description of intermittent claudication. Compartment syndrome (choice D) might have happened at the time of injury, but if that were the case, it would be too late to do a fasciotomy. 45) A 57-year-old alcoholic man is being treated for acute hemorrhagic pancreatitis. He was in the intensive care unit for 1 week, where he required chest tubes for pleural effusions and was on a respirator for several days. Eventually, he improved sufficiently to be transferred to the floor. Three days after leaving the unit, and about 2 weeks after the onset of the disease, he spikes a fever and develops leukocytosis. Which of the following developments do these recent findings most likely suggest? A. Chronic pancreatitis B. Pancreatic abscess C. Pancreatic pseudocyst D. Pelvic abscess E. Subphrenic abscess Explanation: The correct answer is B. A very common complication of hemorrhagic pancreatitis, and often the reason for the demise of the patient, is the development of a pancreatic abscess. The timetable is usually about 10-14 days from the onset of the disease, and the initial manifestations are fever and leukocytosis. Chronic pancreatitis (choice A) develops after several years of recurrent attacks of pancreatitis, and is characterized by steatorrhea, diabetes, and constant pain. Pancreatic pseudocyst (choice C) is another potential complication of pancreatitis, but the manifestations are related to pressure symptoms from the fluid collection, there is no fever or leukocytosis, and the timetable for development is about 6 weeks from the onset of the disease. Pelvic abscess (choice D) and subphrenic abscess (choice E) are indeed in the differential diagnosis, as they also show up with fever and leukocytosis some 10-14 days from the original problem. But, the original problem for these patients is usually an infectious process in the abdomen, e.g., a ruptured appendix or a perforated viscus. If the problem began with pancreatitis, and then there are signs of sepsis, the pancreas is the logical place to harbor the pus. 46) A 31-year-old male immigrant from India is found on a routine physical examination to have a single, 2-cm nodule in the right lobe of his thyroid gland. The mass is firm, moves up and down with swallowing, and is not tender. The skin of his face and neck is pitted with multiple scars, which suggest smallpox; however, he explains that the scars are due to very severe acne that he had as a youngster, for which he eventually received external beam radiation therapy at the age of 14. His thyroid function tests are normal, and a fine needle aspiration (FNA) cytology of the mass is read by the pathologist as "indeterminate." Which of the following is the most appropriate next step in management? A. No further care is needed B. Thyroid function tests should be repeated yearly C. Thyroid scan and sonogram are needed D. FNA should be repeated until it can be read as benign or malignant E. Thyroid lobectomy Explanation: The correct answer is E. The patient is at high risk for thyroid cancer (young, male, with a single nodule and a history of radiation), and a reading of "indeterminate" in an FNA is a surgical indication. No further care (choice A) is totally wrong. It assumes that normal thyroid function means there is nothing wrong with the thyroid, when in fact thyroid cancer almost never alters thyroid function. This choice also assumes that if an FNA is not read as cancer, the patient does not have that disease. Focusing on function (choice B) as the criterion to do something is wrong for the same reasons. Thyroid scan and sonogram (choice C) were formerly valuable criteria to select surgical candidates (cold solid nodules meant a high risk of cancer), but the FNA provides a higher yield of malignancy in resected specimens, and thus has rendered the other tests obsolete for this purpose. Repeating the FNA (choice D) assumes that, given more cells, the pathologist should be able to distinguish benign from malignant. The pathologist has no trouble recognizing malignant features in papillary, medullary, or anaplastic cancers of the thyroid, but cannot do so with follicular neoplasms. Follicular adenoma and follicular carcinoma require a look at the entire specimen to tell them apart. 47) A 33-year-old woman is involved in a high-speed automobile collision. She arrives at the emergency department gasping for breath. Her lips are cyanotic and she has flaring nostrils. There are bruises over both sides of the chest, and tenderness suggestive of multiple rib fractures. Her blood pressure is 60/45 mm Hg, pulse is 160/min and feeble, and central venous pressure is 25 cm H2O. Her neck and forehead veins are distended. She is diaphoretic and has a hint of subcutaneous emphysema in the lower neck and upper chest. Her left hemithorax has no breath sounds and is hyperresonant to percussion. The trachea is deviated to the right, as are the heart sounds. Which of the following is the most likely diagnosis? A. Air embolism from tracheobronchial injuries B. Flail chest due to multiple rib fractures C. Massive intrapleural bleeding from torn intercostal vessels D. Massive mediastinal bleeding from ruptured aorta E. Tension pneumothorax caused by lung punctured by broken ribs Explanation: The correct answer is E. Although we typically associate tension pneumothorax with penetrating chest wounds, a blunt injury can produce lung puncture, as the jagged edges of broken ribs are driven in at the time of impact. All the classic findings of a tension pneumothorax are given in the vignette. Tracheobronchial injuries (choice A) can indeed produce subcutaneous emphysema. They can also produce air embolism if major vessels and major elements of the airway are lacerated next to one another. When that happens, though, the clinical manifestation is sudden death, typically when the patient is placed on a respirator. Flail chest (choice B) is also likely to occur with multiple rib fractures, but the clinical clue is paradoxical breathing, and the eventual problem is respiratory distress but no hemodynamic decompensation. Massive bleeding, whether from torn intercostals or ruptured aorta (choices C and D) would indeed lead to hypovolemic shock, but the central venous pressure would be zero and breathing would not be particularly affected. 48) A 44-year-old woman complains bitterly of severe headache that has been present for several weeks and has not responded to the usual over-the-counter headache remedies. She locates the headache to the center of her head. It is pretty much constant but is worse in the mornings. She has no other neurologic signs or symptoms. She has had "tension headaches" in the past, but she says that those were located in the back of her head and felt different from the present pain. She is currently under considerable stress because she has been unemployed since undergoing modified radical mastectomy for T3, N1, M0 breast cancer 2 years ago. She had several courses of post-operative chemotherapy, which she eventually discontinued because of the side effects. Which of the following is the most appropriate next step in diagnosis? A. CT scan of the head B. Psychiatric evaluation C. Skull x-rays D. Aortic arch arteriogram E. Lumbar puncture Explanation: The correct answer is A. Persistent headache in a patient with recent history of breast cancer (particularly node-positive) is brain metastasis until proven otherwise. The only acceptable course of action is to take a look (radiologically, of course), and the cheapest and most reliable way would be a CT scan. For primary brain tumors, the MRI is favored; however, to show the presence of metastasis, an MRI is not needed. Despite the history of tension headaches and current job worries, psychiatric causes (choice B) are far down the line in the differential diagnosis. Skull x-rays (choice C) are almost a vanishing test. They may still show linear skull fractures when you are looking for them, but they would certainly not show intracranial masses. Vascular studies (choice D) were, at one time, the only reliable way to rule out intracranial tumor, but the CT scan displaced them. We still use them to define vascular lesions, which this vignette does not suggest. Lumbar puncture (choice E) would not diagnose a tumor and would subject the patient to the risk of herniation of the brainstem. Save that test for patients with meningitis. 49) A 59-year-old black man has a rock-hard, discrete, 1.5-cm nodule that is felt in his prostate during a routine physical examination. He is completely asymptomatic, and his prostatic specific antigen (PSA) done 3 months ago was normal for his age. His last rectal examination was performed a year earlier and was unremarkable. Which of the following will best establish the diagnosis? A. Clinical follow-up during the ensuing year B. Repeat determination of PSA C. Transrectal needle biopsy of the mass D. Transrectal sonogram of the prostate E. Transurethral resection of the prostate Explanation: The correct answer is C. Cancer of the prostate will be discovered early by either the discovery of a hard nodule (as in this case), or the identification of elevated PS A. These are complementary examinations. One may be normal, while the other may be revealing. In this case, the recent normal PSA does not exclude the need to biopsy this mass. Clinical follow up (choice A) is inappropriate at this age, but it is not a completely stupid option: it would be the thing to do if the man had been 75. As pointed out above, regardless of PSA levels (choice B) we need to biopsy this mass. A sonogram (choice D) might be needed to identify a tumor that is not palpable, but has been discovered by the PS A. In this case the tumor has been felt. It can be biopsied, guided by the finger or by a sonogram if you prefer. But, the sonogram will not establish the diagnosis, it will only help do the biopsy. Let us not resect the prostate (choice E) before we have a diagnosis. Depending on the results of the complete workup, one might elect a different surgical approach or a different treatment (radiation, for instance). 50) A 9-month-old infant is brought in by her parents because she has an umbilical hernia. Physical examination shows an umbilical defect about 1 cm in diameter, with a small bulge when the girl cries. The hernial contents can be easily reduced. The hernia is not painful, and the girl is otherwise asymptomatic. Which of the following is the most appropriate next step in management? A. No therapy unless the hernia persists beyond the age of 2 years B. Repeated injections of sclerosing agents C. Elective laparoscopic surgical repair D. Elective open surgical repair E. Urgent surgical repair Explanation: The correct answer is A. Small umbilical hernias can close spontaneously up to the age of 2 years. Therefore, if they are asymptomatic and not posing an immediate risk of strangulation, they should be left alone. Obviously, every other answer offered in this question is wrong, because they all advocate aggressive therapy. However, we shall also review other ways in which they might be incorrect. Sclerosing agents (choice B) are not appropriate to manage a hernial sac that communicates with the rest of the peritoneal cavity. Occasionally, if a surgical hernia repair is done when a large distal sac has to be left in place, it might be advisable to destroy the peritoneal lining with sclerosing agents so that it does not secrete fluid. Laparoscopic hernia repair (choice C) makes sense when the size of the incision or incisions can be significantly reduced by the use of laparoscopy (for instance a bilateral inguinal hernia repair). In this case, however, one would need bigger incisions to introduce a TV camera and operating instruments than one would need to directly close a 1-cm superficial defect. Elective open surgical repair (choice D) is what this little girl will need if she still has the hernia past her second birthday. Urgent repair (choice E) would have been indicated if the hernia were tender, or if the girl had been vomiting or getting distended at the same time that the hernia became irreducible. Psychiatry Questions 1) A 32-year-old woman is brought to the emergency department by police for psychiatric evaluation. The officers found her in the street, naked and masturbating. She denies any recent drug use. She is, however, very irritable and has pressured speech. When questioned further, she states that she has had sex with 10 different men in the past 3 days, because she felt that she was "too beautiful to not share" her sexuality. Which of the following is the most likely diagnosis? A. Dysthymic disorder B. Heroin abuse C. Mania D. Partial complex seizures E. Schizophrenia Explanation: The correct answer is C. This patient has evidence of hypersexuality, which is one of the many symptoms of mania encountered in patients with bipolar disorder. Other symptoms of mania include grandiosity, impulsivity, irritability, insomnia, and elevated mood. Dysthymic disorder (choice A) is characterized by depressed mood, more often than not, over the course of at least 2 years. Heroin abuse (choice B) does not manifest with hypersexuality; rather, patients with heroin abuse tend to show signs of slowed activity because of opioid action, with a thin, gaunt appearance and associated lethargy and anorexia. Partial complex seizures (choice D) can present with bizarre behaviors and symptoms, such as olfactory or gustatory hallucinations or brief psychosis, but hypersexuality is not typically one of the behaviors induced. Schizophrenia (choice E) is a thought disorder. This diagnosis requires the presence of auditory hallucinations, flattening of affect, and social autism over the course of at least 6 months. 2) A 50-year-old man presents to an emergency clinic complaining of the onset, over the past day, of bilateral tremor in his hands, diaphoresis, anxiety, headache, and the sensation that "my skin is crawling". He denies other symptoms. His medical history is significant only for hypertension, for which he takes hydrochlorothiazide. He states that he sees a psychiatrist for bipolar disorder and anxiety, and that he takes three medications prescribed by the psychiatrist, the names of which he can not remember. He ran out of his medications three days ago, and he has an appointment for his primary care physician and his psychiatrist tomorrow. His temperature is 37 C (98.6 F), blood pressure is 150/100 mm Hg, pulse is 115/min, and respirations are 20/min. Physical examination is notable for diaphoresis and tremulousness. Administration of which of the following is the most appropriate initial step in this patient's care? A. Clonidine B. Haloperidol C. Hydrochlorothiazide D. Lorazepam E. Prochlorperazine Explanation: The correct answer is D. The patient takes an unknown anxiety medication, and is most likely experiencing benzodiazepine withdrawal symptoms. Commonly observed symptoms of benzodiazepine withdrawal include: anxiety, diaphoresis, irritability, insomnia, fatigue, headache, myalgias, nausea, perceptual disturbances, tremors, and seizures. The most appropriate management step would be parenteral administration of a short-acting benzodiazepine, such as lorazepam. Clonidine (choice A) is often used for the acute treatment of elevated blood pressure. However, it would not be an appropriate initial management choice for this patient, because the elevated blood pressure is most likely caused by or exacerbated by the withdrawal syndrome. Haloperidol (choice B) can be used in the emergency management of extreme anxiety and agitation, but it would not be an appropriate choice for a withdrawal syndrome. Although haloperidol would likely produce sedation, it would not treat the underlying withdrawal; the withdrawal would likely continue to progress. Hydrochlorothiazide (choice C) would not be an appropriate initial management choice. Although the patient has an elevated blood pressure, this is most likely associated with the withdrawal syndrome. Prochlorperazine (choice E) could be used to treat the nausea and headache, but it would not be an appropriate initial management step because these symptoms are most likely due to benzodiazepine withdrawal, which should be treated initially. 3) A 61-year-old woman, who has been treated with amitriptyline for depression, is brought to her psychiatrist by her family. The woman is confused, disoriented, and hallucinating, and her skin appears dry and warm. The family noticed that she took more pills than prescribed. Which of the following is the most likely cause of this development? A. Anticholinergic delirium B. Hypertensive crisis C. Neuroleptic malignant syndrome D. Paradoxical reaction E. Serotonin syndrome Explanation: The correct answer is A. Anticholinergic delirium is caused by the use of anticholinergics or other drugs with anticholinergic properties, like tricyclic antidepressants. In elderly patients, the symptoms can be present even with usual doses. Overdosing results in clouding of consciousness, as well as constipation, urinary retention, dry mouth, elevated temperature, dry flushed skin, worsening of glaucoma, and tachycardia. The primary criterion of a hypertensive crisis (choice B) is an elevated value of both systolic and diastolic blood pressure. Tricyclic antidepressants usually lower blood pressure and cause orthostatic hypotension. Neuroleptic malignant syndrome (choice C) is a rare complication of neuroleptic therapy resulting in muscle rigidity and elevated temperature, as well as difficulties swallowing, tremor, incontinence, diaphoresis, mutism, tachycardia, altered level of consciousness, labile blood pressure, leucocytosis, and elevated creatine phosphokinase. A paradoxical reaction (choice D) is an unusual reaction to benzodiazepines, consisting of paradoxical agitation and confusion instead of relaxation. It is seen in elderly patients, as well as in patients with organic diseases of the CNS. Serotonin syndrome (choice E) can result from a combination of MAO inhibitors and serotonergic agents. Even though altered mental status may be present, tremor, restlessness, hyperreflexia, myoclonus, shivering, and diaphoresis make it different from anticholinergic delirium. 4) A 28-year-old woman presents to the clinic for the first time with symptoms of major depressive disorder lasting several weeks. She requests medication because, apart from feeling low and tired, she feels distracted, forgetful, and unable to focus on her work. She reports having been diagnosed as a child with attention deficit/hyperactivity disorder and dyslexia, and she had been given methylphenidate. Which of the following therapeutic agents would be most appropriate for treatment? A. Alprazolam B. Bupropion C. Lithium D. Olanzapine E. Paroxetine Explanation: The correct answer is B. Bupropion is an antidepressant with both dopaminergic and noradrenergic properties that would essentially help this patient not only improve depression but also cognitive functioning related to her prior history of attention deficit/hyperactivity disorder. Alprazolam (choice A) is a benzodiazepine with a rapid onset of action and a relatively short metabolite half-life. It has strong anxiolytic properties. Even though initially it was claimed to have antidepressant properties too, its highly addictive potential prevents it from wider and longterm use. Lithium (choice C) is a mood stabilizer with potential use for treatment of aggression in attention deficit/hyperactivity disorder. Lithium appears to be effective only as an adjunct in the treatment of depressive disorder. Its long-term use may cause cognitive impairment. Olanzapine (choice D) is an atypical antipsychotic with some mood stabilizing properties. It has not been used solely for treatment of depression. Paroxetine (choice E) is a selective serotonin reuptake inhibitor (SSRI). Although it is effective in most patients, its anticholinergic properties might impair cognitive function more in this case. 5) A 16-year-old boy is brought to the clinic by his father who says that he has been increasingly aggressive and has been stumbling and tripping around the house for several weeks. He is especially worried about his uncharacteristic violent behavior. The patient's temperature is 38 C (100.4 F), blood pressure is 140/90 mm Hg, pulse is 90/ min, and respirations are 22/min. He has slightly dilated pupils and nystagmus. He begins to have convulsions on the table, making the remainder of the examination impossible. Which of the following is the most likely cause of these findings? A. Cocaine withdrawal B. Heroin C. Marijuana D. Morphine E. Phencyclidine (PCP) Explanation: The correct answer is E. This patient is displaying the signs and symptoms of PCP intoxication. PCP causes aggression, distortion of body image, disorganized thoughts, ataxia, nystagmus, middilated pupils, myoclonus, fever, hypersalivation, and hyperacusis. It can lead to seizures, coma, and death. It can also lead to an acute psychosis with a high risk of violent behavior and suicide. Haloperidol is the treatment for the violent behavior. Cocaine withdrawal (choice A) causes severe depression, hypersomnolence, nightmares, headaches, and sweating. The symptoms peak 2-4 days after the last dose. Ataxia and nystagmus are not present. Heroin (choice B) and morphine (choice D) are opioids that produce euphoria, hypoactivity, and impaired concentration. Physical signs include needle "track-marks," miosis, respiratory depression, hypotension, bradycardia, and decreased body temperature. Constipation is very common. Nausea, vomiting, shock, coma, and pulmonary edema may occur. Overdoses are treated with naloxone. Methadone maintenance is used for individuals with demonstrated physiologic dependence and reduces drug-seeking behavior. Marijuana (choice C) produces tachycardia and conjunctival injection. Driving may be impaired for up to 8 hours. Withdrawal is generally mild, but can produce tremor, nystagmus, sweating, irritability, nausea, vomiting, and diarrhea. 6) A 29-year-old woman is brought to the hospital by her husband. She has not slept in several days and cleans the house, drinks wine, and listens to loud music in the middle of the night. She spent $2000 on a shopping spree over 4 days and decided to change her career and start a private business. In the interview room, she talks incessantly, giggles with the nurse, and unbuttons her blouse to shows her newly bought underwear. She has always been cheerful, and has had short periods of time when she was more energetic, but never like this. She denies the use of street drugs, and her urine drug screen is negative. Which of the following is the most likely diagnosis? A. Bipolar disorder type I B. Bipolar disorder type II C. Borderline personality D. Cyclothymia E. Schizophrenia paranoid type Explanation: The correct answer is A. Bipolar disorder type I includes full-blown episodes of mania, with erratic and disinhibited behavior, grandiosity, logorrhea, overextended activities, poor frustration tolerance, and vegetative signs, such as increased libido, excessive energy, decreased sleep, and weight loss. It also includes episodes of mixed mood and major depression. Bipolar disorder type II (choice B) is defined by episodes of major depression and hypomania, but not full-blown mania. Borderline personality (choice C) requires a pattern of unstable personal relationships, self-image, and affect that are seen as efforts to avoid abandonment, unstable relationships, chronic feelings of emptiness, intense anger, transient dissociative symptoms, impulsivity, identity disturbance, and recurrent suicidal behavior. Cyclothymia (choice D) is a less severe form of bipolar disorder, with alternating periods of hypomania and moderate depression. Symptoms must be present at least 2 years for the diagnosis. Schizophrenia paranoid type (choice E) requires the presence of active delusions and hallucinations, disorganized behavior or speech, and negative symptoms. The above symptoms must be present more than 6 months and must include prodromal symptoms and cause impairment in social functioning. Although grandiosity may be part of the clinical picture, it is not the only symptom. 7) A 32-year-old man is brought into the emergency department by a friend because of a heroin overdose. After the administration of naloxone and a complete physical examination, which of the following laboratory studies is most important in the evaluation of this patient to provide long-term follow-up care? A. Albumin level B. Echocardiogram C. Electroencephalogram D. HIV antibody test E. Plasma liver enzyme levels Explanation: The correct answer is D. Because of the frequent use of needles in a patient with heroin dependence, it is absolutely necessary to rule out the possibility of HIV infection. This is especially true with a patient who is unable to provide a history during an episode of heroin overdose. Concomitant HIV infection and the need for diagnosis will make this laboratory study the most important of all the studies listed. Albumin level (choice A) and other plasma liver enzyme levels (choice E) are not usually affected by an episode of heroin intoxication. An echocardiogram (choice B) may be indicated in a chronic IV drug abuser if there is evidence of a murmur on auscultation of the heart, pointing to the possibility of bacterial endocarditis. An electroencephalogram (choice C) is not necessarily indicated in a patient with heroin intoxication. 8) A 52-year-old African American woman is attending her 18-year-old son's funeral, when she cries out "Damn you, Lord, for stealing my baby from me!" During the next several days, she has several outbursts of crying spells and extreme anger at God, and questions her religious faith. After a few days, the crying spells cease. She has never been diagnosed with a psychiatric disorder in the past,. She is well supported by friends and family, and she denies any suicidal ideation. Which of the following is the most likely diagnosis? A. Bereavement B. Brief psychotic disorder C. Major depressive disorder with psychotic features D. Panic disorder E. Paranoid schizophrenia Explanation: The correct answer is A. Bereavement, or normal grief, is often characterized by many of the same characteristics of depression, including sadness, tearfulness, loss of appetite, poor sleep, and diminished interest in activities that used to bring pleasure. Of importance in differentiating grief from major depressive disorder (choice C) is that people with grief have symptoms that are time-limited, whereas people with major depression cannot ever imagine feeling better. In this case, the patient does not have any evidence of psychosis, eliminating brief psychotic disorder (choice B) and paranoid schizophrenia (choice E) from the differential diagnosis. Panic disorder (choice D) is a syndrome that consists of discrete periods of intense fear or discomfort accompanied by somatic complaints, such as palpitations, trembling, shortness of breath or sweating; these symptoms are not consistent with this patient's complaints. 9) A 63-year-old white male who has recently retired from work as a plumber for over 30 years returns to his family physician saying that he has been feeling very down lately, and has been having decreased appetite and a loss of interest in activities that used to give him pleasure. He is a smoker, drinks no alcohol, and is being treated by his family physician for moderate essential hypertension. Which of the following is the most appropriate next step in management? A. Discuss activities that will help him enjoy his retirement B. Order a thyroid stimulating hormone level (TSH) C. Order electroconvulsive therapy (ECT) D. Prescribe an antidepressant E. Review the patient's medication history Explanation: The correct answer is E. Many medications used to control hypertension, such as propranolol, and in the past, reserpine, are known to occasionally lead to depressive symptoms. By evaluation of the patient's medication record, the physician can evaluate which medications were started at what time and can make adjustments to dosage or switching to alternative medications to control hypertension. Changing the antihypertensive medication will possibly improve the depressive symptoms without the need to start an antidepressant (choice D). Choice A is an appropriate intervention, but it is not the most appropriate next step, as the etiology of the patient's depression may be overlooked. Ordering a TSH level (choice B) is also appropriate, as hypothyroidism can be an organic cause of depression. However, given the patient's medication history, evaluating possible pharmacologic causes of depression takes precedence in management of patient depression. Electroconvulsive therapy (choice C) is indicated in severe intractable depression when not contraindicated by seizure disorder or other factors, but is not indicated in this state. 10) A woman who attends weekly psychotherapy sessions becomes furious at her psychiatrist, who is about to leave for vacation and is not willing to reveal where he is going. She angrily says that he is just like her father, who always had his own "own life" outside the family. Which of the following best describes this patient's reaction? A. Acting out B. Countertransference C. Identification D. Projection E. Transference Explanation: The correct answer is E. Transference is defined by psychoanalysts as a patient's unconscious feelings and behavior toward the analyst that are based on infantile wishes the patient has toward parental figures. Acting out (choice A) is a defense mechanism by which a person expresses an unconscious wish or impulse through action in order to avoid being consciously aware of the accompanying affect. Giving in to an impulsive act relieves the tension and brings immediate gratification. Countertransference (choice B) encompasses a spectrum of analyst's reactions to the patient that are unconscious and based on personal conflicts of which the analyst may not be aware. Identification (choice C) is a defense mechanism and also plays a role in normal ego development. Identification with a loved object serves as a defense against pain or anxiety related to threatened or real loss or separation from the object. Projection (choice D) is a defense mechanism by which inner unacceptable impulses are perceived as though they were coming from the outside and are ascribed to someone else. 11) A 26-year-old medical student is arrested for threatening a neighbor with a knife. He is brought to the hospital because he tried to slit his wrists on the way to the police station. His roommate arrives and states that the patient has been "very odd" over the past 7 months. He is socially withdrawn and has been overheard saying that the FBI. is giving him tips on patient-care and that "people from the sky" are telling him to do "bad things." He stopped going to his ObGyn rotation because believes that the babies were "coming to earth" to give him messages. He says he does not want to be a doctor anymore. He appears apathetic and has emotional blunting. The physical examination is otherwise normal. Toxicologic screening is negative. Which of the following is the most likely diagnosis? A. Bipolar I disorder B. Brief psychotic disorder C. Delusional disorder D. Schizophrenia E. Schizophreniform disorder Explanation: The correct answer is D. This patient has schizophrenia. He hears voices, has delusional irrational thoughts, has a flattened affect and lack of motivation, and has become socially withdrawn. This has been going on for 7 months. Schizophrenia is a disease that is characterized by psychotic symptoms (positive symptoms) and flattening of affect and motivation (negative symptoms) and an impairment of social or occupational functioning for at least 6 months. The symptoms are not caused by a mood disorder, schizoaffective disorder, a medical, neurologic or a substance-induced disorder. It commonly begins in the early 20s and an abnormal premorbid level of functioning is common. 10% will commit suicide. The treatment consists of antipsychotic agents and psychosocial treatment, including reality-based therapy, patient and family support, skill training, and assistance with daily living skills. Bipolar I disorder (choice A) is diagnosed after at least one manic episode. It is often characterized by episodes of mania mixed with episodes of depression. Manic episodes must be a distinct period of elevated or irritable mood with grandiosity, pressured speech, flight of ideas, racing thoughts, a decreased need for sleep, distractibility, increased goal-directed behavior, involvement in pleasurable activities with known undesirable consequences (excessive shopping, risky sexual activity and unwise business investments). The episodes cause functional impairment and last for at least 1 week. Treatment for bipolar disorder is lithium. Brief psychotic disorder (choice B) is characterized by psychotic symptoms that last for more than one day, but less than one month. It may be preceded by a stressor, and is self-limited. Delusional disorder (choice C) is characterized by nonbizarre delusions (such as being poisoned, being followed, or having a disease) that are present for at least 1 month. Treatment is psychotherapy. Schizophreniform disorder (choice E) resembles schizophrenia but lasts for more than 1 month but less than 6 months. It is self-limited. 12) A 44-year-old, HIV-positive patient has been treated for Pneumocystis carinii pneumonia in the hospital. He has a prior history of depression and was treated with paroxetine, which was continued in the hospital. While in the hospital, he became delirious and had visual hallucinations. The psychiatry consult team started him on olanzapine. The patient's delirium gradually resolved, but prior to discharge he complained that his urine stream became weak and his bladder felt full. On examination, the physician confirmed lower abdominal distention. Which of the following is the most effective treatment? A. Benztropine B. Bethanechol C. Furosemide D. Lorazepam E. Physostigmine Explanation: The correct answer is B. Bethanechol is direct-acting cholinergic stimulant effective in reducing the peripheral anticholinergic effects of some psychotropic medications. It can be administered intramuscularly, orally, or subcutaneously to efficiently relieve the symptoms of urinary retention. Benztropine (choice A) is an antiparkinsonian drug with anticholinergic properties. It would only worsen the symptoms in the case described. Furosemide (choice C) is a loop diuretic with a target action on the kidneys and thus has no effect on the cholinergic system. Lorazepam (choice D) is a short-acting benzodiazepine; it is not used to counteract peripheral anticholinergic effects. Physostigmine (choice E) produces cholinergic stimulation by inhibiting cholinesterase. It is useful for relieving CNS symptoms (delirium, confusion) produced by anticholinergic medications. Because this patient's symptoms are peripheral in nature rather than central, bethanechol would be the drug of choice. 13) A 24-year-old man was recently hospitalized in a psychiatric unit, where he was started on olanzapine. Upon visiting his new primary care physician for a routine physical examination prior to participating in a vocational rehabilitation program, his physician notices that his thoughts are quite illogical. For example, when she asks the young man what sort of employment he hopes to work toward, he answers, "if you subtract some yellow from the sky, it becomes greener." After a brief silence, he then states, "telephone bills should never exceed twenty dollars ... according to the Book of Numbers." Which mental status examination finding most accurately describes this patient's thought processes? A. Clang associations B. Concrete thinking C. Loose associations D. Tangential thoughts E. Thought blocking Explanation: The correct answer is C. This patient exhibits thought processes characterized by loosening of associations. His ideas are disconnected and seem to jump from one topic to an unconnected topic. Loose associations are one of the characteristic signs of a primary thought disorder, such as schizophrenia. Clang associations (choice A) occur when the selection of words or themes is based on a sound of the words rather than on thought content. Words that rhyme are frequently associated. Clang associations, like most other signs of thought disorder, can either be due to a primary thought disorder, a primary mood disorder (e.g., during a manic episode), or related to other problems (such as substance intoxication or delirium). Concrete thinking (choice B) is characterized by poor ability to think in abstract terms, despite normal intelligence. This case presentation gives no evidence of impairment in abstract thinking. Tangential thoughts (choice D) describe thoughts that go off on a tangent, unrelated, or minimally related to the original idea. With such tangentiality, the patient abandons his ideational objective in pursuit of thoughts peripheral to the original goal. The interviewer is commonly left with the sense that a question to the patient elicited a long string of thoughts that ended up having nothing to do with the original question. Thought blocking (choice E) occurs when thoughts and speech halt, often in midsentence, as if forgotten. The thought may be picked up later, after a period of apparent confusion. 14) An 8-year-old boy is brought to see a child and adolescent psychiatrist because of his mother's complaint that he repeatedly states that he wants to be a girl. She also notes that he has always seemed to prefer girls' clothes and frequently gets upset in the mornings when his mother dresses him in typical boy clothes for school. His play activities are characterized by games more frequently enjoyed by girls, and he prefers to play with girls. When his mother reminds him that he is a boy and should act like a boy, he frequently gets upset and sometimes has a temper tantrum. The boy has no significant past medical history, and physical examination is within normal limits. Into which of the following areas is this boy's difficulty best classified? A. Gender identity B. Intellectual development C. Sexual aversion D. Sexual identity E. Sexual orientation Explanation: The correct answer is A. Gender identity is a person's sense of maleness or femaleness. The formation of gender identity is based on many cultural influences, physical characteristics, and parental attitudes. The standard and healthy outcome in the development of gender identity is a relatively secure sense of identification with one's biological sex. Individuals may be diagnosed with gender identity disorder when the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Intellectual development (choice B) is the process of maturation of normal cognitive functions. There is no evidence of an intellectual impairment in this case. Sexual aversion (choice C) refers to a persistent or recurrent extreme aversion to, and avoidance of all, or almost all, genital sexual contact with a sexual partner. Sexual aversion disorder is an adult sexual desire disorder, along with hypoactive sexual desire disorder. Sexual identity (choice D) refers to a person's biological sexual characteristics: chromosomes, external genitalia, internal genitalia, hormonal composition, gonads, and secondary sexual characteristics. In this case, there is no evidence of a disturbance in sexual identity-it is clear that the patient has a male phenotype, and presumably a male genotype (XY). Sexual orientation (choice E) describes the object of a person's sexual impulses (heterosexuality, homosexuality, bisexuality). In this case, we have no information on the direction of the boy's sexual impulses, or that he experiences conscious sexual impulses at this stage at all. The development of a homosexual orientation is rarely accompanied by a disturbance in gender identity, as these two developmental processes are quite distinct. 15) A 40-year-old man is admitted to the hospital for evaluation and treatment of depression associated with suicidal thoughts. He denies any past psychiatric history. His medical history is significant for hypertension, for which he currently takes hydrochlorothiazide. He also describes a history of once having a painful erection that lasted for eight hours and had to be treated with intracavernous injections in the emergency room. He states that this was thought to be related to an antihypertensive medication that he used to take. During the treatment of this man's psychiatric condition, which of the following medications should be avoided? A. Bupropion B. Clonazepam C. Paroxetine D. Trazodone E. Zolpidem Explanation: The correct answer is D. Trazodone is an older antidepressant medication that is commonly used in lower doses for the treatment of insomnia associated with depression. Due to its significant alpha-adrenergic blocking properties, it has been associated with priapism. Priapism is a serious adverse event defined as a persistent, painful penile erection. Erectile dysfunction occurs in approximately 50% of men suffering an episode of priapism. This patient has a history of a prior episode of priapism associated with an antihypertensive (most likely one with significant alphaadrenergic antagonism, such as prazosin). Given his history of priapism (and due to the fact that he is likely predisposed to subsequent episodes of priapism) trazodone should be avoided in this patient. Bupropion (choice A) is a newer antidepressant that is not associated with the development of priapism. It is also marketed for smoking cessation treatment. Clonazepam (choice B) is a long-acting benzodiazepine that is often used in the treatment of anxiety associated with major depression, during the initiation of antidepressant treatment. It is not associated with priapism and would not be contraindicated in this patient. Paroxetine (choice C) is a selective serotonin reuptake inhibitor (SSRI) that is used for the treatment of depression and a variety of primary anxiety disorders (obsessive-compulsive disorder, panic disorder, social phobia). It is not associated with priapism. Zolpidem (choice E) is a non-benzodiazepine hypnotic agent that acts at the gamma-aminobutyric acid (GABA)-benzodiazepine complex. It is used in the treatment of insomnia. It is not associated with priapism. 16) A 28-year-old man presents to his primary care physician for his yearly physical examination. He currently smokes approximately one pack of cigarettes a day and is interested in quitting. He has no significant past medical history and has no allergies. He is interested in smoking cessation classes, but would like additional help. Which of the following medications would be the most appropriate agent for treating nicotine dependence in this patient? A. Bupropion B. Buspirone C. Clonazepam D. Fluoxetine E. Nefazodone Explanation: The correct answer is A. Bupropion was approved by the U.S. Food and Drug Administration in 1996 as a treatment for nicotine dependence. The specific mechanism of action is unclear, but is thought to relate to reducing craving for nicotine as well as reducing withdrawal symptoms after cessation. Buspirone (choice B) and fluoxetine (choice D) are also used in conjunction with behavioral modification techniques in smoking cessation, but they are not approved as specific treatments for nicotine dependence. Clonazepam (choice C) is a benzodiazepine used to treat anxiety and withdrawal symptoms and is not indicated for use in smoking cessation. Nefazodone (choice E) is an antidepressant medication that does not have demonstrated efficacy in aiding smoking cessation. 17) A 74-year-old woman with a long history of type 2 diabetes mellitus undergoes surgery for small bowel obstruction. After surgery, she develops acute renal failure. However, she refuses to undergo dialysis on the advice of her physician, who then calls for an immediate psychiatric consultation. The patient tells the psychiatrist that she has lived a long life and does not want to be kept alive by or attached to a machine, even if it means she will die. A mental status examination shows that she is not psychotic, that she is fully oriented and alert, and that she has no fluctuations of cognition or level of consciousness. The patient's family is insistent that she be dialyzed immediately. Which of the following is the most appropriate statement the psychiatric consultant could make? A. The patient is aware of the consequences of her decision and does not show signs of a major psychiatric illness. B. The patient is competent to decide on treatment, and her refusal to undergo dialysis must be respected. C. The patient is competent to decide on treatment, but her refusal can be overruled because of a medical emergency. D. The patient is operating in a suicidal manner and should be committed for treatment against her will. E. The patient is temporarily incompetent, so start her on dialysis. Explanation: The correct answer is A. This patient raises one of the most difficult legal and ethical problems in psychiatry. It is important to understand that competency, or lack of competency (choices B, C, and E), can be determined only by a legal authority, such as a court of law. The role of psychiatrists is solely advisory in determining competency. In this situation, only if the patient is suicidal by virtue of a major psychiatric illness, or if the patient were subject to an immediate medical emergency, could treatment be involuntarily administered. The psychiatrist's role is to assess a person's mental status for evidence of cognitive impairment, as well as to ascertain that the patient has a thorough understanding of the consequences of treatment decisions that are made. This patient does not meet criteria for treatment against her will (choice D), which requires both a mental disorder and the threat of impending immediate harm to self or others. 18) A 72-year-old African American man with a history of renal dysfunction, congestive heart failure, and previous myocardial infarction is currently undergoing dialysis. Until the past few weeks, he has been in good spirits and has a strong family support system that helps him in getting to and from dialysis daily. Over the past few weeks, however, he has been feeling increasingly depressed and has begun to act bizarrely, with persecutory delusions that the government is poisoning the chemicals used on him for dialysis. Also in the last few weeks, due to increased stomach pain, his medications have been adjusted and now include cimetidine for stomach ulcers, digoxin, and a baby aspirin daily. He also takes docusate sodium as needed for stool softening and ibuprofen as needed for mild arthritis pain. Which of the following medications would be most likely to have induced the symptoms the patient is now experiencing? A. Aspirin B. Cimetidine C. Digoxin D. Docusate sodium E. Ibuprofen Explanation: The correct answer is B. Cimetidine is the only drug listed known to cause psychiatric effects of clinical significance, including delusions and psychosis. The exact mechanism is unknown, but is thought to be related to the effects of cimetidine on the H-2 histamine receptor in the brain. The treatment of cimetidine-induced psychosis is to reduce the dosage of the medication, and discontinue it if an alternative therapy is available. Aspirin (choice A) has not been shown to induce any clinically significant psychiatric changes. Digoxin (choice C) has been known to cause delirium in toxic levels, but does not cause the long standing delusion that the patient above demonstrates. Docusate sodium (choice D) and ibuprofen (choice E) are medications not known to cause demonstrable psychiatric effects. 19) A 34-year-old man is admitted to the psychiatric temporary observation unit complaining of depression and suicidal ideation following a cocaine binge. During his stay, he starts feeling as if insects are crawling under his skin. This is most typical of which of the following phenomena? A. Depersonalization B. Dyskinesia C. Formication D. Illusion E. Synesthesia Explanation: The correct answer is C. Formication is a form of haptic hallucinations, associated with the sensation of touch. It is commonly seen in delirium tremens, amphetamine psychosis, and cocaine intoxication. Depersonalization (choice A) is a term that describes the feeling of being different, strange, or unreal. The person feels a loss of identity. This phenomenon is seen in dissociative disorders. Dyskinesia (choice B) is a term describing any movement disorder. Illusion (choice D) is an erroneous perception, or a false response to sensory stimulus. It is commonly seen in toxic states as well as in schizophrenia and severe anxiety disorders. Synesthesia (choice E) is a state in which a stimulus in one sensory modality produces a sensation in another modality. It is seen in intoxication with hallucinogens. 20) A 48-year-old man presents to a primary care physician because of a one-week history of symptoms consistent with pneumonia. Since this is the patient's first visit to the clinic, the physician gathers a full history for a new patient assessment. The patient has no significant past medical, surgical, or psychiatric history. Family history is significant for a brother and an uncle with paranoid schizophrenia. Social history reveals that the patient lives alone, has minimal contact with family, and describes no real social activities or friends. When questioned about this, he states, "I've never been much interested in my family or being around people. "He has worked delivering newspapers for the past 15 years. He has not dated since having one girlfriend in the 11th grade. During interview, though he seems emotionally detached, he denies depressive symptoms or psychotic symptoms. Which of the following is the most appropriate psychiatric diagnosis? A. Avoidant personality disorder B. Psychotic disorder, not otherwise specified C. Schizoid personality disorder D. Schizophrenia, undifferentiated type E. Social phobia Explanation: The correct answer is C. Schizoid personality disorder is a cluster A personality disorder (paranoid, schizoid, schizotypal). These disorders are more common in the biological relatives of patients with schizophrenia than among control groups. Schizoid individuals are characterized by a pervasive pattern of detachment from social relationships and a restricted range of emotional expression. Such people usually neither desire nor enjoy relationships with family or friends, choose solitary activities, have little interest in sexual experiences with another person, take pleasure in few (if any) activities, appear indifferent to praise or criticism of others, and show emotional detachment. Avoidant personality disorder (choice A) is a cluster C personality disorder (avoidant, dependent, obsessive compulsive) characterized by a high anxiety level. These individuals have a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to a negative evaluation. They avoid occupational activities that involve significant interpersonal contact because of fears of criticism or disapproval. Avoidant individuals are hesitant in relationships because of fears of being shamed or ridiculed and view themselves as socially inept, personally unappealing, or inferior to others. Unlike in schizoid personality disorder, avoidant individuals strongly desire closer relationships, but are very anxious about them. Psychotic disorder, not otherwise specified (choice B) is a diagnosis that indicates psychotic symptoms (delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior) about which there is inadequate information to make a specific diagnosis. Schizophrenia, undifferentiated type (choice D) is a diagnosis used to classify individuals who meet criteria for schizophrenia, but do not clearly fit into one of the other types (catatonic, disorganized, paranoid, residual). This patient does not have known psychotic symptoms. Social phobia (choice E) is a primary anxiety disorder that has many features in common with avoidant personality disorder. It is characterized by a marked and persistent fear of social situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. 21) A 20-year-old white man is brought to the emergency clinic by two friends on a Sunday morning after a fraternity party the night before. His friends note that since the party, he has been very belligerent, agitated, and loud. They suspect that he may have used drugs with some friends at the party. His temperature is 37 C (98.6 F), blood pressure is 145/95 mm Hg, pulse is 105/min, and respirations are 20/min. Physical examination reveals slurred speech, unsteady gait, and nystagmus. The patient appears to be responding to auditory hallucinations. Which of the following syndromes most likely accounts for this patient's presentation? A. Alcohol withdrawal B. Cocaine intoxication C. Opioid withdrawal D. Phencyclidine intoxication E. Valium withdrawal Explanation: The correct answer is D. Phencyclidine (PCP) intoxication is characterized by maladaptive behavioral changes, and may be associated with vertical or horizontal nystagmus, hypertension, tachycardia, numbness or decreased response to pain, ataxia, dysarthria, muscle rigidity, and seizures. Psychotic phenomena (delusions or hallucinations) may also be present. Alcohol withdrawal (choice A) can be associated with autonomic hyperactivity, but alcohol withdrawal would not account for the dysarthria, ataxia, and nystagmus present in this patient. Other symptoms of alcohol withdrawal include hand tremor, insomnia, nausea or vomiting, transient hallucinations (commonly visual or tactile), agitation, anxiety, and seizures. Cocaine intoxication (choice B) could cause behavioral changes, psychotic phenomena, and elevations in vital signs. However, dysarthria, ataxia, and nystagmus are not usually associated with cocaine intoxication. Opioid withdrawal (choice C) consists of dysphoric mood, nausea or vomiting, myalgias, lacrimation, rhinorrhea, pupillary dilation, piloerection, sweating, diarrhea, yawning, fever, and insomnia. This patient's presentation is not consistent with opioid withdrawal. Valium withdrawal (choice E) would clinically look very much like alcohol withdrawal. Withdrawal from benzodiazepines can result in serious medical complications, such as seizures. The onset of withdrawal symptoms usually occurs 2-3 days after the cessation of use, but with long-acting drugs, such as diazepam (Valium), the latency before onset may be 5-6 days. 22) A psychiatrist on a consult team is asked to see a 32-year-old woman for depression. She was admitted to the hospital for a workup of nausea, vomiting, and abdominal pain. The medical team has so far found no reason for these symptoms. In talking to the patient, the psychiatrist learns that she has had many medical problems and, over the past 10 years, has been in the hospital more than 10 times. She reports having had excessive menstrual bleeding and a miscarriage, as well as difficulty becoming aroused during sexual intercourse. She cannot tolerate high-fiber foods and has heartburn and bloating. Two years ago, she had a lump in her throat and had difficulty swallowing, but nothing was found during that admission. In the past couple of years, she has had frequent migraine headaches and blurred vision and has seen several neurologists. She also hurt her back and now has chronic back pain. Which of the following is the most likely diagnosis? A. Conversion disorder B. Generalized anxiety disorder C. Masked depression D. Pain disorder E. Somatization disorder Explanation: The correct answer is E. Somatization disorder is characterized by multiple medical complaints, resulting in significant diagnostic testing and medical interventions and causing impaired social and occupational functioning. The symptoms, which cannot be explained by medical findings, include pain in at least four sites, one pseudoneurologic symptom, one sexual dysfunction symptom, and at least two or more gastrointestinal symptoms. Conversion disorder (choice A) is a constellation of one or more neurologic symptoms associated with psychological conflict . The symptoms include deficits affecting motor or sensory function under voluntary control, disturbances of consciousness, and pseudoseizures. There is a clear temporal association of the onset of symptoms and a stressor. The symptoms are not consciously produced and are not due to any other medical or psychiatric condition. Generalized anxiety disorder (choice B) is defined by an unrealistic or excessive worry about activities or life events lasting at least 6 months. In addition, six of the following types of symptoms must be present: fatigability, muscle tension, irritability, troubles falling or staying asleep, difficulty concentrating, and restlessness. The symptoms cause significant impairment in everyday functioning. Masked depression (choice C) can be presented through somatic complaints, which can be cardiovascular, gastrointestinal, urinary, or orthopedic, along with depressive symptoms. The disorder meets criteria for depressive disorder but usually not for somatization disorder. Pain disorder (choice D) is characterized by pain as a prominent feature, along with psychological factors that precipitate, exacerbate, and contribute to its severity. It results in impairment of everyday functioning and is not due to any other psychiatric or medical condition. If a general medical condition is present, it doesn't have a role in its onset or maintenance. 23) A 25-year-old woman presents to the emergency department complaining that she is having auditory hallucinations and tremors, along with associated nausea and vomiting. She feels very anxious. On mini-mental status examination, she scores 22 of 30, and she appears to be obtunded. From which of the following substances is this patient most likely withdrawing? A. Alprazolam B. Caffeine C. Cocaine D. Heroin E. Nicotine Explanation: The correct answer is A. This patient has the symptoms of withdrawal from benzodiazepines, such as alprazolam (Xanax). Symptoms include insomnia, tremor, gastrointestinal distress, hallucinosis, and anxiety. Withdrawal from benzodiazepines can also be accompanied by generalized seizures. Caffeine (choice B) withdrawal does not have associated obtundation and usually manifests as mild psychomotor agitation. Cocaine withdrawal (choice C) is characterized by dysphoria, psychomotor agitation or retardation, and marked fatigue. Heroin withdrawal (choice D) is characterized by generalized pain, nausea, vomiting, diarrhea, and piloerection (goose flesh). Nicotine withdrawal (choice E) is characterized by intense craving activity and mild to moderate psychomotor agitation. 24) A 53-year-old female lawyer who has been married for 20 years comes to her physician's office because she has not felt "up to par" over the past 2 months. She is married, has two grown sons, and has a good practice. In the past couple of weeks, she has stopped taking care of her appearance and has frequently called in sick to work, when she actually has been having difficulty getting out of bed. She states that she has lost her appetite recently and her interest in sex with her husband has decreased considerably. She recently told her husband that at times she wonders whether she should go on living. She denies any history of drug or alcohol abuse, and a complete physical examination 3 months earlier showed her to be in good health. Which of the following is the mostly likely diagnosis? A. Bipolar I disorder B. Generalized anxiety disorder C. Major depressive disorder D. Panic disorder E. Schizophrenia Explanation: The correct answer is C. This patient most likely has major depressive disorder. She has had symptoms for 2 months, surpassing the DSM-IV criteria for a minimal length of depression of 2 weeks. Her other symptoms include loss of appetite, hypersomnia, decreased libido, loss of energy and interest in pleasurable activities, and vague suicidal ideation, all of which are criteria for major depression. The diagnosis of bipolar I disorder (choice A), requires an episode of mania, with increased grandiosity, irritability, and impulsiveness, either currently or in the pastnone of which are seen in this case. Generalized anxiety disorder (choice B) requires frequent intermittent episodes of anxiety over a more prolonged period than 2 months. This diagnosis is ruled out in this patient by the absence of any prominent symptoms of anxiety. The diagnosis of panic disorder (choice D) requires discrete episodes known as panic attacks, with tachycardia, diaphoresis, and a sense of impending doom-none of which this patient describes. Schizophrenia (choice E) is ruled out because of the absence of psychotic symptoms, such as delusions, hallucinations, and disorganized thinking 25) A 68-year-old woman with hypertension comes to the physician because of decreased appetite, fatigue, insomnia, inability to concentrate, and feelings of worthlessness over the past two months. She states that her grandchildren are coming to stay with her for three weeks and she "wants to get to the bottom of this" before they arrive. Her antihypertensive medication was changed three months ago. Which of the following antihypertensive medications is the most likely cause of the patient's new symptoms? A. Captopril B. Furosemide C. Minoxidil D. Propranolol E. Verapamil Explanation: The correct answer is D. The symptoms of change in appetite, fatigue, insomnia, lack of concentration, and worthlessness for greater than 2 weeks are consistent with depression. Propranolol is one of the most common pharmacological agents to cause depression. Other side effects of propranolol include dizziness, bronchospasm, nausea, vomiting, diarrhea, and constipation. It may also precipitate asthma, congestive heart failure, and hypoglycemia in susceptible patients. Captopril (choice A) most commonly causes a cough, rash, fever, and hyperkalemia. It is contraindicated in bilateral renal artery stenosis and pregnancy. Furosemide (choice B) causes potassium depletion, hyperglycemia, hyperuricemia, and hypocalcemia. It is contraindicated in patients with hyperuricemia and primary aldosteronism. Minoxidil (choice C) causes hair growth (which is often desirable), tachycardia, and fluid retention. It is contraindicated in patients with severe coronary artery disease. Verapamil (choice E) most commonly causes constipation, heart block, hyperkalemia, and liver dysfunction. 26) A 39-year-old woman with a history of hypomanic episodes in the past presents to her physician complaining of several of the symptoms of a major depressive episode. Given this history, which of the following is the most likely diagnosis? A. Bipolar I disorder B. Bipolar II disorder C. Cyclothymic disorder D. Major depressive disorder E. Substance abuse Explanation: The correct answer is B. Bipolar II disorder is characterized by the presence or history of one or more depressive episodes and one or more hypomanic episodes. Hypomania is defined as a distinct period of persistently elevated, expansive, or irritable mood, lasting at least 4 days, but not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. Bipolar I disorder (choice A), requires the presence or history of at least one episode of full blown mania, with accompanying grandiosity, irritability, and impulsivity. Cyclothymic disorder (choice C) is a diagnosis that requires, for at least 2 years, the presence of numerous periods of hypomanic symptoms and numerous periods with depressive symptoms that do not meet the criteria for a major depressive episode. Major depressive disorder (choice D) is excluded as the most likely diagnosis because of the presence of hypomania. Substance abuse (choice E) is not supported as a diagnosis in this patient without further information. 27) An 82-year-old woman, whose husband passed away 6 weeks ago after a long illness, is admitted to the hospital for worsening of her cardiac problems. During the hospital stay, a psychiatrist is invited to consult at the request of her daughters. The daughters think their mother is depressed, because she is tearful, often talks about her dead husband, and states that she had heard his voice several times. She blames herself for not having gone with him on his last visit to his sister, and she starts crying. She has never seen a psychiatrist before and has been "strong" all her life. Which of the following is the most likely diagnosis? A. Depression secondary to general medical condition B. Dysthymia C. Grief reaction D. Major depressive disorder E. Psychosis not otherwise specified Explanation: The correct answer is C. A normal or uncomplicated grief reaction after the loss of a beloved person may resemble depression in some ways (e.g., changes in sleep or appetite, sadness, withdrawal). However, as the loss becomes remote, the grief-stricken person is able to reexperience joy. Self-blame is focused on what was not done in relation to the deceased person. Illusions or hallucinations of the deceased person are common. The uncomplicated grief reaction can last several months, or longer, depending on the relationship to the deceased. Depression secondary to a general medical condition (choice A) can be seen in association with cardiopulmonary disease, among other disorders; however, since the symptoms are related to the precipitating event, one would have to wait till the normal grief is resolved and then reassess the presence of symptoms of depression. The main diagnostic criterion of dysthymia (choice B) involves milder symptoms of depression occurring every day for at least 2 years. Major depressive disorder (choice D) can be precipitated by the loss of a beloved person, but it has a distinct quality even though some symptoms are the same. Suicidal ideation, guilt related to the person alone and not to the deceased person, and feelings of worthlessness are common. Significant functional impairment is typical. Psychosis not otherwise specified (choice E) is reserved as a diagnosis for the presence of psychotic symptoms that do not meet all the criteria for a specific disorder and there is not enough information available to establish a more specific diagnosis. 28) A medicine consult is requested on a 32-year-old woman with paranoid schizophrenia who is a patient in a closed psychiatric unit. Several days after the patient's admission, she developed polyuria, vomiting, stupor, diarrhea, and restlessness. She is currently taking risperidone, 10 mg given at bedtime, but no other medications. Which of the following is the most likely diagnosis? A. Anticholinergic crisis B. Acute dystonic reaction C. Serotonin syndrome D. Tardive dyskinesia E. Water intoxication Explanation: The correct answer is E. This patient is showing the symptoms of psychogenic polydipsia, which is the excessive intake of water as a result of a psychiatric disorder. The symptoms of excessive water intake include polyuria, vomiting, and diarrhea. As the patient is on a closed psychiatric unit, the chances of reactions to excessive medications are rare, given the careful monitoring of medication intake on most psychiatric units. Surreptitious water consumption would be easy to overlook in a patient without a previous history. Anticholinergic crisis (choice A) is not a possibility in a patient not receiving anticholinergic medications, such as diphenhydramine or Cogentin. Acute dystonic reaction (choice B) is an adverse reaction of some antipsychotics, such as haloperidol or trifluoperazine, and is rare in a patient taking risperidone. Serotonin syndrome (choice C) is a reaction of autonomic instability that is accompanied by fluctuations in blood pressure and flushing. It is associated with the mixing of monoamine oxidase inhibitors and serotonin specific reuptake inhibitors. Tardive dyskinesia (choice D) is a syndrome of abnormal involuntary movements associated with chronic use of typical neuroleptics, such as haloperidol. 29) A 34-year-old woman in her first trimester of pregnancy is evaluated by her psychiatrist. She complains of voices telling her to kill herself because she doesn't deserve to live, and she feels extremely depressed, guilty, and worthless. Which of the following is the most appropriate treatment? A. Clonazepam B. Electroconvulsive therapy (ECT) C. Fluoxetine D. Lithium E. Psychotherapy Explanation: The correct answer is B. Electroconvulsive therapy (ECT) has been safely used in pregnancy. In case of psychotic depression with increased risk for suicide, the situation requires expeditious treatment to protect the mother and fetus, and ECT is the treatment of choice. Clonazepam (choice A) is not indicated as a primary treatment of depression with psychotic features. During the first trimester of pregnancy, the use of benzodiazepines increases the risk of cleft palate 10fold. Fluoxetine (choice C), along with tricyclic antidepressants, is currently considered the safest drug to use during pregnancy. In the case of psychotic depression, however, monotherapy with fluoxetine would not be sufficient and would require longer inpatient treatment. Lithium use (choice D) during the first trimester of pregnancy increases the risk for Ebstein's anomaly 10-20 fold. In addition, lithium has not proven to be an efficient antidepressant in the treatment of psychotic depression. It is primarily used as a mood stabilizer. Psychotherapy (choice E) is important treatment option for helping women understand the conflictual feelings that arise during pregnancy. However, given the psychotic symptoms and severity of depression in this case, pharmacotherapy or ECT are the treatments of choice. 30) A 34-year-old woman with documented bipolar disorder comes to the hospital because of feelings of guilt and worthlessness. She has amassed thousands of dollars of credit card debt in the past 2 months. Her parents are going to pay it off for her, but she believes that this will bankrupt them. On further questioning, she reveals that she bought a gun earlier in the day because it would be easier for everyone if she "wasn't here anymore." She plans to go to the roof of her building, with her new purchase, "and do what needs to be done." Which of the following is the most appropriate next step in management? A. Send home with lithium B. Send home with valproic acid C. Send home with carbamazepine D. Observe in the emergency department E. Admit to the hospital Explanation: The correct answer is E. Any patient with serious suicidal thoughts, suicidal intent, and a plan, must be hospitalized, against her will, if necessary. The patient expressed a desire to die, she bought a weapon, and developed a believable plan. She needs to be hospitalized for her own safety. Patients with bipolar disorder have a lifetime suicide rate of 10-15%. Sending home with lithium (choice A), valproic acid (choice B), or carbamazepine (choice C) are inappropriate choices because this patient requires hospitalization due to her high risk of suicide. A mood stabilizer is indicated, but must be given as inpatient therapy. 31) A 29-year-old, previously successful woman was climbing stairs in her new home about a month ago, when the whole house fell apart. She ended up in a hospital with a fractured left femur. The psychiatry team was consulted because the patient complained of nightmares and flashbacks and was afraid to go to sleep as a result. During the interview, she is tearful, and afraid that her fear of falling is preventing her from participating enough in her rehabilitation, and that the team will discharge her from hospital. Which of the following is the most appropriate treatment for this patient? A. Insight-oriented psychotherapy B. No therapy because the patient needs to take responsibility for her treatment C. Put a sitter to stay in the patient's room 24 hours a day to calm her anxiety D. Start an antidepressant E. Start benzodiazepines Explanation: The correct answer is D. The patient is having symptoms of posttraumatic stress disorder (PTSD), as well as depressive symptoms. Sertraline is an antidepressant approved for treatment of this disorder. Other antidepressants and anticonvulsants have also been shown to be effective in the treatment of PTS D. Insight-oriented psychotherapy (choice A) is focused on getting insight into the underlying unconscious conflicts on the basis of exploration of transference feelings evoked during the process. It is not suitable for the treatment of acute PTS D. No therapy (choice B) in a patient with obvious symptoms that are interfering with his or her treatment and social functioning would be unacceptable and considered neglect. A 24-hour watch by a sitter (choice C) would be indicated if the patient is actively suicidal and has poor impulse control. Having a family member for support is encouraged, but enforcing a regressed and dependent position by a 24-hour watch would not be appropriate. Benzodiazepines (choice E) can be used in for symptom relief in cases of acute stress reaction, but they are not indicated as long-term treatment of PTSD because of their addictive potential. 32) A young woman who sustained minor injuries after a motor vehicle accident is admitted to the hospital. During the observation period, the intern notices that the patient's vital signs are all increased, and she seems confused, disoriented, and delirious. On admission, she states she has been using medication to help with anxiety for couple of months. However, she ran out of it 2 days prior to the accident. From which of the following medications is this patient most likely experiencing withdrawal? A. Alprazolam B. Buspirone C. Hydroxyzine D. Nefazodone E. Paroxetine Explanation: The correct answer is A. Alprazolam is a short-acting benzodiazepine with a rapid onset of action and a relatively short half-life. It is indicated for treatment of panic attacks and anxiety disorders in general. Given its properties, however, it also has a highly addictive potential. The abrupt discontinuation of its use may result in withdrawal delirium, seizures, or death. Buspirone (choice B) is an antianxiety agent chemically unrelated to benzodiazepines, barbiturates, or sedative/anxiolytic drugs. It is indicated for the management of anxiety disorders. In human and animal studies, it has not shown potential for abuse or physical or psychological dependence. Hydroxyzine (choice C) belongs to the piperazine group of antihistamines and is indicated for symptomatic relief of anxiety and tension and as an adjunct to treatment of organic diseases with anxiety present. Because of its sedative properties, it can be used in preanesthesia and it potentiates the effects of other CNS sedatives. Withdrawal delirium has not been reported. Nefazodone (choice D) is an antidepressant structurally unrelated to MAOs, SSRIs, or tri- or tetracyclics It is indicated for depression and not solely for anxiety disorders. Studies have not shown that it has any addictive potential or that its discontinuation causes delirium. Paroxetine (choice E) is a selective serotonin reuptake inhibitor (SSRI) and is indicated in treatment of anxiety disorders. Paroxetine is not considered a controlled substance, and clinical trials have not revealed a tendency for drug-seeking behavior. Abrupt discontinuation may lead to flu-like symptoms, as with some other SSRIs, but not withdrawal delirium. 33) A woman comes to the clinic with her 13-year-old grandson, stating he has had behavioral problems for the past 4 years. He is living with her now because his mother is in drug rehabilitation center. She describes that he has run from home twice and has been kicked off the school bus for threatening other kids and challenging the driver. He is about to be expelled from school, since he was caught extorting money from other children. Which of the following is the most likely diagnosis? A. Attention deficit/hyperactivity disorder B. Conduct disorder C. Intermittent explosive disorder D. Oppositional defiant disorder E. Rett syndrome Explanation: The correct answer is B. Conduct disorder is a childhood/adolescent disorder defined as a pattern of behavior in which the basic rights of others are violated with three or more of the following present in the past 12 months: destruction of property, cruelty to animals and people, deceitfulness or theft, and serious violations of rules. It causes clinically significant impairment in social functioning and it is reserved for patients younger than 18. Attention deficit/hyperactivity disorder (choice A) requires the presence of six symptoms of inattention for at least 6 months to a degree that is maladaptive and six symptoms of hyperactivity/impulsivity that cause social impairment. Symptoms are present in two or more settings (e.g., home and school), and some of the symptoms are present before age 7. The symptoms are not due to a general medical condition or other mental disorder. Intermittent explosive disorder (choice C) is diagnosed in adults only after several episodes of failure to resist aggressive impulses that lead to assaults or destruction of property. The degree of episodes is not proportionate to precipitating stressor. The disorder is not due to any other mental disorder or general medical condition. Oppositional defiant disorder (choice D) is a pattern of negativistic and defiant behavior lasting at least 6 months with four or more of the following: loss of temper, arguments with adults, defying rules, deliberately annoying other people, blaming others for own faults, presence of vindictive behavior, presence of anger, and resentment. Rett syndrome (choice E) belongs to the pervasive developmental disorders. After a normal development, the onset of disorder is between 5 and 48 months and is characterized by deceleration of head growth, loss of previously acquired purposeful hand skills, loss of social engagement, poor coordination of movements, motor mannerisms, and preoccupation with parts or objects. There is no delay in language or cognitive development. 34) A 27-year-old woman is 2 weeks' postpartum with her first child. During her first postpartum follow-up visit, she complains to her physician that she has had several crying spells and has been increasingly irritable; however, she has had some spells during which she has felt almost euphoric. She has had these symptoms over the past week. She has not had any previous psychiatric disorders. Which of the following is the most likely diagnosis? A. Adjustment disorder B. Dysthymic disorder C. Maternity blues D. Postpartum depression E. Postpartum psychosis Explanation: The correct answer is C. Maternity blues is a normal state of sadness, dysphoria, frequent tearfulness, and dependence that about 20% to 40% of women experience in the postpartum period. It is thought to be derived from rapid changes in women's hormonal levels and the stress of childbirth associated with maternity. Adjustment disorder (choice A) requires the development of emotional or behavioral symptoms in response to a stressor occurring within 3 months of the stressor, which also requires significant impairment in social and occupational functioning. It is excluded as a diagnosis when the presence of another Axis I diagnosis, such as postpartum blues, can account for the condition. Dysthymic disorder (choice B) is a disorder of depressed mood, more often than not, over the course of at least 2 years. It is not an appropriate diagnosis for such a short period. Postpartum depression (choice D) is a diagnosis that requires symptoms of major depression lasting longer than 5-7 days. It occurs more often in the months following childbirth rather than immediately subsequent to it. Postpartum psychosis (choice E) is a serious diagnosis that requires the presence of auditory or visual hallucinations in addition to frequent suicidal and sometimes infanticidal ideation. 35) A 37-year-old man lives alone and has no close friends. He works during the night shift at the post office and has little interaction with others. He has not engaged in sexual activity since he was 18 years old, but he does not feel much desire. He maintains a close relationship with his sister, but does not seek out relationships with others. People have told him that he seems "detached" and that he has difficulty experiencing or expressing emotions. Which of the following is the most likely diagnosis? A. Antisocial personality disorder B. Avoidant personality disorder C. Paranoid personality disorder D. Schizoid personality disorder E. Schizotypal personality disorder F. Social phobia Explanation: The correct answer is D. This patient has schizoid personality disorder, which is characterized by the inability to form relationships and difficulty experiencing and expressing emotions. Affected individuals do not seek intimacy and approval from others. They prefer to be alone and may perform well in socially isolated jobs. The incidence is thought to be very high, however it is not known since these individuals generally do not seek help. According to the DSM, personality disorders are characterized by a stable pattern of behavior that deviates from cultural expectations, is inflexible, cause distress, and social or work impairment. Personality disorders are not caused by another medical illness or substance abuse. Individuals with antisocial personality disorder (choice A) show a complete disregard for societal norms, rules, and the interest of others. They frequently end up in prison. Avoidant personality disorder (choice B) is characterized by social withdrawal due to the fear of criticism. Affected individuals are eager to please and desire affection. Individuals with paranoid personality disorder (choice C) are suspicious and mistrustful, and frequently misinterpret the actions of others. Schizotypal personality disorder (choice E) is characterized by odd behavior, cognition, and perception. These people seem similar to schizophrenics, but do not have psychosis. Socially phobic (choice F) individuals desire relationships but their anxiety often interferes with the formation of friendships. They fear unfamiliar situations and scrutiny by others. 36) A 43-year-old woman presents to the emergency department complaining of dizziness, tremor, diaphoresis, and shortness of breath. She indicates to the physician that she has come into the hospital with similar complaints twice in the past several weeks. On those occasions, as well as currently, her physical examination, routine laboratory studies, ECG, and cardiac enzymes have all been unremarkable. The patient states that these episodes are starting to concern her greatly and she is worried about going out of her house alone now. Which of the following is the most likely diagnosis? A. Factitious disorder B. Generalized anxiety disorder C. Panic disorder D. Schizophrenia E. Social phobia Explanation: The correct answer is C. This patient's symptoms are all suggestive of panic attacks. Her symptoms do not appear to be related to substance use or a general medical condition. The frequency of her symptoms and her agoraphobia (fear of social situations) are also indicative of a diagnosis of panic disorder. Factitious disorder (choice A) is a disorder in which physical symptoms are intentionally produced or feigned. The motivation for the behavior in the patient is to assume the sick role. Generalized anxiety disorder (choice B) is characterized by excessive anxiety and worry occurring more days than not for at least 6 months, and concerning activities such as work or school performance, with accompanying muscle tension, irritability, and sleep disturbance. Schizophrenia (choice D) is a thought disorder characterized by auditory hallucinations of at least 6 months' duration. Social phobia (choice E) is characterized by fear and avoidance of social situations, even though it is often accompanied by a desire for social contact and interaction with others. It is often accompanied by low self-esteem. 37) The mother of a 23-year-old man brings her son to a psychiatrist for a second opinion one week after his discharge from the hospital. The young man had been hospitalized for one week due to the new onset of auditory hallucinations and tangentiality of thoughts. During his hospitalization, he was diagnosed with schizophreniform disorder and was treated with risperidone 2 mg PO BI D. A medical work-up for this first episode of psychosis was negative. In discussing course and prognosis with the patient and his mother, which of the following features would be considered a good prognostic indicator? A. Family history of schizophrenia B. Lack of any known precipitating factors or acute stressors C. Onset of psychotic symptoms within a month of the first change in behavior D. Poor premorbid educational and occupational performance E. Withdrawn, autistic behavior and flat affect Explanation: The correct answer is C. In schizophreniform disorder or schizophrenia, several features are associated with better long-term prognosis. The onset of psychotic symptoms within four weeks of the first noticeable change in usual behavior or functioning is one such feature. Other good prognostic features include: confusion or perplexity at the height of the psychotic episode, good premorbid social and occupational functioning, and the absence of blunted or flat affect. A family history of schizophrenia (choice A) is associated with a poorer prognosis in schizophrenia, whereas a family history of mood disorders (especially depressive disorders) is a good prognostic indicator. A lack of precipitating factors or acute stressors (choice B) is a poor prognostic indicator, whereas obvious precipitating factors before an episode of psychosis may be associated with a better prognosis. Poor premorbid educational or occupational functioning (choice D) is a poor prognostic indicator. Withdrawn, autistic behavior and flat affect (choice E) are poor prognostic indicators, whereas the lack of these negative symptoms may be associated with a better prognosis. 38) A 24-year-old graduate student and teaching assistant comes into the student health center after being instructed by his college dean to seek counseling. According to the collateral history obtained from the patient's roommates and instructors, the man exhibits annoyingly grandiose behavior, is frequently demanding of his peers' admiration, and has had to be reprimanded for treating his undergraduate students without empathy or understanding in demanding that their work be submitted in two different forms for each assignment. Given this history, which of the following is the most likely diagnosis? A. Borderline personality disorder B. Narcissistic personality disorder C. Paranoid personality disorder D. Passive-aggressive personality disorder E. Schizotypal personality disorder Explanation: The correct answer is B. Narcissistic personality disorder patients frequently demand constant attention and admiration, and they are often indifferent to criticism. They frequently exhibit grandiosity in behaviors or fantasies, show lack of empathy, often exhibit a sense of entitlement, and frequently exploit whatever interpersonal relationships they have developed. Borderline personality disorder (choice A) is distinguished by instability in self-image, mood, and interpersonal relationships. Paranoid personality disorder (choice C) is marked by rigidity, unwarranted suspicion, envy, and a tendency to blame and attribute evil motives to others. Passive-aggressive (choice D) personality disorder requires the manifestation of aggressive behavior in passive ways such as intentional inefficiency or stubbornness. Schizotypal personality disorder (choice E) is exemplified by eccentric behavior or communication with associated defects in the ability to form social relationships. 39) A mother brings her 8-year-old son to a psychiatrist for new-onset enuresis. A prior workup to determine a medical cause was negative. In conversation, it seems that the enuresis started following parental arguments and separation. The boy wets himself at least twice a week and feels upset about it, refusing to go for a sleep-over at his friend's house. Which of the following is the most commonly used treatment for this condition? A. Behavioral therapy B. Interpersonal therapy C. Pharmacotherapy D. Psychodrama E. Psychotherapy Explanation: The correct answer is A. Behavioral therapy is the most frequently used treatment in children with enuresis. Dry nights are recorded on a calendar and rewarded with a star as a gift. The buzzer and pad apparatus are used less for conditioning nowadays. Interpersonal therapy (choice B) is short-term therapy developed for nonpsychotic, milder forms of depression. It addresses current relationships and roles, and is used with adults. It is not indicated for enuresis treatment. Pharmacotherapy (choice C) is rarely used, given the success of behavioral approaches. Tolerance to imipramine, which has been used, can develop within 6 weeks. Desmopressin has shown some success. Psychodrama (choice D) is a method of group therapy in which conflicts and interpersonal relationships are explored by means of special dramatic methods. It is not indicated in children with enuresis. Psychotherapy (choice E) is not recommended unless there is evidence of other psychopathology. The exploration of conflicts in enuresis has shown little success. 40) A 21-year-old man drops out of college. On questioning, he explains that he is so afraid of having a panic attack that he is no longer willing to sit in class because he would not be able to leave. The same fear has also led him to stop going shopping or to the movies, because he is afraid of having a panic attack in the ticket line or theater. Which of the following is the most likely diagnosis? A. Agoraphobia B. Conversion disorder C. Obsessive-compulsive disorder D. Social phobia E. Somatization disorder Explanation: The correct answer is A. This patient has agoraphobia. Although this condition was originally defined as the fear of open spaces or of the marketplace, a more functional, modern definition is a fear of panic attacks in situations from which it would be difficult to gracefully remove oneself. Like the patient in the question stem, a patient's fear may involve multiple settings and may progress to the point of markedly hampering daily functioning. The panic attacks may or may not actually have been experienced in the past in the particular settings that are of concern to the patient. Some cases resolve spontaneously; others pursue a waxing and waning course. Behavioral therapy is used to encourage patients to modify their activities. Antidepressants are helpful in patients with coexisting depression. Conversion disorder (choice B) refers to the development of physical symptoms in response to psychological conflict. Obsessive-compulsive disorder (choice C) is characterized by recurrent and obtrusive ideas and urges. Social phobia (choice D) specifically refers to clinically significant anxiety induced by social or performance situations. Although the overlap with agoraphobia should be obvious, a tip off that a person has agoraphobia, rather than social phobia, on a test question (real life is fuzzier) is the use of the term "panic attacks. " Somatization disorder (choice E) is a severe psychiatric disorder in which a patient has had many physical complaints over a period of years that do not have an adequate anatomic pathologic explanation. 41) A 35-year-old man is brought to the emergency clinic by his mother because of an episode of slurred speech associated with the uncomfortable sensation that his tongue is thick and curling up. The episode started suddenly 30 minutes ago. The patient is noted to be holding on to his tongue with his thumb and forefinger. When asked about this, the patient responds with dysarthria, saying that his medication has caused this once before and that he needs a shot to make it go away. His mother reports that the patient has had schizophrenia for 10 years and consistently takes two medications prescribed by his psychiatrist. Several days ago he ran out of one of his medications, but has continued to take the other one. What is the most appropriate initial step in the management of this patient? A. Alprazolam B. Benztropine C. Haloperidol D. Lorazepam E. Olanzapine Explanation: The correct answer is B. The patient is experiencing an acute dystonic reaction, which is a form of extrapyramidal side effect (EPS) associated with antipsychotic medications. These side effects are related to antagonism of dopamine receptors in the nigrostriatal pathway. The patient is likely taking a conventional antipsychotic agent plus a prophylactic anticholinergic agent (such as benztropine, diphenhydramine, or trihexyphenidyl). Upon stopping the anticholinergic, the dystonic reaction was more likely to occur. The appropriate initial management of this patient would include immediate IM administration of an anticholinergic agent, such as 2 mg of benztropine or 50 mg of diphenhydramine. Alprazolam (choice A) is a short-acting, highpotency benzodiazepine commonly used for the short-term management of anxiety. It would not be the appropriate treatment for an acute dystonic reaction. Haloperidol (choice C) is a conventional high-potency antipsychotic agent that would be likely to cause EPS such as dystonia. It would make the dystonic reaction worse. Lorazepam (choice D) is, like alprazolam, a benzodiazepine. It is commonly used in the acute management of severe anxiety and agitation. It would not be appropriate in the management of acute dystonia. Olanzapine (choice E) is an atypical antipsychotic agent. Like the other atypical agents (clozapine, risperidone, and quetiapine), it is associated with a lower incidence of EPS while being more efficacious for the negative symptoms of schizophrenia. It would not be a treatment for EPS. 42) A 45-year-old woman presents to her primary care physician because of blurred vision. She states that this symptom started about two days ago. She denies any past history of significant medical or neurological problems. She does state that several days ago she started treatment for depression with a psychiatrist, due to a two-month period during which she had several depressive symptoms. On review of systems, she admits to having increased her water consumption over the last several days, due to a dry mouth. She also complains of dizziness when she stands up from lying or sitting. Her temperature is 37 C (98.6 F), blood pressure lying down is 135/75 mm Hg, blood pressure standing is 110/64 mm Hg, pulse lying down is 84, pulse standing is 95, and respiratory rate is 16/min. Physical examination is unremarkable except for mild mydriasis. Which of the following medications most likely accounts for this patient's symptoms? A. Bupropion B. Citalopram C. Imipramine D. Nefazodone E. Sertraline Explanation: The correct answer is C. Imipramine is a tricyclic antidepressant (TCA) that inhibits norepinephrine and serotonin reuptake. Like most TCAs, imipramine also has antagonistic effects at muscarinic, histaminic, and a-adrenergic receptors. This patient's complaint of blurred vision is most likely due to the antimuscarinic effects of the medication. The blockade of muscarinic acetylcholine receptors causes mydriasis (pupillary dilation) resulting in blurred vision. Dry mouth is also due to the anticholinergic effect of imipramine. Orthostatic hypotension is caused by the a1-adrenergic receptor blockade associated with TCAs. Bupropion (choice A) is an antidepressant with an unknown mechanism of action, though some evidence suggests that it is a norepinephrine and dopamine reuptake inhibitor. Treatment with bupropion is characterized by the absence of significant drug-induced orthostatic hypotension or anticholinergic effects. Citalopram (choice B) is a selective serotonin reuptake inhibitor (SSRI) with no significant effects at cholinergic, adrenergic, or histaminic receptors. Therefore, it would not cause the cluster of symptoms seen in this patient. Nefazodone (choice D) acts primarily as an antagonist at serotonin-2 (5-HT2) receptors, although it is also a weak inhibitor of serotonin reuptake. Although it is related to trazodone, it lacks significant antagonistic activity at other receptors. Sertraline (choice E) is an SSRI, like citalopram, and would not cause the side effects present in this patient. 43) A patient has been coming to psychotherapy for several weeks. The psychiatrist is dealing with countertransference feelings, including problems coping with the patient's intense devaluation of him as a therapist, the patient's arrogant attitude and sense of entitlement, and boredom during sessions resulting from the patient's obliviousness toward him. Which of the following is the most likely diagnosis in this patient? A. Antisocial personality disorder B. Histrionic personality disorder C. Mania D. Narcissistic personality disorder E. Paranoid schizophrenia Explanation: The correct answer is D. Narcissistic personality disorder is defined by grandiose self, belief in one's own special value, need for admiration from others, sense of entitlement, lack of empathy, envy of others, and arrogant attitude. The countertransference feelings that most people have toward these patients include a sense of boredom, since patient is focused completely on his or her own issues and is oblivious of others. Antisocial personality disorder (choice A) is significant for major violation and disregard of the rights of others occurring after age 18, as indicated by failure to conform to social norms, impulsivity, reckless disregard for safety of self and others, lack of remorse, and deceitfulness. Histrionic personality disorder (choice B) includes excessive emotionality and attention-seeking, shallow expression of emotions, speech lacking detail, suggestibility, and a sense that relationships are more intimate than they are. At the initiation of treatment, these patients are seemingly the most interesting. Mania (choice C) requires a distinct period of at least 1 week of abnormally elevated mood, grandiosity, decreased sleep, racing thoughts, pressured speech, and involvement in pleasurable activities. Countertransference feelings in others dealing with these patients include a sense of cheerfulness and irritability, but certainly not boredom. Paranoid schizophrenia (choice E) requires the presence of at least two of the following: delusions, hallucinations, disorganized speech or behavior, and negative symptoms for at least 1 month. Delusions of grandiosity, arrogance, and entitlement can be part of the clinical picture. 44) A 64-year-old male with generalized abdominal pain and jaundice is told by his physician after an extensive workup that he has a diagnosis of pancreatic adenocarcinoma. In the days following the diagnosis, the patient states to his doctors that "I don't have cancer - all I need is a Vitamin B12 shot and I will feel better fast". The patient is oriented at all times, scoring 29/30 on a mini-mental state exam, but refuses all chemotherapy medications, and adamantly refuses to be seen by the hospital oncologist, because "he is a cancer doctor and I don't have cancer." Which of the following diagnoses would be most applicable in this case? A. Acute stress disorder B. Adjustment disorder C. Alzheimer dementia D. Delusional disorder E. Major depressive disorder Explanation: The correct answer is B. Adjustment disorder is the development of emotional or behavioral symptoms in response to an identifiable stressor occurring within 3 months of the onset of the stressor. These symptoms or behaviors are clinically significant as evidenced by marked distress in excess of what would be expected from exposure to the stressor, or by significant impairment in social or occupational functioning. In this case, the stressor is the diagnosis of pancreatic cancer, which impairs the patient's ability to function in the physician-patient relationship without denial. Acute stress disorder (choice A) is a psychiatric disorder resulting from exposure to a traumatic event that involves actual or threatened immediate death or serious injury. The possibility of death in this instance is not immediate. The patient shows no signs of disorientation, and thus does not meet criteria for dementia, so Alzheimer's dementia (choice C) is incorrect. Delusional disorder (choice D) is incorrect because this diagnosis requires the presence of a nonbizarre delusion of at least 1 months duration, and this patient has had his denial for only a few days. Major depressive disorder (choice E) is incorrect because the patient has not had the insomnia, depressed mood, or thoughts of suicide that are typical of a diagnosis of major depressive disorder. 45) A 32-year-old woman presents to a psychiatrist because she "worries too much. " She admits that, over the past 7 months, she has experienced extreme fatigue, muscle tension, and irritability. She has difficulties falling asleep, partly because of worrisome thoughts about her husband and children. She keeps worrying that something bad is going to happen to them. In the past month, she has had episodes of shortness of breath, dizziness, and restlessness, and has been unable to go to work or do anything at home. Her physical examination and laboratory tests, as well as her ECG, are unremarkable. Which of the following is the most likely diagnosis? A. Avoidant personality disorder B. Generalized anxiety disorder C. Hypochondriasis D. Obsessive-compulsive disorder E. Panic disorder Explanation: The correct answer is B. Generalized anxiety disorder is defined as unrealistic worry about life events for a period longer than 6 months, during which time a person is worried most days. It also includes at least six symptoms of the following types: easy fatigability, difficulties falling asleep, restlessness, difficulties concentrating, irritability, and muscle tension. The symptoms are not due to other psychiatric or medical conditions and they cause significant impairment in everyday functioning. Avoidant personality disorder (choice A) is a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation as seen through at least four symptoms of the following type: self-image of social ineptitude, preoccupation with being disliked, avoidance of social activities for fear of being ridiculed, and feelings of inadequacy in interpersonal relationships. Hypochondriasis (choice C) is defined as excessive concern with one's health or diseases. It is present most of the time and is unjustified by the amount of physical pathology. It must be present at least 6 months and does not respond to reassurance. The main features include fear of disease, bodily preoccupation with somatic complaints, feelings of frustration toward doctors, and doctor-shopping. It causes significant impairment in functioning and is not due to other psychiatric or medical conditions. Obsessivecompulsive disorder (choice D) is characterized by recurrent intrusive thoughts or impulses that cause stress. The person unsuccessfully attempts to ignore or neutralize through action the recurrent thoughts or impulses, even though he or she is aware that those thoughts are the product of his or her own mind. Compulsions are repetitive behaviors that the person needs to perform as a result of obsessions or to decrease the stress related to intrusive thoughts. The disorder causes significant impairment in everyday functioning and is not due to other psychiatric or medical conditions. Panic disorder (choice E) is defined by recurrent panic attacks and persistent concern about having new attacks, worries about the implications of attacks, and significant changes in behavior related to attacks. The disorder is not due to any other medical or psychiatric conditions. 46) A 19-year-old student is admitted to the psychiatry inpatient unit with the working diagnosis of first-break psychosis. Because of combativeness and threats to others, he is put in seclusion. At first, he refused to take medication by mouth; however, after attacking a nurse he is given haloperidol intramuscularly on two occasions. He has now developed acute torticollis and twitching of the mouth and face on that side. The family is furious, stating that the treatment caused the seizures. Which of the following reactions did this patient most likely have? A. Acute dystonia B. Akathisia C. Asterixis D. Lennox-Gastaut syndrome E. Pseudoseizures Explanation: The correct answer is A. Acute dystonia is an involuntary spasm of a particular group of muscles that can involve the neck, jaw, tongue, eyes, or the entire body. It can be an early adverse effect of antipsychotics, and it is more common in younger men. It is more common with typical antipsychotics. The treatment of choice is parenteral administration of anticholinergics. Akathisia (choice B) is a subjective feeling of muscle discomfort and restlessness that can cause agitation, pacing, anxiety, and dysphoria. It is related to the use of antipsychotics and can appear any time during treatment. It is treated by antipsychotic dose reduction, propranolol, or benzodiazepines. Asterixis (choice C) consists of coarse arrhythmic lapses of sustained posture. It is related to metabolic disorders and is most easily seen when the patient's arms are outstretched. Asterixis occurs bilaterally. Lennox-Gastaut syndrome (choice D) is a variant of petit mal epilepsy and consists of intellectual impairment, distinctive slow spike and wave pattern, and atonic postural lapses followed by minor tonic-clonic spasms. Pseudoseizures (choice E) are part of conversion disorder and are not directly related to the use of antipsychotics. They are very much like real seizures except that there is no aura and no EEG abnormalities. The movements are asynchronous and non-stereotyped, and they occur when the person is awake. 47) A patient presents to a psychiatrist for depressive symptoms. He talks about his past psychiatric problems. He also mentions he is an alcoholic and has been taking disulfiram for some time to keep sober. He once tried to drink after taking the drug and ended up being terribly sick. Which of the following principles best describes this treatment of alcoholism? A. Conditioned avoidance B. Extinction C. Flooding D. Positive reinforcement E. Reciprocal inhibition Explanation: The correct answer is A. Conditioned avoidance is a term that describes the pairing of an unpleasant stimulus with the stimulus that causes maladaptive behavior. Extinction (choice B) requires the removal of the reward for inappropriate behavior so that maladaptive behavior decreases. It is often used in child psychiatry with patients who have behavioral problems. Flooding (choice C) is a therapeutic technique in which a patient is exposed to the feared situation without the possibility to escape. This experience is stressful and it must be done in a supervised and controlled manner. Positive reinforcement (choice D) happens when a subject is rewarded for manifesting desired behavior. Reciprocal inhibition (choice E) happens when a response that is antagonistic to the undesired behavior is paired with the behavioral response (e.g., relaxing along with anxiety provoking stimuli). 48) A patient is talking to his psychotherapist about his problems. During the session, the patient inquires about the meaning of their talk and asks why the therapist hasn't said anything. The therapist responds, "Perhaps it was difficult to get feedback from your troubled parents, so you got used to turning to others for reassurance that you are worthwhile-just like you are doing now with me." Which of the following types of intervention did the therapist use? A. Advice B. Clarification C. Confrontation D. Facilitation E. Interpretation Explanation: The correct answer is E. Interpretation is a technique used when a therapist states something about the patient's behavior or thoughts of which the patient may not be aware. It is used after good rapport with the patient has been established, in order to be timely and effective. Advice (choice A) is, in many instances, desirable to help the patient. It must be perceived as empathic rather than intrusive. Thus, it should be given after the patient has spoken freely about the problematic issue. Clarification (choice B) is a technique in which the therapist attempts to get details from a patient about the things already said. Confrontation (choice C) is a technique used when the therapist points out a thought or behavior that the patient is not paying attention to, or missing, or denying in some way. It is meant to help the patient face the problem in a direct but respectful way. Facilitation (choice D) is a technique used by the therapist to help the patient continue the interview by providing verbal and nonverbal cues to encourage the patient's talking. 49) A 45-year-old woman returns to her psychiatrist for her routine biweekly appointment two months after being hospitalized for an episode of major depressive disorder, recurrent, severe with psychotic features. During her hospitalization, she was started on two medications, an antidepressant and an antipsychotic, and she has continued these medications daily as an outpatient. At her appointment, she complains to her physician that she has missed her menstrual period for two months. She also complains of tenderness in her breasts, and an occasional small amount of milky discharge from her breasts onto her blouse. When questioned further, she also admits to low libido over the past month. Which of the following medications is most likely responsible for this constellation of symptoms? A. Olanzapine B. Paroxetine C. Quetiapine D. Risperidone E. Sertraline Explanation: The correct answer is D. Although risperidone is an atypical antipsychotic, it is like conventional antipsychotics in its ability to cause significant elevations in plasma prolactin levels. In the tuberoinfundibular dopamine pathway, dopamine inhibits the release of prolactin from the anterior pituitary. Conventional antipsychotics and risperidone can cause hyperprolactinemia due to their dopamine antagonism in this pathway, releasing the tonic dopamine inhibition. Clinical manifestations of hyperprolactinemia may include galactorrhea, sexual dysfunction, menstrual irregularities including amenorrhea, infertility, and weight gain. Olanzapine (choice A) is an atypical antipsychotic agent that causes minimal, if any, elevation in prolactin concentrations. It would be very unlikely that routine doses of olanzapine would cause symptoms of hyperprolactinemia. Paroxetine (choice B) is a selective serotonin reuptake inhibitor (SSRI) used in the treatment of depression and certain anxiety disorders. It would not induce hyperprolactinemia causing the above clinical manifestations. Quetiapine (choice C) is an atypical antipsychotic that causes minimal, if any, elevation in prolactin concentrations. Sertraline (choice E) is an SSRI and would not cause hyperprolactinemia. 50) A 42-year-old, unemployed laboratory technician is admitted to the hospital for nausea, vomiting, and abdominal pain. She tells the physician that she had been diagnosed in the past with disseminated lupus erythematosus and that she had Hodgkin disease. She seems worried that an extensive medical workup failed to confirm any of the previous diagnoses or find a cause of her actual symptoms. She insists on being given meperidine to relieve her pain. On examination, the only physical findings are scars and some abscesses on her thighs. She explains that she had been intentionally injured by the nurses in a previous hospital. Which of the following is the most likely diagnosis? A. Factitious disorder B. Ganser syndrome C. Hypochondriasis D. Malingering E. Somatization disorder Explanation: The correct answer is A. In factitious disorder, the individual deliberately feigns the signs of a medical or mental disorder to assume the "sick" role. The symptoms are under voluntary control and cannot be explained by other underlying condition. External incentives for such behavior are usually absent. The disorder is severely incapacitating to the patients, since they usually have multiple hospitalizations and submit themselves to invasive procedures and surgeries. Ganser syndrome (choice B) belongs to the group of dissociative disorders, not otherwise specified. It has been reported in incarcerated populations and is called "prison psychosis." It is characterized by the provision of approximate answers to questions and is commonly associated with conditions such as amnesia, disorientation, and perceptual disturbances. Hypochondriasis (choice C) involves the excessive and pervasive preoccupation with the fear of having a serious illness based on a misinterpretation of bodily symptoms. It must be present at least 6 months and causes significant impairment in all areas of life. It does not respond to reassurance and it persists despite medical evaluation. Malingering (choice D) is the voluntary production of physical or psychological symptoms to obtain obvious recognizable secondary gain, such as receiving financial compensation and avoiding work or legal problems. Somatization disorder (choice E) is characterized by multiple somatic complaints that begin before the age of 30 and result in medical treatment and significant impairment of social and occupational functioning. The patient has to meet all four criteria: four pain symptoms, two gastrointestinal symptoms, one sexual symptom, and one pseudoneurologic symptom. The symptoms are not due to any medical condition.

Find millions of documents on Course Hero - Study Guides, Lecture Notes, Reference Materials, Practice Exams and more. Course Hero has millions of course specific materials providing students with the best way to expand their education.

Below is a small sample set of documents:

Eastern Virginia Medical School - MEDICINE - 911
THEME: ContraceptionOral contraceptivesEdith WeisbergBACKGROUND There are a plethora of different combined oral contraceptive (COC)formulations marketed in Australia, containing variable doses of ethinyloestrodiol and differentprogestogens, which cli
Eastern Virginia Medical School - MEDICINE - 911
T HEMEDiabetesGestational diabetesBACKGROUNDGestational diabetes (GD) affects 510% of pregnant women in Australia. Long term follow up studies show that mostwomen with GD will progress to type 2 diabetes. The Australian Carbohydrate Intolerance in P
Eastern Virginia Medical School - MEDICINE - 911
T HEMEPelvic painEctopic pregnancyRisk factors and diagnosisBACKGROUNDEctopic pregnancy is still the most common cause of first trimester maternal deaths, accounting for 73% of earlypregnancy mortalities.George CondousMBBS, MRCOG, FRANZCOG,is Se
Eastern Virginia Medical School - MEDICINE - 911
iiiQ u ick Gu id eC a t ch - up i mm un isa tio n f or Vi c tor iaFor people with no documentation ofprevious vaccinesU pda te d J a nua ry 2 0 0 9Quick guide catch up immunisationiiiQ u ick G u id eC a tch - up imm un isa tio nf o r V i ctor
Eastern Virginia Medical School - MEDICINE - 911
AANS - Cartoid Endarterectomy and Stenosis1 of 3http:/www.aans.org/Patient Information/Conditions and Treatments/Car.AANSSearchGoAdvanced SearchDonate to NREFAANS MarketplaceExecutive OfficeSmallerResetLagerText SizeHomeAbout AANSMyAANSMe
Eastern Virginia Medical School - MEDICINE - 911
Algorithm for Diagnosis of Pulmonary Embolism with CT AngiographyA multicenter U.S. study published a simple decision rule based on a set of predictors derived from an outpatient emergencydepartment population (1). A slight modification of this rule usi
Eastern Virginia Medical School - MEDICINE - 911
CPD accreditation/endorsementThe Improving adherence in cardiovascular care online learning modules havebeen accredited/endorsed by the following organisations.RoyalAustralianCollegeofGeneralPractitioners(RACGP)Each module is accredited by the R
Eastern Virginia Medical School - MEDICINE - 911
Advanced Cardiac Life Support Guidelines 2011ANANTHARAMAN V.*, GUNASEGARAN K*IntroductionAdvanced Cardiac Life Support (ACLS), the fourth link inthe Chain of Survival, is very dependent on the optimalconduct of the earlier three links in the chain, v
Eastern Virginia Medical School - MEDICINE - 911
ASSESSINGFITNESS TO DRIVEFOR COMMERCIAL AND PRIVATE VEHICLE DRIVERSMEDICAL STANDARDS FOR LICENSINGANDCLINICAL MANAGEMENT GUIDELINESA RESOURCE FOR HEALTH PROFESSIONALS IN AUSTRALIAApproved by the Australian Transport Counciland endorsed by all Aust
Eastern Virginia Medical School - MEDICINE - 911
ASSESSINGFITNESS TO DRIVEFOR COMMERCIAL AND PRIVATE VEHICLE DRIVERSMEDICAL STANDARDS FOR LICENSINGANDCLINICAL MANAGEMENT GUIDELINESA RESOURCE FOR HEALTH PROFESSIONALS IN AUSTRALIAApproved by the Australian Transport Counciland endorsed by all Aust
Eastern Virginia Medical School - MEDICINE - 911
AMA Workingfor all DoctorsSecuring the medical training pipelineFollowing the release of the Health Workforce 2025 report, the Federal AMA is advocating strongly for increases inprevocational and vocational training positions to ensure that medical gr
Eastern Virginia Medical School - MEDICINE - 911
4. RISK FACTORS AND PREVENTION4.1 Overview . 34.2 Cancer risk factors. 34.3 Modifiable risk factors . 34.3.1 Tobacco smoking . 44.3.2 Sun exposure . 54.3.3 Physical activity, body mass and nutrition. 64.3.4 Alcohol . 84.3.5 Occupational exposure.
Eastern Virginia Medical School - MEDICINE - 911
C HEALTH SERVICEWOMEN AND NEWBORN LINICAL GUIDELINESSECTION B : OBSTETRICS AND MIDWIFERY GUIDELINESKing Edward Memorial Hospital5 INTRAPARTUM CARE5.9 SECOND STAGE OF LABOURDate Issued: July 2003Date Revised: July 2011Review Date: July 2014Authori
Eastern Virginia Medical School - MEDICINE - 911
C HEALTH SERVICEWOMEN AND NEWBORN LINICAL GUIDELINESSECTION B : OBSTETRICS AND MIDWIFERY GUIDELINESKing Edward Memorial Hospital5 INTRAPARTUM CARE5.9 SECOND STAGE OF LABOURDate Issued: July 2003Date Revised: July 2011Review Date: July 2014Authori
Eastern Virginia Medical School - MEDICINE - 911
Vox Sanguinis (2004) 87 (Suppl. 1), S74S76O RIGINAL PAPERES06.02 2004 Blackwell PublishingThe bodys response to blood lossBlackwell Publishing, Ltd.M. A. GarriochSouthern General Hospital and University of Glasgow, Glasgow, UKIntroductionMaintena
Eastern Virginia Medical School - MEDICINE - 911
BLOOD SUBSTITUTESBLOODOxygen carrying solutionsDEVELOPMENTThe nature of CPB has placed a strain onblood banks across the worldResearch and development has beenencouraged as the risk and demand on bloodproducts increasesTerm Oxygen Carrying Soluti
Eastern Virginia Medical School - MEDICINE - 911
Body Dysmorphic Disorder (DSM-IV-TR #300.7)In body dysmorphic disorder (BDD) patients become overly concerned, or at times convinced, that in some fashion or other they are misshapen or deformed, despite all evidence to the contrary. Given these concerns
Eastern Virginia Medical School - MEDICINE - 911
NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines )Breast CancerScreening and DiagnosisVersion 1.2012NCCN.orgContinueVersion 1.2012, 07/16/12 National Comprehensive Cancer Network, Inc. 2012, All rights reserved. The NCCN Guidelines an
Eastern Virginia Medical School - MEDICINE - 911
BURNS SURFACE AREA . %TIME OF BURN . 24 HR CLOCKWEIGHT IN KG .A.***B.BURN RESUSCITATION3 X kg X % = .mLTYPE OF INFUSION1. 4% Normal Serum Albumin Solution(NSAS)2. Remainder as Hartmanns Solution50% of each type solution is usedconcurrently
Eastern Virginia Medical School - MEDICINE - 911
MANAGEMENT OF COMMUNITY ACQUIRED PNEUMONIA (CAP) IN ADULTS:ASSESSMENT OF SEVERITY USING CURB-65 SCORE AND TREATMENT GUIDELINES These guidelines do not apply to children, aspiration pneumonia or exacerbation of chronic airways limitation (CAL). The CURB
Eastern Virginia Medical School - MEDICINE - 911
Recommendations for screening and surveillance for specific cancers:Guidelines for general practitioners.Breast cancerCervical cancerBowel (colorectal) cancerRecommendation: Good evidence for population based screening.Recommendation: Goodevidence
Eastern Virginia Medical School - MEDICINE - 911
Recommendations for screening and surveillance for specific cancers:Guidelines for general practitioners.Breast cancerCervical cancerBowel (colorectal) cancerRecommendation: Good evidence for population based screening.Recommendation: Goodevidence
Eastern Virginia Medical School - MEDICINE - 911
Eastern Virginia Medical School - MEDICINE - 911
1736CELLS/L10020005Bacterial or otherpurulent meningitis&gt; 30010010,000Aseptic meningitisN or 101000LymphocytesNSubacute or chronicmeningitisN or 252000LymphocytesNormalPREDOMINANTCELL TYPELymphocytesPMNsGLUCOSE (mg/dL)PROTEIN(mg/d
Eastern Virginia Medical School - MEDICINE - 911
Current management of atrial fibrillationHimabindu Samardhi, Advanced trainee in cardiology, Maria Santos, Fellow inelectrophysiology, Russell Denman, Clinical director, Electrophysiology service,Darren L Walters, Director of cardiology, and Nicholas B
Eastern Virginia Medical School - MEDICINE - 911
Because you are one of my valued Mary KayClients, I want to extend to you a special20% discount on all of your favoriteMary Kay products this month!You are welcome to order with me via email, on-line, or phone! You can orderonce, twice, three times,
Eastern Virginia Medical School - MEDICINE - 911
DECISION-MAKING TOOL:Responding to issuesof restraint inAged CareCopyright Commonwealth of Australia 2004AcknowledgementsISBN: 0 642 82447 9This project is an initiative of, and funded by, the Australian GovernmentDepartment of Health and Ageing.
Eastern Virginia Medical School - MEDICINE - 911
Difcult PatientsThere are many reasons why patients are difcult, bearing in mind the breadth of the perception of adifcult patient. For example, some patients do not understand the medicine and that it cannot alwaysfull their expectations.Some patient
Eastern Virginia Medical School - MEDICINE - 911
Drug ClassHypertens .Beta-Blockersaaaa+Ca -BlockersACEIDiureticsArrhyth.aaAnginaaaaaaaaaaaaaaaaaaaaNa+-Channel blockersaaaaaaaaaaaaaaaaaaCardiac glycosidesVasodilatorsCHFaaaE. ISHACLow GFR, renal stenosis, tetrogenic, glossitis
Eastern Virginia Medical School - MEDICINE - 911
European Heart Journal (1999) 20, 787788Survival after acute myocardial infarctionSee page 803 for the article to which this EditorialrefersThe reasons for the decline in coronary heart diseasemortality in the Western world have been debated formore
Eastern Virginia Medical School - MEDICINE - 911
Explanation of Laboratory ResultsComplete Blood Count (CBC)White blood cells (WBC) - May indicate infection, elevated with systemicsteroid use, decreased with autoimmune or some blood diseases among other causes. Thefollowing are types of WBCs with ad
Eastern Virginia Medical School - MEDICINE - 911
Kids Health InfoFACT SHEETNappy rashThe most common cause of nappy rash (also called diaper dermatitis)in babies is irritation. Constant moisture and rubbingcancause damage to the skin. This is further irritated by bacteria, yeasts (eg candida or thru
Eastern Virginia Medical School - MEDICINE - 911
Kids Health InfoFACT SHEETPyloric stenosis - an overviewPyloric stenosis is a condition that affects the digestive system. It can cause your baby to vomit forcefully.Pyloric stenosis happens whenmuscles in a part of the lower stomach, called the pylor
Eastern Virginia Medical School - MEDICINE - 911
Medical complications of anorexia nervosa and bulimia nervosaJames E. Mitchella and Scott CrowbPurpose of reviewThis review focuses on recent publications concerningmedical complications in patients with eating disorders,including anorexia nervosa an
Eastern Virginia Medical School - MEDICINE - 911
Good Medical Practice:A Code of Conduct forDoctors in AustraliaDeveloped by a working partyof the Australian Medical Councilon behalf of the medical boards of theAustralian states and territoriesThe development of this code has been a jointproject
Eastern Virginia Medical School - MEDICINE - 911
NCCN Guidelines IndexGenetics Table of ContentsDiscussionNCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines )Genetic/FamilialHigh-Risk Assessment:Breast and OvarianVersion 1.2012NCCN.orgContinueVersion 1.2012, 05/02/12 National Compr
Eastern Virginia Medical School - MEDICINE - 911
Gliclazide The tablet should be taken with breakfast or the first big meal of theday.stated here, it does not mean that all people using this medicinewill experience that or any side effect. Follow the directions on your prescription label carefully,
Eastern Virginia Medical School - MEDICINE - 911
AUSTRALIANRESUSCITATIONCOUNCILGUIDELINE 14ACUTE CORONARY SYNDROMESOVERVIEW AND SUMMARYAs a part of the International Liaison Committee on Resuscitation (ILCOR) process that led tothe International Consensus on Cardiopulmonary Resuscitation and Emer
Eastern Virginia Medical School - MEDICINE - 911
Eastern Virginia Medical School - MEDICINE - 911
European Heart Journal (2008) 29, 29092945doi:10.1093/eurheartj/ehn416ESC GUIDELINESManagement of acute myocardial infarctionin patients presenting with persistentST-segment elevationThe Task Force on the management of ST-segment elevation acutemyo
Eastern Virginia Medical School - MEDICINE - 911
SOGC CLINICAL PRACTICE GUIDELINESSOGC CLINICAL PRACTICE GUIDELINESNo. 203, February 2008Rubella in PregnancyRecommendationsThis guideline was prepared and reviewed by the Clinical PracticeObstetrics Committee, reviewed by the Infectious DiseaseComm
Eastern Virginia Medical School - MEDICINE - 911
Downloaded from qshc.bmj.com on 23 October 2008Trauma: development of a sub-algorithmW M Griggs, R W Morris, W B Runciman, G A Osborne and A D PaixQual. Saf. Health Care 2005;14;e21doi:10.1136/qshc.2002.004499Updated information and services can be f
Eastern Virginia Medical School - MEDICINE - 911
Herpes zosterZOSTER VACCINE FOR AUSTRALIAN ADULTS:INFORMATION FOR IMMUNISATION PROVIDERSDisease and epidemiology Herpes zoster or shingles is a common and usually self-limiting painful rash resultingfrom reactivation of the same virus that causes chi
Eastern Virginia Medical School - MEDICINE - 911
EDITORSCHOICEBrain Stem Infarction :Clinical Clues to Localise ThemKK Sinha*Brain stem infarcts are less common thanhemispheric infarcts but it is often difficult tolocalise them exactly to a particular vascularterritory. With knowledge of their c
Eastern Virginia Medical School - MEDICINE - 911
KINETICS OF ELIMINATIONDr. NOUFIRA. Pwww.similima.com1CONTENTSIntroduction.Clearance.First order kinetics.Zero order kinetics.Mixed order kinetics.Plasma half life .Plateau principle.Dosing schedules.www.similima.com2IntroductionKnowledge
Eastern Virginia Medical School - MEDICINE - 911
Year 4Obstetrics &amp; GynaecologyLabour Ward HandbookThe University of EdinburghVersion Two, 2008Labour Ward HandbookYear 4 Medical StudentLabour Ward WorkbookThis workbook is designed to be a revision aid and will help you make the most of yourtime
Eastern Virginia Medical School - MEDICINE - 911
A Patient/Carers guide toThe Prevention&amp; Treatment ofLeg UlcersIntroductionThere are different causes of ulcers. This booklet will discuss: Arterial Ulcers Venous Ulcers Complications of Arterial &amp; Venous Ulcers What treatment is available Dress
Eastern Virginia Medical School - MEDICINE - 911
EMERGENCY DEPARTMENTMAJOR TRAUMA GUIDELINESCreated April 2002Revised January 20101INTRODUCTIONTrauma is a multidisciplinary condition. Pre-hospital care is usually provided by St JohnAmbulance staff. Upon arrival at hospital it is imperative that t
Eastern Virginia Medical School - MEDICINE - 911
Breast series CLINICAL PRACTICEManagement of earlybreast cancerThe current approachMeagan Brennan, BMed, FRACGP, DFM, FASBP, is a breast physician, NSW Breast Cancer Institute, WestmeadHospital, New South Wales. meaganb@bci.org.auNicholas Wilcken, M
Eastern Virginia Medical School - MEDICINE - 911
General Public Fact SheetKent County Health DepartmentViral and Bacterial MeningitisFact SheetWhat is meningitis?Meningitis is an infection of the fluid of aperson's spinal cord and the fluid thatsurrounds the brain. It is caused by a viralor bact
Eastern Virginia Medical School - MEDICINE - 911
Mental Healthfor EmergencyDepartmentsA r eference guideThis Reference Guide is intended to assist emergency department staff and other clinicians in their care for peopleexperiencing emergency mental health problems.It is intended to support the wea
Eastern Virginia Medical School - MEDICINE - 911
SJS Feb-04COMPLICATIONS OF MYOCARDIAL INFARCTIONLeft ventricular free wall rupture: Epidemiology: occurs in 3% of patients with acute MI. Risk factors: transmural MI, first MI, single vessel disease, lack of collaterals, and female gender. Timing: us
Eastern Virginia Medical School - MEDICINE - 911
PATHOLOGIC HUMERUS FRACTURESREUBEN GOBEZIE, M.D., BRENT A. PONCE, M.D., JOHN READY, M.D.DEPARTMENT OF ORTHOPAEDICS, BRIGHAM AND WOMENS HOSPITAL, BOSTON MAINTRODUCTIONBony lesions may result in pathologic fractures. Theselesions, when not of mesenchym
Eastern Virginia Medical School - MEDICINE - 911
10/27/2010Central Line-associatedBloodstream Infection (CLABSI)Criteria and Case StudiesTeresa C. Horan, MPHNational Health Care Safety NetworkDivision of Healthcare Quality PromotionCentral Line-associatedBloodstream Infections (CLABSI) Estimate
Eastern Virginia Medical School - MEDICINE - 911
Media Release2 February 2010Ovarian cancer journey at the WomensThe Royal Womens Hospital employs a multi-disciplinary approach to oncologytreatment which focuses on the patients journey as they tackle cancer.Miss Orla McNally, Director of Gynaecolog
Eastern Virginia Medical School - MEDICINE - 911
PAP SMEARHelp her learnSOCIAL SAFETY SKILLSHelp her getEMERGENCY CONTRACEPTIONOperating for over 35 years, SHFPACT continues asa strong &amp; vibrant health promotion charity providingservices to the Canberra community.CLINICAL SERVICES and SUPPORT P
Eastern Virginia Medical School - MEDICINE - 911
Human Reproduction Update, Vol.9, No.6 pp. 505514, 2003DOI: 10.1093/humupd/dmg044Ultrasound assessment of the polycystic ovary:international consensus denitionsAdam H.Balen1,5, Joop S.E.Laven2, Seang-Lin Tan3 and Didier Dewailly41Department of Repro
Eastern Virginia Medical School - MEDICINE - 911
pedrazzini9-06-200514:26Pagina 49ACTA BIO MED 2005; 76; 49-52 Mattioli 1885CASEREPORTPost partum diastasis of the pubic symphysis: a case reportAlessio Pedrazzini, Roberto Bisaschi, Remo Borzoni, Dante Simonini, Aldo GuardoliDepartment of Ortho
Eastern Virginia Medical School - MEDICINE - 911
GUIDELINE FOR THE MANAGEMENT OF ORAL ANTICOAGULATIONBEFORE AND AFTER ELECTIVE SURGERYRevised Feb 10, 2004A. OBJECTIVEThe objective of this guideline is to optimize the quality of care for patients who are requireinterruption of chronic oral anticoagu
Eastern Virginia Medical School - MEDICINE - 911
NIH Press Release - Hormone Replacement Therapy, Deep Vein Thrombosis, and Pulmonary Embolism - 10/11/96NATIONAL INSTITUTES OF HEALTHEMBARGOED FOR RELEASEThursday, Oct. 11, 19966:00 PM Eastern TimeOffice of the DirectorLoretta Finnegan, M.D.Jacques
Eastern Virginia Medical School - MEDICINE - 911
ANTIBIOTIC GUIDELINES FOR THE EMPIRICAL TREATMENT OF SEPSIS IN ADULTS (FORNEUTROPENIC PATIENTS SEE OTHER GUIDANCE)Contact Name and Job Title (author)Dr Vivienne Weston (Consultant Microbiologist)Tim Hills Lead pharmacist Antimicrobials and InfectionC