PACKRAT PRACTICE

History & Physical/Hematology

A 55-year-old non-smoking male presents with a hemoglobin of 18.5 g/dl and a hematocrit of 56%. Which of the following physical examination findings is the most likely to be noted with this patient?

A. Splenomegaly

B. Cheilosis

C. Purpura

D. Decreased vibratory sense

Explanations

(c) A. Patients with polycythemia vera present with elevated hemoglobin and hematocrit. On physical examination plethora, engorged retinal veins, and splenomegaly are common.

(u) B. Cheilosis is noted in iron deficiency anemia.

(u) C. Purpura is typically noted in bleeding disorders.

(u) D. Decreased vibratory sense is noted in vitamin B12 deficiency.

History & Physical/Obstetrics/Gynecology

On examination of a pregnant patient the physician assistant notes a bluish or purplish discoloration of the vagina and cervix. This is called

Answers

A. Hegar's sign.

B. McDonald's sign.

C. Cullen's sign

D. Chadwick's sign

Explanations

(u) A. Hegar's sign is the softening of the cervix that often occurs with pregnancy.

(u) B. McDonald's sign is when the uterus becomes flexible at the uterocervical junction at 7-8 weeks.

(u) C. Cullen's sign is a purplish discoloration periumbilical and noted in pancreatitis.

(c) D. Chadwick's sign is a bluish or purplish discoloration of the vagina and cervix.

History & Physical/Orthopedics/Rheumatology

Abduction of the shoulder against resistance helps localize pain in which of the following muscles of the shoulder girdle?

Answers

A. Supraspinatus

B. Infraspinatus

C. Teres minor

D. Subscapularis

Explanations

(c) A. Abduction against resistance tests the supraspinatus.

(u) B. Lateral rotation against resistance tests the infraspinatus and teres minor.

(u) C. See B for explanation.

(u) D. Medial rotation against resistance tests the subscapularis.

History & Physical/Pulmonology

A 45 year-old male presents with sudden onset of pleuritic chest pain, productive cough and fever for 1 day. He relates having symptoms of a "cold" for the past week that suddenly became worse yesterday. Which of the following findings will most likely be seen on physical examination of this patient?

Answers

A. spoken "ee" heard as "ay"

B. hyperresonant percussion note

C. wheezes over the involved area

D. vesicular breath sounds over involved area

Explanations

(c) A. This patient most likely has a bacterial pneumonia with consolidation, which would produce egophony, where a spoken "ee" is heard as "ay."

(u) B. Consolidation from bacterial pneumonia causes findings of dullness to percussion, late inspiratory crackles and bronchial breath sounds over the involved area.

(u) C. See explanation B.

(u) D. See explanation B.

History & Physical/ENT/Ophthalmology

A 4 year-old child presents with a rapid onset of high fever and extremely sore throat. Which of the following findings are suggestive of the diagnosis of epiglottitis?

Answers

A. Croupy cough and drooling

B. Thick gray, adherent exudate

C. Beefy red uvula, palatal petechiae, white exudate

D. Inflammation and medial protrusion of one tonsil

Explanations

(c) A. A croupy cough with drooling in a patient who appears very ill is consistent with epiglottitis. Examining the throat is contraindicated, unless the airway can be maintained.

(u) B. Thick gray adherent exudate is suggestive of diphtheria.

(u) C. Beefy red uvula, palatal petechiae, and white exudate are findings suggestive of streptococcal pharyngitis.

(u) D. Inflammation with medial protrusion of the tonsil is suggestive of a peritonsillar abscess.

Which of the following is a common physical examination finding in early intestinal obstruction?

A. high fever.

B. profuse flatulence.

C. rebound tenderness

D. hyperactive, high-pitched bowel sounds

(u) A. Fever and rebound tenderness occur only if a perforation has occurred.

(u) B. Profuse flatulence is not noted in early intestinal obstruction.

(u) C. See A for explanation.

(c) D. Abdominal distention and high-pitched, hyperactive bowel sounds are common in early intestinal obstruction.

History & Physical/Endocrinology

A 26-year-old obese female complains of a 3-4 month history of discrete erythematous plaques on the pretibial areas of her legs. The lesions have increased in size, become darker, and are painful. She is concerned because the centers of the lesions have become ulcerated. This patient should be screened for which of the following?

Answers

A. Hypothyroidism

B. Diabetes mellitus

C. Melanoma

D. Scleroderma

Explanations

(u) A. In hypothyroidism the skin of the pretibial area may thicken leading to edema. This is a diffuse finding, involving the face and eyelids, without discrete lesions.

(c) B. The description of the skin lesions is characteristic of necrobiosis lipoidica diabeticorum, one of the dermatologic manifestations of diabetes mellitus.

(u) C. The lesions of melanoma are typically not painful and do not ulcerate.

(u) D. Scleroderma is marked by thickening of the skin, with swelling of the fingers and hands. The swelling may involve the forearms and face; the lower extremities are relatively spared.

History & Physical/Neurology

A 73 year-old male presents to the clinic with his wife. His wife has noticed that he has developed a resting tremor in his right hand and a shuffling gait over the last year. What finding on physical examination would support your suspected diagnosis?

Answers

A. Chorea

B. Dystonia

C. Masked facies

D. Hyperreflexia

Explanations

(u) A. See C for explanation.

(u) B. See C for explanation.

(c) C. The patient symptoms are consistent with Parkinsonism. Physical exam findings include masked facies, micrographia, decreased arm swing, and monotonous speech.

(u) D. See C for explanation.

History & Physical/Psychiatry/Behavioral Medicine

Which of the following historical factors differentiates post-traumatic stress disorder from acute stress disorder?

Answers

A. The inability of the person to recall an important aspect of the event. B. Avoidance of stimuli that invokes recollections of the event.

C. A belief that their future has been foreshortened because of the event.

D. The presence of sleep disorder.

Explanations

(u) A. See C for explanation.

(u) B. See C for explanation.

(c) C. Post-traumatic stress disorder and acute stress disorder have many of the same characteristics. A sense of a foreshortened future, such as not expecting a normal life span or a career due to the trauma, distinguishes post-traumatic stress disorder from an acute stress disorder. The other answers are common to both disorders.

(u) D. See C for explanation.

History & Physical/Dermatology

A patient presents with a rash, characterized by red macules and edematous papules with a clearing center. This best describes which of the following?

Answers

A. erythema marginatum

B. erythema multiforme

C. varicella

D. impetigo

Explanations

(u) A. Erythema marginatum is associated with rheumatic fever and is characterized by macular to maculopapular lesions. A clearing center is not found in the rash.

(c) B. Target lesions, also termed iris lesions, are characteristic of erythema multiforme. The rash may be recurrent but typically resolves over 3-6 weeks.

(u) C. The rash of varicella typically has maculopapules, vesicles, and scabs in various stages of development. A clearing center is not found in the rash.

(u) D. The lesions of impetigo are pustules that form a honey-colored crust after rupturing.

History & Physical/Urology/Renal

A patient with a 15-year history of type 2 diabetic mellitus presents for follow-up. Labs reveal a BUN 100 mg/dl, serum creatinine 9.2 mg/dl, and serum glucose 164 mg/dl. Which of the following would you expect to find on physical examination?

Answers

A. Pruritus

B. Hypotension

C. Macroglossia

D. Suprapubic tenderness

Explanations

(c) A. Hypertension, pruritus and xerosis are common findings in the uremic patient.

(u) B. See A for explanation.

(u) C. See A for explanation.

(u) D. Suprapubic tenderness is associated with urinary tract infection or acute obstructive uropathy.

History & Physical/Endocrinology

A 40 year-old male presents to your clinic complaining of nontender, yellow patches on both eyelids. He states his brother and uncle have similar growths. He denies any visual changes or other complaints. Your primary suspicion is

Answers

A. gout.

B. lipoma.

C. hyperlipidemia.

D. seborrheic dermatitis.

Explanations

(u) A. Tophaceous gout may appear as yellow skin lesions but they usually occur around the joints and helix of the ear.

(u) B. Lipomas tend to be flesh-colored and are not usually bilateral.

(c) C. Xanthelasmas, along with xanthomas, are common findings in familial hypercholesterolemia.

(u) D. Eyelids are a common location for seborrheic dermatitis but the lesions are not yellow in color.

History & Physical/Orthopedics/Rheumatology

A 22 year-old male presents to the ED after sustaining a blow to the knee during football practice. The knee exam demonstrates significant forward translation of the tibia when the knee is in 15 degrees of flexion and external rotation at the hip. Which of the following knee maneuvers does this represent?

Answers

A. Abduction stress test

B. Anterior drawer sign

C. Lachman test

D. McMurray test

Explanations

(u) A. The abduction stress test is performed to evaluate medial collateral ligament tears while applying valgus stress.

(u) B. The anterior drawer sign is performed to evaluate the anterior cruciate ligament; however the patient is supine, hips and knees flexed, and feet are flat on the table.

(c) C. The Lachman test is performed to evaluate the anterior cruciate ligament. The knee is placed in 15 degrees of flexion and external rotation of the hip.

(u) D. The McMurray test is performed to evaluate medial and lateral meniscal tears while rotating the lower leg internally and externally.

History & Physical/Pulmonology

Which of the following is a common symptom associated with laryngotracheobronchitis (viral croup)?

Answers

A. drooling

B. high fever

C. "hot potato" voice

D. barking cough

Explanations

(u) A. Drooling and a "hot potato" voice are seen with epiglottitis, not viral croup.

(u) B. Fever is usually absent or low grade in patients with viral croup.

(u) C. See A for explanation.

(c) D. Viral croup is characterized by history of an upper respiratory tract symptoms followed by onset of a barking cough and stridor.

History & Physical/ENT/Ophthalmology

Which of the following are normal findings in a Weber test?

Answers

A. The tympanic membrane is movable with pneumatic otoscopy.

B. The tympanic membrane is pearly gray with a sharp cone of light with apex at the umbo.

C. Sound is heard equally in both ears when a vibrating tuning fork is placed on the mid forehead.

D. Air conduction is greater than bone conduction when a vibrating tuning fork is moved from the mastoid bone to close to the ear canal.

Explanations

(u) A. A movable tympanic membrane indicates there is no effusion, and is not the Weber test.

(u) B. The tympanic membrane is evaluated by direct observation with an otoscope, and is not the Weber test.

(c) C. A normal Weber test means there is no lateralization of sound perception when a vibrating tuning fork is placed on the mid forehead.

(u) D. A normal Rinne test means that tuning fork vibration is heard longer through the air than the bone.

History & Physical/Obstetrics/Gynecology

On examination of a pregnant patient the physician assistant notes the fundal height is at the level of the umbilicus. This corresponds to what gestational age?

Answers

A. 16 weeks

B. 20 weeks

C. 24 weeks

D. 28 weeks

Explanations

(u) A. See B for explanation.

(c) B. At 20-22 weeks the fundal height is typically at the level of the umbilicus.

(u) C. See B for explanation.

(u) D. See B for explanation.

History & Physical/Urology/Renal

When performing a rectal examination, prostatic massage is contraindicated in

Answers

A. prostatodynia.

B. non-bacterial prostatitis.

C. chronic bacterial prostatitis. D. acute bacterial prostatitis.

Explanations

(u) A. Prostatodynia is an inflammatory disorder involving voiding dysfunction and pelvic floor musculature dysfunction. There is no bacterial involvement.

(u) B. Non-bacterial prostatitis is similar to chronic bacterial prostatitis, but no bacteria are cultured, and the cause is unknown.

(u) C. Prostate massage can be performed in the absence of fever. Expressed prostatic secretions are cultured to help identify the organism.

(c) D. Vigorous manipulation of the prostate during rectal examination may result in septicemia. This is contraindicated in the presence of fever, irritative voiding symptoms, and perineal/sacral pain.

History & Physical/Neurology

A patient with an upper motor neuron lesion would exhibit which of the following findings?

Answers

A. Fasciculations

B. Areflexia

C. Muscular atrophy

D. Spasticity

Explanations

(u) A. Fasciculations, areflexia and muscle atrophy are consistent with lower motor neuron lesions.

(u) B. See A for explanations.

(u) C. See A for explanation.

(c) D. Spasticity is an upper motor neuron lesion finding.

History & Physical/Psychiatry/Behavioral Medicine

A patient with obsessive-compulsive disorder would most likely have which of the following findings?

Answers

A. Raw, red hands

B. Priapism

C. Memory impairment

D. Abdominal pain

Explanations

(c) A. Common manifestations of obsessive-compulsive disorder include phobias of germ and contaminants, which results in frequent hand washing leading to chafe and reddened hands. The other answers are inconsistent with obsessive-compulsive disorder.

(u) B. See A for explanation.

(u) C. See A for explanation.

(u) D. See A for explanation.

History & Physical/Dermatology

In a patient suspected of having seborrheic dermatitis, the most common site of involvement would be the

A. upper extremities.

B. thighs.

C. scalp.

D. feet.

Explanations

(u) A. See C for explanation.

(u) B. See C for explanation.

(c) C. The most common site of involvement of seborrheic dermatitis is the scalp. Other common sites include the eyebrows, eyelids, nasolabial fold, and ears.

(u) D. See C for explanation.

Diagnostic Studies/Hematology

An 8-year-old presents with splenomegaly. CBC results reveal the following: WBC- 6,300/microliter, Hgb- 10.5 g/dl, Hct- 31%, MCV- 87 fL, MCHC- 39 g/dl, MCH- 28 pg, and platelets- 317,000/mL. Examination of the RBC morphology reveals 80% spherocytes. Which of the following would be most helpful in confirming the diagnosis?

A. Direct Coombs test

B. Osmotic fragility

C. G-6-PD level

D. Serum ferritin

Explanations

(u) A. The direct Coombs test would be negative and would not be helpful in diagnosing hereditary spherocytosis.

(c) B. Hereditary spherocytosis presents with a normocytic, normochromic anemia and many spherocytes. Diagnosis is confirmed with a positive osmotic fragility test.

(u) C. G-6-PD deficiency presents with minimal or no RBC morphologic abnormalities and is diagnosed by measuring G-6-PD enzyme activity level.

(u) D. Iron deficiency anemia typically presents with microcytic, hypochromic red blood cells and is diagnosed with a serum ferritin.

Which of the following studies is most appropriate to diagnose celiac disease?

A. Urinary D-xylose test

B. Small bowel biopsy

C. Barium contrast x-ray

D. Schilling test

(u) A. Urinary D-xylose test assesses the proximal small intestinal mucosa's absorption of carbohydrates but is not specific to celiac disease.

(c) B. Definitive diagnosis of celiac disease is made by small bowel biopsy.

(u) C. Barium contrast examination would reveal anatomic abnormalities or blind loop syndrome that may lead to malabsorption but it would not help in the diagnosis of celiac disease.

(u) D. The Schilling test is used to determine the cause of cobalamine malabsorption from pernicious anemia, chronic pancreatitis, achlorhydria and bacterial overgrowth syndrome but has no role in the diagnosis of celiac disease.

Diagnostic Studies/Endocrinology

A patient complains of fatigue, tremors, palpitations, and heat intolerance. The thyroid is diffusely enlarged and firm on palpation. Which of the following laboratory findings is the most consistent with this presentation?

Answers A. Low T4

24

B. Low TSH

C. Decreased bilirubin

D. Normal radionuclide scan

Explanations

(u) A. See B for explanation.

(c) B. The presentation is consistent with hyperthyroidism. Laboratory findings include low TSH, elevated free and total thyroid hormone levels, and an increased uptake on radionuclide scan.

There may also be elevated bilirubin, liver thrombocytopenia.

(u) C. See B for explanation

(u) D. See B for explanation

History & Physical/Orthopedics/Rheumatology

A 12 year-old female presents for a routine sports physical. The physical exam reveals asymmetry of the posterior chest wall on forward bending. This is the most striking and consistent abnormality of which of the following?

Answers

A. Spondylolysis

B. Spondolisthesis

C. Scoliosis

D. Herniated disc

Explanations

(u) A. Spondylolysis presents with limitation of lumbar flexibility and tight hamstring muscles.

(u) B. Spondylolisthesis presents with reduced lumbar lordosis and sacral kyphosis.

(c) C. Asymmetry of the posterior chest wall on forward bending is the most striking and consistent abnormality in patients with idiopathic scoliosis.

(u) D. Herniated disc presents with lumbar muscle spasm and a positive straight leg test.

History & Physical/Pulmonology

A foreign body lodged in the trachea that is causing partial obstruction will most likely produce what physical examination finding?

A. stridor

B. aphonia

C. inability to cough

D. progressive cyanosis

Explanations

(c) A. An inspiratory wheeze is called stridor, which indicates a partial obstruction of the trachea or larynx.

(u) B. Aphonia, inability to cough and progressive cyanosis are seen with complete obstruction of the trachea, not partial obstruction.

(u) C. See B for explanation.

(u) D. See B for explanation.

History & Physical/ENT/Ophthalmology

Which of the following is diagnosed by use of the cover/uncover test?

Answers

A. Adie's pupil

B. Strabismus

C. Glaucoma

D. Myopia

Explanations

(u) A. Adie's pupil is a sluggish pupil reaction to light and accommodation, evaluated by papillary reaction to light.

(c) B. The cover/uncover test is used to diagnose strabismus.

(u) C. Tonometry is used to measure intraocular pressure to evaluate for glaucoma.

(u) D. Myopia is evaluated by using a Snellen chart.

History & Physical/Obstetrics/Gynecology

Which of the following is the most common manifestation of polycystic ovarian syndrome?

Answers

A. Desquamation

B. Hirsutism

C. Galactorrhea

D. Rebound tenderness

Explanations

(u) A. Desquamation is noted in toxic shock syndrome.

(c) B. The patient with polycystic ovarian syndrome typically presents with hirsutism or infertility. (u) C. Galactorrhea is noted in hyperprolactinemia.

(u) D. Rebound tenderness is noted in conditions causing peritonitis.

Diagnostic Studies/Urology/Renal

A 38 year-old female presents with right flank pain for several days, shaking chills, fever to 102°F, and general malaise. The flank pain has been intermittently severe, and she has a history of kidney stones. Urinalysis reveals 3+ red blood cells, 3+ leukocyte esterase, trace protein and negative glucose. Which of the following findings would most likely be seen on a renal ultrasound?

Answers

A. Small echogenic kidneys

B. Cysts

C. Hydronephrosis

D. Capsular hemorrhage

Explanations

(u) A. Small echogenic kidneys bilaterally, less than 10cm, support a diagnosis of chronic renal failure.

(u) B. Cysts and capsular hemorrhage are not causes of obstructive pyelonephritis.

(c) C. Hydronephrosis, dilation of the collecting ducts, may be present due to a stone or other source of obstruction.

(u) D. See B for explanation.

Which of the following tumor markers is useful in monitoring a patient for recurrence of colorectal cancer after surgical resection?

A. CA-125

B. Carcinoembryonic antigen

C. 5-hydroxindoleacetic acid

D. Alpha-1-fetoprotein

(u) A. CA-125 tumor marker is useful as a tumor marker in ovarian cancer

(c) B. Carcinoembryonic antigen can be used to monitor a patient for the return of colorectal cancer after treatment.

(u) C. 5-hydroxindoleacetic acid is used as a tumor marker in carcinoid syndrome.

(u) D. Hepatocellular and testicular cancer can be followed by the use of alpha-1-fetoprotein as a tumor marker.

Diagnostic Studies/Neurology

What test is the single most useful test in establishing the diagnosis of multiple sclerosis?

Answers

A. Cerebral spinal fluid cell count and protein level

B. Cerebral spinal fluid immunoglobulin studies

C. Evoked potentials

D. Magnetic Resonance Imaging

Explanations

(u) A. While cerebral spinal fluid cell count, protein levels, and immunoglobins may be abnormal they are not specific for multiple sclerosis.

(u) B. See A for explanation.

(u) C. Evoked potentials are most useful in the detection of subclinical involvement of neuropathways in MS, but does not establish the diagnosis.

(c) D. The presence of plaques on MRI is a key finding in establishing the diagnosis of MS.

Diagnostic Studies/Psychiatry/Behavioral Medicine

A 19 year-old female presents with complaints of intermittent abdominal pain associated with recent, frequent episodes of regurgitation of food for the past several months and worsening over the past 12 hours. She maintains a normal weight for her height however she seems obsessed with losing weight. On examination the physician assistant notes multiple dental caries, bilateral tenderness of the parotid glands and mild epigastric tenderness. Which of the following findings would you expect to find on laboratory tests to support your suspected diagnosis?

Answers

A. hypokalemia

B. hypocalcemia

C. hyperchloremia

D. hypermagnesemia

Explanations

(c) A. This patient most likely has bulimia nervosa - purging type. Self-induced vomiting is the most common method of purging and this is supported by the physical examination findings noted in this patient. Laboratory findings to support this diagnosis include hypochloremia with subsequent hypokalemia due to renal compensatory mechanisms, hypomagnesemia and metabolic alkalosis.

(u) B. See A for explanation.

(u) C. See A for explanation.

(u) D. See A for explanation.

Diagnostic Studies/Dermatology

A 26 year-old male complains of intense itching, especially at night and after hot showers, for the past 4 days. On physical examination he has a few red papules and areas of excoriation on his volar wrists, between his fingers, and around his waist. Proper diagnosis should include which of the following tests?

A. KOH prep

B. Gram stain

C. Skin scraping microscopy

D. Tzanck prep

Explanations

(u) A. A KOH prep would be used to examine for evidence of a fungal infection.

(u) B. A Gram stain would be used for a bacterial infection and would be inappropriate in this situation.

(c) C. The history and exam is consistent with a scabies infection. Scrapings from the burrows should be examined for the presence of mites, eggs, and feces.

(u) D. A Tzanck prep would be used to examine for giant multinucleated cells characteristic of a herpes infection.

Diagnosis/Hematology

A 60-year-old presents with fatigue and splenomegaly. CBC reveals the following: WBC- 24,000/microliter, Hgb- 13.5 g/dl, Hct- 40%, MCV- 87 fL, MCHC- 34 g/dl, MCH- 28 pg, and platelets- 380,000/mL. The differential reveals neutrophils- 11%, lymphocytes- 80%, monocytes- 8%, and basophils- 1%. What is the most likely diagnosis?

A. Acute lymphocytic leukemia

B. Acute myelogenous leukemia

C. Chronic lymphocytic leukemia

D. Chronic myelogenous leukemia

Explanations

(u) A. Acute lymphocytic leukemia is more common in children and presents with blasts in the peripheral blood.

(u) B. Acute myelogenous leukemia presents with pancytopenia and presence of blasts in the peripheral blood.

(c) C. Chronic lymphocytic leukemia presents with a WBC count greater than 20,000/microliter and absolute lymphocyte count of greater than 5000/microliter.

(u) D. Chronic myelogenous leukemia presents with elevated WBC count, marked left shift in the myeloid series of cells, and positive for Philadelphia chromosome.

History & Physical/Orthopedics/Rheumatology

Physical exam findings in a 4 year-old child that include blue sclerae and recurrent fractures indicates which of the following?

Answers

A. Ehlers-Danlos syndrome

B. Marfan syndrome

C. Achondroplasia

D. Osteogenesis imperfecta

Explanations

(u) A. Physical exam findings in Ehlers-Danlos include laxity and hypermobility of joints, mitral valve prolapse, and associated degenerative arthritis.

(u) B. Children with Marfan syndrome have hypotonia, arachnodactyly, joint laxity and dislocations.

(u) C. Children with achondroplasia are below normal standards on growth charts. They have difficulty balancing their large heads when beginning to walk.

(c) D. Mild osteogenesis imperfecta presents with blue sclerae, history of recurrent fractures and presenile deafness.

History & Physical/Pulmonology

On physical examination you note diminished breath sounds over the right lower lobe with decreased tactile fremitus and dullness to percussion. Which of the following is the most likely cause?

Answers

A. asthma

B. consolidation

C. pneumothorax

D. pleural effusion

Explanations

(u) A. Asthma is characterized by decreased tactile fremitus, but would have resonant to hyperresonant percussion, not dullness.

(u) B. Consolidation from pneumonia is characterized by dullness to percussion, but would have an increased, not decreased, tactile fremitus.

(u) C. A pneumothorax is characterized by decreased to absent tactile fremitus, but would have a hyperresonant percussion note, not dullness.

(c) D. A decreased tactile fremitus and dullness to percussion would be found in a pleural effusion.

Diagnostic Studies/ENT/Ophthalmology

A 32 year-old carpenter complains of right eye irritation all day after driving a metal stake into the ground with his hammer. He states that "something flew into my eye." Visual acuity is 20/20. Pupils are equal, round, reactive to light and accommodation. Extraocular movements are intact. There is minimal right corneal injection. No foreign body is noted with lid eversion. Fluorescein stain reveals a tiny pinpoint uptake in the area of the corneal injection. Which of the following is the most appropriate diagnostic test at this stage?

Answers

A. MRI

B. X-ray orbits

C. Applanation tonometry

D. Fluorescein angiography

Explanations

(h) A. MRI should never be used when there is suspicion of an iron-containing intraocular foreign body.

(c) B. Orbital x-rays or CT scan will be most helpful in identifying an intraocular metallic foreign body.

(u) C. Tonometry is used to evaluate intraocular pressure, but not the presence of intraocular foreign bodies.

(u) D. Fluorescein angiography is used to evaluate vessels of the eye, not intraocular foreign bodies.

Diagnostic Studies/Obstetrics/Gynecology

A 25 year-old female presents with vulvar pruritus and a thick, white vaginal discharge. Which of the following tests will be most helpful in making the correct diagnosis?

Answers

A. KOH prep

B. Gram stain

C. Tzanck smear

D. FTA-ABS

Explanations

(c) A. KOH prep is used to assist in the diagnosis of vaginal candidiasis, which presents with vulvar pruritus and white curd like, cheesy vaginal discharge.

(u) B. Gram stain is used in the diagnosis of bacterial infections.

(u) C. Tzanck smear is used to diagnose herpes infections.

(u) D. FTA-ABS is used to diagnose syphilis.

Diagnostic Studies/Endocrinology

A solitary thyroid nodule is noted on physical examination. The TSH level is normal. The next step in the evaluation is

Answers

A. measurement of T4 and free T3 levels. B. a radionuclide thyroid scan.

C. a fine needle biopsy.

D. a surgical excision.

Explanations

(u) A. Measurement of T4 and T3 levels would not be of benefit in the evaluation of a solitary thyroid nodule with a normal TSH level.

(u) B. A thyroid scan would be the next step if there were a low TSH level.

(c) C. Fine needle aspiration (FNA) is the first step in the evaluation of a solitary nodule with a normal TSH level. FNA has a high level of accuracy in diagnosing benign versus malignant nodules in this setting.

(u) D. Surgical excision would be the final step after determination of malignancy or suspicion of malignancy by FNA.

Diagnostic Studies/Urology/Renal

A 65 year-old patient presents with hypertension and peripheral edema. Urinalysis reveals pale urine, with a specific gravity of 1.002, 2+ protein, trace glucose, and is negative for red blood cells and leukocytes. Serum electrolytes include BUN of 58 mg/dl and creatinine of 4.5 mg/dl. These are unchanged from previous results obtained 3 months and 6 months ago. Of the following, what other laboratory abnormalities would you expect?

Answers

A. Hypercalcemia

B. Metabolic alkalosis

C. Hypophosphatemia

D. Anemia

Explanations

(u) A. Patients with chronic renal failure typically present with hypocalcemia, hyperphosphatemia, and metabolic acidosis.

(u) B. See A for explanation.

(u) C. See A for explanation.

(c) D. Anemia of chronic disease is associated with chronic renal failure.

Diagnostic Studies/Neurology

A 22 year-old male presents to the clinic complaining of excessive daytime somnolence and strong desires to sleep at inappropriate times. He came in today because he had an episode of "feeling paralyzed" as he was falling asleep yesterday. What is the most appropriate diagnostic test to confirm this patient's diagnosis?

Answers

A. MRI of the brain

B. Electroencephalogram

C. Multiple sleep latency test

D. Overnight polysomnography

Explanations

(u) A. See C for explanation.

(u) B. See C for explanation.

(c) C. Multiple sleep latency test is required to observe the abrupt transition to REM sleep and establish the diagnosis of narcolepsy.

(u) D. See C for explanation.

Diagnostic Studies/Dermatology

A 35 year-old female who recently returned from a backpacking trip complains of fatigue, malaise, fever, chills, and arthralgias. Physical examination reveals a 6 cm annular lesion with a red border and a clear center on her mid-back. Which of the following laboratory tests would support your diagnosis?

A. KOH prep of skin scrapings

B. Blood cultures

C. RAST testing

D. Serologic antibody testing

Explanations

(u) A. Although the skin lesion may resemble a fungal infection, a fungal dermatophyte would not present with systemic symptoms.

(u) B. Culturing of Borrelia burgdorferi from clinical specimens, with the exception of skin biopsies at the site of the lesion, have resulted in low yields.

(u) C. RAST testing is utilized in evaluation of allergies and is not indicated in this situation.

(c) D. Most people with Lyme Disease will have a positive serologic test after the first few weeks of infection and this would support the diagnosis.

Health Maintenance/Hematology

A patient with multiple myeloma should be immunized against which of the following organisms?

A. Streptococcus pneumoniae

B. Hepatitis C virus

C. Listeria monocytogenes

D. Epstein Barr virus

Explanations

(c) A. Patients with multiple myeloma are prone to infections with encapsulated organisms such as Streptococcus pneumoniae and Haemophilus influenzae.

(u) B. See A for explanation.

(u) C. See A for explanation.

(u) D. See A for explanation.

A 14 month-old male who attends day care presents with a two-day history of frequent watery stools. His mother states that he had a fever and vomiting the day before but these have resolved. His mother denies pain in the child. The child is mildly dehydrated but otherwise appears well. Stool samples are free of blood and white blood cells. The lab reports no ova or parasites noted in the stool samples. Which of the following is the most likely diagnosis?

A. Intussusception

B. Viral gastroenteritis

C. Shigella

D. Lactase insufficiency

(u) A. Intussusception may cause diarrhea, however, after two days the stool would have blood present. The absence of pain or discomfort would also argue against this diagnosis.

(c) B. Rotavirus is the most common cause of gastroenteritis in children and this is frequently passed in the daycare setting.

(u) C. Patients with Shigella have dysentery with the passage of bloody stools in a toxic-appearing child

(u) D. Lactase insufficiency would not have caused fever and vomiting.

Diagnostic Studies/Psychiatry/Behavioral Medicine

A divorced female patient presents for an employment physical. She states she has had a "run of bad luck" with jobs and has not been able to hold any job for longer than 2-3 months. She also states she has been arrested several times for getting into fights when she is out with the girls. She states she drinks an occasional beer, but denies any significant problems with alcohol. Which of the following laboratory findings would support your suspected diagnosis?

Answers

A. decreased triglycerides

B. decreased serum uric acid

C. increased LDL cholesterol

D. increased mean corpuscular volume

Explanations

(u) A. See D for explanation.

(u) B. See D for explanation.

(u) C. The primary lipid abnormalities demonstrated with alcoholism are increased triglycerides and increased HDL cholesterol, not LDL cholesterol.

(c) D. This patient most likely has alcohol abuse as evidence by her social, occupational and legal issues. Laboratory tests will reveal the presence of an elevated mean corpuscular volume, triglycerides, serum uric acid and liver function tests.

Diagnostic Studies/ENT/Ophthalmology

A 45 year-old male complains of loss of hearing in his left ear. He also complains of ringing in the ear, and has had occasional dizziness. On exam, there is unilateral left- sided sensorineural hearing loss and a diminished corneal reflex. Neuro exam is otherwise normal. TMs are normal, and canals are clear. Neck is supple, without adenopathy. Oropharynx is normal. Of the following, the best diagnostic study to identify the cause of this patient's complaints is

Answers

A. auditory brainstem evoked response.

B. gadolinium-enhanced MRI.

C. acoustic reflex testing.

D. vestibular testing.

Explanations

(u) A. See B for explanation.

(c) B. MRI has replaced auditory brainstem evoked response and acoustic reflex testing in the evaluation of patients for acoustic neuromas.

(u) C. See B for explanation.

(u) D. Vestibular testing is not a useful screening test for acoustic neuromas.

Diagnosis/Endocrinology

A 30 year-old female complains of fatigue, weakness, diminished appetite, weight loss, and syncope. She denies fever, chest or abdominal pain, palpitations, changes in bowel patterns or sleep patterns. Physical examination reveals a thin female, BP 90/65 mmHg, and pulse 80 beats per minute. Pulmonary, cardiovascular, abdominal, and neurologic exam are without abnormalities. Areas of brown and bronze hyperpigmentation are noted

39

on her elbows and the creases of her hands. Which of the following is the most likely diagnosis?

Answers

A. Addison's disease

B. Cushing's disease

C. Anorexia nervosa

D. Porphyria

Explanations

(c) A. Addison's disease (adrenal insufficiency) would account for all her symptoms, the hypotension, and the hyperpigmentation of the skin.

(u) B. Cushing's disease, the presence of an ACTH-producing adenoma, is characterized by central obesity, hypertension, moon facies, purple striae, and glucose intolerance.

(u) C. Anorexia nervosa may explain the weakness, weight loss, hypotension, and syncope, however, a normal pulse rate would be an unexpected finding along with the hyperpigmentation.

(u) D. Porphyria presents acutely with anxiety, depression, disorientation, and insomnia.

Diagnostic Studies/Pulmonology

Which of the following is essential to make a diagnosis of cystic fibrosis?

Answers

A. Positive family history

B. Elevated sweat chloride

C. Recurrent respiratory infections

D. Elevated trypsinogen levels

Explanations

(u) A. Cystic fibrosis is a genetic disease, but a positive family history in and of itself is not enough to diagnose the condition.

(c) B. The diagnosis of cystic fibrosis is made only after an elevated sweat chloride test or demonstration of a genotype consistent with cystic fibrosis.

(u) C. While recurrent respiratory infections are a classic presentation of cystic fibrosis, the diagnosis relies on confirmation, as noted in explanation B.

(u) D. Trypsinogen levels are used as a neonatal screening test and if elevated should be followed by more definitive testing to confirm the diagnosis.

Diagnostic Studies/Orthopedics/Rheumatology

A 65 year-old female presents to the office with a six-month history of back pain. The patient states that she is shrinking and thinks she is about an inch shorter than she was a year ago. Serum parathyroid hormone, calcium, phosphorus, and alkaline phosphatase are all normal. Which of the following would you most likely see on the x-ray of her spine?

Answers

A. Radiolucent lesions

B. Demineralization

C. Chondrocalcinosis

D. Subperiosteal resorption

Explanations

(u) A. Paget's disease of bone presents with bone pain, kyphosis, bowed tibias, large head, and deafness. The initial lesions are destructive and radiolucent. Paget's disease has a normal serum calcium and phosphate, but the serum alkaline phosphatase is elevated.

(c) B. Osteoporosis presents with varying degrees of back pain and loss of height is common. The serum calcium, parathyroid hormone, phosphorus, and alkaline phosphatase are normal. X- ray findings demonstrate demineralization in the spine and pelvis.

(u) C. Chondrocalcinosis is the presence of calcium-containing salts in articular cartilage and is commonly seen in hyperparathyroidism, diabetes, hypothyroidism, and gout.

(u) D. Hyperparathyroidism is frequently asymptomatic. Serum parathyroid hormone and serum calcium are elevated. X-ray findings include demineralization, subperiosteal resorption of bone especially in the radial aspects of the fingers.

Diagnostic Studies/Obstetrics/Gynecology

A 25 year-old presents with pelvic pain and uterine bleeding. Her Beta-HCG was 1200 mIU/L six days ago. Her current Beta-HCG is 1600 mIU/L. What is the next best test in the evaluation of this patient?

Answers

A. Laparoscopy

B. Culdocentesis

C. Dilation and curettage

D. Transvaginal ultrasound

Explanations

(u) A. The use of laparoscopy in the diagnosis of an ectopic pregnancy has decreased, but is still useful when a definitive diagnosis is difficult.

(u) B. Culdocentesis is used in the diagnosis of intraperitoneal bleeding, which may or may not be present in an ectopic pregnancy.

(u) C. Dilation and curettage may confirm or exclude intrauterine pregnancy but is not the next best test in the evaluation of ectopic pregnancy.

(c) D. Transvaginal ultrasound is the best test to separate ectopic from intrauterine pregnancy.

Diagnosis/Psychiatry/Behavioral Medicine

A 20 year-old male presents to the ED with complaints of palpitations and agitation, which developed suddenly while attending a party. On examination, the patient is moderately agitated and tremulous. Vital signs include a pulse of 110/minute and regular; respiratory rate 22/minute and blood pressure 160/92 mmHg. Skin is diaphoretic and pupils are dilated. Which of the following is the most likely diagnosis?

Answers

A. Heroin use

B. Cocaine use

C. Scombroid ingestion

D. Alcohol intoxication

Explanations

(u) A. Opioids, such as heroin produce euphoria, drowsiness and constricted pupils. Severe intoxication causes bradycardia, respiratory arrest, and hypotension.

(c) B. Cocaine, as well as amphetamines, leads to a clinical picture of increased sympathetic stimulation and dilated pupils.

(u) C. Clinical findings of scombroid include flushing, reversal of hot and cold sensations and hives.

(u) D. Alcohol, as well as barbiturates and sedative-hypnotic agents, cause central nervous system depression, leading to bradycardia and hypotension.

Diagnosis/Urology/Renal

A 65 year-old male with a 60 pack-year smoking history presents with painless hematuria for two days. He also complains of frequency and dysuria. He denies a history of recent upper respiratory tract infection. Which of the following is the most likely diagnosis?

Answers

A. Bladder cancer

B. Wegener's granulomatosis

C. IgA nephropathy

D. Benign prostatic hypertrophy

Explanations

(c) A. Bladder cancer is associated with smoking and presents with painless hematuria.

(u) B. Wegener's granulomatosis disease involves the kidneys and the lungs. Renal signs include hematuria, red blood cells casts, and proteinuria.

(u) C. IgA nephropathy typically presents after an upper respiratory tract infection and presents with hematuria and proteinuria.

(u) D. BPH presents with voiding symptoms such as hesitancy, straining, weak stream and postvoid dribbling.

Diagnosis/Neurology

A 54 year-old male smoker presents to the clinic complaining of frequent vague headaches with associated vomiting that awaken him from sleep occasionally and have been present upon awakening for about two weeks. The headache typically resolves about an hour into his morning routine. The patient is afebrile. What is the most likely cause of this patient's headaches?

Answers

A. Cluster headaches

B. Depression

C. Glioblastoma

D. Giant cell arteritis

Explanations

(u) A. Cluster headaches can awaken patients, but are not usually "vague".

(u) B. See C for explanation.

(c) C. Morning headaches associated with vomiting are indicative of increased intracranial pressure and raise concern of a CNS tumor such as a glioblastoma.

(u) D. Giant cell arteritis presents in the older patient with headache in the temporal region and loss of vision.

A patient develops abdominal cramps and watery diarrhea 10 to 12 hours after eating a plate of unrefrigerated meat and vegetables. The patient denies vomiting. The causative agent is most likely

A. Staphylococcus aureus.

B. Clostridium perfringens.

C. Escherichia coli.

D. Salmonella.

(u) A. Staphylococcus aureus has an incubation period of 1 to 6 hours and also characteristically has vomiting associated with it.

(c) B. Food poisoning caused by Clostridium perfringens

has an incubation period of 8 to 14 hours and results frompoorly refrigerated cooked meat.

(u) C. The incubation period for Escherichia coli and Salmonella is greater than 16 hours.

(u) D. See C for explanation.

Clinical Intervention/Hematology

It is essential to advise a patient with infectious mononucleosis to

A. avoid contact sports.

B. continue to rest as much as possible.

C. gargle with salt water for relief of throat pain.

D. rest voice to prevent hoarseness.

Explanations

(c) A. Patients with acute infectious mononucleosis often have enlargement of the spleen. Contact sports increase the risk for splenic rupture after contact. The other answers are suggestions that may improve symptoms but do not truly impact the care of the patient.

(u) B. See A for explanation.

(u) C. See A for explanation.

(u) D. See A for explanation.

Diagnosis/Dermatology

A 56 year-old, right hand dominant, carpenter presents to your clinic complaining of a prolonged bruise under his left thumbnail. He states that he first noticed it one year ago. Physical examination reveals a nontender left thumb with a 6 mm macular lesion located under the distal nail bed. It is mixed dark brown and black in color, with irregular borders. The most likely diagnosis is

Answers

A. lentigo.

B. trauma.

C. melanoma.

D. nevus.

Explanations

(u) A. Lentigos are typically uniform in color with well-demarcated borders.

(u) B. If the lesion was from trauma, it should have resolved well before one year.

(c) C. Acral lentiginous melanoma may occur on the palm, sole, nail bed, or mucus membrane. This lesion is suspicious for a melanoma due to its irregular borders, being variegated in color, and its size. A biopsy is required and will insure the diagnosis.

(u) D. A nevus usually has regular, well-demarcated borders.

Diagnosis/Endocrinology

A 72 year-old female is being evaluated for recurrent kidney stones. Physical examination reveals no abnormal findings. Laboratory findings show elevated calcium and decreased phosphate levels. Which of the following is the most likely diagnosis?

Answers

A. Pheochromocytoma

B. Adrenal insufficiency

C. Hyperparathyroidism

D. Breast cancer

Explanations

(u) A. Pheochromocytoma may lead to hypercalcemia but the patient does not have any signs or symptoms suggestive of pheochromocytoma, such as hypertension, headache, profuse sweating, or weight loss.

(u) B. Adrenal insufficiency, Addison's disease, would reveal, in addition to the hypercalcemia, anorexia, nausea and vomiting, weight loss, and cutaneous hyperpigmentation, none of which are evident in this patient.

(c) C. The majority of patients with hyperparathyroidism are asymptomatic. Recurrent nephrolithiasis may be one of the presentations of primary hyperparathyroidism. Measurement of parathyroid levels would be the initial laboratory test for the evaluation of hypercalcemia.

(a) D. Hypercalcemia may be the earliest manifestation of a malignancy and this must be investigated. Most often the signs and symptoms of a malignancy will cause the patient to seek medical care. Malignancy is the second leading cause of hypercalcemia, behind hyperparathyroidism.

Diagnostic Studies/Orthopedics/Rheumatology

In a trauma patient who has a suspected cervical spine injury, the x-ray view that will identify the majority of significant injuries is

Answers

A. lateral.

B. oblique.

C. anteroposterior.

D. odontoid.

Explanations

(c) A. The lateral view shows 70-80% of significant injuries. It is important to visualize all seven cervical vertebrae and the upper margin of T1 to avoid missing possible pathology.

(u) B. The oblique view is usually not included in the initial set of x-rays taken. Bilateral supine oblique is a view that may be ordered if all seven cervical vertebrae are not seen on the lateral view.

(u) C. Anteroposterior view shows < 1% of significant injuries.

(u) D. The odontoid view reveals 10% of significant injuries.

Diagnostic Studies/Pulmonology

An adult patient who is HIV positive receives a PPD. He develops an area of induration that measures 8 mm after 48 hours. Which of the following is the most appropriate interpretation of this test result?

Answers

A. positive

B. negative

C. active infection

D. falsely negative

Explanations

(c) A. A reaction size of greater than or equal to 5 mm in a HIV positive patient is considered a positive tuberculin skin test reaction.

(u) B. See A for explanation.

(u) C. A positive PPD identifies patients that have been infected with Mycobacterium tuberculosis, but does not indicate whether the disease is currently active or inactive.

(u) D. See A for explanation.

Diagnosis/ENT/Ophthalmology

A 23 year-old graduate student presents with sudden onset of severe dizziness, with nausea and vomiting for the past couple of hours. She denies hearing loss or tinnitus. She has had a recent cold. Which of the following is the most likely diagnosis?

Answers

A. Ménière's disease

B. Vestibular neuronitis

C. Benign positional vertigo

D. Vertebrobasilar insufficiency

Explanations

(u) A. Ménière's disease is associated with hearing loss, tinnitus, and vertigo that lasts from seconds to hours.

(c) B. Vestibular neuronitis or labyrinthitis presents with vertigo, nausea, and vomiting, but not hearing loss or tinnitus. It is related to viral URIs, and develops over several hours, with symptoms worse in the first day, with gradual recovery over several days.

(u) C. Benign positional vertigo occurs with changes in position, especially rapid movements of the head. Nausea may occur, but vomiting is not significant.

(u) D. Vertebrobasilar insufficiency is usually accompanied by brain stem findings, such as diplopia, dysarthria, or dysphagia, and is not common in this age group.

Diagnostic Studies/Obstetrics/Gynecology

A couple presents having not been able to conceive over the past 12 months. Evaluation of the male has been normal. The female has had regular menses. Ovulation can be confirmed with mid-luteal phase measurement of which of the following?

Answers

A. Thyroid stimulating hormone B. Luteinizing hormone

C. Progesterone

D. Prolactin

Explanations

(u) A. TSH is used only if signs of thyroid disease are present.

(u) B. LH, FSH, and prolactin are used to confirm ovulation in patients with irregular menstrual cycles.

(c) C. Ovulation can best be confirmed by measuring serum progesterone levels in the mid-luteal phase.

(u) D. See B for explanation.

Diagnosis/Urology/Renal

A patient on acetazolamide for glaucoma complains of increasing shortness of breath. The patient denies cough, chest pain, or fever. Physical examination is unremarkable except for an increased respiratory rate of 30/minute. Labs include Na 132 mEq/L, K 5.6 mEq/L, Cl 120 mEq/L, and CO2 10 mEq/L. Arterial blood gas results are pH 7.18, pO2 98 mmHg, pCO2 22 mmHg, and HCO3 8 mEq/L. Based upon these results, what is the diagnosis?

Answers

A. Metabolic alkalosis

B. Metabolic acidosis

C. Respiratory alkalosis

D. Respiratory acidosis

Explanations

(u) A. See B for explantation.

(c) B. Acetazolamide inhibits carbonic anhydrase, which inhibits bicarbonate ion regeneration, with resulting normal anion-gap, hyperchloremic acidosis. Respiratory compensatory mechanisms lead to hyperventilation.

(u) C. See B for explantation.

(u) D. See B for explantation.

Diagnosis/Neurology

A 28 year-old female presents to the clinic complaining of a "prickly sensation" that started bilaterally in her feet two days ago and difficulty walking. She now has the dysesthesia from her mid-thigh down to her toes. On physical examination she has diminished pain and temperature sensation, absent reflexes, loss of proprioception in her legs bilaterally, and muscle strength is 1+/5+ in the lower extremities and 5+/5+ in the upper extremities. What is the most likely diagnosis?

A. Guillain-Barré syndrome

B. Multiple sclerosis

C. Myasthenia gravis

D. Spinal cord compression

Explanations

(c) A. The pattern of sensory, motor and reflex findings is consistent with the pathophysiology of peripheral nerve demyelination that occurs in Guillain-Barré syndrome.

(u) B. Multiple sclerosis does not present as a symmetrical ascending paralysis.

(u) C. Patients with myasthenia gravis tend to have intermittent symptoms that affect proximal and extraocular muscles most notably and it also lacks sensory involvement.

(u) D. Although the exact type of cord transection can alter the pattern of motor and sensory findings a patient with spinal cord compression who is not in spinal shock would have hyperreflexia instead of areflexia.

Diagnosis/Psychiatry/Behavioral Medicine

A 53 year-old man with a history of hypertension is being treated with atenolol (Tenormin). He currently presents complaining of chronic fatigue, insomnia, decreased appetite, and difficulty concentrating for the past 3 weeks. His wife also notes that he no longer goes bowling with his friends and has lost interest in any sexual intimacy. Physical examination is unremarkable. Which of the following is the most likely diagnosis?

Answers

A. major depression

B. dysthymic disorder

C. atypical depression

D. drug-induced depression

Explanations

(c) A. Diagnostic criteria for a major depressive disorder include a loss of pleasure in usual activities, vegetative or physical changes (poor appetite, loss of energy), and cognitive changes such as difficulty in concentrating.

(u) B. A dysthymic disorder is a chronic depressive disorder whose symptoms are milder, but longer lasting (> 2 years) than those in a major depressive episode.

(u) C. Atypical depression is characterized by hypersomnia, overeating, lethargy, and rejection sensitivity, which are not present in this case.

(u) D. While beta-blockers may cause fatigue and sleep disturbances, they do not cause a depressive disorder.

Diagnosis/Dermatology

A mother brings in her 2 year-old child stating that the child has had a 3-day history of a nonproductive cough, thick copious rhinorrhea, conjunctivitis, and a fever to 103 degrees. Physical examination reveals a well-hydrated child, with numerous 1-2 mm white papules on both buccal mucosa, normal heart and breath sounds. This presentation is most consistent with early

Answers

A. rubeola.

B. rubella.

C. varicella.

D. streptococcal pharyngitis

Explanations

(c) A. Rubeola (measles) is characterized by cough, coryza, and conjunctivitis, along with a fever as a prodrome. Koplik spots appear prior to the onset of the typical erythematous, maculopapular rash and are pathognomonic for rubeola.

(u) B. See A for explanation.

(u) C. See A for explanation.

(u) D. See A for explanation.

Clinical Therapeutics/Hematology

A 6 year-old male presents with hemarthrosis of the left knee. Coagulation studies reveal the following results: PT- 12.5 seconds with an INR: 1.0, aPTT:58 seconds, platelet count: 430,000/microliter, and bleeding time:4 minutes. Which of the following is the best treatment option for this patient?

A. Desmopressin acetate

B. Corticosteroids

C. Vitamin K

D. Cryoprecipitate

Explanations

(u) A. Desmopressin acetate is indicated in von Willebrand's disease, which presents with a prolonged bleeding time.

(u) B. Corticosteroids are indicated in immune-mediated thrombocytopenia.

(u) C. Vitamin K deficiency will prolong the PT greater than the aPTT. Vitamin K supplement is not indicated in this patient.

(c) D. Hemophilia A presents with a prolonged aPTT and normal platelet count and function. Hemophilia A is treated with factor VIII concentrate or cryoprecipitate.

The most common initial presenting symptom of primary biliary cirrhosis is

A. jaundice

B. palmar erythema

C. pruritus

D. xanthomas

(u) A. Jaundice, palmar erythema and xanthomas appear late in the disease.

(u) B. See A for explanation.

(c) C. Pruritus is the most common initial symptom in primary biliary cirrhosis due to the accumulation of bile salts.

(u) D. See A for explanation.

Diagnosis/Endocrinology

A 38 year-old male presents to your clinic complaining of increasing constant headaches and progressive loss of peripheral vision. His medical and family history is unremarkable. Physical examination reveals bitemporal hemianopsia but is otherwise without any abnormalities. Which of the following is the most likely diagnosis?

Answers

A. Aneurysm involving the circle of Willis B. Migraine headache

C. Multiple sclerosis

D. Pituitary tumor

Explanations

(u) A. An aneurysm involving the circle of Willis would result in CN III palsy. This would be a rare finding.

(u) B. Although a migraine headache may produce visual field defects, these defects would remit upon resolution of the migraine. It would also be unusual to have the scotomas occur bilaterally.

(u) C. Optic neuritis associated with multiple sclerosis presents with decreased visual acuity, dimness, or color desaturation in the central visual field. It would not affect the periphery.

(c) D. A pituitary tumor would account for the headaches and the loss of the peripheral vision in both visual fields. As the tumor grows, the optic chiasm will be compressed by the tumor.

Diagnostic Studies/Orthopedics/Rheumatology

A 38 year-old male sustained a fracture of the left distal tibia following a 25-foot fall and is taken to the operating room for an open reduction internal fixation of the distal tibia. Sixteen hours post-op, the patient develops sustained pain, which is not relieved with narcotics. On passive range of motion of the toes the patient "yells" in agony. The patient also states that the top of his foot has decreased sensation. On physical examination the physician assistant notes that the leg is swollen and the foot is cool to touch. Based upon this information what diagnostic testing should be done?

Answers

A. X-ray of the lower leg and ankle.

B. Doppler studies.

C. Bone scan.

D. Compartment pressure

Explanations

(u) A. X-rays of the lower leg and ankle will only determine bone placement.

(u) B. Doppler studies will confirm the presence of a decreased pulse.

(u) C. A bone scan is not indicated in the evaluation of compartment syndrome.

(c) D. Compartmental pressures should be obtained as soon as possible. If they are elevated this is a surgical emergency.

Diagnostic Studies/Pulmonology

A 23 year-old female with history of asthma for the past 5 years presents with complaints of increasing shortness of breath for 2 days. Her asthma has been well controlled until 2 days ago and since yesterday she has been using her albuterol inhaler every 4-6 hours. She is normally very active, however yesterday she did not complete her 30 minutes exercise routine due to increasing dyspnea. She denies any cough, fever, recent surgeries or use of oral contraceptives. On examination, you note the presence of prolonged expiration and diffuse wheezing. The remainder of the exam is unremarkable. Which of the following is the most appropriate initial diagnostic evaluation prior to initiation of treatment?

Answers

A. chest x-ray

B. sputum gram stain

C. peak flow

D. ventilation - perfusion scan

Explanations

(u) A. A chest x-ray should be ordered in an asthmatic patient only if you are concerned about the presence of pneumonia or pneumothorax, neither of which is supported by the H&P findings noted above.

(u) B. A sputum gram stain is performed in patients who you suspect have an infectious process, such as pneumonia.

(c) C. A peak flow reading will help you to gauge her current extent of airflow obstruction and is helpful in monitoring the effectiveness of any treatment interventions.

(u) D. A ventilation-perfusion scan (V/Q scan) is indicated in cases of suspected pulmonary embolism. The patient above does not have any risk factors that would lead you to suspect such a diagnosis.

Diagnosis/ENT/Ophthalmology

A 4 year-old boy presents with purulent, foul-smelling nasal discharge for three days. He has not had any other symptoms of respiratory illness, cough, wheeze, or fever. His activity level and appetite has been normal. On exam, he is afebrile. TM's have normal light reflex, canals are clear. Left nare is clear; there is considerable amount of purulent exudate from the right nare, and a bright reflection of light is noticed. Oropharynx is without inflammation or exudate. Neck is supple, without lymphadenopathy. Lungs are clear, with equal breath sounds and no wheezing. Heart has regular rhythm without murmurs. Which of the following is the most likely diagnosis?

Answers

A. Viral URI

B. Acute sinusitis

C. Allergic rhinitis

D. Nasal foreign body

Explanations

(u) A. Viral URI does not present with foul-smelling nasal discharge.

(u) B. Acute sinusitis may present with purulent nasal discharge, but the observation of a bright light reflection suggests a foreign body.

(u) C. Allergic rhinitis is seasonal, associated with sneezing and other allergy-related symptoms.

(c) D. Nasal foreign body is suggested by unilateral nasal obstruction or discharge .

Diagnosis/Obstetrics/Gynecology

A 30 year-old presents with persistent vaginal discharge and vulvar pruritus. The discharge is profuse, frothy, greenish, and foul smelling. pH of the vagina is 6.0. Which of the following is the most likely diagnosis?

Answers

A. Vulvovaginal candidiasis

B. Bacterial vaginosis

C. Trichomoniasis

D. Atrophic vaginitis

Explanations

(u) A. Vulvovaginal candidiasis presents with a thick, curd-like discharge and vulvar pruritus.

(u) B. Bacterial vaginosis presents with malodorous, gray-white discharge. The pH is typically 5.0-5.5.

(c) C. Trichomoniasis presents with vulvar pruritus and a profuse, frothy, greenish, foul-smelling vaginal discharge with a pH usually exceeding 5.0.

(u) D. Atrophic vaginitis is usually without discharge, but presents with vaginal dryness.

Diagnosis/Neurology

A 51 year-old female presents to the clinic complaining of intermittent sharp pain that originates at the corner of her mouth and radiates toward her ipsilateral eye. She notes "everything makes it worse" including touching the area, talking and eating. What is the most likely diagnosis?

Answers

A. Bell's palsy

B. Cluster headache

C. Post-herpetic neuralgia

D. Trigeminal neuralgia

Explanations

(u) A. See D for explanation.

(u) B. See D for explanation.

(u) C. See D for explanation.

(c) D. This is the classic presentation for trigeminal neuralgia (tic douloureux).

Health Maintenance/Urology/Renal

Patients with recurrent urinary stone disease should be educated to maintain a diet restricted in

Answers

A. sodium and protein.

B. carbohydrates and fat.

C. bran.

D. fluids.

Explanations

(c) A. Increased sodium intake will increase sodium and calcium excretion and increase monosodium urate saturation. Protein also increases calcium, oxalate and uric acid excretion. All these factors can lead to stone formation.

(u) B. Carbohydrates and fat do not have any impact on urinary stone disease.

(u) C. Bran significantly lowers urinary calcium, reducing risk for stone recurrence.

(u) D. Increased fluids is important in reducing stone recurrence.

Health Maintenance/Dermatology

A person with atopic dermatitis should be advised to

A. avoid cutaneous irritants.

B. take hot water baths or showers.

C. use a high potency glucocorticoid on skin after bathing.

D. begin a prophylactic antibiotic.

Explanations

(c) A. Avoidance of cutaneous irritants, such as wool and other rough clothing, is the cornerstone of therapy for atopic dermatitis.

(u) B. Patients should bathe in warm, tepid water, not hot water.

(u) C. Topical glucocorticoids of low or medium potency in a cream or ointment base should be used on the skin immediately after bathing.

(u) D. Prophylactic antibiotics are not indicated in the treatment of atopic dermatitis.

Scientific Concepts/Hematology

Pernicious anemia is due to deficiency in which of the following?

A. Cobalamin-binding proteins

B. Pancreatic enzymes

C. Spectrin

D. Intrinsic factor

(u) A. Cobalamin-binding proteins and pancreatic enzyme deficiencies are causes of vitamin B12 deficiency, but not pernicious anemia.

(u) B. See A for explanation.

(u) C. Abnormalities in spectrin and actin are noted in hereditary spherocytosis.

(c) D. Pernicious anemia is caused by lack of intrinsic factor.

Which of the following medications used in the treatment of peptic ulcer disease is classified as a proton pump inhibitor?

A. Cimetidine (Tagamet)

B. Sucralfate (Carafate)

C. Omeprazole (Prilosec)

D. Misoprostol (Cytotec)

(u) A. Cimetidine is an H2 receptor antagonist.

(u) B. Sucralfate (Carafate) is a cytoprotective agent.

(c) C. Omeprazole is a proton pump inhibitor.

(u) D. Misoprostol is a prostaglandin analog.

Diagnosis/Psychiatry/Behavioral Medicine

A 56 year-old man is admitted to a hospital unit for evaluation of rectal bleeding and weight loss. He has a strong family history of cancer. Soon after admission, a barium enema is scheduled. The patient refuses the "prep" because he fears x-ray radiation. He states he has had previous x-rays, but becomes frightened at the thought of an x-ray and "can't face it." The most likely diagnosis is

Answers

A. hysterical personality.

B. dissociative state.

C. conversion reaction.

D. phobic neurosis.

Explanations

(u) A. Hysterical personality consists of multiple physical complaints referable to several other organ systems.

(u) B. Dissociative state is precipitated by an emotional event that produces fugue, amnesia, somnambulism, multiple personality, and depersonalization.

(u) C. Conversion reaction is characterized by physical symptoms in parts of the body related to psychic conflict.

(c) D. Phobic neurosis is a phobic ideation of displacement where the patient transfers feelings of anxiety from the object to one that can be avoided.

Diagnosis/Orthopedics/Rheumatology

A 32 year-old male presents with an acute onset of pain and swelling to his left ankle. On physical exam the ankle is warm, swollen and erythematous. Evaluation of the synovial fluid reveals only leukocytosis with a low glucose. Which of the following is the most likely diagnosis?

A. Gout

B. Pseudogout

C. Acute rheumatic fever

D. Septic arthritis

(u) A. Gout and pseudogout are excluded by the failure to find crystals on synovial fluid analysis.

(u) B. See A for explanation.

(u) C. Acute rheumatic fever commonly involves multiple joints.

(c) D. Leukocytosis and a low synovial glucose are indicative of septic arthritis.

Which of the following is the therapy of choice for long-term management of esophageal varices in a patient who cannot tolerate beta blocker therapy?

A. Octreotide (Sandostatin)

B. Sclerotherapy

C. Transjugular intrahepatic portosystemic shunt

D. Sengstaken-Blakemore tube

(u) A. Octreotide is used to control acute variceal bleeding but does not have a role in long-term management.

(c) B. Sclerotherapy is effective in decreasing the risk for rebleeding in a patient with esophageal varices.

(u) C. Transjugular intrahepatic portosystemic shunt (TIPS) decreases rebleeding more than sclerotherapy or ligation but is associated with a higher incidence of encephalopathy and has shown no decrease in mortality. TIPS is used in patients who fail endoscopic or pharmacologic therapy.

(u) D. The Sengstaken-Blakemore tube is rarely used today in the treatment of acute variceal bleeding. These are not indicated for long-term use.

Diagnostic Studies/Hematology

An 18 year-old woman presents to the clinic complaining of fatigue. She reports a past history of lifelong frequent nosebleeds and bleeding gums. She also has menorrhagia. Her mother and maternal grandfather have a similar bleeding history. Initial lab results are as follows: WBC 9,500/mm3, Hgb 10.9 g/dL, HCT 33%, MCV 69 fL, MCHC 26 pg and platelets 284,000/mm3. Which of the following tests should be ordered to evaluate this patient's diagnosis?

A. Hemoglobin electrophoresis

B. Bleeding time and platelet aggregometry

C. Bone marrow aspiration

D. PT and aPTT

Explanations

(u) A. Hemoglobin electrophoresis would be utilized to evaluate microcytic, hypochromic anemias.

(c) B. The patient's presentation is consistent with a congential qualitative platelet disorder, most likely von

Willebrand's Disease, necessitating a bleeding time and evaluation of platelet function.

(u) C. Bone marrow aspiration is not utilized in the evaluation of qualitative platelet disorders.

(u) D. A PT and aPTT would be utilized to evaluate for bleeding consistent with abnormalities with the coagulation

cascade. Ref: (11)

Clinical Intervention/Dermatology

An elderly woman presents to your clinic complaining of unilateral facial pain and painful lesions. She also complains of blurred vision in the ipsilateral eye. On examination she has several vesicles on an erythematous base, some of the lesions with crusts. They are distributed in a dermatomal pattern and involve the skin overlying the maxillary region and the tip of her nose. Which of the following is the next most appropriate intervention in the care of this patient?

A. KOH prep

B. Culture for bacteria

C. Referral to an ophthalmologist

D. Application of corticosteroids

(u) A. A KOH prep examining for fungal elements is not indicated in this case.

(u) B. While bacterial infection may occur along with the viral infection, a bacterial culture is not usually employed.

(c) C. Immediate referral to an ophthalmologist is needed when herpes keratitis is suspected, as in this case. A fluorescein stain of the eye might reveal the typical dendritic corneal lesion.

(h) D. Application of corticosteroids may cause proliferation of the virus and should only used by an ophthalmologist

Health Maintenance/Psychiatry/Behavioral Medicine

Rates of alcohol use in the adolescent are reportedly higher in:

Answers

A. families with rigorous parental monitoring

B. Japanese families

C. adoptive children whose biological parent is an alcoholic D. mood disorders in a grandparent

Explanations

(u) A. Families with the lowest measures of parental supervision, children initiated alcohol, tobacco, and drug use earlier than children from families with more supervision.

(u) B. Alcoholism has been reported to be lower among Japanese families.

(c) C. There is a three-to fourfold increase in risk for alcohol dependence in adopted children whose biological parents are alcohol dependents.

(u) D. There is no correlation suggesting that mood disorders in a grandparent increases the risk of alcohol dependency in the adolescent.

Health Maintenance/Neurology

A 45 year-old man presents for a routine appointment. He tells you his mother and father have both had ischemic strokes in their 70's. He does not smoke. His blood pressure is 128/80 mmHg, pulse 78/minutes and regular, respiratory rate of 12/minute. What diagnostic studies would you order to further evaluate this patient's risk of stroke?

Answers

A. Electrocardiogram

B. Fasting lipid profile

C. Carotid Doppler ultrasound

D. MRI with gadolinium

Explanations

(u) A. The main risk factor assessed by ECG is atrial fibrillation and this patient's regular pulse confirms he is currently not in atrial fibrillation

(c) B. Hyperlipidemia is a known risk factors for stroke that can be modified with treatment.

(u) C. The patient does not have signs or symptoms of carotid stenosis at this point.

(u) D. An MRI with gadolinium would be useful in evaluating for the presence of Berry aneurysms, but the history of ischemic strokes does not raise the concern of an aneurysm.

Clinical Intervention/Urology/Renal

A 32 year-old female patient presents with renal colic and hematuria. The patient has a long-standing history of unresponsive treatment for urinary tract infections with documented Proteus species. Urinalysis reveals crystals resembling coffin lids. KUB reveals a staghorn calculus in the right kidney. Which of the following is the best clinical intervention?

Answers

A. High fluid intake with a low salt diet B. A low purine diet

C. Laser lithotripsy

D. Percutaneous nephrolithotomy

Explanations

(u) A. High fluid intake (>3L/day) and a low salt diet is helpful in patients with cystine stones.

(u) B. Low purine diets are instituted in patients who form uric acid stones with hyperuricosuria.

(u) C. Laser lithotripsy is used for removal of ureteral stones via a urethroscope.

(c) D. Percutaneous nephrolithotomy is currently the primary surgical intervention of choice for struvite stones.

Health Maintenance/Endocrinology

The most effective method to prevent diabetic retinopathy is

Answers

A. routine, nondilated eye exams.

B. laser photocoagulation.

C. intensive glycemic control.

D. use of ACE inhibitors.

Explanations

(u) A. Nondilated eye exams are not adequate to properly detect diabetic retinopathy.

(u) B. Laser photocoagulation is used in preserving vision once diabetic retinopathy has taken place, but it is not preventative of the disease itself.

(c) C. The most effective method to prevent diabetic retinopathy is through intensive glycemic control.

(u) D. Although ACE inhibitors help in preventing diabetic nephropathy, they have no effect on retinopathy.

Diagnosis/Obstetrics/Gynecology

A 30-week pregnant patient presents with sudden onset of profuse, painless vaginal bleeding. Which of the following is the most likely diagnosis?

Answers

A. Abruptio placentae

B. Uterine rupture

C. Placenta previa

D. Disseminated intravascular coagulation

Explanations

(u) A. Abruptio placentae presents with abdominal pain and vaginal bleeding.

(u) B. Uterine rupture presents with vaginal bleeding or hematuria with suprapubic pain and tenderness.

(c) C. Placenta previa presents with sudden, painless, profuse bleeding in the third trimester. (u) D. Disseminated intravascular coagulation presents with systemic signs of bleeding and thrombosis and typically presents at the time of delivery.

Diagnosis/ENT/Ophthalmology

A 59 year-old male complains of "flashing lights behind my eye" followed by sudden loss of vision, stating that it was "like a curtain across my eye." He denies trauma. He takes Glucophage for his diabetes mellitus and atenolol for his hypertension. He has no other complaints. On funduscopic exam, the retina appears to be out of focus. Which of the following is the most likely diagnosis?

Answers

A. Central retinal vein occlusion B. Retinal artery occlusion

C. Retinal detachment

D. Hyphema

Explanations

(u) A. Central retinal vein occlusion causes painless, variable loss of vision. Exam shows retinal hemorrhages in all quadrants and edema of the optic disk.

(u) B. Retinal artery occlusion presents with sudden, painless loss of vision. Exam shows pale retina with normal macula, seen as a cherry-red spot.

(c) C. Patients with retinal detachment frequently complain of flashes of light or floaters that occur during traction on the retina as it detaches. This is followed by loss of vision. In small detachments, the retina may appear out of focus, but with larger detachments, a retinal fold may be identified.

(u) D. Hyphema is usually associated with trauma, and is a collection of blood in the anterior chamber.

Diagnostic Studies/Pulmonology

A patient presents with a history of progressive worsening of dyspnea over the past several years. He gives a history of having worked as a ship builder for over 50 years. He denies any alcohol or tobacco use. On examination you note clubbing and inspiratory crackles. Which of the following chest x-ray findings support your suspected diagnosis?

Answers

A. hyperinflation and flat diaphragms

B. interstitial fibrosis and pleural thickening

C. cavitary lesions involving the upper lobes

D. "eggshell" calcification of hilar lymph nodes

Explanations

(u) A. Chest x-ray findings of hyperinflation and flat diaphragms suggest long-standing chronic obstructive lung disease.

(c) B. This patient most likely has asbestosis, which is supported by his occupation as a ship builder and clinical presentation as noted above. Chest x-ray findings include interstitial fibrosis, pleural thickening and calcified pleural plaques on the diaphragm or lateral chest wall.

(u) C. Chest x-ray findings of cavitary lesions involving the upper lobes suggest pulmonary tuberculosis.

(u) D. Chest x-ray findings of "eggshell" calcification of hilar lymph nodes strongly supports the diagnosis of silicosis.

A 3 year-old presents with profuse watery diarrhea for the past three days. The child vomited twice yesterday, but not today. On exam, the child is febrile, with pulse of 142, respiratory rate of 18, and blood pressure of 60/40 mmHg. On exam, the child is alert and responsive, with no focal findings. Which of the following is the most appropriate intervention?

A. Antibiotic therapy

B. Begin soft diet

C. IV fluids

D. Oral rehydration

(u) A. In the US, infectious gastroenteritis is most frequently due to a virus. Antibiotic therapy may be second-line in cases where the causative organism is bacterial, is identified, and symptoms continue.

(u) B. See D for explanation.

(a) C. See D for explanation.

(c) D. The goal of therapy for a child with severe gastroenteritis and dehydration is to restore fluid loss. Oral rehydration with an appropriate electrolyte solution is the best option if the child is not actively vomiting and is alert enough to take oral fluids. IV fluids should be reserved for those who are unable to take fluids orally.

History & Physical/Hematology

Which of the following physical findings suggest pernicious anemia?

A. Splenomegaly and hepatomegaly

B. Petechiae and ecchymosis

C. Loss of position and vibratory sensation

D. Cheilosis and koilonychia

Explanations

(u)A. Splenomegaly and hepatomegaly are typically seen in hemolytic anemias.

(u) B. Petechiae and ecchymosis are seen in thrombocytopenia.

(c) C. Loss of position and vibratory sensation are common neurologic findings in pernicious anemia.

(u) D. Cheilosis and koilonychia are seen in iron deficiency anemia.

Clinical Intervention/Psychiatry/Behavioral Medicine

A patient presents within one hour of ingesting 30 tablets of diazepam (Valium). Which of the following is the most appropriate intervention?

Answers

A. IV naloxone

B. alkalinization of the urine C. cardiac pacing

D. gastric lavage

Explanations

(u) A. Naloxone (Narcan) is an opioid agonist and would have no effect in a benzodiazepine overdose.

(u) B. Alkalinization of the urine may be useful in the management of a barbiturate overdose, but not a benzodiazepine overdose.

(u) C. Cardiac pacing would be useful if there were asystole from the overdose.

(c) D. Gastric lavage, along with the administration of activated charcoal and monitoring of vital signs and CNS status is the mainstay of therapy in the person who has overdosed on benzodiazepines. Vomiting should be induced in the person who is not comatose. Flumazenil (Romazicon), a specific benzodiazepine antagonist, might be used with caution in certain patients.

Clinical Intervention/Neurology

Which of the following interventions is most effective during the early stages of Alzheimer's disease?

Answers

A. Frequent change of caregivers in the home

B. Utilization of memory aids, such as post-it notes

C. Encouragement of independent activities, such as driving

D. Emphasis of new learning activities, such as computer training

Explanations

(u) A. Although caregiver burnout is often encountered, consistency is beneficial to a patient having difficulty with confusion.

(c) B. Memory aids are extremely helpful in assisting Alzheimer patients during the early stages of the disease.

(u) C. Like our shuttle driver demonstrated, most patients should consider relinquishing their license.

(u) D. Pleasant activities should be emphasized, while learning new activities may be a source of frustration.

Clinical Intervention/Urology/Renal

Which of the following is the most appropriate intervention for a stage I testicular seminoma?

Answers

A. Watchful waiting

B. Chemotherapy initially

C. Orchiectomy and radiation

D. Orchiectomy and chemotherapy

Explanations

(u) A. Surveillance is an option in stage I disease of a nonseminoma testicular tumor.

(u) B. Patients with stage IIC and stage III are treated with chemotherapy.

(c) C. Inguinal orchiectomy followed by retroperitoneal radiation therapy cures about 98% of patients with stage I seminoma.

(u) D. Chemotherapy is used for later stage tumors (II/III) and followed by surgery in stage III tumors.

Clinical Intervention/Endocrinology

A diabetic patient returns for follow-up of non-fasting blood work done at a local health fair. The total cholesterol is 230 mg/dl. Which of the following is the appropriate next step?

Answers

A. Reassurance

B. Give advice on diet and exercise

C. Obtain a fasting HDL and LDL lipid measurement.

D. Start an HMG Co-A reductase inhibitor (statin)

Explanations

(u) A. See C for explanation.

(u) B. See C for explanation.

(c) C. A patient with an elevated total cholesterol needs further evaluation through a fasting total lipid profile including LDL and HDL.

(u) D. See C for explanation.

Diagnosis/Obstetrics/Gynecology

A 25 year-old female presents with constant premenstrual pelvic pain. She also notes dysmenorrhea and dyspareunia. Which of the following is the most likely diagnosis?

Answers

A. Uterine leiomyoma

B. Endometrial polyps

C. Ovarian cysts

D. Endometriosis

Explanations

(u) A. Leiomyomas of the uterus may present with abnormal uterine bleeding, but typically do not present with any symptoms.

(u) B. Endometrial polyps present with menorrhagia and intermenstrual and premenstrual bleeding, pain is not typical.

(u) C. Ovarian cysts present with adnexal mass and acute pain upon rupture.

(c) D. Endometriosis presents with premenstrual pelvic pain, dysmenorrhea, and dyspareunia.

Diagnosis/ENT/Ophthalmology

A 64 year-old woman complains of headache and left eye pain for about a day. She says it started yesterday as a dull ache and now is throbbing. She also complains of nausea and vomiting, which she attributes to the popcorn she ate at the movie theater yesterday afternoon. On exam, the left pupil is mid-dilated and nonreactive. The cornea is hazy. A ciliary flush is noted. Which of the following is the most likely diagnosis?

Answers

A. Migraine headache

B. Temporal arteritis

C. Acute glaucoma

D. Retinal artery occlusion

Explanations

(u) A. Migraine headache does not present with eye findings.

(u) B. Temporal arteritis presents with headache and systemic symptoms of fever, myalgias, anorexia, and tenderness over the temporal artery.

(c) C. Acute glaucoma often presents with abdominal complaints that may delay diagnosis. Findings of ciliary flush, mid-dilated and nonreactive pupil, and hazy cornea in a patient with severe eye pain are consistent with acute angle closure glaucoma.

(u) D. Retinal artery occlusion presents with sudden, painless, severe loss of vision. There are no systemic symptoms.

Diagnosis/Pulmonology

You are called to the nursery to see a male infant, born by uncomplicated vaginal delivery. He weighs 2,600 grams and has one deep crease on the anterior third of each foot. Respirations are 88 breaths/minute with expiratory grunting and intercostals retractions. He is cyanotic on room air and becomes pink when placed in 60% oxygen. Chest x-ray shows atelectasis with air bronchograms. Which of the following is the most likely diagnosis?

Answers

A. neonatal pneumonia

B. congenital heart disease

C. hyaline membrane disease

D. chronic lung disease of prematurity

Explanations

(u) A. While tachypnea, grunting, retractions and cyanosis may be signs of neonatal pneumonia, they are primarily late findings of progressive respiratory distress and would not be seen immediately at the time of delivery. A chest x-ray in pneumonia would also most commonly reveal an infiltrate or effusion.

(u) B. While congenital heart disease may present with cyanosis, the chest x-ray will reveal a cardiac abnormality, such as cardiomegaly.

(c) C. Hyaline membrane disease is the most common cause of respiratory distress in the premature infant. The infant typically presents with tachypnea, cyanosis and expiratory grunting. A chest x-ray reveals hypoexpansion and air bronchograms.

(u) D. Chronic lung disease of prematurity is a complication in about 20% of infants with hyaline membrane disease. It is defined as respiratory symptoms, oxygen requirement and chest x-ray abnormalities at 1 month of age so it cannot be diagnosed at this time in this newborn.

Diagnosis/Orthopedics/Rheumatology

A 32-year-old male presents with migratory arthralgias and profound malaise and fatigue. He states that one week ago he returned from a hunting trip in Pennsylvania. He is also complaining of a lesion on his left thigh that he noticed about 3 days ago. Physical exam reveals a large annular lesion with a bright red outer border and partial central clearing. Which of the following is the most likely diagnosis?

Answers

A. Rheumatoid arthritis

B. Kawasaki disease

C. Lyme disease

D. Nongonococcal arthritis

Explanations

(u) A. Rheumatoid arthritis is a symmetrical arthritis that commonly affects the proximal interphalangeal and metacarpophalangeal joints. It is not associated with the rash of erythema migrans.

(u) B. Kawasaki disease is an acute febrile, multisystem disease of children. It is characterized by unresponsiveness to antibiotics, nonsuppurative cervical adenitis, and changes in the skin and mucous membranes such as edema, erythema of the lips and palms, and desquamation of the skin of the fingertips.

(c) C. After an incubation period of 3 to 32 days, erythema migrans develops at the site of the tick bite. Within days or weeks after the onset of erythema migrans the patients develop a severe headache, mild stiffness of the neck, migratory musculoskeletal pain, arthralgias and profound malaise and fatigue.

(u) D. Nongonococcal arthritis occurs in patients with an underlying predisposition such as rheumatoid arthritis. The common presentation is involvement of a single joint.

Clinical Intervention/Dermatology

A 28 year-old female with diabetes mellitus type 2 sustains a partial thickness burn to her left upper arm and her chest when hot grease spilled on her at home. The burn to her arm is circumferential and the estimated total body surface burned is 18%. She has no allergies. The most appropriate treatment of this patient would include

A. outpatient application of silver sulfadiazine.

B. debridement of all intact blisters.

C. IV cefazolin (Ancef, Kefzol).

D. transfer to a burn center.

(u) A. Although treatment may include silver sulfadiazine dressings, this patient should not be treated as an outpatient. Also see D for explanation.

(u) B. Debridement of intact blisters remains controversial, however many authorities recommend leaving intact blisters intact and only debride ruptured blisters.

(u) C. If used in the care of a burn patient, the antibiotic selected should have activity against Pseudomonas and S. aureus. Cefazolin does not have any antipseudomonal activity.

(c) D. Reasons for transfer to a burn center include a partial thickness burn covering greater than 10% of total body surface area. In addition, burns in patients with pre-existing medical conditions, such as diabetes, that could complicate their management, prolong recovery, or affect their outcome, is also a reason for transfer to a burn center.

Clinical Intervention/Endocrinology

Radioactive iodine is most successful in treating hyperthyroidism that results from

Answers

A. Grave's disease.

B. subacute thyroiditis.

C. Hashimoto's thyroiditis.

D. papillary thyroid carcinoma.

Explanations

(c) A. Radioactive iodine is an excellent method to destroy overactive thyroid tissue of Grave's disease.

(u) B. Radioactive iodine is ineffective in subacute thyroiditis due to the thyroid's low uptake of iodine.

(u) C. Radioiodine uptake is low in Hashimoto's thyroiditis and is often transient.

(u) D. Papillary thyroid carcinoma is a common thyroid malignancy and must be treated by a thyroidectomy.