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101
|
A 37-year-old man presents to the emergency department for a persistent fever. The patient has felt unwell for the past week and has felt subjectively febrile. The patient has a medical history of a suicide attempt and alcohol abuse. He is not currently taking any medications. The patient admits to using heroin and cocaine and drinking 5-8 alcoholic drinks per day. His temperature is 103°F (39.4°C), blood pressure is 92/59 mmHg, pulse is 110/min, respirations are 20/min, and oxygen saturation is 96% on room air. Cardiopulmonary exam is notable for a systolic murmur heard best along the left sternal border. Dermatologic exam reveals scarring in the antecubital fossa. IV fluids are administered and the blood pressure is subsequently 120/70 mmHg. Which of the following is the most appropriate next step in management for the most likely underlying diagnosis?
|
{
"A": "Blood cultures",
"B": "CT scan",
"C": "Ultrasound",
"D": "Vancomycin and gentamicin",
"E": ""
}
|
A
|
This patient is presenting with fever and a systolic murmur suggestive of bacterial endocarditis. The most appropriate initial step in management is to draw blood cultures.
Bacterial endocarditis presents with fever, systemic symptoms (aches, myalgias, and fatigue), and a new murmur typically in a patient with intravenous drug use. These patients introduce bacteria intravenously which then flows to the right side of the heart and can cause right-sided endocarditis. The most appropriate initial step in management is to draw blood cultures. Once blood cultures have been drawn, broad-spectrum antibiotics can be started (vancomycin and gentamicin), and an ultrasound can be performed to further support the diagnosis (or rule out vegetations) and plan operative interventions if necessary.
Wang et al. review the evidence regarding the diagnosis and treatment of infectious endocarditis. They discuss how echocardiogram and blood cultures are the mainstay of diagnosis. They recommend broad spectrum antibiotics.
Incorrect Answers:
Answer B: A chest radiograph may be performed in the workup for bacterial endocarditis; however, it is not the most appropriate initial step in management and is neither sensitive nor specific.
Answer C: A CT scan would not be a very helpful confirmatory test in the diagnosis of bacterial endocarditis. A better confirmatory test would be an ultrasound. It may workup alternative causes of fever such as pneumonia.
Answer D: Ultrasound (echocardiography) would be the imaging test of choice for bacterial endocarditis. It would be performed after blood cultures have been drawn and antibiotics had been started.
Answer E: Vancomycin and gentamicin are the broad-spectrum antibiotics of choice for bacterial endocarditis. They would be started after blood cultures have been drawn and reduce mortality when given early in sepsis.
Bullet Summary:
The most appropriate initial step in the management of bacterial endocarditis after initial stabilization is to draw blood cultures.
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102
|
A 67-year-old man presents to the emergency room with difficulty speaking for the past 1 hour. He was having dinner at home with his wife when he suddenly noticed he had difficulty eating and speaking. He also noticed a new-onset weakness on his left side. His medical history is significant for type 2 diabetes mellitus, hypertension, and hyperlipidemia. His current medications include metformin, atorvastatin, and lisinopril. His temperature is 98.6°F (37°C), blood pressure is 130/80 mmHg, pulse is 70/min, and respirations are 15/min. On examination, strength is 5/5 in the right upper and lower extremities and 3/5 in the left upper and lower extremities. On cranial nerve examination, his tongue deviates to the right side. There is also decreased sensation to light touch and vibration on the left side of his body. Which of the following arteries is most likely involved in this patient’s presentation?
|
{
"A": "Anterior spinal artery",
"B": "Lenticulostriate branches of the middle cerebral artery",
"C": "Pontine perforators of the basilar artery",
"D": "Posterior inferior cerebellar artery",
"E": ""
}
|
A
|
This patient with hypertension, diabetes, hyperlipidemia, deviation of the tongue to the right, left-sided hemiparesis, and decreased sensation to light touch and vibration on the left side of his body most likely has a stroke of the right medial medulla. The medial medulla is supplied by paramedian branches of the vertebral arteries and the anterior spinal artery.
Medial medullary syndrome (Dejerine syndrome) is usually caused by atherosclerotic occlusion of paramedian branches of the anterior spinal artery, vertebral arteries, or basilar artery which supply the medial medulla. Medial medullary structures include the lateral corticospinal tract, the medial lemniscus, and the hypoglossal nerve. Lesions to the lateral corticospinal tract lead to contralateral paresis of the upper and lower extremities. Lesions to the medial lemniscus lead to decreased vibration, proprioception, and light touch on the contralateral body. Ipsilateral hypoglossal nerve dysfunction leads to ipsilateral loss of function of the intrinsic and extrinsic muscles of the tongue including the genioglossus muscle, which protrudes the tongue forward from the root and is unopposed on the contralateral side. This pushes the tongue towards the side of the lesion, leading to ipsilateral tongue deviation. Treatment includes reperfusion via thrombolytics if the patient presents within 4.5 hours of the time last known well.
Kim and Han present clinical findings, radiographic findings, angiographic data, and long-term outcomes from a case series of 86 patients with medial medullary infarction. The authors found that old age and severe motor dysfunction at admission were predictive factors portending poor prognosis. The authors recommend close follow-up of these patients for the development of central post-stroke pain.
Incorrect Answers:
Answer A: Anterior inferior cerebellar artery infarction leads to a lesion of the lateral pons, with damage to the facial nucleus, vestibular nuclei, spinothalamic tract, spinal trigeminal nucleus, sympathetic fibers, labyrinthine artery, and middle and inferior cerebellar peduncles. This presents with complete facial hemiparesis, vomiting, decreased pain and temperature sensation on the contralateral body and ipsilateral face, ipsilateral Horner syndrome, ipsilateral ataxia and dysmetria, and ipsilateral sensorineural deafness and vertigo.
Answer C: Lenticulostriate branches of the middle cerebral artery supply the internal capsule. Strokes of the posterior limb of the internal capsule lead to contralateral hemiparesis. The findings of ipsilateral tongue deviation and sensory changes are not consistent with a lesion to the internal capsule.
Answer D: Pontine perforators of the basilar artery supply the medial pons. Strokes of the medial pons lead to quadriplegia and loss of facial, mouth, and tongue movements with preserved sensorium. This patient’s findings of hemiparesis, ipsilateral tongue deviation, and changes in sensorium are more suggestive of a lesion to the medial medulla, not the medial pons.
Answer E: Posterior inferior cerebellar artery infarction leads to a stroke of the lateral medulla (Wallenberg syndrome). This leads to lesions to the nucleus ambiguus, vestibular nuclei, lateral spinothalamic tract, spinal trigeminal nucleus, sympathetic fibers, and inferior cerebellar peduncle. Clinically this presents with dysphagia, hoarseness, decreased gag reflex, vomiting, vertigo, decreased pain and temperature sensation from the contralateral body and ipsilateral face, ipsilateral Horner syndrome, and ipsilateral ataxia.
Bullet Summary:
Occlusion of the anterior spinal artery can lead to medial medullary syndrome, which presents with ipsilateral deviation of the tongue, contralateral paresis of the upper and lower extremities, and contralateral loss of light touch and vibration sensation.
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103
|
A 6-month-old girl is brought to the pediatrician by her father for a scheduled check-up. She was in her usual state of health until 6 weeks ago when she was hospitalized for bacterial pneumonia. She received amoxicillin and had a resolution of her symptoms. Her father reports that she seems “back to normal.” She can roll over by herself and can sit up without support. She often babbles but sometimes does make identifiable sounds like “dada” and “baba.” They recently started feeding her mushy cereal, which she seems to like but occasionally spits up. She has started teething and sometimes becomes “fussy.” Vital signs are within normal limits. A physical examination is unremarkable. The patient’s father brought a 4-week follow-up chest radiograph taken at the hospital, as shown in Figure A. Which of the structures labeled in Figure A would be most likely to change in response to another infectious illness?
|
{
"A": "A",
"B": "B",
"C": "C",
"D": "D",
"E": ""
}
|
A
|
The thymus gland (labeled in A) is visible on a chest radiograph in infants and will change in response to illness due to its immunologic role.
The thymus gland is the site of T-cell maturation. The thymus is visible on a chest radiograph in infants and continues to grow throughout childhood. It is located in the anterior part of the superior mediastinum. On a chest radiograph, the thymus may appear as a “widened mediastinum,” continuous with the superior border of the heart (Figure A) or as a triangular-shaped opacity known as the thymic “sail sign," located towards the right of the mediastinum. At puberty, the gland will decrease in size and eventually be replaced by fatty tissue.
Askin and Young review the evidence regarding the history and function of the thymus. They discuss how this structure is involved in immune function. They recommend monitoring for the absence of this structure in immunodeficient patients.
Figure A shows a normal chest radiograph of an infant with a normal cardiothymic contour.
Incorrect Answers:
Answer B: B points to the trachea. Deviation of this structure can be seen in patients with tension pneumothorax. Treatment is with needle thoracostomy followed by chest tube placement.
Answer C: C points to the apex of the heart. This structure can be enlarged in congenital heart conditions. Treatment is with surgical correction of these conditions.
Answer D: D points to the stomach. This structure can be abnormal in patients with pyloric stenosis. Treatment is with pyloromyotomy.
Answer E: E points to the diaphragm. This structure can be abnormal in patients with diaphragmatic hernias. Treatment is with surgical closure of the defect.
Bullet Summary:
The thymus is normally visible on a pediatric chest radiograph, but it is replaced by fatty tissue after puberty.
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104
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A 27-year-old man presents to his primary care physician for exposure to toxic materials. The patient states that when he left for work this morning he was certain that he had closed the door to his pantry. Upon returning home, he saw that the door to his pantry was wide open. The patient is certain that his neighbors have been tampering with his food and potentially poisoned him. He further states that he knows they have been trying to break into his house and steal his things. He has tried multiple times to get them evicted from the building to no avail. It is for this reason that he is certain that they are trying to get their revenge upon him. His temperature is 98.6°F (37°C), blood pressure is 115/71 mmHg, pulse is 72/min, and respirations are 12/min. The physician performs a physical exam and tells the patient that he thinks there is nothing to be concerned about, but that he should call him or come into the office if he experiences any symptoms. The patient is outraged at this news and requests a competent doctor who is not colluding with his enemies. He storms out of the office angrily, stating that he deserves the best in medical care. Which of the following is the most likely disorder that this patient is suffering from?
|
{
"A": "Paranoid personality disorder",
"B": "Borderline personality disorder",
"C": "Narcissistic personality disorder",
"D": "Schizoid personality disorder",
"E": ""
}
|
A
|
This patient is presenting with a history of mistrust and suspicion of others without frankly psychotic features suggesting a diagnosis of paranoid personality disorder.
Paranoid personality disorder is a cluster A personality disorder that is genetically associated with schizophrenia. These patients present with a pervasive mistrust of others based on little or no evidence. These patients are inclined to believe others have bad intentions that are directed toward them. They are often odd, very emotionally cold, and typically are involved in frequent litigations. Patients can be hard to manage though they often benefit from cognitive behavioral therapy. Anxiolytics may also be helpful in calming these patients.
Triebwasser et al. review the evidence regarding the diagnosis of paranoid personality disorder. They discuss how there is relatively little research on these patients because it is difficult to recruit them for studies. They recommend considering the removal of this diagnosis and replacing it with a domain of paranoia.
Incorrect Answers:
Answer A: Borderline personality disorder presents with emotional instability, unstable relationships, and recurrent self-harm behaviors. These patients will typically demonstrate the defense mechanism of splitting (seeing things as all good or all bad). Dialectical behavioral therapy can be used in order to help these patients mitigate self-injurious behaviors.
Answer B: Intermittent explosive disorder presents with sudden episodes of aggression out of proportion to the stressor. This patient’s response is a result of his paranoia rather than an excessive response to reasonable stimuli. Cognitive behavioral therapy can be used in order to help these patients control their emotional outbursts.
Answer C: Narcissistic personality disorder presents with a grand sense of self-importance and preoccupation with success and admiration. These individuals are typically selfish and lack empathy. Though this patient’s demand for the best medical care may be reflective of narcissistic personality disorder, the majority of his behaviors point more toward a diagnosis of paranoid personality disorder.
Answer E: Schizoid personality disorder presents in patients with isolated and emotionally restricted behavior. These patients are typically alone but enjoy being alone and often seem disinterested in others. These patients typically do not seek relationships and do not seek therapy as they are not bothered by their behaviors.
Bullet Summary:
Paranoid personality disorder presents with mistrustful behavior, suspicion of others, oddness, emotional coldness, and they are typically involved in many litigations.
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105
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A 17-year-old boy presents to his primary care physician with a chief concern of "bad" skin that has not improved despite home remedies. The patient has had lesions on his face that have persisted since he was 13 years of age. He has a diet high in refined carbohydrates and has gained 20 pounds since starting high school. Physical exam is notable for the findings in Figure A. The patient is started on benzoyl peroxide and topical retinoids. He returns 1 month later stating that his symptoms are roughly the same. Which of the following is the most appropriate next step in management?
|
{
"A": "Continue current therapy for 1 more month",
"B": "Dietary intervention",
"C": "Isoretinoin",
"D": "Topical antibiotics",
"E": ""
}
|
D
|
This patient is presenting with persistent acne vulgaris that is refractory to topical benzoyl peroxide and retinoids. The next step in management is topical antibiotics.
Acne vulgaris is caused by blockage or outlet obstruction of the pilosebaceous unit. It presents with erythema, pustules, and comedones typically in young men going through puberty. Risk factors include stress, excessive sweating, greasy skin care products, and steroid use. The management of acne vulgaris, in order, is to start with topical benzoyl peroxide and topical retinoids, topical antibiotics, oral antibiotics, and isoretinoin. It is important to try a therapy for a proper duration before switching to a more invasive therapy.
Eichenfield et al. review the evidence regarding the treatment of patients with acne vulgaris. They discuss how this disease can be treated with benzoyl peroxide. They recommend using antibiotics or isotretinoin for refractory cases.
Figure/Illustration A is a clinical photograph demonstrating diffuse comedones over the forehead (red circle). These findings are classically seen in patients with acne vulgaris.
Incorrect Answers:
Answer A: Continuing current therapy for 1 more month is unnecessary as this patient's symptoms have not improved at all with 1 month of therapy. Continuing current therapy would be appropriate if the patient had only tried therapy for a few days.
Answer B: Dietary interventions have not been shown to improve outcomes in acne vulgaris. Stopping illicit substances such as performance enhancing steroids can be effective in reducing acne symptoms but there is no evidence this patient has been using steroids.
Answer C: Isoretinoin is the last-line therapy for acne vulgaris. It should not be given to pregnant women as it is teratogenic. Women taking isoretinoin should be on reliable birth control. Topical and oral antibiotics should be used first.
Answer D: Oral antibiotics would be indicated after topical antibiotics fail. Topical antibiotics should be tried first as these do not have systemic side effects.
Bullet Summary:
The management of acne vulgaris is to start with topical benzoyl peroxide and topical retinoids, followed by topical antibiotics, oral antibiotics, and isoretinoin in increasing order of severity.
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106
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A 10-year-old girl is admitted to the medical floor for a respiratory infection. The patient lives in a foster home and has been admitted many times. Since birth, the patient has had repeated episodes of pain/pressure over her frontal sinuses and a chronic cough that produces mucus. She was recently treated with amoxicillin for an infection. The patient is in the 25th percentile for height and weight which has been constant since birth. Her guardians state that the patient has normal bowel movements and has been gaining weight appropriately. The patient has a history of tricuspid stenosis. She also recently had magnetic resonance imaging (MRI) of her chest which demonstrated dilation of her airways. Her temperature is 99.5°F (37.5°C), blood pressure is 90/58 mmHg, pulse is 120/min, respirations are 18/min, and oxygen saturation is 94% on room air. Physical exam is notable for bruises along the patient's shins which the guardians state are from playing soccer. The rest of the exam is deferred because the patient starts crying. Which of the following findings is associated with this patient's most likely underlying diagnosis?
|
{
"A": "Diastolic murmur best heard along the right lower sternal border",
"B": "Hypocalcemia",
"C": "Increased chloride in the patient's sweat",
"D": "Repeat sinus infections secondary to seasonal allergies",
"E": ""
}
|
A
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This patient is presenting with recurrent sinus infections suggestive of Kartagener syndrome. Dextrocardia is a common feature in this pathology, which results in right-sided heart sounds or a diastolic murmur best heard along the right lower sternal border for this patient's tricuspid stenosis.
Kartagener syndrome (primary ciliary dyskinesia) occurs secondary to a genetic defect in a patient's cilia. This results in a clinical picture of recurrent sinusitis, recurrent upper respiratory infections, bronchiectasis, and situs inversus (all major organs are a mirror image of where they should be). A physical exam will reveal right-sided heart sounds and a chest radiograph will demonstrate dextrocardia. Treatment is with respiratory support, assistance with mucociliary clearance, and treatment of infections.
Leigh et al. review the evidence regarding the manifestations of Kartagener syndrome. They discuss how about 50% of patients have situs inversus. They recommend respiratory support for these patients given the overlap with other mucociliary clearance disorders such as cystic fibrosis.
Incorrect Answers:
Answer B: Hypocalcemia would be seen in DiGeorge syndrome which presents with CATCH-22 (Cleft palate/lip, Abnormal facies, Thymic aplasia, Cardiac defects, Hypocalcemia, and chromosome 22 deletion). Treatment is with calcium repletion, surgical treatment of cardiac defects, and treatment of infections.
Answer C: Increased chloride in the patient's sweat describes cystic fibrosis which would present with weight loss, failure to thrive, and fatty/foul-smelling stools. Treatment is with respiratory support, assistance with mucociliary clearance, and treatment of infections.
Answer D: Repeat sinus infections secondary to seasonal allergies describe sinusitis, which may be present in this patient but does not explain the entire clinical picture. Treatment is with antihistamines.
Answer E: Social withdrawal and avoidance of eye contact describe child abuse which seems unlikely in this case given the constellation of symptoms that suggest Kartagener syndrome.
Bullet Summary:
Kartagener syndrome presents with recurrent sinusitis, bronchiectasis, and situs inversus.
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107
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A 38-year-old woman presents to the emergency department with difficulty eating. Over the past week, she has had increasing difficulty chewing her food and progressive pain in the left side of her jaw. This morning, she was unable to close her mouth for several minutes after taking a bite of her breakfast. Two months ago, the patient had a root canal on a left molar. Her medical history is significant for hyperlipidemia, mild intermittent asthma, and type 2 diabetes mellitus. She has never smoked and has 10-15 alcoholic drinks per week. She works as an aide at a nursing home. Her temperature is 100.8°F (38.2°C), blood pressure is 133/74 mmHg, pulse is 105/min, and respirations are 14/min. On physical exam, there is a bluish hue to the skin on the lower left side of the patient’s face. A 3x4 cm non-tender mass can be palpated inferior to the angle of the left mandible. Thick exudate is draining from an opening in the skin. The gram stain of the exudate can be seen in Figure A. Which of the following is the most appropriate treatment for this patient?
|
{
"A": "Trimethoprim-sulfamethoxazole",
"B": "Penicillin",
"C": "Clindamycin",
"D": "Amphotericin B",
"E": ""
}
|
B
|
This patient presents with fever, trismus, and cutaneous drainage of sulfur granules in the setting of a recent dental procedure, which points to a diagnosis of cervicofacial actinomycosis. The most appropriate treatment for this disease is penicillin.
Actinomyces is a gram-positive, filamentous rod that causes a cervicofacial infection after direct inoculation during a dental procedure or trauma. It typically presents in an indolent fashion over a time course of weeks to months in which a hard, indurated mass evolves into multiple abscesses that drain through sinus tracts through the skin. The exudate is classically thick with small yellow “sulfur” granules, although it may also be serosanguinous. Since the infection spreads by direct extension, patients may complain of pain when the infection infiltrates or compresses nearby structures. Trismus may occur for the same reasons. The treatment of choice is penicillin.
Valour et al. review the evidence regarding the treatment of Actinomyces infection. They discuss how prolonged (6- to 12-month) high-dose penicillin or amoxicillin is required for the treatment of this disease. They recommend preventive measures such as improvement of dental hygiene to prevent this disease.
Figure/Illustration A demonstrates the histologic appearance of a basophilic “sulfur granule” (red circle). These granules are found in the draining exudate in patients with actinomycosis.
Incorrect Answers:
Answer A: Amphotericin B is the treatment of choice for fungal infections such as mucormycosis. This disease generally presents with a rapidly progressive soft tissue infection that can be fatal if left untreated. Patients would present with black fungal lesions generally in immunocompromised or diabetic hosts.
Answer B: Clindamycin may be used in the treatment of empyema as it has activity against many anaerobes. Although this patient has a substantial weekly alcohol intake and has a chief complaint of “difficulty eating,” she has no true pulmonary symptoms and her presentation is more likely related to her recent dental procedure.
Answer C: Metronidazole may be used in the treatment of empyema. Although this patient has a substantial weekly alcohol intake and has a chief complaint of “difficulty eating,” she has no true pulmonary symptoms and her presentation is more likely related to her recent dental procedure.
Answer E: Trimethoprim-sulfamethoxazole is the treatment of choice for Nocardiosis, which may cause cutaneous lesions in immunocompromised hosts. This disease more commonly causes pulmonary or central nervous system disease. Nocardia would not explain the granule seen in histology.
Bullet Summary:
Actinomyces is a gram-positive anaerobic rod that presents as an indurated mass with draining sinus tracts and should be treated with penicillin.
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108
|
A 16-year-old boy presents to an ophthalmologist with blurry vision. Over the past several months, he has had increasing difficulty seeing the board from the back of the classroom at school. The patient is otherwise doing well in school and enjoys playing basketball. His medical history is otherwise significant for scoliosis which is managed by an orthopedic surgeon. His family history is significant for a mother with type 2 diabetes mellitus and a father who underwent aortic valve replacement last year. His temperature is 98.6°F (37°C), blood pressure is 115/71 mmHg, pulse is 72/min, and respirations are 12/min. On physical exam, the patient is tall for his age and has long arms. He has 20 degrees of thoracic scoliosis, which is stable from previous exams. On slit-lamp examination, the patient is found to have bilateral upward lens subluxation and is prescribed corrective lenses. Which of the following is the most likely cause of this patient’s symptoms?
|
{
"A": "Extra copy of sex chromosome",
"B": "Mutation of RET proto-oncogene",
"C": "Defective metabolism of methionine",
"D": "Mutation of chromosome 15",
"E": ""
}
|
D
|
This patient presents with tall stature, upward lens subluxation, and a family history of aortic valve disease, which suggests a diagnosis of Marfan syndrome. Marfan syndrome is caused by an autosomal dominant mutation in the fibrillin-1 gene on chromosome 15.
The fibrillin-1 gene codes for a glycoprotein in the extracellular matrix of connective tissue. Patients with Marfan syndrome classically present with a triad of musculoskeletal, ocular, and cardiovascular symptoms. The musculoskeletal findings include tall stature, long limbs, arachnodactyly, pectus excavatum, joint hypermobility, skin hyperelasticity, and scoliosis. Patients with Marfan syndrome also often present with upward lens subluxation, and they are at increased risk of cardiac disease, including aortic regurgitation and aortic dissection. Treatment is symptomatic with avoidance of contact sports, beta-blockers, and valve repair to prevent cardiac complications.
Bitterman and Sponseller review the evidence regarding the diagnosis and treatment of Marfan syndrome. They discuss how skeletal manifestations are often the initial presentation of this condition leading to diagnosis. They recommend screening for patients who are suspected to have this disease.
Incorrect Answers:
Answer A: Defective metabolism of methionine describes homocystinuria, an autosomal recessive deficiency of cystathionine synthase. Although patients with homocystinuria may also have tall stature, arachnodactyly, and pectus deformity, the lens dislocation in homocystinuria is downward rather than upwards. Patients with homocystinuria also tend to have a fair complexion, intellectual disability, and thrombophilia. Treatment includes vitamin B6 supplementation.
Answer B: Extra copy of a sex chromosome describes Klinefelter syndrome (47,XXY). Although patients with Klinefelter syndrome classically present with tall stature, they do not have the other clinical features found in this patient, including joint hypermobility and lens subluxation. Patients with Klinefelter also present with hypogonadism and azoospermia. Treatment is supportive
Answer D: Mutation of COL5A1 or COL5A2 leads to Ehlers-Danlos syndrome, a collagen disorder that commonly presents with joint hypermobility, skin hyperextensibility, and skin fragility with easy bruising. Ehlers-Danlos would not explain this patient’s lens subluxation. Treatment may include bracing of unstable joints.
Answer E: Mutation of RET proto-oncogene describes multiple endocrine neoplasia type 2B (MEN2B). Patients with MEN2B may present with Marfanoid habitus and are predisposed to medullary thyroid cancer, pheochromocytoma, and mucosal neuromas. MEN2B would not explain lens subluxation. Treatment is with surgical resection of tumors.
Bullet Summary:
Marfan syndrome is caused by an autosomal dominant mutation in the fibrillin-1 gene on chromosome 15 and presents with a triad of musculoskeletal, ocular, and cardiovascular findings.
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109
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A 32-year-old woman presents to her primary care provider with pelvic pain. She reports that for the last several years, she has had chronic pain that is worse just before her menstrual period. Over the past 2 months, she has also had worsening pain during intercourse. She denies dysuria, vaginal discharge, or vaginal pruritus. The patient has never been pregnant and previously used a copper intrauterine device (IUD) for contraception, but she had the IUD removed 1 year ago because it worsened her menorrhagia. She has now been using combined oral contraceptive pills (OCPs) for nearly 1 year. The patient reports improvement in her menorrhagia on the OCPs but denies any improvement in her pain. Her medical history is otherwise unremarkable. Her temperature is 98.0°F (36.7°C), blood pressure is 124/73 mmHg, pulse is 68/min, and respirations are 12/min. The patient has pain with lateral displacement of the cervix on pelvic exam. A pelvic ultrasound shows no abnormalities, and a urine pregnancy test is negative. Which of the following is most likely to confirm the diagnosis?
|
{
"A": "Hysteroscopy",
"B": "Abdominal ultrasound",
"C": "Hysterosalpingogram",
"D": "Laparoscopy",
"E": ""
}
|
D
|
This patient presents with chronic pelvic pain that is worse before her menstrual period, vaginal tenderness on physical exam, and lateral displacement of the cervix, which is consistent with a diagnosis of endometriosis. Since this patient has failed therapy with oral contraceptive pills (OCPs), she should undergo laparoscopy.
Endometriosis classically presents with chronic pelvic pain and the “3 D symptoms” of dysmenorrhea, dyspareunia, and dyschezia. Since laparoscopy with biopsy is required for definitive diagnosis, patients with suspected endometriosis may be empirically managed with OCPs and NSAIDs. Most patients achieve symptom control on this regimen. If patients fail empiric therapy, have contraindications to hormonal therapy, or have severe symptoms they should undergo laparoscopy for both definitive diagnosis and treatment of the disease.
Vercellini et al. review the evidence regarding the diagnosis and treatment of endometriosis. They discuss how the diagnosis of this disorder is carried out by direct visualization and histologic examination of lesions. They recommend medical treatment for symptomatic relief and surgical excision in refractory patients.
Incorrect Answers:
Answer A: Abdominal ultrasound is less accurate than a transvaginal ultrasound which has already been performed. Since there were no findings on transvaginal ultrasound, it is unlikely that abdominal ultrasound would reveal pathology. This modality would be effective for intra-abdominal disorders such as cholelithiasis or appendicitis (in pediatric and pregnant patients to avoid radiation exposure).
Answer B: Hysterosalpingogram is more useful in the workup of infertility, particularly for patients with a history of pelvic inflammatory disease. It is not routinely used to diagnose endometriosis. Patients with pelvic inflammatory disease present with fever, purulent discharge, and cervical motion tenderness. Treatment is with antibiotics.
Answer C: Hysteroscopy is used in the workup of abnormal uterine bleeding, fibroids, and endometrial thickening or polyps. Since endometriosis is defined as endometrial glands and stroma outside of the uterine cavity, a hysteroscopy is not particularly helpful in making the diagnosis. Treatment for polyps or fibroids is with surgical excision.
Answer E: Pelvic MRI can be used to better characterize an abnormality seen on pelvic ultrasound or CT or to diagnose adenomyosis. It can aid in making the diagnosis of endometriosis but is not the most accurate/confirmatory test. A laparoscopy would both be diagnostic and therapeutic for this disorder.
Bullet Summary:
Patients with suspected endometriosis may be managed empirically with oral contraceptive pills and NSAIDs, but laparoscopy with biopsy is necessary for definitive diagnosis and management.
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110
|
A 26-year-old woman presents to the emergency department with 1 day of vaginal bleeding and lower abdominal pain. The pain is most pronounced in the lower abdomen and has gotten worse over the past day. Her last menstrual period was 7 weeks ago. She denies any recent abdominal or vaginal trauma. She has no other past medical history and takes no medications. She uses a copper intrauterine device and is in a monogamous relationship. Her temperature is 99°F (37.2°C), blood pressure is 79/50 mmHg, pulse is 135/min, and respirations are 20/min. Physical examination is notable for diffuse abdominal tenderness upon palpation. Pelvic examination demonstrates uterine and adnexal tenderness and uterine bleeding. Laboratory studies are shown below:
Hemoglobin: 9.5 g/dL
Leukocyte count: 6,000/mm^3
Serum beta-human chorionic gonadotropin (hCG): 2,700 IU/L
The patient is started on intravenous fluids. Which of the following is the most appropriate next step in management?
|
{
"A": "Laparoscopy",
"B": "Transvaginal ultrasound",
"C": "Methotrexate therapy",
"D": "CT of the abdomen and pelvis",
"E": ""
}
|
A
|
This patient’s acute onset abdominal pain with uterine bleeding and tenderness, positive pregnancy test, anemia, and hemodynamic instability are concerning for a ruptured ectopic pregnancy. Emergency laparoscopy is the most appropriate next step in management.
An ectopic pregnancy, due to implantation of a fertilized ovum outside the uterine cavity, most commonly in the fallopian tube, can be life-threatening if it ruptures leading to intra-abdominal hemorrhage and shock. Initial laboratory studies should include a complete blood count and a pregnancy test. A patient’s hemodynamic stability should be ascertained immediately as it determines the most appropriate next step in management. In patients who are hemodynamically unstable (hypotensive and tachycardic), a Focused Assessment with Sonography for Trauma (FAST) exam should be immediately performed to evaluate for intraperitoneal bleeding, and ob/gyn should be immediately consulted for emergent surgical intervention (e.g., salpingectomy or salpingotomy). In patients who are hemodynamically stable, transvaginal ultrasound should be performed to determine the gestational sac location, and medical therapy can be initiated (e.g., methotrexate therapy, depending on the size and location of the pregnancy).
Cheng et al. compare fertility outcomes of salpingotomy and salpingectomy in women with tubal pregnancies. The authors found that there was no difference in intrauterine pregnancy rates or repeat ectopic pregnancy rates between patients that underwent salpingotomy or salpingectomy. The authors recommend that both salpingectomy and salpingotomy are reasonable options for the surgical management of tubal pregnancies.
Incorrect Answers:
Answer A: CT of the abdomen and pelvis is useful in determining if there is an intra-abdominal hemorrhage in patients who are hemodynamically stable. Unstable patients should generally not undergo CT.
Answer C: Methotrexate therapy is an effective treatment option in patients who are hemodynamically stable. with smaller ectopic pregnancies and lower hCG levels.
Answer D: Repeat beta-hCG in 48 hours is reserved for hemodynamically stable patients with non-diagnostic findings on transvaginal ultrasound. If the beta-hCG level is below the discriminatory zone (beta-hCG level 1,500-2,500 IU/L), then it should be repeated in 48 hours.
Answer E: Transvaginal ultrasound is reserved for hemodynamically stable patients who are presenting with abnormal uterine bleeding with abdominal/pelvic pain.
Bullet Summary:
Patients who present with a ruptured ectopic pregnancy with hemodynamic instability are managed with emergent surgical intervention.
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111
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A 41-year-old man presents to his primary care provider after seeing bright red blood in the toilet bowl after his last 2 bowel movements. He reports that he also noticed some blood mixed with his stool. The patient denies abdominal pain or any changes in his stool habits. He notes a weight loss of 8 pounds in the last 2 months with no changes in his diet or exercise habits. His medical history is significant for an episode of pancreatitis 2 years ago for which he was hospitalized for several days. He drinks 2-3 beers on the weekend and he has never smoked. He has no family history of colon cancer. His temperature is 97.6°F (36.4°C), blood pressure is 135/78 mmHg, pulse is 88/min, and respirations are 14/min. On physical exam, his abdomen is soft and non-tender to palpation. Bowel sounds are present, and there is no hepatomegaly. Which of the following is the most appropriate next step in management?
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{
"A": "Abdominal CT",
"B": "Colonoscopy",
"C": "Ultrasound of abdomen",
"D": "Barium enema",
"E": ""
}
|
B
|
This patient presents with hematochezia and weight loss, which raises concern for colorectal cancer. The most appropriate next step in management is performing a colonoscopy.
The differential diagnosis of hematochezia includes colorectal cancer, inflammatory bowel disease, diverticulosis, and hemorrhoids. The evaluation depends in large part on the age of the patient and whether the patient presents with alarm symptoms such as weight loss, abdominal pain, change in bowel habits, or iron-deficiency anemia. If the patient is over the age of 50, has alarm symptoms, or has a family history of colorectal cancer, the evaluation should begin with a colonoscopy to rule out malignancy. If the patient is between the ages of 40 and 50 and without other red flags, the patient can elect to undergo sigmoidoscopy as a less invasive procedure than colonoscopy. If the patient is under the age of 40 and without alarm symptoms, the workup may begin with an anoscopy to first evaluate for hemorrhoids. Once cancer has been ruled out, additional evaluation for chronic inflammatory diseases such as ulcerative colitis can be conducted.
Church presents evidence regarding the current use of colonoscopy. He discusses how the detection of neoplasia during colonoscopy is suboptimal despite its use as the current screening tool of choice. He recommends understanding which patients are missed and how to better detect neoplasias in these patients.
Incorrect Answers:
Answer A: Abdominal CT might be used to evaluate for metastases if the diagnosis of colorectal cancer is confirmed but it would not be used to diagnose the primary malignancy. A CT scan would be the most appropriate initial step in diagnosis if diffuse metastasis were already suspected such as a presentation of severe weight loss and an enlarged, palpable, and nodular liver.
Answer B: Anoscopy is used for the evaluation of hemorrhoids in a patient < 40 years of age who presents with bright red blood per rectum in the absence of alarm symptoms. It would not be the most appropriate next step for a patient who presents with unexplained weight loss as it cannot be used to diagnose colorectal cancer.
Answer C: Barium enema is sometimes used to screen for colorectal cancer in conjunction with other tests in asymptomatic patients, but it would not be used to diagnose malignancy in a patient with alarm symptoms such as hematochezia and unexpected weight loss.
Answer E: Ultrasound of the abdomen would be effective in diagnosing conditions such as intraperitoneal bleeding and cholecystitis. There is no evidence of abdominal trauma that would suggest intraperitoneal bleeding in this patient. A positive ultrasound with free fluid would be treated with diagnostic laparoscopy.
Bullet Summary:
If a patient is over the age of 50 or has alarm symptoms of weight loss, abdominal pain, change in bowel habits, or iron-deficiency anemia, the patient should undergo a colonoscopy to rule out colorectal cancer.
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112
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A 19-year-old woman presents to her primary care physician with headaches, blurry vision, and tinnitus over the past month. She started treatment for a skin condition with a new oral medication 2 months prior. She has not noticed any changes in her complexion as of yet. Her temperature is 98.2°F (36.8°C), blood pressure 100/65 mmHg, pulse 87/min, and respiratory rate 14/min. She is oriented to person, place, and time. Neurological exam reveals papilledema upon examination of both eyes. Skin examination is notable for the findings in Figure A. Which of the following is the most likely diagnosis?
|
{
"A": "Idiopathic intracranial hypertension",
"B": "Meniere disease",
"C": "Giant cell arteritis",
"D": "Cerebrovascular accident",
"E": ""
}
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A
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This young patient with severe nodulocytic acne who was started on a new oral medication (likely isotretinoin) is likely suffering from idiopathic intracranial hypertension, which can present with papilledema, headache, blurry vision, and diplopia.
Idiopathic intracranial hypertension is characterized by an increase in intracranial pressure without an identifiable cause. Patients often present with symptoms that include headache, blurry vision, and tinnitus. Fundoscopic examination typically reveals bilateral papilledema. Vision loss is a complication of this condition with high morbidity. While there is no identifiable cause, common associations include obesity or a recent increase in weight as well as medications such as isotretinoin - a vitamin A derivative that is often used in the management of severe nodulocystic acne vulgaris. Management should first involve imaging of the brain (CT or MRI) to exclude elevated cerebrospinal fluid pressure due to other causes such as brain tumor, dural sinus thrombosis, or hydrocephalus. The diagnosis is made via lumbar puncture revealing increased opening pressure. Lumbar puncture can also result in therapeutic relief. The specimen should be sent for gram stain, culture, and viral PCR to rule out other etiologies. Long term treatment is centered on weight loss and avoiding causative agents. Acetazolamide and serial lumbar punctures are other treatments.
Boyter reviews the clinical presentation and management of patients with idiopathic intracranial hypertension. They found the condition is most common among obese women in their 20's, but it also may occur in children, men, and older adults. They recommend referral for patients to see a neurologist for ongoing management of headaches and other symptoms, as well as an ophthalmologist or neuro-ophthalmologist for monitoring papilledema, given the risk of vision loss.
Figure/Illustration A: The figure depicts a patient with severe nodules and cysts (red arrows) consistent with severe inflammatory nodulocystic acne that would be suitable for treatment with isotretinoin.
Incorrect Answers:
Answer A: Cerebrovascular accidents can be embolic or hemorrhagic in nature and often result in persistent neurologic deficits or resolution of an acute neurologic deficit in a patient with cerebrovascular risk factors (diabetes, hypertension, hyperlipidemia). This young, healthy patient with intermittent headache and neurologic symptoms without a family history of hypercoagulable state is unlikely to have suffered from a cerebrovascular accident.
Answer B: Giant cell arteritis (GCA) is a vasculitis that is typically seen in elderly patients (>60 years of age) and presents with tenderness of the ipsilateral temple and elevated inflammatory markers. Many patients with GCA have one or more constitutional symptoms (weight loss, fever, fatigue, anorexia, malaise) in addition to symptoms such as new onset headache or jaw claudication.
Answer D: Meniere disease affects the inner ear and is characterized by severe episodes of vertigo, tinnitus, hearing loss, and fullness in the ear. Patients are often women between the ages of 40 and 60. Headaches and blurry vision are not a classic part of the clinical presentation.
Answer E: Migraines present with severe headaches that can be incapacitating with associated photophobia and phonophobia. In some cases, patients may present with an aura that precedes or occurs during the migraine. The presence of papilledema suggests elevated intracranial pressure and is not typically seen in migraines.
Bullet Summary:
Idiopathic intracranial hypertension may be a side effect of isotretinoin.
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113
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A 14-day-old girl is brought to the emergency department for diarrhea. Her mother reports that the patient began having “explosive” diarrhea 6 hours ago. The patient has little interest in feeding since leaving the hospital after her birth and has not yet regained her birth weight. Her immediate postnatal period was otherwise significant for 2 episodes of bilious vomiting that resolved with the temporary use of a nasogastric tube and expulsion of stool during a digital rectal exam. The patient passed meconium on the 3rd day of life. Her temperature is 101.8°F (38.8°C), blood pressure is 58/37 mmHg, pulse is 148/min, and respirations are 38/min. On physical exam, the patient appears to be in moderate distress. She has no dysmorphic features and she has a normal S1/S2 without any murmurs, rubs, or gallops. Her abdomen is firm and distended. A digital rectal exam reveals a tight anal sphincter and precipitates a release of gas and liquid stool. Her abdominal radiograph can be seen in Figure A. Which of the following is the most accurate test to diagnose this patient’s condition?
|
{
"A": "Upper gastrointestinal series",
"B": "Rectal suction biopsy",
"C": "Contrast enema",
"D": "Intraoperative cholangiogram",
"E": ""
}
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B
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This neonatal patient presents with bilious vomiting, failure to thrive, colonic distension on an abdominal radiograph, and new fever and tachycardia, which suggests a diagnosis of Hirschsprung disease complicated by enterocolitis. A rectal suction biopsy is the most accurate test to diagnose Hirschsprung disease.
Hirschsprung disease presents in the neonatal period with bilious vomiting, failure to pass meconium in the first 48 hours of life, failure to thrive, and temporary relief of the intestinal obstruction by digital rectal exam. The most severe neonatal complication of Hirschsprung disease is Hirschsprung-associated enterocolitis, which presents in the first few weeks to months of life with explosive diarrhea, fever, and abdominal pain/distension. The most appropriate first step to diagnose Hirschsprung disease is a contrast enema, which may visualize a “transition zone” where the caliber of the intestine switches from the dilated proximal colon to the narrowed aganglionic segment. The most accurate test is a rectal suction biopsy, which will show a lack of ganglion cells. Surgical removal of the aganglionic portion of the colon is preferred management.
Kessman reviews the evidence regarding the diagnosis and treatment of Hirschsprung disease. She discusses how the diagnosis can be made using a rectal suction biopsy. She recommends monitoring patients closely for enterocolitis for years after surgical treatment.
Figure/Illustration A is an abdominal radiograph demonstrating diffuse proximal colonic distension (red circle) with a paucity of air in the rectosigmoid. This finding suggests a diagnosis of Hirschsprung disease.
Incorrect Answers:
Answer A: A contrast enema is both a diagnostic and therapeutic intervention for intussusception. It may also be used in the workup of bilious emesis to help differentiate between Hirschsprung disease and meconium ileus, but it is not the most accurate test.
Answer B: Genetic testing would be used to diagnose cystic fibrosis, which is associated with meconium ileus. Although meconium ileus presents with delayed passage of meconium (> 48 hours of life), meconium ileus is not relieved by a digital rectal exam. Treatment is with irrigation and removal of the meconium.
Answer C: Intraoperative cholangiogram is the gold standard for diagnosing biliary atresia. Biliary atresia presents with jaundice, pale stools or dark urine, and hepatomegaly over the first week to 2 months of life. Treatment is with urgent surgical intervention to prevent liver failure.
Answer E: Upper gastrointestinal series is used to diagnose intestinal malrotation, as the ligament of Treitz can be visualized on the right side of the abdomen. Malrotation may present with bilious vomiting if the malrotation has been complicated by midgut volvulus, but it would not be relieved by digital disimpaction. Treatment is with surgical derotation of the volvulus.
Bullet Summary:
The most accurate test to diagnose Hirschsprung disease is a rectal suction biopsy to demonstrate the absence of ganglion cells.
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114
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A 32-year-old G1P0 woman delivers a boy at 40 weeks and 3 days of gestation. The delivery is uncomplicated and the neonate has Apgar scores of 9 and 9 at 1 and 5 minutes respectively. After 15 minutes, he attempts to nurse for the 1st time. His mother notices that his face, chest, and extremities turn dusky blue during nursing. She also notes that he seems to be snoring loudly and breathing very quickly. When she removes him from her breast, he begins to cry and his color improves. The neonate’s prenatal course was unremarkable, and his mother has a medical history of asthma with occasional albuterol inhaler use. As the infant is resting, vital signs are taken. His temperature is 98.2°F (36.7°C), pulse is 130/min, respirations are 45/min, and oxygen saturation is 97% on room air. A physical exam demonstrates well-perfused skin but is notable for the facial features shown in Figure A. Which of the following is most likely to be observed in this neonate?
|
{
"A": "Digital clubbing",
"B": "Patent foramen ovale",
"C": "Inability to pass a nasogastric tube",
"D": "Areflexia in all extremities",
"E": ""
}
|
C
|
This neonate presents with central cyanosis upon feeding, resolution with crying, and midface hypoplasia on exam, most consistent with choanal atresia. A nasogastric (NG) tube would not pass through the nasal canal.
Choanal atresia is caused by failed recanalization of the nasal fossae during fetal development. This disease typically presents with noisy breathing, cyanosis when feeding, and improvement with crying and the use of the mouth for breathing. Cyanosis in this condition affects the entire body as opposed to just the hands and feet. Bilateral atresia often presents early in life. Clinical suspicion of choanal atresia should prompt an attempt to pass an NG tube, which will meet resistance at the posterior part of the nasal canal. Treatment is with the surgical creation of the nasal passages.
Lesciotto et al. review the diagnosis and pathophysiology of patients with choanal atresia. They discuss how this condition is often comorbid with craniosynostosis. They recommend a better understanding of how these patients develop decreased nasal airway volume.
Figure/Illustration A is a clinical photograph showing midface hypoplasia with a poorly developed nasal bone (red circle). These findings are consistent with a diagnosis of choanal atresia.
Incorrect Answers:
Answer A: Areflexia in all extremities may be seen in spinal muscular atrophy, a genetic condition that causes loss of motor neurons. This condition may cause difficulty feeding due to weakness of the oropharyngeal and glossopharyngeal muscles, but it typically does not cause cyanosis. Treatment is with steroid use and nusinersen.
Answer B: Digital clubbing can result from chronic hypoxemia, as seen in conditions such as cystic fibrosis. It would be unexpected for a neonate to have clubbing as the characteristic finger appearance depends on the long-term deposition of platelet-derived growth factor and would not develop within minutes. This patient also does not have cyanosis at baseline. Treatment of cystic fibrosis is with enzyme repletion and respiratory therapy.
Answer D: Markedly decreased lung volume can occur in congenital diaphragmatic hernia, in which the abdominal contents herniate into the chest cavity and cause pulmonary hypoplasia. Infants may present with cyanosis due to respiratory failure, but there would be no association with feeding or improvement with crying. Vital signs would also be abnormal. Treatment is with surgical repair of the diaphragm.
Answer E: A patent foramen ovale occurs when the connection between the left and right atria does not close soon after birth. It does not result in cyanosis and is typically asymptomatic, though it may cause paradoxical embolism and stroke later in life. Treatment of a symptomatic patent foramen ovale is surgical closure of the defect.
Bullet Summary:
Choanal atresia presents with cyanosis and respiratory distress that worsens with feeding and improves with crying associated with failure to pass a nasogastric tube.
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115
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Figure A is the lateral radiograph of a 44-year-old male who sustained a fall on his outstretched hand while rollerblading. The patient reports pain localized to the posterior elbow and refuses to attempt elbow extension secondary to pain and swelling. Which of the following is the most likely diagnosis in this patient?
|
{
"A": "Exacerbation of elbow arthritis",
"B": "Olecranon bursitis",
"C": "Lateral collateral ligament tear",
"D": "Triceps rupture",
"E": ""
}
|
D
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The flake sign, as seen in Figure A is pathognomonic of a triceps tendon rupture.
Tricep tendon ruptures are rare injuries to the elbow extensor mechanism that most commonly occur as a result of forceful elbow contraction. Diagnosis can be made clinically, as patients with complete ruptures are unable to extend the elbow against gravity. An MRI may be useful in the diagnosis in patients whom are too painful to examine or who may have partial tears of the triceps tendon. Surgical repair is indicated in patients with complete rupture or in those with >50% tears and significant weakness.
Yeh et al. review distal triceps ruptures. They report that these injuries are commonly caused by a fall on an outstretched hand or a direct blow. If identifiable on plain radiograph a flake sign or avulsion of the olecranon tip will be appreciated. They conclude that diagnosis may be difficult initially in a painful elbow, however, a combination of plain radiographs and MRI can assist in making the correct diagnosis.
Beazley et al. review distal biceps and triceps injuries. They report that these injuries most commonly occur in middle-aged males as a result of eccentric loading of the tendon. They conclude that patients who undergo early diagnosis and surgical treatment can expect to have excellent outcomes.
Keener et al. review distal tricep tendon injuries. They report that most complete tears are treated surgically in medically fit patients. Partial-thickness tears are managed according to the tear severity, functional demands, and response to conservative treatment. They conclude that anatomic footprint repair of the triceps with optimal tendon to bone healing results in an acceptable functional outcome.
Figure A is the lateral radiograph of an elbow demonstrating a flake sign from the olecranon tip indicative of a triceps rupture.
Incorrect Answers:
Answer A: The patient does not show significant elbow degenerative disease on plain radiographs.
Answer C: Olecranon bursitis is not likely to worsen acutely after a fall, nor are there any other indications of this diagnosis in the present patient.
Answer D: While lateral collateral ligament tears may occur following a fall on an outstretched arm, there is no indication that an elbow dislocation occurred here and based on current radiographs a triceps rupture is more likely.
Answer E: Anconeus avulsions fractures are identified as lateral epicondyle fractures.
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116
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A 25-year-old G1P0 woman presents to her physician for a prenatal visit. She is at 12 weeks gestational age and has not received prior prenatal care. She has mild morning sickness but no other symptoms. She has no known medical problems and takes only a prenatal multivitamin. She has unprotected sexual intercourse with 3 male partners. Her temperature is 98.6°F (37.0°C), blood pressure is 118/70 mmHg, pulse is 80/min, and respirations are 18/min. Physical exam reveals a well-appearing woman in no acute distress. There are no lesions appreciated on skin exam. Cardiopulmonary exam is unremarkable. An antibody test for human immunodeficiency virus (HIV)-1/2 is positive. The patient is started on an appropriate treatment regimen. Assuming that her HIV viral load is undetectable by the time of delivery, which of the following maternal regimens is she most likely receiving and what neonatal prophylaxis is indicated (Figure A)?
|
{
"A": "B",
"B": "A",
"C": "C",
"D": "E",
"E": ""
}
|
C
|
This pregnant patient presents with a positive HIV antibody test in the setting of unprotected sexual intercourse. An appropriate maternal HIV treatment regimen is abacavir, lamivudine, and raltegravir; prophylaxis in the infant consists of zidovudine alone if maternal HIV viral load is suppressed to < 50 copies/mL.
All pregnant women should be screened for HIV as early as possible during pregnancy. Maternal treatment for HIV should be initiated as early as possible (before pregnancy if possible) with highly-active anti-retroviral therapy (HAART) consisting of 2 nucleoside reverse transcriptase inhibitors (NRTIs) such as abacavir/lamivudine, plus an integrase inhibitor (e.g., raltegravir) or a protease inhibitor (e.g., ritonavir/atazanavir). Regimens for prophylaxis in infants of HIV-positive mothers depends on the HIV viral load at the time of delivery. If the viral load is < 50 copies/mL, infant prophylaxis with zidovudine alone for 4 weeks is sufficient. If the viral load is ≥ 50 copies/mL or the mother did not receive HAART during pregnancy, infant prophylaxis should consist of the 3-drug regimen of: zidovudine, lamivudine, and either nevirapine or raltegravir for 6 weeks.
Harris et al. reviewed the treatment of HIV infection in pregnancy. They found that although anti-retroviral therapy during pregnancy significantly reduces mother-to-child transmission of HIV, it is still associated with certain perinatal complications such as low birthweight and preterm delivery. Despite these risks, they recommend anti-retroviral therapy during pregnancy and during breastfeeding to prevent transmission.
Figure A shows the answer choices.
Incorrect Answers:
Answer A: Maternal treatment with abacavir/lamivudine/raltegravir and no neonatal treatment is inappropriate because all infants of HIV-positive mothers should receive zidovudine (if maternal viral load < 50 copies/mL at delivery). Lamivudine and raltegravir would be added if maternal viral load is ≥ 50 copies/mL at delivery.
Answer B: Maternal treatment with abacavir/lamivudine/raltegravir and neonatal prophylaxis with zidovudine/lamivudine/raltegravir would be appropriate if the maternal viral load were ≥ 50 copies/mL at delivery. The HIV viral load in this patient was assumed to be undetectable at delivery.
Answer D: Maternal treatment with raltegravir/ritonavir/atazanavir and neonatal prophylaxis with zidovudine/lamivudine/raltegravir is inappropriate because raltegravir is an integrase inhibitor and ritonavir/atazanavir are protease inhibitors. HAART must include 2 NRTIs. Atazanavir is often co-administered with ritonavir to increase the former’s bioavailability. Additionally, zidovudine/lamivudine/raltegravir is the neonatal regimen for infants whose mothers have a viral load ≥ 50 copies/mL at delivery.
Answer E: Maternal treatment with raltegravir/ritonavir/atazanavir and neonatal prophylaxis with zidovudine only is inappropriate because HAART for the mother must include 2 NRTIs.
Bullet Summary:
Maternal HIV infection should consist of highly-active anti-retroviral therapy consisting of 2 nucleoside reverse transcriptase inhibitors plus either an integrase inhibitor or protease inhibito, while neonatal prophylaxis consists of zidovudine only for infants of mothers with viral load < 50 copies/mL at delivery.
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A 25-year-old man presents to his primary care physician with a chief complaint of "failing health." He states that he typically can converse with animals via telepathy but is having trouble right now due to the weather. He has begun taking an assortment of Peruvian herbs to little avail. Otherwise, he is not currently taking any medications. The patient lives alone and works in a health food store. He states that his symptoms have persisted for the past 8 months. When obtaining the patient's medical history, there are several times he attempts to telepathically connect with the animals in the vicinity. His temperature is 98.6°F (37°C), blood pressure is 115/71 mmHg, pulse is 72/min, and respirations are 12/min. On physical exam, you note a healthy young man who is dressed in an all-burlap ensemble. Which of the following is the most likely diagnosis?
|
{
"A": "Brief psychotic disorder",
"B": "Schizoid personality disorder",
"C": "Schizotypal personality disorder",
"D": "Schizophrenia",
"E": ""
}
|
C
|
This patient has several odd and eccentric beliefs without frankly psychotic features and he is able to function in society. This suggests a diagnosis of schizotypal personality disorder.
Schizotypal personality disorder presents with eccentric behavior, magical thinking, odd beliefs, and perceptual disturbances. These patients may seem to have symptoms of schizophrenia; however, they do not respond to internal stimuli and do not experience visual or auditory hallucinations. They are able to function in society and care for themselves. Patients with schizotypal personality disorder typically struggle in maintaining close relationships or making friends. Patients are typically not distressed about their thought patterns but can undergo treatment with psychotherapy if they seek to change their behaviors.
Sher reviews the evidence regarding the treatment of patients with schizotypal personality disorder. He discusses how this disorder often goes undiagnosed and is difficult to treat. He recommends providing suicide prevention measures as this disease is associated with suicidal ideation.
Incorrect Answers:
Answer A: Brief psychotic disorder presents with either visual or auditory hallucinations with symptoms that have lasted for less than 1 month. Patients have frankly psychotic features and should be closely monitored for the development of schizophrenia.
Answer B: Schizoid personality disorder presents with social isolation. These patients are alone but do not desire social contact and are content in their isolation. A typical example is an individual who works in a solitary job on the graveyard shift. Patients do not have strange or magical beliefs.
Answer C: Schizophrenia presents with either visual or auditory hallucinations with symptoms that have lasted for 6 months or longer. These patients typically have trouble caring for themselves and struggle to function in society. Though this patient is attempting to connect/communicate with animals, this likely represents an odd belief rather than responding to internal stimuli. Schizophrenia should be treated with antipsychotic medications.
Answer D: Schizophreniform disorder presents with either visual or auditory hallucinations with symptoms that have lasted for 1-6 months. Patients have symptoms with frankly psychotic features and should be treated with antipsychotic medications.
Bullet Summary:
Schizotypal personality disorder presents with eccentric behavior, magical thoughts, and odd beliefs but patients are able to function within society.
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118
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A 46-year-old woman presents to her primary care doctor to request a referral to ophthalmology. Her vision has been steadily declining over the past 2 years and she thinks she needs a prescription for glasses. She further complains that her lips and feet feel numb. Her medical history is notable for medullary thyroid cancer status post total thyroidectomy. Her periods are regular. She enjoys a diverse diet and takes levothyroxine. Her blood pressure is 110/70 mmHg, pulse is 80/min, and respirations are 12/min. She is alert and oriented. Her pupils are equal, round, and reactive to light, but appear opacified. Extraocular movements are intact, albeit slow. Her visual acuity is decreased bilaterally. The remainder of her physical exam is unremarkable. Her basic metabolic panel is shown below: Na+: 139 mEq/L Cl-: 100 mEq/L K+: 4.9 mEq/L HCO3-: 25 mEq/L BUN: 10 mg/dL Glucose: 110 mg/dL Creatinine: 0.8 mg/dL Thyroid-stimulating hormone: 1.5 µU/mL Ca2+: 7.0 mEq/L Phosphorus: 6.5 mEq/L Albumin: 3.6 mg/dL The patient's ECG is shown in Figure A. What is the most likely cause of this presentation?
|
{
"A": "Iatrogenic hypoparathyroidism",
"B": "Somatization",
"C": "Multiple endocrine neoplasia",
"D": "Hyperkalemia",
"E": ""
}
|
A
|
This patient who presents with cataracts and a prolonged QTc interval on ECG most likely has symptomatic hypocalcemia secondary to the surgical removal of all of her parathyroid glands (iatrogenic hypoparathyroidism).
Thyroid surgery may mandate the removal of parathyroid glands if there is evidence of malignant invasion. One parathyroid gland is enough to maintain eucalcemia, but accidental/intentional removal of all the glands is possible. Less common causes are autoimmune parathyroid destruction or parathyroid infiltration by disorders like sarcoidosis or Wilson disease. Many patients are asymptomatic, but chronic hypocalcemia is associated with increased phosphate levels, prolonged QT interval, Parkinsonian signs, cataracts, and cognitive impairment. Severe, acute hypocalcemia can present with tetany, papilledema, and seizures. Treatment is with calcium and parathyroid hormone replacement.
Clarke et al. review the evidence regarding the diagnosis and etiologies of hypoparathyroidism. They discuss how the most common cause is post-surgical. They recommend obtaining genetic testing in cases where the etiology is unclear.
Figure/Illustration A shows an ECG with a prolonged QTc interval at approximately 500 msec (blue circle).
Incorrect Answers:
Answer A: This patient is mildly hyperkalemic, but her symptoms and signs are not associated with hyperkalemia. Patients with hyperkalemia present with heart palpitations, shortness of breath, chest pain, nausea, or vomiting. ECG will demonstrate peaked T waves.
Answer C: The patient is on levothyroxine with appropriate TSH levels. Hypothyroidism is not associated with QT prolongation. Patients with hypothyroidism will present with cold intolerance, delayed responsiveness, and myxedema coma. Treatment is with increasing the levothyroxine dose.
Answer D: Multiple endocrine neoplasia is associated with medullary thyroid cancer, but this patient has no evidence of additional organ disease. Other signs of multiple endocrine neoplasia include pancreatic tumors, pheochromocytoma, or a Marfanoid habitus. Treatment is with surgical excision of tumors.
Answer E: This patient most likely has a biological reason for her symptoms, so somatization is less likely. Patients with somatizing disorders have psychological distress that manifests as physical symptoms. These patients will not have organic correlates of disease such as abnormal ECG results.
Bullet Summary:
Iatrogenic hyperparathyroidism after the removal of the thyroid gland is the most common cause of hypocalcemia.
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119
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A 2-day-old boy has an episode of vomiting in the hospital nursery. The vomitus was described as “bright green” without any traces of blood. The patient has urinated several times since he was born but has not passed any stool. He was born at 37 weeks of gestation to a 38-year-old G3P3 woman. The pregnancy was uncomplicated and the patient’s mother refused all prenatal testing. The patient’s 2 older siblings are both healthy. His temperature is 98.6°F (37°C), blood pressure is 67/43 mmHg, pulse is 135/min, and respirations are 34/min. On physical exam, the patient has upslanting palpebral fissures, epicanthal folds, and a single transverse palmar crease. His abdomen is non-tender, firm, and distended. Bowel sounds are hypoactive. Digital rectal exam evacuates a small amount of stool and flatulence. A nasogastric tube is placed to decompress the stomach. The patient’s abdominal radiograph can be seen in Figure A. Which of the following is the most likely diagnosis?
|
{
"A": "Pyloric stenosis",
"B": "Intestinal malrotation",
"C": "Hirschsprung disease",
"D": "Meconium ileus",
"E": ""
}
|
C
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This pediatric patient presents with features of Down syndrome (trisomy 21), bilious vomiting, and colonic distention on an abdominal radiograph, which suggests a diagnosis of Hirschsprung disease.
Hirschsprung disease is associated with Down syndrome and presents with bilious vomiting, failure to pass meconium in the first 48 hours of life, and abdominal distension. A digital rectal exam may temporarily relieve the obstruction and lead to the expulsion of gas and stool (the “squirt sign”). Abdominal radiography typically demonstrates signs of distal intestinal obstruction such as proximal dilation and an absence of air in the rectum. Contrast enema may reveal a transition zone between the dilated proximal megacolon and the narrow rectosigmoid colon. A biopsy can confirm the diagnosis. Treatment is with surgical removal of the defective segment of the bowel.
Kessman reviews the evidence regarding the diagnosis and treatment of Hirschsprung disease. She discusses how the diagnosis can be made using a rectal suction biopsy. She recommends monitoring patients closely for enterocolitis for years after surgical treatment.
Figure/Illustration A is an abdominal radiograph that demonstrates colonic distension (red circle). This finding is consistent with a diagnosis of Hirschsprung disease.
Incorrect Answers:
Answer A: Duodenal atresia is associated with Down syndrome (trisomy 21) and may also present in the first 48 hours of life with bilious vomiting. The abdominal radiograph will demonstrate the “double bubble” sign, which reflects air trapping in the stomach and first portion of the duodenum. Treatment is with the surgical opening of the atretic segment.
Answer C: Intestinal malrotation may preset with bilious vomiting in a neonate due to the development of a midgut volvulus. An abdominal radiograph may show the extension of the nasogastric tube into an abnormally positioned duodenum and would not show diffuse colonic distension. Treatment is with surgical derotation of the volvulus.
Answer D: Meconium ileus is associated with cystic fibrosis and also presents with delayed (> 48 hours) passing of meconium. The distal obstruction in these patients will not be temporarily relieved by a digital rectal exam. Contrast enema will demonstrate microcolon involving the entire large bowel. Treatment is with irrigation and removal of the meconium.
Answer E: Pyloric stenosis usually presents in the first 3-6 weeks of life with post-prandial, nonbilious, projectile vomiting and a palpable olive-shaped mass in the epigastrium. This patient is presenting at just 2 days of life and has bilious vomiting. Treatment is with surgical release of the stenosis.
Bullet Summary:
Hirschsprung disease is associated with Down syndrome (trisomy 21) and presents with retention of stool that can be relieved by digital disimpaction, bilious vomiting, and colonic distention on abdominal radiography.
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A 25-year-old man presents to his primary care physician with anxiety and fatigue. During this past week, he has been unable to properly study and prepare for final exams because he is exhausted. He has been going to bed early but is unable to get a good night’s sleep. He admits to occasional cocaine and marijuana use. Otherwise, the patient has no significant medical history and is not taking any medications. His temperature is 98.6°F (37°C), blood pressure is 115/71 mmHg, pulse is 72/min, and respirations are 12/min. On physical exam, the patient is a tired and anxious appearing young man. His neurological exam is within normal limits. The patient states that he fears he will fail his courses if he does not come up with a solution. Which of the following is the most appropriate initial step in management?
|
{
"A": "Polysomnography",
"B": "Sleep hygiene education",
"C": "Alprazolam",
"D": "Melatonin",
"E": ""
}
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B
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This patient is presenting with trouble sleeping without a known organic cause, for which the most appropriate initial step in management is to discuss sleep hygiene with the patient.
In any patient that presents with a chief complaint of fatigue, it is always best to assess how they are sleeping. After a physical exam is performed in order to rule out signs or symptoms of a severe organic cause (neurologic deficits), the most appropriate initial step in management is to discuss sleep hygiene with the patient. Sleep hygiene includes discussing the patient’s exposure to light (eliminate exposure to blue light at night), altering diet (no large meals or caffeine before bed), and behavioral modification (only using the bed for sleep). Once a trial of proper sleep hygiene has been tried, then it would be appropriate to potentially move on to other interventions including pharmacological interventions.
Horne presents evidence regarding the best sleep hygiene practices. He discusses how exercise and avoidance of caffeine near bedtime is beneficial to helping with insomnia. He recommends using these interventions prior to pharmacologic treatment.
Incorrect Answers:
Answer A: Alprazolam is a benzodiazepine that could be used to help with this patient’s anxiety and could help them sleep. However, benzodiazepines are potent drugs with addictive properties and would not be used as first-line treatment for insomnia. Lifestyle modifications should be tried first to determine if these will be effective in helping the patient sleep.
Answer B: Melatonin is a supplement that is often used to improve sleep quality. Starting the patient on a supplement is plausible as an initial step in management, but it would not take precedence over educating the patient regarding sleep hygiene. These interventions often are very effective and have no side effects.
Answer C: Polysomnography could be the most appropriate initial step in management if an organic cause for this patient’s sleep problems (such as obstructive sleep apnea) is suspected. There is nothing suggesting an organic cause for this patient’s sleep issues and it is highly likely that a college-age student near finals period would benefit from a discussion on sleep hygiene prior to an expensive diagnostic test such as polysomnography.
Answer E: Zolpidem is a muscle relaxant and hypnotic with a similar mechanism of action to a benzodiazepine. Zolpidem has the potential to be addicting and would not be tried prior to sleep hygiene interventions. Some patients who are refractory to other interventions may benefit from the use of Zolpidem.
Bullet Summary:
Any patient that presents with fatigue and trouble sleeping without a clear organic cause should first be counseled in sleep hygiene habits prior to any other interventions or diagnostic tests.
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A 53-year-old man presents to the clinic with a non-tender mass in his right anterior neck. The mass has been slowly enlarging over the past 1 year. He reports no dysphagia, difficulty breathing, or changes to his voice. He also denies heat intolerance, palpitations, tremors, or diarrhea. He has hypertension and hyperlipidemia, for which he takes lisinopril and atorvastatin. He has never smoked cigarettes. His temperature is 37.1°C (98.8°F), blood pressure is 130/84 mmHg, pulse is 86/min, respirations are 12/min, and oxygen saturation is 99% on room air. Bedside ultrasound reveals a 1x2 cm hypoechogenic nodule with microcalcifications in the right thyroid lobe, which is biopsied. Pathology results are shown in Figure A. Which of the following is the most appropriate next step in management?
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{
"A": "Repeat ultrasound in 6 months",
"B": "Thyroidectomy followed by radioactive iodine",
"C": "Methimazole",
"D": "Radioactive iodine",
"E": ""
}
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B
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This patient who presents with a slowly enlarging neck mass has ultrasound (hypoechogenic nodule with microcalcifications) and histology findings (concentrically laminated calcifications called psammoma bodies) consistent with papillary thyroid carcinoma. The most appropriate next step in management would be thyroidectomy followed by radioiodine ablation.
Papillary thyroid carcinoma represents the majority of malignant thyroid cancers. They are slow-growing and are found in the hormone-producing follicular cells of the thyroid. Typically, these tumors are found incidentally on imaging. Risk factors for thyroid malignancy include a history of radiation exposure, female sex, and positive family history. Nodules with minimal uptake on radioactive iodine scan, firm and immobile solitary nodules, and rapidly growing nodules with associated hoarseness are more suggestive of thyroid malignancy. Findings on histology include empty-appearing nuclei with central clearing, psammoma bodies, and nuclear grooves. The treatment is thyroidectomy followed by radioactive iodine ablation of any remaining thyroid cells. Long-term care should include levothyroxine at a dose sufficient to suppress thyroid-stimulating hormone (TSH) release that may stimulate any remaining malignant cells.
Oakley et al. studied if relatives of patients diagnosed as having papillary thyroid carcinoma are at increased risk using a retrospective cohort study. The authors found first-degree relatives were at a 5-fold increased risk, and second-degree relatives were at a 2-fold increased risk. The authors recommend more research into optimal approaches to screening for thyroid cancers.
Figure/Illustration A is a histology section showing a psammoma body (blue circle), which are round, concentrically laminated calcifications that are formed after necrosis of papillary structures. Psammoma bodies and nuclei with central clearing (yellow circle) and nuclear grooves are common histology findings for papillary thyroid carcinoma.
Incorrect Answers:
Answer A: Levothyroxine would be the treatment of choice in hypothyroidism and is important in the long-term care of papillary thyroid carcinoma to suppress the TSH release that may stimulate any remaining malignant cells after treatment (thyroidectomy and radioactive iodine).
Answer B: Methimazole is an agent that blocks thyroid peroxidase, thus inhibiting the synthesis of thyroid hormones. It is used in the treatment of hyperthyroidism and does not have a role in the treatment of papillary thyroid carcinoma.
Answer C: Radioactive iodine is used as an adjunct after thyroidectomy in the treatment of papillary thyroid carcinoma in order to target any thyroid cells that may remain even after surgical excision. Surgery is the primary therapy for papillary thyroid carcinoma. Radioactive iodine is the primary method of therapy in cases of Grave disease, toxic adenoma, or multinodular goiter.
Answer D: Repeating an ultrasound in 6 months to assess the growth of the nodule or the development of suspicious characteristics is appropriate in cases where the ultrasound and biopsy findings are consistent with a benign thyroid nodule. The ultrasound findings of hypoechogenicity, microcalcifications, hypervascularity, and taller-than-wide nodules suggest malignancy, and together with a biopsy consistent with thyroid malignancy would warrant surgical treatment with subsequent radioactive iodine ablation.
Bullet Summary:
Papillary thyroid carcinoma is managed with thyroidectomy followed by radioactive iodine ablation and long-term levothyroxine to suppress thyroid-stimulating hormone stimulation of any remaining malignant cells.
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A 29-year-old woman is recovering on the obstetrics floor after the vaginal delivery of 8-pound twin boys born at 42 weeks gestation. The patient is fatigued but states that she is doing well. Currently, she is complaining that her vagina hurts. The next morning, the patient experiences chills and a light red voluminous discharge from her vagina. She states that she feels pain and cramps in her abdomen. The patient's medical history is notable for diabetes which was managed during her pregnancy with insulin. Her temperature is 99.5°F (37.5°C), blood pressure is 107/68 mmHg, pulse is 97/min, respirations are 16/min, and oxygen saturation is 98% on room air. Laboratory values are obtained and shown below. Hemoglobin: 12 g/dL Hematocrit: 36% Leukocyte count: 9,750/mm^3 with normal differential Platelet count: 197,000/mm^3 Serum: Na+: 139 mEq/L Cl-: 101 mEq/L K+: 4.2 mEq/L HCO3-: 23 mEq/L BUN: 20 mg/dL Glucose: 111 mg/dL Creatinine: 1.1 mg/dL Ca2+: 10.2 mg/dL AST: 12 U/L ALT: 10 U/L Which of the following is the most appropriate next step in treatment for this patient?
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{
"A": "Supportive therapy only",
"B": "Vancomycin and clindamycin",
"C": "Cefoxitin and doxycycline",
"D": "Vancomycin and gentamicin",
"E": ""
}
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A
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This patient is presenting with a normal postpartum period which is managed with supportive therapy only.
A normal postpartum period is associated with breast tenderness, chills, edema, and abdominal cramps from a contracting uterus. Vaginal discharge (lochia) is normal in this phase and progresses from a red color (lochia rubra) to a clear/fluid appearance (lochia serosa) to a white color (lochia alba). No management other than supportive therapy is needed during this period. Symptoms that indicate additional intervention may be necessary include fever, foul-smelling drainage, or hypotension.
Fletcher et al. review the evidence regarding normal lochia after pregnancy. They discuss how this discharge can occur for up to 24-36 days after delivery. They recommend understanding normal discharge patterns to allow for the identification of pathologic conditions.
Incorrect Answers:
Answer A: Cefoxitin and doxycycline can be used to treat postpartum endometritis in which the suspected organism is Chlamydia trachomatis or Neisseria gonorrhoea. Suspect these organisms in a patient with risky sexual behavior.
Answer B: Clindamycin and gentamicin offer broad-spectrum coverage for endometritis, which presents with fever, abdominal tenderness, and a foul-smelling vaginal discharge. This patient has no evidence of infection at this time.
Answer D: Vancomycin and clindamycin is not a typical broad-spectrum antibiotic pair that is used routinely. Both of these agents are often effective against MRSA but are typically not used concurrently.
Answer E: Vancomycin and gentamicin offer broad-spectrum antibiotic coverage and can be used for bacterial endocarditis which presents with fever and a new murmur in a high-risk individual (such as those who use IV drugs).
Bullet Summary:
A normal postpartum period presents with chills, abdominal cramps, and lochia (rubra, serosa, or alba) and is managed with supportive care.
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123
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A 3-week-old boy presents to the emergency department with vomiting. His parents report that he suddenly started vomiting this morning and has shown no interest in feeding since then. They describe the vomitus as green and without any traces of blood. Prior to today, the patient was feeding, voiding, and stooling well. He was noted to have surpassed his birth weight at his last office visit 1 week ago. His temperature is 97.6°F (36.4°C), blood pressure is 78/56 mmHg, pulse is 148/min, and respirations are 44/min. On physical exam, the patient is in mild distress. He has no dysmorphic features, and his mucous membranes are dry. His abdomen is soft and distended. Bowel sounds are hypoactive. An abdominal radiograph is performed as in Figure A. Which of the following is the most appropriate next step in the diagnosis of this condition?
|
{
"A": "Upper gastrointestinal contrast series",
"B": "Contrast enema",
"C": "Abdominal CT",
"D": "Rectal suction biopsy",
"E": ""
}
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A
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This neonatal patient presents with sudden-onset bilious vomiting and an abdominal radiograph revealing a gasless abdomen, which is consistent with intestinal malrotation complicated by a midgut volvulus. The most appropriate next step in the diagnosis of intestinal malrotation is an upper gastrointestinal series.
Malrotation classically presents with bilious vomiting due to the formation of midgut volvulus. These patients will have normal development until the development of the obstruction followed by inability to feed and abdominal distention. Findings of malrotation on an upper gastrointestinal series include an abnormally placed ligament of Treitz on the right side of the abdomen and a "corkscrew" appearance of the distal duodenum. If an upper gastrointestinal contrast series confirms the diagnosis, patients should undergo surgery to reduce the volvulus in order to avoid intestinal perforation or other complications.
Adams and Stanton review the evidence regarding the diagnosis and treatment of neonatal bowel obstruction. They discuss how malrotation, jejunoileal atresia, duodenal atresia, and colonic atresia are common causes of this finding. They recommend surgical management of these conditions.
Figure/Illustration A is an abdominal radiograph demonstrating the nonspecific finding of a paucity of air in the abdomen (red circle). This is consistent with intestinal malrotation complicated by midgut volvulus.
Incorrect Answers:
Answer A: Although abdominal CT would detect intestinal malrotation, CT should be avoided in the pediatric population in light of the radiation exposure. A CT scan with oral contrast can be useful in the adult setting in order to determine if there is extravasation of fluid from the gastrointestinal tract.
Answer B: Abdominal ultrasound is the test of choice for diagnosing pyloric stenosis, which presents with non-bilious vomiting and a palpable olive mass in the abdomen. Treatment of this condition is with surgical release of the stenotic pyloric muscle.
Answer C: A contrast enema is used to differentiate between Hirschsprung disease and meconium ileus but would not be helpful in diagnosing malrotation as the midgut volvulus occurs in the small intestine. Both Hirschsprung disease and meconium ileus present in neonatal patients with bilious vomiting and failure to pass meconium in the first 48 hours of life. Treatment is with excision of the defective segment or removal of the meconium respectively.
Answer D: Rectal suction biopsy is the most accurate test to diagnose Hirschsprung disease. Although Hirschsprung disease commonly presents in neonatal patients with bilious vomiting, an abdominal radiograph in Hirschsprung disease would likely show dilation of the proximal colon.
Bullet Summary:
The most appropriate diagnostic test for malrotation in an infant is an upper gastrointestinal series, which will show the abnormal placement of the duodenum and ligament of Treitz on the right side of the abdomen.
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A 3-day-old boy is evaluated in the neonatal intensive care unit for failure to pass meconium. The patient is otherwise doing well and feeding every 2 hours. He is urinating 8-10 times per day. The patient has had 2 episodes of vomiting that were described as green in color. He was born at 39 weeks gestation to a 38-year-old G3P3 mother. The pregnancy was uncomplicated, and the patient’s mother received routine prenatal care. She declined prenatal testing. One of the patient’s older siblings has Down syndrome. The patient's temperature is 98.2°F (36.8°C), blood pressure is 48/32 mmHg, pulse is 164/min, and respirations are 48/min. On physical exam, the patient is in no acute distress. His abdomen is firm, non-tender, and distended with hypoactive bowel sounds. A digital rectal exam fails to relieve the obstruction. An abdominal radiograph is performed and the result can be seen in Figure A. Which of the following is the most appropriate next step in management?
|
{
"A": "Sweat testing",
"B": "Contrast enema",
"C": "Upper gastrointestinal series",
"D": "Abdominal CT",
"E": ""
}
|
B
|
This patient presents with delayed passage of meconium, bilious emesis, unsuccessful disimpaction on digital rectal exam, and dilated loops of bowel on abdominal radiograph which suggests a diagnosis of meconium ileus. The most appropriate next step in management is an enema with water-soluble contrast which may be both diagnostic and therapeutic.
Meconium ileus presents with bilious emesis and failure to pass meconium in the first 48 hours of life. Abdominal radiography typically shows dilated loops of the small intestine proximal to the obstruction. Enema with water-soluble contrast (Gastrografin) is both diagnostic and therapeutic, as the contrast not only visualizes a microcolon but also relieves the obstruction via the osmotic pull of water into the lumen of the colon. Surgery may be necessary if the contrast enema fails. Patients should also be evaluated for underlying conditions such as cystic fibrosis.
Adams and Stanton review the evidence regarding the diagnosis and treatment of neonatal bowel obstruction. They discuss how malrotation, jejunoileal atresia, duodenal atresia, and colonic atresia are common causes of this finding. They recommend surgical management of these conditions.
Figure/Illustration A is an abdominal radiograph demonstrating dilated loops of bowel and a “soap bubble” appearance of meconium mixed with bowel gas in the right lower quadrant (red circle). These findings are classically seen in patients with meconium ileus.
Incorrect Answers:
Answer A: An abdominal radiograph would be faster but less accurate than an abdominal CT. The use of CT should also be restricted in the pediatric population due to the radiation exposure involved.
Answer C: Rectal suction biopsy is the most accurate test to diagnose Hirschsprung disease, which may present like meconium ileus with bilious vomiting, delayed passage of meconium, and dilated loops of bowel on an abdominal radiograph. A digital rectal exam typically temporarily relieves the intestinal obstruction in Hirschsprung disease and produces an expulsion of gas and stool called the “squirt sign.”
Answer D: Sweat testing is used to diagnose cystic fibrosis, which is strongly associated with meconium ileus. An enema with water-soluble contrast would be the best next step to both confirm the diagnosis and relieve the obstruction. The patient should subsequently undergo sweat testing.
Answer E: Upper gastrointestinal series is the diagnostic test of choice for intestinal malrotation which may also present with bilious vomiting. Malrotation is less likely to present with delayed passage of meconium, and an abdominal radiograph would more likely demonstrate a midgut volvulus. Treatment is with surgical derotation.
Bullet Summary:
Patients with meconium ileus should undergo an enema with water-soluble contrast (Gastrografin) to both confirm the diagnosis and relieve the obstruction.
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125
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A 25-year-old woman presents to her primary care physician complaining of recent hair growth along her jawline, now requiring her to shave every 2 days. She has not shaved in about a week. She has also gained about 10 pounds in the last several months, and her periods have become irregular over the last year. Her last menstrual period was 3 months ago. Her temperature is 98.6°F (37.0°C), pulse is 72/min, blood pressure is 136/86 mmHg, and respirations are 13/min. Her BMI is 26 kg/m^2. Her skin exam reveals hirsutism along the jawline and acanthosis nigricans in the axillary folds. Cardiopulmonary and abdominal exams are unremarkable. A pelvic exam reveals normal external genitalia, a mobile and non-tender 6-week-sized uterus, and no adnexal masses or tenderness. Transvaginal ultrasound is performed and shown in Figure A. This patient is at increased future risk of which of the following?
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{
"A": "Endometrial carcinoma",
"B": "Ovarian cancer",
"C": "Type 1 diabetes mellitus",
"D": "Virilization",
"E": ""
}
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A
|
This patient presents with hirsutism, oligomenorrhea, and multiple follicles on pelvic ultrasound, which is most consistent with polycystic ovarian syndrome (PCOS). PCOS is associated with an increased risk of endometrial carcinoma.
PCOS is an acquired endocrinopathy characterized by ovarian dysfunction and high rates of amenorrhea. Patients with PCOS are at risk for endometrial carcinoma due to unopposed estrogen exposure. Anovulation results in decreased progesterone, which prevents excessive endometrial build-up and thus increases the risk of endometrial hyperplasia and subsequent carcinoma. Increased adiposity in PCOS also increases estrogen, which is aromatized from testosterone in adipose cells, and further raises the risk for endometrial carcinoma. Treatment is with weight loss, metformin, and hormonal contraceptives.
Khan et al. review the genetic basis underlying PCOS. They discuss how this disease is the most common endocrinopathy in reproductive-age women resulting in anovulatory infertility. They recommend using multimodal methods to treat this disease.
Figure/Illustration A shows a transvaginal ultrasound of the ovary with many peripheral follicles (red circle). These findings are characteristic of PCOS.
Incorrect Answers:
Answer B: Ovarian cancer does not occur with increased incidence in patients with PCOS. They are at baseline risk and do not require additional screening. The rates of ovarian cancer increase with hereditary cancer syndromes such as BRCA mutation.
Answer C: Ovarian cyst rupture is not a complication of PCOS, as PCOS does not actually cause cysts (despite the name). The cystic spaces seen on ultrasound are immature follicles rather than cysts. Recurrent infections can lead to cysts and rupture.
Answer D: Type 1 diabetes mellitus is not associated with PCOS, but type 2 diabetes mellitus is. Type 2 diabetes can cause acanthosis nigricans via insulin resistance. Patients with recurrent bouts of pancreatitis are predisposed to diabetes mellitus.
Answer E: Virilization is not seen in PCOS, as the testosterone levels are elevated but not to the degree necessary to produce frank masculinization. If there is evidence of virilization, such as voice deepening or clitoromegaly the differential should be broadened to other diagnoses.
Bullet Summary:
Patients with PCOS are at increased risk of endometrial carcinoma as a result of unopposed estrogen from anovulation as well as aromatization in adipose tissue.
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126
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A 45-year-old morbidly obese woman with a history of asthma and type 2 diabetes mellitus presents to her primary care physician for advice on weight loss. She thinks that her husband is having sex with other women because they have not had sex over the past year. She feels that her co-workers also disrespect her for her weight and constant sweat stains around her armpits and chest. She has noticed that the sweat stains get itchy and induce a burning sensation unless she showers or changes her shirt. She has been compliant with her medications, which include albuterol, metformin, glyburide, and atorvastatin. Her temperature is 98.6°F (37°C), blood pressure is 128/85 mmHg, pulse is 91/min, and respirations are 11/min. On physical exam, the patient has a flat affect, with moist oral mucosa and nasal polyps. She denies sinus tenderness. Her neck is thick with a posterior cervical fat pad. During cardiac auscultation, the finding in Figure A is noted below her breasts. What is the most appropriate next step in management for this finding?
|
{
"A": "Topical nystatin",
"B": "Topical clobetasol",
"C": "Prednisone",
"D": "Fluconazole",
"E": ""
}
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A
|
This patient has a rash consistent with candidal intertrigo given the location and history of a damp, pruritic rash. The most appropriate next step in management is topical nystatin powder.
Intertrigo is caused by the Candida species and is characterized by pruritic, painful, and erythematous superficial patches surrounded by satellite lesions. They are commonly seen in intertriginous areas such as the breasts, groin, axilla, or abdominal pannus. Obesity and diabetes are significant risk factors. Initial management involves maintaining skin dryness along with medical treatment using topical nystatin, clotrimazole, or miconazole. Persistent lesions may require oral antifungal treatment.
Nobles and Miller review the evidence regarding the diagnosis and treatment of intertrigo. They discuss how these lesions often become infected with Candida. They recommend the use of antifungal medications.
Figure/Illustration A shows candidal intertrigo in the breast fold. Note the satellite lesions that surround the erythematous patch.
Incorrect Answers:
Answer A: Fluconazole is indicated for moderate to severe disease or if the rash is refractory to topical antifungals. Topical antifungal agents should be used before progressing to oral medications.
Answer B: Prednisone is not indicated and would potentially worsen the rash through immunosuppression and exacerbation of the patient's diabetes mellitus.
Answer C: Topical clobetasol is a high-potency corticosteroid. This would not be used because it can promote infection and lead to skin atrophy. Low-potency corticosteroids such as triamcinolone or hydrocortisone can be used as adjuncts for symptom control only.
Answer D: Topical imiquimod is indicated for autoimmune skin diseases such as alopecia areata not for candidal intertrigo. This disease would present with segmental regions of hair loss
Bullet Summary:
The treatment of candidal intertrigo involves topical antifungals including nystatin, clotrimazole, and miconazole.
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A 4-day-old neonate is brought to the pediatrician with vaginal discharge for the last 2 days. Her daughter has been feeding and voiding well. The neonate was delivered at 39 weeks gestation via an uncomplicated vaginal delivery and was discharged home after 2 days. The prenatal course was complicated by chlamydia in the mother during the first trimester, for which she and the partner were both treated with a confirmatory test of cure. The biological father is no longer involved in the patient's life, but her mother’s boyfriend has been caring for the baby whenever the mother rests. The neonate’s temperature is 98.5°F (36.9°C), blood pressure is 56/35 mmHg, pulse is 138/min, and respirations are 51/min. She appears comfortable, and cardiopulmonary and abdominal exams are unremarkable. There are no bruises or marks on her skin. Examination of the genitals reveals no vulvar irritation or skin changes but there is scant pink mucoid discharge at the introitus. Which of the following is the most appropriate next step in management?
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{
"A": "Reassurance",
"B": "Vaginal culture",
"C": "Warm water irrigation of the vagina",
"D": "Report to child protective services",
"E": ""
}
|
A
|
This neonate presents with bloody vaginal discharge soon after birth without vulvar irritation, which is most consistent with physiologic neonatal vaginal discharge. Reassurance is the most appropriate next step in management.
Vaginal discharge in a neonate that is bloody and/or mucoid is most commonly due to the rapid withdrawal of maternal hormones that cross the placenta. This results in a pink discharge that may be observed as “menses” in the perinatal period. This most commonly presents several days to 1 week after birth and will self-resolve. Without concerning red flags such as genital trauma, mucopurulent discharge, or surrounding skin changes, there is no need for work-up or treatment. Additional concerning findings should prompt a work-up for child abuse.
Guritzky and Rudnitsky review the evidence regarding the work-up of a bloody neonatal diaper. They discuss how using an Apt test can be helpful in distinguishing between maternal and fetal blood. They recommend being aware of neonatal conditions that can cause bleeding to avoid missing pathologies.
Incorrect Answers:
Answer B: Reporting the case to child protective services would be necessary if child abuse were suspected. Although having an unrelated adult as a caregiver is traditionally a risk factor, there is no evidence that this neonate is being abused. Risk factors include vaginal trauma and bruising.
Answer C: Vaginal culture may be indicated if an infectious etiology such as chlamydia or group A streptococcus is suspected; however, this would more commonly present with bloody and mucopurulent discharge with or without surrounding skin inflammation. Furthermore, the patient’s mother was successfully treated for chlamydia during pregnancy, making chlamydial infection unlikely.
Answer D: Vaginal exam under anesthesia would be appropriate if a foreign body or trauma is suspected because prepubescent children should not undergo exams while awake. In a neonate with physiologic discharge, an exam is unnecessary. Foreign bodies would present with bloody discharge, pain, and potential purulence.
Answer E: Warm water irrigation of the vagina may be helpful in locating a foreign body, which is the most common cause of vaginal bleeding and discharge in a prepubertal girl. This is unlikely in a neonate and there is no evidence of trauma or irritation in the perineum.
Bullet Summary:
Vaginal discharge in a neonate is most commonly due to the withdrawal of maternal hormones and will self-resolve.
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128
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A 29-year-old woman comes to the emergency department complaining of painful genital ulcers that have been present for 4 days as well as low-grade fever and malaise. She denies any recent travel, new sexual partners, or antibiotic use. Physical examination reveals multiple clustered vesicles and shallow ulcers in the vulvar region. A Tzanck smear shows multinucleated giant cells. Which of the following medications is most appropriate for treating her condition?
|
{
"A": "Acyclovir",
"B": "Amoxicillin",
"C": "Fluconazole",
"D": "Trimethoprim-sulfamethoxazole",
"E": ""
}
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A
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The patient's painful genital ulcers coupled with the presence of multinucleated giant cells on a Tzanck smear are indicative of a herpes simplex virus type 2 (HSV-2) infection. Acyclovir is the treatment of choice.
Herpes infections can present with painful genital ulcers and low-grade fever. The Tzanck smear showing multinucleated giant cells further confirms the diagnosis though the diagnosis is typically made on clinical grounds and treated empirically. Acyclovir is the drug of choice for treating HSV-2 as it inhibits viral DNA polymerase, preventing the virus from replicating. The drug can reduce the duration and severity of symptoms but does not eradicate the virus entirely.
Groves (2016) emphasizes that genital herpes, caused by the herpes simplex virus (HSV), affects over 400 million people worldwide. The infection is lifelong, with vesicular outbreaks in genital areas that can ulcerate. While HSV-1 and HSV-2 are both culprits, the latter increases the risk of HIV acquisition. The polymerase chain reaction assay is the recommended diagnostic method. Nucleoside analogues are effective treatments, and pregnant women with the condition are advised antiviral prophylaxis from the 36th week until delivery to prevent neonatal complications.
Incorrect Answers:
Answer B: Amoxicillin is an antibiotic ineffective against viral infections like HSV-2. It is commonly used for bacterial infections such as streptococcal pharyngitis.
Answer C: Fluconazole is an antifungal agent is used for treating fungal infections like Candida which may cause esophagitis or vaginitis.
Answer D: Metronidazole is used primarily for anaerobic bacterial and protozoal infections.
Answer E: Trimethoprim-sulfamethoxazole is used for bacterial infections like urinary tract infections and also offers MRSA coverage.
Bullet Summary:
Acyclovir is the drug of choice for treating herpes simplex virus infections.
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129
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A 3-year-old boy presents with his parents to a pediatrician for a new patient visit. The child was recently adopted and little is known about his medical or family history. The child seems to be doing well, but the patient is much larger than any of the other 3-year-olds in his preschool class. He eats a varied diet at home and with limited juice and snack foods. His temperature is 98.6°F (37°C), blood pressure is 101/67 mmHg, pulse is 110/min, and respirations are 24/min. On physical exam, the patient is in the 73rd percentile for weight, 99th percentile for height, and 86th percentile for head circumference. He appears mildly developmentally delayed. He has a fair complexion and tall stature with a prominent sternum. The patient also has joint hypermobility and hyperelastic skin. He appears to have poor visual acuity and is referred to an ophthalmologist, who finds downward lens subluxation of the right eye. This child is most likely to develop which of the following complications?
|
{
"A": "Thromboembolic stroke",
"B": "Wilms tumor",
"C": "Osteoarthritis",
"D": "Aortic dissection",
"E": ""
}
|
A
|
This patient presents with Marfanoid habitus, joint hypermobility, hyperelastic skin, developmental delay, and downward lens subluxation, which suggests a diagnosis of homocystinuria. Homocystinuria predisposes to thromboembolic events such as stroke.
Although homocystinuria shares many features with Marfan syndrome, patients with homocystinuria also present with a fair complexion, intellectual disability, and downward subluxation of the lens (instead of the upward subluxation seen in Marfan syndrome). Patients with homocystinuria are also at an increased risk of thromboembolic events that disproportionally affect the cerebral vessels. Similar to Marfan syndrome, patients have phenotypic features of a Marfanoid habitus, including tall stature, long limbs, arachnodactyly, joint hypermobility, skin hyperelasticity, pectus deformity, and scoliosis. Treatment includes vitamin B6 supplementation.
Hasan et al. review the evidence regarding diseases associated with homocystinuria. They discuss how this disease is associated with cancer and Alzheimer disease. They recommend screening for this disease.
Incorrect Answers:
Answer A: Aortic dissection is a complication of Marfan syndrome, an autosomal dominant mutation of the fibrillin-1 gene. It is also associated with elevated homocysteine levels. Although Marfan syndrome shares many features with homocystinuria, the fair complexion, and intellectual disability seen in this patient are specific to homocystinuria. Treatment involves avoidance of contact sports and beta blockers.
Answer B: Medullary thyroid cancer is part of the syndrome of multiple endocrine neoplasia type 2B (MEN2B), which is caused by a mutation in the RET proto-oncogene. Patients with MEN2B present with Marfanoid habitus, but they do not present with the other features described in this vignette, including fair complexion, intellectual disability, and downward lens subluxation. Treatment is with surgical excision of tumors.
Answer C: Osteoarthritis is a complication of Ehlers-Danlos syndrome (EDS). Although patients with EDS may present with many of the phenotypic features of both Marfan syndrome and homocystinuria, patients are much less likely to have lens subluxation. Osteoarthritis may be seen with higher incidence in patients with homocystinuria. Treatment is with brace support of unstable joints.
Answer E: Wilms tumor is associated with Beckwith-Wiedemann syndrome (BWS), a pediatric overgrowth disorder usually caused by a mutation at chromosome 11p15. BWS presents with macrosomia (“gigantism”), which is defined as height and weight > 97th percentile. BWS additionally presents with omphalocele, hemihyperplasia, visceromegaly, neonatal hypoglycemia, and other embryonal tumors, including hepatoblastoma and neuroblastoma. Treatment is with surgical correction of defects.
Bullet Summary:
Homocystinuria presents with Marfanoid habitus, fair complexion, intellectual disability, downward lens subluxation, and an increased risk of thromboembolic events.
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130
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A 6-hour-old newborn boy is noted to have a “lump on his head” by his mother. She denies that the lump was present at birth and is concerned about an infection. The child was born at 39 weeks gestation to a 34-year-old G2P2 mother by vacuum-assisted vaginal delivery after prolonged labor. His birth weight was 3.8 kg (8.4 lb) and his length and head circumference are at the 40th and 60th percentiles, respectively. The mother was diagnosed during this pregnancy with gestational diabetes mellitus and received prenatal care throughout. All prenatal screening was normal and the 20-week anatomy ultrasound was unremarkable. His temperature is 98.6°F (37°C), blood pressure is 65/42 mmHg, pulse is 131/min, and respirations are 36/min. On physical exam, the child is in no acute distress. He has a 3x3 cm fluctuant swelling over the right parietal bone that does not cross the midline. There is no discoloration of the overlying scalp. Laboratory testing is performed and reveals the following:
Total bilirubin: 5.5 mg/dL
Direct bilirubin: 0.7 mg/dL
Which of the following is the most appropriate next step in management?
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{
"A": "Intensive phototherapy",
"B": "Incision and drainage",
"C": "Red blood cell transfusion",
"D": "Observation only",
"E": ""
}
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D
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This patient presents with a fluctuant swelling of the scalp that is limited by suture lines, which is the classic description of a cephalohematoma. The majority of cases of cephalohematoma self-resolve, thus the most appropriate next step in management is observation.
A cephalohematoma is a relatively common traumatic birth injury that occurs after prolonged labor or instrumentation due to rupture of the periosteal bridging veins. Because bleeding through these veins is slow, they typically present several hours after birth with a fluctuant swelling of the scalp that is limited by suture lines. The majority of cases self-resolve between 2 weeks to 3 months. In rare cases, the sequestration of blood in the cephalohematoma may cause an unconjugated hyperbilirubinemia that requires phototherapy but this is a rare complication. Treatment is with reassurance and outpatient monitoring.
Raines et al. review the evidence regarding the diagnosis and treatment of cephalohematoma. They discuss how this injury presents gradually and does not cross suture lines. They recommend conservative treatment.
Incorrect Answers:
Answer A: An incision and drainage procedure is contraindicated in cephalohematoma without signs of infection, such as erythema of the skin overlying the swelling. In cases where the cephalohematoma is thought to be secondarily infected, patients should undergo incision and drainage to prevent osteomyelitis. Patients would present with increasing pain, erythema, and systemic findings such as fever.
Answer B: Intensive phototherapy may be used to manage the unconjugated hyperbilirubinemia that may occur due to cephalohematoma, but the majority of cases resolve spontaneously. The unconjugated hyperbilirubinemia found in this patient does not necessitate phototherapy. Unconjugated bilirubin is produced due to the metabolism of hemoglobin.
Answer C: Neurosurgical decompression may be necessary to manage other neonatal birth injuries, such as intracranial hemorrhages. Because a cephalohematoma involves bleeding between the periosteum and skull (i.e., outside of the skull), it does not require neurosurgical intervention. Intracranial hemorrhages would present with asymmetric reflexes or obtundation.
Answer E: Red blood cell transfusions are sometimes necessary to manage intracranial hemorrhages in neonates with significant blood loss. They are not usually required to manage cephalohematoma as the bleeding in this condition is limited by the suture lines. Patients who are tachycardic or hypotensive may require transfusion.
Bullet Summary:
Most cases of cephalohematoma resolve spontaneously but can sometimes present with an unconjugated hyperbilirubinemia that requires treatment with phototherapy.
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131
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A 5-year-old girl presents to the emergency room due to difficulty walking. She has been complaining of pain in her right leg for the last few days. Her neighbor’s cat bit her last week and her parents attributed the pain to her healing bite. At the time of the bite, they cleaned the wound and irrigated it with sterile saline water from a first aid kit. She has no medical history and has never been hospitalized. Her temperature is 102.2°F (39°C), blood pressure is 118/78 mmHg, pulse is 90/min, respirations are 21/min, and pulse oximetry is 99% on room air. The open wound remains present on the thigh with surrounding erythema and edema. MRI is consistent with osteomyelitis. Which of the following is the most appropriate next step in management?
|
{
"A": "Doxycycline",
"B": "Ampicillin and sulbactam",
"C": "Amoxicillin and clavulanate",
"D": "Flucanozole",
"E": ""
}
|
B
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This young girl with a recent history of a cat bite and difficulty walking most likely has likely Pasteurella multocida osteomyelitis. Empiric IV antibiotic therapy with ampicillin-sulbactam is the most appropriate initial management.
Pasteurella multocida is a gram-negative rod that is associated with cat and dog bites. Infection can lead to cellulitis and osteomyelitis. Treatment of minor infection is with amoxicillin-clavulanate; however, patients suspected of having osteomyelitis should be treated empirically with IV antibiotics (e.g., ampicillin and sulbactam) and taken for biopsy/culture to identify the pathogen. Antibiotics can then be narrowed down accordingly. Patients will often require between 4-8 weeks of antibiotic treatment. MRSA coverage may initially be started and tapered later once cultures result.
Mollitt reviews the evidence regarding the microbiology of various injuries. He discusses how Pasteurella multocida is a common complication of animal bites. He recommends early effective antibiotic treatment.
Incorrect Answer:
Answer A: Amoxicillin and clavulanate can be used to treat Pasteurella infection. Patients with osteomyelitis should not be treated with oral antibiotics initially, in particular, when there are systemic manifestations as is present in this patient. IV antibiotics such as ampicillin and sulbactam are the mainstay for empiric osteomyelitis treatment after an animal bite in a patient with systemic manifestations.
Answer C: Doxycycline is used to treat uncomplicated chlamydia infections. Gonococcal osteomyelitis may present in sexually active individuals and may be associated with septic arthritis. Sexually active patients may be suspected of having this disease.
Answer D: Fluconazole is an antifungal that is used to treat Candida osteomyelitis. Candida osteomyelitis would be highly unusual in patients with no other risk factors. Instead, this disease is more common in immunodeficient patients or those who use IV drugs.
Answer E: Vancomycin is used for MRSA infections. Although S. aureus is the most common overall cause of osteomyelitis, this patient with a recent animal bite most likely has Pasteurella infection and this organism should be covered accordingly.
Bullet Summary:
Patients with suspicion of Pasteurella osteomyelitis infection after an animal bite should be treated with empiric IV antibiotics such as ampicillin and sulbactam.
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132
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A 27-year-old man presents to the emergency department after he developed pain in his right leg after landing off a ski jump. The patient is otherwise healthy and does not take any medications. He states his pain is 10/10. He is requesting medications and is crying out in pain. His temperature is 98.7°F (37.1°C), blood pressure is 149/85 mmHg, pulse is 103/min, respirations are 15/min, and oxygen saturation is 99% on room air. Physical exam reveals swelling over his right leg and knee. The patient cries out in pain with passive motion of the foot at the ankle. A radiograph is performed as seen in Figure A. Which of the following is the most likely diagnosis?
|
{
"A": "Patellar fracture",
"B": "Apophysitis of the tibial tubercle",
"C": "Posterior dislocation of the knee",
"D": "Tibial plateau fracture",
"E": ""
}
|
D
|
This patient is presenting after an axial load on his lower extremity (landing off a ski jump) with severe pain, a fracture on radiography, and severe pain with passive range of motion. This suggests compartment syndrome in the setting of a tibial plateau fracture.
Tibial plateau fractures occur as a result of an axial load, where the femur forcefully impacts the tibia, leading to intense pain in the proximal tibia region. One potential complication of this type of fracture is compartment syndrome, which presents with exquisite pain out of proportion to exam with passive motion of the lower extremity. While radiography can aid in diagnosing tibial plateau fractures, a negative radiograph should prompt further investigation with a CT scan in patients with a high suspicion of this type of fracture. Treatment involves performing a fasciotomy if compartment syndrome is present. Surgical repair is warranted if there is evidence of neurovascular compromise or a significantly displaced fracture. Otherwise, immobilizing the knee and providing outpatient orthopedic follow-up care is deemed appropriate for certain less severe fractures.
Schneiderman et al. studied compartment syndrome in high-energy tibial plateau fractures. The authors found that younger patients aged 12-29 years old are more likely to develop compartment syndrome, likely due to increased muscle mass and thicker fascial tissue. The risk of deep surgical site infection remains high at 20-25% of cases. The authors recommend that clinicians should be aware of factors associated with increased risk for compartment syndrome, including young age, male gender, and a high-energy mechanism of injury.
Figure/Illustration A is a radiograph demonstrating a tibial plateau fracture with the red arrows demonstrating a fracture of the tibial plateau.
Incorrect Answers:
Answer A: Anterior cruciate ligament tear would present with a sudden popping sensation of the knee with swelling, knee instability, and laxity to anterior traction when force is applied to the tibia causing anterior displacement of the tibia relative to the femur. Management involves assessment with MRI and surgical repair in complete tears or immobilization in partial tears.
Answer B: Apophysitis of the tibial tubercle (Osgood-Schlatter disease) is common in pediatric patients and presents after exertion (such as basketball or jumping) with pain and tenderness over the tibial tubercle. It is caused by repeated microtrauma or microavulsion, separation of the proximal patellar tendon from the tibial tubercle, and subsequent callous deposition at the tibial tubercle. Management involves rest, ice, and nonsteroidal anti-inflammatory drugs.
Answer C: Patellar fracture would present with tenderness over the patella with a fracture line on the patella. Treatment of non-displaced fractures includes rest and immobilization in a straight-leg knee immobilizer.
Answer D: Posterior dislocation of the knee presents with sudden trauma to the knee with pain, swelling, and a loss of pulses in the extremity when the popliteal artery is compromised. Radiography is diagnostic and will show a knee dislocation. Treatment involves immediate reduction to avoid permanent injury to the popliteal artery.
Bullet Summary:
Tibial plateau fractures present after trauma with severe lower extremity pain and are highly associated with compartment syndrome.
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133
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A 35-year-old G0P0000 woman presents to her gynecologist with complaints of irregular menstruation. She has had only 2 periods in the last year. She feels flushed without provocation and is experiencing occasional dyspareunia with post-coital spotting. She has also had more frequent headaches than usual. The patient has a medical history of Hashimoto thyroiditis and takes levothyroxine daily. Her mother has type 1 diabetes mellitus. Her temperature is 98.5°F (36.9°C), pulse is 70/min, blood pressure is 118/76 mmHg, and respirations are 13/min. Cardiopulmonary and abdominal exams are unremarkable. The patient has Tanner 5 breasts and pubic hair. A pelvic exam reveals a normal cervix, an anteverted uterus without tenderness, and no adnexal masses. The following laboratory studies are performed: Serum: Thyroid stimulating hormone (TSH): 28 µIU/mL (9-30 µIU/mL) Cycle day 3 follicle stimulating hormone (FSH): 49 mIU/mL (4.7-21.5 mIU/mL) Cycle day 3 estradiol: 8 pg/mL (27-123 pg/mL) Prolactin: 14 ng/mL (4-23 ng/mL) Testosterone: 42 ng/dL (15-70 ng/dL) Which of the following is the most appropriate next step in management?
|
{
"A": "Combined oral contraceptive",
"B": "Increase levothyroxine dose",
"C": "Brain MRI",
"D": "Estradiol patch with oral medroxyprogesterone",
"E": ""
}
|
D
|
This patient presents with oligomenorrhea, hot flashes, and dyspareunia, and her labs are notable for a high FSH and low estradiol, most consistent with premature ovarian insufficiency/failure (POI). The most appropriate next step in management is an estradiol patch with oral medroxyprogesterone.
POI is defined by the depletion or dysfunction of ovarian follicles, resulting in oligomenorrhea or amenorrhea with symptoms of menopause (hot flashes, vaginal atrophy and dryness, mood swings, etc.) in women under age 40. The cause is unclear and thought to be autoimmune. The main diagnostic markers are a high FSH and low estradiol at the start of the follicular phase. Patients require estrogen supplementation until around age 50, as low estrogen increases the risk of coronary artery disease, osteoporosis, and sexual dysfunction. Vaginal gel or a transdermal patch is the first-line option, but both must be used in conjunction with medroxyprogesterone to avoid unopposed estrogen and the risk of endometrial hyperplasia.
Tsiligiannis et al. review the evidence regarding the outcomes of patients with POI. They discuss how this diagnosis is made in patients younger than the age of 40. They recommend closely managing the cardiovascular risk factors associated with this disease.
Incorrect Answers:
Answer A: Brain MRI would be useful for evaluating for the presence of a prolactinoma, which could cause the headaches and oligomenorrhea seen in this patient. However, her prolactin level is normal, and she has no visual disturbances (e.g., bitemporal hemianopsia), making this study less relevant.
Answer B: The combined oral contraceptive has both estrogen and progesterone, but the doses are higher than those needed for hormone replacement. For this reason, it is generally not considered first-line for the treatment of POI.
Answer D: Increasing this patient’s levothyroxine dose is unnecessary, as her TSH level is within the normal range. Furthermore, while hypothyroidism may cause menstrual irregularities and temperature dysregulation, it is unlikely to cause vaginal dryness and subsequent dyspareunia.
Answer E: Vaginal estradiol gel is an effective method of estrogen replacement in women with POI. However, used alone it may increase the risk of endometrial hyperplasia and cancer, so it should only be used in combination with a systemic progesterone.
Bullet Summary:
Premature ovarian insufficiency should be treated with estrogen and progesterone replacement.
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134
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A 23-year-old woman presents with a 7-day history of abdominal pain, and now bloody diarrhea that brings her to her primary care physician. Review of systems is notable for a 12-pound unintentional weight loss and intermittent loose stools. She has a family history notable for a father with coronary artery disease and a mother with primary sclerosing cholangitis. Her temperature is 37.2°C (98.9°F), blood pressure is 100/72 mmHg, pulse is 72/min, respirations are 12/min, and oxygen saturation is 100% on room air. Her abdomen is soft, mildly diffusely tender to deep palpation, and non-distended. She is found to have the finding on colonoscopy in Figure A. Serum perinuclear antineutrophil cytoplasmic antibodies (p-ANCA) are positive. Which of the following is most likely to be present in this patient?
|
{
"A": "Continuous lesion beginning in the rectum",
"B": "Fistulae and stricture formation",
"C": "Worse disease severity near the ileocecal valve",
"D": "Perianal disease",
"E": ""
}
|
A
|
This patient presents with features suggestive of inflammatory bowel disease (IBD), and her colonoscopic and serologic studies suggest ulcerative colitis (UC). UC typically begins in the rectum and progresses proximally towards the ileocecal valve in a continuous fashion.
The diagnosis of IBD should always prompt further investigation to better delineate between UC, Crohn disease, or indeterminate colitis. Further delineation guides treatment and informs prognosis. UC has a peak incidence in the second and third decades of life. It is characterized by disease extending from the rectum proximally towards the ileocecal valve in a continuous fashion. UC presents as mucosal and submucosal inflammation, with characteristic crypt distortion and presence of crypt abscesses. P-ANCA is positive in most individuals with UC. Repeated mucosal injury can induce pseudopolyp formation, and pancolitis or disease in the descending colon warrants screening colonoscopy due to increased risk of colon cancer. On imaging, the colon can be dilated by edema, losing its haustral markings and giving it a "lead pipe" appearance.
Gajendran et al. review the pathophysiology, diagnosis, and treatment of UC. They found that colonoscopy with biopsy is the best way to make a definitive diagnosis of UC. They recommend the Mayo scoring system as a commonly used method of assessing disease severity, guiding treatment options, and monitoring patients during therapy.
Figure A is a colonoscopy image showing continuous colonic mucosal inflammation typical of ulcerative colitis.
Incorrect Answer:
Answer A: Cobblestoning and skip lesions refer to the patchy areas of inflammation noted in Crohn disease. In contrast, the inflammation seen in UC involves continuous stretches of colon mucosa.
Answer C: Fistulae and stricture formation are features of Crohn disease, not UC. Fistulizing and stricture formation can affect the entire gastrointestinal tract in Crohn disease.
Answer D: Perianal disease is a feature of Crohn disease. Although UC commonly affects the rectum, it tends to spare the anus.
Answer E: Worse disease severity near the ileocecal valve is a feature of Crohn disease and not UC. UC tends to be characterized by more uniform disease severity spanning in continuous fashion from rectum towards the cecum.
Bullet Summary:
Ulcerative colitis is characterized by disease extending from the rectum proximally towards the ileocecal valve in a continuous fashion.
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135
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A 69-year-old man presents to his primary care physician for a general checkup. Overall he is doing well. Since he retired, he has been working on projects at home and taking time to exercise every day. He eats a balanced diet and has been spending time with his wife every evening. Despite this, the patient claims that he feels less well-rested when he wakes up in the morning. The patient states that he used to sleep 9 hours a night in his youth and felt excellent. Now he sleeps 7 hours a night and doesn’t feel as well rested as he used to. The patient’s wife states that he seems to sleep peacefully. His medical history is significant for hypertension and diabetes for which he takes lisinopril and metformin. His temperature is 98.6°F (37°C), blood pressure is 131/85 mmHg, pulse is 71/min, and respirations are 12/min. His neurological exam is within normal limits. The patient is muscular and has a healthy weight with a pleasant demeanor. He denies feeling fatigued or tired currently. Which of the following physiological changes would most likely be seen in this patient?
|
{
"A": "Increased dopamine",
"B": "Decreased orexin",
"C": "Decreased melatonin",
"D": "Increased norepinephrine",
"E": ""
}
|
C
|
This elderly patient is presenting with sleep that is sufficient but less refreshing than sleep was for him in his past suggesting a diagnosis of normal aging. Melatonin levels naturally decrease as patients age.
Normal aging shortens most phases of sleep. It is normal for melatonin levels to decline during normal aging; however, this change is not responsible for all the symptoms associated with declining quality of sleep. Other changes that occur include decreased REM sleep, decreased stage N3 sleep, and a compensatory increase in stage N2 sleep. Patients will often complain of sleep that is less refreshing than it was in their youth, yet they are still functional and not excessively tired. Treatment is with sleep hygiene though some patients will also benefit from treatment with melatonin supplementation.
Cardinali reviews the role of melatonin in aging. He discusses how natural levels of melatonin decrease in aging animals, which may have implications on the circadian clock. He recommends studies on whether melatonin supplementation may be beneficial to mitigate the effects of aging.
Incorrect Answers:
Answer B: Decreased orexin levels would be seen in patients with narcolepsy, which presents with sudden episodes of falling asleep. This tends to occur in younger patients and is also associated with cataplexy or sudden loss in muscle tone. Treatment of this disorder is with stimulant medications such as modafinil.
Answer C: Increased acetylcholine levels would not be seen in patients as they age and would not explain the changes this patient is experiencing. Rather, acetylcholine levels tend to decline as we age. Drinking caffeinated drinks is associated with increased acetylcholine levels in the brain.
Answer D: Increased dopamine would not be a principle change seen in age-related sleep changes. Higher dopamine levels would increase feelings of being awake as well as alertness. In contrast, decreased dopamine levels can be seen in patients with Parkinson disease, which would present with bradykinesia and a resting tremor.
Answer E: Increased norepinephrine would result in increased wakefulness and potentially insomnia; however, it would not explain the changes seen in normal aging. This chemical is naturally produced during the fight or flight response and can be artificially increased by stimulant drugs such as cocaine.
Bullet Summary:
Normal aging results in a shortening of most phases of sleep as well as decreased melatonin levels and presents with sleep that is subjectively less restful.
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136
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A 3-week-old girl presents with her parents to her pediatrician for a routine visit. The child is sleeping at regular 2-hour intervals and feeding and stooling well. The parents have noticed a “swelling of the belly button.” Cord separation occurred at 7 days of age. The swelling seems to come and go but is never larger than the size of a blueberry. They deny any drainage from the swelling. Her temperature is 98.6°F (37°C), blood pressure is 68/43 mmHg, pulse is 128/min, and respirations are 32/min. On physical exam, the child is in no acute distress and appears developmentally appropriate for her age. Her abdomen is soft and non-tender with a soft, 1 cm bulge at the umbilicus. The bulge increases in size when the child cries and can be easily reduced inside the umbilical ring without apparent pain. Which of the following is the most appropriate next step in management?
|
{
"A": "Elective surgical management",
"B": "Immediate surgical management",
"C": "Expectant management",
"D": "Histopathologic evaluation",
"E": ""
}
|
C
|
This infant presents with a soft, 1 cm bulge at the umbilicus that is easily reducible inside the umbilical ring, which suggests a diagnosis of an umbilical hernia. Most umbilical hernias in children resolve spontaneously and can be managed expectantly.
An umbilical hernia is a protrusion of bowel, omentum, or preperitoneal fat through the umbilical ring that can change in size with increases in intra-abdominal pressure (e.g., crying). The majority of umbilical hernias in patients under 5 years of age resolve spontaneously. The indications for surgery on umbilical hernias in that age group are limited to incarcerated hernias or hernias > 1.5 cm in diameter. Incarcerated hernias present with an irreducible mass that is associated with pain and erythema. Surgical closure may be considered in patients whose defects fail to close by the age of 5.
Chirdan et al. review the evidence regarding the diagnosis and treatment of pediatric patients with an incarcerated umbilical hernia. They discuss how most patients with hernias resolve spontaneously before 5 years of age but a small number will have incarcerated hernias that require surgery earlier. They recommend active observation of patients to diagnose incarceration earlier.
Incorrect Answers:
Answer A: Elective surgical management later on in childhood is usually not required to manage umbilical hernias as most umbilical hernias in patients less than 5 years of age close spontaneously. Hernias that persist past age 5 can be closed surgically in an elective fashion.
Answer C: Histopathologic evaluation would be the most appropriate next step in management if the patient had an unknown umbilical mass, such as an umbilical granuloma or polyp. Umbilical granulomas form shortly after birth from excess tissue at the base of the umbilicus and can be treated topically, whereas umbilical polyps are firm masses of omphalomesenteric duct or urachal embryologic remnants and require surgical excision.
Answer D: Immediate surgical management is required in patients with incarcerated hernias, but this patient’s hernia is easily reducible and < 1.5 cm. Incarcerated hernias present with an irreducible mass that is associated with pain and erythema.
Answer E: Thyroid hormone replacement would be indicated in newborns that suffer from hypothyroidism which could present with an umbilical hernia. This patient has no other symptoms of hypothyroidism such as dry skin, hypoactive reflexes, constipation, poor muscle tone, and coarse facial features.
Bullet Summary:
Umbilical hernias are common in children and usually resolve spontaneously in children under 5 years of age.
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137
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A 22-year-old woman presents to the emergency department with shortness of breath. She was hiking when she suddenly felt unable to breathe and had to take slow deep breaths to improve her symptoms. The patient is a Swedish foreign exchange student and does not speak any English. Her medical history and current medications are unknown. Her temperature is 99.5°F (37.5°C), blood pressure is 127/68 mmHg, pulse is 120/min, respirations are 22/min, and oxygen saturation is 90% on room air. Physical exam is notable for poor air movement bilaterally and tachycardia. The patient is started on treatment. Which of the following parameters including forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), and diffusing capacity of carbon monoxide (DLCO) most appropriately describes this patient's underlying pathology?
|
{
"A": "Increased FVC",
"B": "Decreased airway tone",
"C": "Normal DLCO",
"D": "Increased FEV1/FVC",
"E": ""
}
|
C
|
This patient who presents with dyspnea and poor air movement bilaterally most likely has an acute asthma exacerbation. DLCO is the one parameter that is normal in these episodes.
Asthma is an obstructive lung disease that results in intermittent episodes of respiratory compromise. Asthma presents with shortness of breath typically secondary to an allergen/antigen or with exposure to exercise or cold air that causes bronchospasm. Pulmonary function testing will typically reveal a decreased FEV1, a decreased FVC, and a decreased FEV1/FVC in both asthma and emphysema. The DLCO will be normal in asthma in contrast to emphysema where the DLCO is decreased. Patients should be treated with inhaled beta-adrenergic agonists and corticosteroids for acute exacerbations.
Peng et al. review the evidence regarding patients who have COPD versus asthma. They discuss how patients with COPD have reduced DLCO. They recommend measuring parameters to distinguish between these entities.
Incorrect Answers:
Answer A: Decreased airway tone does not describe asthma. Rather, hyperreactive airways with increased tone describes an asthma attack. Decreased airway tone may be seen in patients with connective tissue diseases such as Ehlers-Danlos syndrome.
Answers 2-4: Increased FEV1, FEV1/FVC, and FVC do not describe asthma. All of these laboratory values are decreased in asthma and emphysema. Increased respiratory performance can be seen in patients who are athletes or training for marathons.
Bullet Summary:
Both asthma and emphysema present with a decreased FEV1, FVC, and FEV1/FVC; however, asthma has a normal DLCO while COPD has a reduced DLCO.
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138
|
A 36-year-old G3P2002 woman presents to her obstetrician’s office for her 1st prenatal visit at 10 weeks and 2 days gestation. She has felt nauseous the last several mornings and has been tired for a few weeks. The patient has had 2 uncomplicated spontaneous vaginal deliveries at full term with her last child born 6 years ago. She is concerned about the risk of Down syndrome in this fetus, as her sister gave birth to an affected child at age 43. She has a history of generalized anxiety disorder, atopic dermatitis, and she is currently on escitalopram. Her temperature is 98.6°F (37.0°C), pulse is 70/min, blood pressure is 121/67 mmHg, and respirations are 13/min. The patient appears anxious, but overall comfortable, and cardiopulmonary and abdominal exams are unremarkable. Pelvic exam reveals normal external genitalia, a closed and soft cervix, a 10-week-sized uterus, and no adnexal masses. Which of the following is the most appropriate next step for definitively determining whether this patient’s fetus has Down syndrome?
|
{
"A": "Anatomy ultrasound",
"B": "Genetic testing of patient’s sister",
"C": "Nuchal translucency test",
"D": "Chorionic villus sampling",
"E": ""
}
|
D
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This patient is over 35 years of age and concerned about the risk of Down syndrome (trisomy 21) in her fetus at just over 10 weeks gestation. At this gestational age, the most definitive method for determining whether such an aneuploidy is present is chorionic villus sampling (CVS).
CVS, or sampling of the placental tissue, can be performed as early as 10 weeks gestation. This is in contrast to amniocentesis, which should be avoided prior to 14 weeks. There are other screening tests for a patient concerned about aneuploidy; however, only CVS and amniocentesis offer definitive diagnoses. Complications of this procedure include pregnancy loss (at a rate of 1-2%), transverse limb abnormality, rupture of membranes, and chorioamnionitis. Patients should also have counseling if genetic abnormalities are detected using this procedure.
Farina reviews the evidence regarding the complications associated with CVS. He discusses how this procedure is becoming more common as the definitive method of providing an early diagnosis. He recommends being aware of complications such as possible pregnancy loss.
Incorrect Answers:
Answer A: Amniocentesis is a useful tool for the definitive diagnosis of aneuploidy and other genetic conditions. Due to the higher rate of fetal loss at younger gestational ages, it is reserved for those above 14 weeks.
Answer B: The anatomy ultrasound can be helpful in identifying morphologic features that are concerning for Down syndrome, such as a flat nasal bridge or an echogenic cardiac focus. This screening tool is most accurate after 18 weeks gestation.
Answer D: Genetic testing of the patient’s sister may be able to help identify if there is a parental translocation or aneuploidy that led to the child’s Down syndrome. This is much less likely than meiotic nondisjunction due to advanced maternal age, and this would not help diagnose Down syndrome in the patient’s fetus.
Answer E: The nuchal translucency test examines the thickness of the nuchal fold. When the thickness exceeds normal measurements, there is an increased risk of aneuploidy such as Down syndrome, but this is a screening result that would not provide a definitive diagnosis.
Bullet Summary:
Chorionic villus sampling is a definitive method of identifying aneuploidy in fetuses starting at 10 weeks of gestational age.
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139
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An 8-year-old boy is brought to the emergency department by his parents for evaluation. He has had headache and fever for the last 2 days, and this morning he was confused and had difficulty answering questions. He also developed a rash this morning. He recently returned from summer camp. He has no significant medical history and takes no medications. His temperature is 104°F (40°C), pulse is 120/min, blood pressure is 105/60 mmHg, and respirations are 22/min. On exam, flexion of the neck causes flexion of the hips and knees. Fundoscopic exam reveals no papilledema. Examination of the patient's rash is shown in Figure A. Which of the following is the most appropriate next step in management?
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{
"A": "Lumbar puncture, ceftriaxone, vancomycin, and methylprednisolone",
"B": "MRI brain",
"C": "Vancomycin and ceftriaxone",
"D": "Vancomycin, ceftriaxone, and dexamethasone",
"E": ""
}
|
A
|
This patient with fever, headache, signs of meningeal irritation, and a purpuric rash likely has bacterial meningitis. The most appropriate initial step in management is a lumbar puncture as well as ceftriaxone, vancomycin, and methylprednisolone.
Meningitis classically presents with fever, neck stiffness or headache, and altered mental status. Specific physical exam findings that can suggest the diagnosis include meningeal signs such as a positive Kernig sign (inability to extend the knee while the hip is flexed) and Brudzinski sign (flexion of the neck results in flexion of lower extremities). Common causative agents include Streptococcus pneumoniae and Neisseria meningitidis. The latter of which is associated with the purpuric rash seen in this patient. The best initial step in management is a lumbar puncture followed promptly by IV broad spectrum antibiotics. Once the diagnosis/infectious agent is confirmed, the antibiotic agents can be refined. Other early steps in management include early blood cultures and fluid resuscitation. Steroids should be given in the setting of suspected Waterhouse-Friderichsen syndrome and concern for adrenal failure.
Linder et. al review meningococcal meningitis. They discuss the pathophysiology, clinical manifestations, and diagnosis. They describe the association of purpuric rash with meningococcal infection, and note that this is indicative of disseminated intravascular coagulation.
Figure A. demonstrates a purpuric rash over the lower extremities, which is classically associated with meningococcal meningitis. However, this can occur with meningitis or bacteremia from other infectious agents, as it is indicative of disseminated intravascular coagulation.
Incorrect Answers:
Answer A: Blood and urine cultures would be appropriate initial management for a fever of unknown origin and in this patient. Early antibiotics must be given as well to reduce mortality and improve outcomes.
Answer C: MRI brain would not be appropriate in this setting. While CNS imaging is sometimes indicated prior to lumbar puncture if signs of increased intracranial pressure such as papilledema are present, CT imaging is typically preferred. Time required to obtain MR imaging is prohibitive and would delay definitive care for this patient.
Answer D: Vancomycin and ceftriaxone are an appropriate initial antibiotic regimen for meningitis in children and adults. However, steroids are often added empirically. Lumbar puncture should be performed prior to administration of antibiotics (if possible) to avoid sterilization of the CSF.
Answer E: Vancomycin, ceftriaxone, and prednisone are an appropriate initial regimen for meningitis in adults. Steroids have been shown to reduce inflammation and prevent neurologic sequelae. However, lumbar puncture should be performed prior to administration of antibiotics if possible to avoid sterilization of the CSF. Also, IV steroids are preferred rather than oral in ill patients.
Bullet Summary:
The best initial step in management for meningitis is a lumbar puncture followed by broad-spectrum antibiotics and steroids.
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140
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A 59-year-old man presents to his primary care physician for fatigue. In general, he has been in good health; however, he recently has experienced weight loss, abdominal pain, and general fatigue. He has a medical history of anxiety, diabetes, a fracture of his foot sustained when he tripped, and a recent cold that caused him to miss work for 1 week. His current medications include metformin, insulin, buspirone, vitamin D, calcium, and sodium docusate. His temperature is 99.5°F (37.5°C), blood pressure is 150/100 mmHg, pulse is 90/min, respirations are 18/min, and oxygen saturation is 98% on room air. Physical exam reveals a calm gentleman. A mild systolic murmur is heard in the left upper sternal region. The rest of the physical exam is within normal limits. Laboratory values are ordered as seen below. Hemoglobin: 12 g/dL Hematocrit: 36% Leukocyte count: 66,500/mm^3 with normal differential Platelet count: 177,000/mm^3 Leukocyte alkaline phosphatase: elevated Serum: Na+: 139 mEq/L Cl-: 100 mEq/L K+: 4.3 mEq/L BUN: 20 mg/dL Glucose: 120 mg/dL Creatinine: 1.1 mg/dL Ca2+: 10.9 mEq/L AST: 12 U/L ALT: 10 U/L Which of the following is the most likely diagnosis?
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{
"A": "Chronic lymphocytic leukemia",
"B": "Chronic myeloid leukemia",
"C": "Leukemoid reaction",
"D": "Multiple myeloma",
"E": ""
}
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C
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This patient is presenting with leukocytosis and an elevated leukocyte alkaline phosphatase suggestive of a leukemoid reaction.
A leukemoid reaction typically presents with a drastically elevated leukocyte count (typically > 50,000/mm^3) in the setting of an elevated leukocyte alkaline phosphatase score (LAP). This reaction typically occurs after a major infection and is an immunologic response to the pathogen that caused the illness. In contrast, chronic myeloid leukemia presents with a similar elevation in leukocytes but a low LAP score in addition to symptoms of general malaise, fatigue, and weight loss. The LAP score is the critical differentiating factor when comparing these 2 pathologies. Treatment for a leukemoid reaction is by addressing the underlying pathology.
Portich and Faulhaber review the evidence regarding the diagnosis of leukemoid reaction. They discuss how the most common cause is infection. They recommend considering paraneoplastic syndromes in patients without evidence of infection.
Incorrect Answers:
Answer A: Acute lymphoblastic lymphoma presents in a pediatric patient with pallor, fatigue, easy bruising, fever, bone pain, hepatomegaly, and splenomegaly. Treatment is with combination chemotherapy.
Answer B: Chronic lymphocytic leukemia can present similarly to a leukemoid reaction with non-specific systemic symptoms and lymphadenopathy but is a less likely diagnosis in this patient given his age and LAP score. Treatment is with ibrutinib and rituximab as well as other agents.
Answer C: Chronic myeloid leukemia presents with systemic symptoms, fatigue, malaise, weight loss, and abdominal pain with an elevated leukocyte count (typically > 50,000/mm^3) but a depressed LAP score. Treatment is with tyrosine kinase inhibitors.
Answer E: Multiple myeloma presents with systemic symptoms, weight loss, pathologic fractures, and hypercalcemia. It is not associated with an elevated leukocyte score and an elevated LAP score. Treatment is with steroids and chemotherapy.
Bullet Summary:
Both a leukemoid reaction and chronic myeloid leukemia present with an elevated leukocyte count (> 50,000/mm^3), but an elevated leukocyte alkaline phosphatase score is suggestive of a leukemoid reaction.
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141
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A 30-year-old man presents to the emergency room with a laceration over the 4th metacarpophalangeal (MCP) joint of his right hand. He reports that he is a mailman, and his closed fist was bitten by a dog while he was delivering mail yesterday. He reports pain but denies fevers, chills, drainage, or any other symptoms. The dog is up to date on vaccinations. His last tetanus vaccine was 3 years ago. He has no medical history and takes no medications. His temperature is 98.6°F (37.0°C), pulse is 80/min, blood pressure is 125/75 mmHg, and respirations are 16/min. Examination of the patient's right hand is shown in Figure A. Which of the following is the most appropriate next step in management?
|
{
"A": "Clindamycin",
"B": "Amoxicillin-clavulanate",
"C": "Clindamycin plus doxycycline",
"D": "Wound closure and amoxicillin-clavulanate",
"E": ""
}
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B
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This patient has suffered a clenched fist injury which are generally managed with irrigation and amoxicillin-clavulanate.
Amoxicillin-clavulanate is the usual first-line antibiotic for patients with a human or dog bite. Lacerations sustained from animal or human bites should not be sutured due to the risk of infection. Amoxicillin-clavulanate is first-line therapy for prophylaxis and treatment of human bites and dog bites, in general. Closed fist injuries put the patient at a high risk for osteomyelitis, septic arthritis, and tenosynovitis; therefore, prophylactic antibiotics are appropriate. Amoxicillin-clavulanate provides essential coverage against Pasturella multocida, commonly found in the mouths of dogs, cats, and other mammals. In patients with a penicillin allergy, agents such as TMP-SMX, doxycycline, or cefdinir paired with anaerobic coverage (clindamycin or metronidazole) is appropriate.
Presutti discusses the prevention and treatment of dog bites. Appropriate treatment consists of immediate, copious irrigation, assessment for risk of tetanus and rabies, and administration of prophylactic antibiotics as discussed above.
Figure A shows a dog bite wound over the 4th MCP of the right hand.
Incorrect Answers:
Answer B: Cephalexin does not cover species that are typically present in the mouths of dogs and other mammals and is therefore not an appropriate antibiotic choice for this patient as monotherapy.
Answer C: Clindamycin provides coverage of anaerobic species, but is not sufficient alone for treatment of this patient's injury.
Answer D: Clindamycin plus doxycycline may be appropriate coverage for a dog bite in a patient with an allergy to amoxicillin-clavulanate. However, this patient has no stated allergies and should receive amoxicillin-clavulanate.
Answer E: Wound closure and amoxicillin-clavulanate would not be appropriate. Lacerations sustained from dog or cat bites are not sutured closed due to the risk of infection.
Bullet Summary:
Amoxicillin-clavulanate is the first line antibiotic choice for patients with dog or cat bites.
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142
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A 60-year-old woman presents to the emergency department with back pain after gardening. Her pain is 7/10 in severity, non-radiating, and not relieved by rest. She has never experienced this pain in the past and denies fever, night sweats, unintentional weight loss, and bowel or bladder incontinence. She has hypertension for which she takes hydrochlorothiazide and had a recent asthma flare requiring a prednisone taper. She does not drink alcohol or smoke. Her temperature is 98.6°F (37.0°C), blood pressure is 120/80 mmHg, pulse is 90/min, and respirations are 18/min. Physical exam reveals an uncomfortable middle-aged woman in no acute distress. There is no tenderness to palpation of the spinous processes. Flexion of the hip with the knee extended while the patient is supine does not elicit any pain, nor does forced dorsiflexion of the foot at terminal hip extension. She has 5/5 strength to hip flexion, extension, abduction, and adduction; knee flexion and extension; and ankle dorsiflexion and plantarflexion bilaterally. Bilateral patellar and Achilles reflexes are 2+. Serum laboratory results are as follows: Hemoglobin: 12.0 g/dL Creatinine: 1.1 mg/dL Ca2+: 10.6 mg/dL Which of the following is the most likely diagnosis?
|
{
"A": "Spondylolisthesis",
"B": "Lumbosacral strain",
"C": "Herniated disc",
"D": "Multiple myeloma",
"E": ""
}
|
B
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This patient presents with acute low back pain after physical exertion without radicular signs (e.g., motor or sensory changes in a nerve root distribution) and a negative straight leg raise, which are most consistent with lumbosacral strain.
The evaluation of acute low back pain is focused on eliciting clinical history and signs that would indicate further work-up. In patients without significant trauma, the presence of signs of spinal cord compression (e.g., urinary retention, bowel incontinence, saddle anesthesia, focal neurologic deficits), history of or strong risk factors for cancer, signs of infection, or risk of vertebral compression fracture should prompt additional work-up with imaging such as radiographs or magnetic resonance imaging. If none of these findings are present (most patients with acute low back pain in the primary care setting), then conservative therapy for 4-6 weeks consisting of non-steroidal anti-inflammatory drugs with or without physical therapy is indicated.
Patel and Ogle review the management of acute low back pain in the primary care setting. They outline the Waddell signs, which indicate the presence of a functional (signs of excessive pain behavior) aspect of pain. The authors recommend surgical evaluation only in patients with worsening neurologic deficits or intractable pain resistant to conservative treatment.
Incorrect Answers:
Answer A: Herniated discs occurs when the nucleus pulposus herniates through a weakened part of the annulus fibrosus of an intervertebral disc, resulting in spinal nerve root compression. This causes radicular findings at the level of compression, including weakness in hip abduction and ankle dorsiflexion with L5 involvement and weakness in ankle plantarflexion and reduced Achilles reflex with S1 involvement, and radiation of pain into the ipsilateral lower extremity. The straight leg raise test would be positive, as it exacerbates the nerve root compression.
Answer C: Multiple myeloma presents with hypercalcemia, anemia, renal failure, and lytic bone lesions causing bone pain. This patient has no constitutional symptoms to suggest a malignant process and has a mild elevation in serum calcium, which is likely due to her thiazide diuretic. The clear association of her back pain with exertion makes lumbosacral strain more likely.
Answer D: Spondylolisthesis occurs when a vertebral body is forwardly subluxated relative to the adjacent vertebral body. This presents as back pain alleviated by rest. Since this can narrow the spinal canal, it may also present with neurogenic claudication, manifesting as buttock or leg pain with walking that can be alleviated by bending forward. This patient’s back pain is not alleviated by rest and is associated with exertion.
Answer E: Vertebral compression fractures can present as back pain in a patient with minor or no trauma. These patients have osteoporosis and other risk factors like advanced age or chronic corticosteroid use and would have point tenderness at the site of fracture. This patient does not have point tenderness or risk factors.
Bullet Summary:
Lumbosacral strain is a common cause of acute low back pain that presents after physical exertion with no radicular signs and a negative straight leg raise test.
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143
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A 42-year-old woman is enrolled in a randomized controlled trial to study cardiac function in the setting of several different drugs. She is started on verapamil and instructed to exercise at 50% of her VO2 max while several cardiac parameters are being measured. During this experiment, which of the following represents the relative conduction speed through the heart from fastest to slowest?
|
{
"A": "AV node > ventricles > atria > Purkinje fibers",
"B": "Purkinje fibers > ventricles > atria > AV node",
"C": "Purkinje fibers > atria > ventricles > AV node",
"D": "Purkinje fibers > AV node > ventricles > atria",
"E": ""
}
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C
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The conduction velocity of the structures of the heart are in the following order: Purkinje fibers > atria > ventricles > AV node. A calcium channel blocker such as verapamil would only slow conduction in the AV node.
The conduction velocity of cardiac tissue is determined by a wide variety of factors, including the number and identity of various ion channels, the number and type of gap junctions, and the size and composition of muscle fibers. Conduction through the Purkinje system is the fastest within the heart, allowing for coordinated contraction of the ventricles, and atrial muscle conducts faster than ventricular muscle. Conduction through the AV node is the slowest, to allow the ventricles enough time to fill with blood.
Bonke et al. review the evidence regarding the conduction velocity of parts of the heart. They discuss how the AV node is slower than the SA node. They recommend understanding how different parts of the heart conducts electricity.
Incorrect Answers:
Answers A-C & E: These choices do not correspond to the correct conduction velocities in each part of the cardiac conduction system. A calcium channel blocker would not change the relative velocities of conduction in Purkinje fibers, atria, and ventricles.
Bullet Summary:
The conduction velocity through the heart in order of speed is Purkinje fibers > atria > ventricles > AV node.
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144
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A 1-year-old girl is brought to a neurologist due to increasing seizure frequency over the past 2 months. She recently underwent a neurology evaluation which revealed hypsarrhythmia on electroencephalography (EEG) with a mix of slow waves, multifocal spikes, and asynchrony. Her parents have noticed the patient occasionally stiffens and spreads her arms at home. She was born at 38-weeks gestational age without complications. She has no other medical problems. Her medications consist of lamotrigine and valproic acid. Her temperature is 98.3°F (36.8°C), blood pressure is 90/75 mmHg, pulse is 94/min, and respirations are 22/min. Physical exam reveals innumerable hypopigmented macules on the skin and an irregularly shaped, thickened, and elevated plaque on the lower back. Which of the following is most strongly associated with this patient's condition?
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{
"A": "Cardiac rhabdomyoma",
"B": "Glaucoma",
"C": "Optic glioma",
"D": "Polyostotic fibrous dysplasia",
"E": ""
}
|
A
|
This patient with a seizure disorder, ash-leaf spots (innumerable hypopigmented macules), Shagreen patch (elevated irregular plaque on the lower back), and West syndrome (hypsarrhythmia on EEG and movements consistent with infantile spasms) likely has tuberous sclerosis. Tuberous sclerosis is associated with cardiac rhabdomyomas.
Tuberous sclerosis is a neurocutaneous disorder that is inherited in an autosomal dominant fashion. Mutations in TSC1 and TSC2 lead to unregulated cell growth, leading to the formation of hamartomas in various locations. Manifestations of tuberous sclerosis include seizures (secondary to subependymal nodules and cortical dysplasia), mental retardation, renal angiomyolipomas, facial angiofibromas, mitral regurgitation, and hypomelanotic macules (ash-leaf spots). Cardiac rhabdomyoma is strongly associated with tuberous sclerosis and can lead to arrhythmias. West syndrome, which is characterized by infantile spasms, intellectual disability, and hypsarrhythmia (a chaotic mixture of high-amplitude slow waves, multifocal spikes, and intrahemispheric-interhemispheric asynchrony) on EEG, is also associated with tuberous sclerosis. Diagnosis of tuberous sclerosis is made with genetic testing. Advanced imaging (CT or MRI) may reveal cortical tubers and lesions in the third and fourth ventricles. Abdominal imaging may reveal renal angiomyolipomas. The management of seizures in tuberous sclerosis includes anti-seizure medications, though surgery may also be pursued in select cases.
Hinton et al. studied the cardiac manifestations of tuberous sclerosis. They found that cardiac rhabdomyomas can lead to arrhythmia later in life. They recommended that infantile spasms in tuberous sclerosis be treated with vigabatrin but other seizure types should be treated similar to other epileptic disorders.
Incorrect Answers:
Answer B: Glaucoma may occur in patients with Sturge-Weber syndrome, which is characterized by "tram-track" calcifications in the brain, port-wine stains of the face, mental retardation, and epilepsy. Diagnosis is with MRI of the brain with contrast to demonstrate leptomeningeal vascular malformations that are characteristic of the disease.
Answer C: Optic glioma is associated with neurofibromatosis type 1 (NF1), which presents with hyperpigmented macules (cafe-au-lait spots), axillary freckling, and cutaneous neurofibromas. Neurofibromas in NF1 may also grow on peripheral nerves, leading to malignant peripheral nerve sheath tumors. Lisch nodules, or benign growths of the iris, may also be seen in NF1. Diagnosis of NF1 is clinical, but can be aided by genetic testing.
Answer D: Polyostotic fibrous dysplasia is associated with McCune-Albright syndrome. Polyostotic fibrous dysplasia causes fibrous tissue in bones, leading to growth abnormalities and pathologic fractures. McCune-Albright syndrome is also associated with cafe-au-lait macules, which have irregular borders, and endocrine abnormalities such as precocious puberty and hyperthyroidism. Diagnosis is supported with endocrine tests as well as genetic testing.
Answer E: Renal cell carcinoma is associated with Von-Hippel-Lindau syndrome (VHL), which presents with tumors arising in multiple organs. Patients with VHL present with hemangioblastomas in the brain, spinal cord, cerebellum, and retina, and pheochromocytoma. Pheochromocytomas release catecholamines, leading to episodic hypertension, diaphoresis, and palpitations. Diagnosis of VHL is with genetic testing.
Bullet Summary:
Tuberous sclerosis has numerous manifestations including seizures, angiofibromas, mitral regurgitation, renal angiomyolipoma, ash-leaf spots, mental retardation, and cardiac rhabdomyoma.
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145
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A 55-year-old man presents to the emergency department with right knee pain. He woke last night with sudden-onset, sharp, 10/10 non-radiating pain in his right knee. He denies recent trauma and he has no known medical problems. He denies tobacco use and will often drink 6-8 beers or spirits on weekend nights. His temperature is 98.6°F (37.0°C), pulse is 90/min, blood pressure is 140/90 mmHg, respirations are 16/min, and oxygen saturation is 97% on room air. Physical exam reveals an erythematous, edematous right knee. Passive extension of the knee is limited by pain. Synovial fluid aspiration is performed and sent for analysis, which reveals 20,000 leukocytes/mm^3, and no organisms visualized. Microscopic examination of synovial fluid is shown in Figure A. Which of the following is the most likely diagnosis?
|
{
"A": "Gout",
"B": "Septic arthritis",
"C": "Lyme arthritis",
"D": "Pseudogout",
"E": ""
}
|
A
|
The patient’s sudden-onset knee pain with effusion and synovial fluid findings are characteristic of gout.
Gout is caused by monosodium urate crystal deposition in joint spaces, most commonly in the big toe, ankle, or knee. Crystal deposition in the joint space leads to an intense inflammatory reaction that causes severe pain and joint effusion. Gout is most commonly due to lifestyle factors including a diet high in red meat and alcohol. Medications that cause elevated uric acid levels (such as thiazide diuretics) may also play a role. Conditions resulting in high cell turnover and therefore excessive purine release such as hematologic malignancies may also lead to the development of gout. Patients typically present with sudden-onset, severe pain, erythema, and joint effusion. Synovial fluid analysis will reveal an elevated leukocyte count and negatively birefringent, needle-shaped crystals. Treatment of acute gout is with NSAID medications, colchicine, or steroids depending on presentation and patient-specific factors. Prevention of further attacks is centered around lifestyle changes such as avoidance of red meat and alcohol. Xanthine oxidase inhibitors such as allopurinol are also often used for prevention of further episodes.
Neogi discusses the management of acute gout. She comments that, while synovial fluid analysis is the gold standard of diagnosis, many physicians do not routinely perform it, instead relying on clinical judgment to diagnose gout. The differential diagnosis for a gout-like presentation includes pseudogout, septic arthritis, Lyme arthritis, reactive arthritis, and rheumatoid arthritis.
Figure A shows monosodium urate crystals, which appear as negatively birefringent, needle-shaped crystals under polarized light.
Incorrect Answers:
Answer B: Lyme disease may also presents as a monoarticular arthritis in later stages. However, a recent history of tick exposure and preceding flu-like illness would also be expected.
Answer C: Pseudogout presents similar to gout, but is caused by calcium pyrophosphate deposition. Crystals appear rhomboid shaped and are positively birefringent under polarized light.
Answer D: Septic arthritis typically has higher leukocyte counts (> 50,000/mm^3) in the synovial fluid with organisms visualized on gram stain. Fever would also be expected.
Answer E: Rheumatoid arthritis may present as a monoarticular arthritis with acute flairs. However, crystals visualized in synovial fluid are more suggestive of acute gout.
Bullet Summary:
Acute gout presents with sudden-onset, severe joint pain and is characterized by needle-shaped negatively birefringent crystals visualized under polarized light.
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146
|
A 15-year-old girl is brought to the clinic because her mother is worried the patient has not yet had her period. The patient’s older sister had her first period at age 14. The mother had her first period at age 13. The patient reports she is doing well in school and is on the varsity basketball team. Her medical history is significant for asthma and atopic dermatitis. Her medications include albuterol and topical triamcinolone. Her temperature is 98°F (36.7°C), blood pressure is 111/72 mmHg, pulse is 65/min, and respirations are 14/min with an oxygen saturation of 99% on room air. Her body mass index (BMI) is 19 kg/m^2. Physical exam shows absent breast development and external genitalia at Tanner stage 1. Serum follicle-stimulating hormone (FSH) level is measured to be 38 mIU/mL. Which of the following is the most appropriate next diagnostic step?
|
{
"A": "CYP17 gene work-up",
"B": "Gonadotrophin-releasing hormone stimulation test",
"C": "Karotype",
"D": "Luteinizing hormone levels",
"E": ""
}
|
C
|
The patient is presenting with primary amenorrhea and an increased follicle-stimulating hormone (FSH) level, suggesting a gonadal abnormality and making karyotyping the most appropriate next step in management.
Primary amenorrhea can be diagnosed if a patient has normal secondary sex characteristics but no menarche by age 16, or if she has no secondary sex characteristics and no menarche as early as age 14. Primary amenorrhea is caused by either hypothalamic/pituitary (central) or gonadal (peripheral) abnormalities. Increased FSH indicates a peripheral cause or hypergonadotropic hypogonadism. Karyotyping would be the most appropriate next diagnostic step because these disorders can include Turner syndrome and androgen insensitivity syndrome.
Gravholt et al. review the evidence regarding the diagnosis and treatment of Turner syndrome. They discuss how this disease presents with hypergonadotropic hypogonadism. They recommend growth hormone therapy and hormone replacement therapy in these patients.
Incorrect Answers:
Answer A: CYP17 gene work-up should be done in patients with primary amenorrhea, an absence of secondary sex characteristics, elevated FSH, and hypertension. Alterations in the CYP17 gene can cause congenital adrenal hyperplasia due to 17-hydroxylase deficiency. The resulting excess of deoxycorticosterone is associated with hypertension and hypokalemia. Treatment is with hormone repletion therapy.
Answer B: Estrogen levels would be low in this patient as evidenced by her absence of breast development. Therefore, measuring estrogen levels would provide no additional diagnostic information. Estrogen levels may be useful in cases of peripheral gonadotropin resistance but these are rare.
Answer C: Gonadotropin-releasing hormone (GnRH) stimulation test would be the next diagnostic step if FSH were decreased. A decrease in FSH indicates a central cause or hypogonadotropic hypogonadism. A GnRH stimulation test is used to assess whether the central abnormality is due to the hypothalamus or the pituitary.
Answer E: Luteinizing hormone (LH) levels with a repeat FSH level may be helpful if FSH is low or normal. Low or normal FSH levels indicate hypogonadotropic hypogonadism as caused by hypothalamic-pituitary axis abnormalities. Cases of high FSH represent a different diagnostic entity as adequate gonadotropins are produced.
Bullet Summary:
In a patient with primary amenorrhea and an increased FSH, the next step in management is karyotyping.
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147
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A 31-year-old man presents to the emergency department for fever, malaise, and cough. For the last week, his cough has been progressively worsening, and he has been noticing blood in his sputum. He denies any recent travel or sick contacts and infrequently smokes cigarettes. Approximately 5 weeks ago, he presented with similar symptoms and was found to have a right upper lobe lung infiltrate, a CD4 count of 40/mm^3, and an HIV viral load of 115,000 copies/mL. He was appropriately treated and discharged home. Four weeks after initiation of treatment, his CD4 count was over 400/mm^3 and HIV viral load was negligible. His temperature today is 102°F (38.9°C), blood pressure is 130/90 mmHg, pulse is 100/min, and respirations are 20/min. A radiograph of the chest demonstrates new nodules in the left upper lobe and hilar adenopathy. Which of the following is the most appropriate next step in management?
|
{
"A": "Continue current anti-retroviral treatment, antimicrobial, and anti-tuberculoid therapies",
"B": "Determine drug sensitivities against the patient’s pulmonary infection",
"C": "Obtain a D-dimer level",
"D": "Start high-dose glucocorticoid treatment and discontinue antiretroviral therapy",
"E": ""
}
|
A
|
This patient with recently diagnosed HIV and tuberculosis infection (upper lung lobe infiltrate) is presenting with worsening symptoms after being appropriately treated. Worsening of symptoms after initiation of these therapies is concerning for immune reconstitution inflammatory syndrome (IRIS), which is managed by continuing current combined antiretroviral medications, antibiotics for opportunistic infections and symptom management.
IRIS describes a paradoxical worsening of a patient's underlying infection after initiating antiretroviral therapy for patients with HIV. IRIS can also occur in HIV-uninfected patients with tuberculosis or leprosy who are started on antimycobacterial treatment. The pathogenesis of IRIS is unclear, but in patients with HIV, antiretroviral therapy increases the amount of CD4+ T-helper cells, which can lead to an exaggerated inflammatory response (e.g., increased cytokine release) towards the infection. Thus, there is a paradoxical worsening of the infection symptoms. When patients have a paradoxical worsening of their symptoms in the setting of starting their antiretroviral therapy, the therapy should be continued with symptomatic management (acetaminophen for fever).
Nelson et al review IRIS. They note it is seen in patients with HIV. They recommend antiretroviral therapy and antibiotics for bacterial infections.
Incorrect Answers:
Answer B: Determining drug sensitivities against the patient’s pulmonary infection would be of low diagnostic utility since IRIS best explains his current clinical presentation.
Answer C: Discontinuing antimicrobial treatment would not be appropriate since the patient has findings concerning for tuberculosis (upper lobe lung infiltrate), and lack of treatment can lead to progression of his infection.
Answer D: Obtaining a D-dimer level is only indicated in low-risk patients for pulmonary embolism by Wells criteria.
Answer E: Starting high-dose glucocorticoid treatment and discontinuing antiretroviral therapy would not be appropriate since discontinuing his antiretroviral therapy would not control his HIV infection, which would place him at greater risk of acquiring opportunistic infections. Corticosteroid use is part of symptom management as it decreases the inflammatory response.
Bullet Summary:
Immune reconstitution inflammatory syndrome (IRIS) can result in worsening of infectious symptoms and is managed by continuing antiviral therapy with symptomatic treatment.
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148
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An 84-year-old man presents to the physician with numbness and tingling in the right hand for the last 6 months. He reports these symptoms started intermittently in the middle finger after returning from a golfing trip but has progressed to being nearly constant. The thenar eminence, thumb, and other digits are spared. He reports no other symptoms. His medical problems include hypertension, hyperlipidemia, hypothyroidism, and chronic neck pain for which he takes amlodipine, hydrochlorothiazide, atorvastatin, levothyroxine, and duloxetine. Surgical history consists of posterior lumbar fusion and elective left total hip arthroplasty. He has a 90-pack-year smoking history and quit 10 years ago. The patient’s temperature is 99.6°F (37.6°C), blood pressure is 134/80 mmHg, pulse is 90/min, and respirations are 16/min. Physical exam reveals 4/5 strength in elbow extension and wrist flexion on the right. He has 5/5 strength in the remainder of the motor exam on the right upper extremity and on the left upper extremity. The triceps reflex is 1+ on the right compared to 2+ on the left. There is no spasticity. His neck pain, which radiates down his right arm, is reproduced with axial loading during neck extension with simultaneous rightward rotation and lateral bending. Which of the following is the most likely diagnosis in this patient?
|
{
"A": "Amyotrophic lateral sclerosis",
"B": "Carpal tunnel syndrome",
"C": "Cervical spondylosis",
"D": "Syringomyelia",
"E": ""
}
|
C
|
This patient presents with chronic middle finger paresthesia, weakness in elbow extension and wrist flexion, and a diminished triceps reflex in the setting of a positive Spurling test (pain with axial loading during neck extension, rotation, and lateral bending towards the affected side), indicative of C7 cervical radiculopathy. Cervical spondylosis is a common cause of cervical radiculopathy in elderly patients with chronic neck pain, especially in patients with findings suggestive of degenerative joint diseases (history of lumbar fusion and hip arthroplasty).
Cervical spondylosis is caused by degeneration of the intervertebral disc with possible disc herniation and facet joints with osteophyte formation. These osteophytes and cervical disc herniation can cause compression of exiting nerve roots, leading to radiculopathy. Radicular symptoms depend on the nerve root affected. For example, C6 radiculopathy causes weakness in wrist extension and a decreased brachioradialis reflex while C7 radiculopathy causes weakness in elbow extension and wrist flexion with a decreased triceps reflex. Sensory symptoms may be present depending on the dermatome affected. The diagnosis is confirmed with MRI. Treatment consists of non-steroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, and/or corticosteroids for pain. Surgical treatments for severe or refractory cases include anterior cervical discectomy and fusion.
Young outlines the diagnosis and management of cervical spondylotic myelopathy. The discusses its pathophysiology, including osteophyte formation and spinal cord dysfunction. They recommend considering decompression and fusion operations in selected patients.
Incorrect Answers:
Answer A: Amyotrophic lateral sclerosis (ALS) is a motor neuron disease of the brain and spinal cord that leads to upper and lower motor neuron signs. ALS presents with hyperreflexia (as opposed to hyporeflexia), spasticity, weakness, and fasciculations. Treatment includes riluzole (to improve survival) and symptomatic management.
Answer B: Carpal tunnel syndrome is caused by compression of the median nerve as it travels through the carpal tunnel at the wrist. While the thenar eminence is typically spared due to take-off of the palmar cutaneous branch proximal to the carpal tunnel, the thumb and index finger are also affected. This patient’s symptoms primarily involve the middle finger, which is more indicative of a radiculopathy. Treatment is activity modification, splinting, and ultimately, surgical decompression of the carpal tunnel if refractory.
Answer D: Syringomyelia is caused by a fluid-filled cavity (syrinx) within the spinal cord that leads to central cord syndrome, characterized by weakness that is greater in the upper extremities compared to lower extremities and loss of pain and temperature sensation in a cape-like distribution in the upper back and upper extremities. This patient’s sensory loss is unilateral and in a dermatomal distribution. Treatment of syringomyelia can include surgical decompression.
Answer E: Transverse myelitis is characterized by segmental inflammation of the spinal cord that would present with acute, bilateral flaccid paresis based on the level affected and sensory loss within a sensory level. Autonomic symptoms such as incontinence may also be present. This patient’s symptoms are unilateral and localizable to nerve root compression as opposed to the spinal cord.
Bullet Summary:
Cervical spondylosis is caused by degeneration of cervical discs and facet joints with osteophyte formation and can present with symptoms of cervical radiculopathy or myelopathy in elderly patients with chronic neck pain.
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149
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A 23-year-old woman presents to her psychiatrist concerned about her mood. She has felt tired and unwilling to engage in any activities lately. She states that her limbs feel heavy all the time and that completing any activity takes tremendous effort. She no longer finds any happiness in activities that she previously enjoyed. She struggles to sleep and at times can't sleep for several days. The patient is started on appropriate first-line therapy and sent home. She returns 1 week later stating that her symptoms have not improved. She is requesting help as her performance at work and school is suffering. Her temperature is 99.5°F (37.5°C), blood pressure is 115/72 mmHg, pulse is 60/min, respirations are 13/min, and oxygen saturation is 98% on room air. Which of the following is the most appropriate next step in management?
|
{
"A": "Add lithium to treatment regimen",
"B": "Change treatment to duloxetine",
"C": "Change treatment to lithium",
"D": "Continue current therapy",
"E": ""
}
|
D
|
This patient is presenting with depression and should be treated with a selective serotonin reuptake inhibitor (SSRI) for at least 4 weeks. Patients who have tried the therapy for a shorter duration of time may not yet have experienced the benefit of the medication.
Depression presents with SIGE CAPS (Sleeplessness, Interest loss, Guilt, Energy decreased, Concentration abnormalities, Appetite changes, Psychomotor retardation, and Suicidal ideation). The most appropriate initial step in management is to treat the patient with an SSRI for at least 4 weeks since SSRI's take several weeks to reach their potential. If the treatment has failed after 4 weeks of use, altering the patient's medications could be appropriate. Treatment and side effects should be monitored by a physician.
Kato et al. review the evidence regarding the treatment of depression with SSRI medications. They discuss how medications should be used for at least 4 weeks to determine treatment response. They recommend not allowing patients to switch between drug classes too early.
Incorrect Answers:
Answer A: Adding lithium to the treatment regimen could be an appropriate treatment if this patient had failed to respond to therapy after 4 weeks of using the drug. Lithium is an augmenting agent that could potentiate the effect of an SSRI.
Answer B: Changing the treatment to duloxetine would be inappropriate as this patient has not taken the first-line SSRI for at least 4 weeks. Patients should try a full treatment course in order to determine if they may derive some benefit.
Answer C: Changing the treatment to lithium would be appropriate if this patient's diagnosis was bipolar disorder, which would present with episodes of depression and mania. Altered sleep alone does not indicate mania.
Answer E: Electroconvulsive therapy is the most effective treatment for depression; however, it is typically a last-line treatment. This therapy can be useful in refractory cases.
Bullet Summary:
SSRI medications are the most appropriate first-line agent for depression and should be tried for at least 4 weeks before changing therapy.
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A 72-year-old man presents to his primary care physician for a general checkup. The patient works as a farmer and has no concerns about his health. He has a medical history of hypertension and obesity. His current medications include lisinopril and metoprolol. His temperature is 99.5°F (37.5°C), blood pressure is 177/108 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam is notable for a murmur after S2 over the left sternal border. The patient demonstrates a stable gait and 5/5 strength in his upper and lower extremities. Which of the following is another possible finding in this patient?
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{
"A": "Audible click heard at the cardiac apex",
"B": "Femoral artery murmur",
"C": "Murmur that radiates to the carotids during systole",
"D": "Wedge pressure lower than expected",
"E": ""
}
|
B
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This patient is presenting with aortic regurgitation which could be associated with Duroziez sign (femoral artery murmur).
Aortic regurgitation occurs when the aortic valve closes improperly resulting in retrograde flow during diastole. This is auscultated as a diastolic murmur heard best over the left upper sternal border and the left lower sternal border. This murmur typically occurs in elderly patients and the retrograde flow through the aorta cause a number of physical exam findings. These include a wide pulse pressure, fingernail pulsations, head bobbing, and femoral artery murmur. Treatment is with surgical valve replacement.
Sapira reviews the evidence regarding the physical exam findings in aortic regurgitation. He discusses how Duroziez sign can often be seen in patients with this disease. He recommends using these signs to properly identify patients.
Incorrect Answers:
Answer A: An audible click heard at the cardiac apex describes mitral valve prolapse which typically is asymptomatic and presents in younger women. Treatment is with surgical valve replacement in symptomatic patients.
Answer C: A murmur that radiates to the carotids during systole describes aortic stenosis which is possible in this patient except for the fact that his murmur is diastolic. Treatment is with valvuloplasty or with surgical valve replacement.
Answer D: A rumbling heard at the cardiac apex describes mitral valve stenosis which presents with a diastolic murmur best heard at the cardiac apex. Treatment is with valvuloplasty or with surgical valve replacement.
Answer E: A wedge pressure lower than expected would be seen in tricuspid regurgitation. In tricuspid stenosis, less blood flows to the lungs and thus the left heart, resulting in a low wedge pressure. Treatment is with identification of the underlying cause and valve replacement.
Bullet Summary:
Aortic regurgitation is associated with a wide pulse pressure, fingernail pulsations, head bobbing, and a femoral artery murmur.
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A 55-year-old man presents to the emergency department with chest pain and shortness of breath. He has a medical history of hypertension, diabetes, and obesity. His temperature is 98.6°F (37.0°C), blood pressure is 177/118 mmHg, pulse is 127/min, respirations are 11/min, and oxygen saturation is 98% on room air. An ECG is performed and notable for ST elevation in leads II, III, and aVF. The patient is treated appropriately and transferred to the medical floor. On the 2nd day of his hospitalization, the patient has abdominal pain. His serum lipase is 272 U/L and his creatinine is 1.6 mg/dL. A physical exam is notable for the finding in Figure A. He is requesting pain medication for his abdominal pain. Which of the following is the most likely underlying diagnosis?
|
{
"A": "Cholesterol embolism",
"B": "Medication side effect",
"C": "Pancreatitis",
"D": "Renal failure",
"E": ""
}
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A
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This patient is presenting with abdominal pain and livedo reticularis after a catheterization procedure. These symptoms are suggestive of a cholesterol embolism.
A cholesterol embolism typically presents after any vascular procedure due to a dislodged cholesterol emboli. Symptoms include livedo reticularis, gastrointestinal problems such as mesenteric ischemia or pancreatitis, and acute kidney injury. Patients who have undergone cardiac catheterization should be monitored for the development of this complication. Treatment is centered around treating the current complications, often using supportive therapy as they self-resolve. In addition, patients should be treated carefully to prevent recurrent embolism.
Maningding and Kermani review the evidence regarding the presentation of vasculitis mimics. They discuss how cholesterol embolism can cause diverse systemic symptoms and livedo reticularis. They recommend carefully considering the history of each patient.
Figure/Illustration A is a clinical photograph demonstrating a netlike reticular bluish discoloration of the skin (red circle). These findings are consistent with livedo reticularis.
Incorrect Answers:
Answer B: Heart failure and reinfarction could present with renal failure but would likely present with other symptoms of heart failure as well (pulmonary crackles, edema, and jugular venous distension). Treatment of a repeat infarct involves catheterization and fluid overload involves volume optimization.
Answer C: Medication side effects could explain this patient's livedo reticularis, but the drugs that may cause this (certain antivirals and amantadine) would not have been given to this patient. These medications also typically do not cause abdominal pain.
Answer D: Pancreatitis presents with abdominal pain and an elevated lipase; however, it is not the underlying pathology for this patient's presentation but rather is a complication of the cholesterol embolism. Treatment of pancreatitis is with gastrointestinal rest and fluid support.
Answer E: Renal failure is another complication in this patient secondary to the cholesterol embolism as revealed by the elevated creatinine, but is not the underlying pathology. Treatment is with renal replacement therapy if renal function does not return promptly.
Bullet Summary:
Cholesterol embolism presents after a vascular procedure with livedo reticularis, gastrointestinal complications, and acute kidney injury.
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A 37-year-old machinist presents to his primary care physician with eye problems. He has felt a mass in his eye that has persisted for the past month. The patient has a medical history of blepharitis treated with eye cleansing and squamous cell carcinoma of the skin treated with Mohs surgery. His temperature is 99.5°F (37.5°C), blood pressure is 157/102 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam is notable for a firm and rubbery nodule palpable inside the patient's left eyelid. Physical exam does not elicit any pain. Which of the following is the most likely diagnosis?
|
{
"A": "Chalazion",
"B": "Foreign body",
"C": "Hordeolum",
"D": "Ingrown eyelash follicle",
"E": ""
}
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A
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This patient presenting with a painless firm and rubbery nodule has symptoms that are suggestive of a chalazion.
Chalazion presents with a hard and painless eyelid nodule. This pathology occurs secondary to granulomatous inflammation of the Meibomian gland. The lesion can be treated with simple excision; however, recurrent lesions are concerning for Meibomian cell carcinoma. The most important differential diagnosis to consider in these patients is a hordeolum which presents with a firm and painful lid nodule (in contrast to painless). Treatment is with warm compresses followed by incision and curettage in refractory cases.
Li et al. review the evidence regarding the diagnosis and treatment of chalazion. They discuss how gland loss is a possible sequelae from this disorder. They recommend using warm compresses for symptomatic relief.
Incorrect Answers:
Answer B: Foreign body is a possible diagnosis given this patient's occupation as a machinist; however, this would typically present with pain over the patient's cornea with a sudden onset of symptoms. Treatment is with removal of the foreign body.
Answer C: Hordeolum presents with a hard and painful lid nodule in contrast to a hard and painless lid nodule. Treatment is with warm compresses and possible debridement in refractory cases.
Answer D: Ingrown eyelash follicle could present with a firm lid nodule; however, it would be located near the margin of the eyelid and would likely be inflamed and tender. Treatment is with warm compresses and possible debridement in refractory cases.
Answer E: Meibomian cell carcinoma is a possible diagnosis but is epidemiologically less common than a chalazion. This diagnosis would be more likely if the lesion was recurrent despite excision. Treatment is with wide excision of the lesion.
Bullet Summary:
Chalazion presents with a firm and painless eyelid nodule.
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A 55-year-old man presents with a 2-day history of mono-articular joint pain. He is otherwise healthy and denies fever, chills, or recent trauma. His medical history is notable for a kidney stone 6 months ago. He underwent a dental procedure to extract an infected wisdom tooth 3 weeks ago. The patient does not take any medications. He is a non-smoker and does not drink alcohol or use recreational drugs. His family history is significant for osteoarthritis in his father who is 78. His temperature is 98.6°F (37°C), blood pressure is 133/84 mmHg, pulse is 84/min, and respirations are 15/min. His body mass index is 27 kg/m^2. Physical examination shows a swollen and tender joint with overlying erythema. Diagnostic arthrocentesis is performed and shows a leukocyte count of 30,000/mm^3 with 85% neutrophils. Polarized microscopy of the synovial fluid is shown in Figure A. Which of the following would most likely be found on this patient’s radiograph?
|
{
"A": "Tophi",
"B": "Heberden nodes",
"C": "Juxta-articular osteoporosis",
"D": "Chondrocalcinosis",
"E": ""
}
|
D
|
This patient is presenting with a joint aspiration positive for calcium pyrophosphate dehydrate crystals, suggesting a diagnosis of pseudogout, which may show chondrocalcinosis on radiography.
Pseudogout presents classically with mono- or oligo-articular arthritis that most often affects the knee and proximal joints of elderly patients (> 60 years of age). The disease can be associated with hyperparathyroidism, Gitelman syndrome, familial hypocalciuric hypercalcemia, and hemochromatosis. The patient will have a leukocyte count < 50,000/mm^3 on joint aspiration and positively birefringent, rhomboid-shaped cells on microscopy, which represent calcium pyrophosphate dehydrate (CPPD) crystals. On radiography, chondrocalcinosis can be found, which is the calcification of adjacent cartilaginous structures. Treatment is with indomethacin.
Sidari and Hill review the evidence regarding the diagnosis and treatment of gout and pseudogout. They discuss how diagnosis can be made with fluid microscopy. They recommend treatment with non-steroidal anti-inflammatory drugs.
Figure/Illustration A is polarized microscopy of joint fluid showing rhomboid-shaped crystals that are positively birefringent (red circles). These represent calcium pyrophosphate dehydrate crystals seen in pseudogout.
Incorrect Answers:
Answer A: Boutonniere deformity is characterized by proximal interphalangeal (PIP) joint flexion and distal interphalangeal (DIP) joint extension and is a common hand deformity of rheumatoid arthritis. Rheumatoid arthritis is characterized by insidious onset of morning stiffness and pain that usually affects symmetric PIP and metacarpophalangeal (MCP) joints first. On joint aspiration, leukocyte count ranges from 5,000-50,000/mm^3, but rheumatoid arthritis would not explain the CPPD crystals. Treatment may include methotrexate.
Answer C: Heberden nodes are bony protuberances in the DIP joints, which are characteristic of osteoarthritis. Osteoarthritis presents with insidious onset of joint pain that worsens with activity and weight-bearing. On joint aspiration, the leukocyte count is < 2,000/mm^3.
Answer D: Juxta-articular osteoporosis is decreased bone density of the bone surrounding the joint space. It is a nonspecific sign that can be seen with many inflammatory joint diseases such as rheumatoid arthritis or septic arthritis. Septic arthritis presents with mono-articular joint pain, erythema, and swelling. Joint aspiration will show a leukocyte count > 50,000/mm^3 and Gram stain may be positive.
Answer E: Tophi are deposits of urate crystals in the soft tissue, which are nearly pathognomonic for gout. Gout presents as acute, mono-articular joint pain with physical examination showing a red, inflamed joint (usually the first metatarsophalangeal, knee, or ankle joint). Needle-shaped, negatively birefringent urate crystals are seen in the joint fluid aspirate. Prevention may include allopurinol.
Bullet Summary:
Pseudogout is associated with positively birefringent, rhomboid-shaped crystals and chondrocalcinosis.
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A 27-year-old man presents for an appointment to establish care. He recently was released from prison. He has felt very fatigued and has had a cough. He has lost roughly 15 pounds over the past 3 weeks. He attributes this to intravenous drug use in prison. His temperature is 99.5°F (37.5°C), blood pressure is 127/68 mmHg, pulse is 100/min, respirations are 18/min, and oxygen saturation is 98% on room air. QuantiFERON gold testing is positive. The patient is started on appropriate treatment. Which of the following is the most likely indication to discontinue this patient's treatment?
|
{
"A": "Peripheral neuropathy",
"B": "Red body excretions",
"C": "Hyperuricemia",
"D": "Elevated liver enzymes",
"E": ""
}
|
D
|
This patient is presenting with weight loss and cough with a positive quantiFERON gold test suggestive of tuberculosis and has been started on treatment. The most likely indication to discontinue tuberculosis therapy is elevation of liver enzymes.
Tuberculosis typically presents with weight loss, cough, and night sweats usually in high-risk patients (prisoners or the immunosuppressed). It can be diagnosed using sputum samples as these organisms will be positive on an acid-fast test. These bacteria are slow to grow so cultures need to be held for an extended period of time. QuantiFERON gold testing can be used to make the diagnosis as well. Treatment for tuberculosis is RIPE therapy: Rifampin, Isoniazid, Pyrazinamide, and Ethambutol. The most common indication to alter or discontinue therapy is an elevation of liver enzymes 5 times greater than baseline.
Tweed et al. review the evidence regarding liver injury in patients with RIPE therapy. They discuss how patients on HIV therapy are at higher risk. They recommend measuring liver enzymes to detect this potential side effect.
Incorrect Answers:
Answer B: Hyperuricemia is a side-effect of pyrazinamide; however, this is not the most common indication for discontinuing RIPE therapy. Patients can be treated with supportive therapy or with uric acid lowering agents in those with arthralgias.
Answer C: Optic neuritis is a side-effect of ethambutol; however, it is not the most common indication for discontinuing RIPE therapy. Treatment is with discontinuation of ethambutol.
Answer D: Peripheral neuropathy is a side-effect of isoniazid; however, it is typically not an indication to discontinue RIPE therapy. Treatment is with supplementation of vitamin B6.
Answer E: Red body excretions are a side-effect of rifampin; however, this is a cosmetic concern rather than an indication to discontinue RIPE therapy. Patients should be counseled regarding this side effect prior to initiation of treatment.
Bullet Summary:
Elevation of liver enzymes 5 times above normal is the most common indication to alter or discontinue RIPE therapy when treating tuberculosis.
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A 35-year-old man presents to the emergency department for evaluation of chest pain. The pain starts in his chest and moves into his back, arms, and abdomen. He describes the pain as tearing. He has no known medical history and takes no medications. His temperature is 37.0°C (98.6°F), pulse is 130/min, blood pressure is 210/145 mmHg, respirations are 22/min, and pulse oximetry is 98% on room air. Exam reveals a diaphoretic, anxious-appearing man. Pulses are diminished over the left wrist when compared to the right. A chest radiograph is obtained as shown in Figure A. Which of the following is the most appropriate next step in management?
|
{
"A": "Aspirin",
"B": "CT angiography of the chest, abdomen, and pelvis",
"C": "Echocardiography",
"D": "Lorazepam",
"E": ""
}
|
B
|
This patient with "tearing" chest pain, hypertension, and a chest radiograph demonstrating mediastinal widening likely has an aortic dissection. The most appropriate next step in management would be to obtain CT angiography of the chest, abdomen, and pelvis to confirm the diagnosis.
Aortic dissections develop due to a tear in the intimal layer of the aorta, causing a second blood-filled lumen to form. Risk factors include hypertension, trauma, Marfan syndrome, Turner syndrome, and pregnancy. Prognosis depends on the location and severity of the intimal tear. Aortic dissections are often described by using the Stanford classification, where Type A involves the ascending aorta and Type B involves tears distal to the left subclavian artery. Patients classically present with chest pain described as "tearing" or "ripping" with radiation into the back, arms, or abdomen. Hypertension is common. Chest radiography characteristically demonstrates widening of the mediastinum due to accumulation of blood between layers of the wall of the aorta. Type A dissections are managed with heart rate control, blood pressure control, and surgery. Type B dissections are managed with blood pressure and heart rate control only.
Cooper et al. report on aortic dissections in adolescence. Although rare, aortic dissections have been seen in children with congenital heart disease, connective tissue disorders, or severe traumatic accidents. Severe, migrating abdominal pain should heighten suspicion for this diagnosis. The patient will often look worse clinically than can be explained by physical findings.
Figure A depicts a chest radiograph demonstrating a widened superior mediastinum.
Incorrect Answers:
Answer A: Aspirin is administered for chest pain that is thought to be due to acute coronary syndrome. This patient's presentation, exam, and imaging findings suggest aortic dissection. Aspirin is contraindicated in aortic dissection due to the increased risk for bleeding.
Answer C: Echocardiography offers information on cardiac contractility, valve function, and the presence of effusions. It would not be an appropriate initial diagnostic test in aortic dissection. Transesophageal echocardiography may be used to make the diagnosis in patients who cannot undergo a CTA.
Answer D: Lorazepam would be appropriate for patients presenting with chest pain that is secondary to use of cocaine or other sympathomimetic drugs. Tachycardia, tachypnea, diaphoresis, hyperactive bowel sounds, and dilated pupils suggest a sympathomimetic toxidrome.
Answer E: Serum troponin testing is indicated for risk stratification of patients with suspected acute coronary syndrome.
Bullet Summary:
The most appropriate next step in management for patients with suspected aortic dissection and mediastinal widening on chest radiograph is CT angiography of the chest, abdomen, and pelvis.
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156
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A 33-year-old woman presents to the emergency department with muscle spasms. She has noticed "twitching" in both her upper and lower extremities over the past 3 days that have interfered with her training for a marathon. She has felt more fatigued over the past month. She has no significant medical history. She takes no medication other than whey protein supplements, a multivitamin, and fish oil. Her temperature is 98.5°F (36.9°C), blood pressure is 103/71 mmHg, pulse is 105/min, respirations are 11/min, and oxygen saturation is 100% on room air. Physical exam reveals a thin woman with thinning hair. She appears pale and her mucous membranes are dry. Her neurological and cardiac exams are unremarkable. Laboratory studies are ordered as seen below. Hemoglobin: 10 g/dL Hematocrit: 30% Leukocyte count: 6,100/mm^3 with normal differential Platelet count: 187,500/mm^3 Serum: Na+: 130 mEq/L Cl-: 100 mEq/L K+: 2.3 mEq/L HCO3-: 28 mEq/L BUN: 40 mg/dL Glucose: 79 mg/dL Creatinine: 0.9 mg/dL Ca2+: 8.2 mg/dL Mg2+: 1.8 mg/dL Thyroid stimulating hormone (TSH): 4.0 mIU/L Free T4: 0.4 ng/dL (normal: 0.7-1.53 ng/dL) The patient is given 4 liters of lactated ringer solution and 40 mEq of potassium. Her repeat whole blood potassium 3 hours later is 2.4 mEq/L, and her repeat BUN is 20 mEq/L. Another 40 mEq of potassium is administered. Another repeat whole blood potassium is 2.5 mEq/L. The patient’s muscle spasms persist. Which of the following is the most likely underlying etiology for this patient’s chief concern?
|
{
"A": "Hypocalcemia",
"B": "Hypothyroidism",
"C": "Hyponatremia",
"D": "Hypomagnesemia",
"E": ""
}
|
D
|
This patient is presenting with what appears to be anorexia nervosa (thin habitus, possible excessive exercise in the setting of marathon running, thinning hair, dry mucous membranes, decreased free T4 level, and multiple electrolyte derangements). The lack of improvement in either her muscle spasms with fluid repletion or her hypokalemia with adequate repletion, even in the setting of normal serum magnesium, suggests depleted magnesium stores are the underlying etiology of her symptoms.
Hypomagnesemia typically occurs in alcoholics, malnourished patients, and patients with eating disorders such as anorexia or bulimia nervosa. Patients may present with a wide array of symptoms including weakness, confusion, dysrhythmias, hypotension, and overall malaise. Hypomagnesemia can cause hypocalcemia as magnesium is needed for proper parathyroid hormone secretion. Another pathognomonic finding associated with hypomagnesemia is hypokalemia which is refractory to repletion. The pathophysiology is thought to be due to increased potassium wasting in the kidney due to increased activity of renal outer medullary potassium (ROMK) channels. The serum magnesium level should be checked and repletion should occur accordingly. Serum magnesium levels represent 1% or less of total body magnesium stores and do not reflect if a patient truly has hypomagnesemia, particularly if there is intracellular depletion (such as in chronically malnourished patients). Thus, any patient with findings consistent with hypomagnesemia with normal serum magnesium should have their other electrolytes repleted and be given magnesium. Magnesium repletion is a safe intervention with a wide therapeutic index, and the serum level often does not correlate with total body stores.
Razzaque discusses the relationship between serum magnesium levels and total body magnesium status. The author finds that inadequate magnesium balance is associated with myriad disorders including skeletal deformities, cardiovascular diseases, and metabolic syndrome. The author recommends the use of the magnesium loading test to provide more accurate reflections of total body magnesium status.
Incorrect Answers:
Answer A: Hypocalcemia may present with perioral numbness, paresthesias, and muscle spasms. It can occur secondary to poor nutrition, vitamin D deficiency, and hypoparathyroidism. Low serum calcium may also be seen in patients with low albumin and in states of hyperventilation (which lowers the free calcium but not the total calcium due to a respiratory alkalosis that causes albumin to bind free calcium and release protons). Hypomagnesemia can also cause hypocalcemia as magnesium is needed for proper parathyroid hormone release.
Answer C: Hyponatremia may present with malaise, nausea, vomiting, headache, and confusion. Patients may also be asymptomatic in mild cases. Asymptomatic patients with hyponatremia and functioning kidneys require only fluid restriction. On the other hand, severe hyponatremia presents with very low sodium (often < 120 mEq/L) and neurological symptoms such as profound confusion or seizures. Treatment with hypertonic saline would be indicated in this situation.
Answer D: Hypothyroidism presents with fatigue, malaise, weight gain, bradycardia, scarce lanugo, and depression. This patient’s TSH is on the high end of normal and her T4 is lower than the cutoff value. However, this is likely a compensatory response to her low BMI and excessive exercise in order to slow down her metabolism to conserve energy.
Answer E: Hypovolemia was certainly present in this patient given her dry mucous membranes and prerenal pattern of labs (BUN:Cr ratio > 20:1). After receiving 4L of fluids, it is clear that dehydration is not the cause of her symptoms as her BUN corrects and her symptoms persist. In general, hypovolemia should be treated with oral rehydration, if possible.
Bullet Summary:
Hypomagnesemia can cause hypocalcemia and hypokalemia refractory to repletion (a normal serum level does not indicate normal intracellular levels of magnesium).
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157
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A 27-year-old woman presents to her primary care physician for an abnormal vaginal discharge. The patient has engaged in unprotected intercourse with 12 different partners. She has a medical history of asthma, IV drug abuse, and depression. She has 1 to 2 alcoholic drinks per day. She feels ashamed of her behavior and is requesting treatment for her condition and advice for safe sex. The patient is given antibiotics and is advised on safe sex practices. The patient presents to the emergency department 3 days later with a complaint of a rash. She states that every time she has sex a rash has emerged on her skin. Her temperature is 99.5°F (37.5°C), blood pressure is 127/68 mmHg, pulse is 91/min, respirations are 14/min, and oxygen saturation is 98% on room air. A physical exam is notable for the finding in Figure A. Which of the following is the most likely cause of this patient's symptoms?
|
{
"A": "Photosensitivity",
"B": "Antigen exposure",
"C": "IV drug use",
"D": "Infection",
"E": ""
}
|
B
|
This patient is presenting with urticaria whenever she engages in sexual intercourse suggesting a latex allergy (found in condoms). These allergies are due to antigen exposure.
Anaphylaxis and urticaria are immunologically mediated responses to environmental antigens that are typically IgE-mediated. This results in crosslinking of antigen receptors and the subsequent release of histamine and other inflammatory signals. Patients can present with a spectrum of symptoms from urticaria (hives alone) all the way to full-blown anaphylaxis (hypotension, tachycardia, and bronchoconstriction). Minor cases can be treated with avoidance of antigen exposure. Anaphylaxis is treated with intramuscular epinephrine (1:1,000).
Gawchik reviewed the evidence regarding the diagnosis of latex allergy. She discusses how the diagnosis is primarily made by observing the relationship between exposure and symptoms. She recommends avoidance of latex in these patients.
Figure/Illustration A is a clinical photograph that demonstrates dermal edema and urticaria (red circles). This can occur secondary to allergen exposure such as from a new drug or latex.
Incorrect Answers:
Answer B: Drug reaction could be possible if this patient has an antibiotic allergy (ceftriaxone is a treatment for gonorrhea); however, a rash that only occurs during intercourse is more likely related to latex exposure.
Answer C: Infection is possible given this patient’s IV drug abuse and risky behavior; however, the hives present in this patient are likely not related to an infection. Infectious rashes tend to be painful, ulcerative, or vesicular.
Answer D: IV drug use could expose this patient to any number of foreign substances that could induce an allergic reaction; however, the symptoms that are associated with sexual intercourse point toward latex exposure.
Answer E: Photosensitivity would not present as hives but could occur in this patient given that doxycycline is an appropriate drug to treat her initial sexually transmitted infection and offers coverage for Chlamydia trachomatis. Patients would present with a photosensitive rash.
Bullet Summary:
Anaphylaxis and urticaria can occur secondary to latex exposure (such as from condoms or gloves).
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158
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A 32-year-old man presents to the emergency department for evaluation of headache. His symptoms started last night and have persisted. He occasionally has migraine headaches, but he has not had a headache like this in the past. He reports associated nausea, vomiting, fevers, and neck pain. He has a medical history of asthma. His temperature is 100.4°F (38.0°C), blood pressure is 110/60 mmHg, pulse is 95/min, respirations are 17/min, and oxygen saturation is 98% on room air. On physical exam, he appears uncomfortable. Neurologic exam reveals no focal deficits. There is pain with passive neck flexion. No edema or rashes are noted. Lungs are clear to auscultation bilaterally. Lumbar puncture is performed and CSF results are obtained as shown below. Cerebrospinal fluid (CSF): Cell count: 175/mm^3 RBCs: 0/mm^3 Cl-: 119 mEq/L Glucose: 49 mg/dL Pressure: 150 mmH2O Total protein: 55 mg/dL Based on these results, which of the following is the most appropriate treatment regimen for this patient?
|
{
"A": "Acyclovir",
"B": "Ceftriaxone and vancomycin",
"C": "Ceftriaxone, vancomycin and steroids",
"D": "Supportive care and monitoring",
"E": ""
}
|
D
|
This patient with headache, fever, and neck stiffness has a presentation and CSF studies consistent with a diagnosis of viral or aseptic meningitis. Supportive care is the most appropriate management strategy for patients with viral meningitis.
Aseptic (viral) meningitis presents similarly to bacterial meningitis with neck stiffness, photophobia, fever, malaise, and flu-like symptoms. Patients should be worked up and treated as if they have bacterial meningitis until proven otherwise. CSF findings in aseptic meningitis show an elevated cell count (though typically < 300/mm^3 in contrast to bacterial meningitis), a normal or elevated protein, and a normal glucose. CSF should be sent for Gram stain and culture to confirm the diagnosis and rule out bacterial meningitis. Once the diagnosis has been confirmed, management of viral meningitis consists of supportive care and monitoring for complications such as seizures, cerebral edema, or SIADH.
Kohil et. al review viral meningitis. They discuss the pathophysiology, clinical manifestation and diagnosis. They recommend that most patients with viral meningitis be treated with supportive care.
Incorrect Answers:
Answer A: Acyclovir would be appropriate for suspected HSV or varicella encephalitis or meningitis. This patient with no RBCs in the CSF and no changes in mental status is not likely to have infection with HSV or varicella.
Answer B: Amphotericin and 5-flucytosine followed by long-term fluconazole is the appropriate management of cryptococcal meningitis. Cryptococcal meningitis presents similarly to bacterial and viral meningitis, almost exclusively in immunocompromised patients.
Answer C: Ceftriaxone and vancomycin would be appropriate if bacterial meningitis was suspected. Steroids are generally added if a bacterial source is likely. However, this patient has a presentation that is less concerning for bacterial meningitis, and CSF studies that are more consistent with aseptic meningitis.
Answer D: Ceftriaxone, vancomycin and steroids are an appropriate initial regimen for bacterial meningitis. Dexamethasone reduces inflammatory injury while patients are being treated with antibiotics.
Bullet Summary:
Viral or aseptic meningitis is managed with supportive care and monitoring.
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159
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A 24-year-old man presents to the emergency department with abdominal pain, nausea, and vomiting. The symptoms began towards the end of running a marathon and persisted after finishing the race. The patient is otherwise healthy and has no other medical problems. His temperature is 98.0°F (36.7°C), blood pressure is 105/71 mmHg, pulse is 113/min, respirations are 19/min, and oxygen saturation is 98% on room air. Physical exam reveals a distended and tender abdomen. A radiograph is performed as seen in Figure A. Which of the following is the most likely diagnosis?
|
{
"A": "Cecal volvulus",
"B": "Ileus",
"C": "Sigmoid volvulus",
"D": "Small bowel obstruction",
"E": ""
}
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A
|
This young, healthy patient presents with abdominal pain, nausea, vomiting, and a distended, tender abdomen with a radiograph demonstrating the "coffee bean sign," likely has a cecal volvulus.
Cecal volvulus is the second most common cause of volvulus after sigmoid volvulus and presents with abdominal pain, constipation, vomiting, abdominal distention, and a tympanitic abdomen. It is more common in young patients who are active (e.g. marathon runners). The classic conventional radiographic finding in cecal volvulus is the coffee bean sign, in which closed loops of intestine distend with gas, making visible the medial and lateral walls of dilated bowel. Diagnosis of cecal volvulus can be confirmed with a CT scan. Management involves analgesia, intravenous fluids, and surgical detorsion.
Hasbahceci et al. review the presentation, diagnosis, and management of cecal volvulus. The authors find that abdominal radiography has a low sensitivity for cecal volvulus. The authors recommend surgical management of cecal volvulus with resection with right hemicolectomy and primary ileocolic anastomosis.
Figure/Illustration A is a radiograph demonstrating the "coffee bean" sign which is suggestive of a cecal volvulus.
Incorrect Answers:
Answer B: Ileus presents after surgery or manipulation of the intestines with decreased peristalsis of the intestine leading to a failure to pass gas or have bowel movements. Treatment involves treating any electrolyte abnormalities, encouraging ambulation, and avoiding medications that decrease peristalsis (such as opioids).
Answer C: Ogilvie syndrome occurs when the colon wall is not appropriately undergoing peristalsis leading to a dilated colon with abdominal distension. It is more common in the elderly and critically ill patients. Treatment involves the placement of a rectal tube to decompress the intestines and treatment of any underlying medical conditions.
Answer D: Sigmoid volvulus is more common in elderly and critically ill patients and presents with constipation, an absence of bowel movements, and a distended, tympanitic abdomen. Although the coffee bean sign may also be seen in patients with sigmoid volvulus, patients tend to be older. In addition, plain radiography typically demonstrates multiple air-fluid levels in a sigmoid volvulus versus usually only a single air-fluid level in a cecal volvulus. Treatment involves flexible sigmoidoscopy and surgery.
Answer E: Small bowel obstruction presents with a distended and tympanitic abdomen with nausea, vomiting, and an absence of flatus or bowel movements. Radiography may demonstrate distended bowel and air-fluid levels, and the most accurate test is a CT scan of the abdomen. It occurs secondary to adhesions entrapping the bowel. Management involves the placement of a nasogastric tube, intravenous fluids, and surgery.
Bullet Summary:
Cecal volvulus presents in younger patients with abdominal pain, distention, constipation, nausea, vomiting, and the "coffee bean" sign on radiography.
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160
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A 28-year-old man is brought to the emergency department by helicopter after a high speed motorcycle crash. He was intubated and 2 large bore IVs were placed in the field with administration of 2 liters of lactated ringer's solution while en route. On arrival to the emergency department, his temperature is 98.6°F (37.0°C), pulse is 130/min, blood pressure is 80/50 mmHg, respirations are 22/min, and oxygen saturation is 97%. Examination reveals an ill-appearing intubated patient. Endotracheal tube placement is confirmed with end tidal CO2, and bilateral breath sounds are present. No external bleeding or wounds are noted on exam. Pulses are present in all extremities but are weak and rapid. Significant bruising is noted over the abdomen. The pelvis is stable. Infusion of packed red blood cells is initiated. Which of the following is the most appropriate next step in management?
|
{
"A": "CT scan of the abdomen and pelvis with contrast",
"B": "FAST exam",
"C": "Norepinephrine infusion",
"D": "Diagnostic peritoneal lavage",
"E": ""
}
|
B
|
This patient with hemodynamic instability and abdominal bruising after a high speed motorcycle crash likely has shock secondary to blood loss. The first step in management of patients with blunt trauma and hemodynamic instability is a focused assessment with sonography for trauma (FAST exam)
For any patient with blunt or penetrating trauma, the first step in management is an evaluation of airway, breathing, and circulation. This is referred to as the primary survey and includes the verification of endotracheal tube placement, auscultation of bilateral breath sounds, and assessment of external wounds or bleeding. This is followed by the secondary survey which involves a detailed head to toe inspection for injuries. Blunt abdominal trauma with bruising as well as hemodynamic instability warrants a FAST exam. The FAST exam visualizes the heart chambers and pericardium, left upper quadrant (spleen, splenorenal recess), right upper quadrant (Morrison pouch) and the rectovesical (males) or rectouterine (females) pouch. The extended FAST exam (eFAST) includes an examination of the lungs as well to assess for pneumothorax or hemothorax. Hemodynamically unstable patients with free fluid identified in the abdomen on initial FAST exam should proceed directly to the operating room for emergent surgical intervention with ongoing volume resuscitation. Patients with hemodynamic instability and a negative FAST exam should be evaluated for sources of bleeding elsewhere such as the pelvis.
Barloon et al. review diagnostic imaging in the evaluation of blunt abdominal trauma. Blunt abdominal trauma is a common cause of death and injury, leading to hemodynamic instability. Intra-abdominal imaging is especially important in comatose or sedated (intubated) patients who are unable to provide a history or provide a reliable physical examination. In stable patients, CT of the abdomen often has a role in deciding whether to pursue observation versus surgical intervention.
Stengel et al. evaluate emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma. The systematic review showed that ultrasound-based pathways reduced the number of CT scans obtained. Use of ultrasound can enhance the speed of the primary assessment and cut costs. However, the authors conclude that there is insufficient evidence to promote justification of ultrasound-based pathways for the evaluation of blunt abdominal trauma in terms of patient outcomes.
Incorrect Answers:
Answer A: AP and lateral radiographs of the abdomen and pelvis may be useful for identifying pelvic fracture or intraperitoneal free air. However, this patient's presentation is suggestive of abdominal trauma warranting FAST exam.
Answer B: CT scan of the abdomen and pelvis with contrast would be appropriate for evaluation of blunt abdominal trauma in a patient that is hemodynamically stable. However, this patient's vital signs indicate hemodynamic instability.
Answer C: Diagnostic peritoneal lavage is no longer commonly used in the evaluation of blunt abdominal trauma.
Answer E: Norepinephrine infusion would not be appropriate for this patient with shock secondary to blood loss. Resuscitation for this patient should be achieved with transfusion of blood products.
Bullet Summary:
The most appropriate initial step in management for hemodynamically unstable patience with blunt abdominal trauma is a FAST exam.
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161
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A 26-year-old woman presents to the emergency department because she feels as though her heart is "beating out of her chest." She states that she feels well apart from the discomfort of that sensation. Her temperature is 97.9°F (36.6°C), blood pressure is 124/84 mmHg, pulse is 180/min, respirations are 22/min, and oxygen saturation is 98% on room air. An ECG is obtained as seen in Figure A. After unsuccessful attempts at vagal maneuvers, the emergency physician administers an IV medication. The effect of the medication wears off in seconds. Which of the following is a potential side effect of this medication?
|
{
"A": "Tachycardia",
"B": "Photosensitivity",
"C": "Flushing",
"D": "Seizure",
"E": ""
}
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C
|
This patient presents with a narrow complex tachycardia that is regular which is suggestive of supraventricular tachycardia (SVT) and was pharmacologically cardioverted with adenosine (as it has a very short half-life). Side effects of adenosine include flushing, hypotension, bronchospasm, and heart block.
SVT presents with a narrow-complex, regular tachycardia. The diagnosis is made with these findings on ECG. Management in an unstable patient is centered on cardioversion. Otherwise, the first step in management is centered on vagal maneuvers. If these fail, adenosine is the first-line pharmacologic treatment. While a relatively safe drug, side effects of adenosine include hypotension, heart block, flushing, and bronchospasm. Patients may also report a "sense of impending doom" following administration, thought to be the result of the transient asystole adenosine produces. Persistent SVT refractory to adenosine may be further managed with calcium channel blockers, beta blockers, or cardioversion.
Colucci et al. review the diagnosis and management of common types of supraventricular tachycardias. The most common types of supraventricular tachycardia are caused by a reentry phenomenon producing accelerated heart rates. Symptoms may include palpitations, chest pain, lightheadedness or dizziness, and dyspnea. If Wolff-Parkinson-White syndrome is present, expedient referral to a cardiologist is warranted because ablation is a potentially curative option.
Figure A is an ECG demonstrating SVT. Note the regular narrow complex tachycardia that is a defining feature of this condition.
Incorrect Answers:
Answer A: A disulfiram-like reaction was once thought to be associated with medications such as metronidazole. Metronidazole is an antibiotic that covers anaerobes. When alcohol is consumed in a patient on disulfiram, headache, malaise, nausea, and vomiting may be experienced.
Answer C: Photosensitivity is associated with medications such as sulfonamides, amiodarone, and tetracycline. Patients should be advised to stay out of the sun on these medications.
Answer D: Seizures are not associated with adenosine. Isoniazid, bupropion, imipenem/cilastatin, tramadol, enflurane, and metoclopramide are all known to increase the risk of seizures. Seizures often present with tonic-clonic activity, tongue biting, urinary incontinence, and a postictal phase.
Answer E: Tachycardia can be associated with medications such as atropine which reduce vagal tone on the heart increasing the heart rate. Medications that block the AV node would be expected to cause bradycardia.
Bullet Summary:
Adenosine is a first-line pharmacological agent in supraventricular tachycardia and can cause hypotension, heart block, flushing, and bronchospasm.
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https://step2.medbullets.com/testview?qid=106849
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162
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A 23-year-old woman presents to the emergency department with severe abdominal pain. The pain has been dull and progressive, but became suddenly worse while she was exercising. Her medical history is notable for depression, anxiety, and gonococcal urethritis that was appropriately treated. She is sexually active and does not use condoms. She admits to drinking at least 5 standard alcoholic drinks a day. The patient also recently lost a large amount of weight for a fitness show she planned on entering. The patient's current medications include oral contraceptive pills, fluoxetine, alprazolam, ibuprofen, acetaminophen, and folate. Her temperature is 99.5°F (37.5°C), blood pressure is 80/40 mmHg, pulse is 110/minute, and respirations are 15/minute with an oxygen saturation of 96% on room air. On physical exam, you note an athletic young woman with burly shoulders, a thick neck, and acne on her forehead and back. On abdominal exam you note diffuse tenderness with 10/10 pain upon palpation of the right upper quadrant. Intravenous fluids are started and labs are sent. A urinary ß-hCG has been ordered. Which of the following is the most likely the diagnosis?
|
{
"A": "Inflammation of the pancreas",
"B": "Obstruction of blood flow through the hepatic vein",
"C": "Obstruction of the common bile duct by radio-opaque stones",
"D": "Vascular ectasia within the liver",
"E": ""
}
|
D
|
This patient is presenting with constant right upper quadrant pain in the setting of oral contraceptives (OCP) and likely anabolic steroid use, suggesting a diagnosis of a ruptured hepatic adenoma (HA). The pathophysiology of HA is vascular ectasia from exposure to OCPs and androgens.
A hepatic adenoma typically occurs secondary to exposure to OCPs and androgens (anabolic steroids) causing a generalized vascular ectasia. Both of these drugs should be discontinued in patients with hepatic adenoma. Symptoms include right upper quadrant abdominal pain. Sudden worsening of pain with unstable vitals suggests a ruptured hepatic adenoma. Patients should be managed with fluids and an ultrasound should be performed to support the diagnosis. Additional imaging tests include an abdominal contrast-enhanced CT to better characterize the pathologic anatomy in this disease. The definitive treatment in this disease is surgery in order to remove the hepatic adenoma. In cases of a ruptured hepatic adenomas, patients require transfusion and operative management.
Bioulac-Sage et al. present the current data that are available for classifying hepatic adenomas. They discuss how many of these lesions involve alterations of the HNF1A gene, the JAK/STAT3 pathway, and the CTNNB1 gene. They recommend performing molecular analysis in order to better understand which lesions are likely to undergo malignant transformation.
Incorrect Answers:
Answer A: Ectopic implantation of a blastocyst (ectopic pregnancy) that has ruptured could present similarly to what this patient is experiencing. Symptoms would include lower abdominal pain and unstable vitals. However, this patient's pain is more pronounced in the right upper quadrant and is occurring in the setting of OCP and possible anabolic steroid use.
Answer B: Inflammation of the pancreas represents a diagnosis of pancreatitis. This would present with epigastric pain after a fatty meal or alcohol consumption. Though this patient does drink more than recommended and should be counseled to reduce her consumption, the pain began after exercising at the gym and there are no other symptoms of pancreatitis.
Answer C: Obstruction of blood flow through the hepatic vein causes Budd-Chiari syndrome, which presents with a non-specific triad of abdominal pain, ascites, and hepatomegaly in the setting of a hypercoagulable state (factor V Leiden, polycythemia vera, OCP use, and paroxysmal nocturnal hemoglobinuria). Though this patient has risk factors for this pathology, they do not have any classic symptoms.
Answer D: Obstruction of the common bile duct with radio-opaque stones would present with colicky right upper quadrant pain in a patient that is "fat, female, fertile, and forty." Though the pain presented in this case is localized to the right upper quadrant, it is not colicky and there is not a positive Murphy sign described. OCP's are a risk factor for cholesterol stones as are rapid weight loss, both of which this patient has. This is a strong possibility on the differential; however, the symptoms presented suggest a diagnosis of ruptured hepatic adenoma given the demographics of the patient.
Bullet Summary:
A hepatic adenoma presents with right upper quadrant pain in the setting of OCP and/or androgen use and can rupture leading to unstable vitals.
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163
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A 44-year-old woman presents to the emergency department with fluctuating right upper quadrant abdominal pain. The pain was initially a 4/10 in severity but has increased recently to a 6/10 prompting her to come in. The patient has a medical history of type 2 diabetes mellitus, depression, anxiety, and irritable bowel syndrome. Her current medications include metformin, glyburide, escitalopram, and psyllium husks. Her temperature is 99.2°F (37.3°C), pulse of 95/min, blood pressure of 135/90 mmHg, respirations of 15/min with 98% oxygen saturation on room air. On exam, the patient is an obese woman with pain upon palpation of the right upper quadrant. Initial labs are are below:
Na+: 140 mEq/L
K+: 4.0 mEq/L
Cl-: 100 mEq/L
HCO3-: 24 mEq/L
AST: 100 U/L
ALT: 110 U/L
Amylase: 30 U/L
Alkaline phosphatase: 125 U/L
Bilirubin
Total: 2.5 mg/dL
Direct: 1.8 mg/dL
The patient is sent for a right upper quadrant ultrasound demonstrating an absence of stones, no pericholecystic fluid, a normal gallbladder contour and no abnormalities noted in the common bile duct. MRCP with secretin infusion is performed demonstrating patent biliary and pancreatic ductal systems. Her lab values and clinical presentation remain unchanged 24 hours later. Which of the following is the most appropriate next step in management?
|
{
"A": "Laparoscopy",
"B": "ERCP with manometry",
"C": "Analgesics and await resolution of symptoms",
"D": "MRI of the abdomen",
"E": ""
}
|
B
|
This patient is presenting with classic symptoms of acute cholecystitis or choledocholithiasis such as right upper quadrant pain and direct hyperbilirubinemia with ultrasound findings demonstrating the absence of gallstones. In this setting, sphincter of Oddi dysfunction should be suspected, and ERCP with manometry should be performed to confirm the diagnosis.
Cholecystitis is inflammation of the gallbladder caused by irritation due to an intraluminal stone and possible bacterial translocation. The classic risk factors for this disease can be remembered as "fat, female, fertile and forty". Symptoms of acute cholecystitis are right upper quadrant pain that relapses and remits over time. Lab values will show elevated AST, ALT, alkaline phosphatase, and bilirubin which are also seen in patients where a stone is impacted in the common bile duct. A right upper quadrant ultrasound and MRCP can be used to confirm the diagnosis. Dysfunction of the Sphincter of Oddi should be suspected in patients with classic findings but negative imaging studies. In these cases, the most appropriate test is ERCP with manometry of the sphincter of Oddi. Ultimately, a sphincterotomy will be needed once the diagnosis is confirmed.
Coucke et al. present the current evidence for the diagnosis and treatment of biliary obstruction. They discuss how the most common etiology of biliary obstruction is choledocholithiasis or gallstones. They recommend having a high index of suspicion for cholangitis as this condition can be rapidly fatal if untreated.
Incorrect Answers:
Answer A: Analgesics and await resolution of symptoms (in addition to NPO and IV fluids) would be appropriate management for pancreatitis. The diagnosis in this patient has not yet been confirmed (given the absence of findings on ultrasound) thus prompting another diagnostic test.
Answer B: An elective cholecystectomy would be the most appropriate next step in management if the patient had cholecystitis.
Answer D: Laparoscopy is an inappropriate and invasive method of diagnosing and treating disease of the biliary tree as there are better alternatives such as MRCP or ERCP. Laparoscopy would be effective in the treatment of intestinal tract disorders such as appendicitis.
Answer E: An MRI of the abdomen would not confirm the diagnosis of sphincter of Oddi dysfunction. Though a CT scan could be performed as a more cost-effective alternative, given the absence of stones on ultrasound it is likely that a CT scan will not give more information.
Bullet Summary:
Sphincter of Oddi dysfunction can be diagnosed with ERCP and manometry.
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164
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A 21-year-old man presents to the emergency room with right lower quadrant pain that started this afternoon at his wrestling match. He also endorses loss of appetite and subjective fever. He has had vague, mild discomfort in the right upper quadrant since the start of this wrestling season. He endorses a history of unprotected sex with multiple partners and intravenous drug use during a recent vacation to Mexico but has no other significant medical history. He drinks socially and has never smoked. His temperature is 98.6°F (37°C), blood pressure is 119/72 mmHg, pulse is 102/min, and respirations are 12/min. Physical exam demonstrates pain on palpation of the right lower quadrant and mild pain in the right upper quadrant. He has significant acne on his face, chest, and back. A CT of the abdomen confirms appendicitis. The scan also shows a large liver mass measuring 6 cm as seen in Figure A. Aside from addressing his appendicitis, which of the following is the most appropriate next step in management?
|
{
"A": "Administer metronidazole",
"B": "Administer sofosbuvir",
"C": "Obtain follow-up CT of the abdomen in 3 months",
"D": "Perform liver mass resection",
"E": ""
}
|
D
|
This patient with a history of possible anabolic steroid use (wrestler with acne) who presents with right upper quadrant pain and an enhancing lesion in the liver most likely has a hepatic adenoma. The treatment of hepatic adenomas is surgical removal and discontinuation of precipitating agents.
Hepatic adenomas are benign epithelial tumors that typically arise in the right hepatic lobe. They are typically solitary masses but multiple lesions can be seen in patients with prolonged contraceptive or anabolic steroid use and those who have glycogen storage disorders. Patients present with abdominal pain that is localized in the epigastrium or in the right upper quadrant. Sudden, severe abdominal pain with hypotension suggests rupture of the hepatic adenoma into the peritoneum. The lesions can be confirmed on imaging such as ultrasound, CT, or MRI. For hepatic adenomas that are < 5 cm and asymptomatic, simply discontinuing the causative drug and observing are acceptable. Large or symptomatic lesions requiring surgical resection in addition to discontinuation of the offending agent. Because these tumors are highly vascular, failure to resect may result in rupture, hemoperitoneum, and shock. Biopsy is contraindicated to avoid rupturing the mass and causing hemorrhage.
Klompenhouwer et al. studied the current management strategies in patients with hepatocellular adenoma. They found that various molecular groups have been identified allowing for subtyping of these lesions. They recommend performing a CT scan to better characterize these lesions.
Figure/Illustration A is a CT with an enhancing mass with a hypoattenuating fatty component. This is characteristically seen in large hepatic adenomas, which are solitary well-marginated lesions.
Incorrect Answers:
Answer A: Metronidazole would be an effective treatment if this patient had contracted Entamoeba histolytica from contaminated food or water on his recent trip to Mexico. While this amoeba can lead to a liver abscess presenting as a mass on CT, it often also causes abdominal pain and dysentery due to intestinal involvement.
Answer B: Sofosbuvir is an antiviral medication used for hepatitis C. This patient does have risk factors for hepatitis C (risky sexual behavior and intravenous drug use). Although hepatitis C could lead to hepatocellular carcinoma and cause a liver mass, this patient’s presentation is not consistent with that diagnosis. Even if he did have hepatocellular carcinoma, treating hepatitis C alone without surgical resection or adjuvant therapies would be insufficient.
Answer C: Follow-up CT in 3 months would be dangerous for this man with a large hepatic adenoma. In the interim, the mass will likely continue to grow if he continues to use anabolic steroids, increasing the risk of rupture. Observation and repeat imaging may be suitable for asymptomatic hepatic lesions that are of uncertain but likely benign etiology.
Answer D: Biopsying the liver mass is appropriate if malignancy is suspected and there is no concern for hepatic adenoma. If an adenoma is on the differential, biopsy is contraindicated due to the risk of rupture and hemorrhage intraoperatively.
Bullet Summary:
Hepatic adenomas are benign, vascular liver masses associated with oral contraceptives and anabolic steroids that should be promptly resected if large and symptomatic.
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165
|
A 38-year-old man presents to the emergency department with nasal congestion, blurry vision, and diplopia. His nasal congestion started about 1 week ago and he noticed the blurry vision this morning when he struggled to read the words on his television screen. His medical history is significant for IV drug use, HIV (CD4: 47/mm^3), hypertension, hyperlipidemia, diabetes mellitus, and seasonal allergies. His home medications include hydrochlorothiazide, atorvastatin, metformin, cetirizine, darunavir, tenofovir, and emtricitabine. He denies recent IV drug use. His temperature is 100.8°F (38.2°C), blood pressure is 127/85 mmHg, pulse is 78/min, and respirations are 12/min. He has injected conjunctiva and rhinorrhea. His cranial nerves are intact, and his motor and sensory neurologic exam is normal. A MRI of the brain is performed and can be seen in Figure A. Which of the following is the most appropriate next step in management?
|
{
"A": "Empiric treatment with pyrimethamine-sulfadiazine",
"B": "Lumbar puncture",
"C": "Brain biopsy",
"D": "Empiric treatment with dexamethasone",
"E": ""
}
|
A
|
This patient with a past medical history of immunosuppression due to HIV (CD4 < 100/mm^3), new focal neurologic findings, and ring-enhancing lesions on head MRI should be treated empirically with pyrimethamine-sulfadiazine for 10-14 days.
The differential diagnosis for ring-enhancing lesions in patients with HIV is determined by the degree of immunosuppression. For patients with CD4 counts > 200/mm^3, the most likely diagnoses include primary brain tumors and metastases. In patients with CD4 counts < 200/mm^3, the differential includes toxoplasma encephalitis, primary CNS lymphoma, progressive multifocal leukoencephalopathy (PML), and other infections. Patients with CD4 counts < 100/mm^3 should have empiric treatment for toxoplasma encephalitis with pyrimethamine-sulfadiazine with follow-up head imaging after 10-14 days. If the patient fails to improve clinically or the size of the lesion does not change, the next step would be a biopsy of the lesion.
Robert-Gangneux and Darde present a review of toxoplasmosis diagnosis and treatment. They discuss how the incidence of these infections has increased dramatically since the advent of organ transplantation and HIV. They recommend increasing vigilance and prophylaxis for this disease.
Figure/Illustration A is an MRI of the brain that demonstrates a ring-enhancing lesion (red circle) in the right occipital lobe. This lesion is likely causing the patient's visual complaints and is consistent with toxoplasmosis.
Incorrect Answers:
Answer A: Brain biopsy should be performed if the patient has no response clinically or on follow-up head imaging to empiric treatment with pyrimethamine-sulfadiazine for 10-14 days. Biopsy in these cases may reveal a CNS lymphoma or other neoplastic process.
Answer C: Empiric treatment with dexamethasone is indicated for patients with substantial mass effect on imaging and severely depressed mental status, neither of which is present in this patient.
Answer D: Lumbar puncture is contraindicated in patients with focal neurologic findings due to the risk of transtentorial herniation. Lumbar puncture would be indicated in the diagnosis of meningitis which presents with fever, headache, photophobies, and meningeal signs.
Answer E: There is no role for serology for anti-John Cunningham (JC) virus antibodies in the workup of ring-enhancing lesions. If it were safe to perform a lumbar puncture (if the patient had no focal findings and no evidence of mass effect on head imaging), it would be reasonable to perform PCR of the CSF for JC virus.
Bullet Summary:
For patients with a past medical history of HIV with CD4 <100 cells/µL, focal neurologic findings, and ring-enhancing lesions on head imaging, the next step in management is empiric treatment for toxoplasma encephalitis with pyrimethamine-sulfadiazine for 10-14 days.
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https://step2.medbullets.com/testview?qid=108601
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166
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A 24-year-old woman with no significant medical history presents to the emergency department for progressive shortness of breath. She endorses decreased exercise tolerance as well as intermittent palpitations. She returned from a recent missionary trip to South America 12 months prior where she endorsed eating a local delicacy as well as a period of fevers and eyelid swelling during her stay. Her temperature is 99.1°F (37.3°C), pulse is 95/min, blood pressure is 130/85 mmHg, respirations are 15/min, and oxygen saturation is 97% on room air. Physical exam is notable for a laterally displaced point of maximal impulse as well as a 2/6 diastolic murmur radiating to the axilla. A blood smear is shown in Figure A. Her laboratory results are:
Leukocyte count and differential:
Leukocyte count: 10,000/mm^3
Neutrophils: 57%
Lymphocytes: 30%
Monocytes: 3%
Eosinophils: 9%
Basophils: 1%
Hemoglobin: 13.1 g/dL
Platelet count: 420,000/mm^3
Which of the following is the most appropriate treatment?
|
{
"A": "Benznidazole",
"B": "Ganciclovir",
"C": "Praziquantel",
"D": "Amphotericin B",
"E": ""
}
|
A
|
This patient presents with symptoms of heart failure, eosinophilia, trypanosomes on peripheral smear, and a history of recent travel to South America consistent with the diagnosis of Chagas disease. Treatment options for Chagas disease include benznidazole and nifurtimox.
Chagas disease is caused by the parasite Trypanosoma cruzi and is most commonly transmitted by the reduvvid (kissing) bug. The disease is endemic to South America and presents in an acute and chronic phase. The acute phase is characterized by fever, headaches, myalgias, and unilateral eyelid swelling (Romaña’ sign) where the infectious agent has been rubbed into the eye. The chronic phase of the disease is characterized by dilated apical cardiomyopathy leading to conduction abnormalities and valvular dysfunction, megacolon, and megaesophagus. Laboratory testing reveals a peripheral eosinophilia and a peripheral blood smear may reveal the infectious trypanosomes. Treatment is with benznidazole and/or nifurtimox.
Perez-Molina and Molina present the data surrounding the diagnosis and treatment of Chagas disease. They discuss how many cases progress to a chronic state characterized by cardiomyopathy, arrhythmias, and organomegaly. They recommend prompt treatment of the disease to avoid end organ damage.
Figure/Illustration A shows a peripheral blood smear with the trypomastigote form of Trypanosoma cruzi (red circle). Note the anterior location of the dense basophilic nucleus.
Incorrect Answers:
Answer A: Amphotericin B is a potent antifungal that has application in the treatment of multiple fungal infections. It is used as a first-line agent for mucormycosis and cryptococcal meningitis (in addition to flucytosine). Amphotericin B with sodium stibogluconate is used to treat visceral leishmaniasis, a protozoal infection most commonly caused by Leishmania donovani. Side effects can include nausea, vomiting, rigors, fever, hypertension or hypotension, renal dysfunction, and hypoxia.
Answer C: Erythromycin is a macrolide antibiotic that is used in the treatment of bacterial infections. It has a pro-motility effect and can also be used as a gastric pro-motility agent. Potential side effects include gastrointestinal upset, prolonged QT interval, inhibition of the P450 system, and pyloric stenosis in infants.
Answer D: Ganciclovir is a synthetic nucleoside analogue that is mainly used in the treatment of cytomegalovirus (CMV) infections. The most common side effects are bone marrow suppression (granulocytopenia, thrombocytopenia, and anemia) and gastrointestinal upset.
Answer E: Praziquantel is an anti-helminthic used in the treatment of tapeworms and flukes including Echinococcus, Taenia solium (cysticerosis), Schistosoma sp., Clonorchis sinensis (liver fluke), and Paragonimus westermani (lung fluke). Side effects of praziquantel develop due to release of contents from dead parasites and can include gastrointestinal upset, elevated liver enzymes, and dizziness.
Bullet Summary:
Treatment of Chagas disease is with benznidazole or nifurtimox.
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https://step2.medbullets.com/testview?qid=108604
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167
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A 66-year-old man presents to the clinic for evaluation of a skin lesion on his hand. The lesion has grown rapidly over the previous 2 weeks. He endorses trauma to the area when he accidentally scraped his hand against a window and notes that there was some bleeding. His medical history is significant for chronic renal failure for which he received a renal transplant 5 years prior, as well as multiple surgeries for skin cancer. His current medications include aspirin, atorvastatin, prednisone, tacrolimus, and mycophenolate mofetil. His temperature is 98.6°F (37°C), blood pressure is 136/91 mmHg, pulse is 82/min, and respirations are 11/min. Physical exam is notable for a 2 x 2.5 cm nodular lesion of the dorsal hand as seen in Figure A. Which of the following is the most likely diagnosis?
|
{
"A": "Keratoacanthoma",
"B": "Verruca vulgaris",
"C": "Basal cell carcinoma",
"D": "Molluscum contagiosum",
"E": ""
}
|
A
|
This patient presents with a rapidly enlarging, well-circumscribed, volcano-like papule with a central keratotic core consistent with the diagnosis of keratoacanthoma.
Keratoacanthomas represent a well-differentiated variant of cutaneous squamous cell carcinoma. They present as a rapidly enlarging skin lesion with a characteristic hyperkeratotic core. Most lesions occur on the sun-exposed areas of the body, especially the head, neck, and extremities. Risk factors for developing a keratoacanthoma include immunosuppression, arsenic exposure, old scars or burns, xeroderma pigmentosum, or exposure to high levels of ionizing radiation. Most keratoacanthomas tend to involute within several months after initial onset; however, surgical excision can be performed because of the histologic similarity to squamous cell carcinoma. Biopsy of lesions with malignant transformation will show atypical keratinocytes and malignant cells, invasion into dermis, and keratin “pearls” on histology.
Kwiek and Schwartz present a review of keratoacanthoma diagnosis and treatment. They discuss how these lesions characteristically exhibit spontaneous regression after rapid growth. They recommend surgical excision as first-line therapy for the lesion.
Figure/Illustration A is a clinical photograph showing a well-circumscribed, dome-shaped papule with a hyperkeratotic core (red circle) consistent with keratoacanthoma.
Incorrect Answers:
Answer A: Basal cell carcinoma is the most common skin cancer in humans. It most commonly presents as a pearly pink papule or ulcer with telangiectasias and a rolled border. Compared to keratoacanthoma, basal cell carcinomas are slow-growing and are only locally invasive. Surgical excision is the treatment of choice for most basal cell carcinomas.
Answer C: Molluscum contagiosum is a common viral infection caused by a poxvirus that is most frequently seen in children. It presents with solitary or multiple umbilicated papules and is spread by person-to-person contact. Immunosuppressed individuals, such as those with HIV/AIDS, may have disseminated molluscum contagiosum, which is highly recalcitrant to treatment.
Answer D: Pyogenic granulomas are vascular proliferations that present as rapidly growing, pink to red, friable papules that are prone to bleeding with minor trauma. They are most commonly seen in children and pregnant women. The oral mucosa is a common area of presentation, although pyogenic granulomas may present in any skin location. Treatment is through mechanical removal via surgical excision, laser ablation, or electrical curettage.
Answer E: Verruca vulgaris is a common viral infection of the skin caused by several subtypes of human papilloma virus (HPV). They present as rough-textured or filiform papules. Close examination may reveal pinpoint areas of red/black, which represent thrombosed blood vessels within the wart. Treatment options for common warts include salicylic acid or cryotherapy; however, recurrence after treatment is common.
Bullet Summary:
Keratoacanthomas presents as rapidly enlarging, well-circumscribed, volcano-like papules with a central hyperkeratotic core.
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https://step2.medbullets.com/testview?qid=108605
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168
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A 32-year-old G1P0 woman at 12 weeks gestation presents to her obstetrician for a follow-up appointment. She first presented 4 weeks ago with bilateral hand tremors. At that time, she was found to have a thyroid-stimulating hormone (TSH) concentration <0.01 mU/L and an elevated free T4. She was started on propranolol and propylthiouracil. The dosage of both medications has been titrated to the maximum dose. She reports mild improvement in her symptoms but continues to experience sweating and palpitations. She has a past medical history of polycystic ovary syndrome. Her family history is notable for hypothyroidism in her mother. She does not smoke cigarettes, stopped drinking alcohol prior to pregnancy, and does not use drugs. Her temperature is 97.6°F (36.4°C), blood pressure is 113/70 mmHg, pulse is 126/min, and respirations are 18/min. On physical exam, she appears anxious, mildly diaphoretic and has a non-tender prominence on her neck which is shown in Figure A. Which of the following is the most appropriate next step in management?
|
{
"A": "Oral iodinated contrast",
"B": "Thyroidectomy in the 2nd trimester",
"C": "Methimazole",
"D": "Continue routine prenatal care only",
"E": ""
}
|
B
|
This patient who initially presented with tremors, a suppressed TSH, and elevated T4 has Graves disease which was appropriately treated with propranolol and propylthiouracil. However, she has persistent symptoms (diaphoresis, palpitations, tachycardia, nontender goiter) despite maximum doses of these medications, which should then be treated with surgical thyroidectomy which can be performed safely in the 2nd trimester of pregnancy.
Graves disease is caused by TSH receptor antibodies that activate the TSH receptor to synthesize thyroid hormone, leading to hyperthyroidism with suppressed TSH levels. The initial treatment for Graves disease is symptom control with a beta-blocker (e.g., propranolol) and inhibition of thyroid hormone synthesis with a thionamide (e.g., propylthiouracil or methimazole). In the 1st trimester of pregnancy, propylthiouracil is preferred to methimazole. In the 2nd and 3rd trimesters, methimazole is the preferred thionamide. The treatment of choice in pregnancy for Graves disease that is refractory to propranolol and a thionamide is thyroidectomy, which can safely be performed in the 2nd trimester. This is reserved only for more severe cases refractory to medical treatment. In nonpregnant patients, radioiodine ablation is the preferred treatment for refractory Graves disease but is contraindicated during pregnancy due to the risk of ablating the fetal thyroid.
Davies et al. reviewed the pathogenesis, diagnosis, and treatment of Graves disease. They found that Graves disease is caused by autoantibodies to the TSH receptor, resulting in overactive thyroid hormone secretion. They recommend that Graves's disease be treated with antithyroid drugs, radioiodine ablation, or surgery depending on clinical characteristics.
Figure A demonstrates goiter, a common finding in Graves disease that reflects thyroid growth in response to activation by TSH receptor antibodies.
Incorrect Answers:
Answer A: Continuing routine prenatal care does not address the symptoms of the patient's hyperthyroidism. Poorly-controlled hyperthyroidism can lead to spontaneous abortion, premature labor, low birth weight, heart failure, and preeclampsia in pregnant individuals. Therefore, Graves disease should be treated in pregnant individuals.
Answer B: Methimazole is a thionamide that is an alternative to propylthiouracil in nonpregnant individuals. It is more potent than propylthiouracil. Methimazole is contraindicated during the 1st trimester of pregnancy due to its teratogenic effects on the fetus during organogenesis.
Answer C: Oral iodinated contrast agents inhibit the peripheral conversion of T4 to T3 and may be used in thyroid storm in nonpregnant patients outside of the United States. Patients with thyroid storm present with tachycardia, arrhythmias, heart failure, and hyperpyrexia.
Answer D: Radioiodine ablation is the preferred definitive treatment for Graves disease in nonpregnant individuals. It is contraindicated in pregnancy as fetal thyroid tissue has developed by 10-12 weeks of gestation and may be ablated alongside the maternal tissue.
Bullet Summary:
Initial treatment of Graves disease in pregnancy is propranolol and propylthiouracil, whereas severe symptoms that are refractory to medical management should be treated with thyroidectomy.
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https://step2.medbullets.com/testview?qid=108726
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169
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A 34-year-old man is brought to a rural emergency department by ambulance after being involved in a motor vehicle accident. Paramedics report that the patient was driving the car and crashed into a tree at roughly 25 miles per hour. There were no passengers and he was awake but disoriented at the scene. His temperature is 97.9°F (36.6°C), blood pressure is 131/88 mmHg, pulse is 89/min, and respirations are 14/min. He is speaking but is confused, opens his eyes to voice commands, and follows simple commands. He has multiple lacerations on his face and arms and smells of alcohol and marijuana. His cardiac exam is normal and his lungs are clear to auscultation bilaterally. He has bruising over his abdomen without any tenderness to palpation, distension, or rigidity. Which of the following is the most appropriate next step in management?
|
{
"A": "Focused abdominal sonography for trauma exam",
"B": "Diagnostic peritoneal lavage",
"C": "Chest radiograph anterior-posterior and lateral",
"D": "Abdominal and chest CT",
"E": ""
}
|
D
|
This patient presents following a motor vehicle accident with a tender abdomen and stable vital signs. Given his stability, the most appropriate next step is an abdominal and chest CT.
In blunt abdominal trauma, the next step in management depends upon whether the patient is hemodynamically stable. With a normal blood pressure and pulse within the normal range, patients can undergo imaging to evaluate for injury to the abdominal organs with the most appropriate study being an abdominal CT with contrast. This study can accurately localize bleeding and aid in operative planning. A bedside ultrasound known as the FAST exam is often performed in unstable patients. Unstable patients, patients with abdominal tenderness, and patients with a severe mechanism of trauma may have a bedside FAST exam performed. If the free fluid is localized, the patient can be transferred directly to the operating room. Note that in many hospitals, the FAST exam is done simultaneously with the primary and secondary survey; however, if asked to choose which exam to perform on a trauma patient who is stable with no signs of a surgical abdomen, a CT scan should be performed to more accurately assess the patient's injuries and assess for injuries that may be missed by a FAST exam.
Feliciano reviewed the evidence surrounding the current diagnosis and management of abdominal trauma. He discusses how contrast-enhanced CT of the abdomen and pelvis is an important method for evaluating the etiology of intra-abdominal bleeding. He recommends considering damage control methods in the polytrauma patient.
Incorrect Answers:
Answer B: Chest radiography has limited utility in the setting of blunt abdominal trauma; however, a portable anterior-posterior film is often taken in trauma, in particular, when the patient is intoxicated. However, an anterior-posterior and lateral film would involve transporting the patient to radiology and positioning the patient. Thus it would be both difficult to obtain and less useful when compared to a CT scan given his traumatic injuries. Findings on chest radiograph could suggest abdominal injury, such as lower rib fractures or free air under the diaphragm, which would suggest intestinal perforation.
Answer C: Diagnostic laparoscopy may play a role in evaluating for injury in penetrating traumas such as gunshot wounds or stabbing wounds but would not be indicated as the most appropriate initial step in management in a stable patient. Unstable patients, surgical abdomens, and positive FAST exams or CT scans warrant transfer to the operating room.
Answer D: Diagnostic peritoneal lavage is a historical test to assess for intra-abdominal injury that was typically used with ambiguous FAST exams or patients where it was unclear whether there was abdominal bleeding; however, it has almost entirely been supplanted by the FAST exam.
Answer E: FAST exams are often performed with the primary or secondary survey in large institutions where resources are available. However, in small hospitals with limited resources, the most appropriate next step in management when deciding between a FAST exam or a CT scan should be made based on the mechanism and concern for bleeding. This stable patient with a benign exam can undergo a CT scan, which will offer more data than a FAST exam and would be performed regardless of whether a FAST exam was positive or negative given this patient's intoxication and abdominal bruising.
Bullet Summary:
In a patient who has experienced blunt abdominal trauma the most appropriate initial step in a stable patient is an abdominal CT scan.
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https://step2.medbullets.com/testview?qid=108735
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170
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A 31-year-old woman presents to her obstetrician for her first prenatal visit after having a positive home pregnancy test 1 week ago. Her last menstrual period was 8 weeks ago. The patient has a medical history of type 1 diabetes mellitus since childhood and her home medications include insulin. Her hemoglobin A1c 2 weeks ago was 13.7%. At that time, she was also found to have microalbuminuria on routine urinalysis. Her primary care provider prescribed lisinopril but the patient has not yet started taking it. The patient’s brother is autistic but her family history is otherwise unremarkable. Her temperature is 98.6°F (37.0°C), blood pressure is 124/81 mmHg, pulse is 75/min, and respirations are 14/min. A physical exam is unremarkable. This fetus is most likely at increased risk for which of the following complications?
|
{
"A": "Neonatal hyperglycemia",
"B": "Neural tube defect",
"C": "Oligohydramnios",
"D": "Post-term delivery",
"E": ""
}
|
B
|
This patient has type 1 diabetes mellitus and presents in early pregnancy with a markedly elevated hemoglobin A1c, suggesting poor glycemic control. Poor glycemic control increases the risk of a neural tube defect in the fetus.
Infants of diabetic mothers (IDM) are at increased risk of many congenital malformations as well as postnatal complications. These risks are more likely if there is poor maternal glycemic control, especially in the periconceptional period. Poorly controlled hemoglobin A1c and microalbuminuria on urinalysis indicate long-standing poor glycemic control and indicate a poor prognosis. The most common anomalies in IDM are cardiovascular defects such as septal defects and transposition of the great arteries as well as neural tube defects such as anencephaly and spina bifida. Sacral agenesis, or a poorly developed caudal spine and spinal cord, as well as small left colon syndrome due to a meconium plug, are other common malformations seen in IDM. General complications in IDM include prematurity, intrauterine growth restriction or macrosomia, and miscarriage. Risk is minimized by tight glycemic control throughout pregnancy.
Dean et al. summarize the evidence surrounding micronutrients and obesity in pregnancy. They found that patients with diabetes had a higher risk of having infants with a neural tube or a congenital heart defect. They recommend using folic acid supplementation in all patients to reduce the risk of neural tube defects.
Incorrect Answers:
Answer A: Aneuoploidy risk is not increased in IDM. This complication is associated with advanced maternal age. This patient is at baseline risk since she is below the “advanced maternal age” cutoff of 35 years. Some of the values used in aneuploidy screening (maternal serum alphafetoprotein, estriol, and inhibin A) are generally lower in women with diabetes. Guidelines specific to this patient population should be used for the aneuploidy screen so as to avoid false positive results.
Answer B: Neonatal hyperglycemia is not seen in IDM. Patients may experience hypoglycemia. This is due to the crossing of glucose from the mother to the fetus via the placenta and subsequent hyperinsulinemia and ß-cell hyperplasia from the fetus. After delivery, the high insulin levels cause hypoglycemia because there is no longer an overabundant source of glucose. Hyperglycemia in infants is much less common and can be due to glucose infusion or sepsis.
Answer D: Oligohydramnios is not specifically associated with maternal hyperglycemia. Instead, patients may experience polyhydramnios. The mechanism for increased amniotic fluid is unclear, though some speculate that fetal hyperglycemia results in polyuria and thus polyhydramnios. Severe oligohydramnios can cause pulmonary hypoplasia and clubfoot as well as cord compression, while polyhydramnios is associated with cord prolapse, placental abruption, and prematurity.
Answer E: Post-term delivery occurs after 42 weeks gestation. Maternal diabetes typically causes prematurity. Post-term delivery is associated with fetal malnutrition, hypoxemia, and oligohydramnios due to suboptimal functioning of the placenta. The risk of meconium aspiration increases as gestational age increases. Induction of labor is generally performed at 42 weeks to avoid these complications.
Bullet Summary:
Maternal hyperglycemia from diabetes mellitus is associated with congenital heart defects, neural tube defects, and small left colon syndrome.
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https://step2.medbullets.com/testview?qid=108737
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171
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A 15-year-old boy is brought to his pediatrician for a follow-up visit. His parents report that he is doing well in school and has many friends. Their only concern is that he has a “difficult stomach.” Every few months, he complains of intermittent abdominal pain that takes several days to pass. He occasionally misses school due to the pain. There is blood in his stool during these episodes. These symptoms have persisted for many years. The parents have so far managed the condition using herbal teas and essential oils but have not sought formal medical care. His temperature is 98.2°F (36.8°C), blood pressure is 106/61 mmHg, pulse is 88/min, and respirations are 12/min. He has lost 10 pounds since his annual visit the year before and is the same height. On physical exam, the patient is thin with conjunctival pallor. His sclerae are anicteric and his abdomen is soft and non-tender without hepatosplenomegaly. He also has the findings seen in Figure A. He undergoes an abdominal CT that shows disease affecting the terminal ileum. Which of the following is most likely to be present in this patient?
|
{
"A": "Increased serum methylmalonic acid level",
"B": "Microcytes",
"C": "Decreased serum homocysteine level",
"D": "Prolonged partial thromboplastin time",
"E": ""
}
|
A
|
This patient with episodic abdominal pain, bloody stool, growth failure, and erythema nodosum most likely has Crohn disease. Disease involving the terminal ileum predisposes patients to vitamin B12 deficiency, which would cause anemia with an elevated serum methylmalonic acid level.
Crohn disease is an inflammatory bowel disease that presents with abdominal pain, bloody stools, and growth failure in children. Extra-intestinal manifestations of Crohn disease include fistula formation and erythema nodosum, which appear as multiple tender erythematous nodules that fade after 1-2 weeks into bluish plaques or macules that can be confused with bruises. Complications of Crohn disease when the disease involves the terminal ileum is vitamin deficiency and malabsorption. These deficiencies can include vitamin A, vitamin D, vitamin E, vitamin K, zinc, and vitamin B12. Vitamin B12 deficiency presents with a macrocytic, megaloblastic anemia with hypersegmented neutrophils on peripheral blood smear. Lab findings include elevated serum homocysteine and methylmalonic acid levels. Vitamin B12 deficiency is also associated with peripheral neuropathy and should be treated with intramuscular vitamin repletion.
Akbulut presents the current state of evidence regarding vitamin deficiency in patients with Crohn disease. They found that vitamin B12 and folate levels are often low in patients with this disease. They recommend monitoring vitamin levels and providing repletion when necessary.
Figure/Illustration A is a clinical photograph showing erythematous nodules on the extensor surfaces of the legs (red circles). This finding is consistent with the latter stage of erythema nodosum.
Incorrect Answers:
Answer A: Decreased mean corpuscular volume may be seen in iron deficiency anemia, which can be co-morbid with Crohn disease. While this patient does have recurrent gastrointestinal blood loss, the very low frequency of his symptoms is unlikely to result in iron deficiency, making a decreased MCV less likely compared to an increased MCV given the underlying terminal ileum pathology.
Answer B: Decreased serum homocysteine level is not seen in any common human disease. An elevated (not decreased) serum homocysteine level is seen in vitamin B12 deficiency in addition to folate deficiency. This increase is due to the impaired processing of homocysteine in the absence of these cofactors.
Answer D: Microcytes would not be seen in vitamin B12 deficiency or folate deficiency, which instead present with macro-ovalocytes. Microcytic anemia would be seen in patients with iron deficiency anemia, which can present with fatigue and pallor in patients with occult bleeding. Iron supplementation and treatment of the underlying source of bleeding is appropriate care.
Answer E: A prolonged PTT could be seen in this patient as vitamin K absorption is likely affected. This patient is not presenting with a chief complaint of bruising/bleeding (the physical exam finding is erythema nodosum rather than ecchymosis), and symptoms point toward a diagnosis of anemia which would be associated with poor B12 absorption.
Bullet Summary:
Crohn disease may affect the terminal ileum, resulting in vitamin B12 deficiency (increasing the serum methylmalonic acid level) that would present with macrocytic, megaloblastic anemia with hypersegmented neutrophils on a peripheral blood smear.
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https://step2.medbullets.com/testview?qid=108740
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172
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An 83-year-old man is brought to the emergency department by his daughter due to confusion over the last 2 weeks. The patient initially became less talkative than usual before starting to confuse her with her sister. The patient also could not remember what day of the week it was and he was out of groceries and likely had been for several days when visited. While she was talking to him, he fell asleep and was difficult to rouse. The patient is unable to provide a clear history. He has a medical history of hypertension, glaucoma, and osteoarthritis in his left knee that requires him to walk with a cane. He takes hydrochlorothiazide, timolol eyedrops, and occasional acetaminophen. His temperature is 98.5° F (36.9° C), blood pressure is 122/74 mmHg, pulse is 75/min, and respirations are 14/min. The patient is lethargic but arousable, oriented only to person, and disheveled. Neurologic exam reveals intact cranial nerves, 1+ deep tendon reflexes throughout, and 4/5 strength in all extremities. There is a 3 x 5 cm green-blue area of ecchymosis on the lateral aspect of his left knee. A CT of the head without contrast is performed and shown in Figure A. Which of the following factors plays the earliest role in the progression towards this patient’s presentation?
|
{
"A": "Increased cerebrospinal fluid",
"B": "Aneurysmal rupture",
"C": "Cerebral atrophy",
"D": "Hypertension",
"E": ""
}
|
C
|
This patient is an elderly man with progressive confusion over weeks, a nonfocal neurologic exam, and a CT of the head showing a hypodense crescent, most consistent with chronic subdural hematoma (SDH). Cerebral atrophy plays the earliest role in this presentation, resulting in exposure of the bridging veins and subsequent rupture with even minor trauma.
Chronic subdural hematomas present gradually, most often with headaches, somnolence, light-headedness, cognitive impairment, and rarely, seizures. Typically, the neurologic exam is largely normal but rarely focal deficits such as contralateral hemiparesis from compression of the cortex underlying the hematoma or ipsilateral hemiparesis from the lateral displacement of the opposite cortex may occur. Chronic SDH most often occurs in the setting of cerebral atrophy related to increased age, chronic alcohol use, and prior traumatic brain injury. Exposure of the bridging veins allows even minor trauma to precipitate subdural bleeding. A non-contrast CT of the head is indicated in any elderly patient with decreased mentation and concern for chronic SDH. Since old blood appears hypodense, imaging will allow for the determination of whether the bleed is acute or chronic. Supportive care is usually sufficient for treatment but surgical evacuation of the hematoma can be considered in patients with focal deficits or an expanding hematoma.
Mehta et al. review the evidence regarding the diagnosis and management of chronic subdural hematomas in elderly patients. They discuss how crescentic layering of fluid in the subdural space on a non-contrast computed tomography scan is diagnostic of this condition. They recommend close follow-up as many patients will develop a recurrence of this condition.
Figure/Illustration A shows a non-contrast CT scan of the head with a hypodense crescent left side (red circle). This finding is consistent with a chronic subdural hematoma.
Incorrect Answers:
Answer A: Aneurysmal rupture is an extremely uncommon cause of SDH and typically causes subarachnoid hemorrhage instead. It often presents with “the worst headache of my life” or “thunderclap headache,” and would show hyperdensity in the subarachnoid space on head CT. Surgical clipping or endovascular treatment can prevent rebleeding.
Answer C: Elder abuse can be subtle and should always be considered when an elderly patient presents with confusion, bruising, or dishevelment. In children, abuse is an important cause of SDH, which may occur in the setting of “shaken baby syndrome.” However, abuse is not especially associated with chronic SDH in the elderly population, and there is another plausible reason for this patient’s presentation (trauma from a fall as evidenced by the resolving ecchymosis on his knee).
Answer D: Hypertension is a major risk factor for stroke, which typically presents with focal neurologic deficits such as hemiparesis, aphasia, or sensory loss. Although this patient does have a history of hypertension, he is normotensive in the emergency room and has non-focal neurologic decline that has been slowly progressive, which is less consistent with stroke. Furthermore, in contrast to this patient’s CT scan, acute ischemic stroke would likely present with a normal head CT and prior infarct would cause a hypodensity in the parenchyma itself. Treatment is with risk factor optimization when a patient presents outside the window for thrombolytic agents.
Answer E: Increased CSF due to poor reabsorption by arachnoid granules is the cause of normal pressure hydrocephalus (NPH). Patients typically present with the “wet, wacky, and wobbly” triad – urinary incontinence, mental status changes, and magnetic gait. Head CT would show dilated ventricles and management includes CSF shunting.
Bullet Summary:
Chronic subdural hematomas may occur in elderly patients due to cerebral atrophy and subsequent exposure of bridging veins that may tear with minor trauma.
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https://step2.medbullets.com/testview?qid=108758
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173
|
A 65-year-old man presents to his primary care physician for stiffness in his arm. He has been having trouble combing his hair and reaching objects that are high on the shelf. The patient has a medical history of type 2 diabetes mellitus, obesity, and hypertension. His current medications include metformin, insulin, lisinopril, and hydrochlorothiazide. The patient leads a sedentary life in which he tends to stay home and watch television. He does not engage in any physical or strenuous activity. His temperature is 98.6°F (37°C), blood pressure is 138/85 mmHg, pulse is 75/min, and respirations are 12/min. On physical exam, the patient has decreased passive and active range of motion of his shoulder. The strength of the patient's upper extremity is 4/5 limited by pain. Which of the following is the most likely diagnosis?
|
{
"A": "Glenohumeral osteoarthritis",
"B": "Adhesive capsulitis",
"C": "Subacromial bursitis",
"D": "Biceps tendinopathy",
"E": ""
}
|
B
|
This patient is presenting with stiffness and a decreased range of motion in his shoulders suggestive of a diagnosis of adhesive capsulitis.
Adhesive capsulitis classically presents in elderly, sedentary patients with a chief complaint of stiffness. On physical exam, the key findings are a loss of active, but more importantly, passive range of motion. It is the loss of passive range of motion that suggests a diagnosis of adhesive capsulitis over rotator cuff injuries, biceps tendinopathy, glenohumeral osteoarthritis, and subacromial bursitis. The diagnosis of adhesive capsulitis is made clinically; however, radiography, MRI, and ultrasound can be used to rule out other diagnoses. Treatment includes NSAIDs and physical therapy and can include steroids.
Ramirez reviews the evidence regarding the diagnosis and treatment of adhesive capsulitis. He discusses how non-operative management consists of nonsteroidal anti-inflammatory drugs, short-term oral corticosteroids, intra-articular corticosteroid injections, and physiotherapy. He recommends manipulation under anesthesia and arthroscopic capsule release in patients who fail conservative management.
Incorrect Answers:
Answer B: Biceps tendinopathy presents with pain and weakness overlying the long head of the biceps tendon. This tendon runs in the intertubercular groove on the anterior aspect of the proximal humerus. Patients will often present with pain with resisted flexion of the elbow. Treatment is surgical debridement in patients who fail conservative measures.
Answer C: Glenohumeral osteoarthritis presents with vague and diffuse pain that is exacerbated by activity in addition to a loss of range of motion of the shoulder. Though this patient is experiencing a decreased range of motion, the decreased passive range of motion is more specific for adhesive capsulitis. Treatment is with a total shoulder replacement in patients who fail conservative measures.
Answer D: Rotator cuff impingement presents with pain and weakness of the upper extremity, but also can present with a decreased range of motion as this patient experienced. Of note, the passive range of motion will not be significantly affected by this disease. Treatment is with surgical reconstruction or debridement of the rotator cuff if initial measures fail.
Answer E: Subacromial bursitis presents with localized tenderness, decreased range of motion, pain with motion, and sometimes erythema/edema. Though this patient is experiencing a decreased range of motion and pain with motion, the decreased passive range of motion suggests a diagnosis of adhesive capsulitis. Treatment is with rest and oral anti-inflammatory medications.
Bullet Summary:
Adhesive capsulitis presents with pain and a decreased passive and active range of motion.
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174
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A 35-year-old man presents to his primary care physician with pain along the bottom of his foot. The patient is a long-time runner but states that the pain has been getting worse recently. When running and at rest he has a burning and aching pain along the bottom of his foot that sometimes turns to numbness. Taking time off from training does not improve his symptoms. The patient has a medical history of surgical repair of his Achilles tendon, ACL, and medial meniscus. He is currently not taking any medications. The patient lives with his wife and they both practice a vegan lifestyle. His temperature is 98.6°F (37°C), blood pressure is 114/72 mmHg, pulse is 81/min, and respirations are 12/min. On physical exam, the patient states that he is currently not experiencing any pain in his foot but rather is experiencing numbness/tingling along the plantar surface of his foot. Strength is 5/5 and reflexes are 2+ in the lower extremities. Which of the following is the most likely diagnosis?
|
{
"A": "Plantar fasciitis",
"B": "Vitamin B12 deficiency",
"C": "Tarsal tunnel syndrome",
"D": "Herniated disc",
"E": ""
}
|
C
|
This patient is presenting with pain, tingling, and numbness on the plantar surface of his foot that is not associated with exertion or rest suggesting a diagnosis of tarsal tunnel syndrome.
Tarsal tunnel syndrome occurs due to compression of the tibial nerve as it travels through the tarsal tunnel. Compression of the nerve leads to symptoms along the plantar surface of the foot which can include pain, tingling, or numbness. These symptoms can be exacerbated/triggered by tapping on the tunnel, which lies posterior to the medial malleolus. In addition, the symptoms can occur at rest or during activity and are not improved with rest. Treatment is rest, NSAIDs, properly fitted shoes/orthotics, and in refractory cases, surgical release of the tarsal tunnel.
Gould reviews the evidence regarding the diagnosis and treatment of tarsal tunnel syndrome. He discusses how this syndrome represents a collection of different entities including space-filling lesions and local inflammation. He recommends definitive diagnosis prior to surgical treatment given that the syndrome is often misdiagnosed.
Incorrect Answers:
Answer A: Common fibular nerve compression typically occurs when there is trauma/compression just inferior to the head of the fibula. This can occur when an individual wears work boots and after fractures of the fibular neck. Symptoms of common fibular nerve compression include foot drop and numbness on the dorsum of the foot. Treatment is with activity modification and a foot orthosis to prevent an equinus contracture.
Answer B: Herniated disc presents with symptoms of radiculopathy including pain that travels down the leg through the toes. Symptoms are worsened with flexion of the leg such as during the straight leg raise test. Treatment is with NSAIDs and corticosteroid injections with surgical decompression of the disc in refractory cases.
Answer C: Plantar fasciitis can present very similarly to tarsal tunnel syndrome with pain along the plantar surface of the foot. The pain is typically exacerbated by activity and improves with rest in contrast to this patient. In addition, there is an absence of burning, pain, and numbness that occur in tarsal tunnel syndrome. Tenderness will be at the medial insertion of the plantar fascia into the calcaneal tuberosity. Treatment is conservative with NSAIDs and activity modification.
Answer E: Vitamin B12 deficiency could present with symptoms of peripheral neuropathy. This is possible given this patient's vegan diet. This patient has pain only in one of his feet and he does not have symptoms of anemia such as fatigue or pallor. Treatment is with the repletion of vitamin B12.
Bullet Summary:
Tarsal tunnel syndrome presents with pain, numbness, tingling, and aching along the plantar surface of the foot that is not associated with activity.
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175
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A 71-year-old woman arrives to clinic with sudden vision loss. She was in her usual state of health until waking up this morning unable to see out of her right eye. She denies pain, but reports her right eye “feels funny.” The patient’s medical history is significant for a previous myocardial infarction, hypertension, and osteoporosis. Her current medications include aspirin, metoprolol, rosuvastatin, lisinopril, and alendronate. Her temperature is 98°F (36.7°C), blood pressure is 145/86 mmHg, pulse is 62/min, and respirations are 12/min with an oxygen saturation of 98% on room air. The patient's pupils are symmetric in size and equally reactive to light with accommodation. A fundoscopic exam of the right eye is shown in Figure A. The left optic fundus is unremarkable. Which of the following is the most likely diagnosis?
|
{
"A": "Papilledema",
"B": "Retinal vein occlusion",
"C": "Retinal detachment",
"D": "Closed angle glaucoma",
"E": ""
}
|
B
|
This patient is presenting with sudden, painless, unilateral vision loss with a fundoscopic exam positive for venous dilation and retinal hemorrhage. These findings are consistent with the diagnosis of retinal vein occlusion.
Retinal vein occlusion can occur in either central or branch retinal veins and is often caused by compression from nearby arterial atherosclerosis. It presents as acute onset, painless vision loss, normally in one eye. On fundoscopic exam, classic findings of this disease include venous engorgement, retinal hemorrhage, cotton wool exudates, and edema/swelling of the optic disk can be seen. There is no definitive treatment for this disorder but symptomatic treatment includes intravitreal glucocorticoid injections and retinal laser photocoagulation. Retinal vein occlusion may resolve spontaneously or progress to permanent vision loss.
Robinson and Halpern present evidence regarding the treatment of retinal vein occlusion. They discuss how the treatments for the acute phase of this disease have been disappointing. They recommend managing long-term complications such as neovascularization with phototherapy.
Figure/Illustration A is a fundoscopic exam showing engorged retinal veins, optic disk swelling, and widespread retinal hemorrhages (red circle). These findings are characteristic of central retinal vein occlusion.
Incorrect Answers:
Answer A: Central retinal artery occlusion can present as sudden onset, unilateral vision loss. Fundoscopic exam will show a “cherry-red” spot at the fovea and a “fuzzy” retina with attenuated vessels. Embolic sources may include carotid artery atherosclerosis or cardiac vegetation. Treatment is with risk factor control.
Answer B: Closed-angle glaucoma presents as sudden, painful, vision loss caused by increased intraocular pressure. The eye will appear red and often feel “hard.” The optic disc will show characteristic cupping. Intraocular pressure will be levated and treatment is with acetazolamide, steroids, timolol, bromidine, and pilocarpine. Irodotomy is reserved for refractory cases.
Answer C: Papilledema may present as an enlargement in the blind spot and is usually bilateral, as it is caused by increased intracranial pressure. On fundoscopic exam, there will be bilateral optic disk swelling, seen as an elevated optic disk and blurred margins. Patients should undergo a neurologic evaluation to determine the etiology of the papilledema.
Answer D: Retinal detachment presents as monocular loss of vision, often described as a “curtain pulled down,” and preceded by “flashers” and “floaters.” On fundoscopic exam, crinkling of the retinal tissue and abrupt changes in vessel direction can be seen. Surgical reattachment of the retina is required to prevent loss of vision.
Bullet Summary:
Retinal vein occlusion presents with a sudden, monocular, painless loss of vision with optic disk swelling, dilated veins, cotton wool spots, and retinal hemorrhages.
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176
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An 82-year-old man with a history of atrial fibrillation presents to the emergency room complaining of sudden-onset, painless vision loss in his right eye starting 2 days ago. When it started, he felt like a “curtain was pulled down” over his right eye but wasn't able to seek care immediately because it was snowing outside and he didn't want to travel in inclement weather. A review of systems is significant for occasional palpitations and presyncope. The patient’s medications include aspirin and carvedilol. He reports that he is a smoker with a 50-pack-year history. The patient’s temperature is 99°F (37.2°C), blood pressure is 112/72 mmHg, pulse is 84/min, and respirations are 14/min with an oxygen saturation of 97% on room air. Physical exam reveals 20/800 vision in the right eye. A fundoscopic exam of the right eye is shown in Figure A. Physical and fundoscopic examinations of the left eye are unremarkable. Which of the following is the most appropriate next step in management?
|
{
"A": "Start retinal photocoagulation",
"B": "Continue aspirin and start statin therapy",
"C": "Administer tissue plasma activator",
"D": "Start timolol drops",
"E": ""
}
|
B
|
This patient with a history of atrial fibrillation is presenting with acute-onset, painless, monocular vision loss and a fundoscopic exam positive for retinal whitening. This suggests a diagnosis of central retinal artery occlusion and management should focus on control of underlying risk factors given that he is 2 days out from the event.
Symptoms of central retinal artery occlusion (CRAO) include sudden, painless, complete, and normally unilateral vision loss. A fundoscopic exam can show pallor of the optic disc, diffuse ischemic whitening of the retina, cherry-red macula, retinal edema, and constricted/bloodless retinal arterioles. The center of the macula appears red because the photoreceptor layer at the fovea is perfused by the posterior choroidal vasculature rather than the central retinal artery. Treatment involves surgical decompression of the retinal anterior chamber, ideally within 1 hour of the occlusion. Tissue plasminogen activator should be administered if the patient presents within an acceptable time frame. If surgical intervention is not readily available, additional steps with minimal evidence to support their use include ocular massage (to dislodge the embolus) and either carbogen therapy or hyperbaric oxygen. Chronic management includes control of underlying risk factors with aspirin and statin therapy.
Dattilo et al. review the evidence regarding the treatment of central retinal artery occlusion. They discuss how treatments have not been particularly effective in the treatment of this disorder. They recommend engaging in secondary prevention of vascular events by controlling risk factors.
Figure/Illustration A is a fundoscopic photograph showing retinal pallor surrounding the superior temporal arcade (red circle). This finding is characteristically seen in central retinal artery occlusion.
Incorrect Answers:
Answer A: Administering ranibizumab is not appropriate because this medication is an anti-VEGF antibody, which can be used to treat wet age-related macular degeneration. Symptoms of wet age-related macular degeneration include acute visual distortion and loss of central vision that occurs over months. A fundoscopic exam would show neovascularization.
Answer B: Administration of tissue plasma activator has not been shown to be beneficial in central retinal artery occlusion if the event has occurred several days ago. This medication is used in patients who sustain an ischemic stroke within 4.5 hours of developing symptoms. A stroke in the posterior lobe can present with cortical hemianopsia.
Answer D: Retinal photocoagulation is used to treat diabetic retinopathy. In diabetic retinopathy, symptoms of painless vision loss present gradually. A retinal exam would show retinal hemorrhage and possibly neovascularization.
Answer E: Timolol is a beta-blocker used to treat glaucoma. Assessment of the optic disk would show an enlarged cup-to-disk ratio. Glaucoma can present with pain and pressure in the affected eye. Acute angle closure glaucoma would present with a rock-hard eye and may lead to permanent vision loss if not treated promptly.
Bullet Summary:
Chronic management of central retinal artery occlusion involves control of underlying risk factors with aspirin and statin therapy.
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177
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A 64-year-old man presents to the emergency room with a headache and nausea. He reports that he was rocking his grandson to sleep when the symptoms began. He states the pain is constant and is primarily located on his right side. When asked to indicate the area of pain, he says that it surrounds his eye and upper forehead. He had one episode of vomiting. The patient also reports difficulty seeing out of his right eye, which he attributes to excessive tearing. The patient’s past medical history is significant for hypertension. His medications include hydrochlorothiazide. His temperature is 98.6°F (37°C), blood pressure is 135/91 mmHg, pulse is 72/min, and respirations are 12/min. The patient’s right eye is shown in Figure A. Upon physical examination, the right pupil is minimally responsive to light and the globe feels firm. A right-sided carotid bruit is appreciated. Which of the following is the most appropriate prophylaxis for this patient’s condition?
|
{
"A": "Acetazolamide",
"B": "Clopidogrel",
"C": "Amitriptyline",
"D": "Epinephrine",
"E": ""
}
|
A
|
This patient is presenting with sudden-onset unilateral vision loss and an orbitofrontal headache with a dilated pupil and a hard ocular globe suggesting a diagnosis of acute angle-closure glaucoma. Long-term management of angle-closure glaucoma can include acetazolamide.
Examination of the eye in a patient with acute-closure glaucoma will reveal a red eye that is rock-hard and a mid-dilated pupil which is minimally reactive to light. The fundoscopic exam will show an increased optic cup-to-disk ratio (>0.4) and tonometry will show increased intraocular pressure. Gonioscopy is the diagnostic gold standard. Acute treatment and long-term management involve the administration of beta-blockers, alpha-2-agonists, and carbonic anhydrase inhibitors such as acetazolamide to decrease intraocular pressure. The definitive treatment is iridotomy.
Airaksinen et al. review the treatment of closed-angle glaucoma. They discuss how a combination of acetazolamide and beta-blockers can terminate an attack. They recommend using 1 drop of pilocarpine 3 hours after intravenous acetazolamide administration.
Figure/Illustration A is a clinical photograph showing an eye with injected conjunctiva (red circles) and a mid-dilated pupil. These findings are consistent with angle-closure glaucoma.
Incorrect Answers:
Answer B: Amitriptyline can be used as prophylaxis for migraines. Migraines present as unilateral, pulsating headaches that may be associated with nausea or photophobia. Patients with migraines can sometimes experience an aura with visual field changes; however, they would not have exam findings of a rock-hard eye or injection.
Answer C: Clopidogrel may be used as a conservative treatment for carotid atherosclerosis, which can be an embolic source for central retinal artery occlusion (CRAO). CRAO presents as acute, painless, monocular vision loss. A fundoscopic exam will demonstrate ischemia of the retina.
Answer D: Epinephrine is contraindicated in the treatment of angle-closure glaucoma as it increases pupillary dilation. It is used in the management of open-angle glaucoma. This would present with gradually patchy loss of vision and is generally painless.
Answer E: Verapamil is used as prophylaxis for cluster headaches. Cluster headaches present as unilateral, repetitive, brief headaches associated with severe peri-orbital pain, lacrimation, rhinorrhea, and Horner syndrome (miosis, ptosis, and anhidrosis).
Bullet Summary:
Pharmacologic management of acute angle-closure glaucoma involves beta-blockers, alpha-2 agonists, and carbonic anhydrase inhibitors.
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178
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A 45-year-old African American woman presents to her primary care physician for not feeling well. She states she has had a cough for the past week. She also has abdominal pain and trouble focusing that has been worsening and has lost 5 pounds recently. Her gastroesophageal reflux disease (GERD) has been poorly controlled recently. The patient is a non-smoker and has a history of GERD for which she takes antacids. Her temperature is 98.6°F (37°C), blood pressure is 115/71 mmHg, pulse is 72/min, and respirations are 12/min. A physical exam is within normal limits. Laboratory studies are ordered and are below:
Serum:
Na+: 139 mEq/L
K+: 4.1 mEq/L
Cl-: 101 mEq/L
HCO3-: 24 mEq/L
Urea nitrogen: 12 mg/dL
Glucose: 70 mg/dL
Creatinine: 0.9 mg/dL
Ca2+: 12.5 mg/dL
Alkaline phosphatase: 150 U/L
Phosphorus: 2.0 mg/dL
Urine:
Color: amber
Nitrites: negative
Sodium: 5 mmol/24 hours
Red blood cells: 0/hpf
Which of the following is the most likely explanation of this patient's current presentation?
|
{
"A": "Increased parathyroid hormone",
"B": "Malignancy",
"C": "Viral illness",
"D": "Antacid overuse",
"E": ""
}
|
A
|
This patient is presenting with hypercalcemia and low phosphate levels suggesting a diagnosis of hyperparathyroidism.
Hyperparathyroidism can cause hypercalcemia which typically presents with "bones, stones, moans, and groans," which corresponds to symptoms of bone pain (increased bone resorption), kidney stones, GI pain, and change in mental status/trouble focusing. The increased PTH results in renal phosphate wasting, increased production of 1,25-dihydroxy vitamin D, and increased renal calcium reabsorption. It also results in increased osteoclast activity resulting in increased bone breakdown. This will lead to laboratory changes of hypercalcemia and hypophosphatemia.
Taniegra reviews the evidence regarding hyperparathyroidism. She discusses how this disease is usually discovered asymptomatically with routine blood work. She recommends surgical treatment with intractable cases as success rates are high.
Figure A is a chest radiograph that is within normal limits. No masses are seen which suggests that malignancy is a less likely diagnosis.
Incorrect Answers:
Answer A: Antacid overuse for this patient's GERD can lead to a milk-alkali syndrome which presents with hypercalcemia and metabolic alkalosis. This patient does not have metabolic alkalosis. Treatment is with the discontinuation of the offending agent.
Answer B: Increased 1,25-dihydroxy vitamin D occurs in sarcoidosis which presents with cough, fatigue, and weight loss in an African American woman. Increased vitamin D by itself will result in hypercalcemia, and hyperphosphatemia rather than hypophosphatemia. Treatment is supportive and/or with corticosteroids.
Answer D: Malignancy (lung or renal cancer) is possible given this patient's presentation. Hypercalcemia of malignancy is a common feature with PTH-related protein effects; however, the patient's normal urinalysis and normal chest radiograph as well as non-smoking history point more toward a diagnosis of increased PTH.
Answer E: Viral illness is possible given this patient's systemic symptoms; however, it does not explain this patient's hypercalcemia and hypophosphatemia. Treatment of seasonal viruses is generally supportive though specific viruses such as influenza have agents such as oseltamivir that may be helpful.
Bullet Summary:
Hyperparathyroidism presents with "bones, stones, moans, and groans," as well as laboratory findings of hypercalcemia and hypophosphatemia.
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179
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A 57-year-old immigrant from Nigeria presents to the emergency department for sudden, severe pain and swelling in her lower extremity. She was at a rehabilitation hospital when her symptoms started. The patient has a medical history of obesity, diabetes, bipolar disorder, and tonic-clonic seizures. Her current medications include metformin, insulin, lisinopril, and valproic acid. The patient has IV drug and alcohol use disorder and has presented to the ED many times for intoxication. Her temperature is 98.6°F (37°C), blood pressure is 115/71 mmHg, pulse is 72/min, and respirations are 12/min. Physical exam reveals anasarca and asymmetric lower extremity swelling. Based on the results of a doppler ultrasound of her swollen lower extremity, heparin is started. The patient is then transferred to the general medicine floor for continued management. Laboratory studies are shown below.
Serum:
Na+: 137 mEq/L
K+: 5.5 mEq/L
Cl-: 100 mEq/L
HCO3-: 24 mEq/L
Urea nitrogen: 22 mg/dL
Ca2+: 5.7 mg/dL
Creatinine: 1.7 mg/dL
Glucose: 70 mg/dL
Which of the following is the most likely diagnosis?
|
{
"A": "Nephrotic syndrome",
"B": "Factor V Leiden",
"C": "Liver failure",
"D": "Antithrombin III deficiency",
"E": ""
}
|
A
|
This patient who presents with a deep venous thrombosis (lower extremity swelling, ultrasound followed by treatment with heparin), anasarca, and asymptomatic hypocalcemia most likely has a diagnosis of nephrotic syndrome.
Nephrotic syndrome occurs when large amounts of protein are lost in the urine. This can lead to hyperlipidemia (due to loss of lipoproteins), hypercoagulable state (due to loss of antithrombin III and protein C/S), and hypoalbuminemia. Most serum calcium is bound to albumin, so when albumin is lost in the urine, it can lead to profound hypocalcemia. The ionized or free portion of calcium remains the same; therefore, these patients do not exhibit symptoms of hypocalcemia. Furthermore, the loss of albumin will reduce the oncotic pressure in the vessels resulting in massive extravasation of fluid and anasarca.
Ambler et al. report a case of a patient who presented with a DVT and was found to have nephrotic syndrome. They discuss how the patient had asymptomatic changes in lab values including calcium. They recommend performing a urine dipstick for protein in cases of suspected nephrotic syndrome.
Incorrect Answers:
Answer A: Antithrombin III deficiency is a common cause of a hypercoagulable state because antithrombin III normally helps to neutralize coagulation factors. This disease is a possible explanation for this patient's DVT as it predisposes patients to thrombotic events; however, it does not explain her profound hypocalcemia. Asymptomatic antithrombin III deficiency does not need to be treated; however, patients should have anticoagulation if they undergo surgery.
Answer B: Factor V Leiden is the most common cause of a hypercoagulable state because this mutation renders factor V unable to be inactivated by proteins C and S. This is a possible explanation for this patient's DVT; however, it does not explain her hypocalcemia. Asymptomatic factor V Leiden mutation does not need to be treated; however, patients should have anticoagulation if they undergo surgery.
Answer D: Liver dysfunction is possible given this patient's history of alcohol use and IV drug abuse, placing her at risk for chronic hepatitis C infection. Despite the anasarca, this patient has no other stigmata of liver failure such as jaundice or ascites, making nephrotic syndrome more likely.
Answer E: Prothrombin gene mutation could explain this patient's hypercoagulable state because high levels of this gene can result in unprovoked thrombotic events. This disease would not explain why the patient has anasarca or hypocalcemia. Asymptomatic patients with this mutation do not require treatment.
Bullet Summary:
Nephrotic syndrome can present with a hypercoagulable state due to loss of antithrombin III and protein C/S and hypocalcemia from loss of albumin in the urine.
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180
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A 16-year-old girl who recently immigrated to the United States from Bolivia presents to her primary care physician with a chief complaint of inattentiveness in school. The patient's teacher describes her as occasionally "daydreaming" for periods of time during where the patient does not respond or participate in school activities. Nothing has helped the patient change her behavior, including parent-teacher conferences or punishment. The patient has no other concerns. The only other concern that the patient's mother has is that, upon awakening, she notices that sometimes the patient's arm will jerk back and forth. The patient states she is not doing this intentionally. The patient has an unknown medical history and is currently not on any medications. She is not sexually active and does not intend to become pregnant in the near future. Her temperature is 98.6°F (37°C), blood pressure is 112/74 mmHg, pulse is 63/min, and respirations are 11/min. On physical exam, you note a young, healthy girl whose neurological exam is within normal limits. Which of the following is the most appropriate initial treatment?
|
{
"A": "Ethosuximide",
"B": "Carbamazepine",
"C": "Cognitive behavioral therapy",
"D": "Valproic acid",
"E": ""
}
|
D
|
This patient is presenting with both absence seizures (periods of inattentiveness in school) and juvenile myoclonic epilepsy (abnormal, involuntary spasms of her upper extremity). The most appropriate treatment for these conditions is valproic acid.
Absence seizures classically present with cessation of motor activity and speech with a blank facial expression and occasionally automatisms such as flickering of the eyelids. They can be mistaken for inattentiveness in school-aged children. Juvenile myoclonic epilepsy presents with a "jerky" movement of the patient's extremity that typically occurs in the morning and begins around adolescence. The only medication that can be used to treat both absence seizures and juvenile myoclonic epilepsy is valproic acid. Valproic acid inhibits GABA transaminase, blocks thalamic T-type calcium channels, and blocks voltage-gated sodium channels. In post-pubertal female patients, it is important to counsel them on the potential teratogenic effects of this medication and also to consider alternative treatments in patients who are considering becoming pregnant or who cannot guarantee reliable birth control practices.
Kessler and McGinnis discuss the treatment of childhood absence seizures. They discuss how the treatment of choice is ethosuximide due to its favorable side effect profile. They recommend using valproic acid if there are concurrent seizure conditions.
Incorrect Answers:
Answer A: Carbamazepine would be the appropriate therapy for a partial seizure (tonic or clonic movements in addition to an absence of a post-ictal period) or for trigeminal neuralgia (sudden pain in the distribution of the trigeminal nerve). It would not address both absence seizures and juvenile myoclonic epilepsy.
Answer B: Cognitive behavioral therapy is a useful treatment that helps a patient develop coping strategies and change unhelpful patterns of thought. It could be useful if this girl was having trouble focusing in school for another reason (such as obsessive-compulsive disorder); however, it is not useful in managing seizures.
Answer C: Ethosuximide is the most appropriate initial therapy for absence seizures. In this patient, she is suffering from both absence seizures and juvenile myoclonic epilepsy which could not be treated by ethosuximide alone, in contrast to valproic acid which could treat both conditions.
Answer D: Lamotrigine is an anti-epileptic that can also be used as a mood stabilizer. It carries the potentially severe side effect of Stevens-Johnson syndrome. It is not a first-line treatment for absence seizures and juvenile myoclonic epilepsy. Stevens-Johnson syndrome will present with painful desquamation.
Bullet Summary:
Absence seizures present with periods of inattentiveness and subtle automatisms and are most appropriately treated with ethosuximide or with valproic acid if there is concurrent juvenile myoclonic epilepsy.
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181
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A 23-year-old man presents to the emergency department. He was brought in by police for shouting on a subway. The patient claims that little people were trying to kill him and he was acting within his rights to defend himself. The patient has a medical history of marijuana and IV drug use as well as multiple suicide attempts. He is currently homeless. While in the ED, the patient is combative and refuses a physical exam. He is given IM haloperidol and diphenhydramine. The patient is transferred to the inpatient psychiatric unit and is continued on haloperidol throughout the next week. Though he is no longer aggressive, he is seen making "armor" out of paper plates and plastic silverware to defend himself. His temperature is 98.6°F (37°C), blood pressure is 115/71 mmHg, pulse is 72/min, and respirations are 12/min. The patient's treatment history is significant for failure to obtain symptom control with risperidone, haloperidol, and ziprasidone. Which of the following is the most appropriate next step in management?
|
{
"A": "Clozapine",
"B": "Thioridazine",
"C": "Chlorpromazine",
"D": "Fluphenazine",
"E": ""
}
|
A
|
This patient is presenting with symptoms of schizophrenia that are refractory to treatment with both typical and atypical antipsychotics. The most appropriate next step in management is treatment with clozapine.
Schizophrenia presents with auditory and/or visual hallucinations among many other findings. The most appropriate initial treatments are with a typical antipsychotic (haloperidol) or an atypical antipsychotic (risperidone). Once a patient has failed treatment with multiple medications (at least 2) from different classes, the next best step in management is clozapine. This medication is reserved for patients who have sustained treatment failure (because of the side effects of clozapine). These include weight gain, life-threatening agranulocytosis, and aplastic anemia. Regular complete blood count laboratory testing should be drawn while on clozapine to check for this side effect. Patients who develop this complication should immediately stop the medication but the side effect can be irreversible.
Khokhar et al. review the evidence regarding the use of clozapine to treat schizophrenia. They discuss how side effects of this medication include agranulocytosis, myocarditis, and seizures. They recommend using this medication with care and monitoring for the development of these complications.
Incorrect Answers:
Answer A: Chlorpromazine is a typical antipsychotic that is likely to fail given that haloperidol did not work for him. Important side effects of this medication include hypotension and sedation due to anticholinergic properties. This medication also has an idiosyncratic complication of corneal deposits.
Answer C: Fluphenazine is another typical anti-psychotic that is a strong D2 antagonist like haloperidol. If haloperidol failed, it is unlikely that another typical antipsychotic would work with such a similar mechanism of action. This medication has a high association with extrapyramidal side effects such as dystonia, akathisia, and tardive dyskinesia.
Answer D: Olanzapine is another atypical antipsychotic. Switching to another atypical antipsychotic is a viable option. Given that this patient has already failed another atypical antipsychotic and that his symptoms remain, the best therapy at this point would be clozapine. Side effects include weight gain and dyslipidemia.
Answer E: Thioridazine is a low-potency anti-psychotic that would likely not work if more potent drugs such as haloperidol or risperidone have already failed. Important side effects to be aware of include hypotension and sedation due to anticholinergic properties. This medication also has an idiosyncratic complication of retinal deposits.
Bullet Summary:
Clozapine is the treatment of choice in patients who have failed therapy with multiple different classes of antipsychotics and who have severe symptoms.
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182
|
A 25-year-old man presents to his primary care physician for trouble with focus and concentration. He states that he lives at home with his parents his entire life and recently was able to get a job at a local factory. Ever since the patient started working, he has had trouble focusing on his job. He is unable to stay focused on any task. His boss often observes him "daydreaming" with a blank stare off into space. His boss will have to yell at him to startle him back to work. The patient states that he feels fatigued all the time and sometimes will suddenly fall asleep while operating equipment. He has tried going to bed early for the past month but is unable to fall asleep until 2 hours prior to his alarm. His temperature is 98.6°F (37°C), blood pressure is 112/68 mmHg, pulse is 81/min, and respirations are 12/min. A physical exam is within normal limits. The patient fears that if this continues he will lose his job. Which of the following is the most appropriate initial step in management?
|
{
"A": "Ethosuximide",
"B": "Zolpidem",
"C": "Bright light therapy and decreased light at night",
"D": "Modafinil",
"E": ""
}
|
C
|
This patient is presenting with fatigue and an inability to fall asleep until late in the morning suggesting a diagnosis of delayed sleep phase syndrome. The most appropriate initial therapy is light therapy, behavioral therapy, and sleep hygiene practices in addition to decreasing exposure to light at night.
Delayed sleep phase syndrome typically presents with individuals who naturally fall asleep very late and wake up very late. This becomes problematic when they attend school or have a job that requires them to wake up early. The most appropriate initial therapy for delayed sleep phase syndrome is behavioral therapy, sleep hygiene practices, and bright light therapy. Bright light therapy involves consistent timed exposure to a light box to simulate natural outdoor light, with the hope of resetting the circadian rhythm and moving the sleep phase earlier. If these measures fail, or if a different diagnosis is suspected, a referral for polysomnography may be indicated.
Sletten et al. studied whether melatonin was effective in the treatment of delayed sleep phase syndrome. They found that using this medication as an adjunct to sleep hygiene was effective in improving symptoms. They recommend using multimodal therapy for this disease.
Incorrect Answers:
Answer A: Ethosuximide is the treatment of choice for absence seizures. Though this patient does have episodes of blank staring, this likely does not represent a seizure as he is arousable to return to work by his boss. Patients with absence seizures typically present in childhood and are unable to be aroused during seizure episodes.
Answer B: Polysomnography or a sleep study would be indicated after sleep hygiene practices have failed. Polysomnography could be the most appropriate initial step in management if there was a suspected diagnosis of obstructive sleep apnea or an unknown cause of this patient's fatigue. Patients with sleep apnea typically snore and this disease is associated with obesity and increasing age.
Answer D: Modafinil is a treatment for narcolepsy. Though this patient does have sudden episodes of falling asleep while at work, this is more likely to be related to his sleep schedule. Patients with narcolepsy generally do not feel tired immediately before their episodes of sleep.
Answer E: Zolpidem is a muscle relaxant and hypnotic with the mechanism of action of a benzodiazepine. Though a drug like zolpidem could be used to help this patient fall asleep, the most appropriate first step is to address the patient's sleep hygiene prior to prescribing a potentially addictive drug.
Bullet Summary:
The most appropriate initial step in the management of patients with delayed sleep phase syndrome is behavioral therapy, bright light therapy, and sleep hygiene.
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183
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A 69-year-old man presents to his primary care physician with hip and back pain. He states this weekend he had a barbecue. When he was lifting a heavy object, he suddenly felt pain in his lower back. He describes the pain as in his buttocks but states that at times it travels down his leg. He states that it feels electrical and burning in nature. The patient has a medical history of obesity, diabetes, depression, anxiety, diverticulosis, constipation, and a surgical repair of his anterior cruciate ligament. His current medications include metformin, insulin, lisinopril, fluoxetine, and sodium docusate. His temperature is 98.6°F (37°C), blood pressure is 131/82 mmHg, pulse is 82/min, and respirations are 14/min. On physical exam, he is found to have an intact motor and sensory function in his lower extremities bilaterally. No clonus or Babinski sign is appreciated. An exam of the cranial nerves is intact bilaterally. Which of the following is most likely to help confirm the diagnosis?
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{
"A": "Palpating the paraspinal muscles",
"B": "Radiography",
"C": "Straight leg raise",
"D": "Flexion, abduction, and external rotation of the thigh",
"E": ""
}
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C
|
This patient is presenting with lower back pain that is electrical and travels down his legs after lifting an object suggesting a diagnosis of a herniated disc. The straight leg test can help confirm the diagnosis.
A herniated disc classically presents in a middle-aged or older individual who was lifting a heavy object with improper form. They will typically experience lower back pain that can be described as radicular. The pain will typically travel down the legs or "shoot down" the legs and is typically described as feeling electrical. The straight leg test on physical exam supports the diagnosis without an MRI. When the individual raises their leg, this causes compression of the spinal nerve roots leading to an exacerbation of symptoms. The most appropriate initial step in management for these patients is limiting strenuous activity, physical therapy, and NSAIDs. Patients who have chronic symptoms that have failed conservative management can undergo surgical laminectomy.
Camino and Piuzzi present the data regarding the diagnostic value of the straight leg raise test. They discuss how this test can exacerbate patients with radicular symptoms. They recommend all practitioners learn how to perform and interpret this test.
Incorrect Answers:
Answer A: Flexion, abduction, and external rotation of the thigh is referred to as the FABER test and is used to evaluate for sacroiliitis which can present with lower back pain and pain in the buttocks. This exam maneuver will cause intense pain in patients who have inflammation of the joint. Treatment is with physical therapy and NSAIDs.
Answer B: Internal rotation of the extended hip is the Freiberg test which evaluates for piriformis syndrome. Piriformis syndrome presents with lower back pain similar to a herniated disc; however, is less likely to have occurred after a single lifting episode and does not typically present with electrical pain that originates in the buttocks.
Answer C: Palpating the paraspinal muscles is a non-specific test that could further support a diagnosis of a muscle strain. It will likely not provide much information in the diagnosis of a herniated disc. Patients with muscle strain can be treated conservatively with relative rest and NSAIDs.
Answer D: Radiography is unlikely to offer information regarding this patient's herniated disc. While it can detect bony abnormalities, the detail of this imaging modality will not depict a herniated disc. An MRI is required to offer the detail necessary to make the diagnosis and is the most accurate test for a herniated disc.
Bullet Summary:
A herniated disc typically presents with pain in the lower back that radiates down the legs and is exacerbated by the straight leg raise test.
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184
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A 47-year-old man presents to the emergency department with a headache. He suddenly developed a throbbing, bitemporal headache about 5 hours ago "out of nowhere." He has a history of migraine headaches, but he feels that this headache is significantly more painful than his typical migraines. The patient took his prescribed sumatriptan with no relief of his symptoms. He also endorses nausea and he reports that he vomited once before arrival in the emergency department. The patient denies any recent trauma to the head. His medical history is significant for migraines and hypertension. He has a 20-pack-year smoking history and a history of cocaine use. He drinks 5-6 beers per week. His temperature is 98.6°F (37°C), blood pressure is 147/91 mmHg, pulse is 62/min, and respirations are 12/min. On physical exam, he appears to be in moderate distress and has pain with neck flexion. He has no focal neurologic deficits. A head CT is performed and can be seen in Figure A. This patient’s condition affects the space in between which of the following brain layers?
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{
"A": "Periosteum and galea aponeurosis",
"B": "Arachnoid mater and pia mater",
"C": "Dura mater and arachnoid mater",
"D": "Skull and dura mater",
"E": ""
}
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B
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This patient presents with a sudden, severe headache and a head CT showing bleeding in the subarachnoid space, which confirms a diagnosis of subarachnoid hemorrhage. The bleeding in a subarachnoid hemorrhage occurs between the arachnoid and pia mater.
Subarachnoid hemorrhages present with a sudden, severe headache referred to as a “thunderclap” headache. Patients typically complain that the headache is the "worst headache of their life." Some patients also present with symptoms of meningeal irritation such as nausea and vomiting, nuchal rigidity, or focal neurologic deficits. Although most cases of subarachnoid hemorrhage are secondary to trauma, patients with risk factors such as hypertension and cocaine use can have non-traumatic presentations. Patients with an expanding bleed or acute neurologic changes require surgical clipping or embolization of the bleeding vessels.
Macdonald and Schweizer review the evidence regarding the treatment of patients with subarachnoid hemorrhage. They discuss how survival rates have improved with early aneurysm repair, prescription of nimodipine, and advanced intensive care support. They recommend early diagnosis in order to improve outcomes in these patients.
Figure/Illustration A is an axial slice of a head CT showing hyperintensity in the basal cisterns (red circle). This finding is consistent with bleeding in the subarachnoid space.
Incorrect Answers:
Answer B: Bleeding between the dura and arachnoid mater describes a subdural hematoma. A subdural hematoma presents as a headache with progressive confusion. It appears as a crescent-shaped lesion on head CT. Patients with an expanding bleed will require surgical decompression to avoid herniation syndromes.
Answer C: Bleeding between the periosteum and galea aponeurosis describes a subgaleal hemorrhage. Subgaleal hemorrhages occur in newborns and are caused by vacuum-assisted deliveries. Treatment is usually supportive as the bleeding will resolve by itself. Some patients with severe bleeds may require transfusion due to excessive blood loss.
Answer D: Bleeding between the periosteum and skull describes a cephalohematoma. Cephalohematomas occur in newborns and are caused by rupture of the blood vessels crossing the periosteum. They are usually secondary to a prolonged second stage of labor. Treatment is supportive as the blood will resolve and be resorbed.
Answer E: Bleeding between the skull and dura mater describes an epidural hematoma. An epidural hematoma presents as a brief loss of consciousness followed by a lucid interval and then progressive confusion or somnolence. It appears as a biconvex lesion on head CT. Treatment is with urgent surgical decompression as patients will rapidly decompensate after the lucid interval.
Bullet Summary:
Subarachnoid hemorrhage classically presents as a thunderclap headache with a brief loss of consciousness and meningismus.
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185
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A 36-year-old woman, G1P1001, presents to her gynecologist for an annual visit. She has a medical history of hypertension for which she takes hydrochlorothiazide. The patient’s mother had breast cancer at age 68, and her sister has endometriosis. She states that she feels well and has no complaints. Her temperature is 98.6°F (37.0°C), blood pressure is 138/74 mmHg, pulse is 80/min, and respirations are 13/min. Her BMI is 32.4 kg/m^2. A pelvic exam reveals a non-tender, 12-week-size uterus with an irregular contour. A transvaginal ultrasound is performed and demonstrates two intramural leiomyomas. Which of the following is a likely complication of this patient’s condition?
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{
"A": "Endometrial cancer",
"B": "Iron deficiency anemia",
"C": "Uterine prolapse",
"D": "Uterine sarcoma",
"E": ""
}
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B
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This patient presents with an irregularly enlarged uterus on examination consistent with the intramural leiomyomas (fibroids) seen on ultrasound. Leiomyomas increase the risk of iron deficiency anemia due to heavy menstrual bleeding.
Leiomyoma are benign overgrowths of myometrial tissue. The most common presentation is heavy or prolonged menstrual bleeding or symptoms related to mass effect such as pelvic pressure or pain.. Affected women often develop these symptoms in their 30s or 40s, though they may occur at any age, and many are asymptomatic. Risk factors include early menarche, obesity, family history, and African American race. Submucosal fibroids that disrupt the endometrium may cause heavy menstrual bleeding. Intramural fibroids also commonly cause heavy bleeding despite the fact that they do not disrupt the endometrium due to alterations in the uterine vasculature. Patients may be managed medically with a wide range of options including oral contraceptive pills, tranexamic acid, and GnRH agonists. Definitive management is with surgical intervention. Myomectomy is preferred for patients that desire child bearing in the future. For those that do not have plans for pregnancy in the future, hysterectomy is recommended.
Yang et. al review the diagnosis and management of uterine fibroids. They note the range of clinical presentations to include heavy menstrual bleeding. They discuss management to include surgical intervention with myomectomy or hysterectomy.
Incorrect Answers:
Answer A: Amenorrhea, or the absence of menstrual bleeding, is often due to anovulation or uterine adhesions. Uterine fibroids are not associated with amenorrhea.
Answer B: Endometrial cancer is a known cause of heavy menstrual bleeding. However, this patient’s ultrasound notes the presence of intramural leiomyomas. Her age, history, and ultrasound findings are not suggestive of endometrial cancer.
Answer D: Uterine prolapse is associated with multiparity, chronically increased intra-abdominal pressure (from chronic obstructive pulmonary disease, obesity, etc.), and connective tissue diseases. While fibroids rarely may prolapse, they typically do not cause the entire uterus to prolapse.
Answer E: Uterine sarcoma may very rarely result from uterine fibroids, as both arise from the uterine smooth muscle. However, this patient’s history and ultrasound findings are more suggestive of uterine leiomyoma.
Bullet Summary:
Patients with uterine leiomyomata (fibroids) are at risk for iron deficiency anemia due to heavy bleeding.
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https://step2.medbullets.com/testview?qid=109024
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186
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A 13-day-old boy is brought by his mother for eye redness and ocular discharge. The mother reports that the patient has developed a cough and nasal discharge. Pregnancy and delivery were uncomplicated but the mother had limited prenatal care during the third trimester. Immediately after delivery, the baby was given silver nitrate drops and vitamin K. His temperature is 99°F (37.2°C), blood pressure is 81/52 mmHg, pulse is 135/min, and respirations are 36/min with an oxygen saturation of 98% O2 on room air. Upon visual examination of the eyes, mucoid ocular discharge and eyelid swelling are noted. A fluorescein test is negative. On lung exam, scattered crackles are appreciated. A chest radiograph is performed that shows hyperinflation with bilateral infiltrates. Which of the following is the most appropriate pharmacotherapy?
|
{
"A": "Artificial tears",
"B": "Oral erythromycin",
"C": "Intravenous acyclovir",
"D": "Topical erythromycin",
"E": ""
}
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B
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This patient is presenting with mucoid ocular discharge around 2 weeks post-birth, suggesting the diagnosis of neonatal chlamydial conjunctivitis. The most appropriate treatment for this disease includes oral erythromycin.
Neonatal chlamydial conjunctivitis is caused by Chlamydia trachomatis. It presents in newborns that are 5-14 days old. Symptoms include watery or mucoid discharge and eye swelling. The conjunctiva may be especially irritated. Diagnosis can be established by direct antibody testing or PCR. Treatment for chlamydial conjunctivitis includes both topical and oral erythromycin as there is likely dissemination of the infection. The most common complication of chlamydial conjunctivitis is pneumonia. Of note, all neonates with gonococcal conjunctivitis should also be treated for chlamydia.
Smith-Norowitz et al. studied whether antibiotic prophylaxis was beneficial compared with silver nitrate for chlamydia conjunctivitis. They found that there was no benefit to topical antibiotic treatment compared with silver nitrate alone. They recommend testing infants for the disease if it is suspected so that oral antibiotics can be administered effectively.
Incorrect Answers:
Answer A: Artificial tears can be used in chemical conjunctivitis. The most common cause of neonatal chemical conjunctivitis is post-delivery silver nitrate drops. It usually presents within the first 24 hours following birth/exposure with mild conjunctival injection and tearing, and will spontaneously resolve within 2-4 days.
Answer B: Intravenous acyclovir is used to treat conjunctivitis caused by herpes simplex virus. The newborn would present between 1-2 weeks post-birth with lid edema, conjunctival injection, and non-purulent serosanguineous discharge. Corneal involvement with microdendrites or ulcers may be seen with fluorescein stain.
Answer C: Intravenous ceftriaxone is used to treat gonococcal conjunctivitis. Gonococcal conjunctivitis usually presents in newborns 0-5 days old with irritation or discharge. Patients with this disease will have very thick discharge with a purulent appearance.
Answer E: Topical erythromycin would be used to treat chlamydial conjunctivitis in conjunction with oral erythromycin; however, it is insufficient on its own. Oral erythromycin is the best answer choice for this patient as the disease has likely disseminated. Topical erythromycin can also be used as prophylaxis for gonococcal conjunctivitis.
Bullet Summary:
Neonatal chlamydial conjunctivitis presents with watery or mucoid discharge as well as eye swelling and is treated with topical and oral erythromycin.
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https://step2.medbullets.com/testview?qid=109042
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187
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A 69-year-old man presents to his primary care provider for a general checkup. He has a medical history of type 2 diabetes mellitus, hypertension, depression, obesity, and a myocardial infarction 7 years ago. The patient's prescribed medications are metoprolol, aspirin, lisinopril, hydrochlorothiazide, fluoxetine, metformin, and insulin. The patient has not been filling his prescriptions regularly and can not remember what medications he has been taking. His temperature is 99.5°F (37.5°C), pulse is 96/min, blood pressure is 180/120 mmHg, respirations are 18/min, and oxygen saturation is 97% on room air. Laboratory values are obtained and the results are shown below:
Serum:
Na+: 139 mEq/L
K+: 4.3 mEq/L
Cl-: 100 mEq/L
HCO3-: 24 mEq/L
BUN: 7 mg/dL
Glucose: 170 mg/dL
Creatinine: 1.2 mg/dL
Which of the following cardiac findings would be expected on physical exam?
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{
"A": "Heart sound after S2",
"B": "Holosystolic murmur at the apex",
"C": "Heart sound before S1",
"D": "Fixed splitting of S1 and S2",
"E": ""
}
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C
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This patient who presents with poorly managed hypertension over a long period of time most likely has compensatory hypertrophy of the heart. The most likely heart sound in this patient is an S4 gallop that occurs immediately before S1.
Chronic hypertension that is poorly controlled can lead to concentric hypertrophy of the heart. This adaptive mechanism creates a stiff and non-compliant left ventricle. When blood enters this stiff ventricle, the typical sound heard is an S4 heart sound which is heard right before S1. This sound represents the atrial kick that pushes blood against a non-compliant left ventricle in the last phase of diastole. Treatment is by meticulous control of the underlying cardiac pathophysiology such as hypertension.
Kino et al studied the relationship between the S1 and S4 heart sounds in aging patients. They found that an S4 heart sound can be missed in cases of prominent S1 splitting. They recommend studying heart sounds in order to not accidentally miss an S4 finding.
Incorrect Answers:
Answer A: Fixed splitting of S1 and S2 describes an atrial septal defect. The atrial septic defect allows blood to communicate between both sides of the heart and equalizes atrial pressures. Asymptomatic patients may not need treatment but surgical repair of the defect should be performed in symptomatic cases.
Answer B: A heart sound after S2 suggests a S3 heart sound which would be found in fluid-overloaded states such as heart failure. This post-systolic gallop is the result of incomplete emptying of the ventricle prior to the start of diastole so that the blood from the atria falls against an already full chamber. Treatment is with diuresis and treatment of the underlying heart failure.
Answer D: A holosystolic murmur heard at the apex describes mitral valve regurgitation. This would be possible if a papillary muscle had ruptured in an acute myocardial infarction. Treatment is with mitral valve replacement in symptomatic patients.
Answer E: A normal S1 and S2 is possible but is less likely given this patient's long-standing history of poorly managed hypertension. Hypertension usually causes concentric hypertrophy of the ventricle and thereby leads to increased resistance to diastolic filling.
Bullet Summary:
An S4 heart sound is created by blood entering a stiff and non-compliant left ventricle and is often heard in patients with long-standing hypertension.
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188
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A 1-hour-old newborn boy is evaluated in the delivery room. He was born at 37 weeks gestation to a 39-year-old G3P3 mother. The mother initially labored at home with a midwife but was transferred to the hospital for failure to progress. The infant was eventually delivered via Caesarean section. The mother declined all prenatal screening tests during this pregnancy. His temperature is 98.6°F (37°C), blood pressure is 63/41 mmHg, pulse is 133/min, and respirations are 39/min. His Apgar scores were 7 and 8 at 1 and 5 minutes, respectively. His weight is 3.0 kg (6.6 lb), and his height and his head circumference are in the 30th and 40th percentiles, respectively. On physical exam, he is found to have a 3 cm full-thickness defect in the abdominal wall to the right of the umbilicus with evisceration of a loop of the bowel. The abdominal defect is immediately covered in sterile saline dressings and an orogastric tube and 2 peripheral intravenous lines are placed. This condition is most likely associated with which of the following additional findings?
|
{
"A": "Ventricular septal defect",
"B": "Bicuspid aortic valve",
"C": "A normal cardiac exam",
"D": "Tetralogy of Fallot",
"E": ""
}
|
C
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This patient presents with a full-thickness defect in the abdominal wall lateral to the umbilicus with evisceration of the bowel, which suggests a diagnosis of gastroschisis. Gastroschisis is not associated with any cardiac defects.
Gastroschisis and omphalocele are the most common abdominal wall defects found in infants and there are important differences between them. Whereas the eviscerated bowel in gastroschisis is not covered by a membrane, the exposed bowel in the omphalocele is covered by a membranous sac. The abdominal wall defect in gastroschisis is located lateral to the umbilicus, whereas in omphalocele the defect is midline. The distinction is also important for management, as omphalocele is commonly associated with other extraintestinal defects whereas fewer than 10% of cases of gastroschisis are associated with an extraintestinal abnormality. Treatment is with surgical correction of the abdominal wall defect.
Skarsgard reviews the evidence regarding the diagnosis and treatment of gastroschisis. He discusses how this is one of the most common birth defects managed in the ICU setting. He recommends urgent surgical correction.
Incorrect Answers:
Answer B: A bicuspid aortic valve occurs in many cases of Turner syndrome. This disease presents with a webbed neck, short stature, low hairline, broad (“shield”) chest, bicuspid aortic valve, horseshoe kidney, and streak ovaries. Treatment is supportive with surgical fixation of cardiac defects and hormone supplementation with growth hormone.
Answer C: Endocardial cushion defects are most commonly found in trisomy 21 (Down syndrome). Over a third of individuals with trisomy 21 have a complete atrioventricular septal defect, and another third have isolated ventricular septal defects. Infants with Down syndrome commonly present with the upslanting palpebral fissures, flat nasal bridge, transverse palmar crease, and hypotonia. Treatment is with supportive care of these deformities such as surgical correction of cardiac defects.
Answer D: Tetralogy of Fallot is most often associated with trisomy 21 (Down syndrome) and 22q11 deletion syndromes. Infants with Down syndrome commonly present with upslanting palpebral fissures, flat nasal bridge, transverse palmar crease, and hypotonia. Treatment is with supportive care of these deformities such as surgical correction of cardiac defects.
Answer E: Ventricular septal defects occur in several genetic syndromes, including trisomy 21 (Down syndrome) and trisomy 13 (Patau syndrome). Infants with trisomy 13 commonly present with cleft lip or palate, polydactyly, and severe intellectual disability. This disease is not compatible with survival past 1 year of age so treatment can involve termination of pregnancy or supportive care.
Bullet Summary:
Gastroschisis presents with an abdominal wall defect with evisceration of the bowel that is lateral to the umbilicus and is not usually associated with other birth defects.
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189
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A 6-month-old boy is brought to the pediatrician by his parents for a routine visit. His parents report that he is feeding and stooling well and they have just started experimenting with solid foods. His parents are concerned because a few weeks ago he started rolling from back to front in addition to front to back, but he now struggles when placed on his back. The patient was noted to be developmentally appropriate for his age at his last visit 2 months ago. On physical exam, the patient seems well-nourished and has no dysmorphic features. His temperature is 98.6°F (37°C), blood pressure is 77/49 mmHg, pulse is 112/min, and respirations are 24/min. In the examination room, he is able to roll from front to back but cannot roll from back to front. He is not able to sit without support and makes no attempt at bouncing when supported in a standing position. The patient’s abdomen is non-tender and soft without hepatosplenomegaly. His patellar reflexes are 4+ bilaterally. He is found to have the ocular finding seen in Figure A. Accumulation of which of the following would most likely be found in this patient’s cells?
|
{
"A": "Sphingomyelin",
"B": "Glucocerebroside",
"C": "GM2-ganglioside",
"D": "Galactocerebroside",
"E": ""
}
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C
|
This 6-month-old boy who presents with developmental regression, a “cherry-red” macula, and hyperreflexia most likely has a diagnosis of Tay-Sachs disease. Tay-Sachs disease is caused by a deficiency of beta-hexosaminidase A that results in the accumulation of GM2-ganglioside.
Tay-Sachs disease is a genetic disorder caused by an autosomal recessive deficiency of the beta-hexosaminidase A enzyme. This disease presents in infants aged 2-6 months with progressive neurodegeneration, hypotonia, feeding difficulties, and a “cherry red” spot on the macula. Tay-Sachs disease shares many features with Niemann-Pick disease; however, Niemann-Pick disease presents with the additional findings of hepatosplenomegaly and hyporeflexia whereas Tay-Sachs presents with hyperreflexia without hepatosplenomegaly. Both diseases are more common in the Ashkenazi Jewish population. There is no curative treatment for this disease so treatment is generally supportive.
Solovyeva et al. review the evidence regarding the diagnosis and treatment of Tay-Sachs disease. They discuss how this disease normally presents with muscle weakness, ataxia, speech, and mental disorders. They recommend considering novel treatments such as substrate reduction therapy.
Figure/Illustration A is a fundoscopic exam demonstrating a “cherry-red” spot on the macula (blue circle). This finding is seen in both Tay-Sachs disease and Niemann-Pick disease.
Incorrect Answers:
Answer A: Cerebroside sulfate accumulates in metachromic leukodystrophy, which is caused by an autosomal recessive deficiency in arylsufatase A. This disease presents with optic atrophy and seizures in childhood. Patients will later develop dementia, psychiatric disease, and neuropathy. There is no cure so treatment is supportive.
Answer B: Galactocerebroside accumulates in Krabbe disease, which is caused by an autosomal recessive deficiency in galactocerebrosidase. Krabbe disease presents in early infancy with developmental regression, hypotonia, and areflexia. Treatment is supportive with musculoskeletal bracing as needed.
Answer C: Glucocerebroside accumulates in Gaucher disease, which is caused by an autosomal recessive deficiency in glucocerebrosidase. Gaucher disease presents with pancytopenia and hepatosplenomegaly. “Gaucher cells,” or lipid-laden macrophages resembling crumpled tissue paper, can be seen on histology. Treatment is with enzyme replacement therapy.
Answer E: Sphingomyelin accumulates in Niemann-Pick disease, an autosomal recessive sphingolipidosis caused by a deficiency in sphingomyelinase. Niemann-Pick disease presents with many of the same features as Tay-Sachs disease but has additional findings of hyporeflexia and hepatosplenomegaly.
Bullet Summary:
Tay-Sachs disease is caused by a deficiency of beta-hexosaminidase A resulting in the accumulation of GM2-ganglioside.
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https://step2.medbullets.com/testview?qid=109134
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190
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A 62-year-old man arrives at the emergency room complaining of chest pain and difficulty breathing. He reports that the dyspnea started 2 months ago after he had the flu. At first, the difficulty breathing occurred whenever he went up and down 1 flight of stairs, but the dyspnea progressively worsened since then. This morning, he developed chest pain and difficulty breathing while sitting at the kitchen table. The patient’s medical history is significant for hypertension, type 2 diabetes mellitus, and rheumatoid arthritis. His medications include aspirin, lisinopril, metformin, and sulfasalazine. His temperature is 97°F (36.1°C), blood pressure is 130/78 mmHg, pulse is 88/min, and respirations are 14/min with an oxygen saturation of 97% O2 on room air. On physical exam, jugular venous distension during both inspiration and expiration, mild abdominal distention, and 2+ bilateral lower extremity edema is noted. A chest radiograph is obtained and the result is shown in Figure A. Which of the following is the most likely cause of this patient's symptoms?
|
{
"A": "Restrictive cardiomyopathy",
"B": "Cirrhosis",
"C": "Constrictive pericarditis",
"D": "Cardiac tamponade",
"E": ""
}
|
C
|
This patient is presenting with peripheral edema, ascites, elevated jugular venous distension, and pericardial calcifications on chest radiograph, which are all consistent with a diagnosis of constrictive pericarditis.
Constrictive pericarditis is the result of scarring and loss of elasticity of the pericardial sac. Common etiologies include idiopathic, post-viral, post-cardiac surgery, post-radiation, tuberculosis-related, or connective tissue disorder-related. It presents as right heart failure including symptoms such as dyspnea, chest pain relieved by leaning forward, progressive peripheral edema, and ascites. A physical exam will identify an early diastolic pericardial knock, pericardial calcifications on chest radiograph, and jugular venous distension (JVD). Kussmaul sign can also occur where the JVD paradoxically rises during inspiration instead of falling. The diagnosis is supported with echocardiography. Management may require pericardiectomy for severe cases.
Welch and Oh review the evidence regarding the diagnosis and treatment of constrictive pericarditis. They discuss how this disease can be evaluated using a cardiac MRI. They recommend surgical pericardiectomy in many cases.
Figure/Illustration A is a frontal chest radiograph with pericardial calcifications (red circle). These findings are consistent with constrictive pericarditis.
Incorrect Answers:
Answer A: Cardiac tamponade can present similarly to constrictive pericarditis. Hypotension and pulsus paradoxus (a greater than 10 mmHg decrease in the systolic blood pressure during inspiration), will commonly present in patients with cardiac tamponade. A chest radiograph will show an enlarged cardiac silhouette rather than calcifications in some cases. Treatment is with emergent pericardial decompression.
Answer B: Cirrhosis can present with ascites and peripheral edema, but will not have a marked elevation in jugular venous pressure. Cirrhosis is the end-stage result of many hepatic pathologies. Treatment is with the control of sequelae such as hepatic encephalopathy and venous congestion.
Answer D: Pulmonary arterial hypertension, like constrictive pericarditis, can present with exertional dyspnea, chest pain, and peripheral edema if it progresses to right ventricular failure. A chest radiograph may show enlarged central pulmonary arteries and peripheral pulmonary vessels. Treatment is with reduction of pulmonary pressure such as with endothelin inhibitors.
Answer E: Restrictive cardiomyopathy can also present as right heart failure with similar symptoms to constrictive pericarditis. A history of an infiltrative disease (e.g., amyloidosis and sarcoidosis) often favors restrictive cardiomyopathy, as does an audible S3 on a physical exam. Calcification of the pericardium on the chest radiograph is more consistent with constrictive pericarditis.
Bullet Summary:
Constrictive pericarditis presents with symptoms of right heart failure, progressive peripheral edema, ascites, jugular venous distension, pericardial knock, and pericardial calcifications on a chest radiograph.
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191
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A 69-year-old woman presents with pain in her hip and groin. The pain is present in the morning but is nearly unbearable by the end of the day. Her medical history is notable for a treated episode of acute renal failure, diabetes mellitus, obesity, and hypertension. Her current medications include losartan, metformin, insulin, and ibuprofen. The patient recently started taking high doses of vitamin D as she believes that it could help her symptoms. She also recently fell off the treadmill while exercising at the gym. Her temperature is 98.6°F (37°C), blood pressure is 135/91 mmHg, pulse is 72/min, and respirations are 12/min. On exam, an obese woman in no distress is noted. There is pain, decreased range of motion, and crepitus on exam of her right hip. The patient points to the areas that cause her pain stating that it is mostly over the groin. Which of the following is most likely to be found on plain radiographic imaging of this patient?
|
{
"A": "Femoral neck fracture",
"B": "Posterior displacement of the femoral head",
"C": "Loss of joint space and osteophytes",
"D": "Hyperdense foci in the ureters",
"E": ""
}
|
C
|
This patient is presenting with pain worse on exertion, decreased range of motion, and crepitus in her hip, suggesting a diagnosis of osteoarthritis. A loss of joint space and osteophytes (reactive bone formation) would be seen on radiography.
Osteoarthritis occurs due to wear and tear of the joint typically from repeat trauma in the setting of risk factors such as obesity. Pain can be located in the hip, and can be referred to the groin or knee. The classic presentation is pain that worsens with activity. Crepitus and decreased range of motion can be found on physical exam. Common radiological findings include a loss of joint space and osteophytes. Treatment should start with conservative measures such as activity modification, weight loss, and an unloading brace. A corticosteroid injection may be appropriate as a second-line measure. Refractory cases can be treated with a total joint replacement.
Glyn-Jones et al. review the evidence regarding the diagnosis and treatment of osteoarthritis. They discuss how total joint arthroplasty operations can be limited by the lifestyle of the prosthesis and other complications. They recommend considering joint preserving options such as lifestyle modification.
Incorrect Answers:
Answer A: Femoral neck fracture would present acutely with pain in the hip and a shortened and externally rotated leg. This diagnosis is possible given the patient's recent fall; however, her other symptoms and less acute presentation suggest a diagnosis of osteoarthritis. Treatment is with a hemiarthroplasty.
Answer B: Hyperdense foci in the ureters suggest a diagnosis of renal calculi. Though this patient's referred pain to the groin, history of renal failure, and possible hypercalcemia (due to increased vitamin D intake) could suggest this diagnosis, her other symptoms are more suggestive of osteoarthritis. Treatment is lithotripsy or stone removal for larger kidney stones.
Answer D: Normal radiography would be found with a minor sprain/muscular injury which presents with a self-limited course of pain and tenderness over the affected muscle. Treatment is with rest, ice, compression, and elevation.
Answer E: Posterior displacement of the femoral head suggests a diagnosis of posterior hip dislocation. Posterior hip dislocation would present with a shortened and internally rotated leg and a more acute presentation. Treatment is with closed reduction of the hip under sedation.
Bullet Summary:
Osteoarthritis presents with joint pain that is worse with exertion and radiographical findings of decreased joint space and osteophytes.
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https://step2.medbullets.com/testview?qid=109238
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192
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A 3-day-old boy is evaluated in the hospital nursery for the delayed passage of meconium. The patient is breastfed, has been feeding well every 2 hours, and is urinating over 8 times per day. He was born at 35 weeks gestation to a 27-year-old G4P4 mother. The patient is of Ashkenazi Jewish descent and the patient’s parents refused all prenatal genetic testing. The pregnancy was uncomplicated until the patient’s mother had a spontaneous rupture of membranes at 35 weeks of gestation. The patient’s 3 older siblings are all healthy. The patient’s temperature is 98.2°F (36.8°C), blood pressure is 48/32 mmHg, pulse is 164/min, and respirations are 48/min. On physical exam, he appears to be in moderate distress. He has no dysmorphic features, and his abdomen is distended and non-tender. Bowel sounds are absent. Which of the following is the most appropriate next step in management?
|
{
"A": "Upper gastrointestinal series",
"B": "Sweat testing",
"C": "Abdominal radiograph",
"D": "Abdominal CT",
"E": ""
}
|
C
|
Delayed passage of meconium should be evaluated with an abdominal radiograph to rule out bowel perforation. Patients with a perforation require emergency surgery.
All neonates should pass meconium in the first 48 hours of life. Patients that fail do to so should be evaluated with an abdominal radiograph to exclude the possibility of bowel perforation. If free air is seen on the abdominal radiograph, patients should be taken for emergent surgery to repair the perforation. If bowel perforation is ruled out, a workup should be done to determine the etiology of the delayed passage, which would most likely include a contrast enema to differentiate between meconium ileus and Hirschsprung disease. Treatment is with meconium removal or excision of the defective segment respectively.
Adams and Stanton review the evidence regarding the diagnosis and treatment of neonatal bowel obstruction. They discuss how malrotation, jejunoileal atresia, duodenal atresia, and colonic atresia are common causes of this finding. They recommend surgical management of these conditions.
Incorrect Answers:
Answer A: An abdominal radiograph would be faster than an abdominal CT to rule out an indication for emergency surgery. The use of CT should also be restricted in the pediatric population due to the radiation exposure involved. Adult patients with unclear radiographic findings can be further assessed using a contrast CT scan.
Answer C: Contrast enema is the test of choice to differentiate meconium ileus from Hirschsprung disease, but the most important first step is to rule out bowel perforation. Patients who do not have perforation can then undergo this test to determine the etiology of failure to pass meconium.
Answer D: Sweat testing would aid in the diagnosis of cystic fibrosis, particularly in this patient who has had no prenatal screening. The first step in management should be an abdominal radiograph to rule out bowel perforation. Cystic fibrosis can be treated with pancreatic enzyme replacement and pulmonary therapy.
Answer E: Upper gastrointestinal series is used to make the diagnosis of intestinal malrotation, which more commonly presents with bilious vomiting secondary to midgut volvulus rather than the delayed passage of meconium. Treatment is with surgical derotation.
Bullet Summary:
Neonates who fail to pass meconium in the first 48 hours of life should be urgently evaluated with an abdominal radiograph to rule out bowel perforation.
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https://step2.medbullets.com/testview?qid=109241
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193
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A 7-week-old boy presents to the pediatrician for vomiting. Three weeks ago, the patient began vomiting after meals. The vomitus appears to be normal stomach contents without streaks of red or green. His parents have already tried repositioning him during mealtimes and switching his formula to eliminate cow’s milk and soy. Despite these adjustments, the vomiting has become more frequent and forceful. The patient is voiding about 4 times per day and his urine appears dark yellow. He has fallen 1 standard deviation off of the growth curve. The patient's mother reports that the pregnancy was uncomplicated other than an episode of sinusitis in the 3rd trimester, for which she was treated with azithromycin. The patient's temperature is 98.7°F (37.1°C), blood pressure is 58/41 mmHg, pulse is 166/min, and respirations are 16/min. On physical exam, the patient looks small for his age. His abdomen is soft, non-tender, and non-distended. Which of the following is the most appropriate next step in management?
|
{
"A": "Abdominal ultrasound",
"B": "Thickening feeds",
"C": "MRI of the head",
"D": "Intravenous hydration",
"E": ""
}
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D
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This patient presents with nonbilious, forceful vomiting, poor weight gain, signs of dehydration, and a history of exposure to azithromycin, which suggests a diagnosis of pyloric stenosis. The most appropriate next step in management is intravenous hydration.
Pyloric stenosis classically presents in a male infant between 4 to 6 weeks of age with nonbilious, projectile vomiting after meals. Risk factors for pyloric stenosis include bottle feeding and exposure to macrolide antibiotics in the patient or mother. Protracted vomiting frequently leads to hypochloremic, hypokalemic metabolic alkalosis. Patients should be resuscitated with intravenous hydration and evaluated for electrolyte abnormalities that require repletion. After a patient is adequately resuscitated, patients can undergo an ultrasound to confirm the diagnosis and then be treated surgically for definitive therapy.
Adams and Stanton review the evidence regarding the diagnosis and treatment of neonatal bowel obstruction. They discuss how malrotation, jejunoileal atresia, duodenal atresia, and colonic atresia are common causes of this finding. They recommend surgical management of these conditions.
Incorrect Answers:
Answer A: Abdominal ultrasound is the test of choice to diagnose pyloric stenosis, but evaluation for electrolyte derangements and subsequent intravenous hydration and electrolyte repletion should be initiated first in this patient with signs of dehydration and malnutrition. Further evaluation is reserved after a patient is adequately resuscitated.
Answer B: MRI of the head would be appropriate if this patient had additional signs of a mass in the head, such as neurological changes or worsening of the vomiting in the morning. In the absence of these signs and the presence of a mass in the epigastrium, this patient is more likely to have pyloric stenosis.
Answer C: Pyloromyotomy is the definitive management of pyloric stenosis, but this patient should undergo fluid replacement and have any electrolyte derangements detected and managed before undergoing surgery. Surgical intervention can carry significant risks if patients are not adequately resuscitated.
Answer E: Thickening feeds are one of the techniques used to manage gastroesophageal reflux. In the setting of this patient’s epigastric mass and clinical picture, pyloric stenosis is the more likely etiology of his vomiting. Reflex presents with non-projectile vomiting that is dependent on position.
Bullet Summary:
Patients with pyloric stenosis should first undergo intravenous rehydration and electrolyte repletion, as protracted vomiting may lead to severe hypochloremic, hypokalemic metabolic alkalosis.
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https://step2.medbullets.com/testview?qid=109242
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194
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A 6-week-old girl presents with her parents to the pediatrician for blood-streaked diapers. The patient is breastfed every 2-3 hours and voids 10-12 times daily. The patient previously had several soft stools per day that ranged in color from mustard yellow to dark green. Over the past 2 days, the patient’s stools have become looser and streaked with blood. The patient has also regurgitated several of her feedings in the last few days. Neither the vomit nor bloody stools have seemed to bother the patient. The patient’s weight continues to trend along the 50th percentile. The patient’s temperature is 98.4°F (36.9°C), blood pressure is 66/51 mmHg, pulse is 127/min, and respirations are 26/min. On physical exam, the patient appears well nourished and is cooing. Her abdomen is soft and non-tender. Physical exam reveals the finding seen in Figure A. Which of the following is the most likely etiology of this patient’s presentation?
|
{
"A": "Congenital enzyme deficiency",
"B": "Passage of gastric contents into esophagus",
"C": "Non-IgE-mediated immunologic reaction",
"D": "Hypertrophy of sphincter muscle",
"E": ""
}
|
C
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This patient presents with new regurgitation, blood-streaked stools, and eczema, which is consistent with proctocolitis secondary to milk-protein allergy. This type of delayed onset milk-protein allergy is a non-IgE mediated immunologic reaction.
Allergy to cow’s milk is the most common food allergy in children and encompasses both IgE-mediated and non-IgE-mediated reactions. IgE-mediated reactions occur minutes to 2 hours after ingestion of the allergen and range from mild symptoms to anaphylaxis. Milk protein-induced enterocolitis and proctocolitis are non-IgE-mediated reactions that present by 6 months of life with regurgitation or vomiting and bloody stools. Management of milk protein-induced enterocolitis and proctocolitis involves the elimination of cow’s milk and soy from the mother’s diet if the infant is breastfed or switching to a hydrolyzed formula if the infant is formula fed.
Giannetti et al. review the evidence regarding the diagnosis and treatment of milk protein allergy in infants. They discuss how the selective elimination of certain proteins from the diet is usually effective. They recommend considering oral immunotherapy as an adjuvant in the treatment of this disease.
Figure/Illustration A is a clinical photograph demonstrating the physical exam finding of eczema (red circle), which is commonly found in infants with an allergy to milk protein.
Incorrect Answers:
Answer A: Congenital enzyme deficiency describes lactose intolerance, in which there is an absence of lactase activity in the small intestine. Lactose intolerance classically presents with abdominal pain, bloating, flatulence, and diarrhea. Treatment is with diet modification.
Answer C: Hypertrophy of the sphincter muscle describes the pathogenesis of pyloric stenosis, which presents in patients between 3- and 6-weeks of age with non-bilious, projectile vomiting. Treatment is with surgical pyloromyotomy.
Answer D: Passage of gastric contents into the esophagus describes gastroesophageal reflux, which may present with regurgitation or vomiting. Treatment is with positioning but can include proton pump inhibitors in refractory cases.
Answer E: Telescoping of the intestine describes intussusception, which presents with sudden-onset severe, crampy, abdominal pain with non-bilious vomiting and “currant jelly” stools. Intussusception is rare before 3 months of age and presents with intermittent episodes of pain. Initial treatment is with air or contrast enema.
Bullet Summary:
Milk-protein allergy presents in infants between 2- to 8-weeks of age with regurgitation or vomiting, blood-streaked stools, and eczema, and management involves the elimination of cow’s milk and soy from the infant’s diet.
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https://step2.medbullets.com/testview?qid=109255
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195
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An 8-week-old boy presents with his mother to the pediatrician for a well visit. The patient has been breastfed since birth, and usually feeds for 30 minutes every 2-3 hours. The patient’s mother is concerned that her milk production is not keeping up with the patient’s nutritional requirements. She reports that about 2 weeks ago the patient began regurgitating breastmilk through his nose and mouth after some feeds. He seems mildly upset during the episodes of regurgitation but usually settles down quickly and is hungry again soon afterwards. His mother has already tried limiting the volume of each feed, which seems to have reduced the frequency of regurgitation. She denies any diarrhea, hematochezia, or family history of food allergies. Her older son had a similar problem with vomiting that resolved around 12 months of age. Four weeks ago, the patient’s height and weight were in the 40th and 34th percentiles, respectively. His height and weight are now respectively in the 37th and 36th percentiles. His temperature is 98.6°F (37°C), blood pressure is 72/49 mmHg, pulse is 121/min, and respirations are 32/min. On physical exam, the patient is cooing in his mother’s lap and smiles reciprocally with her. He lifts his head and shoulders off the examination table when placed in the supine position. His abdomen is soft, non-tender and non-distended. Bowel sounds are normoactive. Which of the following is the most appropriate next step in management?
|
{
"A": "Reassurance and counseling on positioning",
"B": "Switch to hydrolyzed formula",
"C": "Recommend modification of mother’s diet",
"D": "Initiate proton pump inhibitor",
"E": ""
}
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A
|
This patient presents with regurgitation after feeding, appropriate appetite after episodes of regurgitation, and good weight gain, which suggests a diagnosis of uncomplicated gastroesophageal reflux. The most appropriate next step in management is reassurance and counseling on proper positioning.
Physiologic or uncomplicated gastroesophageal reflux usually presents in patients in the first few months of life with frequent regurgitation or vomiting, sustained appetite after regurgitation, and minimal irritability. The most appropriate first step in management is reassurance and counseling parents to position patients upright for 20-30 minutes after feeding. For patients with persistent symptoms, parents should be encouraged to provide lower volume feeds more frequently throughout the day, and consider a milk-free diet to address possible underlying cow’s milk allergy. Treatment with a proton pump inhibitor is reserved for intractable cases. For most patients, gastroesophageal reflux self-resolves by 1 year of age.
Chabra and Peeples review the evidence regarding the treatment of neonatal GERD. They discuss how alterations in the infant's environment and feeding pattern are effective in most cases. They recommend proton pump inhibitors if conservative treatments are not effective.
Incorrect Answers:
Answer A: Initiating a proton pump inhibitor is appropriate for infants with gastroesophageal reflux disease who have failed management with lifestyle changes. This patient has uncomplicated gastroesophageal reflux without any signs of feeding refusal, worsening irritability, or nutritional compromise.
Answer B: Obtaining an abdominal ultrasound would evaluate for pyloric stenosis, which presents with non-bilious, projectile vomiting rather than the regurgitation that this patient’s mother is describing. An abdominal ultrasound would be the appropriate next step in management for patients who present with a description of more forceful vomiting or have a classic “olive-shaped” mass in the epigastrium on physical exam.
Answer D: Recommending modification of the mother’s diet would be appropriate if this patient had more severe symptoms that were refractory to lifestyle changes. It would also be appropriate if the patient had signs of an underlying allergy to cow’s milk or soy protein, such as blood-streaked stools.
Answer E: Switching to a hydrolyzed formula would be appropriate for formula-fed patients with refractory symptoms of gastroesophageal reflux disease or signs of an allergy to cow’s milk or soy protein. Unless the patient has evidence of severe nutritional compromise, continued breastfeeding should be encouraged for breastfed patients with possible modification of the mother’s diet to eliminate cow’s milk or soy if an allergy is suspected.
Bullet Summary:
Uncomplicated gastroesophageal reflux in infants should be treated with reassurance and counseling to position the infant upright for 20-30 minutes after feeding.
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https://step2.medbullets.com/testview?qid=109261
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196
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A 4-day-old boy presents to the pediatrician with his mother for his 1st well visit. The patient was born at 36 weeks gestation to a 26-year-old primigravid mother via cesarean section for cervical incompetence. The patient required no resuscitation at birth and both mother and child were discharged from the hospital at 2 days of life. The patient has been exclusively breastfed since birth, and his mother reports that he feeds for 20-30 minutes every 2 hours. The patient urinates 7 times per day and has begun passing 2-3 stools per day that his mother describes as “grainy” and the color of “mustard.” His birth weight was 3670 g (8 lb 1 oz), and his current weight is 3487 (7 lb 11 oz). His temperature is 97.1°F (36.2°C), blood pressure is 57/42 mmHg, pulse is 140/min, and respirations are 38/min. On physical exam, the patient’s anterior fontanelle is soft and flat, and his eyes are moderately icteric. His abdomen is soft and non-distended. The patient has the physical exam finding seen in Figure A. His diaper can be seen in Figure B. Laboratory studies reveal the following:
Total bilirubin: 13 mg/dL
Conjugated bilirubin: 0.6 mg/dL
Which of the following is the most appropriate next step in management?
|
{
"A": "Order serum uric acid concentration",
"B": "Continue current breastfeeding regimen",
"C": "Order spot uric acid to creatinine ratio",
"D": "Administer intravenous hydration",
"E": ""
}
|
B
|
This patient presents at day 4 of life with weight loss of 5% of his birth weight, uric acid crystals in his diaper, desquamation of the palms and soles, and unconjugated hyperbilirubinemia, which are normal findings in a newborn. The most appropriate next step in management is continuing his current breastfeeding regimen.
Healthy newborns may lose up to 7% of their birth weight in the first 5 days of life and exhibit dry, peeling skin on the palms and soles as the skin adapts to a drier environment outside the womb. Uric acid crystals that look like “brick dust” are also a normal finding in the diaper during the 1st week of life, as uric acid excretion is highest at birth. All newborns should be evaluated for signs of dehydration, including sunken fontanelles, dry mucous membranes, low urine output, excessive weight loss, and tachycardia. If these findings are not present, continued breastfeeding should be encouraged.
Westerfield et al. review the evidence regarding the benefits of breastfeeding. They discuss how breastfeeding is associated with decreased risk of atopic dermatitis and gastroenteritis. They recommend ensuring proper breastfeeding techniques.
Figure A demonstrates flaking and peeling of the soles (red circles), which is a normal finding in the 1st week of life.
Figure B demonstrates uric acid crystals (“brick dust”) in the diaper (red circle), which is another normal finding that is caused by high uric acid excretion in the 1st few days of life.
Incorrect Answers:
Answer A: Administering intravenous hydration would be appropriate for a severely dehydrated neonate who cannot tolerate hydration orally. This patient is not exhibiting signs of dehydration.
Answer C: Ordering a serum uric acid concentration may be part of an evaluation for Lesch-Nyhan syndrome, an X-linked recessive disorder of purine metabolism caused by deficiency of the enzyme hypoxanthine-guanine phosphoribosyltransferase (HGPRT) that causes hyperuricemia and hyperuricosuria. The uric acid crystals found in this patient’s diapers are a normal finding in the 1st week of life. Treatment is supportive including allopurinol for gout.
Answer D: Ordering a spot uric acid to creatinine ratio would be an appropriate first step in evaluation for Lesch-Nyhan syndrome, but the uric acid crystals in this patient’s diaper are not concerning for Lesch-Nyhan syndrome. Treatment is supportive as well as with allopurinol for gout.
Answer E: Recommending increasing the frequency of breastfeeding would be appropriate for a dehydrated infant with excessive weight loss, but this patient’s weight loss is within the expected limits for the 4th day of life.
Bullet Summary:
Healthy newborns may present with desquamation of the skin and uric acid crystals in the diaper and continued breastfeeding should be encouraged if no signs of dehydration are present.
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https://step2.medbullets.com/testview?qid=109282
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197
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A newborn boy is evaluated 30 minutes after birth. He was born at 39 weeks gestation to a 27-year-old primigravid mother via cesarean section for cervical insufficiency. The pregnancy was complicated by gestational diabetes and the amniotic fluid was clear. Upon delivery, the patient had strong respiratory effort and a strong cry. His Apgar scores at 1 and 5 minutes were 7 and 8, respectively. The patient now is exhibiting increased work of breathing and is progressively more tachypneic. His birth weight is 3,568 g (7 lb 14 oz). His temperature is 99.0°F (37.2°C), blood pressure is 60/44 mmHg, pulse is 146/min, and respirations are 72/min. On physical exam, the patient is grunting with nasal flaring and subcostal retractions. Breath sounds are decreased at the bases bilaterally. The patient has central cyanosis. His chest radiograph can be seen in Figure A. Which of the following is the most likely etiology of this patient’s presentation?
|
{
"A": "Meconium aspiration syndrome",
"B": "Persistent pulmonary hypertension",
"C": "Neonatal respiratory distress syndrome",
"D": "Transient tachypnea of the newborn",
"E": ""
}
|
D
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This newborn is presenting with increased work of breathing and progressive tachypnea in the 1st hour of life, which is consistent with a diagnosis of transient tachypnea of the newborn.
Transient tachypnea of the newborn presents with respiratory distress and marked tachypnea within 2 hours of delivery. Transient tachypnea of the newborn is caused by delayed resorption and clearance of alveolar fluid, which results in mild pulmonary edema. Chest radiography typically demonstrates bilateral perihilar streaking and hyperinflation of the lungs. Transient tachypnea of the newborn is benign and usually resolves by day 2 of life. The management of this condition is supportive.
Alhassen et al. review the evidence regarding the diagnosis and treatment of TTN. They discuss how this condition sometimes requires extended hospitalization and is associated with wheezing in childhood. They recommend using ultrasound to help make this diagnosis.
Figure/Illustration A demonstrates prominent vascular markings around the hilum (yellow arrows), and increased lung volumes on chest radiograph, which is consistent with transient tachypnea of the newborn.
Incorrect Answers:
Answer A: Meconium aspiration syndrome can cause respiratory distress in the immediate newborn period, but it would be unlikely in a patient with a history of clear amniotic fluid, and a more mild clinical picture. Meconium aspiration syndrome would be seen on chest radiograph as coarse, irregular infiltrates and hyper expansion. Treatment is with antibiotics and airway clearance.
Answer B: Neonatal respiratory distress syndrome is a disease of prematurity and does not often occur in infants born at term to healthy mothers. The chest radiograph in neonatal respiratory distress syndrome is also more likely to demonstrate low lung volumes. Treatment is with surfactant administration.
Answer C: Persistent pulmonary hypertension is a cause of respiratory distress in the newborn period, but a chest radiograph typically shows clear lungs. Treatment is with respiratory support as well as inhaled nitric oxide.
Answer E: Viral pneumonia is uncommon in the immediate newborn period. Bacterial pneumonia is more common but usually presents with signs of infection in the mother, which are not present in this case. Treatment is with broad-spectrum antibiotics.
Bullet Summary:
Transient tachypnea of the newborn presents with worsening tachypnea within 2 hours of delivery and is caused by pulmonary edema resulting from inadequate clearance of alveolar fluid.
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https://step2.medbullets.com/testview?qid=109292
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198
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A newborn boy is evaluated in the hospital nursery 2 hours after birth. The patient was born at 39 weeks of gestation to a 30-year-old primigravid via vaginal delivery. The patient’s mother received routine prenatal care and the pregnancy was uncomplicated. The patient’s anatomy ultrasound at 20 weeks of gestation was unremarkable. The patient’s mother denies any family history of genetic diseases. The patient’s APGAR scores were notable for poor muscle tone at both 1 and 5 minutes of life. The patient’s birth weight is 2.6 kg (5 lb 11 oz), which is at the 5th percentile. His height and head circumference are in the 15th and 3rd percentile, respectively. His temperature is 97.1°F (36.2°C), blood pressure is 57/42 mmHg, pulse is 140/min, and respirations are 38/min. On physical exam, the patient has a wide nasal bridge, down slanting palpebral fissures, and widely spaced eyes. He has good respiratory effort with a high-pitched cry. This patient is most likely to have experienced a deletion on which of the following chromosomes?
|
{
"A": "4p",
"B": "5p",
"C": "7q",
"D": "15q",
"E": ""
}
|
B
|
This patient presents with a characteristic mew, microcephaly, hypertelorism, wide nasal bridge, and hypotonia, which suggests a diagnosis of cri-du-chat syndrome. Cri-du-chat syndrome is caused by a deletion on chromosome 5p.
Cri-du-chat syndrome is most commonly caused by a de novo partial deletion of chromosome 5p. Other cases may be caused by a parental translocation involving the relevant section of chromosome 5p. Patients present with a mew-like cry, microcephaly, hypertelorism, down slanting palpebral fissures, a broad nasal bridge, low-set ears, low birth weight, hypotonia, and intellectual disability. The cat-like cry usually resolves by 2 years of age. Treatment is supportive though some patients may have cardiac abnormalities that require surgical intervention.
Cerruti Mainardi reviews the evidence regarding the etiology and diagnosis of patients with Cri-du-chat syndrome. She discusses how the diagnosis is mostly made clinically at this time. She recommends karyotype and FISH studies for those with ambiguous features.
Incorrect Answers:
Answer A: A deletion on chromosome 4p causes Wolf-Hirshhorn syndrome, which presents with growth restriction, microcephaly, congenital heart disease, severe intellectual disability and dysmorphic "Greek warrior helmet" facies of a high forehead, prominent glabella, arched eyebrows, hypertelorism, and epicanthal folds. Treatment is supportive though some patients may require surgical intervention for heart defects.
Answer C: A deletion on chromosome 5q results in Sotos syndrome, a pediatric overgrowth disorder characterized by an increase in head circumference, hypotonia, delayed acquisition of motor skills, and mild intellectual disability.
Answer D: A deletion on chromosome 7q may results in Williams syndrome, which presents with dysmorphic, “elfin” facies, global developmental delay with a hypersocial personality, and supravalvular aortic stenosis. Treatment is supportive though some patients will require surgical intervention for aortic stenosis.
Answer E: A deletion on chromosome 15q may cause either Prader-Willi syndrome or Angelman syndrome, depending on whether the deletion affects the maternal or paternal chromosome. Prader-Willi syndrome classically presents with dysmorphic facies, hyperphagia, and hypogonadism. Angelman syndrome classically presents with intellectual disability, frequent smiling or laughing, and gait ataxia. Treatment is supportive with seizure control for those who develop seizures.
Bullet Summary:
Cri-du-chat syndrome (presents with a characteristic mew, microcephaly, hypertelorism, wide nasal bridge, and hypotonia) is most commonly caused by a deletion on chromosome 5p.
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https://step2.medbullets.com/testview?qid=109452
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199
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A 57-year-old man presents to the emergency department for shortness of breath. He was riding the train home from a business conference when his symptoms began. The patient has a medical history of obesity, diabetes, diabetic nephropathy, hypertension, and a 40-pack-year smoking history. His current medications include atorvastatin, lisinopril, insulin, metformin, and nicotine gum. His temperature is 99.5°F (37.5°C), blood pressure is 130/87 mmHg, pulse is 120/min, respirations are 15/min, and oxygen saturation is 93% on room air. An ECG is ordered as seen in Figure A. A chest radiograph is ordered as seen in Figure B. Laboratory values are ordered as seen below: Serum: Na+: 137 mEq/L Cl-: 105 mEq/L K+: 4.1 mEq/L HCO3-: 24 mEq/L BUN: 22 mg/dL Glucose: 129 mg/dL Creatinine: 1.2 mg/dL Ca2+: 10.1 mg/dL AST: 11 U/L ALT: 12 U/L On physical exam, the patient appears to be in distress. His cardiac exam is notable for tachycardia. Pulmonary exam reveals bilateral air movement without any wheezes or crackles. The patient's right lower extremity appears mildly inflamed, and palpation of the calf elicits pain. Which of the following is the most appropriate next step in management?
|
{
"A": "Aspirin",
"B": "Cardiac troponins",
"C": "Heparin",
"D": "Ventilation perfusion scan",
"E": ""
}
|
C
|
This patient is presenting with a score of 7.5 on Wells criteria suggesting a diagnosis of pulmonary embolism. The most appropriate initial step in management is heparin administration.
Patients with suspected pulmonary embolism (PE) can be evaluated with Wells criteria which consists of: clinical signs and symptoms of DVT (3 points), PE is the most likely diagnosis (3 points), pulse > 100 (1.5 points), immobilization for 3 days, or surgery within 4 weeks (1.5 points), history of DVT or PE (1.5 points), hemoptysis (1 point), and malignancy (1 point). Scores higher than 3 suggest a high probability of PE. Patients will often present with shortness of breath, with ECG findings of sinus tachycardia, and a chest radiograph that is typically normal. With a high pre-test probability, the most important initial step in management is anticoagulation with heparin versus further diagnostic workup.
Doherty reviews the evidence regarding the diagnosis and treatment of pulmonary embolism. He discusses how clinical criteria such as Wells criteria can be helpful in assessing the likelihood of a PE. He recommends immediate treatment in patients who have a PE.
Figure/Illustration A is an ECG demonstrating sinus tachycardia with a P wave, a QRS complex, and a T wave during every beat (red circle). This is the most common ECG presentation in PE, though right heart strain can also be seen.
Figure B is a chest radiograph that is within normal limits without evidence of fluid in the dependent portions of the lung (red circles). This is the most common radiological presentation in PE.
Incorrect Answers:
Answer A: Aspirin would be the most appropriate initial step in the management of MI and can reduce mortality by up to 25% if administered promptly. PE is a more likely diagnosis in this patient given the ECG that only demonstrates sinus tachycardia.
Answer B: Cardiac troponins could be used to confirm the diagnosis of myocardial infarction (MI). In the presence of this patient's ECG (which does not demonstrate ST elevation), MI is a less likely diagnosis. Treatment would be with aspirin in patients who had an MI followed by emergent revascularization.
Answer C: A CT scan of the chest without contrast would not confirm the diagnosis in this patient; however, a CT angiogram would be the most accurate test. It is more important to begin treatment with heparin when there is a very high clinical suspicion of PE.
Answer E: A ventilation perfusion scan is the most accurate test for PE in a patient who cannot tolerate contrast. This test has a low specificity.
Bullet Summary:
The most appropriate initial step in the management of a pulmonary embolism in patients with a high pre-test probability is anticoagulation with heparin.
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https://step2.medbullets.com/testview?qid=109453
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200
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A 25-year-old woman presents for a new patient physical exam. Aside from occasional shin splints, she has a relatively unremarkable medical history. She takes oral contraceptive pills and a multivitamin daily. All of her age appropriate immunizations are up to date. Her periods have been regular, occurring once every 28 to 30 days with normal flow. She is sexually active with 2 partners, who use condoms routinely. Her prior pap smear was performed last year and was normal. Her mother has diabetes and coronary artery disease, and her father passed away at age 45 after being diagnosed with colon cancer at age 40. Her grand-aunt underwent bilateral mastectomies after being diagnosed with breast cancer at age 60. Her temperature is 36.7°C (98°F), blood pressure is 115/80 mmHg, pulse is 65/min, respirations are 12/min, and oxygen saturation is 100% on room air. Her physical exam is within normal limits. Which of the following is the most appropriate recommendation for this patient?
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{
"A": "Mammogram now",
"B": "Colonoscopy in 5 years",
"C": "Colonoscopy in 10 years",
"D": "Pap smear in 5 years",
"E": ""
}
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B
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This patient is presenting for a health evaluation with a family history significant for her father's death due to colon cancer at age 45. She should thus get a colonoscopy when she reaches the age 10 years prior to her father's age of diagnosis or in 5 years (at age 30).
The age threshold for colon cancer screening varies based on the patient's risk factors, including family history of colon cancer, inflammatory bowel disease, and/or genetic disorders. In the absence of significant risk factors, colonoscopies can be used for screening starting at age 45 and repeated every 10 years if results are normal. If there is family history of colon cancer (one or more first degree relatives, including parent, sibling, or child), colonoscopies should be recommended starting at age 40 or 10 years prior to the age of the family member's diagnosis, whichever is earlier. Polyps or grossly abnormal colon tissue may be biopsied for grading and guide further diagnostic imaging workup.
Aasma et al. review the clinical guidelines for colorectal cancer screening. They found that recent epidemiological data shows an increase in the incidence of colorectal cancer in individuals younger than 50 years. They recommend starting colonoscopy screening at 45 years of age in the average-risk adult population.
Incorrect Answers:
Answer B: Colonoscopy in 10 years is reasonable, but it is not the earlier of the 2 age thresholds mentioned above.
Answer C: Pap smear with HPV DNA screening for cervical cancer is indicated every 5 years for women aged 30 to 65 who wish to extend the screening interval from the 3 year interval for pap smear alone.
Answer D: Pap smear alone is indicated every 3 years for women of ages 21 to 65.
Answer E: Mammogram to screen for breast cancer is recommended every 2 years for women aged 50 to 74.
Bullet Summary:
For patients with a family history of colon cancer, screening should start at age 40 or 10 years prior to the age of the family member's diagnosis, whichever is earlier.
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https://step2.medbullets.com/testview?qid=109573
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