A. Acute anxiety
B. Bipolar disorder
C. Cocaine intoxication
D. Heroin intoxication
EXPLANATION: This patient’s presentation with tachycardia, hypertension, diaphoresis, and mydriasis along with the behavioral changes is consistent with cocaine intoxication
B. cerebral aneurysms
C. mononeuritis multiplex
D. ischemic optic neuropathy
E. respiratory tract complications
EXPLANATION: The most urgent need for diagnosis of a patient with symptoms of polymyalgia rheumatica (PMR) and giant cell arteritis is to prevent blindness caused by ischemic optic neuropathy as a result of occlusive arteritis of the ophthalmic artery. Early diagnosis is imperative as the neurological damage to the optic nerve is not reversible. Most patients with this diagnosis will have a normochromic-normocytic anemia, but this does not create urgency in treatment. Cerebral aneurysms are not common findings with PMR; large vessels such as the subclavian and aorta may be involved in giant cell arthritis in 15% of patients. Mononeuritis multiplex commonly presents with painful paralysis of a shoulder, and respiratory tract complications are more nonclassic findings with the presentation of PMR.
Diabetic retinopathy-EXPLANATION: The patient’s symptoms suggest a likelihood of diabetes. Retinal findings can include microaneurysms, deep hemorrhages, a flame-shaped hemorrhage, exudates, and cotton wool spots.
EXPLANATION: All daughters of a hemophilic male are carriers of hemophilia, whereas all sons are normal. Hemophilia B (or Christmas factor deficiency) is one of only two sex-linked pattern-bleeding disorders, and as such the disease occurs almost exclusively in males. Sons of carriers have a 50% chance of being affected and daughters of carriers have a 50% chance of being carriers themselves.
A. Atrioventricular heart block
B. Atrial fibrillation
C. Bifasicular block
D. Right axis deviation
EXPLANATION: The most likely diagnosis is an atrial septal defect, which usually shows right axis deviation on ECG. The other ECG abnormalities listed do not commonly occur with an atrial septal defect.
A. Counsel the patient to stop smoking
B. Systemic glucocorticoids
C. Take aspirin prior to cold exposure
EXPLANATION: This patient is experiencing Raynaud phenomenon. This is digitalischemia that can occur after exposure to cold or emotional stress. It is more common in smokers or patients whose occupation involvesusing vibratory tools. Management includes patient education toinclude cold avoidance behavior and wearing loose-fitting clothing.Cessation of smoking is imperative. Drug therapy is used in patientswith progressive and severe Raynaud’s.
EXPLANATION: Hypothyroidism is reported in up to 10% of patients taking amiodarone, an antiarrhythmic medication. With the high iodine content of the medication and the structural similarities to thyroxine, thyroid abnormalities occur. Common side effects of amiodarone include bradycardia and constipation, so laboratory evaluation for thyroid dysfunction must be used.
A. Acid supression
B. Dilatation of the lower esophageal sphincter
C. Diverting colostomy
D. Ladd procedure
EXPLANATION: A pyloromyotomy involves an incision along the length of the pylorus, down to the mucosa, and is the treatment of choice in pyloric stenosis. Acid suppression is the treatment of choice in cases of peptic ulcer disease. Dilatation of the LES is performed in cases of achalasia of the esophagus. A diverting colostomy may be used in cases of Hirschsprung disease, after removal of the aganglionic section of colon. The Ladd procedure is used in surgical treatment of intestinal malrotation.
A. Chlamydia pneumoniae
B. Haemophilus influenzae
C. Mycoplasma pneumoniae
EXPLANATION: Haemophilus influenzae (B) is a gram-negative pleomorphic coccobacillus. Strep pneumonia (E) and Staph aureus (D) are gram positive organisms. Mycoplasma pneumonia (C) and Chlamydia pneumoniae (A) aren’t visible on gram stain.
Considering your suspected diagnosis, what would be the management of this patient?
A. Observation until the swelling decreases
B. Attempt manual reduction and get emergent urologic consultation
C. IV fluids and analgesics
D. Dorsal penile nerve block with lidocaine and epinephrine
EXPLANATION: Paraphimosis occurs when a tight ring of foreskin is retracted proximal to the glans of the penis and becomes trapped in the retracted position. Impaired venous and lymphatic draining can cause swelling and is a true urologic emergency. Immediate attempt with manual reduction should be done and if unsuccessful an emergent surgical consult with urology is appropriate (B). If paraphimosis is not quickly reduced the arterial blood flow can become compromised leading to glans necrosis. Observation would increase the risk for necrosis (A). Manual reduction should be attempted immediately with or without a dorsal penile nerve block. If not reduced promptly then an emergent urologic surgical consult should be made. If a nerve block (D) is given it should be without epinephrine. IV fluids and analgesics (C) are used for sickle cell patients with priapism.
EXPLANATION: Osteoid osteoma is a benign bone forming tumor that usually develops during a patient’s second decade of life. This type of tumor is much more common in boys than girls and typically affects the lower extremities (femur and tibia primarily) and spine more than other areas of the body. Patients typically present with gradually progressive bone pain that is worse at night and does not correlate with activity level. The tumor produces high levels of prostaglandins, so symptoms usually improve in 20-25 minutes if the patient takes a medication like ibuprofen, ASA or other NSAIDS that are prostaglandin inhibitors. A lack of improvement in symptoms with these medications should lead health care providers to consider a different diagnosis. The pain of this condition may cause those afflicted in a leg to limp and have swelling, muscle atrophy or contractures and exquisite point tenderness. The condition usually resolves on its own over time, but symptomatic patients may require surgical resection or radioablation of the tumor.
A. Buffalo hump
B. Doughy, thickened skin
EXPLANATION: This woman appears to have Cushing Syndrome (hypercortisolism) which is characterized, in addition to the signs listed above, by plethoric facies, supraclavicular fatpads, and the so-called “buffalo hump.” Doughy, thickened skin (B) and thickened tongue (E) may be found in hypothyroidism, exophthalmos (C) in Graves disease, and lid lag (D) in hyperthyroidism from any cause.
A. Diabetes mellitus
B. Cushing’s syndrome
The correct choice is D, acromegaly. Patients with acromegaly have an abundance of growth hormone secretion. This leads to excessive growth of many areas of the body including soft tissue. Patients with acromegaly also have an increased incidence of hypertension and left ventricular hypertrophy. None of the other choices will cause this patient’s constellation of symptoms. Patients with many endocrine disorders may develop weaknesses as seen in this patient, but the large nose and widely spaced teeth are characteristic of acromegaly.
A. Decreased vibration and position sense
C. Difficulty with balance
EXPLANATION: Features of folate deficiency are similar to vitamin B12 deficiency. However, there are none of the neurologic abnormalities associated with vitamin B12. Glossitis is the only non-neurologic finding in the PE that would support folate deficiency. Alcoholism and poor dietary intake also support the diagnosis of folate deficiency.
A. Acute ischemic stroke
B. Circle of Willis ruptured aneurysm
C. Migraine headache
D. Multiple sclerosis
E. Pituitary adenoma
EXPLANATION: Pituitary adenomas, benign neoplasms associated with pituitary hormone secretory changes, may enlarge and become symptomatic. Symptoms are based upon the location and size of the tumor, and may include bitemporal hemianopsia, double vision, color desaturation, and visual acuity loss. Headaches may occur, due to associated pressure changes within the intrasellar space. Additional evaluation should include a T1-weighted MRI, screening laboratory tests, and a full ophthalmologic evaluation. These tests will also help evaluate for potential differential diagnoses, such as those listed. The patient’s history is not consistent with an acute ischemic stroke or migraine headache. Although an unruptured aneurysm may have very similar findings to a pituitary tumor, ruptured aneurysms present with acute headache, nausea, vomiting, and potential changes in consciousness. Multiple sclerosis (MS) should remain on the differential for this patient and will also be evaluated through MRI (although the current findings are more consistent with a pituitary adenoma), and additional neurologic findings would be likely with MS.
A. Endotracheal intubation
B. Intravenous steroids
C. Ribovirin injection
D. Incision and drainage
EXPLANATION: This case of acute epiglottitis is treated with immediate intravenous steroids. Provided that the patient is able to maintain the airway and also keep oxygen saturation rates above 92%, the patient can improve with steroids and supportive care. Antiviral medications have little effect on the overall illness.
B. extended-release dipyridamole plus aspirin
EXPLANATION: Aspirin, aspirin plus extended-release dipyridamole, and clopidogrel are all antiplatelet agents and approved for use to reduce recurrent TIAs and ischemic cerebrovascular accidents (CVAs). Prasugrel is not FDA-approved for this indication. Warfarin is an anticoagulant and has no role in prevention of either recurrent TIA or ischemic CVA.
A. CT scan of the head
B. Culture and sensitivity
C. Hemoglobin A1C
D. HSV-1 antibody testing
E. MRI of the brain
EXPLANATION: The patient has malignant otitis externa that has most likely extended to osteomyelitis and impingement of the facial nerve. Emergent CT scan (A) is indicated over MRI (E) to assess the extent of disease and the presence of osteomyelitis. Malignant otitis externa is most commonly caused by pseudomonas and empirical antibiotic therapy can be initiated prior to culture and sensitivity (B). Assessment of the patient’s diabetes control (C) should occur, but isn’t the highest priority study to order first. HSV-1 antibody testing (D) is not indicated in this patient.
B. Laser ablation
C. No treatment is necessary
EXPLANATION: This condition is consistent with a linear epidermal nevus. Theycan appear at any age, but are usually present at or shortly afterbirth. The pigmented papules are arranged linearly and can occuron any skin surface. They are not symptomatic and will grow withthe child. There is no treatment necessary.
A. Clozapine (Clozaril)
B. Haloperidol (Haldol)
C. Olanzapine (Zyprexa)
D. Risperidone (Risperdal)
EXPLANATION: Clozapine has a risk of agranulocytosis. While the risk is only 1%, weekly monitoring of the white blood cell count for the first six months, followed by monitoring of the white blood cell count every other week thereafter, is required. The other medications listed do not have the risk of agranulocytosis.
EXPLANATION: This patient is presenting with Wolff-Parkinson-White syndrome, as evidenced by the delta waves on the ECG. These conditions will generally occur in individuals at the onset of early adulthood. Management for this condition pharmacologically includes the use of class IC drugs, such as flecanide. Other choices include procainamide, sotalol, and amiodarone. Digoxin therapy may worsen and widen the QRS complex and place the patient into a ventricular tachycardia.
A. a deep femoral vein deep vein thrombosis (DVT) after a flight from Mumbai, India
B. an iliac vein DVT after a round trip bus trip to Atlantic City and playing slots all day
C. any DVT after a total knee replacement
D. an upper extremity DVT after tripping falling down a flight of stairs
EXPLANATION: DVTs most commonly arise from the deep femoral veins and iliac arteries, most commonly in patients who smoke and take oral contraceptives, after immobilizing surgeries, and/or after immobilization due to long periods of time seated, including but not limited to airplane flights, bus rides, etc. Upper extremity DVTs are rare, even after trauma, and warrant a hypercoaguability work-up to rule out inherited disease.
A. Familial hypoparathyroidism
B. Idiopathic hypoparathyroidism
C. Severe magnesium depletion
D. Surgical removal of the parathyroid
Choice D, surgical removal of the parathyroid glands, is the correct answer. Surgery for head and neck cancer, thyroidectomy, and parathyroidectomy are the most common causes of hypoparathyroidism. Choices A, B, C, and E are all causes of hypoparathyroidism that occur more infrequently.
EXPLANATION: The treatment of rheumatoid arthritis (RA) is aimed at reduction of pain, preservation of function, and prevention of deformity. Although non-steroidal anti-inflammatory drugs (NSAIDs) provide symptomatic relief, they do not alter progression or prevent erosion of the joint. Consequently, in addition to NSAID therapy, disease-modifying anti-rheumatological drugs (DMARDs) should also be initiated as soon as the diagnosis is confirmed. The most common initial DMARD used as treatment of choice in RA is methotrexate. Aspirin should not be added because of the increased risk of gastrointestinal side effects as well as having no effect on altering RA disease progression. Rituximab is a biological DMARD and is indicated to be added in patients with RA refractive to treatment with combination therapy of methotrexate and a tumor necrosis factor inhibitor (TNF). Etanercept is a TNF inhibitor. This class of medication is often added in patients with RA who are not responding to methotrexate therapy alone. Leflunomide is a pyrimidine synthesis inhibitor that is approved for the treatment of RA; however, it is contraindicated for use in premenopausal women secondary to its carcinogenic and teratogenic potential
EXPLANATION: Omalizumab (E), is an antibody that prevents IgE from binding to its receptor on mast cells and is used in the treatment of allergic disease. Daclizumab (B) is anti-IL-2 antibody used to prevent acute rejection of organ transplants. Adlimumab (A), etanercept (C), and infliximab (D) bind TNF, thus inhibiting the action of TNF and are used in the treatment of disorders such as psoriasis and rheumatoid arthritis.
A. high serum calcium
B. low intact PTH
C. low cortisol
EXPLANATION: The correct answer is (A). The hallmark of primary hyperparathyroidism is a high serum calcium and high intact PTH. A low intact PTH is consistent with hypoparathyroidism. The urine serum calcium is usually high in primary hyperparathyroidism. Cortisol is related to endocrine conditions affecting the adrenal cortex.
A. Administer a broad spectrum antibiotic
B. Administer intravenous tissue plasminogen activator (T-PA)
C. Begin a nonsteroidal anti-inflammatory agent
EXPLANATION: This patient’s diagnosis is acute inflammatory pericarditis. Viral infections are the most common cause of acute pericarditis, and males are the most commonly affected. A pericardial friction rub and EKG changes are characteristic of this diagnosis. Treatment is focused on the underlying inflammation, with NSAIDS being first-line and short course corticosteroids also being appropriate. Antibiotics are not indicated unless a bacterial etiology is confirmed or there are significant risk factors. Choices B, D, and E are not appropriate for this condition and could be harmful.
A. Increase threshold for blood transfusions
B. Maintain sustained reduction of body iron
C. Obtain a Dexa scan for osteoporosis
Maintaining sustained reductions in body iron has demonstrated increased overall survival rates through reductions in cardiac disease specifically due to siderosis. While these patients are at increased risk for osteoporosis and cardiac siderosis, the next best step in this patient is to maintain reduced iron levels. There is no place for increased blood transfusion or obtaining regular testosterone levels.
EXPLANATION: Because the elbow is not a weight bearing bone, the rate of osteoarthritis in the elbow is considerably less that what is found in locations like the hips, knees and spine. The hands have one of the highest rates of occurrence of osteoarthritis, likely due to their near constant use and propensity for minor (or major) injury. When elbow arthritis does develop it is often post-traumatic osteoarthritis related to a significant injury in the past that disrupted joint surface integrity or as a result of rheumatoid arthritis, a systemic illness. Osteoarthritis of the elbow will generally present with pain, stiffness, and decreased range of motion. Osteophytes that form on the medial elbow might be implicated should neurological symptoms develop that correlate with ulnar nerve distribution as this nerve does pass in close proximity to the elbow on the medial side.
B. In one month
C. At conception of her next pregnancy
EXPLANATION: Placental implantation occurred and separated with the spontaneous miscarriage. Therefore, there is a slight chance of isoimmunization, so Rhogam should be given now so that the mother does not develop antigens that can cross the placenta during the first half of the next pregnancy.
A. It is best she waits at least a week before having you perform a rapid test, since a false negative may result if seen too soon from onset of symptoms.
B. You may warn your patient that given this time of year, the low prevalence in the community, and her delay in testing, the results are virtually useless and you would not recommend testing.
EXPLANATION: The rapid tests vary in terms of sensitivity and specificity. Research indicates that sensitivities are approximately 50% to 70%, while specificities are approximately 90% to 95%. Specimens to be used with rapid tests generally should be collected as close as is possible to the start of symptoms and usually no more than four to five days later in adults. In very young children, influenza viruses can be shed for longer periods; therefore, in some instances, testing for a few days after this period may still be useful. Most importantly, the positive and negative predictive values vary considerably depending upon the prevalence of influenza in the community. False-positive (and true-negative) influenza test results are more likely to occur when disease prevalence is low, which is generally at the beginning and end of the influenza season, as is the case here. False-negative (and true-positive) influenza test results are more likely to occur when disease prevalence is high, which is typically at the height of the influenza season. When disease prevalence is relatively low, the positive predictive value (PPV) is low and false-positive test results are more likely. By contrast, when disease prevalence is low, the negative predictive value (NPV) is high, and negative results are more likely to be true.
A. triamcinolone 0.025% ointment bid, moisturize with petrolatum frequently, use gloves when hands in water B. withhold all treatments for one week and have patient undergo patch testing to determine allergen
C. punch biopsy at periphery of outbreak, and treat with ketoconazole cream for two weeks
EXPLANATION: The patient is experiencing an irritant contact dermatitis, secondary to having her hands in water frequently and using diaper wipes, which can be very irritating due to the alcohol content. The appropriate treatment would consist of reducing the irritant (water and wipes) by using barrier protection (gloves). A mid-potency topical steroid, such as triamcinolone 0.025% ointment twice daily, until the irritation has improved is appropriate treatment. Petrolatum and petrolatum based emollients are best for frequent moisturization. The history given is classic for irritant dermatitis, and withholding treatment for one week along with patch testing is not necessary, unless the patient does not respond to conservative therapy. A biopsy is not indicated, as this is classic irritant dermatitis. Ketoconazole cream is an antifungal medications and bactroban is a topical antibiotic. This patient presentation is not typical for a fungal infection, and should not be treated with an antifungal unless a positive KOH or fungal culture has been done. The bactroban ointment can help prevent a secondary bacterial infection if fissures are present.
A. Macular degeneration
B. Retinal detachment
C. Central retinal artery occlusion
D. Cerebrovascular accident
E. Central retinal vein occlusion
EXPLANATION: A central retinal vein occlusion is characterized by a “blood and thunder” fundus, with marked hemorrhages, tortuous vessels, and optic disc edema.
EXPLANATION: The correct answer is (B). Decongestants, such as pseudoephedrine, are known to increase blood pressure. Discontinuing pseudoephedrine and rechecking the blood pressure off of this medication may provide further information on the need for additional antihypertensive drug therapy. Loratadine, simvastatin, and acetaminophen are not known to cause secondary hypertension. Lisinopril is an ACE inhibitor used to treat blood pressure.
A. Anesthetic drops, irrigate the eye, and perform tonometry
B. Prescribe antibiotic cream and pain medication
C. Fluorescein stain, irrigate the eye, and prescribe antibiotic cream
D. Fluorescein stain and lid eversion
E. Anesthetic drops, fluorescein stain, and lid eversion
EXPLANATION: The history suggests a retained foreign body to the upper eyelid. A fluorescein stain will reveal significant superficial vertical scratches on the cornea. An upper eyelid eversion must be done, to inspect for and remove the foreign body. If the practitioner is successful in removing the foreign body, relief of the irritation will be immediate.
A. Dexamethasone suppression test
B. Radioactive iodine uptake
C. Glucose tolerance test
D. Cosyntropin stimulating test
The correct choice is A, dexamethasone suppression test. This patient is presenting with classic signs and symptoms of Cushing’s syndrome. The dexamethasone suppression test is a simple test of the hypothalamic-pituitary-adrenal axis, and requires ingestion of oral dexamethasone at nighttime and a blood test in the morning hour, to measure the amount of plasma cortisol. Most patients with Cushing’s syndrome demonstrate a lack of normal axis suppression and present with a morning plasma cortisol level >5 mcg/dL. Choice B, radioactive iodine uptake, is used in patients with suspected thyroid disorders. Choice C, glucose tolerance test, is used in patients with suspected diabetes mellitus and in prenatal testing, to investigate gestational diabetes. Choice D, cosyntropin stimulating test, is used to investigate possible adrenal insufficiency. Choice E, plasma fractionated free metanephrines, is used in the diagnostic workup of pheochromocytoma.
A. Autonomic neuropathy
B. Chronic renal failure
C. Diabetic polyneuropathy
D. Guillain Barre syndrome
E. Middle cerebral artery occlusion
EXPLANATION: Chronic renal disease is associated with functional disturbances in all organ systems, including the central nervous system. Renal disease promotes CNS complications including neuropathies and neuromuscular irritability, along with systemic symptoms. The symptoms are typically progressive if the underlying renal disease is not addressed. Although other conditions promote similar neuropathies, such as diabetes, they are differentiated by the level of involvement, progression, and associated symptoms. With Guillain Barre, an acute polyradiculoneuropathy would be expected to progress, and have associated weakness. Cerebrovascular accidents are not typically accompanied by generalized systemic symptoms, and a middle cerebral artery occlusion would be expected to have contralateral hemiparesis and hemisensory deficit.
A. Direct-current cardioversion
B. Nitroglycerin patch
C. Digoxin 0.125 mg PO daily
D. Neurology consult
EXPLANATION: Among the choices offered here, choice A is the most appropriate next step in management of a patient with new onset atrial flutter, as determined by EKG; it most effectively converts most patients to normal sinus rhythm. Choice B is inappropriate, as the patient is not demonstrating angina pectoris, and the EKG does not demonstrate evidence of ischemia or infarction. Choice C is inappropriate, as it is the least effective agent for slowing the ventricular response when compared to beta blockade or calcium channel blockers, all of which act by blocking the AV node (digixon may occasionally convert atrial flutter to atrial fibrillation). Choice D is inappropriate, as the patient’s symptoms of lightheadedness do not stem from neurologic changes. Choice E is inappropriate, as the patient’s symptoms do not stem from vertigo.
A. Left tube thoracostomy
C. Fluid resuscitation
EXPLANATION: Cardiac tamponade is classically described by the triad of jugular venous distension (JVD), arterial hypotension, and muffled heart sounds. In the emergency department, suspicion of this clinically entity is usually confirmed by ultrasonography and is acutely treated by pericardiocentesis, which will be diagnostic, therapeutic, and buy time until a definitive procedure can be done. A left tube thoracostomy may be indicated in this patient but would not relieve symptoms. Fluid resuscitation though applied to all trauma patients would help stabilize the patient until more therapeutic interventions could be completed. Immediate intubation, even if indicated, would require a prophylactic tube thoracostomy to prevent the development of tension pneumothorax in the event of an unrecognized lung injury. Emergency thoracotomy will relieve the signs and symptoms associated with cardiac tamponade and allow for repair of any underlying cardiac injuries.
C. Long bones
EXPLANATION: Fortunately, hematogenous osteomyelitis is not common in children, but when it does occur it primarily is found in the long bones. The femur, tibia and humerus are the most typical locations for osteomyelitis in children. The highly vascular metaphysis of long bones contribute to the potential for hematogenous spread of the implicated pathogen. Osteomyelitis can occur at any of the locations mentioned in the answer choices given, but at a significantly lower rate than in the long bones. The rate of occurrence at several selected locations is given below:
Feet – 9%
Hands – 6%
Humerus – 13%
Pelvis – 8%
Radius/ulna – 6%
Tibia/fibula – 28%
Vertebrae – 2%
A. MagnesiumB. CalciumC. PhosphorousD. Sodium
EXPLANATION: Hypokalemia is a common electrolyte disturbance in surgical patients. It can be caused by enhanced losses, hyperaldosteronism, inappropriate replacement, and intracellular shifts caused by alkalosis. Symptoms of hypokalemia may include constipation, neuromuscular weakness, diminished tendon reflexes, paralysis, and distinctive electrocardiographic changes. Concomitant deficiencies in magnesium can contribute significantly to the development of hypokalemia as well as hypocalcemia. In the surgical patient with persistent hypokalemia refractory to potassium administration, one should check magnesium levels and correct as appropriate.
A. Hospitalization and IvIg
B. Hospitalization ad IV antibiotics
C. Outpatient antibiotics x 10 days
EXPLANATION: This patient is exhibiting classic signs and symptoms of Kawasaki Disease. Complications of Kawasaki Disease include coronary artery aneurysms, myocarditis, myocardial ischemia or infarction, and stroke. Recommended treatment is hospitalization to monitor for complications and administration of IvIg with aspirin
A. punch biopsyB. imiquimod cream 3x week C. excision with 1 cm margin D. cryotherapy
EXPLANATION: The lesion is asymmetric with irregular margins. The optimal treatment of this lesion would be excision with 1 cm margins. A punch biopsy would only be performed if excision cannot be performed. Cryotherapy would destroy the lesion and prohibit a diagnosis and staging.
A. increase in creatinine from 1.0 to 2.0 mg/dL
B. increase in creatinine from 2.0 to 4.0 mg/dL
C. increase in creatinine from 4.0 to 8.0 mg/dL
EXPLANATION: GFR describes the amount of blood passing through the kidneys per minute. There is an inverse relationship between GFR and serum creatinine. In a patient with normal renal function, doubling of the serum creatinine represents a loss of approximately 50% of GFR. Using this information, the loss of GFR can be estimated from changes in the serum creatinine. For example, assume normal creatinine levels of 1.0 mg/dL and normal GFR of 100 mL/min. A doubling of the serum creatinine from 1.0 mg/dL to 2.0 mg/dL represents an approximate reduction in GFR from 100 mL/min to 50 mL/min (50% of GFR has been lost). Each additional doubling of the creatinine decreases the remaining GFR by approximately one half. When renal function is severely impaired, large increases in the creatinine (ie, from 8.0 to 16.0 mg/dL) represent only small decreases in GFR (from about 12 to 6 mL/min). This example emphasizes the importance of detecting increases in serum creatinine early. However, serum creatinine level does not become abnormal until ~25% of renal function is lost. Therefore, other methods of estimating GFR are more useful in detecting early decreases in GFR.
A. Oral proton pump inhibitorsB. Resection of the entire duodenumC. Resection of the tumor
EXPLANATION: The recommended treatment to cure localized disease in patients with Zollinger-Ellison syndrome is resection of the gastrinoma, before hepatic metastasis spread has occurred.
EXPLANATION: Folic acid or folate (0.4 mg daily) has been shown to reduce the incidence of neural tube defects in offspring, especially when begun in the preconceptional period.
A. somatic delusion
B. delusion of persecution
D. delusion of grandeur
EXPLANATION: Patients who have delusions of persecution often feel that people are taking pictures and tape recording them. Patients often believe that external agencies or relatives are attempting to harm them.
A. ultrasound showing lesion with microcalcifications
B. ultrasound showing a lesion of > 1 cm
C. hot nodule on 123I uptake scan
D. ultrasound showing a solid lesion
EXPLANATION: The correct answer is (C). A hot nodule, which is a hyperfunctioning thyroid nodule, suggests a benign etiology. The other choices, including ultrasound findings of microcalcifications, solid lesions, and lesions > 1 cm, should increase your index of suspicion for possible malignancy. Cold nodules are nonfunctioning thyroid nodules, which should increase your suspicion, especially in combination with suspicious ultrasound and/or clinical examination findings.
EXPLANATION: Persons with a CD4 count less than 200/mL or a CD4 percentage below 14% are now included in the Centers for Disease Control and Prevention category of “definitive AIDS diagnoses with laboratory evidence of HIV infection.” Persons with HIV-AIDS may have positive herpes titers or depressed platelet or white blood cell counts, but these are not diagnostic of AIDS in the absence of symptoms.
EXPLANATION: Antisocial personality disorder consists of clinical findings that include selfishness, callousness, promiscuousness, impulsive behavior, and an inability to learn from experience and legal problems. Avoidant personality disorder presents clinically as someone who fears rejection, overreacts failure, has poor social endeavors, and low self-esteem.
EXPLANATION: In a normal delivery, after the infant is delivered through the introitus it should not be held below it; excessive fluids can be passed to the infant, resulting in increased hematocrit and hemoglobin, which will hemolyze and cause hyperbilirubinemia.
A. IV vancomycin
B. IV vancomycin, IV gentamicin, and PO rifampin with surgical treatment
C. IV amphotericin plus flycytosine, and surgical treatment
EXPLANATION: In patients with prosthetic valve infection with methicillin-resistant S. aureus, the treatment of choice is IV vancomycin for 6 to 8 weeks, plus IV or IM gentamicin for the initial 2 weeks secondary to nephrotoxicity, and PO rifampin for 6 to 8 weeks, with susceptibility to gentamicin determined before initiation of rifampin. Surgical therapy decreases mortality in patients with S. aureus endocarditis, from over 70% with medical therapy alone to 25%, and should be considered in patients with paravalvular abscesses and symptoms suggestive of moderate to severe refractory congestive heart failure. Therefore, choice B is the most appropriate next step in the management of this patient. Choice A does not offer sufficient coverage for methicillin-resistant S. aureus. Choice C is appropriate therapy for infective endocarditis when the causative organism is Candida. Outpatient antibiotic therapy is only appropriate in patients who are stable, without clinical or echocardiographic findings to suggest complications, and IV Ceftriaxone is not appropriate for the treatment of methicillin-resistant S. aureus prosthetic valve endocarditis. Choice E is appropriate therapy for pencillin-susceptible streptococci, such as S. bovis.
A. atropine ophthalmic drops
B. azelastine ophthalmic drops
C. levofloxacin ophthalmic drops
D. prednisolone ophthalmic drops
EXPLANATION: This patient has herpes simplex keratitis is an important cause of ocular morbidity. The ability of the virus to colonize the trigeminal ganglion leads to recurrences precipitated by fever, excessive exposure to sunlight, or immunodeficiency. The dendritic (branching) ulcer is the most characteristic manifestation. More extensive (“geographic”) ulcers also occur, particularly if topical corticosteroids have been used. Ophthalmic corticosteroids in cases of suspected herpes simplex keratitis are contraindicated.
EXPLANATION: Hyperkalemia is a potential adverse reaction of ACE inhibitors such as enalapril. ACE inhibitors should be suspected as a cause of hyperkalemia and may require discontinuation.
A. plasma fractionated free metanephrines
B. serum chromogranin A
C. serum thyroid stimulating hormone
EXPLANATION: The plasma fractionated free metanephrine test is the most sensitive test for a pheochromocytoma which this woman’s symptoms strongly suggest. Serum chromogranin A (B) is elevated in about 90% of patients and its level correlates with tumor size. Serum TSH (C) would not be appropriate since the symptoms are not as suggestive of hyperthyroidism as they are of pheochromocytoma. A positive plasma test should be followed by a urine fractionated metanephrine test and creatinine level (D). A urine toxicology screen (E) would be appropriate if cocaine use were suspected; however the symptoms more strongly suggest pheochromocytoma.
EXPLANATION: There are five stages of CKD. Stage 3 Chronic kidney disease is referred to as a moderately decreased GRF between 30-59 ml/min/1.73m2. All other choices reflect different ranges of GRF above or below stage 3.
A. Tubo-ovarian abscess
C. Ectopic pregnancy
E. Pelvic inflammatory disease
EXPLANATION: Suspicion for PID should be very high in a young, healthy, and sexually active woman with cervical motion tenderness. She is not spotting and just menstruated, making ectopic pregnancy much less likely.
EXPLANATION: Cervical mucus ferning is typical of ovulation or an anovulatory cycle where no progesterone has inhibited the ferning pattern.
During menstruation (A), any mucus would be obscured by blood. During pregnancy (C) and following ovulation (E), circulating progesterone causes the mucus to become thick and crumbly. The comparative lack of estrogen postmenopausally (D) also means that any cervical mucus will not fern.
A. Fresh frozen plasma
D. DDAVP (desmopressin)
E. EACA (aminocaproic acid)
EXPLANATION: While fresh frozen plasma and cryoprecipitate have been used in the past for hemophilia A hemostatis, volumes may be too large or unable to reach levels to achieve hemostasis in severe hemophilic A patients. Recombinate is a commercial lyophilized factor VIII concentrate that can case factor VIII levels to reach hemostasis in smaller volumes, and do not have the disadvantages of plasma or cryopreciptate. DDAVP is not used in severe hemophilics. EACA is used to enhance hemostasis, but is not able to achieve initial hemostasis seen with recombinate therapy.
A. Antithrombin deficiency
B. Increased plasma prothrombin
C. Protein C deficiency
D. Protein S deficiency
E. Resistance to activated protein C
Increased plasma prothrombin concentration results from a prothrombin gene mutation (B), while deficiencies of antithrombin (A), protein C (C) and protein S (D) are rarer causes of prothrombotic states and are not directly associated with factor V Leiden mutation which is the most common cause of thrombophilia in this clinical scenario
EXPLANATION: The correct answer is (E). This patient is at very low risk of CAD based on the 10-year Framingham projections. Based on her < 1%, 10-year risk drug therapy is not indicated. Exercise has been shown to increase HDL. HDL is lower in patients who have a sedentary lifestyle or are obese. Her LDL may also be reduced with exercise, weight loss, and dietary modifications.
D. Antidiuretic hormone
E. Thyroid stimulating
The correct choice is B, Cortisol. The reader must first consider Cushing’s syndrome as the diagnosis for this patient. The clinical manifestations of Cushing’s syndrome are noted in this patient, and include easy bruising, proximal muscle weakness, pinkish-purple wide striae, weight gain, and central obesity. These findings are related to the excess Cortisol present in the plasma of these patients. In addition, hypertension is found in 75 to 85% of patients with Cushing’s syndrome. Choices A, rennin, and C, testosterone, are noted to be low or normal in patients with Cushing’s syndrome. Choice D, Antidiuretic hormone, is lacking in patients with diabetes insipidus. Choice E, thyroid stimulating hormone, is an anterior pituitary hormone that is essential in thyroid stimulation.
A. Allogeneic stem cell transplant
B. Folic acid supplementation
D. Prophylactic penicillinE. Pneumococcal vaccine
EXPLANATION: Hydroxyurea directly reduces hemolysis and increases levels of fetal hemoglobin and reduces complications and transfusion frequency.
Sickle cell disease can be cured in 80% of individuals who receive a suitable transplant (A), but this procedure carries great risk and donors are difficult to identify.
EXPLANATION: Histoplasmosis is caused by a dimorphic fungus, most commonly Histoplasma capsulatum (although other species exist). Within the United States, endemic areas include the Ohio and Mississippi river valleys. Additional areas of risk include other parts of North, South, and Central America, Africa, Mexico, and Central Asia. Large amounts of bird and bat droppings within specific soils promote the growth of the fungus, and exposure typically occurs during activities that disrupt the soil and aerosolize the spores. Depending upon the length and intensity of exposure, and the patient’s immune system and previous lung history, infections may range from asymptomatic to severe. Treatment is based upon the patient’s clinical picture, with mild to moderate disease being treated with oral antifungal agents.
A. Counsel him on target life style changes and recheck his lipid panel in three months and begin therapy if not to goal at that time.
B. Redraw his fasting lipid panel today, counsel him on target life style changes and begin therapy immediately if his follow up lipid panel is not to goal.
C. Counsel him on target life style changes, begin therapy with a statin at this time, and recheck his lipid panel in three months and adjust therapy.
EXPLANATION: The National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP-III) and subsequent revisions generally recommends that healthy male patients reach the following goals for cholesterol: low-density lipoprotein (LDL) of less than 100 mg/dL, high-density lipoprotein (HDL) of greater than 40 mg/dl in men and greater than 45 mg/dL in women, and triglycerides of less than 150 mg/dL. While counseling this patient on lifestyle changes is also important, it would be almost impossible for this patient to reduce his levels to goal without medication. A better strategy would be to combine lifestyle changes and initiate medication concurrently. Statins remain the first-line therapy for treatment of dyslipidemias.
Which of the following is the most likely diagnosis in this patient?
A. Acute myeloid leukemiaB. Chronic myeloid leukemiaC. Chronic obstructive pulmonary disease (COPD)
D. Multiple myeloma
E. Polycythemia vera
EXPLANATION: Polycythemia vera often presents with complaints related to increased red blood cell mass, such as, headache, fatigue, and dizziness with elevated red blood cell mass with leukocytosis and/or thrombocytosis noted on CBC.
Chronic hypoxia from conditions such as COPD (C) can also cause elevated RBC mass, but is unlikely in this non-smoker. The patient lacks white blood cell abnormality symptoms (e.g., recurrent infections, elevated white count) making acute myeloid leukemia (A), chronic myeloid leukemia (B), or multiple myeloma (D) unlikely diagnoses.
A. a recent history of group A strep infection
B. a family history of atopy
C. exposure to nickel in clothing
D. a personal history of allergies
EXPLANATION: This is a classic guttate psoriasis. An acute strep infection is a known precipitating factor of guttate psoriasis. All patients need to be checked and treated for a strep infection. Atopy has no correlation with guttate psoriasis. It is not caused by contact with an allergen or irritant. It is also not caused by an allergic reaction.
A. Chest x-ray
B. Transesophageal echocardiogram
C. Holter monitor
D. Treadmill exercise stress test
E. Transthoracic echocardiogram
EXPLANATION: Choice E, transthoracic echocardiogram, is a simple, sensitive and non-invasive diagnostic tool which can evaluate for the presence of valvulopathy in this patient. Choice A might be able to give evidence of cardiomegaly, but would not be sensitive enough to detect valvulopathy. Choice B, transesophageal echocardiogram, would give information regarding valvulopathy, but is a more invasive test; therefore, choice E is more appropriate. Choice C is a useful diagnostic tool for evaluation of patients complaining of palpitations, but incorrect for this patient who has no symptoms. Choice D, although a useful diagnostic tool for the evaluation of exercise tolerance and in patients complaining of chest pain, does not allow direct visualization of the heart valves to evaluate for valvulopathy. In addition, a patient scheduled for left total knee replacement is unlikely to perform very well on a treadmill, thus the more appropriate test for preoperative evaluation, if necessary after transthoracic echocardiogram, would be a nuclear stress test.
B. At 40.5 weeks
C. 41.5 weeks
EXPLANATION: In the absence of complication, the recommendation from ACOG is to wait for labor to occur. Large for gestational age is not an indication for induction in the absence of diabetes. Gestations greater than 42 weeks increase risk of fetal stillbirth.
A. congenital nevus
C. post-inflammatory hyperpigmentation
D. café-au-lait macule
EXPLANATION: The patient is experiencing melasma secondary to the use of oral contraceptives. This is a frequent cause of melasma. Melasma can also be precipitated by hormonal changes that occur during pregnancy. The condition will resolve upon discontinuation of the oral contraceptive. A congenital nevus is a nevus that presents within the first year of life. It is monitored in the same way as acquired nevi. They can be larger than acquired nevi, with only a slight increase in chance of malignant change over time. Post-inflammatory hyperpigmentation includes darker areas of pigmentation that can result after inflammation on the skin. Common causes include acne and atopic dermatitis. The hyperpigmentation will resolve over time. A Café-au-lait macule is a type of birthmark. It is usually light tan to light brown in appearance, and can vary greatly in size. They are usually benign, but can be associated with neurofibromatosis when more than six, with a diameter greater than 1.5 cm, are present.
A. Child receives fluoride varnishes
B. Maternal smoking
C. Parents are of low socioeconomic status
EXPLANATION: Factors that place children at high-risk for dental caries include the presence of white spots, cavities, or fillings on exam; mother/primary care giver having cavities; mother/primary caregiver being of low socioeconomic status (C); frequent between-meal sugar-containing snacks/beverages; or being put to bed with a bottle that contains sugary beverage. Fluoride (A) and fluoridated water (E) are protective. Maternal smoking (B) and single parenting (D) are not validated risk factors for dental caries.
A. Bipolar disorder
B. Delusional disorder
C. Hypomanic episode
D. Manic episode
EXPLANATION: The patient described is exhibiting behaviors consistent with a manic episode (D). Her symptoms have been present for over a week and are impairing her ability to function, so it is not hypomania (C). As she has no clear history of depression, it is likely that she will have a depressive episode in the future, which will allow for a diagnosis of bipolar disorder (A). She does exhibit grandiosity, but there are no clear delusions (B). Neurosis (E) is a more general term for cognitive distress including some form of anxiety.
A. Roth spots
B. Splenic enlargement
C. Janeway lesions
D. Pericardial friction rub
EXPLANATION: Choice D is the most likely finding, as this patient is exhibiting signs, symptoms, and EKG findings pathognomonic for acute pericarditis, which is likely infectious in the setting of a patient with HIV. A pericardial friction rub is heard best with the patient in a seated position, during expiration, and is frequently found in patients with pericarditis. Choice A B, C, and E are physical exam findings seen in acute bacterial endocarditis.
A. the beta blocker
B. the NSAID
C. the proton pump inhibitor
D. the SSRI
EXPLANATION: Many medications cause hyperprolactinemia, including SSRIs, tricyclic antidepressants, and antipsychotics. Hydralazine and methyldopa, but not beta blockers (A), may also raise prolactin levels; likewise opioids, but not NSAIDS (B). Cimetidine and ranitidine, but not proton pump inhibitors (C) are included among possible pharmaceutical causes. Thiazide diuretics (E) are not know to raise prolactin levels.
A. Morphine, oxygen, nitroglycerin sublingually, aspirin 81 mg PO X 4
B. Reassurance and anxiolytics
C. Diltiazem 20 mg bolus IVP over 2 minutes, then diltiazem 10 mg/h IV infusion
D. Aspirin 81 mg two tablets PO
E. Dopamine 5 mcg/kg/min
EXPLANATION: Choice C is correct; as the patient is demonstrating atrial fibrillation with RVR, the appropriate therapy now that acute myocardial infarction has been ruled out, and as the patient is beyond the therapeutic window for immediate direct current electrocardioversion, is heart rate control. Choice A is inappropriate, as this is standard therapy for acute MI. Choice B can be used in patients suffering palpitations associated with panic attacks. Choice D is insufficient anticoagulation therapy. Choice E is inappropriate as the patient is not in need of pressor support.
B. Holter monitor
C. Exercise treadmill
EXPLANATION: This patient presents with a history that is consistent with restrictive cardiomyopathy. While this is not a common diagnosis, it usually presents in younger males who experience symptoms while exerting themselves. Echocardiography is the best assessment test to determine wall motion and thickness of the myocardium. It can also assess any valvular disorders or areas of decreased wall motion abnormalities.
A. Congestive heart failure
B. Metabolic acidosis
C. Obstructive sleep apnea
D. Respiratory acidosis
EXPLANATION: Kussmaul’s respiration is a form of respiratory compensation, and is most commonly associated with metabolic acidosis. During early acidosis, breathing may be rapid, but when advanced the breaths become deep, slow and labored with an urge to breathe described as “air hunger.” The other etiologies suggest other causes of breathing variation, such as tachypnea, apnea, and Cheyne-Stokes respiration.
A. Asperger’s syndrome
B. Attention deficit/hyperactivity disorder
C. Conduct disorder
D. Oppositional defiant disorder
EXPLANATION: Conduct disorder (C) is defined as a persistent pattern of defiance, aggression towards people, animals, and/or property, and violation of the rights of others. Asperger’s (A) is on the autism spectrum, ADHD (B) involves lack of ability to focus, ODD (D) generally does not involve aggression and is not as long-standing, and mental retardation (E) involves decreased intellectual ability. Symptoms of conduct disorder may often overlap with ADHD as well as with bipolar disorder, but in conduct disorder the defiant attitude is constant and aggression is more prominent.
D. trimethoprim-sulfamethoxazole (TMP-SMX)
E. All are appropriate antibiotics for this patient in this setting.
EXPLANATION: The response to antibiotics in acute bacterial prostatis is usually prompt, perhaps because drugs penetrate readily into the acutely inflamed prostate Antibiotic selection should be guided by results of urine cultures and susceptibility results. Appropriate empiric antibiotics include a fluroquinolone (i.e.levofloxacin 500 mg once daily) or TMP/SMX (one double-strength tablet every 12 hours). Patients who are too ill for oral therapy or are septic on presentation should be hospitalized for initial parenteral treatment (intravenous quinolones with or without an aminoglycoside). Ceftriaxone would not be recommended as first-line.
A. 24-hour urine for porphyrin
B. Bone marrow biopsy
D. Ferritin level
E. Liver biopsy
EXPLANATION: Diagnosis of sideroblastic anemia is made by examination of the bone marrow, using Prussian blue staining and noting the presence of ringed sideroblasts, which are cells with iron deposits encircling the red cell nucleus. None of the other studies are useful in making this diagnosis.
EXPLANATION: Dacryocystitis, whether acute or chronic, is usually secondary to bacterial infections. It presents as an acutely inflamed swelling and tender area over the lacrimal sac just medial and inferior to the inner canthus of the eye. Because the lacrimal sac is inflamed and blocked there is tearing and usually purulent discharge from the eye. There may also be an orbital cellulitis. Treatment consists of oral and topical antibiotics and warm compresses, and surgical drainage may also be indicated. After the acute episode and for chronic cases, surgical correction of the nasolacrimal obstruction is required. Anterior uveitis typically presents with pain, photophobia, blurred vision, and injection without exudates. Blepharitis is an inflammation of the lid margin that presents with crusty debris along the lashes. Unless there is a concomitant conjunctival infection, there is typically no injection noted.
A. Aspirin and dipyridamole
C. Plasma exchange
D. Splenectomy and prostacyclin
E. Supportive therapy and dialysis
EXPLANATION: This patient has a diarrhea-associated hemolytic uremic syndrome with clinical features of TTP. D+HUS is associated with infectious etiologies, usually through food borne illnesses. Treatment consists of supportive therapy, treating the underlying infection, and dialysis if renal function warrants. All other therapies listed are used in the treatment of TTP or diarrhea negative HUS.
A. post-traumatic stress disorder
B. dissociative fugue
D. acute stress disorder
EXPLANATION: Acute stress disorder is characterized by experiencing or witnessing a traumatic event where the person felt threatened by death or injury or the people they witnessed. The person feels fearful and helpless. Symptoms usually occur within a month of the event, last 2 days, and resolve in a month. The person feels numb, has lack of awareness of surroundings, and sees everything in a dreamlike state. Sometimes they develop amnesia. Flashbacks or recurrent images can occur with acute stress disorder. Difficulty sleeping, poor concentration, anhedonia, irritability, and despair are associated with this disorder. If not treated at the early stages, the patient is at risk of developing PTSD.
A. Expectant management aimed at pain reduction
B. Bilateral uterine artery embolization
C. Reduction of blood loss with combined oral contraceptives
D. Immediate hysterectomy
E. Gonadotropin-releasing hormone analog followed by myomectomy
EXPLANATION: GRH causes a reversible hypogonadism, which reduces tumor size, makes surgical intervention safer, and reduces bleeding. The patient wishes to preserve her fertility, making embolization and hysterectomy non-viable options. COC do not significantly reduce bleeding, and do not regress the tumor for optimal surgical removal.
A. platelet transfusions
B. IV anti-D (WinRho SD) 50-70 mg/kg/dose
C. prednisone 2.4 mg/kg/24 hours x 2 weeks
EXPLANATION: In patients with idiopathic thrombocytopenic purpura, treatment options should be initiated when platelet counts fall below 20,000, regardless of whether there is active bleeding or not. Without active bleeding the treatment options include prednisone 2-4 mg/kg/24 hours for 2 weeks; IV immunoglobulin 1 g/kg/24 hours for 1 to 2 days, or IV anti-D 50-75 μg/kg/dose for Rh-positive patients. Splenectomy is indicated for life-threatening bleeding. There is currently no indication for platelet transfusion and none of the above treatments are considered optimal, because in the majority of children, it will resolve on its own within 6 months.
C. Preauricular adenopathy
EXPLANATION: Allergic conjunctivitis is characterized by itching, tearing, redness, and chemosis, with itching being uncommon in other common forms of conjunctivitis (A). Fever (B) and sore throat (E) are more likely to occur in viral or bacterial conjunctivitis. Preauricular adneopathy (C) typically occurs in viral or chlamydial conjunctivitis.
A. Pituitary adenoma
C. GHRH secreting hypothalamic tumor
The correct choice is A, pituitary adenoma. The patient is presenting with classic signs and symptoms of acromegaly. This disorder is caused most commonly by a growth hormone secreting pituitary adenoma. On rare occasions, it has been caused by choice C, a GHRH secreting hypothalamic tumor. Choice B, pheochromocytoma, is a tumor of the adrenal glands that causes high blood pressure, but does not cause the classic body features of acromegaly. Choice D, adrenal carcinoma, and choice E, ectopic ACTH secretion, may cause Cushing’s syndrome, but not acromegaly.
B. Ferrous sulfate
C. Folic acid
E. Vitamin B12
EXPLANATION: The patient most likely has vitamin B12 deficiency, as evidenced by the macrocytic anemia and neurological signs and symptoms. The patient should be treated with vitamin B12.
Anemia secondary to chronic kidney disease (A) typically presents as a normocytic, normochromic anemia. Iron deficiency anemia (B) presents as a microcytic, hypochromic anemia. Folate deficiency (C) typically presents as a macrocytic anemia, but without the classic neurological symptoms consistent with vitamin B12 deficiency.
A. avoidant personality disorderB. borderline personality disorderC. histrionic personality disorde
EXPLANATION: An individual with avoidant personality disorder differs from schizoid in that they desire interaction and closeness but are unable to overcome their deep seated self-beliefs and fears. They tend to be less impulsive and more stable than borderline personality disorder patients and have less of a need to be the center of attention than those with histrionic personality disorders.
A. rubellaB. measlesC. varicella
EXPLANATION: Koplik’s spots, white lesions on the buccal mucosa, are characteristic of measles. The rash in measles usually presents as a red-brown rash starting with the head and moving caudally. It follows a 3- to 4-day prodrome consisting of fever, nasal drainage, conjunctivitis, and cough. Varicella may also present with mucosal lesions but they are vesicular on an erythematous base. Parvovirus, rubella, and Kawasaki disease generally do not have mucosal involvement.
A. Combination low dose pill daily
B. Injectable progestin monthly
C. Transdermal combination patch
D. Levonorgestrel intrauterine device
E. Copper intrauterine device
EXPLANATION: A women who is over 35 and smokes is at high risk for cardiovascular complications. All choices except the copper IUD contain hormones, which may increase the risk of complications. The copper IUD is long term but non-permanent.
A. Decreased or absent femoral pulses
B. Systolic machinery-type murmur
C. Holosystolic murmur at the lower left sternal border
EXPLANATION: Decreased or absent femoral pulses is the correct answer.
A. anion gap metabolic acidosis with respiratory acidosis
B. nonanion gap metabolic acidosis with respiratory alkalosis
C. anion gap metabolic acidosis with respiratory alkalosis
EXPLANATION: An acute salicylate overdose (greater than 150 mg/kg) will produce symptoms of salicylate intoxication. Chronic salicylate intoxication occurs with ingestion of greater than 100 mg/kg/day for at least 2 days. Salicylates affect most organ systems, leading to various metabolic abnormalities. Because salicylates are a gastric irritant, symptoms of vomiting and diarrhea occur soon after the overdose, which may contribute to the development of dehydration. Salicylates stimulate the respiratory center leading to hyperventilation and hyperpnea resulting in respiratory alkalosis and compensatory alkaluria. A characteristic feature of salicylate intoxication is the coexistence of a respiratory alkalosis with a widened anion gap metabolic acidosis.
A. Local anesthesia and observation
B. Surgical exploration and orchidopexy
C. IV antibiotics
EXPLANATION: Testicular torsion is most common between ages 12-18 with the classic presentation of abrupt and severe onset of pain with nausea/vomiting, swollen, tender, high-riding testis, and abnormal transverse lie. It is confirmed by Doppler ultrasound and emergent surgical exploration is indicated with an excellent rate of testicular salvage if symptoms are present <6 hours (B). Manual detorsion (E) and anesthesia can be given but definitive therapy is emergent bilateral orchidopexy. Oral or IV antibiotics (C) can be given to treat epididymitis pending cultures. Scrotal support, limitation of activity, and oral analgesics (D) are used in non-emergent torsion of the testicular appendage, which is confirmed on ultrasound. Local anesthesia and observation is not adequate treatment when time is critical to save the vascular supply to the testicle, this would risk necrosis (A)
A. AIDS dementia complex
B. central nervous system lymphoma
C. cryptococcal meningitis
D. progressive multifocal leukoencephalopathy
EXPLANATION: The most common space-occupying CNS lesion in patients with HIV is toxoplasmosis. This condition may present with headache, focal neurologic deficits, seizures, and/or mental status changes. The typical appearance on brain imaging is that of multiple contrast-enhancing lesions in the periphery, particularly the basal ganglia. CNS lymphoma is more typically a single lesion. AIDS dementia complex presents a diagnosis of exclusion, without a characteristic appearance on imaging. The diagnosis of cryptococcal meningitis is made by examination of the spinal fluid, while PML imaging shows nonenhancing white matter lesions without mass effect.
A. Intravenous fluids
B. Nasogastric suction
D. Surgical exploration
EXPLANATION: Massive distention of the cecum, as detected on plain radiograph, is typically seen in “closed loop” obstructions where the ileocecal valve is competent. When distention approaches 12 cm, there is an increased risk of perforation and/or gangrene. Expedient surgical intervention is indicated. Although observation with intravenous fluids and nasogastric decompression are important adjuncts to management, surgical exploration is the only way to rapidly address this emergent situation.
A. ESR 60 mm/h
B. temporal artery biopsy
C. Elevated CRP
EXPLANATION: The correct answer is (B). This patient has long standing symptoms of polymyalgia rheumatica (PMR) with current symptoms suggestive of giant cell (temporal) arteritis. Temporal artery biopsy is considered the gold standard for diagnosis of giant cell (temporal) arteritis. Patients with temporal arteritis may have an elevated erythrocyte sedimentation rate (ESR) or CRP, but this is not required for diagnosis. A color ultrasound of the temporal artery will sometimes show edema or stenosis of the affected artery but is not very sensitive for giant cell arteritis. MRA is used for diagnosis of larger arteries with vasculitis and not routinely used in the diagnosis of temporal arteritis.
The correct choice is C, IGF-I or insulin like growth factor I. This growth factor leads to increased DNA, RNA, and protein synthesis, which leads to overgrowth of bone, soft tissue, and cartilage. Choice A, c-peptide, is a part of the prohormone of insulin. Choice B, IL-I or interleukin I, is an important cytokine that promotes cell activation. Choice D, thyroxine, potentiates the actions of growth hormone on tissues.
B. 6 months
C. 12 months
EXPLANATION: A comprehensive work up should begin now, due to her advancing age and history of significant PID, which may require surgical treatment.
A. generalized lymphadenopathy
B. aseptic meningitis
D. generalized maculopapular rash
EXPLANATION: Secondary syphilis generally manifests itself a month or two after appearance of the primary chancre. Patients will complain of headache, fever, sore throat, and malaise and will exhibit generalized lymphadenopathy along with a maculopapular rash that begins at the sides of the trunk and later spreads over the rest of the body. The skin lesions may coalesce in warm moist areas, such as the perineum, and form large, flat-topped, pale papules termed condyloma lata. Skin and mucosal lesions are the most common signs of secondary syphilis. Aseptic meningitis and alopecia may also occur in secondary syphilis. Formation of granulomatous nodules (gummas) is not a feature of secondary disease, but rather is the hallmark of tertiary syphilis.
A. alpha interferon
B. chemotherapy with daunorubicin, bleomycin, and vinblastine
C. intralesional vinblastine
EXPLANATION: Kaposi sarcoma that is in a limited area of the skin may be treated with intralesional vinblastine or by simply observing it over time. Liposomal doxorubicin and alpha interferon are used for extensive or aggressive skin disease, while combination chemotherapy is used for visceral disease.
C. Continue monitoring
EXPLANATION: This patient continues to remain in Binet Stage A, and therefore would not benefit from beginning any additional therapy. Monitoring should be continued. If they would develop 3/5 lymphoid regions of involvement (cervical, axillary, ileofemoral, splenomegaly, or hepatomegaly) or doubling of the lymphocyte count in less than six months, then adding additional therapy would be indicated. Fludarabine is first-line therapy for progressing CLL. Chlorambucil is the main alkylating agent used in CLL. Alemtuzumab is a monoclonal antibody specific for human CD52, found on most lymphocytes and useful in CLL treatment. Etoposide is used in patients who failed alkylator-based chemotherapy.
A. Digital fibroma
B. Juvenile xanthogranuloma
C. Molluscum contagiosum
D. Verruca vulgaris
EXPLANATION: This child has a recurrent digital fibroma. It is a smooth, firm,pink nodule that occurs on the fingers and toes up through earlychildhood. Surgical excision is recommended so that the functionof the digit is not impaired.
C. Ferrous sulfate
EXPLANATION: Stage 1 of iron toxicity secondary to ferrous sulfate ingestion (C) is characterized by acute GI irritation; this is followed by a latent phase (Stage 2) that can then progress to systemic iron toxicity (Stage 3), that can progress to hepatic failure (Stage 4) or delayed sequelae (Stage 5). Cisplatin (A), erythropoietin (B), and vincristine (E) are parenterally administered and unlikely to be present in a patient’s purse. Lisinopril (D) toxicity consists of cardiovascular symptomatology (e.g., hypotension and tachycardia).
A. Ventricular tachycardia
B. Atrial flutter
C. Ventricular fibrillation
EXPLANATION: Choice B is correct. As patients with mitral stenosis age, and their mitral stenosis progresses to moderate or moderately severe mitral stenosis (most commonly after their fourth decade), the incidence of atrial arrhythmias—including premature atrial contractions, paroxysmal tachycardia, atrial flutter, and atrial fibrillation—increases. Choices A, C, D, and E are less likely, given that they are ventricular arrhythmias.
Which of the following is the most likely pathophysiologic mechanism responsible for her anemia?
A. Acute blood loss
B. Defective bone marrow/stem cell function
C. Defective DNA production D. Defective hemoglobin production
E. Increased destruction of red blood cells
EXPLANATION: The patient most likely has an underlying vitamin B12 or folate deficiency resulting in macrocytosis (MCV of 112 fL).
Defective DNA production (C) results in failure of RBC maturation and macrocytosis (elevated MCV). Acute blood loss (A) would present more acutely and with normal hemoglobin, hematocrit, and MCV until hemodilution occurs and lowers the hemoglobin concentration and hematocrit. Defective bone marrow/stem cell function (B) tends to produce normocytic red blood cells. Microcytic, hypochromic anemia results from defective hemoglobin production (D). Hemolysis (E) is less likely than vitamin B12 and folate deficiency, but can be confirmed or ruled out through the assessment of the reticulocyte count (increased reticulocyte will increase the MCV and be inconsistent with a nutritional deficiency) and further hematologic labs as necessary.
A. Beta blocker
B. ACE inhibitor
C. Calcium channel blocker
D. Angiotensin receptor blocker
E. Alpha blocker
EXPLANATION: The correct answer is a beta blocker. This is the recommended medication to reduce the risk of first variceal hemorrhage in patients with large or small varices, who either have variceal red wale marks or advanced cirrhosis.
EXPLANATION: Haldol, a typical antipsychotic agent, has been shown to be effective for symptomatic treatment of patients with Tourette syndrome. Haldol blocks dopaminergic action and decreases psychomotor agitation. It is linked to a high frequency of extrapyramidal side effects, likely due to this action. It also has sedative properties within the limbic system. Other medications, such as atypical psychotics, benzodiazepines, alpha-2 agonists, and dopamine-blockers have been used for Tourette management. Each medication should be monitored for effectiveness and side effects, as other medications can cause extrapyramidal side effects, such as metoclopramide.
C. Inhaled hypertonic saline
D. Inhaled levofloxacin
EXPLANATION: Ivacaftor (E) is the only treatment that restores function of the CFTR protein in cystic fibrosis patients with a G551D mutation thereby reversing the effects of the disease, approximately 5% of all cystic fibrosis patients have the G551D mutation. Albuterol (A) and hypertonic saline (C) are indicated to improve lung function and mucous clearance. Azithromycin (B) and inhaled levofloxacin (D) are used to treat chronic infection/colonization with pseudomonous.
A. Chest x-ray
B. Complete blood count (CBC)
C. Nasal bacterial culture
D. Soft tissue neck x-ray
E. CT scan of the neck
EXPLANATION: This patient has a presentation that is consistent with acute epiglottitis. While ensuring that the airway is patent and the patient can maintain the airway, the first step in determining the diagnosis is a soft tissue neck x-ray, to determine inflammation to the epiglottis. While rare, epiglottitis can be from a bacterial infection, and can be quite serious and sometimes fatal.
A. Left ventricular hypertrophy
B. Normal ECG
C. Right axis deviation
D. Supraventricular tachycardia
E. Sick sinus syndrome
EXPLANATION: In this scenario the patient most likely has a small left-to-right shunt of a ventricular septal defect, given the clinical exam findings. The ECG is most frequently normal in a patient with a small ventricular septal defect. If the patient had a large left-to-right shunt left ventricular hypertrophy would be a possibility. The other choices are not commonly seen on ECG when a ventricular septal defect is present.
A. Administer prednisone
B. Administer warfarin
C. Bone marrow aspirate
D. CT of the abdomen
EXPLANATION: The patient most likely has developed heparin-induced thrombocytopenia (HIT), which is associated with qualitative platelet function changes that result in increased risk of thrombosis. She should begin warfarin (B) and be evaluated for thrombosis (e.g., lower extremity Dopplers).
Prednisone (A) is not indicated for the treatment of HIT, and a bone marrow aspirate (C) would not aid in establishing the diagnosis. CT of the abdomen (D) would be indicated if she had symptoms consistent with thrombosis in that region, and observation (E) fails to address her increased thrombotic risk.
A. Cardiac catheterization followed by aortic valve replacement
B. Monitoring via repeat transthoracic echocardiogram in 6 months
C. Monitoring via transesophageal echocardiogram in 6 months
EXPLANATION: In symptomatic patients demonstrating significant aortic stenosis, aortic valve replacement after cardiac catheterization, to evaluate for coronary artery disease and possible concomitant coronary artery bypass surgery with aortic valve replacement, is indicated. As the patient is demonstrating the classic symptoms of severe aortic stenosis, choice A is the most appropriate next step in management. Choices B and C are thus inappropriate, as the patient is already symptomatic. If the patient were not symptomatic, choice B would be a viable choice compared to choice C, because it is less invasive than transesophageal echocardiogram. Choice D would be inappropriate, as strenuous physical activity should be avoided in patients with severe aortic stenosis. Choice E is appropriate therapy for patients at risk for ventricular tachycardia/fibrillation.
B. Acute myocardial infarction
D. Prinzmetal angina
EXPLANATION: Prinzmetal angina, or variant angina pectoris, is defined as coronary artery spasm associated with ST-segment elevation, and usually occurs at rest and at the same time of the day. Patients with a history of migraine cephalgia and Raynaud’s phenomenon demonstrate Prinzmetal angina more frequently than the rest of the patient population. This can occur in patients with normal coronary arteries and with coronary artery stenosis. Choice A, pericarditis, would present with chest discomfort that is worse while supine and improves with sitting up, as well as a pericardial friction rub. Choice B, acute myocardial infarction, would present with troponin elevation, and is unlikely in the setting of a patient with normal coronary arteries on cardiac catheterization. Choices C and E would not be relieved with sublingual nitroglycerin or demonstrate transient ST-segment
A. double the dose of fluoxetine to 20 mg/day
B. maintain the current dose of fluoxetine and comfort the patient that the medication may still take at least 1 to 2 more weeks to work
C. discontinue the fluoxetine and start sertraline
EXPLANATION: Alleviation of symptoms associated with depression is typically slow in onset following initiation with SSRIs. Fluoxetine, for instance, can take anywhere between 2 to 6 weeks to achieve substantial benefit when used for depression. After just 1 week of therapy, there is little justification to increase the current dose or switch to another SSRI such as sertraline. Switching the patient to a TCA such as amitriptyline at this point would further delay symptom relief, as TCAs can take several weeks to produce improvement. Compared to SSRIs, TCAs are also more likely to create unwanted side effects such as weight gain, orthostatic hypotension, and constipation. Combining an SSRI with a monoamine oxidase inhibitor (MAOI) such as phenelzine can cause serotonin syndrome that can be lethal. In order to avoid interaction between SSRIs and MAOIs, it is recommended that at least 4 to 5 weeks pass after discontinuing one and starting the other.
A. Chest X-ray
B. Transesophageal echocardiogram
C. Holter monitor
D. Treadmill exercise stress test
E. Transthoracic echocardiogram
EXPLANATION: Choice E, transthoracic echocardiogram, is a simple, sensitive, and non-invasive diagnostic tool which can evaluate for the presence of valvulopathy in a patient in this age group, who is likely demonstrating severe aortic stenosis secondary to a congenital bicuspid valve. Patients with a congenital bicuspid aortic valve typically develop symptoms once the valve leaflets have become calcified and thickened, secondary to the undue stress over many years on a structurally abnormal aortic valve. Choice A might be able to give evidence of cardiomegaly or calcification of heart valves, but would not be sensitive enough to detect the degree of valvulopathy, if present. Choice B, transesophageal echocardiogram, would give information regarding valvulopathy, but is a more invasive test; therefore, choice E is more appropriate. Choice C is a useful diagnostic tool for evaluation of patients complaining of palpitations, but incorrect for this patient, who has no symptoms of palpitations. Choice D, although a useful diagnostic tool for the evaluation of exercise tolerance and in patients complaining of chest pain, does not allow direct visualization of the heart valves to evaluate the degree of aortic stenosis; as the patient is likely demonstrating severe aortic stenosis, cardiac catheterization to evaluate for coronary artery disease prior to surgery will need to be performed.
A. Atopic dermatitis
B. Lichen striatus
EXPLANATION: Lichen striatus is a benign rash consisting of linearly configured,shiny, and flat lesions that occur on any skin surface. This rashoccurs suddenly and resolves on its own in several weeks. The etiologyis unknown.
A. Plain sinus radiographs
C. Aspiration and culture of maxillary sinuses
D. CT scan
E. Ultrasound of sinuses
EXPLANATION: A CT scan is the current preferred method for sinus imaging of chronic sinusitis. CT imaging has better visualization of mucosal thickening air-fluid levels and bone structures. Plain radiographs and CT scans are of limited use in acute sinusitis, because viral pathogens that cause sinus abnormalities are indistinguishable from bacterial causes.
D. humalog insulin
EXPLANATION: The correct answer is (B). Lisinopril, an ACE inhibitor, is contraindicated in pregnancy due to known problems with fetal toxicity and should be stopped as soon as possible once pregnancy is confirmed. If a patient is planning on becoming pregnant the ACE inhibitor should also be discontinued. ARBs should also be avoided. Choices (A), (C), and (D), and (E) can be used safely in pregnancy and are considered category B. Methyldopa is preferred in the treatment of hypertension in pregnancy and its safety is supported by evidence.
A. Double evert his eyelids to look for remaining foreign bodies
B. Fluorescein stain his eye
C. Instill proparacaine 0.5% ophthalmic solution
D. Irrigate his eye until the pH is between 6.8 and 7.4
E. Refer to ophthalomogist
EXPLANATION: The patient requires all of the above steps and should be given pain relief (C) prior to thoroughly flushing the eye (D), removing foreign bodies (A), assessing for corneal injuries (B), and referring to ophthalmology (E).
C. chronic pain
EXPLANATION: Fatigue is one of the most common symptoms in cancer patients, experienced by 70% to 100% of those receiving cancer treatment. It is most commonly related to the chemotherapeutic agent itself and will resolve when treatment is completed. In the interim, anemia is the most common cause and this can be treated with hematopoietic growth factors, erythropoietin (epoetin alfa and epoetin beta), granulocyte colony-stimulating factor (G-CSF), granulocyte-macrophage colony-stimulating factor (GM-CSF).
EXPLANATION: Clinical findings of obsessive-compulsive disorder include being a perfectionist, egocentric, and indecisive, with rigid thought patterns and need for control. Clinical findings of histrionic personality disorder include being dependent, immature, seductive, egocentric, vain, and emotionally labile. Narcissistic personality disorder presents with the clinical findings of grandiosity, a preoccupation with power, lacking interest in others, and excessive demands for attention. Clinical findings of someone who has paranoid personality disorder would include defensiveness, being overly sensitive, secretive, suspicious, hyper-alert, and with a limited emotional response. Schizotypal clinical findings include being superstitious, socially isolated, and suspicious, and having limited personality ability, odd speech, and eccentric behaviors.
A. Angiotensin II receptor blocker
B. β blocker
C. Calcium channel blocker
E. Thiazide diuretic plus ACE inhibitor
EXPLANATION: ACE inhibitors are recommended, as first line treatment for symptomatic congestive heart failure, based upon clinical trials, reveal an approximately 20% reduction in CHF mortality in symptomatic heart failure patients. Diuretics provide CHF symptom improvement and promote water and sodium excretion to decrease intravascular volume. blockers and Angiotensin II receptor blockers are also beneficial for CHF patients. Nitrates are usually reserved for acute or decompensating patients. Calcium channel blockers may accelerate CHF progression and should be used with caution.
A. Pulsus parvus
B. Pulsus alternans
C. Bisferiens pulses
D. Pulsus bigeminus
E. Pulsus paradoxus
EXPLANATION: Pulsus paradoxus is defined as a decrease in systolic arterial pressure of greater than 10 mmHg. It is an accentuation of the normal decrease in systolic arterial pressure of less then 10mm Hg that normally accompanies inspiration. It is frequently noted in patients with pericardial tamponade.
A. 10 mm Hg
B. 20 mm Hg
C. 30 mm Hg
D. 40 mm Hg
EXPLANATION: Many trauma surgery services use an absolute tissue pressure of approximately 30 mm Hg as the threshold for diagnosing compartment syndrome. Based on the entire clinical picture, patients with numbers in that range or higher will likely require surgical decompression with a fasciotomy, while lower numbers will probably be managed with a more conservative approach.
A. pyloric stenosis
B. mesenteric ischemia
C. Crohn disease
E. Hirschsprung disease
EXPLANATION: Intussusception is the most frequent cause of intestinal obstruction in the first 2 years of life. The patient develops paroxysms of pain followed by bloody bowel movements. Pyloric stenosis typically presents prior to the age of 6 months with vomiting but not with diarrhea. Hirschsprung disease results from an absence of ganglion cells in the colon and typically presents early in life with failure to pass meconium, followed by vomiting and abdominal distension. The typical age of onset is later in adolescence in Crohn disease and in the elderly in mesenteric ischemia.
A. Begin therapy as soon as possible
B. Begin treatment with a serotonin uptake inhibitor
C. Begin treatment with a beta blocker to reduce symptom
EXPLANATION: Therapy to aid in working through the traumatic experience (A), instituted as soon as possible after the event, has proven to be the most helpful way to avert or minimize post-traumatic stress disorder. This patient does not currently have any symptoms of PTSD, so pharmacologic treatment is not indicated. In a patient who is diagnosed with PTSD, SSRIs (B) may be helpful in reducing panic and improving sleep, beta-blockers (C) may reduce symptoms of anxiety, and prazosin (D) may help with sleep. Legal procedures (E) may help a patient in dealing with the event, but there are no data supporting this as a therapeutic intervention.
D. Penicillin V
EXPLANATION: Choice E, indomethacin 25-75 mg QID, and bed rest would be the most appropriate treatment in a patient with acute viral pericarditis, as a nonsteroidal anti-inflammatory agent will ameliorate the inflammatory process. Choices A and C are appropriate in a patient suspected of acute coronary syndrome. Choice B, enoxaparin, is contraindicated in patients with pericarditis, as anticoagulants could lead to worsening of pericardial effusion and cardiac tamponade, especially if it is secondary to bleeding into the pericardial space, such as with trauma or postoperatively.
A. perinephric abscess
B. renal vein thrombosis
C. allergic interstitial nephritis
EXPLANATION: Because pyelonephritis is an infectious disease, the most likely complication is a perinephric abscess, which occurs as the result of inadequate therapy. Since it is not vascular in origin, renal vein thrombosis would not occur. Allergic interstitial nephritis is caused by an antigen-antibody reaction, which does not occur with acute pyelonephritis. Struvite stones are due to chronic infection with urease-producing organisms, such as Proteus and Pseudomonas, not to an acute infection. Hepatic failure can be a complication of acute renal failure, but not acute pyelonephritis.
EXPLANATION: Heparin is indicated as initial therapy for acute pulmonary thromboembolism, followed by oral anticoagulation with warfarin. Heparin promotes the effect of antithrombin, which inhibits factors Xa, IXa, Xia, and XIIa, and has been shown to decrease mortality and recurrent pulmonary embolism. Streptokinase, a thrombolytic agent, is recommended for hemodynamically unstable patients being treated with heparin, but with continued risk of death. Embolectomy, although associated with increased mortality, is another alternative for these patients. Pulmonary angiography, the gold standard for pulmonary embolus diagnosis, is being replaced with helical contrasted CT, due to angiography’s invasiveness, time involvement, and cost. Aspirin, an antithrombotic agent, inhibits platelet aggregation and is effective for preventing platelet thrombosis. It also has a role in thrombosis prevention. However, anticoagulation with heparin remains the mainstay of therapy for pulmonary embolus.
A. Amyotrophic lateral sclerosis
B. Intracerebral neoplasm
C. Lyme encephalitis
D. Simple partial seizure
EXPLANATION: Headaches and neurological changes may be seen with many conditions. However, intracerebral neoplasms are often associated with persistent headaches and described as worse in the morning, and may involve neurologic disturbances of many forms, based on the location of the lesion. Coordination deficits, sensory deficits, ataxia, and limb involvement are often seen with brainstem lesions. Amyotrophic lateral sclerosis, a progressive, degenerative nerve disorder with associated weakness, may have similar symptoms, but is not classically associated with headaches. With Lyme encephalitis, signs and symptoms such as fever, vomiting, meningeal signs, and photophobia would be expected. Simple partial seizures are not associated with headaches, although focal neurologic findings are possible. Transient ischemic attacks may have associated headache and neurologic symptoms, but should have improving symptoms and resolution within 24 hours, and are not likely to recur consistently.
C. Prader-Willi syndrome
The correct choice is B, malnutrition. When not associated with chronic diseases, this is the most common cause of short stature worldwide. Children with malnutrition commonly present with failure of weight gain before growth rate decreases. A dietary history is key to the diagnosis, as well as a history of any parasites in the local area. Choice A, acromegaly, is a disorder of growth hormone excess. Choice C, Prader-Willi syndrome, choice D, congenital growth hormone deficiency, and choice E, IGF-I receptor deficiency, have been found to cause short stature, but are not seen as commonly as malnutrition.
B. uric acid
C. calcium oxalate
EXPLANATION: Struvite stones form when urea-splitting organisms, such as Proteus, Klebsiella, Pseudomonas, and Staphylococcus, are present in the urinary tract. Ammonia is formed when urease breaks down urea. This results in an alkaline urine, which decreases the solubility of struvite, favoring the production of stones. Calcium stones result from hyperabsorption of calcium in the intestine, impaired renal tubular reabsorption of calcium, primary hyperparathyroidism, intestinal hyperabsorption of oxalate, and hypocitraturia. Uric acid stones are due to hyperuricosuria or a urinary pH <5.5, which causes uric acid to dissociate. They are also the only radiolucent calculi. Cystinuria, an inborn error of metabolism, results in cystine stones.
A. Conversion disorder
B. Factitious disorder
C. Generalized anxiety disorder
D. Social phobia
E. Specific phobia
EXPLANATION: Specific phobia (E) is the fear of a very specific object or situation that the individual knows to be excessive. Social phobia (D) involves performance, while generalized anxiety (C) involves anxiety without a known stimulus. Conversion disorder (A) and factitious disorder (B) are both somatoform disorders, involving somatic symptoms with a psychogenic cause.
A. His chance is 0%, because this is not transmitted to men.
EXPLANATION: BRCA1 and BRCA2 gene mutations are expressed in the cells of breast and other tissue, where they help repair damaged DNA, or destroy cells if DNA cannot be repaired. If the BRCA1 or BRCA2 itself is damaged, damaged DNA is not repaired properly and this increases risks for certain cancers. These genes are inherited in an autosomal dominant manner so if his mother is positive (and his father is not), his risk is 50%, and he is also at increased risk for not only breast cancer, but also prostate, pancreatic, and other cancers.
pic-open and closed comedones
A. topical retinoids
B. topical erythromycin
C. topical Benzoyl peroxide and erythromycin
D. oral Doxycycline 100 mg bid
EXPLANATION: The lesions are comedones (open and closed). Optimal treatment should be with topical retinoids such as tretinoin and adapalene, as these are comedolytic. Topical erythromycin is indicated in inflammatory acne, not comedonal acne as pictured. Benzoyl peroxide only has mild comedolytic activity and erythromycin has none. This combination medication would be more appropriate for inflammatory acne. Doxycycline has no comedolytic activity.
A. Corynebacterium diphtheriae
B. Streptococcus pneumoniae
C. parainfluenza virus
EXPLANATION: Bronchiectasis has numerous etiologies. Most commonly, cultures reveal normal oral flora from the lower respiratory tract: Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenzae, Pseudomonas aeruginosa. Parainfluenza viruses typically are responsible for croup. Corynebacterium diphtheriae is the causative organism for diphtheria. Rhinovirus is the most common pathogen isolated with acute viral rhinitis or the common cold
A. Zygomatic arch fractureB. Orbital blowout fractureC. Le Fort I fracture
EXPLANATION: Diplopia is common in an orbital blow out fracture, due to entrapment of the inferior rectus and inferior oblique muscles. Loss of infraorbital sensation occurs from disruption or swelling of the infraorbital nerve. A
A. Torsades de pointes
B. U waves
C. Electrical alternans with sinus tachycardia
D. Peaked T waves
E. Convex elevation of the J point
EXPLANATION: Choice C, electrical alternans with sinus tachycardia, a beat-to-beat alteration in one or more components of the ECG signal, is considered a specific sign of pericardial effusion, often with cardiac tamponade, as it represents the periodic swinging motion of the heart in the effusion at a frequency that is ½ the heart rate. Choice A, torsades de pointes, is a type of ventricular tachycardia frequently seen, and is associated with electrolyte disturbances or the use of certain types of antiarrhythmic drugs. Choice B, U waves, are associated with hypokalemia. Choice D is frequently noted with severe hyperkalemia. Choice E, convex elevation of the J point, is seen in patients suffering from hypothermia.
A. Glatiramer acetate
EXPLANATION: Multiple sclerosis (MS) therapy is often discussed by the goal of the treatment. Medications, such as the glucocorticoids, are utilized for acute exacerbations or initial episodes of MS, to decrease exacerbation severity. Additionally, they are used for associated conditions, such as optic neuritis. Steroids have not been shown to decrease MS progression or impact the relapse rate.
Other medications have shown to be beneficial regarding altering disease progression and/or the relapse rate. These medications include Interferon-β agents, glatiramer acetate, and Natalizumab. Mitoxantrone, an antineoplastic agent, is also indicated as an MS disease-altering agent, but due to a high risk of cardiotoxicity with prolonged use, it is a second-line agent
EXPLANATION: The correct answer is bupropion (A). All the SSRIs, including citalopram (B), fluoxetine (C), and paroxetine (D), as well as venlafaxine (E), which is a combination serotonin and norepinephrine reuptake inhibitor (SNRI), have high rates of sexual side effects for men and women. Bupropion is a norepinephrine and dopamine reuptake inhibitor and can be helpful in averting or reducing both sexual side effects and weight gain. It is also indicated for smoking cessation.
A. absence seizure
B. complex partial seizure
C. febrile seizure
D. simple partial seizure
EXPLANATION: A febrile seizure is a brief (less than 15 minutes), generalized, symmetric, tonic-clonic seizure associated with a febrile illness (temperature greater than 38.8°C) without any central nervous system infection or neurologic cause. An absence (petit mal) seizure is a brief (2 to 25 seconds) loss of consciousness that can occur multiple times per day. There is no loss of tone, and frequently the only observable behaviors are staring or minor movements such as lip smacking and semipurposeful movements of the hands. There is no postictal period. Complex partial seizures (psychomotor) have varied symptoms including alterations in consciousness, unresponsiveness, and repetitive complex motor activities that are purposeless. Often, at the beginning of the attack, there is a psychoillusory phenomenon such as hallucinations, visual distortions, visceral sensations, or feelings of intense emotions. Simple partial seizures include focal motor, adversive, and somatosensory seizures. Manifestations of these seizures are varied including hallucinatory, psychoillusory, or complex emotional phenomena. Children will interact normally with their environment, with the exception of those limitations imposed by the seizure. Following the seizure (minutes to hours), there may be transient paralysis of the affected body part.
EXPLANATION: Of the antibiotics listed, metronidazole is the only one that has the indication in the treatment of H. pylori induced peptic ulcers.
A. necrobiosis lipoidica
B. tinea corporis
C. granuloma annulare
D. atopic dermatitis
EXPLANATION: This is the classic distribution of granuloma annulare. These lesions commonly occur over bony surfaces and are thought to be secondary to minor trauma (such as playing soccer, normal play activities, or insect bites). The lesions will spontaneously resolve and no treatment is indicated. The distribution in this patient is similar to that of classic necrobiosis lipoidica; however, the dermal changes are classic for granuloma annulare. Necrobiosis lipoidica starts as brown-red plaques that evolve to become waxy appearing. They are commonly misdiagnosed as tinea corporis; however, there are no epidermal changes such as scaling. The lesions are completely dermal. Atopic dermatitis in a 6-year-old child is most commonly distributed on the flexural surfaces and consists of red scaling plaques that are pruritic.
A. Bacterial meningitis
B. Guillain Barre syndrome
C. Measles encephalitis
D. Reye’s syndrome
E. Viral meningitis
EXPLANATION: Although rare, Reye’s syndrome is associated with viral infections, salicylate use during illness, and metabolic disorders. Illness is associated with liver fat deposition and degeneration, intractable vomiting, and mental status changes, which may progress to seizures, delirium, and coma. Cerebral edema contributes to these changes and other neurologic findings. Meningeal signs are more consistent with meningitis. Measles encephalitis typically presents days to weeks after the pathognomic measles exanthem and clinical findings. Guillain Barre has been associated with influenza infection, and signs and symptoms would include evolving weakness with ascending paralysis and extremity dysesthesias.
B. Positive Prehn’s sign
C. Positive cremasteric reflex
D. Abnormal transverse lie
EXPLANATION: Testicular torsion is most common between ages 12-18 with the classic presentation of abrupt and severe onset of pain with nausea/vomiting. The testicle on physical examination is painful, swollen, high-riding, tender, and has an abnormal transverse lie (D).
A. Clue cells
B. Increased polymorphonucleocytes
C. Motile flagellates
D. Small, rounded parabasal epithelial cells
EXPLANATION: Examination of vaginal secretions in a woman with bacterial vaginosis demonstrates the presence of clue cells, which are epithelial cells that appear granulated due to G vaginalis cells adhering to them.
A. Behavioral modification
B. Family therapy
C. Individual psychotherapy
D. Nutritional restoration
EXPLANATION: Nutritional deficiencies (D) such as dehydration and electrolyte imbalances must be urgently corrected. After metabolic imbalances have been addressed, a comprehensive, inter-disciplinary approach is optimal, with the primary goal of weight restoration. Behavioral, family, and individual therapies (A, B, and C) should all be a part of the longer-term management plan, and pharmacological therapy (E) may also be helpful.
EXPLANATION: The sciatic nerve does lie midway between the ischial tuberosity and greater trochanter and it can be palpated when the patient is in a hip flexed position. The gluteus maximus obscures the nerve from being effectively palpated when the leg is in an extended position. Tenderness of the sciatic nerve can be caused by a lumbar disk herniation, direct trauma, or spasm of the nearby pyriformis muscle. The femoral nerve is a deep structure that lies lateral to the femoral artery and is not considered to be palpable. The femoral nerve is responsible for the L1-3 dermatomes and for supplying motor function to the iliopsoas muscle. The peroneal nerve originates from the sciatic nerve and splits into the superficial and deep peroneal nerves, which are responsible for much of the sensory and motor nerve function in the lower leg. The saphenous nerve originates from the femoral nerve in the femoral triangle and runs down the medial aspect of the leg. The sural nerve has medial and lateral components that are found in the lower leg. The medial cutaneous sural nerve arises from the tibial nerve just below the knee and eventually connects with peroneal nerve to form the sural nerve. On the lateral side of the lower leg, the sural nerve arises from the common peroneal nerve just above the knee and eventual connects with the previously discussed medial branch to form the sural nerve.
A. Reassurance and monitoring with periodic transthoracic echocardiogram B. Cardiac catheterization
C. Infectious endocarditis prophylaxis
EXPLANATION: Choice A, reassurance and monitoring with periodic transthoracic echocardiogram, is the most appropriate choice given the patient’s findings on echocardiogram. Most patients with mitral valve prolapse are asymptomatic, and do not demonstrate significant progression of their valvulopathy over their lifetime. Periodic transthoracic echocardiogram allows a noninvasive, highly sensitive method of monitoring. Choice B, cardiac catheterization, is useful for evaluation of coronary artery anatomy and for evaluation of valvulopathy; however, it is invasive, and usually reserved for investigation of serious valvular dysfunction, and/or following a stress test suggestive of myocardial ischemia. The chest pain experienced by patients with mitral valve prolapse is varied in presentation, and in this setting, with a young patient with no cardiac risk factors, unlikely to be secondary to coronary artery disease. According to the American Heart Association’s most recent guidelines, patients with mitral valve prolapse alone do not require infectious endocarditis prophylaxis, so choice C is inappropriate. Choice D, mitral valve replacement, is only indicated with severe mitral valve prolapse, resulting in severe mitral regurgitation. Choice E, transesophageal echocardiogram, while an excellent diagnostic tool for the evaluation of mitral valve disease, would be more invasive than monitoring via transthoracic echocardiogram, and thus would not be an appropriate choice in this patient with only mild mitral valve prolapse
EXPLANATION: The correct answer is (C). This patient has a sinus bradycardia with a heat rate of about 38 bpm. Metoprolol is a beta blocker known to cause bradycardia. ARBs (such as losartan) and ACE inhibitors (such as captopril) are unlikely to cause bradycardia. Hydralazine an alpha blocker that may cause symptomatic hypotension, but it is unlikely to cause bradycardia. Hydralazine, a direct vasodilator, is more likely to cause tachycardia. Terazosin does not have an effect on rate.
A. Background retinopathy
B. Closed angle glaucoma
C. Macular degeneration
D. Diabetic cataracts
E. Proliferative retinopathy
The correct choice is E, proliferative retinopathy. The distinguishing factor in the patient’s presentation, which signals this disorder, is the development of newly formed vessels. Proliferative retinopathy is the leading cause of blindness in the United States. Up to 20% of patients with type 2 diabetes have retinopathy at the time of diagnosis. Choice A, background retinopathy, or simple retinopathy includes retinal microaneurysms, hemorrhages, exudates, and edema, without new vessel formation. Choice B, closed angle glaucoma, is relatively uncommon in patients with diabetes, except after cataract extraction. Choice C, macular degeneration, is not associated with diabetes mellitus specifically. Choice D, diabetic cataracts, tends to occur in patients with diabetes earlier than the general population, and may correlate with the severity of the disease.
A. Ancylostoma duodenale (hookworm)
B. Ascaris lumbricoides (ascaris)
C. enterobiasis (pinworm)
EXPLANATION: Enterobiasis or pinworms is a worldwide infection that affects people of all ages and socioeconomic levels. It especially affects children. The classic manifestation of this problem is nocturnal anal pruritis and sleeplessness. The sleeplessness may be secondary to the migration of female worms to the perianal area to lay eggs, during which the tape may pick up the larvae. Transmission of the worms occurs when children ingest the eggs that are present on their hands (from scratching), in the bedclothes, or in house dust. After hatching in the stomach, the larvae migrate to the cecum where they mature into adults. The treatment of choice for pinworms is pyrantel pamoate or mebendazole. Albendazole may also be used. For eradication of this parasite, often the entire family must be treated at once. Ascaris is a helminthiasis infection that is ingested and excreted in the stool. Diagnosis is made by stool examination for the characteristic eggs. Hookworms are found in warm, damp soil and penetrate the skin. From there the infection can spread to the lungs where they ascend into the trachea to be swallowed and live in the intestine. Diagnosis is made by stool examination for the eggs. Whipworm is ingested from the soil and lives in the intestine; detection is also made by egg in the feces.
EXPLANATION: In patients with atrial flutter, choices A, B, and C would help to achieve better heart rate control. Choice D, lisinopril, would not be contraindicated, but would not assist with heart rate control. Choice E, quinidine, is contraindicated as the atrial conduction may decrease to the point that 1:1 atrial to ventricular conduction can occur with the administration of class I antiarrhythmics. The ventricular rate can then increase to rates greater than 200 bpm, and hemodynamic collapse may occur.
C. Ferrous sulfate
D. Folic acid
EXPLANATION: Erythropoietin (B) increases red blood cell mass and toxicity may lead to increased blood viscosity and potential thrombotic events.
Cyanocobalamin (A), ferrous sulfate (C), folic acid (D), and niacin (E) don’t increase thrombotic risk.
EXPLANATION: This patient is having an infection that is consistent with the bacterium Streptococcus pneumoniae. The best and most appropriate treatment for this pathogen is penicillins.
B. fasting plasma glucose
C. liver function tests
D. serum creatinine
E. urine culture
EXPLANATION: Patients on chronic lithium carbonate therapy have an approximate 10% to 20% risk of developing renal problems such as glomerulosclerosis, tubular atrophy, or interstitial nephritis. Each of these conditions can lead to filtration problems and a subsequent rise in serum creatinine. Hence, it is advised to obtain a baseline serum creatinine prior to administering lithium carbonate to follow any changes that may occur in renal function during therapy. It is also advised that lithium carbonate be avoided in patients with pre-existing renal disease.
Which of the following is the most likely pathophysiologic mechanism responsible for her anemia?
A. Chronic blood loss
B. Defective bone marrow/stem cell function
C. Defective DNA production
D. Defective hemoglobin production
E. Increased destruction of red blood cells
EXPLANATION: The time course of the patient’s presentation is consistent with multiple episodes of acute hemolysis.
Defects in bone marrow (B) or red blood cell precursors (C and D) are refuted by the elevated reticulocyte count. Chronic blood loss (A) would have a more insidious, gradual onset and likely result in a decreased MCV.
A. Vibrio cholera
B. Entamoeba histolytica
EXPLANATION: Entamoeba histolytica has two stages in its life cycle. In the active stage in the human intestine, it causes symptoms of dysentery, abdominal pain, stool mucus, and tenesmus. In the dormant stage, the cystic form is excreted in the stool and in developing nations frequently contaminates the supply of drinking water. When the amoeba is in the dormant stage, the cystic form can be excreted in the stool and, in the case of food handlers with poor personal hygiene, be transmitted to others. In addition, because of the cystic stage, individuals engaging in anal intercourse can transmit the infection unknowingly. Diagnosis is made by microscopic evaluation of a stool wet prep and confirmed by serology. Treatment includes agents such as metronidazole or tinidazole. (
A. hyperglycemic hyperosmolar state
B. lactic acidosis
D. urinary tract infection
E. worsening dementia
EXPLANATION: The combination of confusion and dehydration in a patient with diabetes type 2 who is taking a diuretic strongly suggest hyperosmolar state. Patients with lactic acidosis (B) have marked hyperventilation and, usually, signs and symptoms of a serious illness. The lack of lateralizing signs makes a stroke (C) less likely. Urinary tract infection (D) could certainly cause confusion and incontinence in an elderly man and should be investigated. Alzheimer dementia (E) progresses slowly; sudden decompensation is usually due to delirium.
A. IV nitroprusside
B. Oral furosemide
D. IV labetalol
E. Oral hydralazine
EXPLANATION: This patient’s clinical situation is one of a hypertensive emergency. In this situation the goal is to bring down the systolic pressure to prevent end organ damage. Given the possible choices, the best choice would be intravenous labetalol (D) due to its effective quick onset, and its ability to be tolerated with most patients. While oral furosemide (B) and hydralazine (E) can both be effective in managing hypertension, the IV dosing of labetalol would be the better choice. Nitroprusside (A) is no longer a treatment option. Spironolactone (C) would not have strong enough effects to appropriately lower the blood pressure in an efficient manner.
A. Absent or non-functioning spleen
B. Failure of nuclear maturation
C. Intravascular hemolysis
D. Lead intoxication
E. Presence of uremia
EXPLANATION: Schizocytes are present on the peripheral smear and result from intravascular hemolysis.
A. Allopurinol and IV fluids
B. Aluminum hydroxide and calcium carbonate
C. Glucocorticoids and vincristine
EXPLANATION: Hyperuricemia is often a finding in patients with hyperleukocytosis. The optimal treatment is to start IV fluids, due to numbers of circulating white cells and allopurinol, to treat hyperuricemia. The use of aluminum hydroxide is appropriate if they have hyperphosphatemia, and calcium carbonate if they have a low serum calcium concentration. Glucocorticoids and vincristine are used with hyperleukocytosis of >400,000. Leukapheresis and cranial irradiation are used for patients with extreme leukocytosis of >400,000. Sevelamer is used to treat hyperphosphatemia, and mercaptopurine is a byproduct produced during production of leukemic cells.
EXPLANATION: The correct answer is (A). Niacin has a characteristic side effect of hot flashes, flushing, and pruritus. These symptoms can be reduced by addition of ASA or a nonsteroidal anti-inflammatory drug (NSAID) if there are no contraindications. The other choices are unlikely to cause this combination of symptoms.
A. Mitral regurgitation
C. Parkinson’s disease
EXPLANATION: Choice D, sepsis, is one of a long list of disease entities that can cause troponin elevation, including arrhythmias (both tachycardic and bradycardic), aortic valve disease, hypertrophic cardiomyopathy, invasive cardiac surgeries and procedures, severe pulmonary hypertension, pulmonary embolism, myocardial infiltrative diseases (such as amyloidosis, sarcoidosis, scleroderma, and hemochromatosis), acute respiratory failure, burns, pericarditis, endocarditis, myocarditis, and even occasionally due to extreme athletic activities such as marathon running. Not included on this long list, however, are choices A, B, C, and
A. Cerebral aneurysm
B. Poorly controlled hypertension
C. Anticoagulant use
EXPLANATION: Congenital cerebral aneurysms or Berry aneurysms account for 75% to 80% of nontraumatic subarachnoid hemorrhages (SAHs). Poorly controlled hypertension and anticoagulant use are more commonly associated with intracerebral hemorrhages (ICH). AVMs can cause either SAH or ICH.
A. Aortic stenosis
B. Cardiac tamponade
C. Mitral Regurgitation
D. Pulmonary fibrosis
E. Pulmonary hypertension
EXPLANATION: The patients symptoms are due to decreased cardiac output resulting from decreased preload associated with pulmonary hypertension (E). Aortic stenosis (A) presents more commonly in geriatric patients who present with a murmur. Cardiac tamponade (B) can decrease cardiac output, but would lead to decreased heart sounds. Mitral regurgitation (C) would cause pulmonary edema and rales in conjunction with increased jugular venous pressure. Pulmonary fibrosis (E) is unlikely in this patient with normal lung sounds.
glucose- 700 (nl 74-106) osm-380 (nl 275-296)
Given this information, what is the most likely diagnosis?
A. diabetic ketoacidosisB. hyperglycemic hyperosmolar stateC. hypoglycemiaD. dehydration
EXPLANATION: A hyperglycemic hyperosmolar state is characterized by dehydration, significant hyperglycemia, and an elevated serum osmolality with an insignificant or negative ketosis. Because of the lack of ketosis, the patient may present with a gradual onset of symptoms, and it can go unnoticed until the dehydration becomes more severe than in ketoacidosis.
Initial lab results are as follows:
Plasma glucose = 54 mg/dL (70-110 mg/dL)
TSH = 2.0 mIU/L (0.34-4.25 uIU/mL)
Insulin = 35 uU/mL (2.0-20 uU/mL)
C-peptide= 0.4 ng/mL (0.5-2.0 ng/mL)
Her symptoms are relieved with the drinking of orange juice. What is the most likely cause of her hypoglycemia?
A. Alimentary hypoglycemia
B. Factitious hypoglycemia
C. Beta cell insulinoma
D. Congenital hyperinsulinism
The correct choice is B, factitious hypoglycemia. This occurs when patients accidentally or on purpose self-administer insulin or an insulin secretagogue. This occurs most commonly among health care personnel, patients with diabetes or family members of those with diabetes, and people with a history of other factitious diseases. It can also happen secondary to a pharmacy error. Patients with this disorder will have increased measured insulin without the physiologic corresponding increase in C-peptide. Choice A, alimentary hypoglycemia, is a cause of hypoglycemia in patients with a history of gastrectomy. Choice C, beta cell insulinoma would present with elevated levels of both insulin and C-peptide. Choice D, congenital hyperinsulinism would have presented itself earlier than in a patient who is 35 years old. Choice E, reactive hypoglycemia, occurs after eating a meal and must be documented in this fashion.
A. Increase in valvular regurgitation
B. Irregularly irregularly pulse
C. Osler’s nodes
D. Buccal hemmorhages
EXPLANATION: Choice C, Osler’s nodes, confirms the clinical diagnosis of infective endocarditis, as it is a minor criteria. The Duke criteria for the clinical diagnosis of infective endocarditis requires the documentation of two major criteria, or one major criteria and three minor criteria, or five minor criteria. The patient demonstrates the presence of one major criteria (two separate blood cultures with typical microorganisms for infective endocarditis) and two minor criteria (fever greater than 38.0°C and predisposing condition of IV drug use). Only a new valvular regurgitation, not an increase or change in preexisting murmur, is considered sufficient to qualify as a major criteria, so choice A is incorrect. An irregularly irregular pulse, choice B, is commonly seen in patients with atrial fibrillation, not with infective endocarditis. Choice D, conjunctival hemorrhages, not buccal hemorrhages, are one of the minor criteria. Choice E, Koplik spots, are buccal lesions seen in patients infected with measles, whereas the presence of Roth’s spots does fulfill one of the minor criteria.
A. Left colectomy with primary anastomosis
B. Hartmann procedure
EXPLANATION: This vignette is consistent with an emergent resection in an unprepared patient. The most appropriate therapy for an acute perforation is a Hartmann procedure, which includes resection of the affected portion of the bowel, a temporary diverting colostomy, and oversewing of the distal rectal stump; the second stage of the procedure will involve taking down the colostomy with anastomosis to the rectal stump. A colectomy with a primary anastomosis should not be done when the bowel is unprepared due to the significant risk of infection and leakage of the bowel at the site of the anastomosis. Abdominoperineal resection is used in the treatment of malignant disease of the lower rectum. In this procedure, a permanent colostomy is created and the entire rectum, anal canal, and anus are removed. In the management of benign disease of the lower rectum, a proctocolectomy is appropriate to preserve anal function.
A. Anesthesia consultation
B. Chest CT scan
C. Chest x-ray
D. Needle thoracostomy to the second intercostal space, midclavicular line
The diagnosis for this patient is a traumatic tension pneumothorax, a true medical emergency. Diagnosis can be made based on physical exam findings. Although definitive treatment with a properly placed tube thoracostomy is preferred, choice E has the position incorrect. Needle decompression in the second intercostal space, midclavicular line is the correct choice, with this remaining in place until a chest tube is properly in place.
A. Pupillary response
B. Corneal reflex testing
C. Visual field testing
EXPLANATION: Tonometry, gonioscopy, monitoring of the disc-to-cup ratio, and visual field examination are the routine exams done when monitoring primary open angle glaucoma.
Serum TSH = 4.4 uIU/mL
Hemoglobin = 10.0 g/dL
Hematocrit = 30%
MCV = 101
Fasting plasma glucose = 105 mg/dL
BUN = 10 mg/dL
Creatinie = 0.6 ng/mL
Which of the following is the most appropriate intervention?
A. Lithium carbonate 300 mg PO twice daily
B. Resection of the anterior pituitary
C. Levothyroxin 50 to 100 ug PO daily
The correct choice is C, levothyroxin 50 to 100 ug PO daily. This patient has classic signs and symptoms of hypothyroidism and required thyroid hormone supplementation. The most common form of hypothyroidism is primary hypothyroidism (e.g. Hashimoto’s thyroiditis), and the most common thyroid hormone supplementation is levothyroxine. Choice A, lithium carbonate 300 mg PO twice daily, is a medication used in patients with psychiatric disorders and is known to cause hypothyroidism. Choice B, resection of the anterior pituitary, is not indicated without evidence of a tumor or other pituitary pathology. Secondary hypothyroidism related to the anterior pituitary is quite rare. Choice D, ferrous sulfate 325 mg PO three times daily, is a common treatment protocol for patients with iron deficiency anemia. This patient’s MCV is elevated, indicating large red blood cells, as seen in disorders such as vitamin B12 deficiency or folic acid deficiency. Patients with iron deficiency anemia present with microcytic hypochromic anemia. Choice E, radioactive iodine protocol, is a treatment used in patients with hyperthyroidism.
EXPLANATION: A Bishop score greater than 9 is considered a positive predictor for safe delivery in a term pregnancy.
EXPLANATION: Celecoxib is the only selective NSAID listed in the choices. Coxibs preferentially inhibit COX-2, the principle enzyme involved at sites of inflammation, while sparing COX-1. COX-1 is involved in mucosal cytoprotection in the stomach and duodenum. All the other choices listed are nonselective NSAIDs, and inhibit both COX-1 and COX-2 enzymes.
A. Arterial blood gas
B. Inspiratory and forced expiratory chest x-rays
C. PA and lateral chest x-ray
EXPLANATION: The patient most likely has aspirated a foreign body. This is best evaluated through the demonstration of inspiratory localized hyperinflation and expiratory mediastinal shift (B) on chest x-ray. ABG (A) results will vary depending on the severity of airway obstruction. PA and lateral chest x-rays (C) are typically normal. PEFR (D) and Spirometry (E) are not typically able to accurately assess this localized airway obstruction.
EXPLANATION: Thiazide diuretics are indicated for the initial treatment of fluid overload related to dilated cardiomyopathy. Calcium channel blockers are to be avoided, as they can worsen heart failure. Amiodarone is utilized for arrhythmic events and not purely for heart failure.
B. Human Papilloma Virus (HPV)
EXPLANATION: Patients with multiple myeloma are at risk from infections, especially from encapsulated organisms such as Haemophilus influenzae and pneumococcus.
Pneumococcal vaccines should be administered, but the patient response is decreased based on their current immunodeficiency. DTaP (A and C), HPV (B), and varicella (E) vaccines are appropriate for this patient based on general immunization guidelines for adults, but not of increased necessity based on her diagnosis.
A. abdominal ultrasound
B. upper GI barium swallow
C. esophagogastroduodenoscopy (EGD)
D. upright/decubitus abdominal plain film
EXPLANATION: The presence of free intraperitoneal air on an upright or decubitus film in the majority of patients with peptic ulcer perforation. This finding along with a classic history of sudden onset of severe abdominal pain and a rigid, quiet abdomen should establish the diagnosis in most cases without the need for further studies. Barium studies are contraindicated in patients with a possible perforation.
EXPLANATION: The correct answer is (B). Amiodarone is an antiarrhythmic medication containing iodine that is commonly used in treatment of atrial fibrillation. The use of amiodarone can cause thyrotoxicosis by several mechanisms and may also cause hypothyroidism. In this case the patients suppressed TSH would suggest the presence of amiodarone induced thyrotoxicosis. A high T3 and FT4 would support your diagnosis. All the other choices used in the treatment of atrial fibrillation would not cause thyroid dysfunction.
A. A decreased risk of breast cancer
B. A decreased risk of myocardial infarction
C. A decreased risk of stroke
D. A decrease in somatic symptoms
EXPLANATION: The WHI study showed increase chance of cardiovascular risks and breast cancer, and showed no improvement in prevention of cognitive decline.
A. Septic shock
B. Congestive heart failure
C. Benign prostatic hypertrophy
D. NSAID overdose
E. Chronic liver failure
EXPLANATION: The most common causes of intrinsic AKI are sepsis, ischemia, and nephrotoxins, both endogenous and exogenous.
C. Ludwig’s angina
EXPLANATION: The history and physical exam is consistent with suppurative sialadenitis. The preceding episode of pain and swelling while eating indicates that the patient may have a salivary duct stone, which predisposed the patient to the salivary gland infection.
A. Community acquired
B. Hospital acquired
C. From her infant
EXPLANATION: Infants usually contract MRSA due to poor hand washing technique from the hospital staff, but it is then spread to the mother via the infant.
A. Co-administer with a calcium supplement
B. Co-administer with proton pump inhibitors
C. Co-administer with vitamin C
EXPLANATION: An acidic achieved through presence of additional acids (C) (e.g., ascorbic acid) increases absorption of iron.Food (E), other heavy metals (A), and basic stomach environments (B, D) negatively affect the absorption of iron.
A. Clostridium diphtheriae
B. Group A streptococcus
C. Moraxella catarrhalis
D. Mycobacterium tuberculosis
EXPLANATION: The presence of acute hoarseness associated with an upper respiratory infection is consistent with laryngitis, which may be caused by all of the organisms above (A-E), but most likely has a viral (E) etiology.
EXPLANATION: Open angle glaucoma is typically treated first-line with beta adrenergic blocking agents (E) or prostaglandin analogs (A). A common side effect of beta adrenergic agents is their systemic absorption and subsequent beta blockade sides effects (i.e. decreased pulse, blood pressure) leading to symptoms such as fatigue, pre-syncope, or syncope. Treatments (B), (C), and (D) are not typically first-line agents and lack the beta blockade side effects this patient is experiencing
A. dexamethasone suppression test
B. vasopressin challenge test
C. radioactive iodine uptake scanD. cosyntropin stimulation test
E. follicular stimulation test
EXPLANATION: The correct answer is (D). The patient’s symptoms and examination findings are consistent with a diagnosis of Addison’s disease, which is most likely due to an autoimmune process that destroys the adrenal glands resulting in a chronic adrenal insufficiency. The cosyntropin (ACTH) stimulation test should reveal a low am cortisol level and an elevated ACTH level if he has Addison’s disease. The dexamethasone suppression test, choice (A), is a laboratory test for Cushing’s syndrome. The vasopressin challenge test, choice (B), is a laboratory test for diagnosis of diabetes insipidus. A radioactive iodine uptake scan, choice (C), is used in the diagnosis of thyroid disease (hyperthyroidism and thyroid nodules). A follicular stimulation test, choice (E), is a factitious test.
A. Delusional disorder
C. Personality disorder
D. Schizoaffective disorder
E. Schizophrenic disorder
EXPLANATION: This patient is exhibiting all of the features of a personality disorder.
EXPLANATION: Circumstantiality is seen in someone who eventually gets to the point after a delay in the thought process.
A. Avoiding the behavior that brought on the attack
B. Couples counselling
C. Leaving the relationship
D. Prosecuting her husband
E. Referral to a local women’s shelter
EXPLANATION: The appropriate course of action when working with a person who has suffered intimate partner violence is to validate his or her experience, document clearly and non-judgmentally, and assess immediate safety. Referrals to appropriate resources (E) should be made, but decisions regarding the relationship (B, C) and any legal action (D) should be left to the patient rather than continuing a pattern of controlling behavior. Suggesting she avoid behaviors that provoke her attacker (A) puts the blame on the victim.
A. stool for fecal fat
B. barium enema
C. intestinal biopsy
EXPLANATION: Intestinal biopsy is the most specific test in establishing the diagnosis of celiac sprue in a patient who has a positive test for IgA endomysial antibody. Classic symptoms of malabsorption are more common in infants but less common in adults. Stool for fecal fat would be a nonspecific finding. Antimitochondrial antibodies are seen in patients with primary biliary cirrhosis.
EXPLANATION: Choice E, TEE or transesophageal echocardiogram, would be most useful in establishing a diagnosis of infective endocarditis, as a positive echocardiogram demonstrating presence of a vegetation would satisfy one of the Duke criteria’s major criteria, as well as determine the extent of the prosthetic valvular dysfunction, if present. TEE is more sensitive than TTE, transthoracic echocardiogram, for detecting vegetations, so choice C is incorrect. Choices A and B, EKG and CXR, should be performed as part of this patient’s evaluation, but would be less useful than TEE in establishing a diagnosis of infective endocarditis. Choice D, erythrocyte sedimentation rates, are frequently elevated in patients with endocarditis, but are not specific to the diagnosis of endocarditis.
A. amoxicillin-clavulanate orally for 10 days
B. cephalexin orally for 10 days
C. trimethoprim sulfamethoxazole orally for 10 days
D. vancomycin intravenously for 10 days
E. incision and drainage is likely to resolve the abscess without the need for medications
EXPLANATION: The causative agent of this abscess is most likely caused by community-acquired methicillin-resistant S aureus (caMRSA). Infectious Diseases Society of America (IDSA) guidelines issued in January of 2011 generally recommend incision and drainage alone for fluctuant abscesses in an otherwise immunocompetent patient.
A. metronidazole 500 mg i po bid for 1 week
B. metronidazole 500 mg 4 tablets po at HS x 1 night
C. fluconazole 150 mg i po x 1 day
EXPLANATION: The clinical presentation is consistent with vulvovaginal candidiasis. The recent oral antibiotic use increased her risk for developing the infection. The white clumpy discharge and relatively benign bimanual examination support the diagnosis, which is confirmed by 10% potassium hydroxide wet mount of the secretions. Treatment for an uncomplicated case may include topical or oral antifungals. Oral fluconazole in the one dose regimen is effective, convenient, and likely to increase compliance. The metronidazole regimens are appropriate for bacterial vaginosis and trichomoniasis, respectively. Rocephin is an option for gonococcal infection and would likely worsen the candidiasis.
B. Termination of pregnancy
C. Surgical exploration
D. Biopsy of the mass
EXPLANATION: As many as 1-4% of pregnant woman are diagnosed with an adnexal mass and the majority are functional cysts that spontaneously resolve by week 16 of gestation. More than 90% of unilateral, noncomplex masses less than 5 cm in diameter noted in the first trimester are functional and resolve spontaneously. Surgery would be considered for three main reasons: rupture, torsion, and malignancy. In this case, malignancy and torsion are not suspected on appearance of ultrasound and an unremarkable physical exam, not indicating a need for biopsy (D). The size is under 5 cm without an increased risk of rupture. If the mass is present after 14 weeks gestation, is complex, growing in size, or becomes symptomatic, then surgical exploration (C) and pathologic identification are warranted. Termination of pregnancy (B) and salpingo-oophorectomy (A) would be indicated in cases of rupture or miscarriage.
EXPLANATION: A hordeolum (sty) is caused by an acute infection of the Zeis or Moll’s glands of the eyelid. Symptoms include pain and tenderness. An “internal hordeolum” points to the inner conjunctiva of the lid and an “external hordeolum” points to the skin surface of the eyelid.
A. 7 lb at 2 weeks, 14 lb at 6 months, 21 lb at 12 months
B. 7 lb at 2 weeks, 21 lb at 4 months, 28 lb at 12 months
C. 8 lb at 2 weeks, 16 lb at 4 months, 24 lb at 12 months
EXPLANATION: During the first year of life, the average, expected increase in weight of a full-term infant is to regain the birth weight by 2 weeks of age, double the birth weight by 4 months of age, and triple the birth weight by 1 year of age.
A. proceed with colposcopy
B. repeat Pap smear in 12 months
C. repeat Pap smear in 24 months
EXPLANATION: Human papillomavirus subtypes 6, 11, 16, and 18 increase risk for the development of cervical cancer. In a young woman over 21 years old with atypical squamous cells of undetermined significance and positive HPV 16 subtype, the next step in evaluation is the colposcopic evaluation. Alternatively, she could be followed with Pap smears at 6 and 12 months. The LEEP procedure is indicated for those with recurrent histologic finding of cervical intraepithelial neoplasm grade 2 or 3
EXPLANATION: The American Heart Association recommends that patients who are at moderate to high risk for bacterial endocarditis receive antibiotic prophylaxis prior to undergoing oral/dental, respiratory tract, or esophageal procedures. Amoxicillin 2.0 g orally 1 hour before the procedure is the standard regimen. Patients who have a history of amoxicillin/penicillin allergy may be given clindamycin, cephalexin, azithromycin, or clarithromycin. For adults, clindamycin is given at a dose of 600 mg po 1 hour before the procedure.
EXPLANATION: Gonococcal ophthalmia neonatorum presents as a unilateral or bilateral serosanguineous discharge and then within 24 hours the discharge becomes mucopurulent, followed by conjunctival injection and edema of the eyelids. The usual incubation period for Neiserria gonorrhea is 2 to 5 days; however, the infection may be present at birth or delayed greater than 5 days if there has been instillation of silver nitrate prophylaxis. A presumptive diagnosis is made by the demonstration of gram-negative intracellular diplococci on Gram stain. Definitive diagnosis is made by culture. Following a positive Gram stain and pending culture results, treatment should be promptly initiated with ceftriaxone (50 mg/kg/24 hours IV or IM for one dose not to exceed 125 mg), a third-generation cephalosporin with good coverage for gram-negative bacteria. An alternate drug is cefotaxime (100 mg/kg/24 hours IV or IM every 12 hours for 7 days or 100 mg/kg as a single dose), which is also a third-generation cephalosporin. Although erythromycin drops (0.5%) are used prophylactically for N gonorrhea, this is not an effective treatment. Gentamicin would be used for Pseudomonas, and Chlamydia is treated with erythromycin. Cephalexin as a first-generation cephalosporin does not have coverage for gram-negative bacteria.
EXPLANATION: Gentamycin is an aminoglycoside, and can cause ototoxicity. Peak and trough levels must be drawn to determine the lowest effective dose. The remaining medications do not interfere with vestibular function.
A. Anal fissures
B. Ulcerative colitis
C. Colon polyps
D. Pseudomembranous colitis
The correct choice is C, colon polyps. Approximately 30% of patients with acromegaly have been found to have colon polyps. These patients also have an increased risk of colon cancer. Patients with acromegaly have not been found to be at increased risk for the other response choices listed here.
E. Masked facies
EXPLANATION: This patient exhibits classic findings of Parkinson’s disease. Parkinson’s is a nervous system disorder due to decreased dopamine, resulting from a degeneration of the dopaminergic nigrostriatal system. Symptoms may include a combination of tremor, rigidity, bradykinesia, progressive postural instability, slowing of automatic movements, gait changes, decreased facial expression, speech changes, and cognition deficits. Muscle strength and reflexes are typically preserved. Chorea, an irregular, rapid, and involuntary movement, is typically seen with Huntington’s and a variety of other disorders. Parkinson’s must be differentiated from other nervous system disorders.
B. Fibrocystic changes
C. Intraductal papilloma
EXPLANATION: A unilateral serous or serosanguinous nipple discharge from a single duct is more likely a benign intraductal papilloma
A less-likely intraductal malignancy (D), however, is possible and must be ruled out. Fibroadenomas (A) and fibrocystic changes (B) are not usually associated with nipple discharge. A pituitary adenoma (E) is usually associated with galactorrhea, rather than a bloody discharge, from multiple ducts in both breasts.
A. acute bacterial conjunctivitis
B. acute narrow angle glaucoma
C. allergic conjunctivitis
D. herpes simplex ophthalmicus
E. traumatic iritis
EXPLANATION: Patients with acute glaucoma usually seek treatment immediately because of extreme pain and blurred vision, though there are subacute cases. The blurred vision is associated with halos around lights. Nausea and abdominal pain may occur. The eye is red, the cornea steamy, and the pupil moderately dilated and nonreactive to light. Intraocular pressure is usually over 50 mm Hg, producing a hard eye on palpation.