****IF YOU SIGN UP FOR MY USMLE1, 2 OR 3 QUESTIONS TODAY ONLY ....I WILL SEND YOU ALL 1217 PAGES OF KAPLAN Q BANK STEP1**** OR FOR STEP II I HAVE BOTH THE STEP II CS AND CK 2008/9 I CAN SEND INSTEAD****JUST CLICK ON "FREE MEDICAL QUESTIONS" ABOVE (then click USMLE 1 and take a look...the first 100 Q free)...CONTACT ME AT MUDPILES@YAHOO.COM I CAN RE SEND THIS FILE IN WORD OR PDF (BETTER ORGANIZED) WE WORK FOR GOOGLE CLICKS... A 72-year-old retired attorney presents for his annual physical examination. He has not had any medical illnesses over the past year. He formerly drank several cocktails before dinner for many years and has a history of a variceal bleed 2 years ago, but has not re-bled since. His only medications are aspirin and metoprolol. On physical examination, he is afebrile. His blood pressure is 122/68 mm Hg, pulse is 60/min, and respirations are 14/min. He is anicteric and has no stigmata of chronic liver disease. His liver edge is 9 cm in the midclavicular line by percussion, and no spleen tip is palpable. There is no evidence of ascites or peripheral edema. Which of the following medications should the patient most likely avoid? ? A. Ciprofloxacin ? B. Ibuprofen ? C. Lorazepam ? D. Losartan ? E. Prednisone Explanation: The correct answer is C. Patients with a history of portal hypertension are at risk for hepatic encephalopathy. He should therefore strictly restrict or entirely avoid any medications with a sedative effect, e.g., benzodiazepines such as lorazepam. In addition to prescribed medicines, over the counter antihistamines and cough remedies also often contain drugs with sedative effects, and the patient should be encouraged to check with the pharmacist and/or physician's office before using any of them. The antibiotic ciprofloxacin (choice A) does not cause hepatic decompensation, but it can cause hypersensitivity reactions and dizziness. Ibuprofen (choice B) can be used in patients with liver disease and is in fact preferred to acetaminophen as a mild analgesic because of the latter's potential harmful effects on the liver. Ibuprofen, like other nonsteroidal anti- inflammatory drugs, can cause gastrointestinal bleeding related to tiny ulcerations of the stomach. However, there is no evidence that this patient is currently bleeding. Losartan (choice D) is an angiotensin II receptor blocker and is not contraindicated in patients with liver disease. Losartan can cause hypotension in volume-depleted patients and fetal morbidity. The glucocorticoid prednisone (choice E) does not typically cause hepatic decompensation, but it can cause the many other side effects associated with glucocorticoid use, such as cushingoid features, suppression of the inflammatory response with tendency to develop infection, fluid and electrolyte imbalances, and increased intracranial pressure. A 19-year-old college varsity swimmer and diver develops a headache, dizziness, left-sided arm clumsiness and leg weakness. He also develops loss of pain and temperature sensation in the left facial region and right body areas after a practice session. He denies prior illness or use of medications. There is no family history of any diseases. Which of the following is the most likely diagnosis? ? A. Astrocytoma ? B. Benign positional vertigo (BPV) ? C. Labyrinthitis ? D. Multiple sclerosis ? E. Vertebral artery dissection Explanation: The correct answer is E. This patient has findings consistent with a lateral medullary syndrome. Given that this patient has subjected himself to strenuous exercise the most likely explanation is a vertebral artery dissection. An astrocytoma may cause dizziness and unsteadiness along with a headache. Onset is insidious with progressive symptoms (choice A). Benign positional vertigo (choice B) causes sudden episodes of dizziness, typically with position change, and with no associated neurologic symptoms other than nystagmus. Labyrinthitis (choice C) causes severe vertigo. Patients find it difficult to move, preferring to remain still. Multiple sclerosis (choice D) can cause dizziness and clumsiness, but the sudden onset and constellation of findings makes this diagnosis unlikely. A 68-year-old man is admitted to the medical service for chest pain. The patient has an 80 pack-year smoking history and is known to have an elevated total cholesterol but unknown LDL and HDL components. He is a known insulin-dependent diabetic with a recent hemoglobin A1c fraction of 8.3%. He has a history of chronic, stable angina precipitated by exertion and relieved by rest. During the examination, he is free from chest pain. His blood pressure is 160/90 mm Hg, pulse is 90/min, and respirations are 22/min. He is mildly diaphoretic. On physical examination, he has an S3 gallop, bibasilar course rales, and an abdominal bruit. A chest radiograph shows mild pulmonary edema. On ECG obtained on arrival to the floor shows ST segment depressions in leads V3, V4, V5 and V6. Which of the following is the most likely diagnosis? ? A. Costochondritis ? B. Pulmonary embolus ? C. Musculoskeletal chest pain syndrome ? D. Myocardial ischemia ? E. Myocardial infarction Explanation: The correct answer is D. This is a classic patient presenting with a very common disease. The first step in correctly answering this question is to identify this patient as almost certainly having coronary artery disease. His age and risk factors are impressive. Secondly, one must realize that diabetics often have silent ischemia. His clinical picture prior to even obtaining an ECG should alert you to the likelihood that he is having ischemia. The ECG confirms ischemia in the anterior portion of the heart, the left ventricle. Once this is understood, his S3 and pulmonary edema are explained. This is a medical emergency and should be dealt with as such. Treatment requires aggressive lowering of myocardial oxygen demand, i.e., blood pressure and heart rate. Costochondritis (choice A) or musculoskeletal chest pain syndrome (choice C) are in no way supported by the physical examination. There is no tenderness on palpation. A pulmonary embolus (choice B) is unlikely given the nonpleuritic nature of his pain and his ECG changes that are highly suggestive of ischemia. Myocardial infarction (choice E) is not the diagnosis, as this is a clinical one that requires either characteristic ST segment elevations on the ECG OR elevations in serum markers for cardiac injury. A 27-year-old actor presents with a swollen left knee. The pain began 36 hours earlier and has limited his ability to perform in his current play. He has had a fever and shaking chills over the past 24 hours. Physical examination reveals a temperature of 38.9 C (101.9 F) and a pulse of 104/min. The remainder of the physical examination is unremarkable except for a swollen, erythematous knee with an obvious effusion. There is limited range of motion. An arthrocentesis reveals 90,000/mm3 white blood cells and 82% neutrophils. A Gram's stain reveals many neutrophils, and no organisms are seen. Polarizing microscopy reveals no crystals. Which of the following is the most appropriate initial step in therapy? ? A. Ceftriaxone ? B. Colchicine ? C. Indomethicin ? D. Nafcillin ? E. Nafcillin and ceftriaxone Explanation: The correct answer is E. This patient has a monoarticular arthritis with a very high white cell count in the arthrocentesis strongly suggestive of a septic arthritis. Since the gram stain is unrevealing in this case (which you should be aware can happen) as to the specific organism, broad-spectrum antibiotics to cover the two most likely organisms is appropriate. This includes therapy for gonococcus (ceftriaxone) as well as nafcillin for Staphylococcus aureus septic arthritis. Either ceftriaxone or nafcillin alone (choices A and D) would be insufficient. Since the polarizing microscopy is negative, there is no indication for colchicine (choice B). Indomethicin (choice C) may be an adjunctive therapy but is not the appropriate therapy in a patient with this many white blood cells in the joint fluid, consistent with a septic arthritis. A 17-year-old boy presents with chronic low back pain for the past 8 months. He was the most promising member of the high school swim team but was forced to quit because of his back pain. The pain begins frequently at night, radiates down the thighs, and is accompanied by pronounced stiffness of the lumbar spine. He denies any gastrointestinal or genital infections. His temperature is 37.0 C (98.6 F). Examination reveals moderate limitation of back motion and tenderness of the lower spine. A diastolic murmur along the left sternal border is heard on chest examination. Laboratory investigation shows an elevated erythrocyte sedimentation rate (ESR) and negative rheumatoid factor. X-ray films of the vertebral column and pelvic region show flattening of the lumbar curve and subchondral bone erosion involving the sacroiliac joints. Which of the following is the most likely diagnosis? ? A. Ankylosing spondylitis ? B. Degenerative join disease ? C. Reiter syndrome ? D. Seronegative rheumatoid arthritis ? E. Still disease Explanation: The correct answer is A. The patient's young age, occurrence of pain at night, negativity of rheumatoid factor, and especially, bilateral involvement of sacroiliac joints are consistent with ankylosing spondylitis. This is one of the seronegative spondyloarthropathies, characterized by onset before 40 years of age, absence of circulating autoantibodies, frequent association with HLA-B27 histocompatibility antigen, and common involvement of the spinal column. Ankylosing spondylitis should be suspected in any young person complaining of chronic lower back pain and confirmed by radiographs or CT scans of sacroiliac joints. The disease usually progresses to involve the whole vertebral column, producing ankylosis and respiratory failure secondary to restrictive lung disease. Uveitis and aortic insufficiency are additional manifestations. Degenerative joint disease (choice B) would be exceptional at such a young age, unless predisposing conditions were present. Degenerative joint disease is not associated with systemic signs and symptoms. Radiographs of affected joints show narrowed interarticular spaces, osteophytes, and increased density of subchondral bone. Sacroiliac joints are not involved. Reiter syndrome (choice C) is one of the seronegative spondyloarthropathies. It develops as a sequela of gastrointestinal infections due to Salmonella, Shigella, or Campylobacter, or after sexually transmitted infection caused by Chlamydia or Ureaplasma. Arthritis of large joints (knee and ankle), conjunctivitis, and skin vesicular eruption are the hallmarks of this condition. Seronegative rheumatoid arthritis (choice D) refers to those cases in which a typical picture of rheumatoid arthritis is associated with negative rheumatoid factor. Rheumatoid arthritis involves small joints, especially those of the hands. Still disease (choice E) is a rare systemic form of arthritis with onset before age 17. It manifests with spiking fever and systemic symptoms that usually antedate arthritis. Associated manifestations include a morbilliform rash, hepatosplenomegaly, serositis, anemia, and leukocytosis. A neonate develops severe cyanosis that begins within minutes of birth. Blood drawn one hour after birth shows metabolic acidosis with respiratory acidosis. A chest x-ray film shows a narrow base to the great vessels and the heart resembles an egg on its side. ECG is normal. Which of the following is the most likely diagnosis? ? A. Aortic valve stenosis ? B. Complete atrioventricular canal defect ? C. Tetralogy of Fallot ? D. Transposition of the great arteries ? E. Underdeveloped (hypoplastic) left ventricle syndrome Explanation: The correct answer is D. This is transposition of the great arteries, in which the aorta arises from the right ventricle and the pulmonary artery arises from the left ventricle. Approximately 5% of congenital cardiac anomalies have transposition of the great arteries. Affected babies present within minutes of birth with severe cyanosis and metabolic acidosis secondary to inability to oxygenate tissues. The only exchange of blood between pulmonic and circulatory systems is typically occurring through a patent ductus arteriosus. The chest x-ray changes illustrated in the question stem are typical, and are due to superposition of the great vessels (rather than the normal side-to-side position). Surgical repair is usually performed within 7 to 10 days of life. Aortic valve stenosis (choice A) produces a loud ejection murmur with a prominent systolic click heard best at the upper right sternal border. Complete atrioventricular canal defect (choice B) can also cause cyanosis at birth, but will show marked ECG changes, sometimes including absent Q waves. Tetralogy of Fallot (choice C) may present at birth , with ECG changes showing right ventricular hypertrophy and right axis deviation. Chest x-ray films usually show a small heart with a concave main pulmonary artery. Underdeveloped left ventricle syndrome (choice E) causes an abrupt onset of severe heart failure with loss of peripheral pulses at 2-3 days of life. A 26-year-old man is brought to the hospital by his family after sitting in his room with the lights out and the door closed for two-days. He has not eaten over this time. About a week ago, the family noticed the patient becoming increasingly agitated and paranoid about cars driving by on the street in front of their house. He covered the windows of his bedroom with newspaper and unplugged his radio and television. At night, he was heard pacing in his room and talking to himself. Although he had taken olanzapine after a psychiatric hospitalization about six months previously, the family reported that he threw away the medication about a month ago. On admission, the patient is sitting in a chair with his head hung low. He is disheveled and malodorous, after having urinated on himself several times over the past two days. During physical examination, the patient appears to be awake, but firmly resists any attempts to be moved. He does not follow instructions, and the nurse was unable to move his arm to obtain a blood pressure measurement without assistance. Which term would best describe this patient's resistance to being moved? ? A. Akathisia ? B. Cataplexy ? C. Echopraxia ? D. Negativism ? E. Stereotypy Explanation: The correct answer is D. This patient is exhibiting the catatonic symptom known as negativism, which is a motiveless resistance to all attempts to be moved or to all instructions. Signs of catatonia include stupor, negativism, rigidity, posturing, mutism, stereotypies, mannerisms, waxy flexibility, and catatonic excitement. Catatonia may be associated with schizophrenia (catatonic type), mood disorders (with catatonic features), or general medical conditions. Akathisia (choice A) is usually classified as an extrapyramidal side effect of antipsychotic medications. It is characterized by a subjective feeling of muscular tension (an inner sense of restlessness) that can cause distressing restlessness, pacing, or repeated movements. It may be mistaken for psychotic agitation, and thus inappropriately treated. Cataplexy (choice B) is a temporary loss of muscle tone and weakness precipitated by a variety of emotional states. It is most characteristically associated with narcolepsy. Echopraxia (choice C) is a pathological imitation of the movements of one person by another. It can be seen in catatonia, delirium, dementia, and other disorders. Stereotypy (choice E) is a repetitive fixed pattern of physical action, movement, or speech. It may be seen in catatonia. This patient does not currently exhibit stereotypies. A 37-year-old woman, gravida 3, para 2, comes to her physician for follow- up on her ectopic pregnancy. She was diagnosed with an ectopic pregnancy 7 days ago and given methotrexate. She now presents with abdominal pain that started this morning. Examination is significant for moderate left lower quadrant tenderness. Laboratory analysis shows that her beta-hCG value has doubled over the past week. Transvaginal ultrasound shows that the ectopic pregnancy is roughly the same size but there is an increased amount of fluid in the pelvis. Which of the following is the most appropriate next step in management? ? A. Expectant management ? B. Repeat methotrexate ? C. Laparoscopy ? D. Oophorectomy ? E. Hysterectomy Explanation: The correct answer is C. An ectopic pregnancy is a pregnancy that is located outside of the normal intrauterine location, most often in the fallopian tube. In a stable patient, an ectopic pregnancy may be treated medically or surgically. Medical management is with methotrexate. When methotrexate is given, it is essential to have the patient return for follow-up to ensure that the beta-hCG value is falling, the indication that the methotrexate is working. This patient not only has a beta-hCG value that is rising, but also has other signs and symptoms consistent with a rupturing ectopic pregnancy. The worsening abdominal pain and left lower quadrant tenderness are concerning for rupture as is the increased amount of fluid in the pelvis on the ultrasound. This fluid likely represents blood. The management for a ruptured ectopic is surgical. In this case laparoscopy could be performed to identify the ectopic pregnancy and either a salpingostomy (i.e. making a hole in the tube to remove the ectopic pregnancy) or a salpingectomy (i.e. removing the entire tube) could be performed. Expectant management (choice A) would be absolutely inappropriate, as this patient has a doubling beta-hCG value in spite of the methotrexate therapy and has findings consistent with a ruptured ectopic. Repeat methotrexate (choice B) can be given to women with an ectopic pregnancy that show persistently high levels of serum beta-hCG on a day 7 evaluation (i.e. 7 days after the first dose of methotrexate). However, this patient would not be a candidate, as she appears to be actively rupturing her ectopic pregnancy. Oophorectomy (choice D) and hysterectomy (choice E) are not the treatments of choice for women with an ectopic pregnancy. All reasonable steps should be taken to preserve the patient's uterus and ovaries during a surgery for ectopic pregnancy. Preferably, only the tube itself should be operated upon, with either a salpingectomy or salpingostomy being performed. A 53 year old-man is brought to the emergency department by a friend. The friend reports that the patient has "liver disease" and has been drinking heavily lately and has not taken his medications. He has gotten progressively more confused over the past few days. On examination, the man is afebrile, his blood pressure is 120/70 mm Hg and his heart rate is 100/min. He has no obvious signs of trauma but has some old, well-healed lacerations on his forehead. He has deep scleral icterus and his skin is jaundiced. His lungs are clear. and cardiac examination is normal, but he has a distended abdomen with shifting dullness. He is alert to person only and his neurological examination is remarkable for the inability to perform finger-to-nose touching and heel-to-shin maneuvers. Asterixis is present. Laboratory studies show: Sodium.....................................125 mEq/L Potassium.................................3.1 mEq/L Bicarbonate..............................18 mEq/L Urea nitrogen............................25 mg/dL Creatinine.................................1.2 mg/dL Aspartate aminotransferase.......230 U/L Alanine aminotransferase..........310 U/L Prothrombin time......................14.8 seconds Alkaline phosphatase................75 U/mL Leukocyte count.......................6,400/mm3 Hematocrit...............................35% Blood alcohol level....................2100 mg%Which of the following is the most likely diagnosis? ? A. Acute hyponatremia ? B. Ascending cholangitis ? C. Hepatic encephalopathy ? D. Metabolic acidosis ? E. Subdural hematoma Explanation: The correct answer is C. The patient most likely has developed hepatic encephalopathy, one of the many complications that affect cirrhotic patients. One of the most useful and essential components of the evaluation of such a patient is the history. When the history is given of a confused cirrhotic "not taking his medications", an understanding that encephalopathy is a possible diagnosis should immediately come to mind. Acute hyponatremia (choice A) is not supported by the serum sodium level of 125. Acute signs of hyponatremia are seen when the serum sodium falls more than 12 mEq/L in less than 24 hours. The signs of such an illness involve nausea, vomiting, confusion and neurological findings related to brain edema. Ascending cholangitis (choice B) is not supported by the physical examination or by the classic Charcot's triad (fever, right upper quadrant pain, and jaundice). Metabolic acidosis (choice D) is not supported by the data. The patient does have a low bicarbonate level, but his pH is not known. He is likely acidemic, but this is not the most likely cause of his confusion. Subdural hematoma (choice E) is not supported by the physical examination. The most common cause of SH is traumatic tearing of the bridging veins of the dura. A 49-year-old woman presents to the office because of complaints of fatigue. She has had progressive exercise intolerance over the prior 6 months. On physical examination, she is pale and afebrile. Her blood pressure is 112/68 mm Hg, and her pulse is 88/min. Heart and lung examinations are normal except for a I/VI systolic flow murmur at the left sternal border. Routine laboratory results reveal hemoglobin of 8.3 g/dL, a mean corpuscular volume of 118 µL/m3, and a B12 of 82 pg/mL (normal >210 pg/mL). She undergoes a Schilling test, which reveals malabsorption of radiolabeled B12. Intrinsic factor is administered and the radiolabeled B12 is subsequently absorbed. Which of the following is the diagnosis? ? A. Atrophic gastritis ? B. Bacterial overgrowth ? C. Chronic pancreatitis ? D. Crohn disease ? E. Gastric ulcer Explanation: The correct answer is A. This patient has pernicious anemia, as demonstrated by correction of her deficiency in intrinsic factor production by her parietal cells. This is an autoimmune disease directed against the parietal cells of the stomach, which are the normal producers of the intrinsic factor needed for absorption of vitamin B12. The lack of B12 then causes development of a megaloblastic (with high mean corpuscular volume) anemia. Biopsy of the gastric mucosa in these cases reveals atrophic gastritis. The Schilling test examines the absorption of radioactively labeled vitamin B12 before and after administration of intrinsic factor. A result of poor absorption of B12 before administration of intrinsic factor and good absorption after strongly suggests pernicious anemia as the diagnosis. Patients with pernicious anemia require long-term (probably life-long) parenteral replacement of vitamin B12 and may also have other significant autoantibodies, notably those directed against thyroid antigens. Choices B, C, and D may all produce a B12 deficiency, but they do not correct with intrinsic factor. In patients with bacterial overgrowth (choice B), the excess bacteria will preferentially absorb intraluminal B12. Chronic pancreatitis (choice C) may predispose to a B12 deficiency by failing to secrete the enzymes that are necessary to cleave the salivary R factor from the B12, making it unavailable for binding to intrinsic factor. Crohn disease (choice D) may cause a B12 deficiency if the terminal ileum is severely inflamed or has been resected. Gastric ulcer (choice E) can cause anemia secondary to bleeding, but it would be a normocytic anemia (unless there had been enough blood loss to cause iron deficiency, in which case it would microcytic) and would not be expected to respond to B12. The longtime primary care physician of an 85 year-old woman is asked to help mediate care between the family and the hospital's medical service. The patient sustained an anoxic brain injury during an in-hospital cardiac arrest one week ago in which the patient had a pulseless period for at least 5 minutes. On physical examination, her vital signs are normal and stable with the assistance of continuous mechanical ventilation. Pupillary and corneal reflexes are present bilaterally. There is episodic decorticate rigidity, but no purposeful movement present. An electroencephalogram (EEG) suggests severe, diffuse cortical damage. The patient's husband asks the physician if she is brain dead. Which of the following is the most appropriate response? ? A. It is too early to predict brain death by the legal definition ? B. The diagnosis of brain death can only legally be made by a neurologist ? C. The decision on brain death must await the completion of a magnetic resonance image (MRI) ? D. The presence of brain stem function and posturing rules out brain death, but the examination findings and supportive data suggest extensive brain damage ? E. The suggestion of severe cortical damage by the EEG implies brain death Explanation: The correct answer is D. As part of the widely accepted University of Pittsburgh criteria for brain death, the presence of either posturing or brain stem function (e.g.,. pupillary reflexes or corneal reflexes), as are present in this case, violates the brain criteria for the formal definition of brain death. That said, the fact that the patient has no purposeful activity one week after an anoxic brain injury bodes poorly for a meaningful neurological recovery. There are published studies that stratify long-term prognosis of such patients based upon neurological examinations made in the first 48 hours after injury. While the passing of time often aids in the prognosticating of likely neurological recovery, the diagnosis of brain death can be made at any time and is not time-dependent (choice A). Neurologists are often asked to help predict neurologic recovery and diagnose brain death (choice B), but any physician (generally two are required) may do so within current accepted diagnostic guidelines. MRI (choice C) may help assess the extent of brain injury but has no role in the formal diagnosis of brain death. The EEG, even when suggestive of minimal or no cortical function (choice E), does not exclude brainstem activity and therefore can not be used in isolation to make the diagnosis of brain death. A 40-year-old woman comes to the physician for an annual examination. She has no complaints. She has menses every 28-30 days that last for 3 days. She has no intermenstrual bleeding. She has asthma, for which she uses an occasional inhaler. She had a tubal ligation 10 years ago. She has no known drug allergies. Examination is unremarkable, including a normal pelvic examination. One of her friends was recently diagnosed with endometrial cancer, and the patient wants to know when and if she needs to be screened for this. Which of the following is the most appropriate response? ? A. Screening for endometrial cancer is not cost effective or warranted ? B. Screening is with endometrial biopsy and starts at age 40 ? C. Screening is with endometrial biopsy and starts at age 50 ? D. Screening is with ultrasound and starts at age 40 ? E. Screening is with ultrasound and starts at age 50 Explanation: The correct answer is A. Endometrial cancer is the most common gynecologic cancer in women older than 45. There are tens of thousands of new cases every year in the U.S., and thousands of deaths from it yearly. However, there is no effective screening test for endometrial cancer at this point. It is not cost-effective to screen asymptomatic women for endometrial cancer. Occasionally, a Pap test will detect abnormal endometrial cells, but it is not a proper screening tool for endometrial cancer. Patients with endometrial hyperplasia or cancer often present with irregular uterine bleeding. Therefore, patients with irregular uterine bleeding should be considered for endometrial biopsy or ultrasonic evaluation of the endometrial cavity. This strategy may be modified for young patients, in whom the risk of endometrial hyperplasia or cancer is limited. To state that screening is with endometrial biopsy and starts at age 40 (choice B) or age 50 (choice C) is incorrect. Endometrial biopsy can and should be used in certain circumstances. For example, a woman with postmenopausal bleeding should undergo the procedure. However, endometrial biopsy should not be used as a screening tool. To perform endometrial biopsies on women with no indication other than screening would place these women at risk for bleeding, infection, and uterine perforation, and would not be cost-effective. To state that screening is with ultrasound and starts at age 40 (choice D) or age 50 (choice E) is incorrect. Pelvic ultrasound can be used to help diagnose endometrial hyperplasia and endometrial cancer. For example, studies have shown that in postmenopausal women, measurement of the endometrial stripe can be useful in helping to rule out these conditions. However, pelvic ultrasound has not been shown to be cost-effective or warranted for screening for endometrial cancer. A 25-year-old woman comes to the physician because of a facial rash, fatigability, joint and muscle pains, and temperatures up to 38.5 C (101 F) for two weeks. Her temperature is 37 C (98.6 F), blood pressure is 12/80 mm Hg, pulse is 80/min, and respirations are 20/min. She does not take any medications. Physical examination reveals a bilateral malar rash, tenderness to palpation of the knees and wrists, and a pleuritic rubbing sound on chest auscultation. Laboratory investigations show: Hemoglobin............................8.5 g/dL Leukocyte count.....................3,800/ mm3 Platelets.................................110,000/ mm3 Urinalysis...............................negative for glucose and protein Antinuclear antibody titer........elevated Antiphospholipid antibodies......positive Which of the following is the most appropriate next step in diagnosis? ? A. Assay for anticentromere antibodies ? B. Assay for anti-double stranded DNA and anti-Smith antibodies ? C. Assay for anti-neutrophil cytoplasmic antibodies (ANCAs) ? D. Assay for rheumatoid factor ? E. X-ray studies of affected joints ? F. Skin biopsy Explanation: The correct answer is B. The manifestations are highly suggestive of systemic lupus erythematosus (SLE). This immune-related connective tissue disease has a predilection for women of childbearing age. Joint pains, low-grade fever, weight loss, fatigability, and rash over sun-exposed areas are among the most frequent early signs. Often, physical examination reveals evidence of fibrinous pleuritis or pericarditis. Antinuclear antibodies (ANAs) are highly sensitive but not specific, and thus elevated levels of ANA confirm the clinical suspicion of SLE but do not establish a definitive diagnosis. Anti-double stranded DNA and anti-Smith antibodies are most specific of SLE and are thus extremely useful to confirm the diagnosis. Anti-double stranded DNA antibodies also reflect disease activity, while anti-Sm antibodies do not. Note also that antiphospholipid antibodies are positive, which is often the case with SLE. Mild-to-moderate anemia, low leukocyte count, and low platelet counts are frequently found in SLE patients. Occasionally, anemia is due to autoantibodies to red blood cells. Anticentromere antibodies (choice A) are virtually pathognomonic of the CREST variant of scleroderma, manifesting with calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia. Assay for anti-neutrophil cytoplasmic antibodies (ANCAs) (choice C) would aid in the investigation of the possibility of certain forms of vasculitis syndromes, such as Wegener granulomatosis, Churg-Strauss syndrome, and microscopic polyangiitis. Assay for rheumatoid factor (choice D) is not useful in this situation. Rheumatoid factor is often positive not only in rheumatoid arthritis, but also in other collagen vascular conditions, including SLE. X-ray studies of affected joints (choice E) would yield nonspecific results. Arthritis in SLE is usually not associated with destructive or deforming changes of the joints. Skin biopsy (choice F) may be helpful in supporting a diagnosis of SLE in uncertain cases, especially when dermatologic manifestations are the predominant signs. A 30-year-old woman presents with low back pain, and a swollen and painful right ankle and left knee for 1 week. She also reports temperatures to 39.0 C (102.2 F). She recalls that a few weeks ago, she had diarrhea, abdominal cramps, and fever, which lasted for a few days. She does not have previous history of joint diseases or sexually transmitted diseases. Examination reveals skin pustules and crusted vesicles on her palms and soles, red conjunctivae, and arthritis of the left knee and right ankle. There is no hepatomegaly, splenomegaly, or lymphadenopathy. Laboratory analysis show an elevated erythrocyte sedimentation rate (ESR), but no anemia. Which of the following is the most likely diagnosis? ? A. Psoriatic arthritis ? B. Reiter syndrome ? C. Rheumatic fever ? D. Rheumatoid arthritis ? E. Syphilitic infection Explanation: The correct answer is B. Reiter syndrome develops as a complication of two types of infections: enteric infections due to Shigella, Salmonella, Yersinia, or Campylobacter, and sexually transmitted diseases caused by Chlamydia or Ureaplasma. Eighty percent of cases occur in HLA-B27- positive individuals. A male predominance of 9:1 is characteristic of cases following sexually transmitted infections. Nonsteroidal anti-inflammatory drugs (NSAIDs) are used for treatment; antibiotics are used to reduce the likelihood of developing Reiter syndrome after sexually transmitted diseases, but not after enteric infections. Psoriatic arthritis (choice A) is similar to rheumatoid arthritis with regard to the pattern of joint involvement, but is not associated with a positive rheumatoid factor. Usually, psoriasis antedates the onset of arthritis, but sometimes the opposite occurs. Involvement of sacroiliac joints is common in this condition. Arthritis associated with rheumatic fever (choice C) is characterized by a migratory course and is associated with signs and symptoms of cardiac involvement. Skin lesions are known as erythema marginatum. Rheumatoid arthritis (choice D) characteristically affects small joints (most commonly in the hands) in a symmetric fashion. Most cases show circulating rheumatoid factor. The manifestations of syphilitic infection (choice E) are classically divided into primary, secondary, and tertiary stages. The primary stage is characterized by a painless ulcer at the site of entry, ie, a chancre. The secondary stage develops up to 6 months following the primary stage and is associated with a diffuse maculopapular eruption involving skin and mucous membranes, generalized lymphadenopathy, fever, hepatitis, iritis, osteitis, aseptic meningitis, and arthritis. The tertiary stage manifests after long periods of latency and involves the ascending aorta, bones, liver, skin, and CNS. A 24-month-old child is seen in the pediatrician's office for a regular health supervision visit. He has no history of developmental delay. He was born by an uncomplicated normal vaginal delivery at term, and he has not had any significant illness or injury prior to this visit. Which of the following motor milestones is most consistent with his age? ? A. Building a tower of two cubes ? B. Copying a circle ? C. Scribbling ? D. Throwing a ball overhead ? E. Walking backward Explanation: The correct answer is D. Throwing a ball overhead is most consistent with the motor development of a 24-month-old child. As the cerebral cortex develops, the child's hands and arms are more able to perform more skillful and delicate motor functions. Building a tower (choice A) is a good way to assess a child's motor function. A child should be able to build a tower of two cubes by 14 months of age. By 24 months, he or she should be able to build a tower of at least 6 cubes. A 24-month-old child will not usually be able to copy a circle (choice B). This ability emerges around 36 months of age. Imitative scribbling (choice C) appears around 16 months; spontaneous scribbling appears around 18 months. A child should be able to walk backward (choice E) by 18 months. Climbing stairs or going down stairs with support are more consistently seen at 24 months. Two other milestones that are consistent with 24 months of age are jumping up and kicking a ball forward. A 29-year-old female comes to the physician because of fevers and back pain. She is otherwise healthy with no significant past medical history. Examination is significant for a temperature of 38.3 C (101 F), moderate costovertebral angle tenderness, leukocytosis, and white blood cells and red blood cells in the urine. The patients is diagnosed with pyelonephritis and started on intravenous antibiotics. Over the next two days, she rapidly improves, and by hospital day 3, she is tolerating oral intake, voiding without difficulty, feeling no pain, and she has not had a fever for 48 hours. Which of the following is the most appropriate next step in management? ? A. Continue intravenous antibiotics for 2 weeks ? B. Discharge home and recommend post-coital prophylaxis ? C. Discharge home off all antibiotics ? D. Discharge home to complete a 2-week course of oral antibiotics ? E. Obtain surgical evaluation Explanation: The correct answer is D. This patient has had an uncomplicated course of pyelonephritis thus far. Pyelonephritis is an infection of the kidney. Patients with pyelonephritis typically present with some combination of back pain, dysuria, hematuria, frequency, urgency, fevers, chills, nausea, and vomiting. Examination often shows an elevated temperature, costovertebral angle tenderness, leukocytosis, and white cells and red cells in the urine. Completely uncomplicated cases of pyelonephritis can be treated on an outpatient basis. When there are any complicating factors (e.g., concern for sepsis, pregnancy, old age, or other medical illnesses), the patient should be admitted to the hospital for intravenous antibiotics. However, once the patient's condition has improved and she is tolerating oral intake, she may be discharged home to complete a 2-week course of antibiotics. When discharged, however, she should be given strict instructions and precautions regarding the need to return for recurrence of the symptoms or worsening condition. To continue intravenous antibiotics for 2 weeks (choice A) would not be necessary. Once a patient with pyelonephritis is afebrile, doing better, and able to tolerate oral intake, she may be converted to oral antibiotics and be discharged to home. To keep the patient hospitalized for a full 2 weeks would not be necessary. To discharge home and recommend post-coital prophylaxis (choice B) or to discharge home off all antibiotics (choice C) would not be correct. Even though the patient is feeling better, she must still complete a 2-week course of oral antibiotics and not just use antibiotics for post-coital prophylaxis. To obtain surgical evaluation (choice E) would not be necessary. If a patient with pyelonephritis is not improving, then surgical evaluation may be required to determine if another etiology is responsible or to determine if surgical intervention is required. This patient, however, is improving and surgical evaluation would not be necessary. A 74-year-old woman presents to her physician for a postoperative medical visit. Three days ago, she underwent a left total knee replacement for severe osteoarthritis. She has a past medical history significant for type 1 diabetes mellitus and glaucoma. Her hospital course was uneventful. She continues to take daily NPH insulin and has good control of her blood glucose. She also takes oxycodone, which was given to her in the hospital for pain. She is involved in a physical therapy rehabilitation program at the local hospital. On review of her medications, which of the following is most acutely indicated at this time? ? A. An ACE inhibitor ? B. A nonsteroidal anti-inflammatory agent ? C. Oral aspirin ? D. Oral Coumadin ? E. Subcutaneous unfractionated heparin Explanation: The correct answer is D. This patient is post a total knee replacement and is currently not on any anticoagulation therapy. The risk of deep venous thrombosis (DVT) and subsequent pulmonary embolism is very high in this population, and it is the standard of care to initiate Coumadin or low-molecular-weight heparin postoperatively for a period of 6 weeks to 6 months. An ACE inhibitor (choice A) is, in the long term, an excellent drug for this patient given her diabetes. In the post-surgical period, however, the greatest consideration should be given to the most pressing issue. A nonsteroidal anti-inflammatory agent (choice B) does not appear to be indicated at this time, as the patient appears to have reasonable pain control with her opiate. Oral aspirin (choice C) is an anti-platelet agent that has no role in the prevention of DVT. Subcutaneous unfractionated heparin (choice E) is used for prevention of DVT in immobile patients or in hospitalized patients unable to ambulate. However, after orthopedic surgery, especially after joint procedures, its efficacy is very poor, given the increased venous stasis. A 24-year-old white woman presents complaining of 6 months of crampy abdominal pain. The pain has been localized to the right lower quadrant and is made worse by eating. She has also noted an increase in the number of her bowel movements to approximately four per day, and the stools have become semi-formed. She denies any fevers, chills, or night sweats during this period. She has lost 15 pounds from her baseline weight of 128 pounds over the past 6 months. She has also noted aching in her knees and ankles during this interval. On physical examination, she is slightly pale and has two oral aphthous ulcers on the inner lower lip. The abdomen is soft but tender in the right lower quadrant. No masses are palpable, and there is no hepatosplenomegaly. A rectal examination reveals brown stool, which is guaiac positive. Which of the following diagnostic tests would be most appropriate for this patient? ? A. Abdominal CT scan ? B. Barium enema ? C. Sigmoidoscopy ? D. Abdominal sonogram scan ? E. Upper gastrointestinal and small bowel barium x-ray films Explanation: The correct answer is E. This patient has the classic presentation of Crohn disease. This generally presents in young adults with subacute or chronic symptoms, typically of right lower quadrant pain, diarrhea, and weight loss. She also has extraintestinal manifestations of aphthous ulcers and arthralgias. The description of this patient's pain suggests that it is located in the terminal ileum. This area is best seen with an upper gastrointestinal and small bowel barium study. An abdominal CT scan (choice A) is sometimes useful in patients with Crohn disease with a suspected abscess or fistula. However, this is not suggested by the history or physical in this case. An abdominal sonogram (choice B) would not provide sufficient infromation for the diagnosis of Crohn disease. Barium studies are much better for visualization of the typical features of inflammatory bowel disease. A barium enema (choice C) is not as effective a test as a small bowel series at visualizing the terminal ileum. The barium enema would demonstrate evidence of colonic Crohn disease but the history and physical here suggest ileal disease is more likely. A sigmoidoscopy (choice D) would not be of value in assessing the terminal ileum. A 51-year-old welder presents complaining of severe fatigue and the onset of jaundice. He has a known history of hepatitis C, which he acquired after IV drug use 20 years earlier. Over the past 6 months, he has developed ascites and has had two admissions to the hospital for esophageal variceal bleeding. On physical examination, he is icteric with bitemporal wasting and multiple stigmata of chronic liver disease. On abdominal examination, his liver is 7 cm in the midclavicular line, and splenomegaly is present. There is near-tense ascites and moderately severe lower extremity edema, which extends to the mid-calf. Laboratory results reveal an albumin of 2.1 g/dL, total bilirubin of 12.1 mg/dL, and a prothrombin time of 19 seconds. Which of the following is the most appropriate therapy for this patient? A. Interferon B. Ribavirin C. Interferon plus ribavirin D. Mesocaval shunt E. Evaluation for liver transplantation Explanation: The correct answer is E. This patient has known hepatitis C. Features indicating that he has advanced signs of cirrhosis and portal hypertension include ascites, hepatosplenomegaly, jaundice with elevated bilirubin, hypoalbuminemia with leg edema, increased prothrombin time probably secondary to inadequate synthesis of clotting factors by the liver, and esophageal variceal bleeding. In the setting of disease this advanced, antiviral treatment for hepatitis C is without value and the patient should undergo evaluation for a liver transplant. As discussed above, all anti-viral therapy (choices A, B, and C) would be futile given the advanced stage of his cirrhosis at this point. A mesocaval shunt (choice D) is a surgical procedure whereby portal flow is diverted from the superior mesenteric vein into the inferior vena cava to reduce portal pressures. It is often complicated by encephalopathy and does not improve the underlying liver dysfunction. The parents of a 5-year-old boy come to the physician concerned about their child's recurrent leg pains. The boy has been complaining for several weeks about pain in both legs, usually occurring soon after going to bed. He derives relief from rubbing his legs and knees. He does not limp and is able to participate in sports activities. Which of the following is the most likely diagnosis? A. "Growing" pains B. Juvenile rheumatoid arthritis C. Osgood-Schlatter disease (osteonecrosis of the tibial tuberosity) D. Osteoid osteoma E. Osteosarcoma F. Stress fractures Explanation: The correct answer is A. The clinical history provided by the parents is consistent with "growing" pains. Although such pains are most likely unrelated to growth, they do affect children between 3 and 10 years. Growing pains are most commonly bilateral, involve the lower leg and knees, manifest with pain during rest (usually at bedtime), and are relieved by massaging or rubbing. Children awaken the next morning feeling fine. Physical activity is not impaired. Limb pains produced by organic disease will usually be unilateral (except for rheumatoid arthritis) or associated with physical signs (swelling, warmth, etc.). The child with physical injuries or disease cannot bear to have the affected area touched. Growing pains often have a familial predisposition. Juvenile rheumatoid arthritis (choice B) is one of the most common connective tissue disorders of childhood. It affects large joints (< 5 joints in the oligoarticular form, > 5 in the polyarticular form). Affected joints become warm and swollen. Antinuclear antibodies are often present. Osgood-Schlatter disease (osteonecrosis of the tibial tuberosity) (choice C) affects children between 4 and 12 years of age. It is due to osteonecrosis (aseptic necrosis) of the tibial tuberosity. The patient limps and experiences pain during physical activities. The condition is self- limiting, but activities such as jumping, football playing, and running should be discontinued for 2-3 months. Osteoid osteoma (choice D) is a small benign tumor of the bone that frequently affects the tibia. The tumor is usually unilateral and manifests with nocturnal pain, which awakens the child and is promptly relieved by aspirin or NSAIDs. Osteosarcoma (choice E) is a malignant bone tumor affecting children and adolescents. Unilateral bone pain in the segment involved (usually proximal tibia or distal femur) or pathologic fracture is the usual mode of presentation. Stress fractures (choice F) affect small bones that normally have a thin cortical bone. When subjected to repeated mechanical stress, such as marching, skiing, ballet dancing, etc., the bone accumulates microfractures that eventually result in chronic pain and swelling. Metatarsal bones are the most frequently affected. A 26-year-old man with schizophrenia comes to the emergency department with a 2-hour history of involuntary contractions of the muscles in his neck. He states that he was watching television and "all of a sudden I turned my head and my neck locked". He began taking a high-potency antipsychotic agent 3 days earlier. Examination shows no abnormalities except torticollis. Which of the following is the most appropriate pharmacotherapy? A. Amantadine B. Benztropine C. Bromocriptine D. Clonidine E. Propranolol Explanation: The correct answer is B. This patient has acute dystonia. Dystonia is characterized by involuntary muscle spasms, which in this patient, are due to a high potency antipsychotic agent. Dystonia is most common in young men, and often begins within days of starting the drug therapy. It usually involves the muscles of the head and neck, leading to torticollis and blepharospasm. It can produce a life-threatening laryngospasm requiring intubation. The treatment of acute dystonia is with anticholinergic medications, such as benztropine or diphenhydramine. Amantadine (choice A) enhances dopaminergic transmission and may improve the bradykinesia, rigidity, and tremor of Parkinson's disease. It may also be helpful in the treatment of neuroleptic malignant syndrome (NMS). It is not used for acute dystonia. Bromocriptine (choice C) is a dopamine agonist that is used in Parkinson disease and NMS. It is not used for acute dystonia. Clonidine (choice D) is an alpha agonist that is used in hypertension and alleviates the motor and phonic tics in Tourette syndrome. Propranolol (choice E) is a beta-blocker that is used in hypertension, angina, arrhythmias, tremor, and social phobias. It may be helpful for patients with akathisia. It is not used for acute dystonia. A 75-year-old woman comes to the physician because of irregular vaginal bleeding. She has been menopausal for the past 25 years, but has noted on-and-off spotting for the past 2 years, which she finds intolerable. She has a complicated past medical history including hypertension, diabetes, and severe chronic obstructive pulmonary disease. Examination is unremarkable. An endometrial biopsy is performed that demonstrates an endometrial polyp with atypical cells that are difficult to grade. Which of the following is the most appropriate next step in management? A. Hormone replacement therapy B. Oral contraceptive pill C. Hysteroscopy D. Laparoscopy E. Hysterectomy Explanation: The correct answer is C. This patient is likely having irregular spotting secondary to the polyp. Endometrial polyps are projections of endometrial tissue that protrude into the endometrial cavity. They can be seen in women of any age, but are most commonly seen in perimenopausal women. This problem should be addressed for 2 reasons: 1. The bleeding per vagina is distressing to the patient. 2. There are some atypical cells from the biopsy that may represent cancer and polyps can contain malignant cells within them. Therefore, the polyp should be removed. The question then becomes how best to remove it. A hysteroscopy can be performed under monitored anesthesia care (MAC), an approach that provides adequate anesthesia without requiring the patient to have general anesthesia. It would be preferable to avoid general anesthesia in a patient with so many medical conditions. Hysteroscopy would allow visualization of the entire uterine cavity and removal of the polyp. A curettage should be performed afterward to fully sample the cavity. Hormone replacement therapy (choice A) would not be the most appropriate next step. First, the polyp must be removed and histologic evaluation of the polyp and endometrial tissues performed to rule out malignancy prior to instituting hormone replacement therapy. The oral contraceptive pill (choice B) would not be appropriate management for a 75-year-old woman, as the dose of hormones is higher than necessary. Laparoscopy (choice D) would not be indicated. This patient is having spotting, which is an intrauterine process. Laparoscopy allows visualization of only the external, serosal uterine surface. Hysterectomy (choice E) would not be the most appropriate management. Hysterectomy would take care of the patient's spotting and would provide tissue for pathologic diagnosis. However, in this patient with multiple medical problems, the same goals can be achieved with the less invasive procedure of hysteroscopy. A 46-year-old woman, who had always been in good health, comes in because of the sudden onset of very severe back and leg pain that she experienced 2 hours ago when attempting to lift a heavy object. She says that she felt "a bolt of lightening" running down the back of her leg, and she still has very severe pain that prevents her from walking or moving. The pain is exacerbated by coughing, sneezing, or straining. She keeps the affected leg flexed; straight leg raising gives her excruciating pain. She has good sphincteric tone and intact sensation in the perineum. Once the diagnosis is confirmed with the appropriate studies, which of the following will be the most appropriate treatment? A. Analgesics and bed rest for about 3 weeks B. Appropriate antibiotics C. Body cast for 3-6 months D. Radiotherapy to the affected area E. Surgical decompression Explanation: The correct answer is A. The clinical features are those of a herniated lumbar disc. The diagnosis should be confirmed with an MRI, and then the patient should be treated conservatively with bed rest. Most patients get better with this simple approach. Giving antibiotics (choice B) assumes an infectious process. Infections can occur in the lumbar spine or the discs, but their symptoms do not start suddenly, like this vignette describes. A body cast (choice C) might be needed for fractures, scoliosis, or other spinal pathology, but casting is not needed for an extruded disc. Radiotherapy (choice D) assumes a neoplastic process. Although a weakened bone may indeed rupture suddenly, such patients are usually known to have had the kind of tumor that is likely to metastasize to bone (in women, breast cancer would lead the list), and would have been complaining of localized bony pain before the process gets to the point of fracture. Surgical decompression (choice E) would have been required if she had sphincteric deficits or perineal anesthesia. A 40-year-old woman is brought to the hospital after overdosing on alcohol and pills. In talking to a psychiatrist, she denies any prior psychiatric problems but says that about a week ago her apartment burned down. She was trying to get a job before that happened, but when she realized that she had lost everything she had, and that moving in with her family would probably not be possible, she decided to take her own life. Which of the following is the most likely diagnosis? A. Acute stress disorder B. Adjustment disorder C. Antisocial personality disorder D. Brief psychotic disorder E. Major depressive disorder Explanation: The correct answer is B. Adjustment disorder is exemplified by a set of behavioral or emotional symptoms developing as a response to an identifiable stressor within 3 months after exposure to the stressor. The symptoms are excessive compared with what one would expect from the exposure, and they cause marked impairment in social functioning. Acute stress disorder (choice A) is anxiety produced by extraordinary life stress. An event is relived in dreams and waking thoughts. The symptoms include re-experiencing, avoidance, and hyperarousal lasting less than a month. Antisocial personality disorder (choice C) involves a pervasive pattern of violation of the rights of others after the age of 15, as indicated by a failure to conform to social norms, deceitfulness, impulsivity, irritability, disregard for the safety of others, and a lack of remorse. Brief psychotic disorder (choice D) requires the presence of one or more of the following: delusions, hallucinations, or disorganized speech. Duration of an episode is 1 day up to 1 month, and it is not due to any other medical condition or substance abuse. Major depressive disorder (choice E) involves the presence of depressed mood or anhedonia for at least 2 weeks on a daily basis in the past month, as well as the additional symptoms of changes in appetite, weight, sleep, energy, and concentration; the presence of guilt and suicidal ideation; and changes in psychomotor activity. The symptoms are not due to a medical condition or the use of substances. A 71-year-old West Texas farmer of Irish ancestry has a nonhealing, indolent, punched out, clean-looking 2-cm ulcer over the left temple. The ulcer has been slowly growing over the past 3 years. There are no enlarged lymph nodes in the head and neck. Which of the following would best dictate proper management? A. Full thickness biopsy of the center of the lesion B. Full thickness biopsy of the edge of the lesion C. Pathologic studies after the entire lesion is resected with a margin of 1 cm of normal skin all around D. Response to a trial of radiation therapy E. Scrapings and culture of the ulcer base Explanation: The correct answer is B. The history (a fair skinned person who is out in the sun all day) suggests a skin cancer, and the location (the upper part of the face) favors a basal cell cancer but does not exclude a squamous cell carcinoma, or even a melanoma. Thus, diagnosis is needed before proper therapy is instituted. The edge of the lesion offers the best information for the pathologist. A biopsy of the center of the lesion (choice A) deprives the pathologist of all the clues that are found at the interface between the tumor and the normal skin, and in large lesions it runs the risk of sampling necrotic tumor that has outgrown its blood supply. A wide excision before pathologic diagnosis (choice C) risks doing too much (a basal cell cancer needs only 1 or 2 mm of margins) or too little (a melanoma should have at least 2 cm). Radiation therapy (choice D) is a viable therapeutic choice for squamous cell carcinoma, but not before a diagnosis has been established. Here, we are expecting a basal cell carcinoma, thus this course of action would be even less appropriate. Scrapings and cultures (choice E) assume an infectious process, ignoring the strong clinical suspicion of a tumor in this case. A 39-year-old man comes to medical attention because of a 1-year history of personality changes, abnormal involuntary movements, and memory dysfunction. His father and grandfather died in their 50s because of progressive mental deterioration accompanied by movement abnormalities. The patient is married but has no children. Neurologic examination and psychometric testing reveal difficulty in concentration, mild depression, and marked restlessness. During the examination, grimacing of the face and intermittent shrugging of the shoulders are noted. MRI examination of the brain reveals hyperintensity in the region of the caudate on T2-weighted images. Which of the following is the most likely diagnosis? A. Creutzfeldt-Jakob disease B. Gilles de la Tourette syndrome C. Huntington disease D. Sydenham chorea E. Tardive dyskinesia Explanation: The correct answer is C. The clinical manifestations and family history are consistent with Huntington disease. This autosomal dominant condition is caused by an unstable expansion of a CAG trinucleotide repeat in a gene encoding a novel protein named huntingtin. The age of clinical onset is commonly between 30 and 50 years, but may be as early as 5 years. Behavioral abnormalities and personality changes often precede the characteristic choreiform movements. Irritability, restlessness, and difficulty in concentration are among the most frequent early clinical manifestations. The pathologic substrate of this condition is degeneration of the striatal neurons, especially those in the caudate nucleus. Caudate nucleus changes may be appreciated on MRI examination or PET scans. Creutzfeldt-Jacob disease (choice A) is characterized by rapidly progressive dementia associated with myoclonic movements. The disorder is familial in 10% to 15% of cases. It is probably caused by spontaneous mutations of the gene coding for prion protein. The onset of Gilles de la Tourette syndrome (choice B) is usually between 2 and 15 years of age. Motor or phonic tics are the principal manifestations, including sniffing, blinking, spitting, grunts, coughs, and coprolalia. Sydenham chorea (choice D) is one of the major Jones criteria for the diagnosis of rheumatic disease. Tardive dyskinesia (choice E) is a late complication of antipsychotic drugs that block dopamine D2 receptors. It most commonly manifests with persistent chewing movements and intermittent protrusion of the tongue. A 23-year-old female comes to the physician because of a swelling in her vagina. She states that the swelling started about 3 days ago and has been growing larger since. The swelling is not painful, but it is uncomfortable when she jogs. She has asthma for which she uses an albuterol inhaler, but no other medical problems. Examination shows a cystic mass 4 cm in diameter near the hymen by the patient's left labia minora. The mass is nontender and there is no associated erythema. The mass is freely mobile. The rest of the pelvic examination is unremarkable. Which of the following is the most likely diagnosis? A. Bartholin's cyst B. Condyloma lata C. Granuloma inguinale D. Hematocolpos E. Vulvar cancer Explanation: The correct answer is A. This patient has a presentation and findings that are most consistent with a Bartholin's cyst. Bartholin's cysts develop when a Bartholin's gland becomes obstructed. The Bartholin's glands are bilateral structures that are present near the posterior fourchette of the vagina at the 5 and 7 o'clock positions. They secrete mucus, particularly during sexual stimulation, which drains into the posterior vagina.They undergo rapid growth during the process of puberty and they shrink after the menopause. When the duct of the Bartholin's gland becomes obstructed, a Bartholin's cyst results. If the cyst becomes infected, the result is a Bartholin's abscess. These abscesses are usually polymicrobial in nature, although the gonococcus is implicated in about 25% of cases. Treatment of a symptomatic Bartholin's cyst is with placement of a Word catheter. This is a small balloon-tipped catheter device that is placed into a small hole that is punched into the cyst itself. This catheter allows drainage of the cyst and the formation of an epithelialized tract that will allow continued drainage once the catheter is removed. This tract should prevent the cyst from reforming. If Bartholin's cysts continue to form in spite of the use of the Word catheter, a marsupialization procedure may be tried. In this procedure, the cyst walls are sutured open to the surrounding skin to prevent re-closure and re-formation of the cyst. Condyloma lata (choice B) is a manifestation of secondary syphilis. They appear as coalesced, large, pale, flat-topped papules and not as a cystic mass. Granuloma inguinale (choice C) is also known as Donovanosis and is a sexually transmitted disease associated with the gram-negative bacillus Calymmatobacterium granulomatis. The disease is characterized by papules progressing to ulcers and not by a vulvar cyst. Hematocolpos (choice D) describes the condition in which there is blood filling the vagina. This is often seen with an imperforate hymen. Vulvar cancer (choice E) does not usually present as a single cystic mass at the introitus and, in young women, is far less common than Bartholin's cysts. A 19-year-old woman consults an allergist about constant nasal stuffiness she experiences. She has a variety of pets in her house, including fish, dogs, and a cat. Screening tests demonstrate blood elevations of eosinophils and IgE. The patient undergoes extensive skin testing, which demonstrates marked sensitivity to cat dandruff. Which of the following is the preferred treatment for her cat allergy? A. Oral chlorpheniramine maleate B. Cromolyn nasal spray C. IM diphenhydramine HCL D. Allergen immunotherapy E. Get rid of the cat Explanation: The correct answer is E. Unfortunately for many patients who are attached to their towns, houses, jobs, and pets, the preferred and most effective treatment for allergies is avoidance of the allergen. In the case of pet allergies, the most effective method of avoidance is to give the family pet away. Chlorpheniramine maleate (choice A) is an alkylamine type H1 blocker that is commonly used for relief of allergy symptoms. Cromolyn nasal spray (choice B) acts by inhibiting mast cell granule release and is used prophylactically for control of allergy symptoms. IM diphenhydramine HCL (choice C) is usually reserved for potential anaphylactic reactions, such as during a blood transfusion reaction. Allergen immunotherapy (choice D), commonly called "allergy shots", is sometimes (but not always) helpful in desensitizing individuals to particular antigens. A 70-year-old man is found unresponsive at home. The emergency medical technicians note his blood pressure to be 70 mm Hg by palpation. His pulse is 120/min. He is brought to the emergency department, where his temperature is 39.5 C (103 F), and respirations are 30/min. He has rales halfway up his chest. Heart sounds are inaudible. His urine output is 10 mL/hr. A chest x-ray film reveals Kerley B lines, and an ECG shows sinus tachycardia. He is given antibiotics and is taken to the intensive care unit, where a right-sided catheterization shows an elevated wedge pressure and diminished cardiac output. His right atrial pressure is not elevated. Which of the following is the most likely cause of this man's hypotension? A. Gastrointestinal bleeding B. Gram-negative sepsis C. Left ventricular dysfunction D. Pericardial tamponade E. Pulmonary embolus Explanation: The correct answer is C. This patient is hypotensive and has oliguria. He has shock, fever, and pulmonary edema. His elevated wedge pressure is an indication of left ventricular failure. This may be the result of a myocardial infarction. This patient has cardiogenic shock, severe cardiomyopathy, or myocarditis. Gastrointestinal bleeding (choice A) would present with hypotension, tachycardia, and shock. Hypovolemia from a gastrointestinal bleed would cause a decrease in the wedge pressure as well. Similarly, septic shock (choice B) would lead to hypotension and decreased wedge pressure. The cardiac output would be increased, and the systemic vascular resistance would be decreased. In the setting of fever, however, this diagnosis must be considered. Treatment would include supportive therapy with vasopressors and fluids, as well as antibiotics. Pericardial tamponade (choice D) could produce elevated wedge pressures, but the obstruction to the right ventricular inflow should be associated with equally abnormal right atrial mean, right ventricular end diastolic, and pulmonary artery end-diastolic pressures. A pulmonary embolus (choice E) would lead to decreased wedge pressure. The patient would be tachycardic, tachypneic, and hypotensive. Pulmonary edema would not be seen, however. Treatment would include administering a lytic agent and heparin. A 6-month-old infant presents to the emergency department with the new onset of weak cry, decreased activity, and poor feeding. The mother also states that the infant has been constipated for the past 2 days. On physical examination, the infant has a very weak cry, poor muscle tone, and absent deep tendon reflexes. Which of the following is the most likely diagnosis? A. Congenital hypothyroidism B. Guillain-Barré syndrome C. Infant botulism D. Myasthenia gravis E. Vaccine-associated poliomyelitis Explanation: The correct answer is C. Infant botulism results from the production of toxin after colonization of the gastrointestinal tract by Clostridium botulinum in young children aged 1-9 months. The most common source of the organism is the soil or, less frequently, honey. Nearly all cases are due to types A or B. The incubation period is usually between 18 and 36 hours. Short incubation periods are associated with more severe disease. The disease spectrum varies considerably, but the most commonly recognized form is the "floppy baby syndrome." Initial symptoms are lethargy, diminished suck, constipation, weakness, feeble cry, and diminished spontaneous activity with loss of head control. These symptoms are followed by extensive flaccid paralysis. The case fatality rate is only 1%. The bulbar musculature is usually affected first. In older children, it results in diplopia, dysarthria, and dysphagia. Involvement of the cholinergic autonomic nervous system may result in decreased salivation, with dry mouth and sore throat, ileus, or urinary retention. Neurologic evaluation often shows bilateral paresis of the 6th cranial nerves, ptosis, dilated pupils with sluggish reaction, decreased gag reflex, or medial rectus paresis. These symptoms are followed by descending involvement of motor neurons to peripheral muscles, including the muscles of respiration. Patients are usually afebrile with clear mentation. The most common cause of death is respiratory failure. The spectrum of disease is quite variable; some patients have mild disease, whereas others have severe paralysis requiring mechanical ventilation. Respiratory failure is the major risk, and patients must be monitored carefully with liberal use of ventilatory support. Toxins can be removed from the gastrointestinal tract with gastric lavage, cathartics, and enemas early in the course of disease. The trivalent antitoxin or type-specific antitoxin for types A, B, and E is usually given only to adults. Infants with botulism should not receive either antibiotics directed against C. botulinum or antitoxin, because most do extremely well with supportive care alone and it has been suggested that antibiotics may cause toxin release. Honey has been implicated as a vehicle for spores and should not be fed to infants younger than 1 year. Congenital hypothyroidism (choice A), or cretinism, manifests as impaired development of the skeletal system and CNS. It is associated with severe mental retardation, short stature, coarse facial features, a protruding tongue, and umbilical hernia. Guillain-Barré syndrome (choice B) presents with weakness that develops symmetrically over several days. The weakness typically occurs first in the legs and ascends with time to involve the muscles of the trunk, intercostals, upper extremity, and neck. Muscles innervated by cranial nerves are also involved. Respiratory paralysis can lead to death within hours to days. Myasthenia gravis (choice D) is a disorder of the neuromuscular junction resulting in a pure motor syndrome characterized by weakness and fatigue, particularly of the extraocular, pharyngeal, facial, cervical, proximal limb, and respiratory musculature. Fifteen percent of infants born to myasthenic mothers have neonatal myasthenia gravis because of the transplacental passage of acetylcholine receptor antibodies. The condition completely resolves in weeks to months. Vaccine-associated poliomyelitis (choice E) is exceedingly rare; only eight or nine cases are reported yearly. Most symptomatic cases have nonspecific manifestations of infection. Illness is biphasic, and paralysis occurs in the second phase. Paralytic disease occurs with rapid onset, involving the cranial nerves, arms, and legs. A 32-year-old man is in twice-weekly insight-oriented psychotherapy with a psychiatrist. Recently, the patient has been exploring his thoughts and feelings around his wife's complaint that he is too restricted and inhibited in their sexual activity. The patient admits that he wishes to be more sexually available for his wife, but finds himself maintaining a restricted stance. Which of the following defense mechanisms would best describe this patient's tendency in his sexual relationship with his wife? A. Projection B. Reaction formation C. Sexualization D. Somatization E. Sublimation Explanation: The correct answer is B. Reaction formation, often seen in obsessional characters, is the term for the defense mechanism in which an unacceptable impulse is transformed into its opposite. In this case, during insight-oriented psychotherapy, the patient realizes his wish to be freer in his sexual relationship with his wife (an impulse which he finds unacceptable on some level) but finds himself responding in the opposite way (maintaining a restricted stance). Inhibition may also partly account for this man's difficulty, in that a renunciation is used to evade anxiety arising out of impulses. Projection (choice A) occurs when an unacceptable inner impulse is perceived and reacted to as though it was outside oneself. On the psychotic level, this takes the form of delusions and hallucinations. Sexualization (choice C) occurs when an object or function is endowed with sexual significance that it did not previously have in order to ward off anxieties associated with prohibited impulses. Somatization (choice D) describes the defense mechanism that occurs when emotional concerns are converted into bodily symptoms, and the person tends to react with somatic manifestations. If the patient in this case had a tendency to use somatization, he might unconsciously use physical symptoms to get rid of the anxiety around his conflicted sexual thoughts. Sublimation (choice E) is a mature defense mechanism that occurs when a socially acceptable means of expressing an impulse replaces one that would be socially unacceptable. Sublimation allows instincts to be channeled, rather than blocked or diverted. Feelings are acknowledged, modified, and directed toward a significant object or goal, and modest instinctual satisfaction occurs. A 27-year-old woman comes to the physician because of fevers and back pain. She states that a few days ago she had burning with urination. Over the next few days she developed fevers and chills and a pain on the right side of her back. She has no medical problems and takes no medications. Her temperature is 38.9 C (102 F), blood pressure is 110/70 mm Hg, pulse is 102/minute, and respirations are 16/minute. Examination shows a patient in mild distress with shaking chills and right costovertebral angle tenderness. Leukocyte count is 18,000/mm3. Urinalysis shows 100 leukocytes/high powered field. Which of the following is the most appropriate next step in management? A. Observation only B. Spinal magnetic resonance imaging (MRI) scan C. Outpatient management with oral trimethoprim-sulfamethoxazole D. Hospital admission and initiation of IV trimethoprim- sulfamethoxazole E. Hospital admission and administration of a 2-week course of IV tetracycline Explanation: The correct answer is D. This patient has a presentation that is most consistent with pyelonephritis. Patients with pyelonephritis typically complain of some combination of back pain, fevers, chills, dysuria, nausea, and vomiting. Examination will often show an elevated temperature, costovertebral angle tenderness, and an elevated leukocyte count. Urinalysis may demonstrate positive nitrite and leukocyte esterase testing. Urine sediment often reveals white blood cells, red blood cells, and white cell casts. Pyelonephritis can be managed on an outpatient basis if the patient is otherwise healthy, has no complicating factors, and is reliable to return if her condition worsens. A patient cannot be managed as an outpatient if there is any evidence of sepsis. This patient, with her high fevers, shaking chills, and elevated leukocyte count may have sepsis and should therefore be admitted to the hospital for intravenous antibiotics. Treatment is with IV trimethoprim-sulfamethoxazole, IV ceftriaxone, IV gentamicin with or without ampicillin, or an IV fluoroquinolone. Once the patient is afebrile, her condition is improving, and she is able to tolerate oral intake, she may be converted to an oral antibiotic regimen to complete a 14-day course. Observation only (choice A) would not be correct for this patient. This patient has pyelonephritis, which is unlikely to resolve without antibiotic therapy. Spinal MRI (choice B) is often used to evaluate patients with back pain. This patient, however, has back pain that is almost certainly related to a renal infection, therefore spinal MRI would not be necessary. Outpatient management with oral trimethoprim-sulfamethoxazole (choice C) is appropriate in some cases of uncomplicated pyelonephritis, as explained above. This patient, however, is quite ill and possibly septic. She, therefore, requires hospital admission. Hospital admission and administration of a 2-week course of IV tetracycline (choice E) would not be appropriate. Tetracycline is not a drug-of-choice in the treatment of pyelonephritis. A 37-year-old woman undergoes a lumpectomy and axillary dissection for a 3-cm infiltrating ductal carcinoma, diagnosed by core biopsies, located on the upper outer quadrant of her left breast. The pathology report of the surgical specimen is received 3 days after the operation. It indicates that all margins around the tumor are clear, and that 4 of 17 axillary lymph nodes have metastatic tumor. The tumor is reported to be estrogen and progesterone receptor negative. Which of the following should further therapy most likely include? A. Antiestrogen medication (tamoxifen) B. Conversion to modified radical mastectomy C. Radiation to the remaining left breast D. Radiation to the remaining left breast and systemic chemotherapy E. Radiation to both breasts and tamoxifen Explanation: The correct answer is D. Lumpectomy alone has an unacceptably high incidence of local recurrence, which can be significantly reduced by radiation therapy. In addition, the presence of metastatic disease in the axillary nodes requires systemic therapy. As a rule, chemotherapy is preferred for premenopausal women, which this woman is, but it is also indicated here because she is not receptor positive. Antiestrogens alone (choice A) would not reduce the likelihood of local recurrence, and it would not help much with systemic disease because she is premenopausal and receptor negative. Conversion to mastectomy (choice B) is not needed because her surgical margins are clear of tumor. Radiation alone (choice C) would not suffice because her positive axillary nodes require the addition of systemic therapy. Radiation to the opposite breast (choice E) is not required in any event, and tamoxifen is the wrong drug for a premenopausal woman who had a receptor negative tumor. An 18-year-old girl comes to the physician for a "check-up" before going off to college. She has no complaints. She states that she is very excited to finally be on her own. She exercises "regularly", gets good grades in school, and is sexually active. Her weight is normal for her height. Physical examination shows many dental caries, periodontal disease, pharyngeal abrasions, nail changes, and multiple, linear lacerations on her forearms in various stages of healing. Laboratory studies show hypokalemia and metabolic alkalosis. Which of the following would most likely establish a diagnosis? A. "Do you ever feel guilty about drinking alcohol?" B. "Do you typically restrict your diet to under 800 calories a day?" C. "Have you ever taken laxatives as a way to lose weight?" D. "Have you ever consumed large quantities of food and then regurgitated it to prevent weight gain?" E. "Please describe your exercise routine." Explanation: The correct answer is D. This patient most likely has bulimia nervosa. It is a condition characterized by recurrent episodes of binge eating followed by a compensatory behavior to prevent weight gain (vomiting, exercise, laxative abuse). Other features include stealing (food), alcohol and drug abuse, self-mutilation, and depression. The individuals are usually at or slightly over the normal weight for their height, sexual activity is normal or increased, and they continue to menstruate. Clinical findings that are caused by recurrent vomiting include dental caries, periodontal disease, pharyngeal lacerations and nail changes. Metabolic alkalosis and hypokalemia are also present. Complications include aspiration and rupture of the esophagus or stomach. "Do you ever feel guilty about drinking alcohol?" (choice A) is a question that would be asked to an alcoholic. While alcohol abuse has been associated with bulimia nervosa, it does not seem that this patient is an alcoholic. "Do you typically restrict your diet to under 800 calories a day?" (choice B) would be an indication of anorexia nervosa, which is characterized by the refusal to maintain a normal, healthy body weight and the disturbance of body image. These individuals have an intense fear of gaining weight and therefore restrict food intake to dangerously low levels. Women become amenorrheic, have decreased sexual desire, ritualized exercise routines, and changes in their skin and hair. Complications include ventricular tachyarrhythmias. "Have you ever taken laxatives as a way to lose weight?" (choice C) and "Please describe your exercise routine." (choice E) are questions that should be asked to both anorexics and bulimics. Laxative abuse and exercise rituals are common in both diseases, but laxative abuse is probably more common in bulimia, while ritualized exercise is more common in anorexia. This patient has the clinical findings associated with vomiting and therefore the question about bingeing and purging would more likely establish a diagnosis. A 32-year-old woman comes to the physician because of recurrent painful outbreaks on her labia and vagina. Her first outbreak was six years ago. At that time she developed what she thought was a bad "flu" with malaise and a fever, along with a painful rash on her labia. This initial outbreak resolved, but since then she has had approximately 8 -10 outbreaks each year. Each outbreak is preceded by burning in her perineal area. A few days later she develops vesicles, then shallow, painful ulcers that resolve in about 10 days. Which of the following is the most appropriate pharmacotherapy? A. Daily oral acyclovir B. Daily oral estrogen C. Daily topical estrogen D. Daily oral ferrous sulfate E. Daily oral penicillin Explanation: The correct answer is A. This patient has a classic presentation of herpes genitalis, a venereal disease caused by herpes simplex virus type II (90% of cases) or type I (10%). Initial infection usually results in generalized illness including malaise, myalgias, and low-grade fever along with the perineal lesions. These lesions start out as clear vesicles that progress to ulcers over the following days. The ulcers may then coalesce to form a larger, shallow, painful ulcer. After the initial infection, the virus resides in the dorsal root sacral ganglia. From there it is periodically reactivated. Recurrent episodes are characterized by a prodrome of tingling, burning, or itching prior to the appearance of the lesions. There is no "cure" for herpes genitalis. Acyclovir can be used to shorten the duration of symptoms. In patients who have more than 6 outbreaks per year, daily oral acyclovir is recommended to prevent these frequent outbreaks. Daily oral estrogen (choice B) or daily topical estrogen (choice C) would not be appropriate pharmacotherapy for these outbreaks. Estrogen (oral and topical) is used for patients with atrophic vaginitis. Atrophic vaginitis is characterized by pale vaginal mucosa with a loss of rugae. It is associated with estrogen deficient states such as menopause. This patient has no evidence of estrogen deficiency and therefore estrogen would not be recommended. Daily oral ferrous sulfate (choice D) is appropriate pharmacotherapy for patients with iron-deficiency anemia. Sufficient iron stores are necessary for effective erythropoiesis. There is no evidence that this patient is iron deficient and the most appropriate pharmacotherapy to prevent recurrent herpes outbreaks is acyclovir, not ferrous sulfate. Daily oral penicillin (choice E) would not be appropriate pharmacotherapy for this patient. This patient has herpes genitalis and not a bacterial infection. Thus, acyclovir, and not penicillin, would be indicated. A 74-year-old woman with a long history of type 2 diabetes mellitus undergoes surgery for small bowel obstruction. After surgery, she develops acute renal failure. However, she refuses to undergo dialysis on the advice of her physician, who then calls for an immediate psychiatric consultation. The patient tells the psychiatrist that she has lived a long life and does not want to be kept alive by or attached to a machine, even if it means she will die. A mental status examination shows that she is not psychotic, that she is fully oriented and alert, and that she has no fluctuations of cognition or level of consciousness. The patient's family is insistent that she be dialyzed immediately. Which of the following is the most appropriate statement the psychiatric consultant could make? A. The patient is aware of the consequences of her decision and does not show signs of a major psychiatric illness. B. The patient is competent to decide on treatment, and her refusal to undergo dialysis must be respected. C. The patient is competent to decide on treatment, but her refusal can be overruled because of a medical emergency. D. The patient is operating in a suicidal manner and should be committed for treatment against her will. E. The patient is temporarily incompetent, so start her on dialysis. Explanation: The correct answer is A. This patient raises one of the most difficult legal and ethical problems in psychiatry. It is important to understand that competency, or lack of competency (choices B, C, and E), can be determined only by a legal authority, such as a court of law. The role of psychiatrists is solely advisory in determining competency. In this situation, only if the patient is suicidal by virtue of a major psychiatric illness, or if the patient were subject to an immediate medical emergency, could treatment be involuntarily administered. The psychiatrist's role is to assess a person's mental status for evidence of cognitive impairment, as well as to ascertain that the patient has a thorough understanding of the consequences of treatment decisions that are made. This patient does not meet criteria for treatment against her will (choice D), which requires both a mental disorder and the threat of impending immediate harm to self or others. A 39-year-old woman, gravida 2, para 1, at 30-weeks gestation comes to the physician for a prenatal visit. The patient's due date was determined by a 7-week ultrasound. Her prenatal course has been unremarkable. She has no complaints of contractions, loss of fluid, or bleeding from the vagina, and her baby is moving well. Examination demonstrates a fetal heart rate of 150 and a fundal height of 27 centimeters, which is the same measurement as that determined 4 weeks ago. This patient's fundal height measurement is most suggestive of which of the following? A. Inaccurate estimated date of delivery (due date) B. Intrauterine growth restriction C. Premature labor D. Twin gestation E. Uterine cancer Explanation: The correct answer is B. Fundal height measurement is a portion of the physical examination that should be performed routinely during prenatal care. It is performed by placing a measuring tape on the pubic symphysis and measuring to the top of the fundus. Between the gestational ages of 18 to 34 weeks, there is a rough correlation between weeks of gestation and fundal height in centimeters. For example, a woman at 26 weeks' gestation should have a fundal height that is roughly 26 centimeters. This patient is at 30 weeks' gestation and has a fundal height of 27 centimeters. Furthermore, and perhaps more importantly, there has been no change in the fundal height over the past four weeks. These findings are concerning for intrauterine growth restriction (IUGR). IUGR is a disorder in which the fetus is not growing appropriately. It is most commonly defined as an estimated fetal weight less than the 10th percentile for a given gestational age. Given that this patient's fundal height does not appear to have increased over the past 4 weeks and that it is 3 centimeters less than expected, IUGR is of concern and this patient should be sent for an ultrasound to evaluate fetal size. This patient is unlikely to have an inaccurate estimated date of delivery (due date) (choice A) because her due date was determined by a 7-week ultrasound. Ultrasound dating of a pregnancy is more accurate the earlier in pregnancy that it is performed and a 7-week ultrasound is considered excellent for establishing a due date. Premature labor (choice C) would not be a concern in this patient with no contractions and no other symptoms. A twin gestation (choice D) should have been seen on the 7-week ultrasound. Furthermore, a fundal height that is less than the gestational age would predict makes twins less likely. Uterine cancer (choice E) is very uncommon during pregnancy and would not be expected to present as decreased fundal height. A 34-year-old man presents with a swollen left knee of 2 days' duration. He denies any known trauma to that region and has no prior history of any musculoskeletal complaints. He is in otherwise excellent health. He is homosexual and practices safe sex with a single partner. On physical examination, his knee is swollen, tender to palpation, and erythematous and has a limited range of motion. An arthrocentesis is performed. Which of the following is most suggestive of a septic arthritis in this patient? A. A complete blood cell count with 14,300 white blood cells per mL B. A joint fluid aspirate with a white blood cell count of 28,000 per mL C. A joint fluid aspirate with a white blood cell count of 36,000 per mL D. A joint fluid aspirate with a white blood cell count of 48,000 per mL E. A joint fluid aspirate with a white blood cell count of 93,000 per mL Explanation: The correct answer is E. Septic arthritis will produce the highest joint fluid white blood cell counts, typically with counts of greater than 75,000 per cc. Non-inflammatory arthritis, such as osteoarthritis, will typically produce joint aspirate counts of less than 10,000. If septic arthritis is suspected based upon the aspirate white blood cell count, then appropriate antibiotics should be started, while awaiting cultures. Failure to initiate appropriate antibiotic therapy until final identification of the organism would potentially lead to irreversible joint destruction. An elevated peripheral white blood cell count of 14,300 (choice A) may be seen in either a crystalline or septic arthritis and will not distinguish between the two. Inflammatory arthritis, i.e. crystalline arthritis, will typically produce a joint fluid aspirate with a white blood cell count of approximately 25-50,000 (choices B, C, and D). Since the aspirated fluid is also routinely examined for crystals, differentiation of any cases of septic versus crystalline arthritis with borderline values for white blood cell count can usually be made on that basis. A 43-year-old bus driver presents to his gastroenterologist with complaints of difficulty swallowing solid foods. The evaluation demonstrates a smooth, tapered stricture of the distal esophagus, and biopsies reveal changes consistent with chronic esophagitis and fibrosis. The stricture is dilated with an endoscopic balloon dilator, and the patient's symptoms resolve. He reports that although he has had dysphagia for the past 2 months prior to the endoscopy, he rarely has heartburn and uses an over-the-counter antacid only occasionally. Which of the following is the most appropriate future management of this patient? A. Famotidine B. Lansoprazole C. Magnesium hydroxide D. Metoclopramide E. No medication is necessary Explanation: The correct answer is B. Although this patient has rarely been aware of symptoms of gastroesophageal reflux disease (GERD), the development of a peptic stricture clearly indicates longstanding acid reflux into the distal esophagus. This will be a persistent process and, if not treated, will lead to recurrent strictures. He therefore requires chronic treatment with a proton pump inhibitor to suppress acid secretions. Famotidine and antacids, such as magnesium hydroxide (choices A and C), are adjuncts to the mainstay of therapy, which is proton pump inhibition. Even though the patient is not symptomatic, he does require continued acid suppression. Metoclopramide (choice D) reduces the lower esophageal sphincter pressure and is an adjunct to acid suppression in the management of patients with reflux. It is not used as first-line therapy, however. It is nowhere near as effective as proton pump inhibitors and frequently leads to side effects of sedation because of its ability to cross the blood-brain barrier and inhibit dopamine, producing Parkinson-like symptoms. As stated above, this patient will have recurrent strictures if he does not receive treatment. Therefore, choice E is incorrect. A 3-week-old African American boy is brought to the Emergency Department because of a generalized seizure 2 hours ago. The infant is highly irritable with incessant high pitched crying. The infant's weight is 2.5 kg (250 gm below birth weight), blood pressure is 70 /40 mm Hg, pulse is 145/min and respirations are 50/min. Laboratory results show: Blood glucose Urea nitrogen Serum sodium Serum calcium 120 mg/dL 50 mg/dL 170 mEq/L 8.5 mg/dL Serum magnesium 1.5 mg/dL Which of the following is the most likely cause of this infants seizure? A. Hypocalcemia B. Hypoglycemia C. Hypomagnesemia D. Intracranial hemorrhage E. Meningitis Explanation: The correct answer is D. The level of serum sodium in this patient is 170 mEq/L. Infants who have hypernatremic dehydration are irritable and lethargic, and have a high-pitched cry. This type of dehydration results from a greater loss of hypotonic fluid than sodium and accounts for about 15% cases of dehydration. Because the patient has no history of diarrhea or vomiting, the hypernatremia may be due to inadequate supply of mother's milk that does not match the insensible water loss. Another cause can be the high concentration of sodium in mothers milk. Generally, after the child's birth, sodium in the colostrum decreases from its highest level to its lowest level by the fourth week. However, some mothers continue to excrete high sodium in their milk and can potentially cause recurrent hypernatremia and in some case intracranial hemorrhage in the infant. Hypocalcemia (choice A), hypoglycemia (choice B) and hypomagnesemia (choice C) are all potentially metabolic causes of seizures, however in this vignette serum calcium, glucose and magnesium are within normal limits. In patients with hypernatremic dehydration, hyperglycemia can result due to excess glucagon stimulation. Meningitis (choice E) should be considered in any infant with a seizure with or without fever. However, the marked rise of the serum sodium makes this diagnosis unlikely. A 27-year-old woman is 2 weeks' postpartum with her first child. During her first postpartum follow-up visit, she complains to her physician that she has had several crying spells and has been increasingly irritable; however, she has had some spells during which she has felt almost euphoric. She has had these symptoms over the past week. She has not had any previous psychiatric disorders. Which of the following is the most likely diagnosis? A. Adjustment disorder B. Dysthymic disorder C. Maternity blues D. Postpartum depression E. Postpartum psychosis Explanation: The correct answer is C. Maternity blues is a normal state of sadness, dysphoria, frequent tearfulness, and dependence that about 20% to 40% of women experience in the postpartum period. It is thought to be derived from rapid changes in women's hormonal levels and the stress of childbirth associated with maternity. Adjustment disorder (choice A) requires the development of emotional or behavioral symptoms in response to a stressor occurring within 3 months of the stressor, which also requires significant impairment in social and occupational functioning. It is excluded as a diagnosis when the presence of another Axis I diagnosis, such as postpartum blues, can account for the condition. Dysthymic disorder (choice B) is a disorder of depressed mood, more often than not, over the course of at least 2 years. It is not an appropriate diagnosis for such a short period. Postpartum depression (choice D) is a diagnosis that requires symptoms of major depression lasting longer than 5-7 days. It occurs more often in the months following childbirth rather than immediately subsequent to it. Postpartum psychosis (choice E) is a serious diagnosis that requires the presence of auditory or visual hallucinations in addition to frequent suicidal and sometimes infanticidal ideation. A 28-year-old primigravid woman at term comes to the labor and delivery ward with a gush of fluid and regular contractions. Her prenatal course was remarkable for her being Rh negative and antibody negative. Her husband is Rh positive. Over the following 10 hours, she progresses in labor and delivers a 3600-g boy via a normal spontaneous vaginal delivery. The placenta does not deliver spontaneously, and a manual removal is required. To determine the correct amount of RhoGAM (anti-D immune globulin) that should be given, which of the following is the most appropriate laboratory test to send? A. Complete blood count B. Kleihauer-Betke C. Liver function tests D. Prothrombin time E. Serum potassium Explanation: The correct answer is B. Women who are Rh negative are at risk for developing Rh isoimmunization. Rh isoimmunization occurs when an Rh- negative mother becomes exposed to the Rh antigen on the red blood cells of an Rh-positive fetus. This exposure may lead the mother's immune system to become sensitized to the Rh antigen such that in a future pregnancy with an Rh-positive fetus, the mother's immune system may "attack" the Rh antigen on the fetal red blood cells. This immune response may lead to the development of fetal anemia, hydrops, and death. To prevent Rh isoimmunization from occurring, Rh-negative women who are not Rh alloimmunized should receive RhoGAM (anti-D immune globulin) at 28 weeks' gestation, within 72 hours after the birth of an Rh-positive infant, after a spontaneous abortion, or after invasive procedures such as amniocentesis. RhoGAM should also be strongly considered in cases of threatened abortion, antenatal bleeding, external cephalic version, or abdominal trauma. The amount that is usually given after the delivery of an Rh-positive fetus is 300 µg. This amount is sufficient to cover a fetal to maternal hemorrhage of 30 mL (or 15 mL of fetal cells). However, some women will have a fetal to maternal hemorrhage that is in excess of this 30 mL—especially in cases such as manual removal of the placenta (like this patient had) or placental abruption. To determine the amount of fetal to maternal hemorrhage that occurred, it is necessary to perform a Kleihauer- Betke test. This acid-dilution procedure allows fetal red blood cells to be identified and counted. Knowing the amount of fetal to maternal hemorrhage that took place allows the correct amount of RhoGAM to be given. A complete blood count (choice A) will demonstrate the amount of maternal hemorrhage, but not the amount of fetal to maternal hemorrhage. Liver function tests (choice C), prothrombin time (choice D), and serum potassium (choice E) do not allow for the determination of the amount of fetal to maternal hemorrhage. Ten days after undergoing liver transplantation, a patient's levels of gamma- glutamyl transferase (GGT), alkaline phosphatase, and bilirubin begin to rise. Which of the following is the most appropriate next step in diagnosis? A. Measurement of preformed antibody levels B. Ultrasound of biliary tract and Doppler studies of the anastomosed vessels C. Liver biopsy and determination of portal pressures D. Liver biopsy and more detailed liver function tests E. Liver biopsy and trial of steroid boluses Explanation: The correct answer is B. In all other solid organ transplants, deterioration of function 10 days out would suggest an acute rejection episode, and appropriate biopsies would be done to confirm the diagnosis. In the case of the liver, however, antigenic reactions are less common, whereas technical problems with the biliary and vascular anastomosis are the most common cause of early functional deterioration. They are, therefore, the first anomalies to be sought. Preformed antibodies (choice A) are responsible for hyperacute rejection, which would be evident within minutes of establishing blood flow to the graft. Choices C, D, and E are centered on liver biopsy, which would be done only after technical problems have been ruled out. A 30-year-old woman calls her new primary care physician to request a refill of her alprazolam, which had been prescribed by her former physician for severe anxiety. Her new physician has only seen her once, about a month ago, after the patient made several superficial lacerations on her wrists during a fight with her boyfriend. At that time, she had been referred for emergency psychiatric evaluation. On the telephone, she describes intense anxiety related to an unstable relationship with a new boyfriend, binges on alcohol over the last few days, alternating irritability, anger, and depression, and recurrent vague suicidal thoughts, without a plan or intent to harm herself. Contact with her former physician reveals that these feelings and behaviors were unchanged over the five years that he had seen her for routine health maintenance examinations and minor illnesses. Which of the following is the most likely diagnosis? ? A. Borderline personality disorder ? B. Dependent personality disorder ? C. Histrionic personality disorder ? D. Narcissistic personality disorder ? E. Schizotypal personality disorder Explanation: The correct answer is A. The probable diagnosis is borderline personality disorder. This disorder is marked by a pervasive pattern of instability of interpersonal relationships, self-image, and affect, as well as marked impulsivity by early adulthood. Criteria for this diagnosis evident in this patient's history include: affective instability marked by severe anxiety, irritability, and depression, inappropriate and intense anger, impulsivity as made evident by cutting behavior and binges on alcohol, a pattern of unstable and intense relationships, and recurrent suicidal ideation and behaviors. The chronicity of these behaviors also supports this diagnosis. Dependent personality disorder (choice B) is characterized by an excessive need to be taken care of, which leads to submissive and clinging behavior and fears of separation. Histrionic personality disorder (choice C) is a cluster B personality disorder, like borderline personality disorder. Histrionic patients need to be the center of attention, and exhibit a pattern of excessive emotionality and attention seeking, seductive or provocative behavior, shallow expressions of emotion, self-dramatization, suggestibility, and an impressionistic style of speech. Narcissistic personality disorder (choice D) is also a cluster B personality disorder. This disorder is characterized by a pattern of grandiosity, need for admiration, and lack of empathy. Schizotypal personality disorder (choice E) is characterized by a pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships, as well as by cognitive or perceptual distortions and eccentricities of behavior. A 44-year-old woman is recovering from a mild episode of acute ascending cholangitis secondary to choledocholithiasis. When seen initially, she had a spiking fever, leukocytosis, and a very high alkaline phosphatase; however,all these findings subsided rapidly after she was placed on IV antibiotics. A sonogram of the right upper quadrant on the day of admission showed the presence of gallstones in the gallbladder, but the diameter of the biliary ducts was normal. It was assumed that she had passed a common duct stone, and plans to do an endoscopic retrograde cholangiopancreatogram (ERCP) were canceled. While awaiting elective cholecystectomy, she again developed a fever and leukocytosis, and her liver function tests showed minimal elevation of her bilirubin (to 2.5 mg/dL) and alkaline phosphatase (to 115 U/L). A repeat sonogram shows no changes in her biliary ducts, but now there is a 6-cm abscess in the right lobe of the liver. Which of the following is the most appropriate treatment for this new development? ? A. Metronidazole ? B. Long-term IV antibiotics ? C. ERCP and biliary drainage ? D. Percutaneous drainage of the liver abscess ? E. Open surgical resection of the right lobe of the liver Explanation: The correct answer is D. Liver abscess complicating biliary tract disease is described as "pyogenic" abscess (to contrast it with amebic abscess), and it requires drainage like any abscess anywhere else in the body. The percutaneous route is favored. Metronidazole (choice A) is the therapy of choice for amebic abscesses of the liver, and that condition represents the only exception to the rule that all abscesses have to be drained. However, this is not an amebic abscess. Amebic abscesses are seen in men (4 to 1 ratio compared with women) who come from Mexico, where the disease is very common. Long-term antibiotics (choice B) will not reach and sterilize an abscess. Abscesses have to be drained. Endoscopic retrograde cholangiopancreatogram (ERCP) (choice C) is often urgently needed to treat acute ascending cholangitis, but it will not do anything for a liver abscess. Resection (choice E) is not needed for a liver abscess. Drainage is enough. A previously healthy 37-year-old woman comes to the physician because of recurrent episodes of double vision and drooping of her eyelids for the last month. Such episodes occur without apparent reason, last for hours, and resolve spontaneously. She also reports occasional hoarseness and difficulty in swallowing, which also come and go. Vital signs and physical examination are normal. Which of the following is the most appropriate next step in diagnosis? Which of the following is the most appropriate next step in diagnosis? ? A. Blood, urine, and CSF analysis ? B. MRI of the head ? C. EEG recording ? D. Electromyography under repetitive stimulation ? E. Muscle biopsy Explanation: The correct answer is D. The clinical manifestations are highly characteristic of myasthenia gravis. This disorder has three general features: the fluctuating nature of muscle weakness, predominant involvement of ocular muscles (with diplopia and ptosis), and positive clinical response to administration of cholinergic agents. Crisis of weakness involving respiratory muscles was the most frequent cause of death before the advent of positive pressure respirators. The disease is autoimmune-mediated and results from autoantibodies to the muscular nicotinic receptors. Besides the pharmacologic test, a progressive decrease in the amplitude of muscle potential is the diagnostic feature of myasthenia gravis. Electromyography is therefore very useful in the diagnosis of this condition. Blood, urine, and CSF analysis (choice A) are entirely within normal limits in myasthenia gravis, although they are indeed frequently performed in the initial screening. MRI of the head (choice B) and EEG recording (choice C) would be entirely useless in this setting. Since the disorder is due to impaired cholinergic transmission at the neuromuscular junction, skeletal muscle biopsy (choice E) is within normal limits at the light microscopic level. Occasionally muscle biopsy is performed to rule out other causes of muscle weakness, such as myopathic processes. A 72-year-old woman with no prior medical history presents in the emergency department with a 3-hour episode of crushing substernal chest pain. The pain radiates to her arm and neck. An ECG reveals ST segment elevation in leads II, III and aVF. The patient has no obvious contraindication to anticoagulation. Which of the following is the most optimal treatment at this time? ? A. Avoidance of thrombolytic treatment given the patient's age ? B. Administration of IV fluids ? C. Administration of aspirin and heparin only ? D. Administration of thrombolytic therapy, heparin, and aspirin ? E. Cardiac surgery to bypass the occluded vessel Explanation: The correct answer is D. The patient is having an acute myocardial infarction. The infarct occurs as a result of an atherosclerotic plaque with thrombus formation, leading to coronary artery obstruction. Lysis with a thrombolytic agent has been shown to decrease mortality from early postmyocardial infarction. Aspirin prevents both platelet aggregation and reocclusion of the reperfused vessels. In association with aspirin and lytic therapy, heparin reduces mortality to a greater degree. Thrombolytic therapy is indicated in patients up to 75 years of age (choice A). Absolute contraindications include a bleeding diathesis, major surgery or trauma within 6 months, gastrointestinal bleeding, or the presence of aortic dissection or a known intracranial tumor. If the patient is hypotensive, IV fluids may be needed (choice B). The hypotension may result from cardiogenic shock as a result of heart failure from the acute myocardial infarction. At this time, the patient is hemodynamically stable, and the treatment in choice D is more appropriate. Aspirin is a platelet aggregation inhibitor and has been shown to reduce mortality in myocardial infarction and ischemia (choice C). Given alone, however, it will not prevent mortality in this patient unless the thrombus is immediately lysed. Heparin forms a complex with antithrombin III, and prevents action by thrombin. It is more effective when given in association with a lytic agent. If medical treatment fails, the patient may require cardiac surgery for a coronary artery bypass graft (choice E). In the immediate period, the thrombus must be lysed and the patient stabilized. Stent placement and balloon angioplasty should be explored as options. A 57-year-old man comes to the emergency department because of excruciating pain in his right big toe. He describes the pain as so severe that it woke him from a deep sleep. He has no chronic medical conditions, does not take any medications, and denies any similar episodes in the past. He admits to a few "drinking binges" over the past 2 weeks. His temperature is 38.1 C (100.5 F), blood pressure is 130/90 mm Hg, and pulse is 80/min. Examination shows an erythematous, warm, swollen, and exquisitely tender right great toe. The skin overlying the first metatarsophalangeal joint is dark red, tense, and shiny. Synovial fluid analysis reveals negatively birefringent, needle-shaped crystals within polymorphonuclear leukocytes (PMNs). Laboratory studies show: Serum Leukocytes........16,000/mm3 Uric acid...........15 mg/dL Calcium.............9 mg/dL Which of the following is the most appropriate pharmacotherapy? ? A. Allopurinol ? B. Ceftriaxone ? C. Indomethacin ? D. Probenecid ? E. Sulfinpyrazone Explanation: The correct answer is C. This patient has the classic presentation of a patient with acute gouty arthritis with the sudden onset of severe pain (typically in the middle of the night), swelling, erythema and warmth of a single joint. Low-grade fever and leukocytosis may be seen. It is more common in men and it is associated with hyperuricemia, usually due to decreased renal excretion of uric acid. Common causes are thiazides and alcohol. Diagnosis is made by examination of joint fluid under polarizing light. Negatively birefringent, needle-shaped crystals within polymorphonuclear leukocytes, hyperuricemia, and acute monoarticular arthritis make the definitive diagnosis of gout. Indomethacin or colchicine is the treatment during an acute attack. Allopurinol, probenecid, and sulfinpyrazone are used for prophylaxis against further attacks. Allopurinol (choice A) is a xanthine oxidase inhibitor that is used as an antihyperuricemic agent by individuals with recurrent gouty attacks. Common side effects include rash, headache, and gastrointestinal upset. Ceftriaxone (choice B) is the treatment of acute gonococcal arthritis. It has no role in the treatment of gout. Probenecid (choice D) is a uricosuric agent that increases the rate of urate excretion. It is used to prevent gouty attacks. It may precipitate nephrolithiasis. Sulfinpyrazone (choice E) is another uricosuric agent that increases urate excretion. It is used to prevent gouty attacks. It, too, may precipitate nephrolithiasis. A 52-year-old carpenter complains of swelling in his right knee, which began 2 days earlier. He denies any history of arthritis or trauma in that region. Until the swelling began, he had been jogging approximately 2 miles daily. Over the past 48 hours, his knee has become swollen and painful to weight bearing. His temperature 38.2 C (100.7 F), and the knee has a tender effusion, which is erythematous and warm. There is a limited range of motion. Which of the following would be the most relevant in this patient's history? ? A. Family history of rheumatoid arthritis ? B. History of a bacterial gastroenteritis ? C. History of hepatitis B exposure ? D. History of a recent upper respiratory tract infection ? E. Unprotected sex with a prostitute Explanation: The correct answer is E. A monoarticular arthritis with an acute onset, such as this patient has, should raise the question of an acute infectious arthritis. In this regard, the major differential is between Staphylococcus and Gonococcus. The Gonococcus, Neisseria gonorrhea, is usually obtained through sexual contact and is now the most common cause bacterial arthritis in adults. The organism spreads from infected mucosal surfaces to joints, with the small joints of the hands, wrists, knees, and ankles the most commonly affected. Involvement of the axial skeleton is uncommon. Patients with gonococcal arthritis may demonstrate features of a disseminated gonococcal infection with a 5-7 day history of fever and shaking chills. A variety of skin lesions may also be present, including petechiae, papules, pustules, hemorrhagic bullae, or necrotic lesions. A history of migratory arthralgias and tenosynovitis may also precede the development of persistent inflammatory arthritis in one or a few joints. Rheumatoid arthritis (choice A) rarely presents with a monoarticular arthritis and is uncommon in men. Although a bacterial gastroenteritis (choice B) does not cause a monoarticular arthritis, it may cause Reiter syndrome, with diffuse arthralgias and conjunctivitis. Hepatitis B (choice C) may be associated with a serum sickness-like illness, which affects multiple joints with arthralgias. Upper respiratory tract infections (choice D) are not associated with monoarticular arthritis. A 15-year-old girl presents to a pediatric cardiology clinic with a complaint of chest pain. She states the pain has come and gone over the past year, but has increased in frequency over the past few weeks. She describes it as a sharp pain over her left chest. Physical examination reveals a healthy- appearing 15-year-old girl. Her temperature is 37.2 C (99 F), pulse is 90/min, and respiratory rate is 20/min. Lung examination is normal. Cardiac examination reveals a late systolic murmur preceded by a click at the apex. No heave or rub is present. An electrocardiogram and chest x-ray film are unremarkable. Which of the following is the most likely diagnosis? ? A. Atrial septal defect ? B. Mitral regurgitation ? C. Mitral stenosis ? D. Mitral valve prolapse ? E. Tricuspid regurgitation Explanation: The correct answer is D. An apical click followed by a late systolic murmur is classic for mitral valve prolapse. It can be a source of subjective chest pain in children. Mitral valve prolapse is more common in females. Antibiotic prophylaxis is recommended prior to dental procedures. An atrial septal defect (choice A) is characterized by a fixed and widely split second heart sound. Mitral (choice B) and tricuspid regurgitation (choice E) produce holosystolic murmurs with relatively uniform intensity. Mitral regurgitation is heard at the apex while tricuspid regurgitation is best heard along the lower left sternal border. Mitral stenosis (choice C) is characterized by a mid-diastolic murmur heard after an opening snap. A 27-year-old successful businesswoman has developed a fear of flying after an extremely rough landing. She is paralyzed with fear and unable to travel for business. Her physician tried giving her lorazepam to take during the flight, but it didn't help. Which of the following is the most commonly used treatment for this disorder? ? A. Exposure therapy ? B. Hypnosis ? C. Insight-oriented psychotherapy ? D. Medication ? E. Supportive therapy Explanation: The correct answer is A. Exposure therapy, a type of behavior therapy, is the most commonly used treatment of specific phobia. The therapist usually desensitizes the patient by a gradual exposure to the phobic stimulus. Relaxation and breathing control are important parts of the treatment. Hypnosis (choice B) is used to enhance the therapist's suggestions that the phobic object is not dangerous. At times, self-hypnosis can be taught so that the patient uses it as a method of relaxation when confronted with the phobic stimulus. Insight-oriented psychotherapy (choice C) was initially used to treat phobias, but analyzing unconscious conflicts didn't resolve phobic symptoms. It does help the patient understand the origins of the phobia and how to deal with anxiety-provoking stimuli. Medication (choice D) is used in the treatment of a specific phobia only if it is associated with panic attacks and generalized anxiety. The pharmacologic treatment is then directed toward the panic attacks. Supportive therapy (choice E) may be used in helping the patient actively confront the phobic stimulus during treatment. It is usually used in addition to an ongoing treatment. A 25-year-old woman, gravida 2, para 1, at 22 weeks' gestation comes to the physician with complaints of burning with urination and frequent urination. Her prenatal course has been uncomplicated except for a urinary tract infection (UTI) with E. coli at 12 weeks' gestation, which was treated at that time. Physical examination is unremarkable. Urine culture demonstrates greater than 100,000 colony-forming units per milliliter of E. coli. After treating this patient for her current infection, which of the following is the most appropriate next step in management? ? A. No further treatment or diagnostic study is necessary ? B. Prophylactic antibiotics for the remainder of the pregnancy ? C. Intravenous antibiotics for the remainder of the pregnancy ? D. Intravenous pyelogram ? E. Abdominal CT Scan Explanation: The correct answer is B. The most common medical complication of pregnancy is infection of the urinary tract. Because of the anatomic and physiologic changes that occur during pregnancy, asymptomatic bacteriuria is more likely to become symptomatic and there is also an increased progression to pyelonephritis during pregnancy. Escherichia coli is the causative organism in approximately 80% of cases of UTI while other gram-negative organisms (e.g., Klebsiella, Enterobacter, and Proteus species) and gram-positive cocci (e.g. enterococci and group B streptococci) are responsible for the remainder. UTI in pregnancy can be treated with a 3-day course of antibiotics including trimethoprim- sulfamethoxazole, nitrofurantoin, and cephalexin. It is essential to document successful treatment with a follow-up urine culture 10 days after treatment. All women who are treated for UTI during pregnancy should have periodic rescreening for infection with urine cultures or urine dipstick for nitrites or leukocyte esterase. If a woman develops a second infection, as this patient has, she should be retreated and then placed on chronic suppression with prophylactic antibiotics. The drug of choice for such prophylaxis is nitrofurantoin once a day or sulfisoxazole once a day. To state that no further treatment or diagnostic study is necessary (choice A) is incorrect. Women with bacteriuria during pregnancy are at increased risk of developing pyelonephritis and are at higher risk for low birth weight and preterm deliveries. Therefore, this patient should be placed on prophylactic antibiotics for the remainder of the pregnancy. To place the patient on intravenous antibiotics for the remainder of the pregnancy (choice C) would not be indicated. Once a day oral therapy is usually sufficient to prevent recurrence of the infection. Intravenous pyelogram (choice D) and abdominal CT scan (choice E) result in significant fetal exposure to radiation. They should only be performed when absolutely necessary. This patient has a second UTI, which does not require that either of these studies be performed. An older, overweight man complains of disabling, sharp heel pain every time his foot strikes the ground. The pain is worse in the mornings, preventing him from putting any weight on the heel. X-ray films show a bony spur matching the location of his pain, and physical examination shows exquisite tenderness to direct palpation right over that heel spur. Furthermore, when the ankle is dorsiflexed, the entire inner border of the fascia is tender to palpation. Which of the following is the most likely diagnosis? ? A. Epiphysitis of the calcaneus ? B. Fracture of the posterolateral talar tubercle ? C. Plantar fasciitis ? D. Posterior Achilles tendon bursitis ? E. Posterior tibial nerve neuralgia Explanation: The correct answer is C. All the details are in the vignette, including the association with a heel spur that in the past led many of these patients to undergo unnecessary surgery to remove the spur. The spur is caused by the pull of the fascia and is not the cause of the plantar fasciitis. Epiphysitis of the calcaneus (choice A) affects children, and the pain occurs along the sides of the heel where the heel growth centers are located. Fracture of the posterolateral talar tubercle (choice B) occurs from a sudden jump on the ball of the foot, and the pain and swelling are behind the ankle. Posterior Achilles tendon bursitis (choice D) occurs mostly in young women, and an erythematous, indurated, tender area is present at the posterosuperior aspect of the heel. Posterior tibial nerve neuralgia (choice E) is the foot's equivalent of the carpal tunnel syndrome, with the pain often extending to the toes, and tingling being produced by tapping the nerve. An adult develops insidious onset of a severe infectious disease. The condition is characterized initially by high fever, headache, pharyngitis, and arthralgias. The patient then goes on to develop intestinal complaints of constipation, anorexia, and abdominal pain and tenderness. During the second week of the illness, he has a rash with discrete pink, blanching lesions (rose spots) on the chest and abdomen. The rash resolves about three days later. By the third week of the disease, the patient appears very ill and has developed a florid diarrhea that is positive for occult blood. During this same period, the man also develops secondary pneumococcal pneumonia. At the height of the patient's illness, he was stuporous and had short periods of delirium. The spleen was palpable during this period. Blood studies demonstrate leukopenia, anemia, liver function abnormalities, and a mild consumption coagulopathy. Which of the following is the most likely diagnosis? ? A. Brucellosis ? B. Cholera ? C. Melioidosis ? D. Plague ? E. Typhoid fever Explanation: The correct answer is E. This is typhoid fever, which, despite widespread immunization in many parts of the country, still has an incidence of 400 to 500 cases per year in the United States. The organism is an enteric organism spread most frequently by a fecal-oral route (including contamination of food or water supplies). Many of the estimated 2000 carriers of the disease in the United States are elderly women with biliary tract disease. The disease can be difficult to diagnose, often because it is not suspected. It should be considered in patients who appear much more ill than a simple listing of their complaints would suggest. The rose spot rash described in the question stem is a classic diagnostic clue that will probably show up in test questions about the disease, but you should be aware that it is only seen in about 10% of cases. CNS symptoms and superinfections such as the pneumococcal pneumonia are relatively common in severe cases. The blood study results noted in the question stem can be another helpful clue to the possibility of typhoid fever, and are unusual in other GI conditions. The organism can be cultured from blood or bone marrow in the first two weeks of illness, and from stool in the third to fifth week of illness. Antibiotic therapy with cephalosporins or quinolones may decrease the severity or duration of the illness; relapses may occur, which also usually respond to antibiotic therapy. Severely ill patients may benefit from supportive care including nutritional support and sometimes glucocorticoid therapy. Brucellosis (choice A) causes a recurrent fever after exposure to contaminated milk products. Cholera (choice B) causes a profound secretory diarrhea with rice water stools and has fewer systemic manifestations (other than those due to dehydration and electrolyte imbalance) than typhoid fever. Melioidosis (choice C) causes pneumonia and disseminated infection. Plague (choice D) causes massive lymph node enlargement and pneumonia after exposure to infected rodents and their parasites. A 16-year-old female comes to the physician because of an increased vaginal discharge. She developed this symptom 2 days ago. She also complains of dysuria. She is sexually active with one partner and uses condoms intermittently. Examination reveals some erythema of the cervix but is otherwise unremarkable. A urine culture is sent which comes back negative. Sexually transmitted disease testing is performed and the patient is found to have gonorrhea. While treating this patient's gonorrhea infection, treatment must also be given for which of the following? ? A. Bacterial vaginosis ? B. Chlamydia ? C. Herpes ? D. Syphilis ? E. Trichomoniasis Explanation: The correct answer is B. This patient has a gonorrhea infection. Gonorrhea is one of the most prevalent sexually transmitted diseases (STDs) in the United States. It is more common in patients of lower socioeconomic status, patients with multiple sexual partners, and in urban settings. The causative organism is N. gonorrhoeae, a gram-negative aerobic diplococcus. Up to 80% of women that are infected with the organism will have no symptoms at all or only vague symptoms. Symptoms that are frequently noted are vaginal discharge, postcoital spotting, and urinary symptoms if the urethra is involved. Examination may reveal a cervicitis, although this is not always present. A patient found to have gonorrhea should be treated with intramuscular ceftriaxone or oral cefixime, ofloxacin, or ciprofloxacin. These medications will effectively eradicate the gonococcus. However, because Chlamydia trachomatis can be isolated in up to 50% of women with gonorrhea and because women treated for gonorrhea only may soon go on to develop Chlamydia or pelvic inflammatory disease (PID), any woman receiving treatment for gonorrhea should also be treated for Chlamydia. Treatment of Chlamydia is with azithromycin or doxycycline. It is also essential that this patient's partner be treated as well. When treating a patient for gonorrhea, there is no need to treat the patient with metronidazole to treat bacterial vaginosis (choice A) as well, unless there is evidence of a bacterial vaginosis . Herpes (choice C) often presents as painful vesicles and ulcers. Patients with gonorrhea do not need to be treated for herpes as well, unless there is evidence for herpes infection. Patients with gonorrhea are at increased risk of having other sexually transmitted diseases, including syphilis (choice D). It would be prudent to check this patient for syphilis with a blood test. However, in the absence of a positive syphilis test, patients with gonorrhea do not need to be treated for syphilis. Trichomoniasis (choice E) is treated with metronidazole. Again, as with bacterial vaginosis, herpes, and syphilis, unless there is evidence of Trichomonas infection, the patient does not needed to be treated for trichomoniasis. A 29-year-old woman, gravida 2, para 1, at 38 weeks' gestation comes to the labor and delivery ward with frequent painful contractions. Her prenatal course was significant for a urine culture that showed 100,000 colony- forming units/milliliter of Group-B streptococci and asthma, for which she uses an albuterol inhaler. Examination shows that she is contracting every 2 minutes and her cervix is 5 centimeters dilated and 100% effaced. Which of the following medications should this patient be treated with during labor and delivery? ? A. Betamethasone ? B. Folic acid ? C. Magnesium sulfate ? D. Oxytocin ? E. Penicillin Explanation: The correct answer is E. The Group B Streptococcus (GBS) is a bacterium that is a part of the normal bacterial colonization of many women. During pregnancy, as many as 20-40% of women will be colonized with GBS. Most babies born to colonized mothers will not develop infection with GBS. However, approximately 1 to 4 % of neonates will develop infection. The likelihood of infection is increased if the mother has preterm labor and delivery (< 37 weeks), prolonged rupture of the membranes (>18 hours), or intrapartum temperature greater than 38.0 C (100.4 F). Two primary methods are used to determine which women will receive antibiotics during labor. The first method is based upon risk factors. The five risk factors are: 1. History of a GBS-affected neonate. 2. Urine culture with GBS. 3. Preterm labor (<37 weeks). 4. Membranes ruptured for greater than eighteen hours in labor. 5. Temperature greater than 38.0 C (100.4 F) in labor. A woman with any one of these five risk factors should receive antibiotics in labor. The second method is based on screening, with pregnant women being screened for GBS at 35 to 37 weeks with a culture of the vagina, perineum, and anus. Women should be screened only if they do not have a history of a GBS-affected neonate or GBS bacteriuria. This patient has GBS bacteriuria; therefore, she did not undergo screening. She should be treated with penicillin during labor and delivery. Betamethasone (choice A) is a corticosteroid that is given to women to accelerate fetal maturity to help prevent neonatal respiratory distress syndrome and other sequelae of prematurity. This patient is at 38 weeks' gestation and, therefore, does not require betamethasone. Folic acid (choice B) is a supplement that women should take preconceptionally and during pregnancy (not during labor and delivery) to help prevent neural tube defects. Magnesium sulfate (choice C) is used in obstetrics to prevent preterm labor and for seizure prophylaxis. This patient does not have preterm labor and does not have preeclampsia. Oxytocin (choice D) is given to women to induce or to augment labor. This patient, however, appears not to need oxytocin as she is contracting every 5 minutes and progressing in labor. A 59-year-old man, who is scheduled for an abdominal aortic aneurysm (AAA) repair in 3 weeks, presents to the physician's office. The patient's AAA was diagnosed last week via ultrasound. Imaging at that time revealed a 5.5-cm aneurysm of his abdominal aorta extending bilaterally into his iliac arteries. The patient also has moderate hypertension, with a mean daily blood pressure of 150/95 mm Hg. On physical examination, the patient appears in no distress. He weighs 274 pounds and is 5 feet 9 inches tall. His lungs are clear, and he has a loud S4. His AAA is palpable as a pulsatile mass in his abdomen. Which of the following is the most appropriate intervention to prepare this patient for surgery? ? A. Arrange long-term physical therapy ? B. Improve blood pressure control ? C. Initiate a weight loss program ? D. Prescribe a nonsteroidal anti-inflammatory drug (NSAID) ? E. Prescribe a regimen of regular aerobic exercise Explanation: The correct answer is B. The most important interventions involve limiting the chance of a ruptured abdominal aortic aneurysm (AAA), which is the suspected diagnosis here. These include counseling for smoking cessation and improving blood pressure control. Physical therapy (choice A), although often effective for the relief of back pain, plays no role in the treatment of AAA. Initiating a weight loss program (choice C) or prescribing an exercise program (choice E) can both potentially play an important role in improving the patient's general health. However, they will unlikely alter his short-term risk from AAA rupture. Prescribing a nonsteroidal anti-inflammatory drug (NSAID) (choice D) may decrease the back pain, but may worsen the effect of a rupture because of the antiplatelet effects of NSAIDs. A 59-year-old man, who is scheduled for an abdominal aortic aneurysm (AAA) repair in 3 weeks, presents to the physician's office. The patient's AAA was diagnosed last week via ultrasound. Imaging at that time revealed a 5.5-cm aneurysm of his abdominal aorta extending bilaterally into his iliac arteries. The patient also has moderate hypertension, with a mean daily blood pressure of 150/95 mm Hg. On physical examination, the patient appears in no distress. He weighs 274 pounds and is 5 feet 9 inches tall. His lungs are clear, and he has a loud S4. His AAA is palpable as a pulsatile mass in his abdomen. Which of the following is the most appropriate intervention to prepare this patient for surgery? ? A. Arrange long-term physical therapy ? B. Improve blood pressure control ? C. Initiate a weight loss program ? D. Prescribe a nonsteroidal anti-inflammatory drug (NSAID) ? E. Prescribe a regimen of regular aerobic exercise Explanation: The correct answer is B. The most important interventions involve limiting the chance of a ruptured abdominal aortic aneurysm (AAA), which is the suspected diagnosis here. These include counseling for smoking cessation and improving blood pressure control. Physical therapy (choice A), although often effective for the relief of back pain, plays no role in the treatment of AAA. Initiating a weight loss program (choice C) or prescribing an exercise program (choice E) can both potentially play an important role in improving the patient's general health. However, they will unlikely alter his short-term risk from AAA rupture. Prescribing a nonsteroidal anti-inflammatory drug (NSAID) (choice D) may decrease the back pain, but may worsen the effect of a rupture because of the antiplatelet effects of NSAIDs. A 17-year-old boy comes to medical attention because of recurrent sinusitis and pneumonia, and persistent watery diarrhea due to Giardia lamblia. His parents and a sister are in excellent health. Physical examination reveals enlarged lymph nodes in cervical, axillary and inguinal regions. A lymph node biopsy shows hyperplastic follicles with an absence of plasma cells. Laboratory investigations show: Hematocrit.......................44% Leukocyte count...............9,800/mm3 Neutrophils.....................55% Lymphocytes..................30% Monocytes.....................5% CD4 T-cell count............1000 cells/mm3 Proteins, serum...............6.2 g/dL Albumin........................5.0 g/dL Globulin........................1.2 g/dL Additional studies demonstrate severely depressed levels of serum IgG, with slightly below-normal levels of IgM and IgA. Which of the following is the most likely diagnosis? ? A. Acquired immunodeficiency syndrome (AIDS) ? B. Common variable immunodeficiency ? C. Hodgkin disease ? D. Isolated IgA deficiency ? E. X-linked agammaglobulinemia of Bruton Explanation: The correct answer is B. The clinical picture and laboratory findings are consistent with common variable immunodeficiency syndrome. Important clues to the diagnosis are onset in late adolescence/young adulthood, hypogammaglobulinemia with markedly decreased IgM, recurrent pyogenic infections of the upper respiratory tract and intestinal giardiasis, and failure of lymphocytes to differentiate into plasma cells. The latter finding, appreciable on lymph node biopsy, explains deficient immune globulin production, but the exact molecular mechanism is obscure. Some believe that the underlying defect affects B-lymphocytes, others propose that T- lymphocytes are unable to produce specific lymphokines that promote B- lymphocyte maturation. These patients have an increased risk for B-cell lymphomas, gastric carcinoma, and skin cancer. The only therapy available consists of monthly intravenous infusion of immune globulin. Acquired immunodeficiency syndrome (AIDS) (choice A) is caused by HIV and manifests with opportunistic infections and neoplasms that are extremely unusual in immunocompetent hosts. The CD4 T-cell count is decreased, with a reversed CD4:CD8 ratio. A normal CD4 cell count rules out AIDS in this case. Hodgkin disease (choice C) may induce immune deficiency and recurrent infections due to T-cell dysfunction. Serum immunoglobulins are normal, however. Hodgkin disease may also be excluded, in this case, by the biopsy results, which show hyperplastic follicles instead of the characteristic pathologic features of Hodgkin disease (e.g. Reed-Sternberg cells within a polymorphic cellular infiltrate rich in lymphocytes, eosinophils, plasma cells and histiocytes). Isolated IgA deficiency (choice D) is the most common form of congenital immune deficiency (incidence about 1 in 600 Caucasians) due to decreased production of IgA. Its clinical manifestations may mimic those of common variable immunodeficiency syndrome, but IgG levels are within normal limits, unless there is an associated IgG abnormality. X-linked agammaglobulinemia of Bruton (choice E) is due to failure of B- cell precursors to undergo maturation. Consequently, mature B- lymphocytes do not form, and germinal centers are absent in lymph nodes. All classes of immunoglobulins are deficient. Sinopulmonary and intestinal infections begin in the first year of life, soon after the mother-derived immunoglobulins become depleted. The underlying molecular defect is a mutation of the gene encoding Bruton tyrosine kinase (btk), located in the X chromosome. A 43-year-old woman comes to the office for evaluation of high blood pressure. She was informed that she had high blood pressure 1 week ago during a routine screening at a health fair in a local shopping mall. She has been previously healthy and is on no medications. On examination today her blood pressure is 145/95 mm Hg. Which of the following is the most appropriate step in management? ? A. Advise her to monitor her blood pressure twice a day and return in 6 months ? B. Ask her to return for reexamination after her next menstrual cycle ? C. Ask her to return for reexamination in 2 weeks ? D. Ask her to return for reexamination in 4 months ? E. Measure her blood pressure after she exercises for 5 minutes Explanation: The correct answer is C. Blood pressure may be elevated in times of stress. Multiple determinations over several visits, and some form of home or workplace monitoring should be conducted prior to initiating pharmacological therapy in hypertensive patients. A couple of weeks of home blood pressure monitoring should be adequate to establish the baseline blood pressure (choice A). Menstrual cycles should not have an effect on the blood pressure and should not guide therapy (choice B). Returning after 4 months of untreated hypertension would not be advisable (choice D). Her blood pressure might be elevated after exercise, and would not aid in the diagnosis or management decision (choice E). An 8-month-old previously preterm infant with bronchopulmonary dysplasia presents to the emergency department with lethargy. His regular medications include furosemide and spironolactone. His temperature is 37.4 C (99.3 F), blood pressure is 68/32 mm Hg, pulse is 110/min, and respirations are 10/min. He has poor skin turgor and dry mucous membranes. Laboratory chemistry evaluation reveals: sodium, 131 mEq/L; potassium, 3.0 mEq/L; chloride, 84 mEq/L; bicarbonate, 38 mEq/L; blood urea nitrogen, 36 mg/dL; and creatinine, 0.4 mg/dL. An arterial blood gas shows pH, 7.52; PaCO2, 49 mm Hg; and PaO2, 92 mm Hg. Which of the following is the most likely explanation for these findings? ? A. Bartter syndrome ? B. Primary hyperaldosteronism ? C. Primary respiratory acidosis with metabolic compensation ? D. Pseudohyperaldosteronism ? E. Volume depletion Explanation: The correct answer is E. The findings of dry mucous membranes, poor skin turgor, and tachycardia suggest that the infant is volume depleted. He has been taking the loop diuretic furosemide, which is used to treat bronchopulmonary dysplasia. Furosemide causes increased excretion of sodium (therefore water), potassium, and chloride in the urine. The body is therefore hypovolemic. Excessive loss of potassium causes the hydrogen- potassium pump across the cell membranes to transport hydrogen into the cells in exchange for potassium out of the cells. Transportation of hydrogen into the cells causes the number of hydrogen ions in the plasma to decrease and results in alkalosis. The chemoreceptors in the medullary respiratory center of the brain sense the metabolic alkalosis and respond by lowering the respiratory rate. Therefore, more carbon dioxide is retained in the bloodstream and partially corrects the metabolic alkalosis. Bartter syndrome (choice A) is a rare autosomal-recessive disorder that manifests as hypokalemia, hypochloremia, and high renin and aldosterone levels. Primary aldosteronism (choice B) is characterized by hypertension, hypernatremia, hypokalemia, and a suppressed renin-angiotensin system. Primary respiratory acidosis with metabolic compensation (choice C) represents a primary process of respiratory failure and increased retention of carbon dioxide. The kidneys compensate by retention of bicarbonate in an attempt to correct the acidosis. However, compensatory mechanisms will never overcompensate for the primary process. Therefore, the pH should never be more than 7.40. Pseudohyperaldosteronism (choice D), also known as the Liddle syndrome, is a rare disorder of renal transport of sodium and potassium that resembles primary hyperaldosteronism. Affected people present in infancy or early childhood with hypertension, polyuria, polydipsia, and hypokalemic metabolic alkalosis. The serum concentration of aldosterone is low. A 39-year-old businessman with no prior medical problems is rushed to the emergency department following the sudden onset of dizziness, shortness of breath, and palpitations. His blood pressure on admission is 190/110 mm Hg, his pulse is 124/min, and he is diaphoretic. His wife says that his behavior has changed over the past couple month since he became CEO of his company. He has become moody. At times, he seems energetic, euphoric, or irritable; then he seems "to be down" for no reason. He just returned from one of many business meetings and again spent more money than ever before. The patient is smiling inappropriately and denies any alcohol or drug abuse. Which of the following will most likely be found on a urine drug screen? ? A. Cocaine ? B. Heroin ? C. Nicotine ? D. Organic inhalants ? E. Phencyclidine Explanation: The correct answer is A. Cocaine intoxication is characterized by sympathic stimulation, including tachycardia, hypertension, and sweating. The mood is elated and euphoric while intoxicated, and there is restlessness and pressured speech. Psychotic symptoms can occur with prolonged use. Heroin intoxication (choice B) causes significant behavioral changes and impaired social functioning, as well as pupillary constriction, drowsiness, slurred speech, and impairment of attention and memory. Signs of nicotine intoxication (choice C) are nausea, vomiting, salivation, pallor, weakness, abdominal pain, diarrhea, dizziness, headache, tremor, cold sweats, tachycardia, confusion, and sensory disturbances. Organic inhalant intoxication (choice D) causes dizziness, nystagmus, incoordination, lethargy, unsteady gait, slurred speech, muscle weakness, tremor, blurred vision, psychomotor retardation, and stupor. Phencyclidine intoxication (choice E) causes behavioral changes shortly after the use of drug, as well as two or more of the following signs: ataxia, nystagmus, hypertension, tachycardia, dysarthria, muscle rigidity, numbness, seizures, or coma. A 36-year-old woman, gravida 5, para 4, at 30 weeks' gestation comes to the physician for a prenatal visit. She feels the baby moving and has not had bleeding per vagina, contractions, or loss of fluid. The prenatal course has been uncomplicated thus far. The patient is interested in having a postpartum tubal ligation. She has many questions regarding the procedure, including whether there is a risk of failure. Which of the following represents the closest estimate for the likelihood of failure of a postpartum tubal ligation? ? A. 1 in 10 ? B. 1 in 100 ? C. 1 in 1000 ? D. 1 in 1,000,000 ? E. There are no reported failures of postpartum tubal ligation. Explanation: The correct answer is B. Postpartum tubal ligation is a highly effective method for giving a woman permanent sterilization. Many methods have been developed, but the most common methods involve doubly ligating a portion of each tube and excising an intervening segment. A postpartum tubal ligation can be performed at the time of cesarean delivery or after a vaginal delivery. If the procedure is performed after a vaginal delivery, a relatively small skin incision is usually made in or near the umbilicus. Patients undergoing postpartum tubal ligation should be warned, however, that the procedure could fail. Failure may result from many factors including recannalization of the tube and poor surgical technique. The most commonly quoted failure rate is about 1 in 100, although a more accurate figure may be closer to 1 in 300. However, it is impossible to give one exact rate, because the risk of failure depends on the patient's age. A 25- year-old woman undergoing tubal ligation is more likely to experience failure than a 40-year-old woman, because the 25-year-old has so many more years of fertility ahead of her. If the failure rate were 1 in 10 (choice A) few doctors would recommend the procedure. For a birth control method to be useful, it must have a low overall failure rate. A failure rate of 10% would be too great to justify the risk of the procedure. 1 in 1000 (choice C) or 1 in 1,000,000 (choice D) are the failure rates that obstetricians would like to see from tubal ligation. Perhaps with time and changes in methodology, the failure rates will continue to fall. At present, however, the most commonly quoted failure rate is 1 in 100. To state that there are no reported failures of postpartum tubal ligation (choice E) is absolutely incorrect. Patients need to be cautioned that the procedure can fail and that if pregnancy is suspected, they should notify their doctor immediately, as the risk of ectopic pregnancy after tubal ligation is significant. An 80-year-old woman complains of a 4 month history of worsening gait and low back pain that is worse on walking. She denies any trauma and is not incontinent. She has been fairly healthy and only takes iron supplements. On examination, she has hypoactive muscle stretch reflexes in the legs. The plain x-rays of the lumbosacral region show degenerative changes that seem age-appropriate. Which of the following is the most likely diagnosis? ? A. Acute lumbar disc herniation ? B. Cervical stenosis ? C. Lumbar stenosis ? D. Myopathy ? E. Normal pressure hydrocephalus (NPH) Explanation: The correct answer is C. Lumbar stenosis is caused by degenerative changes in the lumbosacral spine. The history is that of vague low back pain with subtle physical examination findings referable to impingement on motor and sensory roots. Acute disc herniation (choice A) is characterized by low back discomfort and pain extending in a radicular fashion. Examination is consistent with impingement on a single sensory or motor root. Cervical stenosis (choice B) can cause a myelopathy and resultant gait problem, but this patient has degenerative changes in the lumbosacral region. Myopathy (choice D) can cause an impaired gait, low back discomfort and hypoactive muscle reflexes, typically at the knee. Weakness tends to be symmetric and proximal. NPH (choice E) causes an apraxic gait, dementia and urinary incontinence. A 34-year-old tax lawyer presents to his physician complaining of difficulty swallowing. On several occasions over the past few months, he was aware of meat becoming stuck in his mid-chest immediately after eating. After each episode, he had several hours of chest pain, which gradually resolved. On two occasions, he induced vomiting to obtain relief. Over the past 10 days, the swallowing difficulty has become worse, and he now has trouble with even soft foods and is limiting himself to pureed food. He has been taking ranitidine, magnesium hydroxide, and omeprazole for 4 years, but has remained symptomatic despite these measures. He has been smoking one pack of cigarettes daily for 15 years and denies any alcohol use. The physical examination is normal. Which of the following is the most likely explanation for these symptoms? ? A. Diffuse esophageal spasm ? B. Esophageal squamous carcinoma ? C. Lower esophageal web ? D. Peptic esophageal stricture ? E. Scleroderma Explanation: The correct answer is D. This patient presents with symptoms consistent with gradual luminal narrowing of the esophagus after many years of gastroesophageal reflux disease (GERD). These symptoms suggest the development of a benign peptic stricture. This may occur even if the patient is on medical therapy to reduce acid secretion, since many patients will continue to produce acid despite standard medical regimens and may require very high doses of proton pump inhibitors. Treatment consists of endoscopic dilation of this stricture and continued aggressive anti-reflux therapy. Diffuse esophageal spasm (choice A) presents with "noncardiac chest pain," usually described as a mid-chest(squeezing chest pain. It typically presents with a motility-type dysphagia. Although GERD is a common underlying factor, the type of dysphagia in esophageal spasm would be consistent with a motility-type dysphagia, i.e., patient has difficulty with liquids as well as solids from the onset of his symptoms. Squamous carcinoma (choice B) is not a sequelae of longstanding GERD. Furthermore, his age makes it extremely unlikely that he would develop esophageal carcinoma (even with his history of smoking as a risk factor). A lower esophageal web (choice C) or Schatzki ring produces dysphagia in an episodic pattern as foods that are greater in size than the diameter of the web, become lodged in the distal esophagus. Scleroderma (choice E) could cause dysphagia, but this would be accompanied by Raynaud's phenomenon and characteristic changes in the skin. Additionally, scleroderma is about three times as common in women than in men. A 36-year-old man develops rapid mental status deterioration two days after sustaining a femoral fracture in a skiing accident. Physical examination shows multiple petechiae in the anterior chest and abdomen. On the third day, the patient lapses into coma and dies. Postmortem examination of the brain reveals numerous petechial hemorrhages in the corpus callosum and centrum semiovale. Which of the following is the most likely diagnosis? ? A. Diffuse axonal injury ? B. Fat embolism ? C. Septic embolism ? D. Systemic thromboembolism ? E. Watershed infarction Explanation: The correct answer is B. The clinical manifestations are consistent with fat embolism. This complication is frequent, following fractures of long bones, but is usually asymptomatic. Fat embolism mainly affects the lungs and the brain, and the clinical picture consists of dyspnea, tachycardia, and mental status changes. Only rarely, does this condition lead to death. In the lungs, fat emboli can be visualized histologically. In the brain, multifocal petechiae in the white matter represent the most common pathologic change. Diffuse axonal injury (choice A) is one of the most common forms of traumatic brain injury. It involves the central white matter, especially the corpus callosum and cerebral peduncles. It is sometimes associated with small petechiae in these areas. The patient may develop coma a few hours to days after head trauma. Septic embolism (choice C) results from septic emboli lodging in the terminal intraparenchymal arteries of the brain. It leads to multiple cortical infarcts, usually of the hemorrhagic type. The white matter is spared. Systemic thromboembolism (choice D) is usually of cardiac origin—for example, in patients with cardiac arrhythmias with thrombi in the right atrium or ventricle. Thromboemboli in the brain cause hemorrhagic infarction in the cortex. Watershed infarction (choice E) is often seen in patients suffering from acute hypotensive episodes, especially if the circle of Willis is already compromised by atherosclerotic change. The cortical regions at the border zone between different vascular territories (e.g., between the distribution of the anterior and middle cerebral arteries) undergo ischemic necrosis. A 22-year-old woman goes to the emergency department because she feels very weak and is having muscle cramping and fasciculations. Blood chemistry studies demonstrate a plasma potassium of 1.5 mEq/L. On questioning, she admits to chronic use of laxatives and diuretics to control her weight. Which of the following ECG changes would be most characteristic of changes related to her K+ level? ? A. Increased U wave amplitude ? B. Prolongation of the P wave ? C. Shortening of the QT interval ? D. Tall, symmetric, peaked T waves ? E. Widening of the QRS complex Explanation: The correct answer is A. Both chronic laxative use and chronic diuretic use can produce hypokalemia. Severe hypokalemia, with plasma potassium <3 mEq/L, can markedly affect skeletal, smooth, and cardiac muscles. Skeletal muscle effects can include weakness, cramping, fasciculations, paralysis (with risk of respiratory failure), tetany, and rhabdomyolysis. Smooth muscle effects include hypotension and paralytic ileus. Cardiac muscle effects include premature ventricular and atrial contractions, tachyarrhythmias, and AV block. Additional ECG changes can include ST segment depression, increased U wave amplitude, and T wave amplitude less than U wave. The changes illustrated in choices B, C, D, and E are characteristic of hyperkalemia. A 58-year-old dental hygienist presents complaining of swelling in the right knee. Over the past 24 hours, her right knee suddenly became swollen and painful to weight bearing, with a limited range of motion. She does not recall any history of arthritis or trauma in that region. She is not aware of any needle-stick injuries while at work. Until the onset of knee pain, she had been exercising daily on a treadmill. A physical examination reveals tenderness, swelling, and erythema in the right knee. There is painless flexion and limitation in extension. Which additional information would be most relevant in this patient's history? ? A. Family history of rheumatoid arthritis ? B. History of bacterial gastroenteritis ? C. History of hepatitis B vaccination ? D. History of a traumatic right ankle injury ? E. Sexual history Explanation: The correct answer is E. This patient has monoarticular arthritis of the right knee. The major differential diagnosis in these patients is of a crystalline arthritis (gout) versus an infectious arthritis (Staphylococcus vs. Gonococcus). In this regard, knowledge of her sexual history and any high- risk sexual behaviors that would put her at risk for gonococcal infection would be relevant. Bacterial gastroenteritis (choice B) may be associated with Reiter syndrome, but this involves multiple joints in association with conjunctivitis and urethritis and does not present as monoarticular arthritis. Hepatitis B vaccination (choice C) is appropriate in occupations such as dental hygiene, which are exposed to bodily fluids. However, hepatitis B is not associated with a monoarticular arthritis, although polyarthralgias may occur in patients with hepatitis B who develop a serum-sickness like illness. A traumatic joint injury (choice D) is always of relevance in the setting of monoarticular arthritis. However, since the arthritis is in the right knee, trauma to the right ankle would be unlikely to be causative. A 40-year-old woman presents with complaints of burning and tingling sensations in the left hand for several months. She relates that she has been frequently awakened at night by aching pain in the same hand. She is otherwise in good health. Examination fails to detect any impairment in sensation, but pain is elicited by extreme dorsiflexion of the wrist. The patient is unable to correctly identify different clothes by rubbing between the left thumb and index finger. Which of the following is the most likely diagnosis? Which of the following is the most likely diagnosis? ? A. Angina pectoris ? B. Carpal tunnel syndrome ? C. Dupuytren contracture ? D. Fibrositis ? E. Reflex sympathetic dystrophy Explanation: The correct answer is B. The symptomatology is classic for carpal tunnel syndrome, which is a form of neuropathy resulting from anatomic compression of the median nerve. Pain, tingling sensations, and hypoesthesia in the distribution of the median nerve are the cardinal manifestations. These often undergo exacerbations at nighttime. A shock- like pain upon percussion on the volar aspect of the wrist (Tinel sign) is an additional characteristic sign. Carpal tunnel syndrome is most often idiopathic, but may represent a manifestation of underlying disorders such as rheumatoid arthritis, sarcoidosis, amyloidosis, acromegaly, and leukemia. Carpal tunnel syndrome may be confused with angina pectoris (choice A) when located on the left side. However, angina pectoris typically manifests with physical or emotional stress and very rarely results in pain limited to the hand. Dupuytren contracture (choice C) is a relatively common disorder characterized by fibrous thickening of the palmar fascia. Contracture and nodule formation ensue. This condition is most common in Caucasian men over 50. Fibrositis (choice D), also known as fibromyalgia, refers to a poorly understood syndrome of widespread musculoskeletal pain associated with tenderness in multiple trigger points. Fatigue, headache, and numbness are also common. Women between 20 and 50 years of age are most commonly affected. Neck, shoulders, low back and hips are usually involved. Reflex sympathetic dystrophy (choice E) describes a syndrome of pain and swelling of one extremity (most commonly a hand), associated with skin atrophy. It is thought to be secondary to vasomotor instability. Sometimes, it follows injuries to the shoulder (shoulder-hand variant). A 69-year-old woman presents to her physician of 3 years with progressive shortness of breath. The dyspnea was initially limited to exertion but has progressed to shortness of breath at rest. She has had intermittent cough but no fever. Her past medical history is significant for mild hypertension and seropositive rheumatoid arthritis. Which of the following aspect of her social history is the most important consideration to review at this point? A. Alcohol history B. Drugs of abuse history C. Marital status D. Occupation E. Tobacco history Explanation: The correct answer is E. In the U.S., lung damage from smoking is by far the most important contributor to lung disease, from an epidemiologic standpoint. In addition, smoking can significantly exacerbate the clinical course of other diseases that affect the lungs, such as asthma or cystic fibrosis. Fortunately, smoking behavior can be potentially altered by new pharmacologic approaches. Although the physician may have asked this patient about smoking before, it is now time to review her smoking history in detail. Asking about alcohol (choice A) and drugs of abuse (choice B) is always important, even in the elderly, but reviewing the smoking history should take precedence here. Alcohol use typically does not directly lead to lung pathology or cause dyspnea. Some drugs of abuse, such as marijuana, crack cocaine, and heroin, have deleterious effects when introduced into the lungs. That said, the age of this patient makes it much more likely that she would be using tobacco. Although exploring the marital status (choice C) and key relationships in a patient's life is very important in terms of the patient's overall health, this process has little additional role during this visit. Reviewing the occupational history (choice D) is also an important part in the evaluation of dyspnea. Although smoking usually overshadows occupational-related lung injuries, the occupational history should take a close second to the smoking history. Occupational exposures can exacerbate diseases such as asthma and can cause diseases such asbestosis and silicosis. If the patient had been a 50-year-old brake mechanic or shipyard worker, the occupational history may have been a more important component of the social history on which to concentrate. A 3-year-old boy is brought by his father to the Emergency Department with fever, headache and neck pain that developed over the past several hours. The father states he is not the birth father, and that he and his wife adopted the boy at 18 months of age after his birth mother abandoned him. Physical examination reveals a lethargic male with a temperature of 39.7 C (103.5 F). There is photophobia, and mildly injected conjunctiva are appreciated. Pupils are equal and reactive and funduscopic examination is unremarkable. The patient has neck stiffness with a positive Kernig's sign. A complete blood count reveals a leukocyte count of 24,000/mm3 with 64 segmented neutrophils and 25 bands. A lumbar puncture is performed that reveals elevated CSF pressure, decreased glucose, and elevated protein. A Gram's stain shows gram-negative pleomorphic rods. There is no growth on blood agar. Growth on chocolate agar reveals white colonies. Which of the following is the most likely pathogen? A. Haemophilus ducreyi B. Haemophilus influenzae type b C. Neisseria meningitidis D. Listeria monocytogenes E. Streptococcus pneumoniae Explanation: The correct answer is B.Haemophilus influenzae is now a rare cause of meningitis in children since development of the Haemophilus influenzae type b (Hib) vaccine. The case reveals a questionable immunization history, thus making this patient susceptible to H. influenzae type b. Kernig's sign is elicited by placing the patient in a supine position, flexing the leg at the hip to 90 degrees and then straightening the knee to elicit pain in the back or posterior thigh as predictive evidence of meningitis. Laboratory and CSF data support a bacterial etiology, and Gram's stain with growth on chocolate agar confirms the diagnosis of Haemophilus influenzae as the causative agent. Haemophilus ducreyi(choice A) is the causative agent for chancroid (soft chancre). Neisseria meningitidis(choice C) is a gram-negative diplococcus that also can grow on chocolate agar, but grows best on modified Thayer-Martin media. Meningococcal meningitis classically presents with a petechial rash. Streptococcus pneumoniae(choice E) and Listeria monocytogenes(choice D) are both organisms that cause meningitis. Both, however, are gram- positive. Listeria monocytogenes is predominantly seen as a cause of neonatal meningitis. A mother brings her 8-year-old son to a psychiatrist for new-onset enuresis. A prior workup to determine a medical cause was negative. In conversation, it seems that the enuresis started following parental arguments and separation. The boy wets himself at least twice a week and feels upset about it, refusing to go for a sleep-over at his friend's house. Which of the following is the most commonly used treatment for this condition? A. Behavioral therapy B. Interpersonal therapy C. Pharmacotherapy D. Psychodrama E. Psychotherapy Explanation: The correct answer is A. Behavioral therapy is the most frequently used treatment in children with enuresis. Dry nights are recorded on a calendar and rewarded with a star as a gift. The buzzer and pad apparatus are used less for conditioning nowadays. Interpersonal therapy (choice B) is short-term therapy developed for nonpsychotic, milder forms of depression. It addresses current relationships and roles, and is used with adults. It is not indicated for enuresis treatment. Pharmacotherapy (choice C) is rarely used, given the success of behavioral approaches. Tolerance to imipramine, which has been used, can develop within 6 weeks. Desmopressin has shown some success. Psychodrama (choice D) is a method of group therapy in which conflicts and interpersonal relationships are explored by means of special dramatic methods. It is not indicated in children with enuresis. Psychotherapy (choice E) is not recommended unless there is evidence of other psychopathology. The exploration of conflicts in enuresis has shown little success. A 41-year-old woman, gravida 4, para 3, at term is admitted to the labor and delivery ward with regular contractions every 2 minutes. Examination shows that her membranes are grossly ruptured and that her cervix is 5 cm dilated. Over the following 3 hours, she progresses to full dilation and +2 station. A fetal bradycardia develops, and the decision is made to proceed with vacuum-assisted vaginal delivery. A 7 pound, 8 ounce boy is delivered. APGAR scores are 8 at 1 minute and 9 at 5 minutes. Which of the following best represents an advantage of vacuum extraction over the forceps for expediting delivery? A. The vacuum can be used at higher stations B. The vacuum can be used for fetuses in breech presentation C. The vacuum can be used in face presentations D. The vacuum can be used with intact membranes E. The vacuum does not occupy space next to the fetal head Explanation: The correct answer is E. Both forceps and the vacuum extractor can be used to expedite the delivery of a fetus. These instruments are most often used when there are fetal indications, such as a non-reassuring fetal heart rate tracing, or maternal indications, such as maternal exhaustion or maternal contraindications to pushing (such as maternal cardiac disease.) The choice of forceps or vacuum depends most on the experience and preference of the physician. In certain cases, one instrument is favored or mandatory. For example, forceps may be used in face presentation with a mentum anterior presentation; in such a case, vacuum is contraindicated. Those who favor vacuum delivery make several arguments. For example, as opposed to forceps, the vacuum extractor does not occupy space next to the fetal head; this should lead to less trauma to maternal tissues. Also, attempted delivery with the vacuum in a situation of true cephalopelvic disproportion (i.e., the fetus cannot be delivered through the maternal pelvis) will lead to a loss of suction and failure of the procedure; forceps do not necessarily dislodge and this could lead to continued efforts being made with increased likelihood of maternal or fetal morbidity or mortality. To state that the vacuum can be used at higher stations (choice A) is incorrect. Both the vacuum and forceps should preferably be used only in low- or outlet- situations (i.e., with the fetal vertex at +2 station or lower.) To state that the vacuum can be used for fetuses in breech presentation (choice B) is incorrect. Neither the vacuum nor forceps should be used when the fetus is presenting as a breech. To state that vacuum can be used in face presentations (choice C) is not correct. Vacuum cannot be used when the fetus is presenting face first. Forceps may be used as long as the fetus is in mentum-anterior position (i.e., with the chin facing toward the maternal pubic symphysis.) To state that the vacuum can be used with intact membranes (choice D) is incorrect. Neither forceps nor vacuum should be used with intact membranes. A 61-year-old man comes in because of colicky abdominal pain and vomiting of 3 days' duration. On physical examination, he is moderately distended and has high pitched hyperactive bowel sounds and a 5-cm tender groin mass. On direct questioning, he explains that he has had that bulge for many years, but has always been able to "push it back in" when he lies down. For the past 3 days, however, he has been unable to do so. He has a temperature of 38.9 C (102 F) and a white blood cell count of 12,500/mm3. Which of the following is the most appropriate management at this time? A. A sonogram of the mass B. A trial of nasogastric suction and IV fluids for a few days C. Insertion of a long rectal tube via sigmoidoscopy D. Manual reduction of the hernia, followed by a period of observation E. Urgent surgical intervention Explanation: The correct answer is E. The clinical picture is that of a strangulated inguinal hernia. If he only had the tender mass without signs of intestinal obstruction, he might have omentum trapped. If he had the intestinal obstruction without fever, leukocytosis, and the tender mass, he could be obstructed but not strangulated. But, the combination that he has is clearly that of obstruction with strangulation. He needs urgent surgery. A sonogram to make a diagnosis (choice A) might be appropriate for a mass without signs of obstruction, if we could not clinically be sure that it was a hernia. Nasogastric suction and IV fluids (choice B) is the standard approach for obstruction due to adhesions, when there are no signs suggestive of strangulation. We do not operate for adhesions (they form again), but do so only to rescue the bowel that is trapped. In hernias, on the other hand, we want not only to rescue the bowel but also to repair the hernia. A long rectal tube (choice C) is used in Ogilvie's syndrome or volvulus, but not in strangulated hernias. Manual reduction (choice D) would actually be dangerous in this case, as it might force a dead segment of bowel into the abdomen, increasing morbidity and delaying definitive treatment. If he had no fever, no leukocytosis, and no tenderness, such an approach might be justified to gain time for an elective, non-rushed hernia repair. A 39-year-old woman, gravida 3, para 2, at 40 weeks' gestation comes to the labor and delivery ward after a gush of fluid with regular, painful contractions every two minutes. She is found to have rupture of the membranes and to have a cervix that is 5 centimeters dilated, a fetus in vertex presentation, and a reassuring fetal heart rate tracing. She is admitted to the labor and delivery ward. Two hours later she states that she feels hot and sweaty. Temperature is 38.3 C (101 F). She has mild uterine tenderness. Her cervix is now 8 centimeters dilated and the fetal heart tracing is reassuring. Which of the following is the most appropriate management of this patient? A. Administer antibiotics to the mother after vaginal delivery B. Administer antibiotics to the mother now and allow vaginal delivery C. Perform cesarean delivery D. Perform cesarean delivery and then administer antibiotics to the mother E. Perform intra-amniotic injection of antibiotics Explanation: The correct answer is B. Chorioamnionitis is an infection that can develop at any time before and during delivery. The most common findings in patients with chorioamnionitis are a fever and uterine tenderness. An elevated fetal heart rate is also often seen. This patient has a temperature elevation and uterine tenderness, which make the diagnosis of chorioamnionitis. It is essential that antibiotics be started immediately because prompt initiation of antibiotics, once the diagnosis of chorioamnionitis is made, results in better maternal and neonatal outcomes than if therapy is delayed. It is also essential that broad-spectrum antibiotic therapy be chosen because a mixture of organisms is usually involved including aerobes and anaerobes. The most frequently used regimen is ampicillin or penicillin with gentamicin. In terms of the mode of delivery, vaginal delivery is acceptable in patients with chorioamnionitis. While it is desirable to have an expeditious delivery, chorioamnionitis is not an indication for cesarean delivery. To wait to administer antibiotics to the mother after vaginal delivery (choice A) would not be correct, as the delay would deprive both the mother and the fetus of the beneficial effects of the antibiotics. To perform cesarean delivery (choice C) or to perform cesarean delivery and then administer antibiotics to the mother (choice D) would not be indicated. As explained above, when a woman has chorioamnionitis, it is desirable to expedite delivery, but cesarean delivery should be performed only for obstetric indications. To perform intra-amniotic injection of antibiotics (choice E) would not be indicated. Intra-amniotic injection of antibiotics during labor is not a therapy used to treat chorioamnionitis during labor.