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A new test is devised to measure serum cholesterol leveL A sample of blood is taken from a patient, and the test is performed three times. The results are 200, 190 and 184 mg/dl. Based on these results, one can conclude that the new test is
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A new test is devised to measure serum cholesterol leveL A sample of blood is taken from a patient, and the test is performed three times. The results are 200, 190 and 184 mg/dl. Based on these results, one can conclude that the new test is
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A Not reliable [66%1 B. Not valid [3%1 C. Not accurate [26%1 D. Not sensitive [2%1 E. Not specific [3%1
Explanation: This example deals with test-retest reliability A reliable test gives similar or very close results on repeat measurements. In this example, repeat measurements of the same sample yielded different results; therefore, the new test is not reliable. (Choices 8 and C) Validity or accuracy is defined as the test's ability to measure what it is supposed to measure. In order to determine the validity of a test, the resuns are compared to those obtained from the gold standard test In this case, since there were no test results obtained using the gold standard, the validity or accuracy of the test cannot be determined. (Choices D and E) The sensitivity and specificity of a test compare results to those obtained using the gold standard. These parameters can show how accurate the results are, but do not measure reliability Educational objective: A reliable test gives similar resuns on repeat measurements. Reliability is maximal when random error is minimaL Time Spent 9 seconds
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A large-scale randomized, double-blinded clinical trial was conducted to evaluate the effect of beta-blocker therapy on the survival of patients with chronic heart fa ilure, class IV. The patients with severe heart fa ilure were randomly assigned to receive either carvedilol (a beta-blocker) or a placebo. In their report of the results of the study, the investigators included the table with baseline characteristics (ie , age, race, prevalence of hypertension, etc .) of the patients in the treatment and placebo groups. Acco rding to the table, both groups had a similar distribution of these characteristics. W ith the info rmation given, which of the following is most probable?
® A The sample size is adequate ® B. The study is negative ® C. The power of the study is big
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C. The power of the study is big [7% J
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A The sample size is adequate [4%] B. The study is negative [3%]
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baseline characteristics (i.e , age, race, prevalence of hypertension, etc .) of the patients in the treatment and placebo groups. According to the table, both groups had a similar distribution of these characteristics. With the information given, which of the following is most probable?
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D. Randomization is successful [78%] E. Observer's bias might be an issue [8%]
Explanation: The purpose of randomization is to make the distribution of all potential confounders even (i. e , between the treatment and placebo groups). Unlike all the other methods of controlling confounding (e g , matching, stratified analysis), randomization potentially controls known, as well as unknown confounders. One of the methods to assess the adequacy of randomization is to look at the distribution of baseline characteristics in both groups. If they are similar , one can assume that the randomization evenly distributed the confounders between the groups, and that randomization was successfuL {Choices A and C) From the information given, we cannot judge the adequacy of the sample size to detect the diffe rence in the survival (if it is present) between the treatment and placebo groups We also cannot judge the power of the study based on the above info rmation. (Choice B) The results of the study were not mentioned. (Choice E) Observer's bias can be controlled with blinding, not randomization. Educational Objective: In cl inical trials, randomization is said to be successful when a similarity of baseline characteristics of the patients in the treatment and placebo groups is seen. Time Spent 3 seconds
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A 30-year-old school teacher presents with a three-day history of fever, chills, and sore throat He also complains of difficulty swallowing that started yesterday He denies any cough, chest pain, or difficulty breathing. He is married and denies any new sexual encounters. His temperature is 39.8° C (102.2° F), blood pressure is 118/76 mmHg, pulse is 102/min, and respirations are 19/min. On examination, his vo ice is muffled . Enlarged, tender cervical lymph nodes are palpated on the left, and his uvula is deviated to the right W hat is the most appropriate treatment for this patient?
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This patient's symptoms are most likely secondary to a peritonsillar abscess. Although the three-day history of fever , chills, and sore throat were most likely secondary to tonsillitis, his muffled or "hot potato voice" and deviation of the uvula suggest that a peritonsillar abscess has developed as a complication of his tonsillitis. Patients with a peritonsillar abscess typically have prominent unilateral lymphadenopathy , as seen in this patient This condition can be fatal secondary to either airway obstruction or spread of the infection into the parapharyngeal space, which may lead to involvement of the carotid sheath. Initial treatment consists of aspiration of the peritonsillar abscess and initiation of intravenous antibiotics. Surgical intervention may be necessary if the purulent material cannot be removed with aspiration alone. {Choice A) Throat swabs and oral antibiotics are the usual treatment of tonsillopharyngitis, but this patient's muffled voice and deviation of his uvula suggest that a more complicated infection is present {Choice B) This patient's unilateral lymphadenopathy , deviation of his uvula, and muffled voice are not consistent with mononucleosis. (Choice C) Emergency laryngoscopy is typically required in patients with epiglottitis to ensure adequate protection of the airway Epiglottitis can present with difficulty swallowing and a muffled vo ice similar to that seen in this patient, but the unilateral lymphadenopathy and deviation of the uvula are more suggestive of a peritonsillar abscess. In addition, the epiglottis is located more distal in the airway and is not adjacent to the uvula. (Choice D) Cricothyroidotomy is used as a last resort in patients who are unable to protect their airway This patient, however , is not complaining of any difficulty breathing at this time. Educational objective: A muffled vo ice should make one consider a diagnosis other than uncomplicated pharyngitis or tonsillitis. A peritonsillar abscess is a potential complication of tonsillitis and requires both intravenous antibiotic therapy and urgent drainage of the abscess. Deviation of the uvula and unilateral lymphadenopathy can be helpful in distinguishing a peritonsillar abscess from epiglottitis Time Spent 2 seconds
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This patient's symptoms are most likely secondary to a peritonsillar abscess. Although the three-day history of fever , chills, and sore throat were most likely secondary to tonsillitis, his muffled or "hot potato voice" and deviation of the uvula suggest that a peritonsillar abscess has developed as a complication of his tonsillitis. Patients with a peritonsillar abscess typically have prominent unilateral lymphadenopathy , as seen in this patient This condition can be fatal secondary to either airway obstruction or spread of the infection into the parapharyngeal space, which may lead to involvement of the carotid sheath. Initial treatment consists of aspiration of the peritonsillar abscess and initiation of intravenous antibiotics. Surgical intervention may be necessary if the purulent material cannot be removed with aspiration alone. {Choice A) Throat swabs and oral antibiotics are the usual treatment of tonsillopharyngitis, but this patient's muffled voice and deviation of his uvula suggest that a more complicated infection is present {Choice B) This patient's unilateral lymphadenopathy , deviation of his uvula, and muffled voice are not consistent with mononucleosis. (Choice C) Emergency laryngoscopy is typically required in patients with epiglottitis to ensure adequate protection of the airway Epiglottitis can present with difficulty swallowing and a muffled vo ice similar to that seen in this patient, but the unilateral lymphadenopathy and deviation of the uvula are more suggestive of a peritonsillar abscess. In addition, the epiglottis is located more distal in the airway and is not adjacent to the uvula. (Choice D) Cricothyroidotomy is used as a last resort in patients who are unable to protect their airway This patient, however , is not complaining of any difficulty breathing at this time. Educational objective: A muffled vo ice should make one consider a diagnosis other than uncomplicated pharyngitis or tonsillitis. A peritonsillar abscess is a potential complication of tonsillitis and requires both intravenous antibiotic therapy and urgent drainage of the abscess. Deviation of the uvula and unilateral lymphadenopathy can be helpful in distinguishing a peritonsillar abscess from epiglottitis Time Spent 2 seconds
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A 65-year-old female complains of difficulty eating over the last two days. She states that food drops out of her mouth. She has also been having some discharge in her left ear recently She denies any sore throat, nasal discharge, chest pain, cough, or difficulty breath ing Her past medical history is significant for type 2 diabetes mellitus, hypertension, and hyperlipidemia She has been poorly compliant with follow-up appointments. Her temperature is 38.8° C (101.7o F), pulse is 96/min, blood pressure is 140/90 mmHg, and respirations are 18/min. Examination of the left ear canal shows granulations There is facial asymmetry, and the angle of the mouth on the left is deviated downward . Which of the following is the most likely causative organism fo r this patient's condition?
e; A Rhizopus species 6 B. Pseudomonas aeruginosa
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Explanation: This patient's presentation is most consistent with malignant otitis externa (MOE) , which is a severe infection typically seen in elderly diabetic patients that is most commonly caused by Pseudomonas aeruginosa Patients typically present with ear pain and ear drainage that is not responsive to topical medications. The granulation tissue seen within the ear canal in this patient is a characteristic manifestation of MOE, and her history of poorly controlled diabetes is also a diagnostic clue. Progression of the infection can lead to osteomyelitis of the skull base and cranial nerve damage. This patient's facial drooping, which is likely causing food to drop out of her mouth, is a result of damage to the left facial nerve. CT or MRI can be used to confirm the diagnosis. Treatment consists of systemic antibiotics that are effective against Pseudomonas aeruginosa, such as ciprofloxacin. Topical antibiotics are ineffective. {Choice A) Patients with poorly controlled diabetes are susceptible to Rhizopus infections, but these infections typically begin in the paranasal sinuses and extend into the orbit and brain.
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(Choice C) Staphylococcus aureus is a rare cause of malignant otitis externa.
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A 43-year-old man is found wandering in the street in winter and is brought to the emergency department by a passing motorist The patient is confused and unable to provide any additional history He has no previous hospital reco rds. On examination, there is mild hypothermia at 35 C (95 F), but vital signs are otherwise normal. The patient appears disheveled and lethargic but follows commands. Oral mucosa is moist and he has extensive dental caries. He has no cervical lymphadenopathy, but there is bilateral nontender submandibular swelling consistent with salivary gland enlargement Which of the following is the most likely cause of this latter finding? e')
A Alcoholism
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F. Vitamin A deficiency
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This patient has nontender enlargement of the submandibular glands, which is consistent with sialadenosis. Sialadenosis is commonly found in patients with advanced liver disease (eg, alcoholic and nonalcoholic cirrhosis). It is also seen in patients with altered dietary patterns or malnutrition (eg, diabetes, bulimia) Sialadenosis is a benign, noninflammatory swelling of the salivary glands. It is associated with abnormal autonomic innervation of the glands, with accumulation of secretory granules in acinar cells. Diffe rential diagnosis includes sialadenitis (focal tenderness, erythema, feve r), salivary gland stones (glandular swelling and pain with meals) (Choice D), and malignancy No management is needed other than to address any underlying nutritional disorders. (Choice B) Parotitis due to mumps or other viral infections presents with pain and swelling in the parotid glands, often with systemic symptoms (eg, fever) Involvement of the other salivary glands is uncommon.
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(Choice C) Pleomorphic adenoma is a benign neoplasm affecting the salivary glands that presents as a firm nodule. Bilateral or diffuse enlargement of the gland is more consistent with sialadenosis.
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(Choice E) Sjogren syndrome is characterized by autoimmune sialadenitis and presents with dry mouth associated with enlargement of the parotid and submandibular glands. The lacrimal glands are also usually affected. (Choice F) Vitamin A deficiency causes a number of ocular manifestations, including impaired night vision, dry eyes, and keratinization of the conjunctiva and co rneas. Educational objective: Sialadenosis is a benign, noninflammatory enlargement of the saliva ry glands It is seen in patients with advanced liver disease as well as a va riety of dietary and nutritional disorders.
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A new serum biomarker fo r the diagnosis of early-stage pancreatic cance r is being studied by a group of investigators The marker represents a fetal antigen that has minimal expression in healthy adults but has increased expression in pancreatic cancer cells. The sensitivity and specificity of the marker were determined at various serum concentration cutoff points using surgical biopsy results as the gold standard. The following rece iver operating characteristic curve is constructed.
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Point X on the curve best corresponds to wh ich of the following? Sensitivity
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e A 0.95
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False positive rate ( 1-specificity)
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ROC curve
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Explanation:
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Many quantitative diagnostic tests are based on substance values or parameters that are continuous in nature. Examples of such variables include blood sugar levels, arterial blood pressure, body temperature, and serum enzyme levels. In order to be useful fo r diagnostic purposes, an arbitrary cutoff point is chosen to separate normal from abnormal results. Patients
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False positive rate (1·specifici ty)
1
Many quantitative diagnostic tests are based on substance values or parameters that are continuous in nature. Examples of such va riables include blood sugar levels, arterial blood pressure, body temperature, and serum enzyme levels. In order to be useful for diagnostic purposes, an arbitrary cutoff point is chosen to separate normal from abnormal results. Patients with abnormal values are considered to test positive fo r the disease; those with normal values are considered to test negative for the disease. The ROC curve emphasizes the importance of choosing the appropriate cutoff value when designing a diagnostic test based on continuous values. It shows how the sensitivity and specificity of the test change as the cutoff point is raised and lowered. At any particular cutoff point, there is a trade-off between sensitivity and specificity Changing the cutoff point to increase the number of patients with the disease who test positive will inc rease the true-positive rate (which is directly proportional to sensitivity) , but it will also increase the number of patients without the disease who test positive (increasing the false-positive rate, which is inversely proportional to specificity). As a result, specificity usually decreases as sensitivity increases and vice-versa. At point X, the true-positive rate (sensitivity) is very close to 1.0 ( ie, sensitivity is near 100%) , while the false-positive rate (1 -specificity) is near 0.8 (ie, specificity is close to 20%) (Choice
A) Educational objective: The receiver operating characteristic curve of a quantitative diagnostic test demonstrates the trade-off between the test's sensitivity and specific ity at various cutoff points. Changing the cutoff point to inc rease the true-positive rate (directly proportional to sensitivity) will also inc rease the false-positive rate (inversely proportional to specificity) Time Spent 8 seconds
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A Aortic rupture
6 B. Aspiration pneumonia
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e; D. Hemothorax
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C. Fat embolism E. Myocardial contusion
6 F. Pulmonary contusion Submit
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A 53-year-old man is brought to the emergency department after a high-speed motor vehicle collision. The patient was an unrestrained driver and admits to consuming a moderate amount of alcohol before driving He has bilateral chest pain and left leg pain The patient's medical history is significant fo r emphysema, type 2 diabetes mellitus, and remote illicit drug use. A traumatic fracture of the left femur and diffuse chest tenderness are evident on physical examination. Initial arterial blood gas analysis shows a pH of 7.45, P02 of 81 mm Hg, and PC02 of 32 mm Hg. Chest x-ray reveals right fourth and fifth rib fractures. An intravenous analgesic and 3000 ml of lactated Ringer solution are administered. Four hours later, the patient reports increasing shortness of breath. Pulse oximetry shows an oxygen saturation of 90% on 3 L of 0 2 . He is alert and oriented and has no neurological deficits. Lung auscultation reveals ·diffuse rales in both lower lung fields. The remainder of the examination shows no new changes Repeat chest x-ray reveals alveolar opacities over the right and left lower lobes, and repeat arterial blood analysis shows a P02 of 75 mm Hg Pulmonary capillary wedge pressure is 12 mm Hg (normal, 5-16 mm Hg) Which of the following is the most likely diagnosis in this patient?
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Pulmonary contusion Clinical features
• Present <24 hours after blunt thoracic trauma • Tachypnea, tachycardia, hypoxia • Rales or decreased breath sounds
Diagnosis
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• CT scan (most sensitive) or CXR with patchy, alveolar infiltrate not restricted by anatomical borders
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• Pain control
Management
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• Pulmonary hygiene (eg, nebulizer treatment, chest PT) • Supplemental oxygen & ventilatory support
CXR =chest x-ray; PT = physiotherapy. @UW011d
This patient with acute dyspnea and hypoxia after a motor vehicle collision likely has a pulmonary contusion. As an unrestrained driver, he is prone to significant blunt thoracic trauma (BTT) due to impact with the steering wheel. Pulmonary contusion results in intraalveolar hemorrhage and edema and complicates 25%-35% of cases of BTT. Characteristic features include tachypnea , tachycardia, and hypoxia with rales and decreased breath sounds, all of which develop <24 hours after BTT. Pulmonary contusion may not be clinically evident immediately following an injury, and initial
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Pulmonary contusion may not be clinically evident immediately following an injury, and initial chest x-ray may be negative. CT scans are more sensitive and can identify the hallmark patchy nonlobular opacification (not restricted by anatomical landmarks) This patient's respiratory alkalosis is due to hyperventilation, which is driven by hypoxia Management involves pain control, pulmonary hygiene (eg, nebulizer treatment, chest physiotherapy), and respiratory support, including mechanical ventilation in severe cases. Administration of large volumes of intravenous fluid may worsen the underlying pulmonary edema. (Choice A) Radiographic signs of aortic rupture include mediastinal widening, depression of the left main bronchus, displacement of the trachea and esophagus to the right, and obliteration of the aortic knob shadow. (Choice B) Aspiration pneumonia, which typically involves feve r and cough, is usually restricted to one lobe or one segment on chest x-ray In contrast, pulmonary contusion is not restricted by anatomical borders and commonly involves multiple areas. (Choice C) Classically , patients with fat embolism develop respiratory distress, neurological abnormalities, and a petechial rash following a latent period of 12-72 hours after the initial injury. Although this patient's femur fracture places him at increased risk, the relatively rapid onset of symptoms and the lack of neurological symptoms and rash make fat embolism less likely than pulmonary contusion. (Choice D) Hemothorax can occur due to aortic rupture, injury to hilar structures, or injury to the intercostal vessels after BTT. It often appears as a pleural effusion on chest x-ray (Choice E) Myocardial contusion can occur due to BTT but is asymptomatic in most cases. When symptoms are present, they typically include hypotension, sinus tachyca rdia or other arrhythmias, and (in severe cases) signs of heart failure. This patient's focal pulmonary findings and normal pulmonary capillary wedge pressure make this unlikely . Educational objective: Blunt thoracic trauma can injure the underlying pulmonary parenchyma, resulting in pulmonary contusion. Signs and symptoms include dyspnea, tachypnea, tachycardia, and hypoxia, which
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(Choice A) Radiographic signs of aortic rupture include mediastinal widening, depression of the left main bronchus, displacement of the trachea and esophagus to the right, and obliteration of the aortic knob shadow . (Choice B) Aspiration pneumonia, which typically involves feve r and cough, is usually restricted to one lobe or one segment on chest x-ray In contrast, pulmonary contusion is not restricted by anatomical borders and commonly involves multiple areas. (Choice C) Classically , patients with fat embolism develop respiratory distress, neurological abnormalities, and a petechial rash following a latent period of 12-72 hours after the initial injury. Although this patient's femur fracture places him at increased risk, the relatively rapid onset of symptoms and the lack of neurological symptoms and rash make fat embolism less likely than pulmonary contusion. (Choice D) Hemothorax can occur due to aortic rupture, injury to hilar structures, or injury to the intercostal vessels after BTT. It often appears as a pleural effusion on chest x-ray
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(Choice E) Myocardial contusion can occur due to BTT but is asymptomatic in most cases. When symptoms are present, they typically include hypotension, sinus tachyca rdia or other arrhythmias, and (in severe cases) signs of heart failure. This patient's focal pulmonary findings and normal pulmonary capillary wedge pressure make this unlikely . Educational objective: Blunt thoracic trauma can injure the underlying pulmonary parenchyma, resulting in pulmonary contusion. Signs and symptoms include dyspnea, tachypnea, tachycardia, and hypoxia, which can be worsened by intravascular volume expansion, and patchy, irregular alveolar infiltrates on chest x-ray. References: 1. Lung contusion: a clinico-pathological entity with unpredictable clinical course.
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<0 A Epstein-Barr virus <0 B. Infl uenza virus <0 C. Legionella pneumophila <0 D. Moraxella catarrhalis
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<0 E. Mycoplasma pneumoniae
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<0 F. Parvovirus 819
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<0 G. Streptococcus pneumoniae
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A 19-year-old man comes to the office due to a week of persistent dry cough that disturbs his sleep. He has also had a sore throat, headaches, and fatigue. Yeste rday, he noticed a rash on his arms and legs. The patient has no known medical problems and takes no medications. He has not had any sick contacts. Temperature is 37.8 C (100 F), blood pressure is 115/78 mm Hg, pulse is 86/min, and respirations are 16/min. Mild pharyngeal erythema is present There is no cervical lymphadenopathy Cardiopulmonary examination is normal. A faint macular rash is present on the extremities. Chest x-ray reveals inc reased interstitial markings and a small right-sided pleural effusion. W hich of the following organisms is most likely causing this patient's condition?
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F. Parvovirus 819 [11 %) G. Streptococcus pneumoniae [6%)
Explanation:
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Mycoplasma pneumonia • Respiratory droplets
Epidemiology
• Close quarters/young (eg, school, military) • Fall or winter
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• Indolent headache, malaise, fever, persistent dry cough
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Manifestations
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• Interstitial infiltrate (chest x-ray)
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• Macular/vesicular rash • Subclinical hemolytic anemia (cold agglutinins)
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• Pharyngitis (nonexudative)
• Usually empiric
Treatment
• Macrolide or fluoroquinolone
@UWorld
Mycoplasma pneumoniae is a highly infectious, low-virulence bacterium that is spread by direct contact with respiratory droplets. Outbreaks are common among young individuals who share close quarters (eg, school children, college students, military recruits), with peak prevalence in I'"'
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contact with respiratory droplets. Outbreaks are common among young individuals who share close quarters (eg, school children, college students, military recruits), with peak prevalence in the fall and winter. Many infections are subclinical, but patients may develop illness in the upper or lower respiratory tract M pneumoniae is the most common cause of atypical pneumonia Symptoms are indolent and include headache, malaise, fever , and incessant dry cough. Nonpurulent pharyngitis, macular skin rash, and subclinical hemolytic anemia (due to cold agglutinins) may occur. W hite blood cell count is usually normal. Chest x-ray typically reveals interstitial infiltrates; a serous pleural effusion may be present in approximately 25% of patients Diagnosis is usually made with cl inical and radiographic findings; laboratory testing is not generally needed in the outpatient setting Empiric treatment with oral antibiotics (eg, azithromycin) is almost universally effective.
(Choice A) Epstein-Barr virus causes infectious mononucleosis with symptoms of headache, malaise, fever, exudative pharyngitis/tonsillitis, lymphadenopathy , and splenomegaly. This patient does not have lymphadenopathy or exudative pharyngitis and has prominent respiratory symptoms, making Mycoplasma more likely {Choice B) Influenza tends to present with abrupt (eg, malaise, myalgia, fever , headache), not indolent, symptoms (Choice C) Legionella pneumophila usually causes high fever with prominent gastrointestinal (eg, vomiting, diarrhea) and systemic (eg, headache, confusion, malaise) symptoms Pulmonary manifestations (eg, cough, dyspnea) tend to evolve slowly over days. This patient has upper and lower respiratory symptoms, no gastrointestinal symptoms, and low-grade fever , making L pneumophila less likely (Choice D) Moraxella catarrhalis primarily causes otitis media (in children) and chronic obstructive pulmonary disease exacerbations; it is an uncommon cause of pneumonia in healthy adults. {Choice F) Parvovirus 819 may cause influenza-like symptoms (eg, myalgias, fever, malaise) and a malar rash. Prominent pulmonary symptoms and an interstitial infiltrate are not typical.
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{Choice A) Epstein-Barr virus causes infectious mononucleosis with symptoms of headache, malaise, feve r, exudative pharyngitis/tonsillitis, lymphadenopathy, and splenomegaly . This patient does not have lymphadenopathy or exudative pharyngitis and has prominent respiratory symptoms, making Mycoplasma more likely {Choice B) Infl uenza tends to present with abrupt (eg, malaise, myalgia, feve r, headache) , not indolent, symptoms {Choice C) Legionefla pneumophila usually causes high fever with prominent gastrointestinal (eg, vomiting, diarrhea) and systemic (eg, headache, confusion, malaise) symptoms Pulmonary manifestations (eg, cough, dyspnea) tend to evolve slowly over days. This patient has upper and lower respiratory symptoms, no gastro intestinal symptoms, and low-grade fever, making L pneumophila less likely {Choice D) Moraxefla catarrhalis primarily causes otitis media (in children) and chronic obstructive pulmonary disease exacerbations; it is an uncommon cause of pneumonia in healthy adults.
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{Choice F) Parvovirus 819 may cause influenza-like symptoms (eg, myalgias, fever , malaise) and a malar rash. Prominent pulmonary symptoms and an interstitial infiltrate are not typicaL
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{Choice G) Streptococcus pneumoniae is the most common cause of community-acquired pneumonia and typically presents abruptly (not indolently) with feve r, productive cough, dyspnea, and lobar (not interstitial) infiltrate on chest x-ray Upper respiratory symptoms (eg, pharyngitis) and skin rash are uncommon. Educational objective: Mycoplasma pneumoniae causes atypical pneumonia with indolent symptoms of headache, malaise, low-grade fever , incessant cough, and nonexudative pharyngitis. Chest x-ray often reveals interstitial infiltrate with or without a small, serous pleural effusion. Empiric oral antibiotics (eg, azithromycin) usually resolve the infection completely Time Spent 3 seconds
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<0 A Acoustic neuroma <0 B. Antibiotic treatment <0 C. Chronic otitis media
e; D. Hypertension of pregnancy
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<0 E. Meniere's disease
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A 27-year-old woman at 30 weeks gestation complains of difficulty hearing, especially on the right side. She has no ear pain or discharge. At 22 weeks, her pregnancy was complicated by acute pyelonephritis, which was treated with antibiotics. The patient eats a balanced diet and does not use tobacco or alcohol. She takes no medications aside from a multivitamin. Her blood pressure is 160/ 100 mm Hg and pulse is 75/min. Cardiac and pulmonary examinations are unremarkable. She can hear a vibrating sound when a tuning fork is placed on her right mastoid process fo r nearly 10 seconds. W hen the vibrating tuning fork is immediately placed near her right external auditory meatus, she can no longer hear the sound. W hen it is placed on the middle of her forehead, she feels the vibration better in her right ear than the left. No other focal abnormalities are found on neurologic examination. Audiometry shows right low-frequency hearing loss. W hich of the following is the most likely cause of this patient's compla ints?
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Explanation: This patient presents with hearing loss and an abnormal Rinne test on the right consistent with conductive hearing loss. Hearing loss is classified as conductive (obstruction of external sound to inner ear) or sensorineural (involving the inner ear, cochlea, or auditory nerve) Mixed hearing loss is defined as having both processes. The Rinne test is performed by placing a vibrating tuning fork on the patient's mastoid bone until the patient indicates that it can no longer be heard. The still-vibrating tuning fork is then quickly held outside the external auditory meatus (EAC) until the patient ca n no longer hear the sound. Air-conducted (AC) sound should be heard twice as long as bone-conducted (BC) sound. A normal Rinne test (AC > BC) is defined as the patient being able to hear the vibrating tuning fork at the EAC after moving it from the mastoid. An abnormal Rinne test is defined as the patient sensing the vibrating tuning fork on the mastoid but being unable to hear it when placed outside the EAC. An abnormal Rinne test ( BC > AC) suggests conductive hearing loss. The W eber test may also help diffe rentiate between conductive and sensorineural hearing loss. The Weber test is performed by placing a vibrating tuning fork on the middle of the head or forehead equidistant from both ears and then asking the patient if the vibration is sensed equally in both ears. A normal test (midline Weber) is the vibration being heard equally with no lateralization. An abnormal test is the vibration being heard louder and lateralizing to one ear. Patients with conductive hearing loss lateralize to the affected ear on this test because the affected ear cannot hear the ambient noise of the room. As a result, the inner ear is able to pick up the vibration better and perce ives it as louder. Patients with sensorineural hearing loss lateralize to the unaffected ear on W eber as the inner ear of the affected ear cannot sense the vibration (Table)
Interpretation of Weber & Rinne tests Rinne result
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Norm al
Air conducted > bone
We ber result M1dhne
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vibration (Table)
Interpretation of Weber & Rinne tests Rinne result
We ber result
Air conducted > bone conducted bilaterally
Midline
BC > AC in affected ear, AC > BC in unaffected ear
Lateralizes to affected ear
Sensorineural h earing lo ss
AC > BC in both ears
Lateralizes to u naffected ear, aw ay from affected ear
Mixed hearing loss
BC > AC in affected ear, AC > BC in unaffected ear
Lateralizes to unaffected ear, away from affected ear
No rm al
Cond uctive hearing loss
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@USMLEWorld, lLC
Conductive hearing loss is commonly caused by ce rumen impaction, middle ear fluid or infection, decreased movement of the small bones of the ear, or bony tumors of the middle ear. Otosclerosis is a common cause of conductive hearing loss in adults, especially those in their 20s and 30s, with a slight female predominance The disorder involves an abnormal remodeling of the otic capsule thought to be a possible autoimmune process in genetically susceptible individuals. The stapes footplate becomes fixed to the oval window, resulting in loss of its piston action. This disorder is sometimes referred to as otospongiosis as CT scan may show a lucent (as opposed to sclerotic) focus in the temporal bone near the oval window. Treatment involves hearing amplification or surgical stapedectomy. (Choice A) An acoustic neuroma , also known as a vestibular schwannoma, typically results in sensorineural hearing loss.
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and 30s, with a slight female predominance The disorder involves an abnormal remodeling of the otic capsule thought to be a possible autoimmune process in genetically susceptible individuals. The stapes footplate becomes fixed to the oval window, resulting in loss of its piston action. This disorder is sometimes referred to as otospongiosis as CT scan may show a lucent (as opposed to sclerotic) focus in the temporal bone near the oval window. Treatment involves hearing amplification or surgical stapedectomy (Choice A) An acoustic neuroma , also known as a vestibular schwannoma, typically results in sensorineural hearing loss. {Choice B ) Ototoxic antibiotics such as aminoglycosides usually result in sensorineural as opposed to conductive hearing loss. (Choice C) Chronic otitis media may cause conductive hearing loss, but it is typ ically accompanied by ear pain and tinnitus. (Choice D) This patient's high blood pressure will likely require further evaluation and treatment, but it is unlikely to be contributing to her hearing loss. (Choice E) Meniere's disease affects the inner ear and typically presents with aural fullness, tinnitus, and sensorineural hearing loss. (Choice G) Presbycusis is sensorineural hearing loss that occurs in adults of advanced age. Educational objective: Bone conduction that is greater than air conduction on the Rinne test is suggestive of conductive hearing loss and can be comb ined with the Webe r test to confirm the findings Otosclerosis is a common cause of conductive hearing loss in adults, particularly those in their 20s and 30s. Refer ences: 1. The etiology of otosclerosis: a combination of genes and environment
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0 E. Enalapril 6 F. Simvastatin
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61
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A 50-year-old man comes to the emergency department due to acute onset respiratory difficulty He also has periorbital, circumoral and facial edema. He denies any itching or skin rash. Two weeks ago, he experienced chest pain, profuse sweating and anxiety, and was subsequently admitted to the cardiac intensive care unit At that time, his ECG showed ST segment elevation and Q waves in the inferior leads. He was taken to the catheterization lab and had an angioplasty with stent done for 100% occlusion of the right coronary artery. He was discharged with the following medications: aspirin, clopidogrel, metoprolol, enalapril, simvastatin and isosorbide mononitrate. In the ED, his pulse is 102/min, blood pressure is 110/70 mmHg, respirations are 24/min and temperature is 36.s•c (984°F) W hich of the following is most likely responsible for his present symptoms?
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ACE inhibitors are the most common cause of acquired angioedema Patients present with edema in the face , mouth, lips, tongue, glottis and larynx Laryngeal edema can cause airway obstruction and be life threatening Angioedema occurs due to the pro-inflammatory action of bradykinin, which promotes edema, inflammation and the sensation of pain Angiotensin conve rting enzyme (ACE) is also known as kininase; it functions to degrade bradykinin W hen ACE is inhibited, levels of bradykinin increase, thereby leading to angioedema ACE inhibitors are usually started on the first post-infarction day in non-hypotensive patients, and patients typically present with angioedema within days to weeks after starting therapy (as in this patient) However, it is important to note that angioedema from ACE inhibitors can occur at ANYTIME, not just within weeks of starting the medication. The first step in management of angioedema is to check for airway comp romise and vasomotor instability, which require subcutaneous epinephrine administration if present If airway obstruction fails to respond to epinephrine, an emergency tracheostomy is done. The ACE-inhibitor should be stopped immediately
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{Choice A) The common adverse effects of beta-blockers (metoprolol) are bradycardia, AV block, bronchoconstriction (clinically significant in patients with asthma and COPD), and male sexual dysfunction {Choice B ) Nitrates can cause headaches, hypotension and development of tolerance to the drug with continuous use. (Choice C) Clopidogrel uncommonly causes adverse reactions, the most significant of which is thrombotic thrombocytopenic purpura. {Choice D) Asp irin and NSAIDs can cause allergic angioedema. It typically happens immediately after exposure and it is accompanied by itching and skin rash (urticaria) (Choice F) Statins are associated with hepatotoxicity and myopathy Educational objective:
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ANYTIME, not just within weeks of starting the medication. The first step in management of angioedema is to check for airway compromise and vasomotor instability, which require subcutaneous epinephrine administration if present If airway obstruction fa ils to respond to epinephrine, an emergency tracheostomy is done. The ACE-inhibito r should be stopped immediately (Choice A) The common adverse effects of beta-blockers (metoprolol) are bradyca rdia, AV block, bronchoconstriction (cl inically significant in patients with asthma and COPO), and male sexual dysfunction (Choice B) Nitrates can cause headaches, hypotension and development of tolerance to the drug with continuous use. {Choice C) Clopidogrel uncommonly causes adverse reactions, the most significant of which is thrombotic thrombocytopenic purpura.
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(Choice D) Asp irin and NSAIDs can cause allergic angioedema It typically happens immediately after exposure and it is accompanied by itching and skin rash (urticaria)
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{Choice F) Statins are associated with hepatotoxicity and myopathy
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Educat ional objective: ACE inhibito rs are the most common cause of acquired angioedema It is important to note that angioedema from ACE inhibitors can occur at ANYTIME, not just with in weeks of starting the medication. Other adverse effects of ACE inhibitors are cough, hyperkalemia, and precipitation of acute renal failure in patients with bilateral renal artery stenosis. References: 1. Angiotensin-converting enzyme inhibitors and angioedema.
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e; A Contact dermatitis 6 B. Herpetic whitlow
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61
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A 62-year-old man comes to the office with a 4-week history of itchy, dry skin on the hands. He has experienced scaly, cracking skin at the dorsum of both hands extending to the fingers The patient has tried moisturizer lotions with some relief, but the symptoms are persistent Medical history is notable for seasonal allergies, hypertension, benign prostatic hyperplasia, and an occasional herpes rash on his upper lip following upper respiratory infections. He works as a dentist and does not use tobacco, alcohol, or illicit drugs. Examination shows dry, crusted, and irritated skin with erythema at the fingers, finger webs, and dorsum of the hands, as shown in the image. A few vesicles are noted at the finger webs. No other skin lesions are seen. Which of the following is the most likely diagnosis?
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Contact dermatitis Allergic
Irritant
Type IV hypersensitivity
Physical or chemical irritation
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Pathophysiology
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• Poison oak/ivy/sumac
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• Nickel
• Soaps/detergents
• Rubber/latex
• Chemicals
• Leather dyes
• Acid/alkali
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• Medications
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Appearance
• Primarily on exposed skin, well demarcated
• Commonly on hands
• Erythema
• Erythema
• Papules/vesicles
• Fissures
• Chronic lichenification @UWorld
This patient with a scaly, pruritic rash on the hands has irritant contact dermatitis (lCD), possibly due to frequent hand washing as a dentist lCD is a localized inflammatory reaction that
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This patient with a scaly, pruritic rash on the hands has irritant contact dermatitis ( lCD), possibly due to frequent hand washing as a dentist lCD is a localized inflammatory reaction that can be triggered by a va riety of chemicals, solvents, cleaning products, or acidic/alkaline solutions. lCD is nonimmunologically mediated but can resemble allergic contact dermatitis with pruritus, erythema, local swelling, and ves icles. Symptoms can develop acutely (within hours of exposure) but are often chronic, leading to excoriations, hype rkeratosis, and fissuring of involved skin. Emollients and use of protective barriers can often relieve symptoms However, identification and avoidance of the offending agent are also essential, although this is frequently challenging, as many common household and occupational products can contribute to symptoms. The diagnosis of lCD (and allergic contact dermatitis) is usually based on clinical findings , but if initial measures do not clear the rash, skin biopsy may be required for confirmation. {Choice B) Herpetic whitlow is due to inoculation of herpes simplex virus into broken skin. Patients experience tingling and burning of the hand associated with a localized vesicular rash. Symptoms would not be bilateral and symmetric
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(Choice C) Palmoplantar psoriasis causes thickened erythematous plaques with fissuring on the palms and/or soles, often with scaling. Features that would differentiate palmoplantar psoriasis from contact dermatitis include typical psoriatic scaling, nail changes, and the presence of psoriasis elsewhere on the body. (Choice D) Typical scabies lesions are small, erythematous, papules and irregular burrows . They predominantly involve the finger webs, flexural surfaces , belt line, and buttocks. More diffuse skin involvement can be seen in crusted scabies, but this is typically seen in immunocompromised individuals. (Choice E) Tinea manuum is a superficial fungal infection of the hands. It typ ically presents as pruritic , hyperkeratotic patches on the palms or annular erythematous lesions resembling tinea corporis on the dorsum of the hands and finger webs. Most patients have concurrent tinea pedis.
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diagnosis of lCD (and allergic contact dermatitis) is usually based on clinical findings , but if initial measures do not clear the rash, skin biopsy may be required fo r confirmation. {Choice B) Herpetic whitlow is due to inoculation of herpes simplex virus into broken skin. Patients experience tingling and burning of the hand associated with a localized vesicular rash. Symptoms would not be bilateral and symmetric (Choice C) Palmoplantar psoriasis causes thickened erythematous plaques with fissuring on the palms and/or soles, often with scaling. Features that would differentiate palmoplantar psoriasis from contact dermatitis include typical psoriatic scaling, nail changes, and the presence of psoriasis elsewhere on the body. (Choice D) Typical scabies lesions are small, erythematous, papules and irregular burrows. They predominantly involve the finger webs, flexural surfaces, belt line, and buttocks. More diffuse skin involvement can be seen in crusted scabies, but this is typically seen in immunocompromised individuals.
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(Choice E) Tinea manuum is a superficial fungal infection of the hands. It typically presents as pruritic , hyperkeratotic patches on the palms or annular erythematous lesions resembling tinea corporis on the dorsum of the hands and finger webs. Most patients have concurrent tinea pedis. Educational objective: Irritant contact dermatitis can be triggered by a variety of chemicals, solvents, cleaning products, or acidic/alkaline solutions. It is nonimmunologically mediated but can resemble allergic contact dermatitis with pruritus, erythema, local swelling, and vesicles. Chronic symptoms include exco riations, hyperkeratosis, and fissuring of skin. Refer ences: 1. Hand dermatitis: review of etiology, diagnosis , and tr eatment .
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(:) A Intravenous ampic illin/sulbactam e') B. Intravenous ciprofloxacin
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(:) E. Topical neomycin
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A 78-year-old woman comes to the physician with a week-long history of worsening left-sided ear pain and drainage The pain is unrelenting, but it is especially severe at night and is exacerbated by chewing. She reports a sense of fullness in the ear and mild hearing loss on the left side. The patient's past medical history is significant for hypertension. type 2 diabetes mellitus, and hype rlipidemia Current medications include lisinopril, a statin, and metformin. She has missed her last 2 appointments with her primary ca re physician Her temperatu re is 38.3 C (101 F). blood pressure is 140/90 mm Hg, and pulse is 98/min. On examination. the left external auditory canal is edematous with purulent discharge and granulation tissue in the floor . The tympanic membrane is clear. Her erythrocyte sedimentation rate is 89 mm/h. An ear swab is obtained. W hich of the following is the best initial treatment fo r this patient?
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This patient's presentation is concerning for malignant (necrotizing) otitis externa (MOE), a severe infection of the external audito ry canal and base of the skull usually caused by Pseudomonas aeruginosa Most patients with MOE are elderly and often have poorly controlled diabetes or are otherwise immunosuppressed. The most common symptoms are severe, unrelenting ear pain (especially prominent at night); purulent drainage with a sense of fullness; and conductive hearing loss on the affected side. Otoscopy shows granulation tissue and an edematous external audito ry canal, although the remainder of the examination may be proportional with the severity of the pain As the infection spreads beyond the external auditory canal, osteomyelitis of the skull base or tempo romandibular joint can develop and present with pain exacerbated by chewing Cranial nerve involvement is sometimes seen. Given the severity of MOE, systemic therapy with an anti-pseudomonal antibiotic is recommended. In adults, intravenous ciprofloxacin remains the drug of choice; in patients with fl uoroquinolone-resistant P aeruginosa, alternate therapies include anti-pseudomonal penicillins or cephalosporins such as piperacillin and ceftazidime. Ampicillin/sulbactam is not effective {Choice A) Surgical debridement (of necrotic bone) and biopsy (to exclude cancer) can be performed if a patient fa ils to respond to antibiotics. Surgical excision, commonly used before the advent of anti-pseudomonal antibiotics, is no longer a component of MOE management (Choice C) Cholesteatoma, a ke ratinized epithelial growth in the middle ear , can present with hearing loss and discharge and requires surgical management However, MOE is a much more likely diagnosis in this patient given the severe pain, fever , and elevated erythrocyte sedimentation rate. (Choices 0 and E) Topical antibiotics and corticosteroids are appropriate for otitis externa (OE), but they are not recommended in the treatment of MOE. The severity of the pain, the presence of granulation tissue, and the elevated erythrocyte sedimentation rate are all clues that distinguish OE from MOE. Educational objective: Malignant (necrotizing) otitis externa is a severe infection of the external auditory canal and skull base usually caused by Pseudomonas aeruginosa It is seen most frequently in elderly patients with diabetes or immunosuppression. Intravenous ciprofloxacin is empiric treatment
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® A The mean would inc rease significantly ® B. The median would increase significantly ® C. The mode would increase significantly
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® E. The standard deviation would not change Submit
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In an intensive care unit, 10 measurements of systolic blood pressure were obtained over several hours from a patient using an intra-arterial cannula. The maximal value recorded was 120 mm Hg, and the minimal value was 100 mm Hg. If the next measurement shows a value of 240 mm Hg, which of the following is most likely to happen?
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Explanation: An outlier is defined as an extreme and unusual value observed in a dataset It may be the result of a recording error , a measurement erro r, or a natural phenomenon. An outlier can affect the measures of central tendency (mean, median, mode) as well as the measures of dispersion (eg, standard deviation) The mean (mathematical average) is extremely sensitive to outliers and easily shifts toward them, especially with a small sample size. In this case, the value of 240 mm Hg is the outlier and would cause the mean to increase, especially given that there were only 10 total measurements obtained prior to th is value, all of which were between 100 and 120 mm Hg (Choice B) The median splits an ordered dataset in half. The median tends to be more resistant to outliers because it is located in the middle of the dataset where the observations usually do not diffe r much from one another. (Choice C) The mode (the most frequently observed value) is not affected by outliers. For example, if the value of 115 mm Hg was recorded most often out of the first 10 measurements, then 115 mm Hg would be the mode; having an additional value of 240 mm Hg in the dataset would not change that because 115 mm Hg would still be the most frequently observed value.
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(Choice D) The range is the diffe rence between the maximal value and the minimal value; therefore, it would definitely change from 20 mm Hg (given by 120- 100 mm Hg) to 140 mm Hg (given by 240- 100 mm Hg) (Choice E) The standard deviation (a measure of dispersion within the dataset) is sensitive to outliers because outliers significantly inc rease the dispersion. A value of 240 mm Hg would very likely affect the standard deviation of a dataset of 10 elements, all of which lie between 100 mm Hg and 120 mm Hg Educational objective: An outlier is defined as an extreme and unusual value observed in a dataset The mean is ve ry sensitive to outliers and easily shifts toward them. The median and mode are more resistant to outliers. Time Spent 3 seconds
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A 47-year-old diabetic woman comes to the physician due to the recent onset of tremors. She has undergone combined panc reatic and kidney transplantation secondary to end stage renal disease and diabetes. She takes multiple medications, including immunosuppressants. Her temperature is 36.1 oc (97°F), blood pressure is 152/90 mm Hg, pulse is 78/min, and respirations are 16/min. Examination shows gum hypertrophy Laboratory studies show:
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8,000/cmm
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135 mEq/L
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5.3 mEq/L
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26 mg/dl
Serum Creatinine
1.7 mg/dl
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W hich of the following immunosuppressants is most likely responsible for her presentation?
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6 A Tacrolimus
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<0 B. Cyclosporine
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6 C. Azathioprine ® D. Mycophenolate Submit
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1. Nephrotoxicity This is the most common and serious side effect It may manifest as reversible acute azotemia or irreversible progressive renal disease. Hyperuricem ia with accelerated gout, hyperkalemia, hypophosphatemia, and hypomagnesemia can be seen as manifestations of renal-induced dysfunction Rarely , hemolytic uremic syndrome (HUS) may be seen. 2. Hypertension This is due to renal vasoconstriction and sodium retention. It is generally seen in the first few weeks of therapy Calcium channel blockers are the drugs of choice for treatment 3. Neurotoxicity: This is often reversible. It manifests as headache, visual disturbances, seizure, mild tremors, akinetic mutism, etc . 4. Glucose intolerance This is fairly common. Patients who are concurrently taking prednisone (steroids) might develop significant hyperglycemia 5. Infection Chronic therapy with cyclosporine is associated with infection in 40% of patients 6. Malignancy: There is an increased risk of squamous cell carcinoma of the skin and lymphoproliferative diseases. 7. Gingival hypertrophy and hirsutism. 8. Gl manifestations, such as anorexia, nausea, vom iting, and diarrhea These are fairly common but mild.
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Some of the most common side effects of cyclosporine are:
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Cyclosporine is a commonly used immunosuppressant It acts by inhibiting the transcription of inter/eukin-2 and several other cytokines, mainly the T-helper lymphocytes
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(Choice A) Tacrolimus is a macrolide antibiotic produced by fungi It has the same mechanism of action as cyclosporine and has a similar toxicity profile (including nephrotoxicity and hyperkalemia); however, in contrast to cyclosporine, tacrolimus does not cause hirsutism or gum hype rtrophy , and has a higher incidence of neurotoxicity, diarrhea, and glucose intolerance. (Choice C) Azathioprine is a purine analog that is enzymatically converted to 6-mercaptopurine It
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5. Infection Chronic therapy with cyclosporine is associated with infection in 40% of patients 6. Malignancy There is an increased risk of squamous cell carc inoma of the skin and lymphoproliferative diseases. 7. Gingival hypertrophy and hirsutism. 8. Gl manifestations, such as anorexia, nausea, vomiting, and diarrhea These are fairly common but mild. (Choice A) Tacrolimus is a macrolide antibiotic produced by fungi It has the same mechanism of action as cyclosporine and has a similar toxicity profile (including nephrotoxicity and hyperkalemia); however, in contrast to cyclosporine, tacrolimus does not cause hirsutism or gum hypertrophy , and has a higher incidence of neurotoxicity , diarrhea, and glucose intolerance. {Choice C) Azathioprine is a purine analog that is enzymatically conve rted to 6-mercaptopurine It acts primarily by inhibiting purine synthesis. The major toxicity of azathioprine is dose-related diarrhea, leukopenia, and hepatotoxicity
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(Choice D) Mycophenolate is a reversible inhibitor of inosine monophosphate dehydrogenase (IMPDH), which is the rate-limiting enzyme in de novo purine synthesis The major toxicity of mycophenolate is bone marrow suppression. Educational Objective: Cyclosporine and tacrolimus have the same mechanism of action (calcineurin-inhibitors) The major side effects of cyclosporine include nephrotoxicity, hyperkalemia, hypertension, gum hypertrophy, hirsutism, and tremor. Tacrolimus has similar toxicities, except fo r hirsutism and gum hypertrophy
•The major toxicity of azathioprine is dose-related diarrhea, leukopenia, and hepatotoxicity . •The major toxicity of mycophenolate is bone marrow suppression • Extremely high yield question for the USMLE!!! Time Spent 3 seconds
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e A Mean is equal to median o B. Mean is greater than median e; C. Mean is greater than mode
® D. Median is greater than mean
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E. Mode is greater than mean
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A group of investigators is planning a study to evaluate the relationship between serum fibrinogen levels and the incidence of acute coronary syndrome. They assume that serum fibrinogen levels are normally distributed in the population of interest W hich of the following statements is most consistent with this assumption?
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Mean Median Mode
Mode
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Positively skewed
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@USMLEWorld. LLC
The normal distribution is one of the most commonly occurring statistical distributions. Many variables in real life (eg, laboratory values) are normally distributed or close to normaL The normal distribution is bell-shaped and symmetric Consequently , all its measures of central tendency are equal mean = median = mode. (In real life , the values are not exactly equal due to small variations, but they lie very close to each other.) Skewed distributions do not have this property (Choices 8 and C) In a positively skewed distribution (tail on the right) , the mean is greater than the median and greater than the mode. (Choices 0 and E) In a negatively skewed distribution (tail on the left), the mean is less than the median and less than the mode. Educational objective: A I d. t 'b t' .
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Mode
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Normal distribution
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©USMLEWotld, LLC
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The normal distribution is one of the most commonly occurring statistical distributions. Many variables in real life (eg, laboratory values) are normally distributed or close to normaL The normal distribution is bell-shaped and symmetric Consequently , all its measures of central tendency are equal mean = median = mode. (In real life, the values are not exactly equal due to small variations, but they lie very close to each other.) Skewed distributions do not have this property (Choices B and C) In a positively skewed distribution (tail on the right) , the mean is greater than the median and greater than the mode. (Choices D and E) In a negatively skewed distribution (tail on the left) , the mean is less than the median and less than the mode. Educational objective: A normal distribution is symmetric and bell-shaped All its measures of central tendency are equal: mean = median = mode. Time Spent 2 seconds
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e A Aphthous stomatitis e B. Candidiasis e C. Herpes simplex virus infection e D. Leukoplakia e E. Squamous cell carcinoma Submit
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lab Values
A 62-year-old man comes to the physician fo r a routine follow-up appointment He has a 20-pack-year smoking history and recently began chewing tobacco. He drinks 6-10 beers each weekend. The patient's past medical history is significant for type 2 diabetes mellitus and hypertension. His last hemoglobin A 10 was 8.3% . His body mass index is 27.5 kg/m2 On oral examination, a white patch is seen on the buccal mucosa. The lesion appears to have a granular texture, is not indurated, and is not removed by scraping with a tongue depressor. There is no regional lymphadenopathy . W hich of the following is the most likely cause of the oral lesion in this patient?
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The risk factors for development of leukoplakia are similar to those fo r squamous cell carcinoma, with smokeless tobacco and alcohol use accounting fo r the majority of cases. The natural history of oral leukoplakia depends on the degree of dysplasia, with 1o/o-20% of lesions progressing to squamous carcinoma within 10 years Fortunately , most lesions resolve within a few weeks after cessation of tobacco use. The development of areas with induration and/or ulce ration should prompt biopsy to rule out malignant transformation of the lesion.
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(Choice A) Aphthous stomatitis refers to localized, shallow, painful ulce rs with a gray base. Recurrent aphthous stomatitis is the most common cause of oral ulcers.
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(Choice B) Or al candidiasis, or thrush, occurs in patients with diabetes, immunodeficiency states, and use of antibiotics or inhaled glucocorticoids The lesions of candidiasis typically consist of white plaques on the oral mucosa, tongue, or oropharynx with underlying erythema. In contrast to leukoplakia, the plaques of candidiasis can usually be scraped off with a tongue depressor
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The clinical description of the lesion, with the presence of a white granular patch or plaque over the buccal mucosa in a patient with a history of alcohol and tobacco use, is most consistent with oral leukoplakia. Leukoplakia is a reactive precancerous lesion that represents hype rplasia of the squamous epithelium
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(Choice C) Herpes simplex virus type 1 can cause gingivostomatitis It can present with multiple ves icular lesions with an erythematous and inflammatory base and erythematous border within the oral cavity and perioral area. Herpes simplex virus type 1 does not cause the white plaque seen in this patient (Choice E) This patient has several risk factors fo r squamous cell ca rcinoma of the oral cavity, including extensive use of tobacco and alcohoL Squamous cell carc inoma usually presents as persistent nodular, erosive, or ulcerative lesions with surrounding erythema or induration. Reg ional lymphadenopathy can be present as welL The white granular lesions in this patient are more consistent with oral leukoplakia Educational objective: 0 II k •I k. • t
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The risk facto rs for development of leukoplakia are similar to those for squamous cell ca rcinoma, with smokeless tobacco and alcohol use accounting fo r the majority of cases. The natural history of oral leukoplakia depends on the degree of dysplasia, with 1%-20% of lesions progressing to squamous carcinoma within 10 years Fortunately , most lesions resolve within a few weeks after cessation of tobacco use. The development of areas with induration and/or ulceration should prompt biopsy to rule out malignant transformation of the lesion. {Choice A) Aphthous stomatitis refers to localized, shallow, painful ulcers with a gray base. Recurrent aphthous stomatitis is the most common cause of oral ulcers. (Choice B) Oral candidiasis, or thrush, occurs in patients with diabetes, immunodeficiency states, and use of antibiotics or inhaled glucoco rtico ids. The lesions of candidiasis typically consist of white plaques on the oral mucosa, tongue, or oropharynx with underlying erythema contrast to leukoplakia, the plaques of candidiasis can usually be scraped off with a tongue depressor
In
(Choice C) Herpes simplex virus type 1 can cause gingivostomatitis. It can present with multiple vesicular lesions with an erythematous and inflammatory base and erythematous border within the oral cavity and perioral area. Herpes simplex virus type 1 does not cause the white plaque seen in this patient
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{Choice E) This patient has several risk factors fo r squamous cell carcinoma of the oral cavity, including extensive use of tobacco and alcohol. Squamous cell carcinoma usually presents as persistent nodular, erosive, or ulcerative lesions with surrounding erythema or induration. Regional lymphadenopathy can be present as well. The white granular lesions in this patient are more consistent with oral leukoplakia Educational objective: Oral leukoplakia presents as white patches or plaques over the oral mucosa that usually cannot be scraped off. The risk factors for development of leukoplakia are similar to those fo r squamous cell ca rcinoma (tobacco and alcohol use) Development of areas with induration and/or ulceration should prompt biopsy to rule out malignant transformation of the lesion. Time Spent 2 seconds
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e> A. Closer proximity of the urethral meatus to the anus in females 10 B. Frequent use of spermicide and diaphragms in females
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C. Shorter urethral length in females
0 D. Higher post-void urine residual in females 10 E. Hormonal fl uctuation of females
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Lab Values
A 34-year-old sexually active female comes to your office because of urinary frequency and dysuria for two days She has had two such episodes in the past, each treated with oral antibiotics. Physical examination reveals suprapubic tenderness and her urinalysis is positive fo r nitrite, leukocyte esterase, many W BC, and a moderate amount of bacteria. W hich of the following is the most common reason fo r the higher incidence of urinary tract infections in females than in males?
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Urinary tract infections (UTI ) are more commonly seen in females than males, and half of all adult women have a UTI at some time in their life. The high incidence of UTis in women is primarily due to the shorter length of the female urethra. After the periurethral area becomes colonized by rectal flora, the bacteria ascend to the bladder to cause infection. This is facilitated in females by a short urethra. Predisposing factors for UTis include alteration of the normal vaginal flora by recent antibiotic use, sexual intercourse, diaphragm or spermicide use, or a family history of multiple UTis. Males, on the other hand, are less likely to develop a UTI mainly because they have a longer urethra than females. They also have a drier periurethral environment and antibacterial substances in prostatic fluid, which also help to fight off infection. (Choice A) A shorter distance between the anus and urethra in women is associated with a higher incidence of recurrent UTis within the female population, but is not the main reason for the difference in UTI frequency between men and women.
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{Choice B) Spermicide and diaphragm use are risk facto rs for UTis in females. A shorter urethral length in females , however, is responsible for their higher frequency of UTis compa red to males.
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(Choice D) Inc reased post-void urine residual is not associated with a higher incidence of recurrent UTis in females. (Choice E) Female hormonal fluctuation is not related to an increased incidence of UTis in females . Educational objective: The increased incidence of urinary tract infections in women is due to the shorter length of the female urethra compared to males. Other predisposing factors for UTis include sexual intercourse, recent antibiotic use, the use of spermicidal contraceptives, and a close proximity of the urethra to the anus. Time Spent 3 seconds
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® A. The first study results are more specific ® B. The second study results are more sensitive
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® C. The first study results are more valid
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® E. The second study results are more precise
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Lab Values
Two cross-sectional studies were conducted using different questionnaires to determine the prevalence of over-the-counter analgesics use in a population The first study showed a prevalence of 7.5% (95% confidence interval 6.0- 9 0) , and the second study demonstrated a prevalence of 7.3% (95% confidence interval 6.9- 7 6). If the true prevalence of over-the-counter analgesics use in the population is 7.4%, which of the following statements about the results of the study is the most accurate?
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A. The first study results are more specific [3%] B. The second study results are more sensitive [8%] C. The first study results are more valid [4%]
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prevalence of over-the-counter analgesics use in a population. The first study showed a prevalence of 7.5% (95% confidence interval 6.0- 9 0), and the second study demonstrated a prevalence of 7.3% (95% confidence interval 6.9 - 7 6). If the true prevalence of over-the-counter analgesics use in the population is 7.4%, which of the following statements about the results of the study is the most accurate?
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D. The first study results are more accurate [4%] ~
E. The second study results are more precise [81 %]
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Explanation:
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Precision is the measure of random error in the study The study is precise if the results are not scattered widely; this is reflected by a tight confidence interval. The first study has a wider confidence interval compared to the second study; therefore, the second study is more precise
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{Choices A and B) Specificity and sensitivity are measures of validity The sensitivity and specificity of the questionnaires used in these studies cannot be determined from the given information. {Choices C and D) Validity and accuracy are measures of systematic error (bias) Accuracy is reduced if the result does not reflect the true value of the parameter measured. Increasing the sample size increases the precision of the study, but does not affect accuracy In our case, the results of both studies are pretty close to the true value, and are thus seemingly accurate. Educational Objective: Precision is the measure of random error. The tighter the confidence interval, the more precise the result. Increasing the sample size increases precision. Time Spent 3 seconds
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A Ascending aortic aneurysm
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B. Constrictive perica rditis
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A 62-year-old Caucasian female is being evaluated after she had an episode of syncope She complains of having progressive exertional dyspnea over the last two months with an occasional dry cough. Cardiac auscultation findings over the apex are given below. Which of the following best explains the physical findings in this patient?
e') C. Mitral regurgitation
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D. Tricuspid valve stenosis [3%] Explanation: The combination of this patient's exertional dyspnea, dry cough, and holosystolic murmur on auscultation are most suggestive of mitral regurgitation (MR) Although the clinical manifestations of MR vary significantly with the degree of regurgitation, exertional dyspnea and fatigue are the most common symptoms, which occur secondary to a combination of decreased cardiac output and inc reased left atrial pressure This patient's dry cough may relate to pulmonary congestion and edema, which is an indicato r of more severe disease that has resulted in left ventricular dysfunction The murmur of MR is classically a holosystolic murmur heard best over the apex with radiation to the axilla. Mitral regurgitation can occur as a result of primary mitral valve disease (e g. rheumatic heart disease, infective endocarditis, or trauma) or may be associated with other ca rdiac conditions (e g ischemic heart disease or hypertrophic cardiomyopathy)
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(Choice A) An ascending aortic aneurysm can be associated with aortic regurgitation, which would result in a diastolic murmur.
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(Choice B) Although patients with constrictive perica rditis often present with exertional dyspnea, physical findings such as elevated jugular venous pressure, pulsatile hepatomegaly , and signs of fluid overload are often present as well. (Choice D) Tricuspid stenosis would cause a diastolic murmur, not systolic disease is the most common cause of tricuspid stenosis.
Rheumatic heart
Educational objective: Mitral regurgitation classically results in a holosystolic murmur heard best at the apex with radiation to the axilla. Common clinical features of MR include exertional dyspnea, fatigue, atrial fibrillation , and signs of heart failure. Time Spent 3 seconds
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B. There is a 0.1% probability of observing the given relative risk (or more extreme) by chance alone assuming no differences in mortality C. There is a 71 % decrease in all-cause mortality in the new aldosterone receptor
0 antagonist compared to the placebo group
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A group of investigators conducted a randomized placebo-controlled clinical trial to assess the effect of a new aldosterone receptor antagonist on the progression of chronic heart failure. The primary outcome was all-cause mortality A decrease in all-cause mortality in the treatment group was reported, with a relative risk of 0.71 (p = 0.001) W hich of the following statements is the best interpretation of the reported association?
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C. There is a 71 % decrease in all-cause mortality in the new aldosterone receptor antagonist compa red to the placebo group [14%) D. There is only a 0.1% chance that the relative risk calculated is biased in favo r of the aldosterone receptor antagonist group [7%) E. The results obtained are not statistically significant [3%1 Explanation: Relative risk (RR) is a point estimate of association, but it does not account for random error. It is always possible that the calculated RR occurred by chance. The p-value is used to strengthen the results of the study and represents the probability of observing a given (or more extreme) result by chance alone, assuming the null hypothesis is true. In this scenario, assuming there were no difference in all-cause mortality between the treatment and placebo groups (null hypothesis) , the probability of obtaining a RR of 0.71 or a more extreme value due to chance alone is 0.1% (ie, p = 0 001) The commonly accepted upper limit (cut-off point) of the p-value fo r a result to be considered statistically significant is 0.05 (ie, p <5% is statistically significant)
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{Choices A and E) Both the p-value and the confidence interval are measures of statistical significance A 95% confidence interval that contains 1.0 (null value for RR) would mean that the results are not statistically significant This is not consistent with the obtained p-value of 0.001, which is statistically significant (Choice C) A RR = 0.71 shows that the drug decreased the risk of mortality by 29%. (Choice D) The p-value reflects random variability. not bias (which is systematic error) Educational objective: The p-value is the probability of observing a given (or more extreme) result due to chance alone, assuming the null hypothesis is true. A result is generally considered statistically significant when p <0.05. Time Spent 4 seconds
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A cohort study was conducted to assess the relationship between a high-fat diet and colorectal adenocarcinoma. The study concluded that no association exists between the exposure and the outcome after controlling for known risk factors (age, fiber consumption, and family history of cancer) as the relative risk was 1.15 with a p value of 0.25. The investigators also reported that 40% of the subjects in the high-fat group and 36% of the subjects in the low-fat group were lost to follow-up by the end of the study and were not included in the final analysis According to this information, which of the following biases is most likely to be present?
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Common types of systematic errors in statistical studies Inappropriate selection or poor retention of study subjects • Ascertainment (sampling) bias: Study population differs from target population due to nonrandom selection methods
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• Nonresponse bias: High nonresponse rate to surveys/questionnaires can cause errors if non responders differ in some way from responders Selection biases
• Berkson bias: Disease studied using only hospital-based patients may lead to results not applicable to target population • Prevalence (Neyman) bias: Exposures that happen long before disease assessment can cause study to miss diseased patients that die early or recover
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Inaccurate measurement or classification of disease, exposure, or other variable
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• Recall bias: Common in retrospective studies, subjects with negative outcomes are more likely to report certain exposures than control subjects
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• Observer b ias: Observers misclassify data due to individual differences in interpretation or preconceived expectations regarding study • Reporting bias: Subjects over- or under-report exposure history due to perceived social stigmatization
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• Observer b ias: Observers misclassify data due to individual differences in interpretation or preconceived expectations regarding study
• Surveillance (detect ion) bias : Risk factor itself causes increased monitoring in exposed group relative to unexposed group, which increases probability of identifying a disease
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• Reporting bias: Subjects over- or under-report exposure history due to perceived social stigmatization
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Loss to follow-up is a problem for prospective studies as it creates the potential for a type of selection bias known as attrition bias. Subjects may drop out of a study for a number of reasons, but if the reason is somehow related to the outcome, the lost subjects will differ in their risk of developing the outcome compared to the remaining subjects W hen a substantial number of subjects are lost to follow-up, the study may overestimate or underestimate the association between the exposure and the disease. In this case, a substantial number of subjects were lost from both the exposed (high-fat) and unexposed (low-fat) groups. People in the low-fat .group may have left the study for different reasons than those in the high-fat group. For instance, maybe most subjects in the low-fat group left due to noncompliance with a strict low-fat diet, while more individuals in the high-fat group dropped out due to health-related problems (eg, obesity, diabetes, cardiovascular disease) The selective loss of high-risk subjects in the high-fat group would then cause the measure of association between fat consumption and colorectal cancer to be underestimated. To reduce the potential for attrition bias in prospective studies, investigators try to achieve high rates of follow-up Losses to follow-up must be reported in study articles fo r readers to know about the potential fo r selection bias. (Choice A) Observer bias occurs when observers misclassify data due to individual diffe rences in interpretation or preconceived expectations regarding the study The question gives no I I
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dropped out due to health-related problems (eg, obesity, diabetes, cardiovascular disease). The selective loss of high-risk subjects in the high-fat group would then cause the measure of association between fat consumption and colo rectal cancer to be underestimated. To reduce the potential for attrition bias in prospective studies, investigators try to achieve high rates of follow-up Losses to follow-up must be reported in study articles for readers to know about the potential for selection bias. {Choice A) Observer bias occurs when observers misclassify data due to individual differences in interpretation or preconceived expectations regarding the study The question gives no information on exactly how outcomes were classified and recorded. (Choice B) Recall bias occurs in retrospective studies when subjects with negative outcomes are more likely than control subjects to report certain exposures. This leads to misclassification of the exposure status, likely magnifying the effect of any exposure.
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{Choice E) Surveillance bias occurs when the exposed group undergoes increased monitoring relative to the general population. This tends to increase disease diagnoses compared to the general population Educational objective: Loss to follow-up in prospective studies c reates a potential for attrition bias, a subtype of selection bias. When a substantial number of subjects are lost to follow-up, the study may overestimate or underestimate the association between the exposure and the disease. Investigators try to achieve high rates of follow-up to reduce the potential for attrition bias. References: 1. Reporting attrition in randomised controlled trials.
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W hich of the following is the best statistical method to assess the association between HRT and elevated CRP levels?
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A study was conducted to assess the association between hormone replacement therapy (HRT) in post-menopausal women and the level of serum C-reactive protein (CRP) The data from the study are presented below:
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Wh ich of the following is the best statistical method to assess the association between HRT and elevated CRP levels?
A Two-sample z-test [ 5%) B. Two-sample t-test [33%)
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C. Chi -square test [55%] D. ANOVA [5%] E. Meta-analysis [2%)
Explanation: The chi-square test is used to compare the proportions of a categorized outcome. In this case, the outcome (serum CRP level) is categorized as either "high" and "normal," and then presented with the exposure ("HRT' or "no HRT') in a 2 x 2 table. In one of the commonty used chi-square tests, the observed values in each of the cells are compared to expected (under the hypothesis of no association) values. If the difference between the observed and expected values is large, an association between the exposure and the outcome is assumed to be present (Choices A and B) The two-sample z-test and two-sample t-test are used to compare two means, not proportions (Choice D) Analysis of variance (ANOVA) is used to compare the means of three or more variables. (Choice E) Meta-analysis is an epidemiologic method of pooling the data from several studies to do an analysis having a relatively big statistical power. Educational Objective: The chi-square test is used to compare proportions A 2 x 2 table may be used to compa re the observed values with the expected values. Time Spent 3 seconds
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A Lisinopril
e> B. Aspirin e')
C. Metoprolol
e> D. Furosem ide
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E. Hydrochlorothiazide
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A 60-year-old man comes to your office complaining of difficulty hearing for the past few weeks. He has type 2 diabetes mellitus, which is well-controlled by diet alone. His past medical history is also significant for essential hypertension, congestive heart fa ilure secondary to diastolic dysfunction, and chronic renal failure. Medications include aspirin, diuretics, an ACE inhibitor, and a beta-blocker. His pulse is 82/min, blood pressure is 140/90 mmHg, and respirations are 14/min. Examination reveals hearing loss in both ears. W hich of the following medication is a potential cause of this patient's hearing problems?
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Explanation: This patient's complaints of new-onset, bilateral hearing loss raises conce rn for medication-induced ototoxicity There are a large number of ototoxic medications that can cause sensorineural hearing loss, including aminoglycoside antibiotics, chemotherapeutic agents, aspirin, and loop diuretics. With this patient's history of congestive heart failure, one of the diuretics he may be taking is the loop diuretic furosemide, which is well-known to potentially cause ototoxicity Loop diuretics are associated with reversible or permanent hearing impairment, reversible deafness, and/or tinnitus. The risk of ototoxicity is greater in patients taking high doses of furosemide, but patients who have coexistent renal failure, as is the case in this vignette, may experience hearing loss or deafness at lower doses. (Choice A) Lisinopril is an ACE inhibitor that is class ically associated with the side effects of cough, hyperkalem ia, and angioedema It does not cause ototoxicity. {Choice B) Asp irin usually causes tinnitus; but in ve ry higher doses it can cause (6 to 8 grams/day) hearing loss. This patient's hearing loss is more likely to be associated with loop diuretics. (Choice C) Beta-blockers, such as metoprolol, are associated with many significant side effects, incl uding increased airway resistance, bradycardia, fatigue, and depression among many others. Hearing loss, however , is not a common side effect of beta-blockers. (Choice E) Hydrochlorothiazide is a thiazide diuretic that can cause orthostatic hypotension, photosensitivity, hypercalcem ia, or other potential side effects. Hearing loss, however, is not associated with hydrochlorothiazide Educational objective: Loop diuretics can cause reversible or permanent hearing loss and/or tinnitus. These ototoxic effects typically occur in patients taking high doses of loop diuretics, those with coexistent renal fa ilure, or in patients who are also being treated with other known ototoxic medications, such as aminoglycosides Time Spent 3 seconds
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A Cigarette smoking and bronchogenic cancer had a strength of association, but the
0 dose response relationship was not clear
B. Smoking and bronchogenic cance r did not have strength of association, but had a
0 dose response relationship
C. Smoking and bronchogenic cancer were weakly associated and did not show a clea r
0 dose response relationship
D. Smoking and bronchogenic cancer had a strong association and a dose response
0 relationship
E. Smoking and bronchogenic cance r had strength of association but no dose response
0 relationship Submit
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In a selected study of bronchogenic cancer , it was found that in people smoking 1 PPD (pack per day) of cigarettes, the RR (relative risk) was 2.4. For those smoking 2 PPD, the RR was 3.0. For those smoking 3 PPD, the RR was 4 .1 . W hich of the following statements is true regarding these findings?
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C. Smoking and bronchogenic cance r were weakly associated and did not show a clear dose response relationship [1%) D. Smoking and bronchogenic cancer had a strong association and a dose response relationship [90%) E. Smoking and bronchogenic cance r had strength of association but no dose response relationship I1%I Explanation: Relative risk (RR) is used as a measure of association in cohort studies. It is the ratio of the risk in an exposed group to that of the unexposed group A RR > 1 means that there is a positive association between the risk factor and the outcome. A RR < 1 means that there is a negative association between the risk factor and the outcome. The farther the value of RR from 1, the stronger the association. In the given example, the RR fo r bronchogenic cancer in smokers is more than 2, thus indicating a strong association between smoking (risk factor/exposure) and bronchogenic cancer (outcome)
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W hen exposure is measured on a continuous scale (e.g , number of smoked cigarettes per day or PPD) , the classification in two or more ordinal categories enables the risk to be assessed as a function of exposure, and the dose response effect can be calculated for the exposure and outcome. The present example illustrates a dose response relationship between smoking and bronchogenic cancer (i. e., the RR for bronchogenic cance r increases as the number of smoked PPD increases) (Choices A, B , C and E) In the given study, there was a strong association between cigarette smoking and bronchogenic cancer. There was also a clear dose response relationship between smoked PPD and bronchogenic cancer. Educational objective: Know how to interpret the strength of association and dose response relationship from a study Time Spent 3 seconds
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e; A Otosclerosis e; B. Presbycusis () C . Middle ear effusion
e; D. Meniere's disease
() E. Acoustic neuroma e; F. Depression
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A 70-year-old man comes to your office with complaints of difficulty hearing. His wife says that he has been raising the television volume much louder recently. The patient cla ims that he can hear well when he talks to his fam ily members at home, but he has significant difficulty hearing in restaurants or during other family gatherings, which is why he prefers to stay at home most of the time. He wo rked in a shipbuilding ya rd for 30 yea rs, and retired five years ago He has no history of significant noise exposure. W hat is the most likely diagnosis?
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Explanation: This patient's hearing difficulties are most likely caused by presbycusis, defined as sensorineural hearing loss that occurs with aging The hearing loss associated with presbycusis is typ ically first noticed in the sixth decade of life, and characteristically begins with symmetrical, high-frequency hearing impairment Patients often complain of difficulty hearing in crowded or noisy environments, similar to what this patient describes. In addition, affected patients usually have trouble hearing high-pitched noises or voices. Although presbycusis is a disease of aging, multiple factors have been shown to influence the rate of hearing loss, including medications, genetics, a history of infection, and exposure to loud noise. (Choice A) Otosclerosis is a type of chronic conductive hearing loss associated with bony overgrowth of the stapes It typically begins with low-frequency hearing loss and is often found in middle-aged individuals. {Choice C) A middle ear effusion, as is seen in patients with serous otitis media, often produces tinnitus and a sensation of pressure in addition to conductive hearing loss.
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(Choice D) Patients with Meniere's disease present with episodes of tinnitus, vertigo, and sensorineural hearing loss. This patient does not complain of ve rtigo or tinnitus. (Choice E) The most common tumor that causes sensorineural hearing loss is an acoustic neuroma . It is associated with unilateral hearing loss as opposed to the bilateral hearing loss of presbycusis {Choice F) Although presbycusis can contribute to the development of low self esteem and depression, this patient's complaints are not indicative of depression Educational objective: Sensorineural hearing loss that occurs with aging is referred to as presbycusis It is usually fi rst noticed in the sixth decade of life , and presents with high-frequency, bilateral hearing loss. Patients with presbycusis often have difficulty hearing in noisy, crowded environments. Time Spent 3 seconds
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e> A
Neoplasia
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D. Opportunistic infection
10 E. Demyelinization
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A 32-year-old male complains of difficulty hearing in his left ear fo r the past month. He denies any headaches, feve r, chills, weight loss, or ear discharge He is HIV positive, and is currently being treated with highly active antiretroviral therapy (HAART). He also takes trimethoprim/sulfamethoxazole daily His most recent CD4 count was 425/ mm3. Examination of the affected ear shows a dull, hypomobile tympanic membrane. W hat is the most likely cause of hearing loss in this patient?
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Explanation: Serous otitis media is the most common middle ear pathology in patients with acquired immunodeficiency syndrome It is due to the auditory tube dysfunction arising from HIV lymphadenopathy or obstructing lymphomas Serous otitis media is characterized by the presence of a middle ear effusion without evidence of an acute infection. Conductive hearing loss is the most common symptom experienced by patients with serous otitis media, and examination typically reveals a dull tympanic membrane that is hypomob ile on pneumatic otoscopy (Choice A) HIV-infected individuals are at risk of developing one of many different malignancies This patient, however, appears to be fairly well-controlled on his HAART therapy. In addition, unilateral hearing loss would be an unusual presentation of an HIV-associated malignancy. (Choice C) Otosclerosis is a form of conductive hearing loss that results from bony overgrowth of the stapes It does occur in middle-aged individuals, but would not be associated with the examination findings seen in this patient (Choice D) As mentioned above, patients with HIV are at risk of developing one of several opportunistic infections. This patient, however , is well-controlled on the current regimen of HAART and trimethoprim/sulfamethoxazole, and therefore an opportunistic infection is unlikely to be the cause of his hearing loss. (Choice E) Progressive multifocalleukoencephalopathy (PML) is a demyelinating disease that can occur in patients with HIV/A IDS, but is less likely in patients on HAART and usually only occurs in patients with CD4 counts < 200/mm3. In addition, hearing loss would be an atypical presenting symptom in patients with PML Educational objective: Serous otitis media is defined as the presence of a middle ear effusion without signs of an active infection. Examination commonly reveals a dull tympanic membrane that is hypomob ile on pneumatic otoscopy. Time Spent 2 seconds
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(:) A. Angiofibroma 10 B. Inverted papilloma
e> C. Nasal polyp
o
D. Perforated nasal septum
10 E. Pyogenic granuloma
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A 28-year-old African American female complains of recurrent nasal discharge and increasing nasal congestion She has a constant sensation of dripping in the back of her throat, and states that food has tasted bland to her recently She is known to have sickle cell trait She came to the emergency department for severe wheezing after taking naproxen for menstrual c ramping one yea r ago. She has no history of head trauma. She does not smoke cigarettes, but she admits to smoking marijuana occasionally. W hich of the following is the most likely diagnosis?
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This patient's history of wheezing following the ingestion of naproxen as well as her symptoms of rhinitis and post-nasal drainage are highly suggestive of aspirin exacerbated respiratory disease (AERO) , a condition commonly associated with the development of nasal polyps. AERO consists of the following features asthma, chronic rhinosinusitis with nasal polyposis, and bronchospasm or nasal congestion following the ingestion of aspirin or non-steroidal anti-inflammatory drugs (NSAIOS) The diagnosis of AERO can often be made clinically when all three of these conditions are present This patient's current symptoms of bland tasting food (secondary to anosmia) and recurrent nasal discharge/congestion are typ ical in patients with nasal polyps, and examination should reveal the presence of bilateral, grey, glistening muco id masses in her nasal cavities. Although surgery can often provide temporary relief, the polyps tend to recur and ultimate treatment should be geared toward medical management of the underlying etiology. (Choice A) Juvenile nasal angiofibroma is a rare, benign tumor of the nasopharynx that can cause nasal obstruction and nasal drainage, but also usually results in epistaxis. In addition, it occurs almost exclusively in teenage males.
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{Choice B) An inve rted papilloma is a tumor of unknown etiology that clinically presents with signs of unilateral nasal obstruction and/or epistaxis It is not associated with AERO.
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(Choice E) Pregnant women have an increased incidence of pyogenic granulomas on the anterior nasal septum These highly vascular lesions are frequent sources of nose bleeds during pregnancy Educational objective: Nasal polyps are often associated with chronic rhinosinusitis, asthma, and aspirin- or NSAIO-induced bronchospasm in a condition known as aspirin-exacerbated respiratory disease. They frequently cause symptoms of bilateral nasal obstruction, nasal discharge, and anosmia. Time Spent 5 seconds
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A new screening test was devised to detect pancreatic cancer at early stages using a serum marker (CA19-9) of the disease. A study of this new test showed that its use prolongs the survival of patients with pancreatic cancer by several months. The researchers concluded that use of the test improves the prognosis of patients with pancreatic cancer. Which of the following is a potential problem with this conclusion?
® A Observer's bias ® B. Measurement bias ® C. Lead-time bias
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D. Confounding
® E. Ascertainment bias
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A Observer's bias [3%) B. Measurement bias [3%) ~
C. Lead-time bias [85%) D. Confounding [4%) E. Ascertainment bias [4%)
Explanation: Lead-time bias should always be considered while evaluating any screening test This bias occurs when there is an incorrect assumption or conclusion of prolonged apparent survival and better prognosis due to a screening test W hat actually happens is that detection of the disease was made at an earlier point in time, but the disease course itself or the prognosis did not change, so the screened patients appeared to live longer from the time of diagnosis to the time of death. (USMLE tip think of lead-time bias when you see "a new screening test" fo r poor prognosis diseases like lung or pancreatic cancer )
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(Choices A, B and E) Observer's bias, measurement bias and ascertainment bias refer to misclassification of an outcome and/or exposure (e g , labeling diseased subjects as non-diseased and vice versa) and are related to the design of the study. The scenario described does not mention how the study was designed. (Choice D) Although the results of the study could be potentially confounded, there is no info rmation on how potential confounders were treated during the design or analys is stage of this study Educational Objective: Understand the concept of lead-time bias in screening tests. The typical example of lead-time bias is prolongation of apparent survival in patients to whom a test is applied, without changing the prognosis of the disease. Time Spent 2 seconds
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Last updated: [07/ 16/2016)
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This item has associated media that may require the use of headphones. Please ensure your system/speaker volume is set to an audible leveL A 54-year-old male with a past medical history of type 2 diabetes mellitus comes to the emergency department complaining of shortness of breath. His blood pressure is 146/92 mmHg, respiratory rate is 26/min, and oxygen saturation is 87% on room air. Cardiac auscultation findings over the apex are given below. Based on the physical findings, which of the following is the best initial therapy for this patient? Play Media
6 A Inhaled bronchodilators e') B. Intravenous beta-blockers
6 C. Intravenous diltiazem e') D. Intravenous diuretics
6 E. Pericardiocentesis
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Explanation: In addition to hearing the normal S1 and S2 on auscultation, there is an extra sound occurring after S2 known as the third heart sound (S3) The presence of this additional heart sound produces a rhythm that has been described as sounding like "ken-tuc-KY", with the third syllable corresponding to the S3. The S3 is believed to result when inflow from the left atrium strikes blood that is already in the left ventricle, causing reverberation of blood between the left ventricular walls. Although this extra sound can be normal in younger individuals and well-trained athletes, its appearance later in life is often a sign of left ventricular fa ilure. This patient has several signs consistent with left heart failure including shortness of breath, tachypnea, and hypoxemia. When combining these clinical findings with a S3, the most likely diagnosis is left ventricular fa ilure, fo r which the most appropriate treatment at this time would be intravenous diuretics. {Choice A) Inhaled bronchodilators would be the appropriate treatment for patients suffe ring from an acute COPD or asthma exacerbation. However , such patients would present with wheezing on chest auscultation. {Choice B) Although patients with heart failure will benefit from beta-blockers in the long term, they are not as effective as diuretics at providing symptomatic benefits in the short term.
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(Choice C) Due to its negative inotropic effects, diltiazem is not beneficial in the treatment of patients with decompensated heart fa ilure .
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{Choice E) A pericardiocentesis is indicated in some patients with a pericardia! effusion, which is not associated with S3.
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Educational objective: The third heart sound (S3) is a low frequency diastolic sound heard just after S2 that is associated with left ventricular fa ilure. Intravenous diuretics provide symptomatic benefits to patients with decompensated heart failure. Time Spent 2 seconds
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0 A Arterial embolism
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A 68-year-old man comes to the emergency department due to right leg pain for the past several hours. The patient was resting at home when he suddenly had severe pain in the right leg; the leg has since become numb. He has never had similar symptoms and has no history of trauma, fever , or chills. The patient recently suffered an acute anterior wall myocardial infa rction resulting in cardiogenic shock and is currently undergoing cardiac rehabilitation. His other medical problems include hypertension, type 2 diabetes mellitus, and hyperlipidemia Temperature is 36.7 C (981 F), blood pressure is 120/70 mm Hg, pulse is 90/min and regular, and respirations are 16/min. Cardiopulmonary examination is unremarkable. Compared to the left leg, his right leg appears pale and cool to the touch. In the right lower extremity, the popliteal pulse is normal, but more distal pulses are not palpable. Pulses in the other extremities are normal. Neurologic examination shows loss of sensation over the dorsum of the right foot and mild weakness with dorsiflexion. W hich of the following is the most likely cause of this patient's symptoms?
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Acute limb ischemia
Etiology
• Cardiac/arterial embolus (eg, AF, LV thrombus, IE) • Arterial thrombosis (eg, PVD) • Iatrogenic/blunt trauma
6 Ps of acute limb ischemia Clinical features
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Pain Pallor Paresthesias Pulselessness Poikilothermia (cool extremity) Paralysis (late)
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Management
• Anticoagulation (eg, heparin) • Thrombolysis versus surgery
AF = atrial fibrillation; IE = infective endocarditis; l V = left ventricle, PVO = peripheral vascular disease. @UWolid
This patient has the classic 6 Ps- pain, pallor, paresthesias, pulselessness, poikilothermia (cool extremity), and paralysis (due to nerve ischemia) - of acute arterial occlusion of the right lower extremity (acute limb ischemia). Acute arterial occlusion can result from 1 of 3 major causes embolus from a cardiac or arterial source, arterial thrombosis, or iatrogenic or direct blunt trauma to the artery The sudden development of symptoms in a previously asymptomatic patient is most consistent
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septic emboli), and thrombus from prosthetic valves. (Choice B) Arterial thrombosis usually develops at the site of an atherosclerotic plaque in patients with preexisting peripheral vascular disease. Due to the presence of collateral circulation in these patients, limb ischemia manifestations are typically less severe than they are in patients with an acute embolus. In addition, pulses are often diminished in both extremities in patients with peripheral vascular disease. {Choice C) Arterial vasculitis of any cause is usually accompanied by constitutional symptoms (eg, feve r, malaise, weight loss) as well as other systemic findings specific to each vasculitic syndrome. Examples of arterial vasculitis include Takayasu arteritis, polya rteritis nodosa, and temporal arteritis. (Choice D) Cerebral ischemia (eg, transient ischemic attacks) typically causes focal sensory or motor neurologic deficits, not pulselessness (Choice E) Nerve compression alone can cause paresthesias and muscle weakness; however, it usually does not cause acute-onset pulselessness (Choice F) Deep venous thrombos is typically causes pain, swelling, and tenderness of the lower extremity However , the pain is typically dull and aching in contrast to the severe, sudden-onset pain seen with acute arterial occlusion. Pulselessness is not a typical feature of deep venous thrombosis. Educational objective: The classic presentation of acute arterial limb ischemia includes pain, pallor, paresthesias, pulselessness, poikilothermia (cool extremity) , and paralysis (6 Ps) Sudden development of ischemic symptoms in a previously asymptomatic patient is most consistent with an embolic arterial occlusion. References: 1. Clinical practice. Acute limb ischemia.
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<0 A Inhaled beta agonist <0 B. Intranasal decongestant <0 C. Intranasal glucocorticoid
e; D. Oral antibiotics
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A 28-year-old man comes to the office asking for antibiotics to treat a "sinus infection." He reports recurrent episodes of nasal congestion, rhinorrhea, and dry cough The patient has used over-the-counter allergy medicines with some relief but continues to feel uncomfortable and has difficulty concentrating at work. He does not have shortness of breath, chest pain, or ocular symptoms. The patient has no prior history of allergies or asthma but had eczema during childhood. He does not use tobacco, alcohol, or illic it drugs His temperature is 37 C (98.6 F), blood pressure is 120/78 mm Hg, and pulse is 76/min. Physical examination shows a transverse nasal c rease, swollen and pale nasal turbinates, and a clear nasal discharge. There is no maxillary sinus tenderness. The posterior pharyngeal wall has a "cobblestone" appearance Breath sounds are normal with no added sounds. W hich of the following is the most effective therapy fo r this patient's condition?
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Symptoms
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Rhinorrhea, nasal congestion, sneezing, nasal itching Cough secondary to postnasal drip Fatigue, irritability Ocular itching & tearing
Physical examination
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"Allergic shiners" (infraorbital edema & darkening) Dennie-Morgan lines (prominent lines on lower eyelids) "Allergic salute" (transverse nasal crease) Pale, bluish, enlarged turbinates Pharyngeal cobblestoning "Allergic facies" (high-arched palate, open-mouth breathing)
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• Intranasal corticosteroid • Allergen avoidance
©UWo~d
This patient has typical features of allergic rhinitis including nasal congestion, clear rhinorrhea, and pale, edematous nasal mucosa. Patients may also have nasal creases, pharyngeal cobblestoning, conjunctival edema, or thick, green nasal discharge During peak allergy seasons, patients can experience systemic (eg, fever) or neuropsychiatric (eg, fatigue, irritability) symptoms Atopic disorders (eg, allergic rhinitis, "hay fever, " asthma, eczema) fr equently cluster in families, but individual patients usually experience only a subset of these manifestations. Allergen avoidance can mitigate the symptoms of allergic rhinitis but is not always possible, and even low-level exposure can trigger bothersome symptoms. Glucocorticoid nasal sprays (eg, fluticasone, mometasone) are the most effective single agents An initial response can be seen
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Allergic rhinitis
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cobblestoning, conjunctival edema, or thick, green nasal discharge During peak allergy seasons, patients can experience systemic (eg, fever) or neuropsychiatric (eg, fatigue, irritability) symptoms Atopic disorders (eg, allergic rhinitis, "hay fever, " asthma, eczema) fr equently cl uster in families, but individual patients usually experience only a subset of these manifestations. Allergen avoidance can mitigate the symptoms of allergic rhinitis but is not always possible, and even low-level exposure can trigger bothersome symptoms. Glucocorticoid nasal spr ays (eg, fluticasone, mometasone) are the most effective single agents An initial response can be seen within several hours of administration, but maximal benefits may require continuous treatment for several days or weeks. Nonsedating oral antihistamines (eg, loratadine, cetirizine), antihistamine (eg, azelastine) or cromolyn nasal sprays, and leukotriene modifiers (eg, montelukast) are less effective but can be considered based on the patient's symptoms and drug tolerances (Choice E) (Choice A) Inhaled beta agonists are indicated fo r patients with asthma. Patients with wheezing should be evaluated for possible asthma, but a dry cough alone is a nonspecific symptom
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(Choice B) Nasal decongestant sprays can reduce mucosal edema but are less effective overall than glucoco rticoids and can cause rebound congestion (rhinitis medicamentosa)
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(Choice D) This patient has no fever or sinus tenderness to suggest bacterial sinusitis.
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Educational objective: Glucocorticoid nasal sprays are the most effective single agent for allergic rhinitis, although maximal benefits may require continuous treatment fo r several days or weeks. Oral antihistamines, antihistamine or cromolyn nasal sprays, and leukotriene modifiers can be considered based on the patient's symptoms and drug tolerances. References: 1. Mechanisms and clinical implications of glucocorticosteroids in t he treatment of allergic rhinitis .
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A 60-year-old man with chronic obstructive pulmonary disease comes to the emergency department with severe dyspnea, a productive cough, and fever for the last 3 days His temperature is 39.4 C (103 F), blood pressure is 110/62 mm Hg, pulse is 120/min, and respirations are 35/min. His chest x-ray shows a right lower-lobe infiltrate. Sputum examination shows gram-positive cocci. The patient is given intravenous antibiotics and eventually improves On hospital discharge, he is offered a polysaccharide vaccine that can help prevent future occurrences of his infection. This vaccine induces immunity by which of the following mechanisms?
6 A Increased mucosal lgA production
e; B. Natural killer cell response
6 C. Relatively T- cell-independent B-cell response e; D. Proliferation of CD8+ T cells
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6 E. T-cell-dependent B-cell response with memory B-cell production
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Polysaccharide vaccine Polysaccharide
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Moderate levels of intermediate-affinity antibodies
B-cell
Advantages • ~ Incidence of replacement strains due to lack of mucosal immunity
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Polysaccharide protein-conjugate
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Protein component allows activation of T-cell receptor
t Levels of high-affinity
antibodies with memory cell formation
Advantages
• t Efficacy in the elderly & children <2 years . t Mucosal immunity reduces colonization (herd protection) . t Immunogenic memory @UWortd
This patient has pneumococcal pneumonia, which is caused by a variety of Streptococcus pneumoniae serotypes Each infectious serotype produces a distinct capsular polysaccharide, and anti-capsular antibodies formed during an immune response provide immunity against only a single serotype As such, at-risk patients are given a pneumococcal vaccine containing multiple capsular antigens. Two types of vaccines are currently available for use in the United States: 1. Pneumococcal polysaccharide vaccine ( PPSV23) contains capsular material from 23 serotypes that have historically been responsible for the majority of pneumococcal infections. Because polysaccharides alone cannot be presented toT cells, the vaccine induces a relatively T-cell-independent 8-cell response that is less effective in young children and the elderly 2. Pneumococcal conjugate vaccine (PCV13) consists of capsular polysaccharides from 13 of the most common serotypes that have been covalently attached to inactivated diphtheria toxin protein. This polysaccharide-protein conjugate induces aT-cell-dependent 8-cell response, resulting in improved immunogenicity due to the formation of higher-affinity antibodies and memory cells (Choice E). Routine administration of the PCV13 is recommended for all infants and young children. PPSV23 is administered to adults age <65 with predisposing comorbidities (eg, chronic heart
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2. Pneumococcal conjugate vaccine (PCV13) consists of capsular polysaccharides from 13 of the most common serotypes that have been covalently attached to inactivated diphtheria toxin protein. This polysaccharide-protein conjugate induces aT-cell-dependent B-cell response, resulting in improved immunogenicity due to the formation of higher-affinity antibodies and memory cells (Choice E). Routine administration of the PCV13 is recommended for all infants and young children. PPSV23 is administered to adults age <65 with predisposing comorbidities (eg, chronic heart or lung disease, diabetes mellitus, cirrhosis) lmmunocompromised patients and all individuals age >65 should receive both vaccines to maximize protection. (Choice A) Certain vaccines induce a predominantly lgA (mucosal) response An example is the oral polio vaccine, which promotes the secretion of anti-poliovirus lgA antibodies into the gastrointestinal tract (Choice B) The natural killer (NK) cell response is a component of the body's innate immunity NK cells are lymphocytes that can nonspecifically recognize stressed and abnormal cells. They attack principally cancer cells and virus-infected cells. NK cells are not involved in the immune response to vaccines.
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(Choice D) Proliferation of C08+ T cells occurs mainly in response to intracellular pathogens. Certain live attenuated vaccines, such as the measles (MMR) and intranasal influenza vaccines, produce a predominately C08+ T-cell response Educational objective: The 23-valent pneumococcal vaccine contains capsular polysaccharides and induces a relatively T-cell-independent B-cell response In contrast, the 13-valent pneumococcal vaccine contains capsular polysaccharides conjugated to a protein antigen, which allows for a more robust T-cell-dependent B-cell response References: 1. Review: current and new generation pneumococcal vaccines
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6 D. Kawasaki disease
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0 E. Polymyos itis 0 F. Takayasu arteritis ® G. Thromboangiitis obliterans Submit
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A 29-year-old woman comes to the office due to a 6 month history of numbness and pain in her upper arms. The pain is worse on the left side and is exacerbated by lifting or other activity. Associated symptoms incl ude fatigue, fleeting joint pains, and a 5-kg (11-lb) weight loss. The patient's medical history is unremarkable, and she does not use tobacco or illic it drugs. She emigrated from Vietnam 5 years ago and works in a furniture repair shop The patient's blood pressure is 140/90 mm Hg in the right arm and 90/55 mm Hg in the left arm, and her pulse is 78/min and regular. Conjunctival and oral mucosa are moist and without lesions. Cardiopulmonary examination shows clear lung fields and no heart murmurs; however , a bruit is heard in the right supraclavicular fossa , and the left radial and brachial pulses are decreased. Abdominal examination is unremarkable. No skin lesions are present Complete blood count, electrolytes, and renal function are normaL Eryth rocyte sedimentation rate is 40 mm/hr. W hich of the following is the most likely diagnosis fo r this patient?
0 A Ao rtic dissection
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Takayasu arteritis • Female Risk factors
• Asian • Age 10-40 • Constitutional (eg, fever, weight loss)
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• Arterio-occlusive (eg, claudication, ulcers) in upper extremities
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• Arthralgias/myalgias
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• Blood pressure discrepancies
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• Pulse deficits • Arterial bruits
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• Elevated inflammatory markers (eg, ESR, CRP) Diagnosis
• Chest x-ray: Aortic dilation, widened mediastinum • CT/MRI: Wall thickening, narrowing of lumen
Treatment
• Systemic glucocorticoids
CRP = C-reactive protein; ESR = erythrocyte sedimentation rate.
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Th is patient with exertional arm pain (likely claudication), systemic symptoms, and pulse deficits has typical features of Takayasu arter itis, a chronic large artery vasculitis that predominantly affects Asian women age <40. It primarily involves the aorta and its branches and is characterized by mononuclear infiltrates and granulomatous inflammation of the vascular media, leading to arterial wall thickening with aneurysmal dilation or narrowing and occlusion. Initial symptoms are nonspecific (eg, feve r, arthralgias, weight loss) As the disease progresses, vascular involvement with arterio-occlusive manifestations (eg, claudication, distal ulce rs) may develop, particularly in the upper extremities. Examination findings include blood pressure discrepancies, pulse deficits, and bruits. Patients commonly have anemia and elevated inflammatory markers (eg, erythrocyte sedimentation rate, C-reactive protein). Chest x-ray can reveal aortic dilation and a widened mediastinum, and CT and MRI may reveal thickening of large artery walls and lumenal narrowing Initial treatment includes systemic glucocorticoids. (Choice A) Aortic dissection presents with acute chest pain radiating to the back. It is most common in patients with underlying hypertension. (Choice B) Aortic coa rctation can cause pulse deficits and blood pressure discrepancies but is more likely to be found in the lower rather than the upper extremities. Also, coa rctation is more commonty diagnosed in neonates and young children and is not typically associated with constitutional symptoms or elevated inflammatory markers. (Choice C) Giant cell arteritis is a large artery vasculitis similar to Takayasu arteritis. However, it occurs almost exclusively in patients age >50. Typical findings include temporal or scalp tenderness, and most patients have chronic pain and stiffness of the shoulders and hips (ie, polymyalgia rheumatica) (Choice D) Kawasaki disease is an acute i llness of children characterized by fever , mucositis, conjunctivitis, cervical adenopathy, rash, and edema of the hands and feet It is a self-limited disorder and resolves within 1-2 weeks. (Choice E) Polymyositis is characterized by painless proximal muscle weakness with elevated serum levels of muscle enzymes (eg, creatine kinase) . It does not cause arteria-occlusive
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(Choice B) Aortic coarctation can cause pulse deficits and blood pressure discrepancies but is more likely to be found in the lower rather than the upper extremities. Also, coarctation is more commonly diagnosed in neonates and young children and is not typically associated with constitutional symptoms or elevated inflammatory marke rs. (Choice C) Giant cell arteritis is a large artery vasculitis similar to Takayasu arteritis. However , it occurs almost exclusively in patients age >50. Typical findings include temporal or scalp tenderness, and most patients have chronic pain and stiffness of the shoulders and hips (ie, polymyalgia rheumatica) {Choice D) Kawasaki disease is an acute illness of children characterized by feve r, mucositis, conjunctivitis, cervical adenopathy , rash, and edema of the hands and feet It is a self-limited disorder and resolves within 1-2 weeks. (Choice E) Polymyositis is characterized by painless proximal muscle weakness with elevated serum levels of muscle enzymes (eg, creatine kinase). It does not cause arteria-occlusive manifestations. (Choice G) Thromboangiitis oblite rans (Buerger disease) occurs primarily in men who are heavy smoker s. Findings include superficial thrombophlebitis and ischemia and gangrene of the digits Educational objective: Takayasu arteritis is a large artery vasculitis that is most common in young Asian women. Initial symptoms include fever, arthralgias, and weight loss. Later features include arteria-occlusive symptoms, blood pressure discrepancies, and pulse deficits. CT and MRI can reveal aneurysm fo rmation or lumenal narrowing. Treatment includes systemic glucocorticoids. References: 1. Update on Takayasu arteritis. 2. Diagnostic and classification criteria of Takayasu arteritis.
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A Case control study
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D. Randomized control trial
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A group of infectious disease specialists interested in the rising prevalence of multidrug-resistant tuberculosis conducts a study to determine predisposing risk factors for the condition. They identify 40 patients with multidrug-resistant tuberculosis and 64 with pansensitive tuberculosis who were admitted to the hospital over the last 5 years. The investigators review the patients' past medical records fo r demographic characteristics, previous anti-tuberculosis treatment, HIV status, and major co-morbidities. They then compare the differences between the groups W hich of the following best describes the study design being used?
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Temporality of different study designs
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Clinical trial
1-1---~ Compare ~·~~~~~~l·---• for outcome I Control group ~ of interest Treatment group
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Prospective cohort Risk factor +
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Review past records
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Compare d isease incidence
Case control Compare risk factor frequency
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Compare disease incidence
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Observational epidemiological studies (eg, case series, case control, cohort, and cross-sectional studies) differ from experimental studies (eg, clinical trials) in that the researchers passively observe the study participants rather than monitor the result of a specific intervention. Observational studies can be subdivided into descriptive and analytical Descriptive epidemiology deals with the collection of data to characterize a specific health problem (eg, disease prevalence; incidence rates; distribution over time, location, and demographics) Analytical epidemiology is used to test hypotheses generated after analyzing the data from descriptive studies (eg, risk factor associations). Case control studies are analytical observational studies that retrospectively associate outcomes with specific risk factors. The researcher begins by selecting cases with a ce rtain outcome (eg, multidrug-resistant tuberculosis infection) and controls without that outcome (eg, pansensitive tuberculosis infection) The cases and controls are then assessed retrospectively for the presence of risk factors. Exposure status is determined by such activities as personal interviews and analysis of health records and laboratory reports. The c ritical distinction between case control and retrospective cohort studies is the order in which outcomes and risk factors are o1
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multidrug-resistant tuberculosis infection) and controls without that outcome (eg, pansensitive tuberculosis infection). The cases and controls are then assessed retrospectively fo r the presence of risk factors. Exposure status is determined by such activities as personal interviews and analysis of health records and laboratory reports The critical distinction between case control and retrospective cohort studies is the order in which outcomes and risk factors are assessed case control studies determine the outcome and then look fo r associated risk factors; retrospective cohort studies ascertain risk factor exposure and then determine the outcome. (Choice B) Cross-sectional studies are observational stud ies that can be either descriptive or analytical depending on study design Since they assess both exposure and outcome at a single point in time, they can show that an association exists but cannot establish causation. (Choice C) Prospective cohort studies are analytical observational stud ies in which a group of exposed and unexposed individuals is followed prospectively over time for development of the outcome of interest Cohort studies are considered stronger than case control and c ross sectional studies because of their greater ability to prove causation. (Choice D) A randomized control trial is an experimental study that is considered the gold standard for studying the efficacy of a treatment or procedure Subjects are randomly assigned to an experimental or control group and monitored for the outcome of interest This study design often has the least bias and provides the strongest evidence for a causal relationship
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(Choice E) A retrospective cohort study is similar to a prospective cohort study except that risk factor exposure and the outcome of interest both occur in the past and are assessed through review of records. Unlike a case control study, risk factor exposure is determined before the outcome is known, thus allowing calculation of the relative risk. Educational objective: The critical distinction between case control and retrospective cohort studies is the order in which outcomes and risk facto rs are assessed. Case control studies determine the outcome first and then look for associated risk factors; retrospective cohort studies first ascertain risk factor exposure and then determine the outcome. Time Spent 3 seconds
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B. No further intervention necessary
e; C. Single dose of Tdap vaccine
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e; E. Three doses of tetanus toxoid vaccine
D. Tetanus immune globulin and tetanus toxoid vaccine
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e; A Human tetanus immune globulin
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A 35-year-old man comes to the emergency department after stepping on a nail that punctured his right sole while jogging at a park He brought the nail, which is about 4 em long and rusty, with him. The patient's medical history is unremarkable and he takes no medications. He received a 3-dose primary tetanus vaccination series in ch ildhood but has not received any booster doses since then. Vital signs are within normal limits. Physical examination shows a puncture wound at the middle of the right plantar area with some dry blood and tenderness. There is no surrounding erythema. Radiographs of the right foot reveal no bony injury or foreign body The wound is cleaned with iodine solution. Which of the following additional interventions for tetanus prevention is most appropriate in this patient?
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;::3 tetanus toxoid doses
Clean o r m inor wound
Dirty or severe wound
• Tetanus toxoid-containing vaccine• only if last dose was ~10 years ago
• Tetanus toxoidcontaining vaccine- only if last booster given ~5 years ago
• No TIG
• NoTIG Unimmunized, uncertain, or <3 tetanus toxoid doses
• Tetanus toxoid-containing vaccine• only • NoTIG
• Tetanus toxoidcontaining vaccine• PLUS • TIG
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• Booster given as tetanus/diphtheria toxoids adsorbed (Td) or tetanus toxoid/reduced diphtheria toxoid/acellular pertussis (Tdap)
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TIG = tetanus immune globulin.
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Clostridium tetani is an anaerobic, spore-forming, gram-positive bacillus that is found in soil. Following traumatic tissue inoculation, it can release a neurotoxin (tetanus toxin), leading to symptomatic tetanus. Typical symptoms include tonic contraction and spasm of skeletal muscle (eg, neck stiffness, masseter spasm), wh ich can last up to 4-6 weeks. The risk fo r tetanus is greatest in wounds that are deep (eg, puncture wounds) or contain devitalized tissue (eg, burns, crush injuries) Tetanus is a vaccine-preventable illness, and symptomatic cases are uncommon in developed f'f'Uinfrioc
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Tetanus prophylaxis
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symptomatic tetanus. Typical symptoms include tonic contraction and spasm of skeletal muscle (eg, neck stiffness, masseter spasm), which can last up to 4-6 weeks. The risk for tetanus is greatest in wounds that are deep (eg, puncture wounds) or contain devitalized tissue (eg, burns, crush injuries). Tetanus is a vaccine-preventable illness, and symptomatic cases are uncommon in developed countries. Current recommendations are fo r children to receive a primary 3-dose vaccine series at ages 2, 4, and 6 months, with additional doses recommended at 15-18 months and 4-6 years Adults should receive a single dose of tetanus-diphtheria-acellular pertussis ( Tdap), followed by revaccination (booster) for tetanus and diphtheria (Td) every 10 years thereafter. Patients (such as this one) with significant or dirty puncture wounds who have received ~3 tetanus toxo id doses but have not received revaccination fo r tetanus within 5 years should be vaccinated. This patient has not received Tdap in adulthood and should therefore receive a single dose of Tdap at this time (Choices B and E)
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(Choices A and D) Tetanus immune globulin (TIG), which provides immediate passive (but temporary) immunity, is recommended in addition to tetanus vaccination fo r patients with significant puncture wounds who have not received at least 3 doses of tetanus vaccine and for those whose vaccine status is uncertain. TIG is never administered without tetanus vacc ination.
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Educational objective: Patients with significant puncture wounds who have not received revaccination for tetanus within 5 years should be vaccinated. In addition, tetanus immune globulin should be given to patients with significant or dirty wounds who have not previously received at least 3 doses of tetanus vaccine or whose vaccine status is uncertain. References: 1. Are curr ent UK tetanus prophylaxis procedures for wound management optimal?
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(:) A The p-value in study 8 is likely <0.05 10 B. The result in study A is not accurate (:) C. The result in study A is not statistically significant
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10 E. The sample size is likely smaller in study 8 than study A
D. The result in study 8 is likely biased
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Two studies were conducted on different samples from the same population to assess the relationship between oral contraceptive use and the risk of deep venous thrombosis (DVT) Study A showed an increased risk of DVT among oral contraceptive users, with a relative risk of 2.0 and a 95% confidence interval of 1.2-2.8. Study 8 showed a relative risk of 2.01 and a 95% confidence interval of 0.8-3.1 . Which of the following statements is most likely to be true regard ing these 2 studies?
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Statistical significance: Relationship between confidence intervals and p-values
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A confidence interval that does not cross the null value ...
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The relative r isk (RR) is the risk of an outcome (eg, deep venous thrombosis [DVTJ) in the exposed group (eg, oral contraceptive [OCJ users) divided by the risk of that outcome in the unexposed group. If the RR = 1.0 (null value), then there is no association between exposure and outcome (or disease). An RR >1 .0 indicates that exposure is associated with increased risk of disease. An RR <1 .0 means that exposure is associated with decreased risk of disease. The RR in studies A and B was >1 0, suggesting increased DVT risk among OC users. For a result to be considered statistically significant, its corresponding confidence interval (CI) must NOT contain the null value. When the 95% Cl does not include the null value, this gives a corresponding p-value <0.05 and the association between exposure and outcome is considered statistically significant A p-value <0 05 reflects that there is a very low probability that the result was due to chance alone; formally, the p-value is the probability of observing a given (or more extreme) result due to chance alone, assuming that the null hypothesis is true. The RR obtained in study A is statistically significant as its 95% confidence interval (1.2-2 8) does not include the null value (RR = 1 0) (Choice C) The 95% confidence interval for study B (0 8-31) includes the null value (RR = 1 0), and thus the study is not statistically significant; in other words, the corresponding p-value would be >0 05 (Choice A).
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of disease. An RR <1 .0 means that exposure is associated with decreased risk of disease. The RR in studies A and B was >1 .0, suggesting increased DVT risk among OC users. For a result to be considered statistically significant, its corresponding confidence interval (CI) must NOT contain the null value. When the 95% Cl does not include the null value, this gives a corresponding p-value <0.05 and the association between exposure and outcome is considered statistically significant A p-value <0.05 reflects that there is a very low probability that the result was due to chance alone; formally, the p-value is the probability of observing a given (or more extreme) result due to chance alone, assuming that the null hypothesis is true. The RR obtained in study A is statistically significant as its 95% confidence interval (1 2-2 8) does not include the null value (RR = 1 0) (Choice C) The 95% confidence interval fo r study B (0 8-31) includes the null value (RR = 1 0), and thus the study is not statistically significant; in other words, the corresponding p-value would be >0.05 (Choice A) The Cl in study B is wider than in study A , and it contains the null value (ie, not statistically significant). This wider Cl is most likely due to a smaller sample size, which decreases the study's power (ie, its ability to detect the difference between exposed and unexposed subjects) Increasing sample size would increase the study's power and make the Cl narrower. By doing so, the null value (RR = 1 0) would likely have been excluded (as in study A) , thus increasing statistical significance Although there are several causes of a wide Cl, small sample size is a common one.
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(Choices 8 and D) Measurements that lack accuracy (proximity to the true value) generally reflect a bias (systematic deviation from the true value). The accuracy of the studies cannot be judged because there is no information on how they were designed and conducted. Educational objective: The power of a study represents its ability to detect a difference between 2 groups (eg, exposed versus unexposed) when there truly is a difference . Increasing the sample size increases the power of a study and consequently narrows the confidence interval surrounding the point estimate. Confidence intervals express statistical significance and are interrelated with p-values Time Spent 2 seconds
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The abstract shown on the left applies to the next 2 items
Coronary-Artery Bypass Surgery in Patients with Left Ventricular Dysfunction
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Hypothesis:
Item 1 of 2
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Is co ronary-artery bypass grafting (CABG) superior to optimal medical therapy alone in the treatment of patients with co ronary artery disease and heart fa ilure?
A 67-year-old man recently diagnosed with co ronary artery disease comes to the physician fo r a follow-up appointment He was hospitalized fo r congestive heart failure 4 weeks ago and underwent co ronary angiography showing significant narrowing of left anterior descending and right co ronary arteries with <50% stenosis. The patient's left ventricular ejection fraction is 30%. Prior to starting medication, he could walk only 3 blocks on a flat surface before experiencing chest discomfort and shortness of breath. However , now he is symptomatic only with strenuous physical activity During the appointment, the patient asks about the risks and benefits of co ronary bypass surgery Based on the study results, which of the following is the best statement?
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Methods: Design Randomized clinical trial Blinding: none Median follow-up 56 months Setting Multicenter (99 medical centers in 22 countries) Patients: Patients with a left ventricular ejection fraction of 35% or less and co ronary artery disease amenable to CABG. Patients with a stenotic lesion leading to loss of 50% or more of the diameter of the left main coronary artery and/or Canadian Cardiovascular Society class Ill or IV angina while receiving medical therapy were excluded from the study (The Canadian Cardiovascular Society angina classification ranges from class 0, which indicates no symptoms, to class IV, which indicates angina at any level of physical exertion ) Intervention CABG plus optimal medical therapy vs optimal medical therapy alone
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A Surgery ca rries a higher short-term risk of dying
C)
B. Surgery causes inc reased risk of heart failure exacerbation
C)
C. Surgery leads to more procedures over the long term
C)
D. Surgery would not affect overall long-term quality of life E The benefits of surgery are limited to
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A total of 1212 patients were randomly assigned to medical therapy alone (602 patients) or medical therapy plus CABG (610 patients) By the end of the follow-up period , 100 patients in the medical-therapy group (17%) underwent CABG, and 555 patients in the CABG group (91%) underwent CABG.
Item 1 of 2
Primary outcome (CABG vs medical therapy alone) Rate of death from any cause Hazards Ratio (HR) 0.86 (0 72-1 04) P= 0.12 Secondary outcomes (CABG vs medical therapy alone) Death from any cause within 30 days after randomization HR 3.12 (1 33-7 31) P=0.006 Death from cardiovascular causes HR 0.81 (0 66-1 00) P=0.05 Death from any cause or hospitalization fo r heart fa ilure HR 0.84 (0 71 -0 98) P=0.03 Death from any cause or hospitalization fo r cardiovascular causes HR 0.74 (064-085) P<0.001 Death from any cause or hospitalization fo r any cause HR 0.81 (0 71 -0 93) P=0.003 Death from any cause or revascularization HR 0.60 (0 51-0 71) P<0.001
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A 67-year-old man recently diagnosed with coronary artery disease comes to the physician fo r a follow-up appointment He was hospitalized fo r congestive heart failure 4 weeks ago and underwent coronary angiography showing significant narrowing of left anterior descending and right coronary arteries with <50% stenosis. The patient's left ventricular ejection fraction is 30%. Prior to starting medication, he could walk only 3 blocks on a flat surface before experiencing chest discomfort and shortness of breath. However, now he is symptomatic only with strenuous physical activity During the appointment, the patient asks about the risks and benefits of co ronary bypass surgery Based on the study results, which of the following is the best statement?
e
dying C)
B. Surgery causes inc reased risk of heart failure exacerbation
C)
C. Surgery leads to more procedures over the long term
C)
D. Surgery would not affect overall long-term quality of life
Conclusion:
In this randomized trial, there was no significant difference between medical therapy alone and medical therapy plus CABG with respect to the primary end point of death from any cause.
A Surgery ca rries a higher short-term risk of
E The benefits of surgery are limited to
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A total of 1212 patients were randomly assigned to medical therapy alone (602 patients) or medical therapy plus CABG (610 patients) By the end of the follow-up period , 100 patients in the medical-therapy group (17%) underwent CABG, and 555 patients in the CABG group (91%) underwent CABG. Primary outcome (CABG vs medical therapy alone) Rate of death from any cause Hazards Ratio (HR) 0.86 (0 72-1 04) P= 0.12 Secondary outcomes (CABG vs medical therapy alone) Death from any cause within 30 days after randomization HR 3.12 (1 33-7 31) P=0.006 Death from cardiovascular causes HR 0.81 (0 66-1 00) P=0.05 Death from any cause or hospitalization fo r heart fa ilure HR 0.84 (0 71 -0 98) P=0.03 Death from any cause or hospitalization fo r cardiovascular causes HR 0.74 (064-085) P<0.001 Death from any cause or hospitalization fo r any cause HR 0.81 (0 71 -0 93) P=0.003 Death from any cause or revascularization HR 0.60 (0 51-0 71) P<0.001 Conclusion:
In this randomized trial, there was no significant difference between medical therapy alone and medical therapy plus CABG with respect to the primary end point of death from any cause.
r
A 67-year-old man recently diagnosed with coronary artery disease comes to the physician fo r a follow-up appointment He was hospitalized for congestive heart fa ilure 4 weeks ago and underwent coronary angiography showing significant narrowing of left anterior descending and right coronary arteries with <50% stenosis. The patient's left ventricular ejection fraction is 30%. Prior to starting medication, he could walk only 3 blocks on a flat surface before experiencing chest discomfort and shortness of breath. However, now he is symptomatic only with strenuous physical activity During the appointment, the patient asks about the risks and benefits of coronary bypass surgery Based on the study results, which of the following is the best statement?
A Surgery carries a higher short-term risk of 6 dying
6
B. Surgery causes inc reased risk of heart failure exacerbation C. Surgery leads to more procedures over the
6 long term
D. Surgery would not affect overall long-term
6 quality of life
E. The benefits of surgery are limited to
6 preventing a heart attack Submit
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Explanation:
A total of 1212 patients were randomly assigned to medical therapy alone (602 pat1ents) or medical therapy plus CABG (61 0 pallents) By the end of the follow-up period. 100 pallents 1n the medical-therapy group (17%) underwent CABG, and 555 pat1ents 10 the CABG group (91%) underwent CABG
The study presented 111 the abstract is a randomized clinical trial companng the benefit of coronary-artery bypass graftmg (CABG) w1th medical therapy versus medical therapy alone for the management of coronary artery d1sease and heart failure (defined as <35% left ventricular 8j8CIIon rracbon [EF)) Th1s patient meets the inclusion cntena for the study (EF <35%, coronary artery disease w1th <50% stenosts, mmimal symptoms while receMng med1cal therapy}, so the study findings are likely to apply to h1m
Primary outcome (CABG vs med1cal therapy alone) Rate of death from any cause Hazards Ratio (HR) 0.86 (0.72-1 04) P= 0 12 Secondary outcomes (CABG vs medical therapy alone} Death from any cause w1th1n 30 days after randomization HR 3.12 (1 33-7 31) P=O 006 Death from cardiovascular causes HR 0.81 (0.66-1.00) P=0.05 Death from any cause or hospitalization for heart failure HR 0.84 (0 71-0.98) P=O 03 Death from any cause or hospitalization for cardiovascular causes HR 0.74 (0.64-0.85) P
Conclusion: In this randomized tnal, there was no significant difference between med1cal therapy alone and medical therapy plus CABG w1th respect to the pnmary end point of death from any cause ~"ndJDCL
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The results of the study are reported in terms of the hazard rabo, wh1ch IS the rabo of an event rate occurring 1n the lreatment group compared to an event rate occurring 1n the non-treatment group. A ratio <1 indicates that the treatment group had a lower event rate and a value >1 indicates that the treatment group had a higher event rate .
=
In this study, overall mortality was the primary end point The hazard ratio for all-cause mortality was 0.86 (CI=[O.72-1.04), p=0.12). However, the p-value is >0.05, meaning that there was no significant difference in an-cause mortality between the study groups during the average follow-up penod of 56 months. In contrast CABG w1th med1cal therapy was associated with a sigmficantly higher mortality 1n the first 30 days after randomizabon than med1cal therapy alone, with a hazard rabo of 3 12 (CI=[1 33-7 31), p=0.006). This is most likely due to the mherent nsks or surgery and
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Conclusion: In this randomized tnal, there was no significant difference between med1cal therapy alone and medical therapy plus CABG w1th respect to the pnmary end point of death from any cause SunnortP.d b
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(Choice C) The hazard rallo for death due to any cause or revasculanzallon was 0 60 (CI=[051-0.71 ), p <0.001) Th1s 10d1cates that the surgery in addition to medical therapy leads to fewer revasculanzation procedures than med1cal therapy alone, since at-cause mortalrty 1s not s1gn1ficantty different between the 2 groups.
Primary outcome (CABG vs med1cal therapy alone) Rate of death from any cause Hazards Ratio (HR) 0.86 (0.72-1 04) P= 0 12 Secondary outcomes (CABG vs medical therapy alone} Death from any cause w1th1n 30 days after randomization HR 3.12 (1 33-7 31) P=O 006 Death from cardiovascular causes HR 0.81 (0.66-1.00) P=0.05 Death from any cause or hospitalization for heart failure HR 0.84 (0 71-0.98) P=O 03 Death from any cause or hospitalization for cardiovascular causes HR 0.74 (0.64-0.85) P
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cause or hosp1tallzallon for heart failure was 0.84 (CI=[0.71-0 98). p=0.03). This means that surgery in addition to med1cal therapy Improves heart failure symptoms compared to med1cal therapy alone as all-cause mortality was not s1gmficantty different between the 2 groups
A total of 1212 patients were randomly assigned to medical therapy alone (602 pat1ents) or medical therapy plus CABG (61 0 pallents) By the end of the follow-up period. 100 pallents 1n the medical-therapy group (17%) underwent CABG, and 555 pat1ents 10 the CABG group (91%) underwent CABG
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(Choic·e D) The hazard rat1o for death or hospitafJZation due to any cause was 0.81 (CI=[O 71-0.93). p=0.003). This 10d1cates that the surgery added to medical therapy leads to fewer hospitallzahons than medical therapy alone because all-cause mortality was not significantly different between the 2 groups. Fewer hospitalizations help to improve patient quality of life.
=
(Choice E) All the secondary outcomes except 30-day mortality were favorable for surgery with medical therapy, indicating that there are other benefits to surgery with medical therapy aside from heart attack prevention. Educational objective: Hazard rahos are the raho of an event rate occurring in the treatment group versus the non-treatment group_ Ratios <1 10d1cate that the treatment group had a lower
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groups A total of 1212 patients were randomly assigned to medical therapy alone (602 patients) or medical therapy plus CABG (610 patients) By the end of the follow-up period , 100 patients in the medical-therapy group (17%) underwent CABG, and 555 patients in the CABG group (91%) underwent CABG. Primary outcome (CABG vs medical therapy alone) Rate of death from any cause Hazards Ratio (HR) 0.86 (0 72-1 04) P= 0.12 Secondary outcomes (CABG vs medical therapy alone) Death from any cause within 30 days after randomization HR 3.12 (1 33-7 31) P=0.006 Death from cardiovascular causes HR 0.81 (0 66-1 00) P=0.05 Death from any cause or hospitalization fo r heart fa ilure HR 0.84 (0 71 -0 98) P=0.03 Death from any cause or hospitalization fo r cardiovascular causes HR 0.74 (064-085) P<0.001 Death from any cause or hospitalization fo r any cause HR 0.81 (0 71 -0 93) P=0.003 Death from any cause or revascularization HR 0.60 (0 51-0 71) P<0.001 Conclusion: In this randomized trial, there was no significant difference between medical therapy alone and medical therapy plus CABG with respect to the primary end point of death from any cause.
(Choice D) The hazard ratio for death or hospitalization due to any cause was 0.81 (CI=[O 71-0 93). p=O 003) This indicates that the surgery added to medical therapy leads to fewer hospitalizations than medical therapy alone because all-cause mortality was not significantly different between the 2 groups Fewer hospitalizations help to improve patient quality of life . (Choice E) All the secondary outcomes except 30-day mortality were favorable for surgery with medical therapy, indicating that there are other benefits to surgery with medical therapy aside from heart attack prevention Educational objective: Hazard ratios are the ratio of an event rate occurring in the treatment group versus the non-treatment group. Ratios <1 indicate that the treatment group had a lower event rate and ratios >1 indicate that the treatment group had a higher event rate. Refer ences: 1. Biostatistics primer: what a clinician ought to know: hazard ratios . 2. Estimation of the 2-sample hazard ratio function using a semi parametric model.
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Methods:
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At the end of the follow-up period, investigators reported that 17% of patients in the medical therapy group and 91 % of patients in the medical therapy plus CABG group underwent CABG. Combining both groups and then analyzing outcomes for patients who actually underwent CABG versus those who received only medical therapy might introduce which of the following?
Design Randomized clinical trial
ro A Lead-time bias
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r{)
B. Measurement bias
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C. Observer bias
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D. Recall bias
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Median follow-up 56 months Setting Multicenter (99 medical centers in 22 countries) Patients: Patients with a left ventricular ejection fraction of 35% or less and co ronary artery disease amenable to CABG. Patients with a stenotic lesion leading to loss of 50% or more of the diameter of the left main coronary artery and/or Canadian Cardiovascular Society class Ill or IV angina while receiving medical therapy were excluded from the study (The Canadian Cardiovascular Society angina classification ranges from class 0, which indicates no symptoms, to class IV, which indicates angina at any level of physical exertion ) Intervention CABG plus optimal medical therapy vs optimal medical therapy alone
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Hypothesis: Is co ronary-artery bypass grafting (CABG) superior to optimal medical therapy alone in the treatment of patients with co ronary artery disease and heart fa ilure?
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ro E. Selection bias Submit
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Coronary-Artery Bypass Surgery in Patients with Left Ventricular Dysfunction Hypothesis : Is coronary-artery bypass grafting (CABG) superior to opbmal medtcal therapy alone tn the treatment of patients wrth coronary artery dtsease and heart failure?
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Methods: Destgn- RandomiZed cllmcal tnal Blinding. none Medtan follow-up 56 months Sett~ng ·
Multicenter (99 med1cal centers in 22 countries)
To avoid selection b1as in studies, patients are randomly asstgned to treatments to minimize potential confounding variables. Many studies also perfo rm an intention-to-treat (ITI) analysis to deal with selection bias. An ITI analysis compares the initial randomized treatment groups (the anginal intention) regardless. of the eventual treatment to avoid counting crossover patients. Conversely , as-treated analysis (suggested in question stem) compares the groups based on the actual treatment rece1ved An as-treated analysis is performed to gauge the effectiveness of the treatment itself, wtth less regard for potenbal confounders.
Patients: Patients w1th a left ventricular ejection fraction of 35% or less and coronary artery disease amenable to CABG. Patients w1th a stenotic lesion leading to loss of 50% or more of the diameter of the left main coronary artery and/or Canadian Cardiovascular Society class Ill or IV angina while receiving medical therapy were excluded from the study. (The Canadian Cardiovascular Society angina classtficalion ranges from class 0, which indicates no symptoms, to class IV, which Indicates angina at any level of physical exert1on ) lnterven!Jon CABG plus opbmal medical therapy vs optimal medical therapy alone OulctvnA lliAJ'\«all'AA ThA. nnmarvllUfcorne was the rate of
The study presented in the abstract is a randomized clinical tnal companng the benefit of CABG with medical therapy versus medtcal therapy alone. Despite high-quality mediCal therapy prOVIded to aU patients in the study, 17% of patients tn the med1cal therapy group clinically detenoraled to the po10t where CABG was uncontrover!Jbly JOdtcated When the treatment regimen selected for a patten! depends on the severity of the pa!Jenrs cond1bon, a form of selectton bias known as suscep!Jbtllty btas (confounding by tndtcation) can result. Thts occurs because surgery patients arising from the medtcal therapy group may have undertying confounders that were responsible for worsening of their disease Group10g them WJth pa!Jents from the surgery group may lead to erroneous analysis and weaken the conclustons that can be drawn from the study.
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{Choice A) Lead-llme btas happens when two disease intervenbons are compared and one dtagnoses the
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Coronary-Artery Bypass Surgery in Patients with Left Ventricular Dysfunction
diagnosed the disease sooner.
{Choice C) Observer btas occurs when the observer is influenced by pnor knowledge or details of the study in a way that affects the resuns Studtes attempt to avoid this btas by bhndtrtg observers from knowing treatment asstgnments and by measunrtg objective outcomes (eg, mortality) that are less ltkely to be skewed by observers Observer btas could potenbaly be present from the outset as thts study was not blinded. However, chartgtng the type of data analysts would not introduce this btas
Is coronary-artery bypass grafting (CABG) superior to optimal medtcal therapy alone tn the treatment of patients wrth coronary artery dtsease and heart failure? Methods: Destgn Randomtzed cltntcaltnal Blindtng none Medtan follow-up 56 months
{Choice D) Recall btas occurs when a study partictpant's answer to a queslton is affected by prior exposures. However, this ts more common in retrospecttve studtes rather than prospective studies such as randomized clinical trials.
Setting Muntcenter (99 medtcal centers in 22 countries) Patients: Patients with a left ventricular ejection fraction of 35% or less and coronary artery disease amenable to CABG. Patients wtlh a stenotic lesion leading to loss of 50% or more of the diameter of the left main coronary artery and/or Canadian Cardiovascular Society class Ill or IV angina while receiving medical therapy were excluded from the study (The Canadian Cardiovascular Society angina classification ranges from class 0, which indicates no symptoms, to class IV, whtch indicates angina at any level of physical exertton ) lntervenllon CABG plus opltmal medtcal therapy vs optimal medtcal therapy alone
Thannmarv nutrnm<> w"s the rate nf
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{Choice B) Measurement btas occurs from poor data collection wtth Inaccurate resuns (not described in this case).
Hypothesis :
_outcor:ruunAa"-lU'A~
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Educational objective: When the treatment regimen selected for a patient depends on the severity of the patient's condition, a form of selection bias known as susceptibility bias (confounding by indtcatton) can result. To avoid selection bias tn studies, paltents are randomly assigned to treatments to mtntmize potential confounding variables Many studtes also perfonn an intention-to-treat analysts, whtch compares the initial randomtzed treatment groups (the original intention) regardless of the eventual treatment.
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Is co ronary-artery bypass grafting (CABG) superior to optimal medical therapy alone in the treatment of patients with co ronary artery disease and heart fa ilure?
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Methods: Design Randomized clinical trial Blinding: none Median follow-up 56 months Setting Multicenter (99 medical centers in 22 countries) Patients: Patients with a left ventricular ejection fraction of 35% or less and co ronary artery disease amenable to CABG. Patients with a stenotic lesion leading to loss of 50% or more of the diameter of the left main coronary artery and/or Canadian Cardiovascular Society class Ill or IV angina while receiving medical therapy were excluded from the study (The Canadian Cardiovascular Society angina classification ranges from class 0, which indicates no symptoms, to class IV, which indicates angina at any level of physical exertion ) Intervention CABG plus optimal medical therapy vs optimal medical therapy alone
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this bias by blinding observers from knowing treatment assignments and by measuring objective outcomes (eg, mortality) that are less likely to be skewed by observers. Observer bias could potentially be present from the outset as th is study was not blinded. However, changing the type of data analysis would not introduce this bias. {Choice D) Recall bias occurs when a study partic ipant's answer to a question is affected by prior exposures. However , this is more common in retrospective studies rather than prospective studies such as randomized clinical trials. Educational objective: W hen the treatment regimen selected for a patient depends on the severity of the patient's condition, a form of selection bias known as susceptibility bias (confounding by indication) can result To avoid selection bias in studies, patients are randomly assigned to treatments to minimize potential confounding variables. Many studies also perform an intention-to-treat analysis, which compa res the initial randomized treatment groups (the original intention) regardless of the eventual treatment References: 1. The r ole of susceptibility bias in epidemiologic research.
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A 0.04
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A prospective cohort study was conducted to evaluate the long-term effects of a high-fat diet on the incidence of colon cancer. The study participants were randomly selected from the population of interest Dietary patterns were assessed through the use of periodic self-completed questionnaires The investigators reported a 5-year relative risk of 1.60 for people who consumed a high-fat diet compa red to individuals who consumed a low-fat diet The 95% confidence interval was 1.02 to 2.15. This study is most likely to have which of the following p values?
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Relative risk (RR) is the probability of the outcome of interest occurring in the exposed group compared to the probability of it occurring in the non-exposed group The null value of the RR is 1.0; a RR of 1.0 means that the outcome occurs with equal frequency in both groups and that there is no association between the exposure and the outcome. A RR > 1.0 means that the outcome occurs more frequently in the exposed group (positive association) The RR says nothing about the statistical significance of a study Statistical significance can be expressed with either p values or confidence inte rvals, but both are interrelated. For instance, p < 0.05 corresponds to a 95% confidence interval that does not contain the null value. Likewise p < 0.01 is equivalent to a 99% confidence interval that does not contain the null value. Conversely , if the null value is within a given confidence interval, then the p value is ~ the equivalent confidence interval.
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@UWond
In general, for study results to be statistically significant, the 95% confidence interval must not contain the null value. This is equivalent to p < 0.05, which means that there is less than a 5% chance that the results are due to chance alone. In this case, the 95% confidence interval is 1.02 to 2.15 and does not contain the null value of 1.0. This corresponds to p < 0.05, thus 0.04 is the only co rrect answer choice.
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interrelated. For instance, p < 0.05 corresponds to a 95% confidence interval that does not contain the null value. Likewise p < 0.01 is equivalent to a 99% confidence interval that does not contain the null value. Conversely , if the null value is within a given confidence interval, then the p value is ~ the equivalent confidence interval.
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In general, for study results to be statistically significant, the 95% confidence interval must not contain the null value. This is equivalent top < 0.05, which means that there is less than a 5% chance that the results are due to chance alone. In this case, the 95% confidence interval is 1.02 to 2.15 and does not contain the null value of 1.0. This corresponds top < 0.05, thus 0.04 is the only correct answer choice. {Choices B , C, D, and E) These p values are all > 0.05, meaning the associated 95% confidence interval would contain the null value. Educational objective: Confidence intervals and p values are interrelated and express the statistical significance of a study. In a statistically significant study, p should be< 0.05. This corresponds to a 95% confidence interval that does not include the null value. Time Spent 3 seconds
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A 32-year-old woman comes to the office due to persistent cough and shortness of breath. She has had 3 episodes of pneumonia over the last 3 years. The patient had severe sinusitis a year ago and an episode of bloody diarrhea that required hospitalization 6 months ago She usually responds to antibiotics but takes several days to clear the infection. No other family members have similar problems The patient has not traveled outside of the United States. She does not use tobacco, alcohol, or illicit drugs and currently takes no medications. All of her immunizations are up to date. Blood pressure is 130/80 mm Hg and pulse is 90/min. BMI is 22 kg/m2 . Phys ical examination reveals fine crackles over the right lower lung field. No lower extremity edema is present Neck palpation does not show any lymph node enlargement Leukocyte count is 14,000/mms HIV testing is negative Chest x-ray reveals a right lower lobe infiltrate. W hat is the best next step in management of this patient?
<0 A Measurement of CD4+ T lymphocyte count <0 B. Measurement of serum alpha-1 antitrypsin level <0 C. Methacholine challenge test @ D. Quantitative measurement of serum immunoglobulin levels
<0 E. Sweat chloride test
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• Recurrent respiratory (eg, pneumonia, sinusitis, otitis) & Gl infections (eg, Salmonella, Campylobacter) Manifestations
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• Autoimmune disease (eg, RA, thyroid disease) • Chronic lung disease (eg, bronchiectasis)
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Common variable immunodeficiency
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• Gl disorders (eg, chronic diarrhea, IBD-Iike conditions)
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I I lgG, I lgA/IgM
• No response to vaccination
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• lg replacement therapy
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Gl = gastrointestinal; lBO = inflammatory bowel disease; lg = immunoglobulin; RA = rheumatoid arthritis. ©UWond
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This patient with evidence of acute pneumonia (cough, shortness of breath, leukocytosis, right lower lobe infiltrate) and recent history of recurrent pneumonia, sinusitis, and bloody diarrhea likely has common variable immunodeficiency (CVID) CVID is a collective diagnosis that includes a number of genetic defects resulting in impaired 8 cell differentiation and hypogammaglobulinemia. CVID is the most common primary immunodeficiency in adults and is characterized mainly by increased susceptibility to bacterial infection. Recurrent respi ratory infections (eg, pneumonia, sinusitis, otitis) and gastrointestinal infections (eg, Salmonella, Campy/obacter) are common, and the latter may lead to episodes of bloody diarrhea. Chronic giardiasis may occur, but opportunistic infections (eg, Candida, Pneumocystis jiroveci1) are rare. Other characteristics of CVID include concomitant autoimmune disease (eg, hemolytic anemia,
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y p y g y occur, but opportunistic infections (eg, Candida, Pneumocystisjirovecil) are rare . Other characteristics of CVID include concomitant autoimmune disease (eg, hemolytic anemia, rheumatoid arthritis, pernicious anemia), inflammatory bowel-like disease, granuloma development, and increased risk fo r non-Hodgkin lymphoma Enteropathy (eg, sprue-like illness) is common, and affected patients may present with malabsorption and weight loss. I
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Most cases of CVID are due to sporadic mutation, and family history of the disease is typically absent (as in this patient) The majority of patients are diagnosed in adulthood (age 20-45) due to a combination of variable presentation and diagnostic delay. Diagnosis is made by quantitative measurement of immunoglobulin levels (significantly reduced serum lgG with low levels of lgA and/or lgM) as well as by markedly reduced or absent immune response to vaccination. {Choice A) Low CD4+ lymphocyte counts occur in DiGeorge syndrome and HIV infection and create susceptibility to opportunistic infection. DiGeorge syndrome typically manifests shortly after birth, and this patient is HIV negative {Choice B) Alpha-1 antitrypsin deficiency is an inherited disorder that leads to emphysema and liver damage but does not increase the risk of recurrent infections. {Choice C) Methacholine challenge is used to diagnose asthma, which is not characterized by recurrent bacterial respiratory infections. {Choice E) Sweat chloride test is used to diagnose cystic fibrosis (CF) Recurrent pneumonia and sinusitis can occur in CF; however, CF is often diagnosed prior to adulthood. In addition, although diarrhea and malabsorption may be seen (due to pancreatic insuffic iency), bloody diarrhea would be unusual. Educational objective: Recurrent bacterial infections in an adult should raise suspicion fo r common variable immunodeficiency. Quantitative measurement of serum immunoglobulin levels is needed to establish the diagnosis
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The following vignette applies to the next 2 items. The items in the set must be answered in sequential order. Once you click Proceed to Next Item, you will not be able to add or change an answer. This item has associated media that may require the use of headphones. Please ensure your system/speaker volume is set to an audible level.
A 73-year-old man comes to the physician for evaluation of a tremor. Over the past several months, he has noticed that he becomes tremulous when trying to hold a newspaper and when drinking his morning cup of coffee. The tremor is not noticeably worse during any particular time of day. He has no medical problems other than hypertension, for which he takes chlorthalidone. His vital signs are normal. Physical examination, including evaluation of his gait, is normal. The patient does exhibit a tremor , which is shown in the video.
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W hich of the following is the most likely diagnosis in this patient?
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® A Essential tremor
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® B. Huntington chorea
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® C. Parkinson disease
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® D. Side effect from caffeine
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® E. Spinocerebellar ataxia Submit
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Clinical features
• Bilateral action tremor of the hands, usually without leg involvement
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• Possible isolated head tremor without dystonia
Essential
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• Usually no other neurologic signs • Relieved with alcohol in many cases • Resting tremor (4-6 Hz) that decreases with voluntary movement
Parkinson's disease
• Usually involves legs & hands • Facial involvement less common
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• Usually associated with ataxia, dysmetria, or gait disorder
Cerebellar
• Tremor increases steadily as the hand reaches its target
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• Acute onset with increased sympathetic activity (eg, drugs, hyperthyroidism, anxiety, caffeine)
Physiologic
• Usually worse with movement & can involve the face & extremities ©UWor1d
This patient's clinical history and visualized tremor are typical of essential tremor (ET), which is diagnosed by the presence of an action tremor in the absence of additional neurologic signs Features of ET are highly variable. It most often affects the upper extremities and is ~o l
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diagnosed by the presence of an action t remor in the absence of additional neurologic signs Features of ET are highly va riable. It most often affects the upper extremities and is wo rse with motion ("action tremor"), especially fine motor movements. However, it may affect any part of the body and be present at rest In the video, the tremor is exacerbated as the patient gets closer to the examiner's finger and attempts to place his finger in a specific location. (Choice B) Huntington chorea is an autosomal dominant condition associated with involuntary, non-repetitive movements of the face , trunk, and extremities. These choreifo rm movements are not exacerbated in fine motor actions. (Choice C) In contrast to ET, the tremor associated with Parkinson disease is a resting tremor , which is worse during rest and improved with intention. (Choice D) The consumption of large amounts of caffe ine can exacerbate physiologic tremors. However, this patient has tremors throughout the day and not just when he consumes caffeine. Phys iologic tremors associated with excessive caffeine intake do not typically have a distinct intention characteristic . (Choice E) Spinocerebellar ataxia (SCA) is a genetic degeneration of the cerebellum, in which hand tremor may be present However, patients with SCA will have additional signs, such as an ataxic gait SCA also typically presents at a younger age. Educational objective: Essential tremor is characterized by a fine tremor that is typically suppressed at rest and exacerbated at the end of goal-directed movements. It is most common in the upper extremities but is highly variable and may affect any part of the body It is usually not associated with other neurologic symptoms References: 1. Differentiation and diagnosis of tremor
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W hich of the following is the next best step in the management of this patient?
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® A Carbidopa/levodopa ® B. Cessation of coffee intake ® C. Deep-brain stimulation
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D. Genetic counseling
® E. Propranolol
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Explanation: The treatment of essential tremor typically begins with the beta-blocker propranolol, which is especially helpful if the patient also has coexistent hypertension Other treatment possibilities include anticonvulsants, such as primidone and topiramate. Although benzodiazepines such as alprazolam are effective in reducing the symptoms of essential tremor, their use should be restricted due to the potential for dependence {Choice A) Carbidopa/levodopa is the first-line treatment for patients with Parkinson disease. (Choice B) Any agent that increases adrenergic activity (eg, caffeine) can exacerbate physiologic tremor. However, studies have shown that caffeine use is not necessarily correlated with the severity of essential tremor. (Choice C) Surgical options such as deep-brain stimulation and thalamotomy would be considered only if the tremor had a significant impact on daily function and after failure to control the tremor with several medications. (Choice D) Genetic counseling may be beneficial in the management of diseases such as Huntington disease and spinocerebellar ataxia due to their profound effect on quality of life and life span However, genetic counseling is not indicated in this patient Educational objective: First-line treatment fo r essential tremor is propranolol, especially if the patient is also hypertensive Alternate medications include primidone and top iramate References: 1. Semiquantitative study of current coffee, caffeine, and ethanol intake in essential tremor cases and controls.
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e; A Prostate biopsy and PSA measurement
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e; C. Trans rectal ultrasound of the prostate
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e; E. Discuss checking the PSA with the patient
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A 65-year-old man comes to the physician fo r an annual visit and says that he feels well overall. His medical history is unremarkable and he takes no medications except docusate occasionally fo r constipation He has a 40-pack-year smoking history but does not use alcohol or illicit drugs. He has no family history of colon or prostate cancer. The patient's blood pressure is 130/80 mm Hg and pulse is 85/min. His ca rdiac, respiratory, and abdominal examinations are within normal limits. His digital rectal examination shows mild prostate enlargement with a smooth prostate surface and hard stool in the rectal vault that is negative for occult blood. The patient had a normal colonoscopy 5 years ago and asks if he should have any preventive screening. W hat is the most appropriate next step in management of this patient?
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W ith the recent US Preventive Services Task Force (USPSTF) guidelines, PSA screening recommendations have become controve rsial. The USPSTF does not recommend any population screening using PSA, regardless of age, based on 2 recently published trials PLCO from the United States and ERSPC from Europe (2012 gradeD recommendation) The USPSTF states that screening does not save lives and often leads to more tests and treatments that needlessly cause pain, impotence, and incontinence in many patients However, there are several other societies that have not changed their PSA recommendations. The American Urological Association recommends that PSA screening in conjunction with digital rectal examination be offered at age 40 with counseling that includes the risks and benefits of screening. The American Cancer Society and American Urological Association recommend screening in patients up to 75 years with a life expectancy of at least 10 years. Due to the current controversy, screening decisions are left up to the individual and the physician and best determined with a discussion of the risks and benefits of screening with PSA and/or digital rectal examination. (Choices A and D) Performing a prostate biopsy at this time would be premature If the patient desires screening for prostate cancer , a PSA test alone would be the next step. Prostate biopsy also would not be recommended as the patient's smooth prostate enlargement is more suggestive of benign prostatic hyperplasia.
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(Choice B) Colonoscopy is recommended every 10 years fo r colorectal cancer screening if the initial screen is normal. This patient had a normal test 5 years ago and needs rescreening in 5 years (Choice C) Transrectal ultrasound of the prostate has low sensitivity and positive predictive value in primary screening for prostate cancer and is not recommended as an initial test Ultrasound is used to guide prostate biopsy rather than as a screening test Educational objective: With the recent US Preventive Services Task Force (USPSTF) guidelines, PSA screening recommendations have become controversial. The USPSTF does not recommend any population screening using PSA, but the American Cance r Society and the Ame rican Urological Association guidelines disagree with this recommendation. Due to the controversy, PSA screening should be
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A case-control study was conducted to evaluate the association between alcohol consumption and cancer of the oral cavity . The crude analysis showed a strong association between the exposure and outcome odds ratio = 4.5, 95% confidence interval 3.4- 5.6. Smoking was considered as a potential confounder of the association. W hich of the following properties of smoking is essential in order to be considered as a confounder?
e; A It should not be related to cancer of the oral cavity
® B. It should be highly prevalent in the population of interest ® C. It should be related to alcohol consumption ® D. It should be observed only in alcohol consumers ® E. It should be evenly distributed among alcohol consumers and non-consumers Submit
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smoking is essential in order to be considered as a confounder?
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A. It should not be related to cancer of the oral cavity [5%] B. It should be highly prevalent in the population of interest [23%) ~
C. It should be f elated to alcohol consumption [51%) D. It should be observed only in alcohol consumers [9%) E. It should be evenly distributed among alcohol consumers and non-consumers [13%)
Explanation: Confounding is defined as mixing up of the effect of exposure with the effect of an extraneous factor (confounder) In order to be a confounder, the extraneous factor must have some properties linking it with the exposure and outcome of interest In this example, smoking is the possible confounder. Smoking is related to the exposure (ie , people who consume alcohol are more likely to smoke) , as well as the outcome of interest (ie., smoking, by itself, is associated with cancer of the oral cavity). If smoking is the confounder, it explains at least part of the association observed between alcohol consumption and cancer of the oral cavity . (Choice A) If smoking is not related to cance r of oral cavity , it cannot be a confounder in this case. (Choice B) The prevalence of a factor in the population is not related to its effect as a confounder. (Choice D and E) A confounder is commonly observed both in exposed and unexposed subjects and it is not evenly distributed between the groups Educational Objective: A confounder is an extraneous factor which has properties linking it with the exposure and outcome of inte rest Time Spent 3 seconds
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A 44-year-old man comes to the office for follow-up after a recent hospitalization Two weeks ago, he went to the emergency department with palpitations and was found to have atrial fibrillation with rapid ventricular response. Overnight, he spontaneously converted to normal sinus rhythm and was discharged home the next day. The patient has no history of hypertension, diabetes mellitus, hypercholesterolemia, or heart disease. He does not use tobacco, alcohol, or illicit drugs His blood pressure is 124/70 mm Hg and pulse is 78/min and regular. Jugular venous pressure is estimated at 5 em H,O. Examination shows no abnormalities. Review of laboratory results from the hospital admission shows normal creatinine level, live r function tests, thyroid studies, and lipid panel. An echocardiogram shows a mildly dilated left atrium, normal left and right ventricular function, and no major valvular abnormalities. W hich of the following is the best additional treatment for this patient?
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Explanation: This patient had paroxysmal atrial fibrillation (AF) that spontaneously converted to normal sinus rhythm. Systemic thromboembolism is a major cause of long-term morbidity in patients with AF, and treatment with warfarin or target-specific oral anticoagulants has been shown to significantly reduce the risk of embolization in patients at moderate to high risk of thromboembolic events. Recent guidelines have recommended the use of a modified CHA,DS,-VASc score fo r stroke risk assessment in patients with nonvalvular AF. The term "lone AF" is occasionally used for patients with paroxysmal, persistent, or permanent AF with no evidence of cardiopulmonary or structural heart disease. Patients with lone AF are generally age <60 and, by definition, have a CHA,DS,-VASc score of 0. The risk of systemic embolization in such patients is extremely low, and anticoagulant therapy is not indicated. (Choice A) Am iodarone is used occasionally fo r maintenance of sinus rhythm in patients with recurrent, symptomatic episodes of AF (rhythm-control strategy) This patient has spontaneously converted to sinus rhythm, and amiodarone is not indicated. (Choices 8 , C, and E) In patients with CHA,DS,-VASc score of 1, antithrombotic therapy with aspirin or an oral anticoagulant is indicated (with anticoagulant therapy preferred over aspirin) Rivaroxaban is an oral factor Xa inhibitor approved for prevention of thromboembolism in patients with non-valvular AF. This patient has a low risk of embolic events, and no antithrombotic therapy is indicated at this time.
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Educational objective: Warfarin or target-specific oral anticoagulants (eg, rivaroxaban, apixaban, dabigatran) should be used to reduce the risk of systemic thromboembolism in patients with atrial fibrillation (AF) and moderate to high risk of th romboembolic events (CHA,DS,-VASc score <::2). Patients with lone AF (score 0) are at low risk of systemic embolization and anticoagulant therapy is not indicated. References: 1. 2014 AHAIACC/HRS Guidelines for the management of patients with atrial fib ·n f A • rt f th A C II • f C d' I • I A H rt
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® A Time to rescue breathing ® B. Time to rhythm analysis and defibrillation ® C. Time to endotracheal intubation
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® E. Time to ca rdiac catheterization lab Submit
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A 59-year-old man comes to visit a friend in the hospital and collapses in the parking lot He had been feeling unwell all day due to vague chest discomfort A bystander witnesses his collapse, finds no pulse, and immediately calls for help W hich of the following is the most important factor fo r survival in this patient?
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Factors associated with poor outcome after witnessed out-of-hospital sudden cardiac arrest • Time elapsed prior to effective resuscitation (delayed bystander CPR, delayed defibrillation) • Initial rhythm of pulseless electrical activity or asystole • Prolonged CPR (>5 minutes) • Absence of vital signs • Advanced age • Prior history of cardiac disease • ~2 Chronic illnesses • Persistent coma after CPR • Need for intubation or vasopressors • Pneumonia or renal failure after CPR • Sepsis, cerebrovascular accident, or class Ill or IV heart failure @UWOI!d
This patient had a witnessed out-of-hospital sudden ca rdiac arrest (SCA) The most common cause of out-of-hospital SCA in adults is sustained ventricular tachycardia or fibrillation due to acute myocardial ischemia or infarction. Despite best efforts, resuscitation for out-of-hospital SCA is successful in only one-third of patients, and only about 10% of all patients are eventually discharged from the hospital Multiple factors affect overall survival in patients with witnessed SCA (see table) The most critical factor determining overall patient survival is elapsed time to effective resuscitation. This includes effective bystander CPR, prompt rhythm analysis, and early defibrillation fo r patients found to be in ventricular fibrillation . Ventricular fibrillation almost never terminates
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factor determining overall patient survival is elapsed time to effective resuscitation. This includes effective bystander CPR, prompt rhythm analysis, and early defibrillation fo r patients found to be in ventricular fibrillation. Ventricular fibrillation almost never terminates spontaneously, and early rhythm analysis and defibrillation are the only effective means to reestablish perfusing cardiac rhythm and improve patient survival
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(Choice A) Early administration of effective bystander CPR is an important factor that determines patient survival after out-of-hospital SCA Studies in SCA patients have shown better outcomes and improved survival to discharge with compression-only CPR as compared to standard CPR that includes rescue breathing The 2010 Ame rican Heart Association guidelines fo r CPR recommend that bystanders should perform compression-only CPR prior to arrival of emergency personnel (Choice C) Endotracheal intubation should be performed to secure the airway as a part of overall management only after the patient has been resuscitated successfully with restoration of circulation. Placement of an endotracheal tube should not delay the initial efforts of rhythm analysis and early defibrillation. (Choice D) The initial approach in patients with out-of-hospital SCA should be prompt and effective CPR, prompt rhythm analys is, and early defibrillation if indicated. Advanced ca rdiac life support guidelines recommend epinephrine only in patients with asystole, pulseless electrical activity , or refractory ventricular arrhythmias unresponsive to defibrillation. (Choice E) Acute myocardial ischemia or infarction is the leading cause of SCA due to ventricular tachyca rdia/fibrillation Patients who survive the initial resuscitation efforts should undergo coronary angiography to evaluate for co ronary artery disease. Educational objective: Despite advances in therapy , the overall survival rate for patients with sudden cardiac arrest remains quite poor The most important factors in improving patient survival are prompt effective resuscitation with adequate bystander CPR, prompt rhythm analysis, and defibrillation in patients found to be in ventricular fib rillation. Time Spent 3 seconds
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A 35-year-old woman who has recently emigrated from Asia presents to the emergency room with acute onset of dyspnea She denies any cough, chest pain, or fever. She has a history of rheumatic heart disease as a teen. On examination, she has an irregular pulse of 97/min, blood pressure of 125/75 mm of Hg and temperature of 37.2°C (98.9°F). The first heart sound is loud and a mid-diastolic rumble is heard at the apex Crackles are present in both lung fields. ECG shows an irregularly , irregular heart rhythm and the absence of 'P' waves. W hich of the following is the most likely cause of this patient's abnormal heart rhythm? e')
A Left atrial dilatation
e> B. Right atrial dilatation e')
C. Left ventricular dilatation
e> D. Left ventricular hypertrophy e')
E. Pulmonary hypertension
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Explanation: This patient has mitral stenosis as a consequence of rheumatic heart disease. The mitral stenosis has in turn led to dilatation of her left atrium and resulted in atrial fibr illation. Rheumatic fever is more common in patients from developing countries. W hile rheumatic feve r can cause damage to any heart valve, mitral stenosis is the most common valvular manifestation. The auscultative findings of a loud S1 and a mid diastolic rumbling murmur at the apex are classic for mitral stenosis. The pressure in the left atrium can become greatly elevated in order to compensate for the high resistance of the stenotic mitral valve. The inc reased pressure in the left atrium causes it to dilate, which predisposes to the development of atrial fibrillation. In fact, up to 70% of patients with mitral stenosis develop atrial fibrillation. The ECG with an irregularly irregular rhythm and loss of 'P' waves describes atrial fib rillation. Atrial fibrillation causes a lack of an "atrial kick", which could cause worsening flow through the stenotic mitral valve and increased congestion in the lungs, thus leading to the patient's acute onset of dyspnea. {Choice B) Rheumatic fever can affect any valve, incl uding the tricuspid valve. Tricuspid stenosis could lead to right atrial enlargement, which in turn would increase the patient's propensity to develop atrial fib rillation. However , the murmur of tricuspid stenosis would be most prominent at the left lower sternal border and symptoms of right sided heart fa ilure (peripheral edema, hepatomegaly, jugular venous distention) would predominate. (Choice C & D) The left ventricle is usually normal in patients with mitral stenosis from rheumatic disease unless they have associated aortic valve disease. (Choice E) Mitral stenosis can result in secondary pulmonary venous hypertension. However , mitral stenosis is the primary disease process in this patient, and the cause of atrial fibrillation. Educational objective: Up to 70% of patients with mitral stenosis will develop atrial fibr illation because of the significant left atrial dilatation. Time Spent 2 seconds
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Explanation: This patient presents for evaluation of infe rtility likely due to anabolic steroid ( e g , testosterone analog) abuse. Anabolic steroids are commonly used by many bodybuilders and athletes to enhance performance and muscle mass. Anabolic steroids contain exogenous androgens that inhibit GnRH release by the hypothalamus (due to feedback inhibition), which causes decreased LH and FSH release by the pituitary gland and leads to decreased sperm and testosterone production by the testes. The exogenous androgen suppresses native testosterone production but is detected as testosterone by current assays, so patients can have normal serum testosterone levels. Other adverse effects include acne, gynecomastia (due to conve rsion of the androgens to estrone) , decreased testicular size, aggressiveness, and psychotic symptoms. Laboratory findings can show erythrocytosis (due to increased erythropoiesis) with elevated hemoglobin, cholestasis, hepatic failure, dyslipidemia, and slightly elevated creatinine (due to increased muscle mass) (Choice A) Klinefelter syndrome (ie , XXY seminiferous tubule dysgenesis) is an inherited disorder characterized by testicular fibrosis (primary hypogonadism) , azoospermia, gynecomastia, decreased intelligence, increased axial skeletal growth, and high FSH and LH levels.
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(Choice B) Mumps orchitis is a potential cause of infe rtility that is characterized by acute testicular pain and inflammation during the acute viral illness.
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(Choice D) Myotonic dystrophy is characterized by testicular atrophy as well as widespread muscular atrophy , weakness, lower-than-normal testosterone level, and high FSH and LH levels. (Choice E) Varicocele results in scrotal swelling, with a "bag of worms" sensation on palpation. (Choice F) Cryptorchidism manifests in infancy, with a failure to palpate two testes in the scrotum on examination. Patients are at an inc reased risk of testicular cance r. (Choice G) Testicular torsion produces acute testicular pain
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Laboratory findings can show erythrocytosis (due to increased eryth ropoiesis) with elevated hemoglobin, cholestasis, hepatic failure, dyslipidemia, and slightly elevated creatinine (due to increased muscle mass) (Choice A) Kl inefelter syndrome (i. e., XXY seminiferous tubule dysgenesis) is an inherited disorder characterized by testicular fibrosis (primary hypogonadism), azoospermia, gynecomastia, decreased intelligence, increased axial skeletal growth, and high FSH and LH levels. {Choice B) Mumps orchitis is a potential cause of infertility that is characterized by acute testicular pain and inflammation during the acute viral illness. {Choice D) Myotonic dystrophy is characterized by testicular atrophy as well as widespread muscular atrophy , weakness, lower-than-normal testosterone level, and high FSH and LH levels. (Choice E) Varicocele results in scrotal swelling, with a "bag of wo rms" sensation on palpation (Choice F) Cryptorchidism manifests in infancy, with a failure to palpate two testes in the scrotum on examination. Patients are at an increased risk of testicular cance r. (Choice G) Testicular torsion produces acute testicular pain. (Choice H) Chronic medical illness typically results in anemia of chronic disease rather than erythrocytosis Educational objective: Anabolic steroid use by a man can produce infe rtility by suppressing the production of GnRH, LH, and FSH. References: 1. Anabolic steroids and semen parameters in bodybuilders
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® A Aspirin ® B. Enalapril ® C. Amlodipine ® D. lsosorbide dinitrate
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® F. Coumadin
® E. Digoxin
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A 67-year-old homeless male presents 24 hours after the onset of substernal chest pain and is diagnosed with an anterior wall myocardial infarction. There is no history of previous chest pain, dyspnea, palpitations, syncope or leg swelling He has no hypertension or diabetes mellitus. He does acknowledge a 40 pack-year smoking history Upon discharge, echocardiography shows normal left ventricular size, left ventricular anterior wall hypokinesis and an ejection fraction of 50% . Two years later , the patient is found dead in the street. Autopsy reveals a dilated left ventricle with a globular shape and thinned walls along with a scar on the anterior waiL W hich of the following would have most likely prevented this patient's pathologic findings?
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--------------------------Explanation: Following a myocardial infa rction, ventricular remodeling occurs and gradually causes dilatation of the left ventricle with thinning of the ventricular walls. This can result in CHF. Ventricular remodeling occurs in the weeks to months following a myocardial infarction; therefore it was not seen on the patient's discharge echocardiogram. ACE inhibitors have been shown to limit ventricular remodeling. An ACE inhibitor should be initiated within 24 hours of myocardial infarction in all patients without a contraindication. (Choice A) Aspirin is typically given to patients after myocardial infarction to inhibit platelet aggregation and prevent recurrence of coronary artery blockage However , aspirin has no effect on ventricular remodeling (Choice C) Calcium channel blockers such as amlodipine are not routinely prescribed fo r patients following myocardial infarction. They could be added if a patient has hypertension not completely controlled with ACE inhibitors and j3-blockers (Choice D) lsosorbide dinitrate is a long-acting nitrate used to prevent anginal chest pain It may be needed by some patients with chronic symptoms of stable angina, but it does not prevent ventricular remodeling (Choice E) Digoxin is shown to provide symptomatic relief in patients with systolic heart fa ilure. However , it does not provide a mortality benefit, and it does not help to prevent the remodeling process (Choice F) Antiplatelet agents such as aspirin are favored over warfarin in post Ml patients, but neither will reduce ventricular remodeling Educational objective: Ventricular remodeling in the weeks to months following myocardial infarction can lead to dilatation of the ventricle. This process is lessened by ACE inhibitors. Time Spent 3 seconds
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10 A Confounding 10 B. Respondent bias 10 C. Recall bias 10 D. Selection bias 10 E. Observer bias
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A study was conducted to assess the relationship between ethnicity and end-stage renal disease. Two groups of pathologists independently studied specimens from 1,000 kidney biopsies The fi rst group of pathologists was aware of the race of the patient from whom the biopsy came, while the second group was blinded from the patient's race. The first group reported 'hypertensive nephropathy' much more frequently for black patients than the second group W hich of the following types of bias is most likely present in this study?
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B. Respondent bias [4%) C. Recall bias [2%) D. Selection bias [5%) .;
E. ObsetVer bias [87%)
Explanation: Obse tVer bias occurs when the investigator's decision is adversely affected by knowledge of the exposure status. In this case, some pathologists' decisions were influenced by the fact that hypertensive nephropathy is a common cause of ESRD in the black population. The pathologists who were blinded from the patients' race were not under this influence, so their interpretation was more unbiased. {Choice A) Confounding is present when at least part of the exposure-disease relationship can be explained by another variable (confounder). No information on possible confounders is given in this scenario. {Choice B) Respondent bias is present when the outcome is obtained by the patient's response, and not by objective diagnostic methods (e g., migraine headache) In this case, the diagnosis was ascertained via kidney biopsy. (Choice C) Recall bias results from inaccurate recall of past exposure by patients It is not applicable to this case. (Choice D) Selection bias results from the manner in which the subjects are selected for the study, or from the selective losses from the follow-up Educational objective: Obse tVer bias occurs when the investigator's decision is adversely affected by knowledge of the exposure status. Time Spent 2 seconds
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6 A Asystole
e; B. Atrial fibrillation
6 C. Atrio-ventricular conduction block e; D. Paroxysmal supraventricular tachyca rdia
6 E. Pulseless electrical activity
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A 47-year-old man develops sudden onset of mid-sternal chest pain and diaphoresis during a meeting in his office. W hile waiting fo r emergency medical personnel to arrive, he complains of dizziness and becomes unresponsive. His coworkers perform cardiopulmonary resuscitation and he regains consciousness after 60 seconds. The patient has a history of diet-controlled type 2 diabetes mellitus, hypertension, and hyperlipidemia In the emergency department, his blood pressure is 142/88 mm Hg and pulse is 92/min. Electrocardiogram shows normal sinus rhythm, ventricular premature complexes, and a 3-mm ST-segment elevation in leads V1-V3. W hat is the most likely primary pathophysiologic mechanism responsible for this patient's syncopal episode?
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Explanation: Ventricular arrhythmias, including ventricular premature beats, nonsustained or sustained ventricular tachycardia, and ventricular fibrillation, are quite common in the immediate post-myocardial infarction (MI) period Ventricular fibrillation is the most frequent underlying arrhythmia responsible for sudden cardiac arrest in the setting of acute Ml; more than 50% occur within the first hour of symptom onset. Reentry is the predominant mechanism responsible fo r ventricular arrhythmias in the immediate post-infarction period The underlying mechanism responsible for periinfarction ventricular arrhythmias varies according to the time elapsed since the onset of MI. Arrhythmias occurring within 10 minutes of co ronary occlusion are known as "immediate" or phase 1a ventricular arrhythmias Acute ischemia causes heterogeneity of conduction with areas of marked conduction slowing and delayed activation, which in turn predisposes to reentrant arrhythmias. On the contrary, "delayed" or phase 1b arrhythmias occur about 10-60 minutes after acute infarction and are thought to result from abnormal automaticity (Choices A and E) Pulseless electrical activity is defined as the presence of electroca rdiographic rhythm in the absence of adequate ca rdiac mechanical contraction to generate a palpable pulse Asystole is the complete absence of electrical and mechanical cardiac activity Patients with prolonged duration of ca rdiac arrest can degenerate into pulseless electrical activity or asystole, which usually signifies the presence of severe and irreversible myocardial damage (Choice C) Atrio-ventricular conduction block can occur in patients with acute Ml, especially those with inferior wall MI. It is usually transient and resolves after successful reperfusion with thrombolytics or primary percutaneous coronary intervention. (Choices B and D) Supraventricular tachyca rdias other than atrial fib rillation or flutte r are uncommon in the periinfarction period Even atrial fibrillation occurs rarely (about 3%) during the first 3 hours of acute Ml; if it does occur, it rarely presents with syncope
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to the time elapsed since the onset of MI. A rrhythmias occurring within 10 minutes of coronary occlusion are known as "immediate" or phase 1a ventricula r arrhythmias Acute ischemia causes heterogeneity of conduction with areas of marked conduction slowing and delayed activation, which in turn predisposes to reentr ant arrhythmias On the contrary, "delayed" or phase 1b arrhythmias occur about 10-60 minutes after acute infarction and are thought to result from abnormal automaticity (Choices A and E) Pulseless electrical activity is defined as the presence of electrocardiographic rhythm in the absence of adequate ca rdiac mechanical contraction to generate a palpable pulse Asystole is the complete absence of electrical and mechanical cardiac activity. Patients with prolonged duration of ca rdiac arrest can degenerate into pulseless electrical activity or asystole, which usually signifies the presence of severe and irreversible myocardial damage (Choice C) Atrio-ventricular conduction block can occur in patients with acute Ml, especially those with inferior wall MI. It is usually transient and resolves after successful reperfusion with thrombolytics or primary percutaneous coronary intervention. (Choices 8 and D) Supraventricular tachyca rdias other than atrial fib rillation or flutter are uncommon in the periinfarction period Even atrial fibrillation occurs rarely (about 3%) during the fi rst 3 hours of acute Ml; if it does occur, it rarely presents with syncope Educational objective: Reentrant ventricular arrhythmias (eg, ventricular fibrillation) are the most common cause of sudden cardiac arrest in the immediate post-infarction period in patients with acute myocardial infarction. References: 1. Sustained ventricular arrhythmias in patients receiving thrombolytic therapy: incidence and outcomes. The GUSTO investigators.
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(:) A Ejection-type systolic murmur 10 B. Fixed splitting of S2
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D. Friction rub
10 E. Pulsus paradoxus
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Lab Values
A 54-year-old man comes to the physician after having woken up in the middle of the night with substernal discomfort, which he describes as a burning sensation. The patient also has left-sided neck pain and feels sweaty and short of breath. He has never had similar pain before. His past medical history is significant for type 2 diabetes mellitus and hypertension. He has a 30-pack-year smoking history W hich of the following physical findings is most commonly associated with this patient's clinical presentation?
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Gallop heart sounds
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• Ventricular gallop sound (after S2)
Third heart sound (S3)
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Abnormal/associated conditions
Normal
• Heard during rapid filling of ventricles in diastole
• Children
• Age >40
• Young adults
• Heart failure
• Pregnancy
• Restrictive cardiomyopathy • High-output states
• Turbulent blood flow to the ventricles due to increased volume
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• Atrial gallop sound (before S1)
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Fourth heart sound (S4)
• Healthy older adults
• Younger adults, children
• Heard immediately after atrial contraction phase as blood is forced into a stiff ventricle
• Ventricular hypertrophy • Acute myocardial infarction
@UWortd
This patient's presentation with substernal discomfo rt, left-sided neck pain, diaphoresis, and dyspnea is consistent with acute coronary syndrome Acute myocardial ischemia or infarction causes myocardial dysfunction and stiffening of the left ventricular myocardium and can lead to 1.,11'"'
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dyspnea is consistent with acute coronary syndrome Acute myocardial ischemia or infarction causes myocardial dysfunction and stiffening of the left ventricular myocardium and can lead to changes in normal heart sounds. An abnormal S4 (atrial gallop) can be heard in most patients during the acute phase of myocardial infarction due to ischemia induced myocardial dysfunction An S4 is also frequently heard in patients with decreased left ventricular compliance, including those with hypertensive heart disease, aortic stenosis, and hypertrophic ca rdiomyopathy It can also sometimes be heard in healthy older adults without any other cardiac abnormality. (Choice A) Ejection-type systolic murmurs typically reflect the flow of blood across the aortic or pulmonic valves. They are not usually associated with acute myocardial ischemia or infarction. (Choice B) W ide and fixed splitting of second heart sound (S2) is typically heard in patients with an atrial septal defect Patients with myocardial ischemia/infarction can have paradoxical splitting of 52 due to delayed myocardial relaxation and delayed closure of the aortic valve.
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(Choice D) Perica rdia! friction rub is occasionally heard in patients with acute perica rditis; the chest pain is often sharp and pleuritic , worsens with inspiration or coughing, and diminishes when the patient sits up and leans forward . However , this patient's clinical features are more suggestive of acute coronary syndrome
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(Choice E) Pulsus paradoxus refers to an exaggerated drop in systolic blood pressure (<::1 0 mm Hg) during inspiration It is most commonly seen in patients with cardiac tamponade but can also occur in severe asthma and chronic obstructive pulmonary disease, hypovolemic shock, and infrequently with constrictive pericarditis Educational objective: An abnormal fourth heart sound (atrial gallop) can often be heard during the acute phase of myocardial infarction due to left ventricular stiffening and dysfunction induced by myocardial ischemia. References:
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Hemoglobin
13.1 g/dl
W hite blood cells
12,000/IJL with 7% band forms
Platelets
329,000/IJL
Dipstick urinalysis is positive fo r leukocyte esterase. W hich of the following is the most appropriate next step in management of this patient?
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e> A. Alpha-adrenergic blocking agents 0 B. Computed tomography scan of the pelvis
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0 C. Culture of mid-stream urine sample
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0 D. Prostate specific antigen measurement
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6 E. Urethral catheterization
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Lab Values
A 54-year-old man comes to the physician with a 2-day history of fever, chills, and perineal pain He has repeated urges to urinate along with pain on micturition. He is not sexually active. His temperature is 37.8 C (100 F), blood pressure is 120/70 mm Hg, pulse is 94/min, and respirations are 18/min. Rectal examination shows a boggy and tender prostate. Laboratory results are as follows:
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Overview of prostatitis
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Acute • Fever, chills, malaise, myalgia • Pelvic pain, cloudy urine
• Dysuria and j urinary frequency • No symptoms of acute prostatitis • Recurrent urinary tract infection
Diagnosis
• Pyuria, tender prostate • Urine culture positive (usually E coli)
• Pyuria with possible tender prostate • Urine culture positive (usually E coli)
Treatment
• TPM-SMX or fluoroquinolones
• Fluoroquinolones
Clinical presentation
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Chronic
E coli = Escherichia coli; TPM-SMX = trimethoprim-sulfamethoxazole. @UWo ~d
This patient's urinary symptoms with fever , leukocytosis, and prostate tenderness suggest acute bacterial prostatitis. Acute bacterial prostatitis is typically caused by the same organisms that cause other infections of the urinary tract (especially Escherichia colt) , and initial symptoms may resemble cystitis However, acute bacterial prostatitis can be differentiated from cystitis by more pronounced systemic symptoms (eg, fever , chills, ill appearance), associated regional pain, and tenderness on prostate examination. Obtaining a mid-stream urine sample would be the most appropriate next step to help direct antibiotic therapy. Prostate massage to increase culture yield has been recommended in some references, but it is painful and may induce bacteremia. Empiric antibiotic therapy with
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antibiotic therapy Prostate massage to increase culture y ield has been recommended in some references, but it is painful and may induce bacteremia. Empiric antibiotic therapy with trimethoprim-sulfamethoxazole or a fl uoroquinolone should be started while awaiting culture results, and treatment should be continued for 4-6 weeks in most cases. {Choice A) Alpha-adrenergic blocking agents are used to treat benign prostatic hype rplasia ( BPH) Although urgency is a common complaint among patients with BPH, this patient's infectious symptoms make acute bacterial prostatitis much more likely (Choice B) A computed tomography scan of the pelvis is not needed for a diagnosis of acute bacterial prostatitis, and the results are likely to be nonspecific Computed tomography scan can be useful to diagnose a pr ostatic abscess, which would be suspected if a patient with acute bacterial prostatitis continues to have fever despite appropriate antibiotic therapy. (Choice D) Prostate specific antigen can be elevated in acute bacterial prostatitis, but this finding is nonspecific as elevation can also be seen in BPH, prostate cance r, sterile prostate inflammation, and perineal trauma. {Choice E) Urethral catheterization should be avoided in patients with acute bacterial prostatitis as there may be inflammation involving the urethra. Patients with acute bacterial prostatitis who develop urinary retention may require suprapubic catheterization of the bladder. Educational objective: Acute bacterial prostatitis presents in a manner similar to other urinary tract infections, but with the addition of perineal pain, pronounced systemic symptoms (feve r, chills, acute illness), and a tender, boggy prostate on examination. Urine culture should be obtained to help direct antibiotic therapy References: 1. Diagnosis and therapy of acute prostat itis, epididymitis and orchitis.
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® A Bronchodilator therapy e; B. Continuous oxygen therapy
® C. Diuretic and ACE inhibitor ® D. Endothelin receptor antagonist ® E. Graded exercise program
6 F. Oral anticoagulation
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® G. Phosphodiesterase-S inhibitor
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61
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A 60-year-old woman has had progressive shortness of breath and dry cough over the last 2 months. The patient has no known medical problems and takes no medications. She does not use tobacco, alcohol, or illicit drugs. Family history is insignificant Her blood pressure is 155/92 mm Hg, and pulse is 96/min and regular Pulse oximetry shows 92% on room air BMI is 31 kg/m2 The jugular venous pressure is estimated at 9 em H,O. A 2/6 systolic murmur is heard at the lower sternal border and increases with inspiration. Lung auscultation reveals scattered wheezes and bibasilar crackles. There is 2+ symmetric peripheral edema. Echocardiogram shows a dilated left ventricle with ejection fraction of 30% and a mildly dilated right ventricle. The pulmonary artery systolic pressure is estimated at 55 mm Hg (normal <35 mm Hg) W hich of the following is the best initial treatment for this patient's pulmonary hypertension?
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This patient's progressive shortness of breath, tricuspid regurgitation (systolic murmur at the sternal border, increased with inspiration), peripheral edema, and echocardiogram findings are suggestive of pulmonary hypertension (PH). PH is defined as mean pulmonary arterial pressure of ~25 mm Hg at rest (normal 520 mm Hg) PH can be idiopathic (group 1 PH) or secondary to left heart disease, chronic lung disease, or chronic th romboembolism, and is often multifactorial. This patient's PH is likely due to severe left ventricular (LV) systolic dysfunction (reduced ejection fraction and signs of pulmonary edema), which is a common cause of PH. Management of PH due to LV systolic dysfunction should include loop diuretics and ACE inhibitors (or angiotensin II receptor blockers), often with beta blockers, and in some cases aldosterone antagonists. (Choices A and B) Oxygen and/or bronchodilator therapy is indicated fo r PH due to hypoxemia from chronic lung disease. This patient has severe LV dysfunction and no history of lung disease.
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(Choices D and G) Endothelin receptor antagonists (eg, bosentan), phosphodiesterase-5 inhibitors (eg, sildenafil), and/or prostanoids (eg, epoprostenol) are indicated for symptomatic idiopathic PH. These agents are not currently indicated for PH due to LV dysfunction (Choice E) Graded exercise training improves long-term outcomes (walking distance, peak oxygen consumption, overall functional status) in all patients with PH, with or without LV systolic dysfunction However, this patient first needs appropriate stabilization of her underlying cardiac disease. (Choice F) Long-term anticoagulation is indicated for patients with PH due to chronic thromboembolic occlusion of pulmonary vasculature. These patients typically have normal LV systolic function. Educational objective: Left ventricular systolic or diastolic dysfunction is a common cause of pulmonary hype rtension Initial management includes loop diuretics and ACE inhibitors (or angiotensin II receptor blockers).
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e; A Ramsay Hunt syndrome
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e; C. Otitis media
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e> B. Glossopharyngeal neuralgia e> D. Temporomandibular joint dysfunction e; E. Otitis extern a
e> F. Cerumen impaction
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61
Lab Values
A 26-year-old man comes to your office with a one-week history of right-sided ear pain The pain often wakes him up at night, and increases in severity when he chews food. He cannot recall any recent episodes of pharyngitis. He denies having any ear discharge, sinus tenderness, or skin rash. He exercises by swimming frequently at a local club. He is sexually active and uses condoms "quite regularly." He lives with his brother , who often comments on his habit of grinding his teeth at night On examination, his ears are normal with a mild amount of wax. Pain is not elicited by pulling on the pinna. There are no hearing deficits appreciated Mobility of the tympanic membrane is normal, and the Weber and Rinne test results are within normal limits. W hat is the most likely diagnosis?
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----------------------------------------
Explanation: The most likely diagnosis in this patient is temporomandibular joint (TMJ) dysfunction. Most patients with TMJ dysfunction have a history of nocturnal teeth grinding, and patients often interpret the pain as coming from the ear due to anatomic proximity The pain associated with TMJ dysfunction is characteristically worsened with chewing because of the strain that this places on the TMJ. Although many patients may have audible clicks or crepitus in the TMJ with jaw movement, this is not seen in all patients A thorough physical examination should be done to exclude other conditions within the ear itself. Radiologic imaging of the TMJ is often of limited utility. Initial treatment consists primarily of conservative measures such as a nighttime bite guard, but surgical intervention is sometimes necessary
(Choice A) Ramsay Hunt syndrome is a form of herpes zoster infection that causes Bell's palsy. In this condition, ves icles are typically seen on the outer ear.
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(Choice B) Glossopharyngeal neuralgia is a condition in which patients experience intermittent, severe, stabbing pain in areas innervated by cranial nerves IX and X, which includes the ear. However, this patient's history of worsening pain with chewing makes TMJ dysfunction more likely .
(Choice C) Otitis media can result in ear pain, but it will usually cause erythema and/or limited mobility of the tympanic membrane as well. (Choice E) Otitis externa usually results in ear discharge and pain with pulling on the pinna, neither of which is seen in this patient
(Choice F) Cerumen impaction usually causes conductive hearing loss as opposed to pain, and ca n easily be excluded with otoscopic examination.
Educational objective: Temporomandibular joint (TMJ) dysfunction can result in referred pain to the ear that is worsened with chewing Patients typically report a history of nocturnal teeth grinding Time Spent 3 seconds
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A 58-year-old man comes to the physician and complains of "problems with erection." He has recurrent and persistently painful erections. His other medical problems include ulcerative colitis, kidney stones, insomnia, depression, hypertension, drug-induced diabetes, obesity and hypercholesterolemia He does not use tobacco, alcohol, or drugs He takes prednisone, mesalamine, insulin, 6-mercaptopurine, simvastatin, glyburide, enalapril, trazodone, and fl uoxetine. He has no known drug allergies. His vital signs are stable. The general physical examination is unremarkable. Avoidance of which of the following medications could have prevented his condition?
6 A Fluoxetine
e; B. Trazodone
6 C. Enalapril e; D. Glyburide
6 E. Simvastatin e; F. Prednisone
6 G. 6-Mercaptopurine Subm it
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p p Explanation: Trazodone is an antidepressant which is mainly used for sleep disturbances. Its disturbing side effect is priapism, which is a persistent, painful erection that develops without sexual stimulation and has a long duration. Remember the common causes of priapism 1. Sickle cell disease and leukem ia - usually in children or adolescents 2. Perineal or genital trauma - results in laceration of the cavernous artery 3. Neurogenic lesions- such as spinal cord injury, cauda equina compression, etc . 4. Medications- such as trazodone and prazosin None of the other medications listed can cause priapism
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(Choice A) Fluoxetine can lead to sexual dysfunction, resulting in impotence, decreased libido and ejaculatory problems, but it usually does not cause priapism SSRis typically cause delayed orgasm; fo r this reason, these drugs can be used in the treatment of premature ejaculation. (Choice C) Most antihypertensive medications (including enalapril) can cause impotence, but do not cause priapism Nonselective beta-blockers such as propranolol usually cause impotence. (Choice D) Glyburide also does not cause this side effect {Choice E) Some degree of erectile dysfunction is associated with the use of simvastatin, although this is rarely seen. Priapism is not a side effect of this medication. Educational Objective: If a patient presents with priapism, always check his medications fi rst This symptom is often drug-induced The most common drug that causes priapism is prazosin, although for the boards, it is important to remember the association of priapism with trazodone. Time Spent 3 seconds
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11)
A. Observe and recheck the mass after one month
11) B. Platinum based chemotherapy 11) C. Trans-scrotal biopsy 11) D. Fine needle aspiration cytology 11) E. Radical orchiectomy
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A 28-year-old male comes for complete physical examination for a new job he is starting next week. He is healthy and has no complaints. He smokes 1 pack/day cigarettes for the last 10 yea rs He drinks 4 oz of alcohol daily His mother has hype rtension and father has heart problems. Vitals signs are within normal limits. Physical examination is within normal limits except for a painless, hard mass in the left testicle. Ultrasound shows high likelihood of a testicular tumor. W hat is the next best step in management?
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W hat is the next best step in management?
A Observe and recheck the mass after one month [3%) B. Platinum based chemotherapy [4%) C. Trans-scrotal biopsy [18%)
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D. Fine needle aspiration cytology [21%) .;
E. Radical orchi ectomy [53%)
Explanation:
After the diagnosis of a solid testicular mass has been made, (a painless hard mass in testicle+ suggestive ultrasound) , the initial management is removal of the testis and its associated co rd, orchiectomy. This is done th rough a small inguinal incision. The procedure is called high inguinal orchiectomy The testis and abnormal tissue present is then examined under the microscope to determine the type of cancer. Depending on the cell type of the cance r present other therapies, i.e. additional surgery, radiation therapy, or possibly chemotherapy may be indicated. Using a combination of these therapies, testicular cancer has one of the highest cure rates of all cancers. This has been achieved using a combination of surgery and chemotherapy, as well as radiation in certain instances. Cure from testicular cance r can even be achieved in individuals who have had the cancer spread into other parts of the body This is the tumor that we kill first and investigate later. So observation, chemotherapy, and biopsies are not the next best step in this case. FNAC, or transscrotal biopsy, is contraindicated because of the risk of spillage of cancer cells, which can potentially spread through lymphatics and blood vessels. Educational Objective: After the diagnosis of a solid testicular mass has been made, (a painless hard mass in testicle + suggestive ultrasound) , the initial management is removal of the testis and its associated cord.
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e; A Bacterial infection of the mitral valve
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e; C. Myoca rdial ischemia
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B. Mitral annular calcification
D. Myxomatous degeneration of the mitral valve
e; E. Rheumatic mitral valve disease
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61
Lab Values
A 38-year-old woman comes to the physician complaining of occasional palpitations. She describes a fast and irregular heartbeat She has had 3 such episodes over the past 2 months, each lasting about 2 hours. The patient has no associated chest pain, shortness of breath, cough, or ankle swelling. She drinks alcohol on social occasions and does not smoke. She has no other medical problems and takes no medications. Her temperature is 37.1°C (98 9°F), blood pressure is 130/70 mm Hg, pulse is 80/min, and respirations are 14/min. The apical impulse is displaced to the left, and a third heart sound is heard at the apex in the left decubitus position. There is also a holosystolic murmur that is loudest at the apex and radiates to the axilla. W hich of the following is the most likely cause of this patient's condition?
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This patient's examination findings (displaced apical impulse, holosystolic murmur, and third heart sound) are consistent with chronic severe mitral regurgitation (MR) Mitral valve prolapse (MVP) is the most common cause of chronic MR in developed countries. MVP occurs due to myxomatous degeneration of the mitral valve leaflets and chordae and causes a mid-systolic click followed by a mid-to-late systolic murmur. As the severity of leaflet dysfunction and MR wo rsens, the murmur becomes holosystolic and the cl ick may not be audible. The third heart sound is from left ventricular vol ume overload and does not necessarily represent congestive heart failure. Chronic severe MR can cause left atrial dilation, which can eventually lead to atrial fibrillation (symptoms of palpitations) (Choice A) Infective endocarditis can cause MR due to inadequate leaflet coaptation or, rarely , leaflet perforation It is unlikely in this patient, who has no accompanying signs or symptoms (eg, fever , embolic findings) suggesting infective endocarditis. (Choice B) Mitral annular calcification refers to a degenerative process involving the fibrous annulus of the mitral valve. It is a common incidental finding in older adults and is usually associated with mild-to-moderate MR Mitral annular calcification is less likely to cause significant MR in a younger patient (Choice C) Myoca rdial ischemia can cause papillary muscle dysfunction, which in turn can cause MR It usually presents with chest discomfort, dyspnea, or sudden onset of pulmonary edema.
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(Choice E) Rheumatic heart disease can cause mitral stenosis, MR, and aortic regurgitation. However, it is a much less common cause of chronic MR than MVP. Educational objective: Mitral valve prolapse is the most common cause of mitral regurgitation (MR) in developed countries. It usually causes mild MR with mid-systolic click and mid-to-late systolic murmur. Patients with severe leaflet dysfunction and prolapse can develop severe MR and holosystolic murmur on physical examination. Chronic severe MR causes left atrial and ventricular enlargement leading to atrial fib rillation, left ventricular dysfunction, and congestive heart failure.
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0 A CT scan of the head 0 B. Long-term urinary catheter 0 C. Tolte rodine therapy 6 D. Urinalysis and culture 0 E. Urodynamic study 6 F. Vaginal estrogen cream
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61
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A 78-year-old woman is brought to the hospital for urinary incontinence. The patient has a history of Alzheimer dementia and has been living in a nursing home fo r the past 3 years She requires assistance for most of her daily activities. The patient can indicate to the nursing home staff when she needs to use the bathroom. She has been less active fo r the past week and sleeps most of the time. She also has developed urinary incontinence, which she has never had before. Her temperature is 36.7 C (98 F), blood pressure is 130/70 mm Hg, and pulse is 76/min. On examination, the patient is somnolent but responsive to voice. She is disoriented but has no focal neurologic deficits. The abdomen is soft and nontender. Genitourinary examination shows thin and pale vaginal mucosa with ill-defined labia minora. W hich of the following is the best next step in managing this patient's urinary incontinence?
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Causes of urinary incontinence in the elderly
• 1detrusor contractility, detrusor overactivity
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Genitourinary
• Bladder or urethral obstruction (eg, tumor, BPH)
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• Urethral sphincter or pelvic floor weakness
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• Urogenital fistula
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• Multiple sclerosis Neurologic
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• Dementia (eg, Parkinson, Alzheimer, normal pressure hydrocephalus) • Spinal cord injury, disc herniation
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• Delirium
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• Infection (eg, UTI)
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• Atrophic urethritis/vaginitis
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Potentially reversible
• Pharmaceuticals (eg, alpha blockers, diuretics) • Psychological (eg, depression) • Excessive urine output (eg, diabetes mellitus, CHF) • Restricted mobility (eg, postsurgery) • Stool impaction
BPH = benign prostatic hyperplasia; CHF = congestive heart failure; UTI = urinary tract infection. @UWorld
This patient with dementia has acute urinary incontinence (UI) Acute infections, especially
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This patient with dementia has acute urinary incontinence (UI) Acute infections, especially urinary tract infections (UTis), are leading causes of Ul in elderly patients. Other potentially reversible causes of Ul include medications, excess urine output (eg, congestive heart failure, diabetes mellitus), alcohol, and delirium due to any cause. Restricted mobility and stool impaction may also contribute to Ul in elderly patients. Medications that commonly cause Ul incl ude • Alpha-adrenergic antagonists (urethral relaxation) • Anticholinergics, opiates, calcium channel blockers (urinary retention/overflow) • Diuretics (excess urine production) Reve rsible causes of Ul (mnemonic DIAPPERS in table) should be identified and managed before evaluating fo r chronic causes. As older adults often lack typical signs or symptoms of UTI, urinalysis with cultur e should be obtained routinely Once infection is excluded, additional testing is based on clinical findings that suggest other etiologies (eg, focal neurologic deficits, cognitive impairment, systemic symptoms) (Choice A) CT scan of the head is obtained with focal neurologic deficits. This patient has altered mental status but no focal neurologic findings; infection should be excluded first, before further testing, as atyp ical presentations are common in the elderly (Choice B) Long-term urinary catheter placement may be required in patients with neurogenic bladder or urinary retention due to anatomic obstruction, neither of which is evident from this history Long-term urinary catheters can further increase the risk of infections and delirium. (Choice C) Tolterodine, an anticholinergic agent, is indicated for urge incontinence or overactive bladder symptoms However, transient causes of Ul need to be excluded first {Choice E) Routine urodynamic studies are not recommended for evaluating UL Urodynamic studies may be helpful for evaluating complicated stress/mixed Ul or clarifying the mechanism of overflow incontinence after infection has been excluded. (Choice F) This patient has vaginal atrophy and may benefit from vag inal estrogen However, vaginal atrophy alone would not explain acute delirium whereas UTI may Vaginal estrogen may
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(Choice A) CT scan of the head is obtained with focal neurologic deficits. This patient has altered mental status but no focal neurologic findings; infection should be excluded fi rst, before further testing, as atypical presentations are common in the elderly {Choice B) Long-term urinary catheter placement may be required in patients with neurogenic bladder or urinary retention due to anatomic obstruction, neither of which is evident from this history Long-term urinary catheters can further increase the risk of infections and delirium. {Choice C) Tolterodine, an anticholinergic agent, is indicated for urge incontinence or overactive bladder symptoms However, transient causes of Ul need to be excluded fi rst (Choice E) Routine urodynamic studies are not recommended fo r evaluating Ul. Urodynamic studies may be helpful for evaluating complicated stress/mixed Ul or cla rifying the mechanism of overflow incontinence after infection has been excluded. (Choice F) This patient has vaginal atrophy and may benefit from vag inal estrogen. However , vaginal atrophy alone would not explain acute delirium whereas UTI may Vaginal estrogen may or may not improve symptoms of stress incontinence in patients with concurrent vaginal atrophy , but it is a low-risk intervention. Educational objective: Acute urinary incontinence in elderly patients may have atyp ical presentations. Consider reversible etiologies first, especially if new onset (remember DIAPPERS) Fever may not present with urinary tract infections limited to the lower urinary tract Initial evaluation should include urinalysis with culture. References: 1. Urinary incontinence in women. 2. Atypical presentations of older adults at the emergency department and associated factors .
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0 A Acute blood loss 0 B. Adrenal insufficiency 0 C. Anaphylactic shock 6 D. Cardiac tamponade
0 E. Disseminated intravascular coagulation 0 F. Myoca rdial infarction ® G. Pulmonary embolism ® H. Septic shock
0 I. Tension pneumothorax
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A 25-year-old woman is undergoing an elective cholecystectomy after 2 episodes of acute calculous cholecystitis The procedure is converted from laparoscopy to open due to difficulty with visualization. The patient suddenly becomes hypotensive and develops a diffuse generalized rash. Her past medical history is significant for obesity and polycystic ovarian syndrome. Two months ago, she developed hives after having protected sex with her partner for the fi rst time. W hich of the following is the most likely cause of this patient's hypotension?
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The clinical scenario described is suggestive of anaphylactic shock caused by latex. The widespread use of latex in medical products has made it a common cause of allergy The development of hives after sexual intercourse in this patient was likely due to sensitization to latex condoms. Latex gloves used by surgeons provoked the anaphylactic reaction. Pre-existing atopic dermatitis increases the risk of latex allergy. Health ca re workers and surgical patients, especially those undergoing abdominal or genitourinary surgery, are at higher risk as well. Latex allergy rates peaked in the 1990s and have since decreased with the use of powder-free latex gloves and latex alternatives, but the risk remains elevated in these populations (Choices A, D, F, G, and I) Hemorrhage, cardiac tamponade, myocardial infarction, pulmonary embolism, and tension pneumothorax can cause hypotension but do not cause a rash. {Choice B) Adrenal insufficiency should also be suspected in any patient who suddenly becomes hypotensive under a stressful condition such as surgery Patients with primary adrenal insufficiency (Addison's disease) can have gradual development of hype rpigmentation due to increased production of melanocyte-stimulating hormone. However, a sudden onset of rash is not seen with adrenal insufficiency
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(Choice E) Disseminated intravascular coagulation may cause hypotension due to excessive bleeding from the operative site and venous punctures. Petechiae and ecchymoses, not hives, are commonly present (Choice H) Septic shock is characterized by fever , and an established focus of infection is usually present Educational objective: Anaphylaxis can result from exposure to latex-containing products such as surgical gloves and condoms. Health care workers and patients with atopic disease are at higher risk of latex allergy References: 1. Outcomes of a natural rubber latex control program in an Ontario teaching hospital.
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e; A Urinary tract infection e; B. Enlarged prostate
6 C. Carc inoma of the bladder e; D. Multiple sclerosis
() E. Urinary fistula
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e; F. Spinal cord comp ression
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A 73-year-old man comes to the emergency department because of a 12-hour history of inability to void. He also complains of nocturia and problems with initiating micturition for the past few weeks. He denies feve r, weakness, numbness, dysuria, or hematuria. His other medical problems incl ude hypertension that is well-controlled with lisinopril He does not use tobacco, alcohol, or illicit drugs His blood pressure is 110/60 mm Hg, pulse is 74/min, and respirations are 12/min. Neurologic examination shows no abnormalities except absent Achilles tendon reflexes bilaterally Straight catheterization of the bladder produces 600 ml of urine. Further evaluation will most likely show which of the following?
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Acute urinary retention in the elderly can be an emergency and is usually caused by obstruction, neurogenic bladder, or detrusor muscle underactivity The most common cause of urinary retention in older men is bladder outlet obstruction due to benign prostate hyperplasia or ca rcinoma of the prostate Patients commonly present with postvoid dribbling, decreased urinary stream, hesitancy, urgency, nocturia, and urinary retention. Rectal examination shows an enlarged prostate and a high postvoid urinary residual vol ume when a Foley catheter is inserted. The Achilles tendon reflex can decrease or even be absent with age, so this can be a normal finding in many elderly patients. Possible etiologies include decreased sympathetic tone with age or , possibly, changes in the muscles themselves. The presence of lower extremity weakness, bowel/bladder incontinence, or decreased rectal tone and brisk lower extremity deep tendon reflexes would indicate a possible spinal co rd lesion with compression in the lumbar region. This patient presents with urinary retention rather than incontinence and has an otherwise normal neurologic exam, so is less likely to have spinal cord comp ression (Choice F)
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{Choice A) Urinary tract infection usually presents with dysuria, frequency, hematuria, and abnormal urinalysis with evidence of infection. Postvoid residual volume will be low or normal, as frequent emptying of the bladder occurs with this condition. (Choice C) Carcinoma of the prostate, not the bladder, can commonly cause urinary retention. Bladder cancer usually causes gross hematuria, which was not present in this patient (Choice D) Overflow incontinence fror:n an acontractile bladder is usually due to diabetic neuropathy, multiple sclerosis, anesthetic blocks, or drugs, such as anticholinergics Multiple sclerosis is usually seen in females of child-bearing age This is a very unlikely presentation in this patient, especially with a normal neurologic exam and no incontinence. (Choice E) Patients with a history of pelvic surgery or irradiation can develop a urinary fistula, with continuous loss of urine through the fistula. The diagnosis is made with intravenous pyelography , which shows dye leaking from the fistula. Educational objective: The most common cause of urinary retention in elderly males is an enlarged prostate, which is
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or , possibly , changes in the muscles themselves. The presence of lower extremity weakness, bowel/bladder incontinence, or decreased rectal tone and brisk lower extremity deep tendon reflexes would indicate a possible spinal cord lesion with compression in the lumbar region This patient presents with urinary retention rather than incontinence and has an otherwise normal neurologic exam, so is less likely to have spinal cord compression (Choice F) {Choice A) Urinary tract infection usually presents with dysuria, frequency, hematuria, and abnormal urinalysis with evidence of infection. Postvoid residual volume will be low or normal, as frequent emptying of the bladder occurs with this condition. {Choice C) Carcinoma of the prostate, not the bladder, can commonly cause urinary retention. Bladder cancer usually causes gross hematuria, which was not present in this patient (Choice D) Overflow incontinence from an acontractile bladder is usually due to diabetic neuropathy, multiple sclerosis, anesthetic blocks, or drugs, such as anticholinergics. Multiple sclerosis is usually seen in females of child-bearing age. This is a ve ry unlikely presentation in this patient, especially with a normal neurologic exam and no incontinence. (Choice E) Patients with a history of pelvic surgery or irradiation can develop a urinary fistula, with continuous loss of urine through the fistula. The diagnosis is made with intravenous pyelography , which shows dye leaking from the fistula.
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Educational objective: The most common cause of urinary retention in elderly males is an enlarged prostate, which is usually revealed by rectal examination and characterized by a high postvoid residual volume. An absent or decreased Achilles tendon reflex can be a normal finding in elderly patients. References: 1. Acute urinary retention in elderly men 2. Age and sex dependency of the Achilles tendon r eflex
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0 A Daily furosemide
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0 E. Smoking cessation
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A 63-year-old woman comes to the office due to leg swelling that is especially bothersome in the evening. Her symptoms have gradually worsened over the last year. Her medical problems include hypertension treated with lisinopril and obstructive sleep apnea for which she uses continuous positive airway pressure during sleep. She was hospitalized 2 years ago for a chest infection that was treated with antibiotics. The patient has smoked a pack of cigarettes daily for 30 years and does not drink alcohol. Blood pressure is 160/90 mm Hg and pulse is 80/min. BMI is 32 kg/m2 . Jugular venous pulsation is seen 2 em above the sternal angle with the head of the bed elevated to 45°. Chest examination shows bilateral scattered wheezes and prolonged expirations Her abdomen is soft and nondistended. She has bilateral 2+ pitting edema in her lower extremities to the midshin with dilated and tortuous superficial veins. A small ulcer is noted on the left medial ankle. All peripheral pulses are palpable W hich of the following is most likely to relieve this patient's current symptoms?
0 B. Dietary sodium restriction 0 C. Frequent leg elevation
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C. Frequent leg elevation (44%) D. Improved control of hypertension [5%) E. Smoking cessation [ 11%I
Explanation:
This patient's lower extremity (LE) swelling is likely due to chronic venous insufficiency (CVI), which is most commonly caused by incompetence of venous valves leading to venous hypertension in the deep venous system of the legs. Patients may present with leg discomfort, pain, or swelling that is typically worse in the evening or following prolonged standing and improves after walking or leg elevation. Pitting edema is the most common physical examination finding. In relatively severe cases, redirection of blood from the deep venous system to the superficial venous system may lead to other phys ical examination findings, including abnormal venous dilation (eg, telangiectasia, varicose veins) , skin discoloration, lipodermatosclerosis, or skin ulceration (characteristically on the medial aspect of the lower leg) Risk facto rs for CVI include advancing age, obesity, fam ily history, pregnancy, sedentary lifestyle, previous LE trauma, and previous LE venous th rombos is. The diagnosis of CVI is often based on history and physical examination, and initial treatment includes leg elevation, exercise, and compression stockings. Patients who do not respond to initial conservative measures should undergo venous duplex ultrasound to confi rm the diagnosis of CVI by identification of venous reflux (retrograde venous blood flow) in the deep venous system (Choice A) Diuretics (eg, furosem ide) are likely to cause dehydration in patients with CVI and are generally not recommended in the management of LE edema due to CVI. (Choices B and D) Dietary sodium restriction and hype rtension control are important interventions in the management of LE edema due to heart fa ilure, but do not play a significant role in the management of CVI. This patient's normal jugular venous pressure and absence of crackles on lung examination (wheezing is likely due to underlying chronic obstructive pulmonary disease rather than pulmonary edema) make heart fa ilure unlikely
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includes leg elevation, exercise, and compression stockings Patients who do not respond to initial conservative measures should undergo venous duplex ultrasound to confi rm the diagnosis of CVI by identification of venous reflux (retrograde venous blood flow) in the deep venous system (Choice A) Diuretics (eg, furosemide) are likely to cause dehydration in patients with CVI and are generally not recommended in the management of LE edema due to CVI. {Choices 8 and D) Dietary sodium restriction and hypertension control are important interventions in the management of LE edema due to heart fail ure, but do not play a significant role in the management of CVI. This patient's normal jugular venous pressure and absence of c rackles on lung examination (wheezing is likely due to underlying chronic obstructive pulmonary disease rather than pulmonary edema) make heart failure unlikely (Choice E) Smoking is considered a risk factor for CVI; however, there is no evidence to support smoking cessation as an effective management strategy for CVI. Smoking cessation is a fi rst-line intervention in the management of arterial insufficiency, which does not cause significant LE edema and is unlikely in this patient with palpable peripheral pulses. Educational objective: Chronic venous insufficiency is a common cause of lower extremity edema that may be accompanied by varicose ve ins, skin discoloration, and medial skin ulceration. Initial treatment includes conservative measures with leg elevation, exercise, and compression therapy
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References: 1. Effect of leg elevation on the skin microcirculation in chronic venous insufficiency. 2. Chronic venous insufficiency and venous ulceration. 3. Chronic venous insufficiency: mechanisms and management.
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An imaging study detects an incidental 3.5-cm infrarenal abdominal aortic aneurysm in a 60-year-old man. He has no associated symptoms His medical history is significant fo r hypertension, type 2 diabetes, hypercholesterolemia, and hypothyroidism His medications include aspirin, metformin, glipizide, hydrochlorothiazide, lisinopril, low-dose atorvastatin, and levothyroxine He has smoked 1-2 packs of cigarettes daily for the past 40 yea rs, and he drinks 1 or 2 glasses of wine daily . On physical examination, his blood pressure is 160/90 mm Hg and pulse is 80/min. Heart sounds are normal and his lungs are clear. Laboratory results are as follows Serum creatinine
1.7 mg/dL
Low-density lipoprotein (LDL)
150 mg/dL
HbA1C
8.5%
Serum thyroid-stimulating hormone
3.0 1,1U!mL
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W hich of the following is associated with the highest rate of aneurysm expansion and rupture in this patient?
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0 A Uncontrolled hypertension 0 B. LDL >130 mg/dL 0 C. Uncontrolled diabetes mellitus 0 D. Active smoking 0 E. Daily alcohol consumption S ub mit
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Explanation: Most patients with abdominal aortic aneurysm (AAA) are initially asymptomatic and the diagnosis is made during an imaging study performed for an unrelated cause. The risk factors associated with development of AAA include older age (>60 yea rs), cigarette smoking, family history of AAA, white race, and atherosclerosis. The main risk factors associated with aneurysm expansion and rupture include large diameter , rate of expansion, and current cigarette smoking. Of the answer choices, current cigarette smoking is associated with the highest rate of aneurysm expansion and rupture The exact mechanism is unclear but is thought to be associated with degeneration of connective tissue in the aortic wall.
{Choice A) Based on observational studies, hypertension has a weak association with AAA formation and its rate of expansion and rupture All such patients need adequate blood pressure control fo r overall risk reduction, but treatment with beta blockers or angiotensin-converting-enzyme inhibitors has not been shown clearly to reduce the rate of aneurysm expansion (Choice B) Hyperlipidemia is an important modifiable risk factor in patients with atherosclerosis, but it has not been found to be associated with AAA growth and expansion Statin use has not been shown to reduce the rate of AAA expansion in multiple studies. {Choice C) Diabetes is a strong risk factor fo r atherosclerosis and ca rdiovascular disease. However , fo r unclear reasons, the risk of AAA in patients with diabetes is lower than in those without diabetes. In observational studies, AAA growth rate was also noted to be lower in diabetics. (Choice E) Modest alcohol intake (1 or 2 drinks a day for men and 1 drink a day for women) is associated with decreased inc idence of coronary heart disease and cardiovascular mortality. However, the effect of alcohol consumption on the risk of AAA expansion is not clear and is not considered to be a risk factor for expansion or rupture.
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fo rmation and its rate of expansion and rupture All such patients need adequate blood pressure control fo r overall risk reduction, but treatment with beta blockers or angiotensin-converting-enzyme inhibitors has not been shown clearly to reduce the rate of aneurysm expansion. (Choice B) Hyperlipidemia is an important modifiable risk factor in patients with atherosclerosis, but it has not been found to be associated with AAA growth and expansion Statin use has not been shown to reduce the rate of AAA expansion in multiple studies. (Choice C) Diabetes is a strong risk factor fo r atherosclerosis and ca rdiovascular disease. However, for unclear reasons, the risk of AAA in patients with diabetes is lower than in those without diabetes. In observational studies, AAA growth rate was also noted to be lower in diabetics. (Choice E) Modest alcohol intake (1 or 2 drinks a day fo r men and 1 drink a day for women) is associated with decreased incidence of coronary heart disease and cardiovascular mortality However, the effect of alcohol consumption on the risk of AAA expansion is not clear and is not considered to be a risk factor for expansion or rupture Educational objective: In observational studies, the strongest predictors of abdominal aortic aneurysm expansion and rupture are large aneurysm diameter, rapid rate of expansion, and current c igarette smoking. The current indications for operative or endovascular repair include aneurysm size >5.5 em, rapid rate of aneurysm expansion (>0 5 em in 6 months or >1 em per year) , and presence of symptoms (abdominal, back, or flank pain; limb ischemia) regardless of aneurysm size. References: 1. Abdominal aortic aneurysm expansion: risk factors and time intervals for surveillance. 2. The association between cigarette smoking and abdominal aortic aneurysms.
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® A 10% Weight loss ® B. Aerobic exercise ® C. Cessation of alcohol intake
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® D. Dietary salt restriction
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A 43-year-old man with a 2-year history of type 2 diabetes mellitus comes to the physician for a routine preventive examination. He has no complaints. His medications include metformin and aspirin The patient works as a computer programmer and has a sedenta ry lifestyle. He drinks 1 or 2 cans of beer on weekends and has a 20-pack-year smoking history His blood pressure is 2 153/94 mm Hg and his pulse is 82/min. The patient's body mass index is 32.5 kg/m The remainder of the physical examination is unremarkable. Laboratory studies show an HbA1c of 7.6%. At a previous visit 3 months ago, the patient's blood pressure was 149/92 mm Hg W hich of the following interventions would be most effective in controlling his blood pressure?
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Explanation:
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Treatment of hypertension Modification
Recommended plan
Approximate l systolic BP (mm Hg)
Weight loss
Reduce BMI <25 kg/m2
5-20 per 10 kg loss
DASH diet
Diet high in fruits and vegetables and low in saturated fat and total fat
8-14
Exercise
30 minutes/day for 5-6 days/week
4-9
Dietary sodium
<3 g/day
2-8
Alcohol intake
2 drinks/day in men and 1 drink/day in women
2-4
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Weight loss is the most effective nonpharmacologic measure to decrease blood pressure in overweight individuals. Weight loss with other nonpharmacologic measures can prevent or delay the onset of hypertension and reduce the overall risk of cardiovascular events in such patients In some patients with established hypertension, lifestyle changes alone may control their blood pressure. These changes can also allow for fewer drugs and lower doses of .. .
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patients In some patients with established hype rtension, lifestyle changes alone may control their blood pressure. These changes can also allow for fewer drugs and lower doses of antihype rtensive medication when needed. (Choice B) Moderate-intensity aerobic exerc ise can lower blood pressure in both hypertensive and normotensive individuals and facilitates weight loss. However, we ight loss has a greater impact on blood pressure than exercise alone. (Choice C) Daily alcohol consumption (~3 drinks per day in men, ~2 in women) can raise blood pressure and is a common cause of refractory hypertension that remains uncontrolled despite multiple medications. However , moderate alcohol intake (as in this patient) does not significantly affect blood pressure (Choice D) Sodium restriction is recommended for most patients with hype rtension, but its effect on blood pressure is inconsistent in some individuals. Sodium restriction is more effective in older (especially postmenopausal women), African American, and overweight individuals. The DASH diet (low in sodium and saturated fat and high in potassium, calcium, and dietary fiber) combined with sodium restriction can lower blood pressure more than sodium restriction alone. {Choice E) Improved glycem ic control will decrease this patient's risk of developing microvascular disease (eg, neuropathy , nephropathy , retinopathy) However , it will not improve his blood pressure control, and its effect on macrovascular events (eg, stroke, acute myocardial infarction) is uncertain. {Choice F) Smoking cessation is an important component of lifestyle modification that reduces the risk of future cardiovascular events. Although smoking cessation may directly lower blood pressure, its impact is not as significant as that fo r weight reduction. Educational objective: Most patients will require pharmacotherapy for blood pressure control , but lifestyle changes can make a significant diffe rence in motivated patients Weight control is the most effective intervention in overweight patients Other effective measures include the DASH diet, low sodium intake, moderation of alcohol intake, regular moderate exercise, and smoking cessation.
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e; A Captopril
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F. Spironolactone
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A 66-year-old white male presents for evaluation of progressively worsening dyspnea that affects him at rest and wakes him from sleep. He also notes bilateral ankle swelling His medical history is significant for coronary artery disease for wh ich he has undergone angioplasty and co ronary artery bypass grafting. On examination today , his pulse is 86/min, blood pressure is 110/70 mmHg, and respirations are 19/min. His neck ve ins are distended and there is bilaterally symmetric pitting ankle edema. On chest auscultation, you hear crackles at the bilateral lung bases and a third heart sound. Chest x-ray shows an enlarged ca rdiac silhouette and bilateral alveolar and interstitial pulmonary edema. Of the medications listed below, which has not been shown to improve survival in patients with the above presentation?
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F. Spironolactone [5%] Explanation: Of the above medications, digoxin is the only one that does not improve survival in patients with CHF. Digoxin is a cardiac glycoside that helps inc rease the heart's contractility. It is therefore ve ry useful for improving CHF symptoms like dyspnea and fatigue Though it has no mortality benefit, digoxin has been shown to decrease hospitalizations in patients with CHF. (Choice A) Captopril is an ACE inhibitor shown to improve mortality in CHF. It is a first-line therapeutic agents. (Choice B) Losartan is an angiotensin receptor blocker (ARB). ARBs have been shown to improve survival in CHF, though to a lesser degree than ACE inhibitors. ARBs are typically reserved for patients unable to tolerate ACE inhibitors. (Choice C) Metoprolol is a beta-blocker shown to improve mortality in CHF, particularly in NYHA classes II and Ill. The beta-blockers carvedilol and bisoprolol also have a survival benefit in CHF, while beta-blockers with intrinsic sympathomimetic activity should be avoided. (Choice E) Given that this patient's CHF is likely due to his underlying coronary artery disease, aspirin would have a survival benefit fo r this patient by helping to prevent myocardial infa rction. (Choice F) Loop diuretics are extensively used in patients with heart failure. However , they provide only symptomatic relief, not survival benefit The only class of diuretics with a demonstrated survival benefit in patients with heart failure is aldosterone antagonists like spironolactone and eplerenone Use of spironolactone was associated with a 30% reduction in overall mortality at twenty-four months in patients with NYHA class Ill to IV heart fa ilure who were receiving an ACE inhibitor and loop diuretic (RALES trial). Educational objective: ACE inhibitors, ARBs, beta-blockers, and spironolactone all confe r a survival benefit in CHF. W hile digoxin and furosem ide (loop diuretics) can reduce CHF symptoms and hospitalizations,
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Explanation: Of the above medications, digoxin is the only one that does not improve survival in patients with CHF. Digoxin is a cardiac glycoside that helps increase the heart's contractility. It is therefore very useful for improving CHF symptoms like dyspnea .and fatigue. Though it has no mortality benefit, digoxin has been shown to decrease hospitalizations in patients with CHF. (Choice A) Captopril is an ACE inhibitor shown to improve mortality in CHF. It is a first-line therapeutic agents (Choice B) Losartan is an angiotensin receptor blocker (ARB) ARBs have been shown to improve survival in CHF, though to a lesser degree than ACE inhibitors. ARBs are typ ically reserved for patients unable to tolerate ACE inhibitors. (Choice C) Metoprolol is a beta-blocker shown to improve mortality in CHF, particularly in NYHA classes II and Ill. The beta-blockers carvedilol and bisoprolol also have a survival benefit in CHF, while beta-blockers with intrinsic sympathomimetic activity should be avoided. (Choice E) Given that this patient's CHF is likely due to his underlying coronary artery disease, aspirin would have a survival benefit for this patient by helping to prevent myocardial infa rction. {Choice F) Loop diuretics are extensively used in patients with heart fa ilure. However , they provide only symptomatic relief, not survival benefit The only class of diuretics with a demonstrated survival benefit in patients with heart failure is aldosterone antagonists like spironolactone and eplerenone Use of spironolactone was associated with a 30% reduction in overall mortality at twenty-four months in patients with NYHA class Ill to IV heart failure who were receiving an ACE inhibitor and loop diuretic (RALES trial) Educational objective: ACE inhibitors, ARBs, beta-blockers, and spironolactone all confer a survival benefit in CHF. W hile digoxin and furosem ide (loop diuretics) can reduce CHF symptoms and hospitalizations, they do not improve survival. Time Spent 2 seconds
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A 41-year-old woman comes to the office for the evaluation of a lump on her left breast She feels, "generally well," and denies having any medical problems She takes a multivitamin and Tums daily She stopped smoking after getting married 21 years ago She drinks wine only on weekends. Her only surgery was a bilateral tubal ligation last year , after giving birth to her fourth child. Physical examination of the left breast reveals a 4 em lump at the 11 o' clock position and two axillary nodes on the left side. Mammography shows irregular mic ro-calcifications. The result of the FNA is suggestive for infiltrating ductal carcinoma. W hich of the following is the single most important prognostic factor in this patient? 6 A TNM staging e') B. Estrogen and progesterone receptor status
6 C. Her-2/neu oncogene expression e') D. Histological grade of the tumor
6 E. Irregular mic ro calcifications in mammogram
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single most important prognostic facto r in this patient?
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A. TNM staging [72%) B. Estrogen and progesterone receptor status [14%) C. Her-2/neu oncogene expression [8%) D. Histological grade of the tumor [5%) E. Irregular micro calcifications in mammogram (1%)
Explanation: Tumor burden is the single most important prognostic consideration in the treatment of patients with breast cancer . It is based on TNM staging. Patients with stage IV disease have the worst prognosis.
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The following are other important prognostic factors of breast cance r, in the order of decreasing significance
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{Choice B) ER+ and PR+ are good prognostic features.
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{Choice C) Overexpression of the Her-2/neu oncogene is related to a wo rse prognosis (Choice D) The histological grade also tends to reflect the outcome. Poorly diffe rentiated tumors have the worst prognosis (Choice E) There is currently inconclusive data regarding the prognostic significance of mammogram findings Educational Objective: Tumor burden is the single most important prognostic consideration in the treatment of patients with breast cance r. It is based on TNM staging. Time Spent 2 seconds
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A 34-year-old man comes to the emergency department with palpitations for the past 4 hours. He has no associated chest pain, shortness of breath, or dizziness. His medical history is significant for Wolff-Parkinson-White syndrome with 3 prior episodes of supraventricular tachycardia. The patient does not use tobacco or illicit drugs and drinks alcohol only on social occasions. He had 5 cans of beer at a party the previous night On examination, his blood pressure is 120/80 mm Hg and pulse is irregularly irregular ECG shows atrial fib rillation with a rate of 160/min. W hat is the best next step in management of this patient? e')
A Adenosine
e> B. Digoxin e')
C. Lidocaine
e> D. Procainamide e')
E. Ve rapamil
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In Wolff-Pa rkinson-White syndrome (WPW), an accessory pathway conducts depolarization directly from the atria to the ventricles without traversing the atrioventricular (AV) node. Atrial fibrillation (AF) occurs in 10%-30% of individuals with WPW, and is a potentially life-threatening emergency; AF in WPW can bypass the usual rate-limiting function of the AV node, leading to very rapid ventricular response rates. Persistent AF with rapid ventricular response in patients with WPW can ultimately deteriorate into ventricular fibrillation (VF) Acute treatment of AF in patients with WPW is aimed at prompt control of ventricular response and termination of AF as follows: • Hemodynamically unstable patients require immediate electrical cardioversion • For stable patients, rhythm control with anti-arrhythmic drugs such as intravenous ibutilide or procainamide is preferred {Choices A, Band E) AV nodal blocking agents such as adenosine, beta blockers, calc ium channel blockers (especially verapamil), and digoxin should not be used for AF in patients with WPW as they may promote conduction across the accessory pathway and lead to degeneration of AF into VF.
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(Choice C) lidocaine is used for ventricular arrhythmias and is not indicated for AF.
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Educational objective: Patients with Wolff-Parkinson-White syndrome who develop atrial fibrillation with a rapid ventricular rate should be treated with ca rdioversion or antiarrhythmics such as procainamide. Atrioventricular nodal blockers such as beta blockers, calcium channel blockers, digoxin, and adenosine should be avoided as they can cause increased conduction through the accessory pathway
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References: 1. 2014 AHAIACC/HRS guideline for the management of patients with atrial fibrillation : executive summary: a report of the American College of .
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6 A Alteration in heart rate
e; B. Decreased left ventricular ejection fraction
6 C. Decreased left ventricular volume e; D. Increased cardiac preload
6 E. Increased left ventricular compliance e; F. Inc reased systemic afterload
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A 63-year-old man comes to the emergency department with substernal chest pain and diaphoresis The pain started one hour ago and was not relieved with antacids. His medical problems include asthma, for which he uses inhaled fluticasone, and peptic ulcer disease, for which he takes omeprazole Blood pressure is 160/ 100 mm Hg and pulse is 90/min. A bruit is heard over the right carotid artery, and a mild systolic murmur is present at the ca rdiac apex Sublingual nitroglycerin and aspirin are administered and with in minutes the patient reports resolution of pain W hich of the following most likely accounts for the improvement in his symptoms?
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Explanation: Nitrates are excellent antianginal drugs and are used frequently to relieve chest pain in patients with stable angina pectoris and acute co ronary syndrome Nitrates are primarily vasodilators and dilate veins, arterioles, and co ronary arteries by relaxing vascular smooth muscle cells. Although nitrates act as venodilators and coronary vasodilators, their primary anti- ischemic effects are due to systemic vasodilation rather than coronary vasodilation. Systemic venodilation lowers preload and left ventricular end-diastolic volume and reduces myocardial oxygen demand by reducing wall stress. Nitrates also cause arterial and arteriolar vasodilation, although to a lesser degree, and can decrease systemic vascular resistance and blood pressure The fall in systemic blood pressure reduces wall stress, which leads to further decrease in myocardial oxygen demand. (Choice A) Nitrates do not have a direct effect on heart rate. However , a fall in blood pressure with nitrates can induce reflex tachyca rdia with an increase in myocardial oxygen demand and worsening angina. This can best be prevented by concomitant use of beta blockers. (Choice B) Nitrates have no direct effect on ca rdiac chronotropy or inotropy (contractility) and left ventricular ejection fraction. They can indirectly cause reflex tachyca rdia in patients with a significant fall in blood pressure (Choices D and F ) Systemic venodilation caused by nitrates leads to a decrease, not an increase, in preload Systemic arterial dilation also causes a decrease in afterload, which occurs to a much lesser degree than a decrease in preload. In contrast, an increase in preload and/or afterload will cause an increase in wall stress with increased myocardial oxygen demand and worsening angina. (Choice E) Nitrates have no direct effect on left ventricular compliance Educational objective: The primary anti-ischemic and antianginal effects of nitrates are due to systemic vasodilation rather than co ronary vasodilation. Systemic venodilation lowers preload and left ventricular end-diastolic volume, reducing wall stress and myocardial oxygen demand.
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This item has associated media that may require the use of headphones. Please ensure your system/speaker volume is set to an audible leveL A 62-year-old Caucasian female is being evaluated after she had an episode of syncope She complains of having progressive exertional dyspnea over the last two months with an occasional dry cough. Cardiac auscultation findings over the apex are given below. W hich of the following best explains the physical findings in this patient? Play Media
e')
A Ascending aortic aneurysm
e>
B. Constrictive perica rditis
e') C. Mitral regurgitation
e>
D. Tricuspid valve stenosis
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D. Tricuspid valve stenosis [3%] Explanation: The combination of this patient's exertional dyspnea, dry cough, and holosystolic murmur on auscultation are most suggestive of mitral regurgitation (MR) Although the clinical manifestations of MR vary significantly with the degree of regurgitation, exertional dyspnea and fatigue are the most common symptoms, which occur secondary to a combination of decreased cardiac output and inc reased left atrial pressure This patient's dry cough may relate to pulmonary congestion and edema, which is an indicato r of more severe disease that has resulted in left ventricular dysfunction The murmur of MR is classically a holosystolic murmur heard best over the apex with radiation to the axilla. Mitral regurgitation can occur as a result of primary mitral valve disease (e g. rheumatic heart disease, infective endocarditis, or trauma) or may be associated with other ca rdiac conditions (e g ischemic heart disease or hypertrophic cardiomyopathy) (Choice A) An ascending aortic aneurysm can be associated with aortic regurgitation, which would result in a diastolic murmur.
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(Choice B) Although patients with constrictive perica rditis often present with exertional dyspnea, physical findings such as elevated jugular venous pressure, pulsatile hepatomegaly , and signs of fluid overload are often present as well. (Choice D) Tricuspid stenosis would cause a diastolic murmur, not systolic disease is the most common cause of tricuspid stenosis.
Rheumatic heart
Educational objective: Mitral regurgitation classically results in a holosystolic murmur heard best at the apex with radiation to the axilla. Common clinical features of MR include exertional dyspnea, fatigue, atrial fibrillation, and signs of heart failure. Time Spent 2 seconds
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A 33-year-old woman comes to the office with intermittent dizziness. The patient describes a sensation of severe spinning accompanied by intense nausea that lasts 1-2 hours. She feels unsteady during these episodes and has to lie down with her eyes closed for relief. The patient has had several similar episodes during the past 2 years and has not noted any particular factors that precipitate the symptoms She also reports hearing a "mechanical humming" sound in her right ear during these episodes, causing distortion of speech The patient has no associated headaches, ear pain, or ear discharge Her temperature is 36.6 C (98 F), blood pressure is 130/84 mm Hg, and pulse is 86/min. On examination, air conduction is greater than bone conduction in both ears. W hen the base of a tuning fo rk is placed against her forehead, the sound is heard more prominently in the left ear. W hich of the following is the most likely cause of this patient's condition?
<0 A Benign tumor compressing a cranial nerve
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<0 B. Central nervous system demyelination
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e; D. Inflammation of the membranous labyrinth
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<0 E. Loose calcium debris in the semicircular canal
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<0 C. Elevated endolymphatic pressure
<0 F. Reduced mobility of the ossicles
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Common causes of vertigo
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• Recurrent episodes
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Meniere disease
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• Unilateral hearing loss & t innitus • Feeling of fullness in the ear
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• Brief episodes triggered by head movement
BPPV
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• Dix-Hallpike maneuver causes nystagmus
Vestibular neurit is
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• Acute, single episode that can last days • Often follows viral syndrome • Abnormal head thrust test
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Migraine
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• Vertigo associated with headache or other migrainous phenomenon (eg, visual aura) • Symptoms resolve completely between episodes
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Brainstem/ cerebellar stroke
• Sudden-onset, persistent vertigo • Usually other neurologic symptoms
BPPV = benign paroxysmal positional vertigo. © UWorld
This patient has Meniere disease, a disorder of the inner ear characterized by increased volume
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This patient has Meniere disease, a disorder of the inner ear characterized by increased volume and pressure of endolymph (endolymphatic hydrops), likely due to defective resorption of endolymph The resulting distension of the endolymphatic system causes damage to the vestibular and cochlear components of the inner ear. Meniere disease is characterized by the following triad • Low-frequency tinnitus in the affected ear, often accompanied by a feel ing of fullness • Episodic vertigo, commonly associated with lightheadedness, nausea, and vomiting • Sensorineural hearing loss, va riable in severity but usually worsening over time The diagnosis of Meniere disease is based primarily on clinical findings, although audiometry is helpful to fully characterize hearing loss and follow its course over time. Initial management includes restriction of sodium, caffeine, nicotine, and alcohol. Benzodiazepines, antihistamines, and antiemetics can relieve acute symptoms Diuretics can be considered for long-term management. {Choice A) Vestibular schwannoma can cause unilateral sensorineural hearing loss, sometimes with imbalance and tinnitus. However, symptoms are usually persistent and progressive rather than episodic , and true ve rtigo is not typical. {Choice B) Multiple sclerosis can cause episodic vertigo and sensorineural hearing loss. However, most patients have manifestations in multiple systems (eg, paresthesias, weakness, visual disturbances, urinary incontinence) (Choice D) Like Meniere disease, labyrinthitis (vestibular neuritis) can cause vertigo, hearing loss, and tinnitus. However , symptoms are typically acute and resolve within several weeks. (Choice E) Benign paroxysmal positional vertigo causes brief, often intense episodes of vertigo triggered by changes in head position Patients can have headaches or a feeling of ear fullness, but tinnitus and hearing loss are not typical. {Choice F) Otosclerosis is characterized by progressive conductive rather than sensorineural hearing loss. Some patients may experience tinnitus, but vertigo is not reported
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• Low-frequency tinnitus in the affected ear , often accompanied by a feeling of fullness • Episodic vertigo, commonly associated with lightheadedness, nausea, and vomiting • Sensorineural hearing loss, va riable in severity but usually worsening over time The diagnosis of Meniere disease is based primarily on clinical findings, although audiometry is helpful to fully characterize hearing loss and follow its course over time. Initial management includes restriction of sodium, caffeine, nicotine, and alcohoL Benzodiazepines, antihistamines, and antiemetics can relieve acute symptoms Diuretics can be considered for long-term management (Choice A) Vestibular schwannoma can cause unilateral sensorineural hearing loss, sometimes with imbalance and tinnitus. However , symptoms are usually persistent and progressive rather than episodic, and true ve rtigo is not typicaL (Choice B) Multiple sclerosis can cause episodic ve rtigo and sensorineural hearing loss. However, most patients have manifestations in multiple systems (eg, paresthesias, weakness, visual disturbances, urinary incontinence). (Choice D) Like Meniere disease, labyrinthitis (vestibular neuritis) can cause vertigo, hearing loss, and tinnitus. However , symptoms are typically acute and resolve within several weeks.
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(Choice E) Benign paroxysmal positional vertigo causes brief, often intense episodes of ve rtigo triggered by changes in head position. Patients can have headaches or a feel ing of ear fullness, but tinnitus and hearing loss are not typicaL {Choice F) Otosclerosis is characterized by progressive conductive rather than sensorineural hearing loss. Some patients may experience tinnitus, but vertigo is not reported Educational objective: Meniere disease is a disorder of the inner ear characterized by increased volume and pressure of endolymph (endolymphatic hydrops) Clinical features include tinnitus, episodic vertigo, and sensorineural hearing loss. Time Spent 3 seconds
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<0 A Breast cyst <0 B. Costochondritis <0 C. Fat necrosis <0 D. Fibroadenoma <0 E. Fibrocystic changes <0 F. Intraductal papilloma
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<0 G. Lipoma
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6 H. Medication side effect <0 I. Phyllodes tumor Submit
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A 25-year-old woman comes to the office for evaluation of "chest pain" that began 2 days ago. The pain is described as a constant "soreness," and the patient is unable to sleep prone due to the pain. She is an avid runner and has been unable to run due to discomfort wearing her sports undergarments The patient is sexually active with her husband and recently stopped taking her oral contraceptives because they are trying to have a child. Her last menstrual period was 3 weeks ago; menses are regular and occur approximately every 28 days and last for 6 days The patient takes a daily folic acid supplement and no other medications. Her maternal aunt died of breast cancer at age 52. On examination, palpation reveals bilateral, nonfocal chest tenderness and diffuse, cordi ike thickening of the breasts. W hich of the following is the most likely diagnosis?
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Explanation:
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Benign breast disease Diagnosis
Clinical features
Breast cyst
• Solitary, well-circumscribed, mobile mass • +/-Tenderness
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Fibrocystic changes
• Multiple, diffuse nodulocystic masses • Cyclic premenstrual tenderness
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Fibroadenoma
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• Solitary, well-circumscribed, mobile mass • Cyclic premenstrual tendemess
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Fat necrosis
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• Post-trauma/surgery • Firm, irregular mass • +/- Ecchymosis, skin/nipple retraction
@UWOI!d
This patient's diffusely nodular (eg, cordlike thickening) breasts and bilateral, nonfocal premenstrual tenderness are consistent with fibrocystic changes of the breast Fibrocystic breast changes are benign and common in women of reproductive age The changes may develop from fl uctuations in estrogen and progesterone during the menstrual cycle Symptoms typically improve during or after menstruation . Patients can be offered nonsteroidal anti-inflammatory drugs and/or oral contraceptives (OCs) for symptomatic relief.
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(Choice B) Costochondritis can cause parasternal pain/discomfort due to rib ca rtilage inflammation. The pain is typically sharp and/or pressure-like and worsens with coughing or deep inhalation. Focal tenderness to chest wall palpation is usually diagnostic (Choice C) Fat necrosis of the breast is an uncommon complication of trauma that presents as a firm, irregular mass. Some patients may also have ecchymosis or skin/nipple retraction. None of these findings are present in this patient {Choice D) A fibroadenoma is classically a single, unilateral, and mobile round breast mass. This lesion is common in young women and can also vary in size and tenderness with the menstrual cycle {Choice F) An intraductal papilloma typically presents with bloody or serosanguinous discharge This patient has no nipple discharge (Choice G) A breast lipoma is usually asymptomatic but may present as a soft, mobile, painless lump. (Choice H) Breast tenderness is a potential side effect of OC use that typically subsides after several months of treatment This patient's symptoms likely became prominent after cessation of her OCs.
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(Choice I) Phyllodes tumor is a rare breast mass that presents as a unilateral, smooth, painless, and mobile fi rm breast lump of variable size. It is highly unlikely in a young patient with bilateral premenstrual breast tenderness.
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Educational objective: Fibrocystic breast changes are a common cause of cyclic breast pain in women of reproductive age Classic clinical findings are diffusely nodular breasts with nonfocal tenderness and no nipple discharge or lymphadenopathy . References: 1. From the archives of the AFIP: br east masses in children and adolescents: d' I • • th I • I f
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A 29-year-old woman comes to the office in the fall for a health maintenance examination. She has been feel ing well and her medical history is unremarkable. She received her last vaccinations at age 17. Her last Pap smear , performed at age 25, showed no abnormalities. The patient works as an administrative assistant and does not use alcohol, tobacco, or illicit drugs She started a new sexual relationship 3 months ago There is no family history of cance r. W hich of the following screening tests and vaccinations are recommended for this patient? Abbreviations: HPV - Human papillomavirus Tdap -Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis Td - Tetanus and diphtheria toxoids
0 A HPV vaccine, infl uenza vaccine, and Pap smear
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0 B. HPV vaccine, influenza vaccine, Pap smear, and Tdap!Td vaccine
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0 D. Infl uenza vaccine, Pap smear, and Tdap!Td vaccine
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0 E. Pap smear and Tdap!Td vaccine
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0 C. HPV vaccine, Pap smear, and Tdap!Td vaccine
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D. Influenza vacc ine, Pap smear, and Tdap!Td vacc ine [77%) E. Pap smear and Tdap!Td vacc.i ne [3%)
Explanation:
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The United States Advisory Committee on Immunization Practices recommends a single dose of Tdap vaccine at age 11-18 (preferably age 11-12) . Tdap is also recommended for those age <::19 who did not receive it earlier. Subsequent vaccination with Td should be continued every 10 years thereafter to maintain immunity . A dose of Tdap is also recommended during each pregnancy regardless of the number of years since a woman's prior Td or Tdap vaccination. Current guidelines recommend ce rvical cance r screening with cytology (Pap smear) every 3 years starting at age 21 in women age 21-29. For women age 30-65, screening is recommended with either continued Pap smears every 3 years or with a combination of Pap smear and human papillomavirus (HPV) testing every 5 years In immunocompromised patients, Pap screening is recommended annually beginning at age 21 , and patients with HIV should also be screened twice in the fi rst year after HIV diagnosis and annually thereafter. {Choices A, 8, and C) HPV vaccination is recommended for both male and female patients at age 11-12 and may be considered as early as age 9. For patients who did not receive the initial vaccine series, it is recommended through age 26 for women and through age 21 for men. It is not currently recommended for older patients. {Choice E) Influenza vaccination is recommended annually fo r all patients age >6 months and should be given as soon as it is available in the fall. Educational objective: Women should be screened for cervical cancer with a Pap smear every 3 years at age 21-65 (or with Pap smear and HPV testing every 5 years at age 30-65) A single dose of Tdap (tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis) is recommended beginning at age 11 , with Td (tetanus and diphtheria toxoids) every 10 years thereafter. References:
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Test results Positive Negative Total
e> A 130/ 180 0 B. 130/ 190
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0 D. 760/810 (:) E. 60/ 190
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True Tuberculosis infection state No Total Yes 130 60 190 50 760 810 180 820 1000
Which of the following is the positive predictive value of the screening test under study?
0 C. 50/810
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A study is undertaken to evaluate a new serological screening test for the diagnosis of tuberculosis infection. In the study, 1000 people were randomly selected from the population and given the new diagnostic test. and positive and negative resu~s were recorded . Each study participant also was given the gold standard diagnostic procedure to determine the true infection state of the individual. The findings are as follows:
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Explanation: Although predictive values are not true indices of the validity of a test, these are still of prime importance to physicians In clinical practice, patients will more often present with a positive or negative test result, rather than a disease or disease-free state; therefore, one should have sufficient knowledge about the predictive values of a test Positive predictive value is defined as the proportion of subjects with a positive test, and actually have the disease. Negative predictive value is defined as the proportion of subjects with a negative test, and are free of disease. Consider the following 2 x 2 table Test results Positive Negative Total
Disease Present Absent B ~ ~rue positive (TP) False positive (FP) c D False Negative (FN) True Negative (TN) B+D ~+C
Total A+B C+D
I I I I
A+B+C+D
Positive predictive value = TP!TP+FP (NA+B) Negative predictive value = TN!TN+FN (0 /C+D) In this case, the PPV is 130 I 190. (Choice A) Sensitivity and specificity are useful for assessing the validity of a test the sensitivity of the test
130/180 is
(Choice D) 760/810 is the negative predictive value of the test Educational objective: Know how to calculate the predictive values of a test Time Spent 3 seconds
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A 62-year-old man visits his fam ily physician because of generalized aches and pains. He denies associated feve rs, headaches, chest pain, or abdominal discomfort. His past medical history is significant for an inferior wall myocardial infa rction 6 yea rs ago. His other medical problems include hypertension, diabetes, hypercholesterolemia, and gout His current medications are aspirin, losartan, naproxen, atenolol, glipizide, colchicine, and simvastatin. On physical exam today, he is afebrile, with blood pressure 130/90 mm Hg, pulse 80/min and respirations 18/min. Lab results are as follows:
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Sodium
140 mEq/L
Potassium
4.2 mEq/L
Bicarbonate
21 mEq/L
Chloride
100 mEq/1
BUN
30 mg/dL
Creatinine
1.6 mg/dL
AST
113 1U/L
A LT
120 lUlL
Creatine phosphokinase
14,998 mg/dL
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W hat is the most appropriate next step in the management of this patient?
6 A Stop losartan
6 B. Stop simvastatin e; C. Start N-acetylcysteine 6 D. Order hepatitis panel 6 E Obt . I' b. I
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D. Order hepatitis panel [3%)
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B. Stop simvastatin [91%) C . Start N-acetylcysteine [2%)
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A. Stop losartan [2%)
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W hat is the most appropriate next step in the management of this patient?
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E. Obtain live r biopsy [1%) Explanation: This patient's highly elevated creatine phosphokinase (CPK) points towa rds muscle injury, a possible side effect of statins. The muscle injury can progress to rhabdomyolysis with renal failure, so statin medications should be stopped in patients who develop highly elevated CPKs. This patient's BUN and creatinine are also elevated; comparison to prior labs would be helpful in determining if this renal compromise is acute or chronic . This patient also has slightly elevated transaminases, another potential side effect of statin therapy {Choice A) Losartan is an angiotensin receptor blocker (ARB) , and as such its common side effects are hyperkalemia, hypotension, and renal failure. (Choice C) N-acetylcysteine has three primary uses: dissolution of mucus, protection against contrast induced renal failure, and therapy fo r acetaminophen overdose. {Choice 0 & E ) The mild elevation of this patient's transaminases is likely the result of his statin therapy To confirm that this is the case , live r function tests can be repeated after the statin is stopped to ensure that the AST and A LTare trending down. Educational objective: CPK levels should be checked in any patient on a statin who presents with myalgias elevated, the first step is to discontinue the statin. Time Spent 4 seconds
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A Have you considered whether you want to know the test results, regardless of the outcome?
® B. I'm sorry to have bad news about your test results; it seems that cance r has metastasized to your back. 6
C. It looks like you have cancer in your back, and we should be able to do something about it with radiation and chemotherapy.
e
D. The test results are not good Do you want to know them?
6 E. W hat do you think is going on with your back?
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A 57-year-old woman comes to the physician for a follow-up visit regarding her lower back pain She originally presented last month with significant continuous lower back pain that was worse at night and would awaken her from sleep. She tried over-the-counter ibuprofen, with no relief of her symptoms. W hen her pain persisted, the patient was scheduled for magnetic resonance imaging of her back. The report returned today and shows findings consistent with metastatic lesions in her spine The source of the primary neoplasm remains undetermined. The patient has not yet been told about the findings and is waiting in a private room. W hich of the following is the most appropriate next step in initiating a conversation about her condition?
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"SPIKES" step-by-step mnemonic for family meetings • Arrange for privacy
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• Include all appropriate participants Set up situation
• Provide facial tissue • Sit down and maintain eye contact • Introductions of family and team members • Eliminate or minimize interruptions
Assess family's Perception
• Use open-ended questions to assess the family's perception of the medical situation
Obtain family's Invitation
• Ask family how much information they would like to know
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Give Knowledge and information
• Warn the family that bad news is coming • Speak in simple and straightforward terms • Stop and check for understanding
Use Empathic statements
• Use empathic statements when responding to emotions
Strategy and summary
• Summarize and create follow through plan, including end-of-life discussions if applicable
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Breaking bad news is one of the most difficult situations a physician will encounter. A sensitive yet honest approach must be used to make the patient feel more comfortable. One such approach is the SPIKES method (Table) , which involves a series of 6 sequential steps In the first step, setting the stage, it is helpful to ask if the patient would like the company of fam ily or friends before the discussion begins If the patient does not know the physician, it is also appropriate to explain the physician's role in subsequent ca re. The next step is to assess the patient's perception of what has happened and get an idea of his/her vocabulary and comprehension of medical facts. It would be appropriate to ask th is patient about her back to determine how she perceives her condition. The physician should then invite the patient to receive additional information and determine if he/she wishes to know the results. If the patient declines to hear the results, this request should be honored. Choice A would be considered an invitation for the patient and would be appropriate after the question in Choice E. Once the diagnosis has been stated, the patient's feelings should be explored and support should be provided. It is also important to let the patient ask questions but not overload him/her with too much information. Finally, it is imperative to clearly outline the treatment plan and prognosis This information may need to be repeated later, after the reality of the situation has been absorbed. {Choice B ) Immediately stating the diagnosis is not an appropriate way to begin the discussion with the patient because he/she will have difficulty adapting to the news. Also, it is better to use simpler vocabulary rather than medical words such as "metastasized." {Choice C) It is too early to state that this patient has cance r in her back and then jump straight to treatment options The physic ian should pause after delivering the diagnosis and see how the patient reacts as there is usually some degree of shock and/or denial. (Choice D) It is important to make the patient feel at ease before stating the diagnosis
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The physician should then invite the patient to receive additional information and determine if he/ she wishes to know the results. If the patient declines to hear the results, this request should be honored. Choice A would be considered an invitation for the patient and would be appropriate after the question in Choice E. Once the diagnosis has been stated, the patient's feelings should be explored and support should be provided It is also important to let the patient ask questions but not overload him/her with too much information. Finally, it is imperative to clearly outline the treatment plan and prognosis Th is info rmation may need to be repeated later, after the reality of the situation has been absorbed. (Choice B) Immediately stating the diagnosis is not an appropriate way to begin the discussion with the patient because he/ she w ill have difficulty adapting to the news. Also, it is better to use simpler vocabulary rather than medical words such as "metastasized." (Choice C) It is too early to state that this patient has cancer in her back and then jump straight to treatment options The physician should pause after delivering the diagnosis and see how the patient reacts as there is usually some degree of shock and/or deniaL (Choice D) It is important to make the patient feel at ease before stating the diagnosis Beginning the discussion with "The test results are not good" is not appropriate.
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Educational objective: W hen breaking bad news, a physician should first set the stage and assess the patient's comp rehension before delive ring the news in an empathetic yet comp rehensible manner. References: 1. Communicate with cancer patients: 1. Handling bad news and difficult questions 2. Breaking bad news education for emergency medicine residents : A novel training module u sing simulation with the SPIKES protocol
Time Spent 3 seconds
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(:) A. Cor pulmonale e') B. Pneumoconiosis
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C. Psittacosis
e') D.
e>
Trypanosoma cruzi infection
E. Tuberculosis
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A 45-year-old man who recently immigrated to the United States from China comes to the physician because of dyspnea, fatigue, and abdominal distention for the past 2 months. He has no other medical problems and takes no medication. The patient has worked as a farmer his entire life. His temperature is 36.r C (98° F), blood pressure is 110/60 mm Hg, pulse is 80/min, and respirations are 16/min. Examination shows pedal edema, increased abdominal girth with free fl uid, and elevated jugular venous pressure without inspiratory decline. Chest auscultation reveals decreased heart sounds and an accentuated sound directly after the second heart sound in early diastole. Chest x-ray demonstrates a ring of calcification around the heart, and jugular venous pressure tracings show prominent x and y descents. W hich of the following is the most likely cause of this patient's symptoms?
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Etiology
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Clinical presentation
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Diagnostic findings
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• Idiopathic or viral pericarditis • Cardiac surgery or radiation therapy • Tuberculous pericarditis (in endemic areas) • Fatigue & dyspnea on exertion • Peripheral edema & ascites • t Jugular venous pressure • Pericardia! knock may be heard • Pulsus paradoxus • Kussmau l's sign
• Imaging shows pericardia! thickening & calcification
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• Jugular venous pulse tracing shows prominent x & y descents
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• ECG may be nonspecific or show atrial fibrillation or low-voltage QRS complex
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Features of constrictive pericarditis
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The most likely diagnosis in this patient is constrictive pericarditis, a condition marked by pericardia! fibrosis and obliteration of the pericardia! space Constrictive pericarditis impairs ventricular filling during diastole, causing patients to experience symptoms related to decreased cardiac output (fatigue and dyspnea on exertion) and signs of venous overload (elevated JVP, ascites, and pedal edema). Kussmaul's sign, defined as lack of the typical inspiratory decline in central venous pressure, and the presence of a pericardia! knock (early heart sound after S2) may also be seen. Sharp x and y descents are characteristically seen on central venous tracing. Pericardia! calcifications can sometimes be seen on chest x-ray and, when present, I
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may also be seen. Sharp x andy descents are characteristically seen on central venous tracing. Per icardia! calcifications can sometimes be seen on chest x-ray and, when present, help confi rm the diagnosis In developing countries and endemic areas (eg, Africa, India & China), tuberculosis is a common cause of constrictive perica rditis In the United States, the most common causes include idiopathic or viral pericarditis (>40%), radiation therapy (-30%), cardiac surgery (-10%), and connective tissue disorders. (Choice A) Chronic obstructive pulmonary disease and pulmonary emboli are the most common causes of co r pulmonale, which develops due to pulmonary hype rtension Signs of pulmonary hypertension on physical examination include a widely split S2 and increased intensity of the pulmonic component of S2. This patient's perica rdia! calcifications are more suggestive of constrictive pericarditis. (Choice B) The pneumoconioses are occupational lung diseases caused by inhalation of inorganic dust; examples include asbestosis and silicosis. Patients may gradually develop dyspnea on exertion, pulmonary hypertension, and cor pulmonale years after exposure Chest x-ray shows parenchymal nodules (silicosis) and pleural plaques (asbestosis) (Choice C) Psittacosis is a disease transmitted to humans by birds. Patients present with fever , dry cough, and headache. On physical examination, pulmonary findings are most prominent Cardiac involvement is rare. {Choice D) Trypanosoma cruzi is the cause of Chagas disease. It is endemic in South America and may cause megacolon, megaesophagus, and cardiac disease. Chagas disease causes both systolic and diastolic heart fa ilure. It may also cause arrhythmias and mitral/tricuspid regurgitation. This patient's pericardia! calcification and lack of ca rdiomegaly on chest x-ray make this diagnosis unlikely Educational objective: Constrictive perica rditis is caused by perica rdia! scarring and thickening that result in diastolic heart dysfunction. Patients present with signs of decreased ca rdiac output and venous overload. Common etiologies in the United States include viruses, cardiac surgery, chest radiation, and
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VORL FTA-ABS Hematocrit WBC Platelets PT APTI
positive negative 33% 7 ,OOO/mm 3 88,000/mm 3 10 sec 46 sec
Urinalysis does not show any blood or protein. W hat is the most appropriate next step in the management of this patient?
6 A Benzathine penicillin
6 B. Benzathine penicillin and azithromycin 6 C. Low molecular weight heparin e; D. Prednisone 6 E. Warfarin Submit
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A 25-year-old G3PO white female in her 6th week of gestation comes to the antenatal clinic . She feels fine except for mild nausea. Her obstetric history is significant for two first trimester miscarriages She is currently taking folic acid and iron supplementation. She does not smoke, but she drinks alcohol on social occasions. She is in a monogamous relationship with her husband. She has never been diagnosed with or treated for any sexually transmitted diseases. Laboratory studies reveal the following
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Explanation: W hile this patient's two prior miscarriages may have been a coincidence, her presentation is concerning for an underly ing disorder contributing to recurrent pregnancy losses. The VORL test is often administered to pregnant patients and has a high sensitivity for syphilis However, the specificity of this test is somewhat low and the diagnosis should be confi rmed with the FTA-ASS test Antiphospholipid antibody syndrome (APS) is a common cause of a false positive VORL in women of this age group APS can promote arterial and venous th romboses and a resultant tendency toward spontaneous abortions. Thrombocytopenia and a prolonged PTT are also common findings in affected patients W hile further testing should probably be performed to confi rm the diagnosis, this patient should be started on low molecular weight heparin (LMWH) to reduce the risk to her current pregnancy (Choice A) Benzathine penicillin is unnecessary as this patient is unlikely to have syphilis since the FTA-ABS is negative Her false positive VORL is likely secondary to APS. (Choice B) This patient does not have a bacterial infection that would benefit from the addition of azithromycin. (Choice D) The role of co rticoste roids in APS is controversial and currently not the standard of care. (Choice E) Vitam in K antagonists such as warfarin are often used in the long-term management of patients with APS. However, warfarin is contraindicated in pregnancy Educational objective: Antiphospholipid antibody syndrome (APS) is associated with a false positive VORL, prolonged PTT, and thrombocytopenia. APS can promote arterial and venous thromboses and a resultant tendency toward spontaneous abortions. Prophylaxis with low dose aspirin and LMWH are recommended to avoid pregnancy loss. I
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A 40-year-old man comes to the physician because of increasing urinary frequency and urgency He has had these symptoms in the past, but they are more troublesome now. He has also had urinary hesitancy and interruption of flow. His temperature is 37° C (98 6° F), blood pressure is 130/75mm Hg, pulse is 76/min, and respirations are 15/min. Physical examination shows no abnormalities except inc reased tone of the anal sphincter and mild periprostatic tenderness. Urinalysis and urine culture shows no abnormalities and expressed prostatic secretions show a leukocyte count of four WBCs/HPF (normal is less than 10 WBCs/HPF) Serum prostate-specific antigen is 2 ng/ml (normal value is less than 4ng/ml). W hich of the following is the most likely diagnosis?
e; A Chronic bacterial prostatitis
e>
B. Inflammatory chronic prostatitis
e; C. Non-inflammatory chronic prostatitis
e>
D. Prostatic cance r
e; E. Acute bacterial prostatitis
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Explanation: Patients with non-inflammatory chronic prostatitis are afebrile and have irritative voiding symptoms Physical examination is unremarkable and urinalysis is normal. Expressed prostatic secretions show a normal number of leukocytes and culture of these secretions is negative for bacteria. There is usually no history of past UTI but voiding abnormalities may be present in the past (Choice A) Patients with chronic bacterial prostatitis are afebrile and have irritative voiding symptoms like urinary frequency, urgency and suprapubic or perineal discomfort Urinalysis is normal. Expressed prostatic secretions show leukocyte count greater than 10 WBCs/HPF and culture of these secretions grows the colonies of causative pathogen Rectal examination may show normal or indurated prostate.
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(Choice B) Patients with inflammatory chronic prostatitis are afebrile and have irritative voiding symptoms like urinary frequency, urgency and suprapubic or perineal discomfort Urinalysis is normaL Expressed prostatic secretions show a leukocyte count greater than 10 WBCs/HPF and culture of these secretions is negative
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(Choice D) Prostatic cancer is highly unlikely with normal PSA levels and with normal digital rectal examination in a young patient (Choice E) Patients with acute bacterial prostatitis are febrile with suprapubic or perineal pain Irritative vo iding symptoms like urinary frequency or urgency may be present Exquisitely tender prostate is noted on rectal examination and urinalysis shows bacteriuria and pyuria. Educational Objective: Patients with non-inflammatory chronic prostatitis are afebrile and have irritative vo iding symptoms. Expressed prostatic secretions show a normal number of leukocytes and culture of these secretions is negative for bacteria. Time Spent 3 seconds
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140 mEq/L
Potassium
3.6 mEq/L
Chloride
101 mEq/L
Bica rbonate
24 mEq/L
20
Blood urea nitrogen
13 mg/dl
21 22 23
Creatinine
0.9 mg/dl
Glucose
98 mg/dl
Calcium
11.7 mg/dl
Albumin
3.7 g/dl
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Laboratory results are as follows Sodium
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A 42-year-old woman is evaluated for depression, mood swings, and poor sleep. She also complains of mild headaches and muscle weakness. She has had 2 emergency department visits for kidney stones over the past year She does not use illicit drugs Her blood pressure is 160/ 105 mm Hg and pulse is 85/min.
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W hich of the following is the most likely cause of this patient's hypertension?
0 A Renal parenchymal disease 0 0 0 0
B. Renal vascular stenosis C. Coarctation of the aorta D. Hypothyroidism E. Parathy roid gland disease
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160/ 105 mm Hg and pulse is 85/min. Laboratory results are as follows Sodium
140 mEq/L
Potassium
3.6 mEq/L
Chloride
101 mEq/L
Bica rbonate
24 mEq/L
Blood urea nitrogen
13 mg/dl
Creatinine
0.9 mg/dl
Glucose
98 mg/dl
20
Calcium
11.7 mg/dl
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Albumin
3.7 g/dl
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W hich of the following is the most likely cause of this patient's hypertension?
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0 A Renal parenchymal disease 0 0 0 0
B. Renal vascular stenosis C. Coarctation of the aorta D. Hypothyroidism E. Parathy roid gland disease
0 F. Cushing's syndrome 0 G. Amphetamine abuse Submit
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Condition
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Renal parenchymal disease
• Elevated serum creatinine • Abnormal urinalysis (proteinuria, red blood cell casts) • Severe hypertension (2180 mm Hg systolic &/or 120 mm Hg diastolic) after age 55
Renovascular disease
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• Possible recurrent flash pulmonary edema or resistant heart failure • Unexplained rise in serum creatinine
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• Abdominal bruit Primary aldosteronism
• Easily provoked hypokalemia • Slight hypernatremia • Hypertension with adrenal incidentaloma
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Pheochromocytoma
• Paroxysmal elevated blood pressure with tachycardia • Pounding headaches, palpitations, diaphoresis • Hypertension with an adrenal incidentaloma
Cushing syndrome
• • • •
Hypothyroidism
Central obesity, facial plethora Proximal muscle weakness, abdominal striae Ecchymosis, amenorrhea/erectile dysfunction Hypertension with adrenal incidentaloma
• Fatigue, dry skin, cold intolerance • Constipation, weight gain, bradycardia
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ry hyperparathyro idis m •
Coarctat io n of the ao rta
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• Neuropsychiatric presentations (confusion, depression, psychosis) • Differential hypertension with brachial-femoral pulse delay
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This patient's presentation (muscle weakness, recurrent nephrolithiasis, neuropsychiatric symptoms, and hypercalcemia) is consistent with primary hyperparathyroidism (PHPT) Excess parathyroid hormone causes hypercalcem ia due to increased renal calc ium reabsorption, gastrointestinal calcium absorption, and bone resorption Patients can present with bone pain, kidney stones, gastrointestinal symptoms, and neuropsychiatric symptoms ("bones, stones, abdominal moans, and psychic groans") The majority (80%) of PHPT cases are due to parathyroid adenoma. PHPT can cause hypertension, arrhythmias, ventricular hypertrophy, and vascular and valVular calcification . However, it is unclear how PHPT causes hypertension. Significant hypertension with PHPT suggests possible multiple endocrine neoplasia syndrome type 2 with pheochromocytoma and requires further evaluation. (Choice A) Renal parenchymal disease can cause secondary hypertension but usually presents with elevated serum creatinine and abnormal urinalysis. This patient's normal serum creatinine makes this unlikely. (Choice B) Renal artery stenosis can present with severe hypertension P-180 mm Hg systolic and/or 120 mm Hg diastolic) after age 55, abdominal bruit on auscultation, recurrent flash pulmonary edema or resistant heart fa ilure, and elevated serum creatinine (especially after starting an angiotensin-converting-enzyme inhibitor or angiotensin receptor blocker) {Choice C) Patients with coarctation of the aorta typically present with headaches, epistaxis, blurred vision, elevated blood pressure in the upper extremities, possible "to-and-fro machinery murmur" from the aorta over the posterior chest, and brachial-femoral pulse delay on examination.
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and/or 120 mm Hg diastolic) after age 55, abdominal bruit on auscultation, recurrent flash pulmonary edema or resistant heart failure, and elevated serum creatinine (especially after starting an angiotensin-converting-enzyme inhibitor or angiotensin receptor blocker) (Choice C) Patients with coarctation of the aorta typically present with headaches, epistaxis, blurred vision, elevated blood pressure in the upper extremities, possible "to-and-fro machinery murmur" from the aorta over the posterior chest, and brachial-femoral pulse delay on examination. {Choice D) Hypothyro idism can cause hypertension but typically also presents with other symptoms, including weight gain, fatigue, bradycardia, and dry skin. It would not explain hypercalcem ia and renal stones. (Choice F) Patients with Cushing's syndrome tend to have other findings such as central obesity, muscle wasting, thin skin, hirsutism, and purple striae. Laboratory findings show hyperglycem ia, leukocytos is, lymphocytopenia, and hypokalemia. {Choice G) Amphetamine abuse usually presents with signs and symptoms of sympathetic stimulation (eg, tachycardia, hypertension, diaphoresis, hyperthermia, confusion). It would not explain hypercalcemia and renal stones. Educational objective: Hyperparathy roidism is an uncommon cause of secondary hypertension and should be suspected in patients with hypertension, hypercalcemia, renal stones, and neuropsychiatric symptoms. Significant hypertension with primary hyperparathyroidism suggests possible multiple endocrine neoplasia syndrome type 2 with pheochromocytoma and requires further evaluation. References: 1. Secondary hypertension: evaluation and treatment. 2. Parathyroidectomy decreases systolic and diastolic blood pressure in hypertensive patients with p rimary hyperparathyroidism.
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e A. Chest x-ray e B. Colonoscopy e C. Electrocardiogram e D. Lipid profile e E. Mammography e F. Pap smear
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A 70-year-old woman comes to the physician for a routine preventive visit She has no specific complaints and feels well. The patient is a retired school teacher, lives alone, and does not smoke. She drinks alcohol occasionally Other than an emergency appendectomy 40 years ago, she has no significant past medical history. The patient takes no medications and has no personal or fam ily history of cancer or heart disease. She had a normal mammogram, Pap smear, and lipid panel at her examination 2 years ago. A colonoscopy 7 years ago showed no lesions. W hich of the following studies is most appropriate at this visit?
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The US Preventive Services Task Force recommends biennial (every 2 yea rs) screening mammography for women age 50-74 yea rs Routine mammography is not necessary beyond age 75, although screening for those age 75-85 may be individualized. Other recommended screening procedures are summarized in the table. (Choice A) Chest radiography is not recommended for lung cancer screening in asymptomatic individuals as it has low sensitivity and specificity fo r detecting early-stage cancers that are amenable to treatment For patients with a significant smoking history, screening with low-dose computed tomography has been advocated, but protocols are not widely standardized. (Choice B) Patients should be offered screening for colon cancer at age 50-75 with either annual fecal occult blood testing or colonoscopy every 10 yea rs More frequent colonoscopy is not recommended as the benefit has not been proven to outweigh the potential risk. {Choice C) Although some experts advise screening high-risk patients fo r asymptomatic co ronary artery disease with resting electrocardiography, there is no evidence to support its routine use in patients at average risk. (Choice D) The Task Force recommends routine cholesterol screening in men at average risk for coronary artery disease beginning at age 35 and in women at increased risk beginning at age 45. The ideal age to discontinue screening is not known, but the yield likely decreases in elderly patients with consistently normal lipid results. A 5-year interval is most commonly recommended, and there is likely little benefit from more frequent testing in patients with normal risk for coronary artery disease and normal lipids in the past {Choice F) The incidence of cervical cancer in the United States peaks before age 50 and declines thereafter. Pap smears can therefore be discontinued at age 65 if the patient has had adequate screening until then with no evidence of malignant or premalignant findings Educational objective: Mammograms should be performed every 2 years starting at age 50 in women at average risk for breast cancer. Routine mammography is not necessary beyond age 75.
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A 50-year-old man comes in for his annual check-up There is a swelling on his left eyelid, which he casually acknowledges by saying that it has appeared "on-and-off for the past 2 years " It initially starts as a painful lesion which regresses with hot comp resses, but then eventually reappears On examination of his left eye, you note a nodular , painless, rubbery lesion on the eyelid without any discharge, redness or other abnormalities. W hat is the best next step in the management of his eye lesion?
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B. Direct steroid injection [5%] C. Incision and curettage [27%] D. Frequent hot compresses [26%]
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E. Histopathological examination [33%]
Explanation: Chalazion initially presents as a painful swelling that progresses to a nodular rubbery lesion. This is a chronic granulomatous condition that develops when a meibomian gland becomes obstructed. Persistent or recurrent chalazion may be due to meibomian gland ca rcinoma (sebaceous ca rcinoma). Additionally, basal cell carcinoma frequently presents as a solitary nodule on the lid margin, and may initially be clinically difficult to distinguish from a chalazions. The patient in this case therefore requires histopathologic examination to rule out malignancy {Choice A) Anti-staphylococcal antibiotics are used to treat a hordeolum (stye) , which is an acute infection of one of the glands of the eyelid These infections are most commonly caused by Staphylococci
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{Choices 8 & C) Direct steroid injection and incision and curettage are used in symptomatic patients who did not respond to other modes of treatment after histopathologic analysis has ruled out malignancy
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(Choice D) Application of frequent hot comp resses is used to treat hordeolum as hot compresses may promote such lesions to drain. Educational objective: Recurrent chalazion requires histopathologic examination because there is a risk fo r an underlying sebaceous (meibomian gland) carcinoma. Additionally, basal cell ca rcinoma is the most common malignancy of the lid margin, and may appear cl inically similar to a chalazion. Time Spent 8 seconds
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<0 A Apical mid and late diastolic murmur <0 B. Early peaking of the systolic murmur
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e; D. Soft second heart sound (S2)
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<0 C. Loud first heart sound (S 1) <0 E. Third heart sound (S3)
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A 60-year-old man comes to the office due to several episodes of lightheadedness over the last 3 months. He experiences these episodes while trying to walk too quickly or climb the stairs. He "almost passed out" during the last episode. The patient describes his lifestyle as active but recently has felt more tired than usual during his daily activities. He has had no chest pain or palpitations. His medical history is significant for diverticulosis, for which he takes fiber supplements The patient is not on any other medication. His temperature is 37.1 C (98 8 F), blood pressure is 110/98 mm Hg, pulse is 88/min and regular , and respirations are 14/min. On examination, he has a 3/6 mid-systolic murmur that is best heard over the right upper sternal border. Carotid pulses are slow-rising and delayed bilaterally The lung fields are clea r to auscultation. There is no peripheral edema. Which of the following additional findings is most likely to be seen on physical examination?
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D. Soft second heart sound (S2) [29%) E. Third heart sound (S3) [16%)
Explanation:
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This patient's cl inical presentation - progressive fatigue and exertional lightheadedness and presyncope, delayed carotid pulses, and midsystolic murmur over the right sternal border - is suggestive of aortic stenosis (AS) Patients with AS are asymptomatic for a prolonged period, and classic symptoms typically occur in those with severe AS (aortic valve area <1 cm2). Some physical examination findings suggestive of sever e AS include 1. Diminished and delayed ca rotid pulse ("pulsus parvus and tardus") due to blood flow obstruction 2. Mid- to late-peaking systolic murmur from turbulence due to the stenosis 3. Presence of soft and single second heart sound (S2) Thickening and calcification of the aortic leaflets leads to reduced mobility and causes a soft S2, as S2 is due mainly to sudden aortic valve closure (A2). In addition, as a result of the reduced mobility, A2 is delayed and occurs simultaneously with pulmonic valve closure (P2), leading to a single S2. {Choice A) A mid to late diastolic murmur at the cardiac apex is typically heard in patients with mild mitral stenosis (MS). As the MS becomes severe, the diastolic murmur starts earlier and is heard soon after the opening snap (Choice B) An early-peaking systolic murmur suggests mild to moderate AS, whereas a late-peaking systolic murmur is more consistent with severe AS. This patient with exertional presyncope and delayed carotid upstroke most likely already has severe AS. {Choice C) A loud fi rst heart sound (S1 ) is typically heard in patients with MS. S1 remains normal in patients with valvular AS. {Choice E) S3 (third heart sound) can be heard in patients with chronic severe mitral .. ... ... ... .. ... .. . . .. .. .. . ... .. .. .. ...
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Thickening and calcification of the aortic leaflets leads to reduced mobility and causes a soft S2, as S2 is due mainly to sudden aortic valve closure (A2). In addition, as a result of the reduced mobility, A2 is delayed and occurs simultaneously with pulmonic valve closure (P2), leading to a single S2. (Choice A) A mid to late diastolic murmur at the ca rdiac apex is typically heard in patients with mild mitral stenosis (MS). As the MS becomes severe, the diastolic murmur starts earlier and is heard soon after the opening snap (Choice B) An early-peaking systolic murmur suggests mild to moderate AS, whereas a late-peaking systolic murmur is more consistent with severe AS. This patient with exertional presyncope and delayed carotid upstroke most likely already has severe AS. (Choice C) A loud first heart sound (S1 ) is typically heard in patients with MS. S1 remains normal in patients with valvular AS. (Choice E) S3 (third heart sound) can be heard in patients with chronic severe mitral regurgitation, chronic aortic regurgitation, heart failure, and occasionally in those with high cardiac output states such as pregnancy or thyrotoxicosis
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Educational objective: Patients with severe aortic stenosis can present with decreased exercise tolerance, exertional dyspnea, angina, and/or syncope Physical examination typically reveals delayed and diminished carotid pulse, a soft second heart sound, and a mid to late systolic murmur with maximal intensity at the second right intercostal space References: 1. Physical examination in valvular aortic stenosis: correlation with stenosis severity and prediction of clinical outcome.
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A 28-year-old kindergarten teacher complains of a gritty sensation and discharge from the right eye for 3 days She also has rhinorrhea, mild sore throat, and low-grade fever of 37.9 C (100 3 F). The symptoms began a week after classes started in the faiL Her past medical history is significant for genital herpes and endometriosis. Eye examination shows mild injection and granular appearance of the tarsal conjunctiva of the right eye with profuse watery discharge Nasal mucosa is normal, and the pharynx has mild erythema without exudates. Which of the following is the most appropriate next step in management of this patient?
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Conjunctivitis treatment • Erythromycin ointment Bacterial conjunctivitis
• Polymyxin-trimethoprim drops • Azithromycin drops • Preferred agent in contact lens wearers: fluoroquinolone drops
Viral conjunctivitis
• Warm or cold compresses
• +/- Antihistamine/decongestant drops
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A llergic conjunctivitis
• Over-the-counter antihistamine/decongestant drops for intermittent symptoms • Mast cell stabilizer/antihistamine drops for frequent episodes
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Explanation:
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©uwond This patient, with conjunctival inflammation and watery discharge in the setting of an upper respiratory illness, has typical features of viral conjunctivitis ("pink eye"). Most cases are caused by adenovirus, and outbreaks are common among small children and caregivers in late summer and early fall. Symptoms typically last several days and are self-limited. Occasional cases can develop a secondary bacterial infection ("bacterial superinfection") with more severe pain and grossly purulent exudate. Purulent bacterial conjunctivitis responds to topical antibiotic therapy (Choice B), but uncomplicated viral conjunctivitis can be managed symptomatically
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caused by adenovirus, and outbreaks are common among small children and caregivers in late summer and early fall. Symptoms typically last several days and are self-limited. Occasional cases can develop a secondary bacterial infection ("bacterial superinfection") with more severe pain and grossly purulent exudate. Purulent bacterial conjunctivitis responds to topical antibiotic therapy (Choice B), but uncomplicated viral conjunctivitis can be managed symptomatically (Choice C) Mast cell stabilizing agents, such as olopatadine and azelastine, are indicated for treatment of allergic conjunctivitis. Although symptoms of allergic and viral conjunctivitis are often similar, allergic conjunctivitis typically occurs episodically with a shorter duration of symptoms. In addition, although many viral conjunctivitis symptoms may be due to release of histamine from mast cells, mast cell stabilizers have not been well studied for this purpose and are generally not needed. {Choice D) Oral antiviral medications, such as acyclovir and valacyclovir, are recommended for treatment of herpes simplex keratitis. This condition causes a painful, red eye with impaired vision, opacification of the cornea, and corneal ulcers. Antiviral agents would not be effective in this patient with typical adenoviral conjunctivitis
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(Choice E) Prednisolone ophthalmic drops are approved for use in ocular inflammato ry and allergic conditions. They are relatively contraindicated in viral conjunctivitis and are not needed as symptoms will resolve spontaneously Educational objective: Viral conjunctivitis is a self-limited condition associated with adenovirus and other viral upper respiratory illnesses. It is common in sporadic outbreaks, especially among children and caregive rs in late summer and early fall. No specific treatment is needed, although some patients may develop a bacterial superinfection which requires topical antibiotics. References: 1. Adenovirus.
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A 24-year-old woman comes to the office due to skin lesions on her trunk and proximal upper limbs. The patient noticed the lesions after returning from a summer vacation at a Florida beach a week ago. During the vacation, she had sun exposure on several occasions without prior application of sunscreen. The lesions are mildly itchy but not painful Medical history is notable fo r hypothyroidism, for which she takes levothyroxine She drinks alcohol on social occasions but does not use tobacco or illicit drugs Examination shows hypop igmented lesions as shown in the image below.
W hich of the following is the most likely cause of this patient's current condition?
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0 A Autoimmune melanocyte injury
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Tinea versicolor (pityriasis versicolor) Pathogenesis
Clinical features
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Ma/assezia g/obosa skin flora grows in exposure to hot & humid weather • Hypopigmented, hyperpigmented, or mildly erythematous lesions (face in children, trunk & upper extremities in adolescents & adults)
• +/- Fine scale • +/- Pruritus
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Diagnosis
KOH preparation shows hyphae & yeast cells in a "spaghetti & meatballs" pattern
Treatment
Topical ketoconazole, terbinafine, or selenium sulfide
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KOH = potassium hydroxide. © UWorld
Tinea versicolor (pityriasis ve rsicolo r) is a superficial fungal skin infection caused by Malassezia species (nondermatophytic , lipid-dependent yeasts; eg, M g/obosa, M furfur) It is characterized by salmon-colored, hyper- or hypopigmented macules that are sometimes covered by fine scales, most commonly on the upper trunk and extremities. Hypopigmented areas are frequently noticed following sun exposure due to tanning of the surrounding skin.
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Malassezia species (nondermatophytic , lipid-dependent yeasts; eg, M g/obosa, M furfur) It is characterized by salmon-colored, hyper- or hypopigmented macules that are sometimes covered by fine scales, most commonly on the upper trunk and extremities. Hypopigmented areas are frequently noticed following sun exposure due to tanning of the surrounding skin. Potassium hydroxide (KOH) preparation of skin scrapings shows large, blunt hyphae and thick-walled budding yeast ("spaghetti and meatballs" appearance) Topical treatment with selenium sulfide or ketoconazole is recommended, but the pigmentation changes ca n take months to resolve following treatment {Choice A) Vitiligo is characterized by complete depigmentation (from melanocyte destruction, possibly due to autoimmune mechanisms), most commonly on the face and hands. (Choice B) Cutaneous candidiasis presents with an erythematous, ves iculopapular rash in warm, moist areas (eg, skinfolds). It is often associated with recent antibiotic use or immunocompromised states (eg, uncontrolled diabetes) (Choice C) Irritant contact dermatitis is caused by physical or chemical irritation, most commonly due to soaps, solvents, or acid/alkali. It presents with erythema and fissuring, usually on the hands. (Choice D) linea corporis (ringworm) presents as annular lesions with advancing scaly borders and central clearing or as scaly patches over the trunk. Other dermatophyte infections include tinea pedis (athlete's foot), tinea cruris fjock itch), and tinea cap itis (scalp ringworm) Tinea versicolor is the only tinea infection that is not caused by dermatophytes (which require keratin for growth) {Choice E) Psoriasis is characterized by epidermal hyperproliferation and abnormal diffe rentiation, and causes erythematous plaques over extensor surfaces. Guttate psoriasis presents with scattered, scaly, erythematous papules or small plaques, typ ically following an acute streptococcal infection. (Choice G) Ultraviolet injury can lead to acute (eg, sunburn) or chronic (eg, photoaging) dermal injury Sunburn may show patchy involvement due to uneven application of sunscreen, but round
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warm, moist areas (eg, skinfolds) It is often associated with recent antibiotic use or immunocompromised states (eg, uncontrolled diabetes) {Choice C) Irritant contact dermatitis is caused by physical or chemical irritation, most commonly due to soaps, solvents. or acid/alkali. It presents with erythema and fissuring, usually on the hands. (Choice D) Tinea corporis (ringworm) presents as annular lesions with advancing scaly borders and central clearing or as scaly patches over the trunk. Other dermatophyte infections include tinea pedis (athlete's foot), tinea cruris Gock itch), and tinea capitis (scalp ringworm) Tinea versicolor is the only tinea infection that is not caused by dermatophytes (which require keratin for growth) {Choice E) Psoriasis is characterized by epidermal hyperproliferation and abnormal differentiation. and causes erythematous plaques over extensor surfaces. Guttate psoriasis presents with scattered, scaly , erythematous papules or small plaques, typically following an acute streptococcal infection.
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(Choice G) Ultraviolet injury can lead to acute (eg, sunburn) or chronic (eg, photoaging) dermal injury. Sunburn may show patchy involvement due to uneven application of sunscreen. but round hypopigmented maculas would be unusual Educational objective: Tinea versicolor is a superficial nondermatophyte fungal skin infection caused by Ma/assezia species and characterized by salmon-colored, hyper- or hypopigmented maculas. The diagnosis is confirmed with potassium hydroxide preparation of skin scrapings, and treatment is with topical antifungals
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References: 1. Pityriasis versicolor : an update on phar macological treatment options.
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A 52-year-old man comes to the office with an enlarging rash at his left ankle. The rash began 6 weeks ago and is associated with significant itching. The patient has tried topical antihistamines and calam ine lotion without relief. Medical history is notable for hypertension, type 2 diabetes mellitus, and mild chronic obstructive pulmonary disease. Current medications include metformin, lisinopril, atorvastatin, and acetaminophen as needed for intermittent muscular back pain Temperature is 37 C (984 F) , blood pressure is 135/82 mm Hg, pulse is 76/min, and respirations are 12/min. BMI is 25 kg/m2 Examination shows a skin rash at the ankle as in the image below.
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W hich of the following is the most likely diagnosis?
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A. Erythema multiforme
e; B. Pityriasis rose a 6 C. Psoriasis 6 D. Secondary syphilis
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E. Tinea corporis
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Explanation:
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Tinea corporis (ringworm)
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Risk factors
• Athletes who have skin-to-skin contact • Humid environment • Contact with infected animals (eg, rodents)
Presentation
• Scaly, erythematous, pruritic patch with centrifugal spread • Subsequent central clearing with raised annular border
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Treatment
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• First-line/localized: Topical antifungals (eg, clotrimazole, terbinafine) • Second-line/extensive: Oral antifungals (eg, terbinafine, griseofulvin)
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@UWOI1d
This patient has a pruritic rash with a scaly, erythematous border and central clearing consistent with tinea corporis (ringworm). Patches of tinea corporis are typically round or ovoid but may become confl uent to form a "flower petal" shape Skin contact, especially in warm and humid environments, is a common risk factor. Any species of dermatophyte may cause this condition, but Trichophyton rubrum is the most frequent culprit Tinea corporis is often more extensive in patients with immunocompromising conditions (eg, HIV, diabetes mellitus). The diagnosis is confirmed using potassium hydroxide (KOH) preparation of skin scrapings, which can show the characteristic segmented hyphae and arthrospores Mild to moderate cases can be treated with topical antifungal preparations (eg, terbinafine, clotrimazole), but patients who fa il topical therapy or have extensive disease may need systemic therapy In adults, oral '"'I 1 ..
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The diagnosis is confirmed using potassium hydroxide (KOH) preparation of skin scrapings, which can show the characteristic segmented hyphae and arthrospores. Mild to moderate cases can be treated with topical antifungal preparations (eg, terbinafine, clotrimazole), but patients who fa il topical therapy or have extensive disease may need systemic therapy In adults, oral terbinafine, fluconazole, and itraconazole are preferred over griseofulvin due to greater efficacy and fewe r side effects. {Choice A) Erythema multiforme is an inflammatory disorder characterized by erythematous papules and plaques that evolve into target lesions. It is often associated with a recent herpes simplex infection. (Choice B) Pityriasis rosea is characterized by numerous oval, scaly plaques that follow the cleavage lines of the trunk. It often presents with an initial lesion called a herald patch, which is much larger than the later lesions. (Choice C) Psoriasis is characterized by salmon-colored plaques with silvery scales over the extensor surfaces (eg, elbows, knees) and scalp
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(Choice D) Secondary syphilis is characterized by a diffuse maculopapular rash. The lesions often involve the palms and soles and oral mucosa. Educational objective: Tinea co rporis is characterized by ring-shaped scaly patches with central clearing and distinct borders. The diagnosis is confi rmed with potassium hyd roxide preparation of skin scrapings Mild to moderate cases are treated with topical antifungals, whereas more extensive cases may require systemic therapy References: 1. Mycology -an update. part 1: Dermatomycoses: causative agents, epidemiology and pathogenesis.
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A 5-yea r-old Caucasian female is brought to the office with several months history of decreased visual acuity and decreased brightness sensation in the right eye. Slight exophthalmos of the right eye is present on physical examination, and ophthalmoscopy shows pallor of the right optic disk. Several cafe-au-lait spots and intensive axillary freckling are present W hich of the following is the most likely cause of this patient's visual problems?
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following is the most likely cause of this patient's visual problems?
A. Pigment retinitis [6%)
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B. Retinal hamartoma [26%)
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C. Optic gli oma [61 %) D. Pituitary adenoma [2%) E. Optic neuritis [5%)
Explanation: Intensive axillary freckling and cafe-au-lait spots are suggestive of neurofibromatosis, type 1. Optic glioma is a well-known complication of neurofibromatosis, type 1. It occurs in 15% of patients with this disease, mostly in children younger than 6 years of age. A history of slowly progressive unilateral visual loss and dyschromatopsia are characteristic. Exophthalmos is sometimes present on physical examination. The optic disk may be normal, swollen, or atrophic. The other conditions listed are less likely to occur in patients with neurofibromatosis, type 1. (Choice A) Pigment retinitis leads to bilateral vision loss. It is not characteristic for neurofibromatosis. {Choice B) Retinal hamartoma is typical fo r tuberous sclerosis. (Choice D) Pituitary adenoma results in bitemporal hemianopsia (Choice E) Optic neuritis is frequently the early manifestation of multiple sclerosis. Visual loss develops typically faster, and no exophthalmos is present Educational objective: Optic glioma occurs in 15% of patients with neurofibromatosis, type 1. Time Spent 3 seconds
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A 56-year-old man comes to the office due to 3 months of dyspnea that was initially exertional but has progressively worsened to the point that the patient is now breathless even at rest He has not had any chest pain, palpitations, syncope, or ankle swelling The patient has no significant past medical history, and he takes no medications. He has been smoking a pack of c igarettes daily for the last 30 years and has been drinking alcohol heavily for the past 5 years His mother died of breast cance r at age 57. The patient's temperature is 37.1 C (98 8 F) , blood pressure is 113/76 mm Hg, and pulse is 86/min. A third heart sound is heard on cardiac auscultation; there are no murmurs. Chest auscultation indicates bibasilar crackles. His abdomen is soft and with no evidence of ascites. Laboratory results are as follows: Complete blood count Hematocrit
32%
Mean corpuscular volume
101 1-1m'
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Platelets
60,000/mm'
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Leukocytes
6000/mm'
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Liver function studies Alkaline phosphatase
44 U/L
Aspartate aminotransferase
180 U/L
Alanine aminotransferase
66 U/L
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Chest x-ray reveals cardiac silhouette enlargement and signs of pulmonary venous congestion Echocardiography shows a dilated left ventricle with an estimated left ventricular ejection fraction of 25% . Coronary angiography reveals no evidence of obstructive coronary artery disease. W hich of the following measures is most likely to reverse this patient's heart function?
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Hematocrit
32%
Mean corpuscular volume
101 !Jm'
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Platelets
60,000/mm'
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Leukocytes
6000/mm'
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Liver function studies Alkaline phosphatase
44 U/L
Aspa rtate aminotransferase
180 U/L
Alanine aminotransferase
66 U/L
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Chest x-ray reveals ca rdiac silhouette enlargement and signs of pulmonary venous congestion. Echocardiography shows a dilated left ventricle with an estimated left ventricular ejection fraction of 25%. Coronary angiography reveals no evidence of obstructive coronary artery disease. W hich of the following measures is most likely to reverse this patient's heart function?
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0 A Abstinence from alcohol 0 B. Cessation of cigarette smoking 0 0 0 0 0
C. Initiation of ACE inhibito r therapy D. Initiation of digoxin therapy E. Niacin supplementation F. Prednisolone therapy G. Reduction of salt intake
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Explanation: This clinical presentation - dyspnea, third heart sound, bibasilar c rackles, and low ejection fraction on echocardiogram - is consistent with decompensated congestive heart failure due to left ventricular (LV) systolic dysfunction In this patient with no evidence of coronary artery disease on angiography, the most likely etiology is dilated cardiomyopathy due to heavy alcohol consumption (macrocytic anemia [mean co rpuscular volume >1 00 !Jm'], thrombocytopenia, >21 ratio of aspartate aminotransferase to alanine aminotransferase). Alcoholic ca rdiomyopathy is a diagnosis of exclusion in patients with dilated cardiomyopathy and history of alcohol abuse in whom no other potential causes of ca rdiomyopathy (eg, co ronary artery disease, valvular heart disease) are suspected or identified. The degree of LV dysfunction in alcoholic ca rdiomyopathy is directly related to the daily amount and overall duration of alcohol intake. The primary therapy for such patients is complete abstinence from alcohol use; this intervention is associated with improvement or normalization of LV function over time.
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{Choice B) Cigarette smoking is a strong risk factor for coronary heart disease, and smoking cessation should be encouraged in all patients, regardless of the presence or absence of coronary artery disease. However , tobacco cessation does not reverse the progression of alcoholic cardiomyopathy. (Choices C, D, and G) Patients with alcoholic cardiomyopathy should be managed in the same way as patients with other forms of dilated ca rdiomyopathy: salt and water restriction, diuretics as needed, ACE inhibitors or angiotensin II receptor blockers, beta blockers, mineralocorticoid receptor antagonists, and (if indicated) digoxin However, strict abstinence from alcohol use remains the mainstay of therapy to reverse or halt further progression of cardiomyopathy. (Choice E) Niacin deficiency can occur with alcoholism, but supplementation has no role in management of patients with alcoholic cardiomyopathy. (Choice F) Glucocorticoid therapy (prednisolone) is occasionally used for patients with alcoholic hepatitis who have a high discr iminant function, but it has no role in management of alcoholic cardiomyopathy
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in alcoholic cardiomyopathy is directly related to the daily amount and overall duration of alcohol intake. The primary therapy for such patients is complete abstinence from alcohol use; this intervention is associated with improvement or nor malization of LV function over time. {Choice B ) Cigarette smoking is a strong risk factor fo r co ronary heart disease, and smoking cessation should be encouraged in all patients, regardless of the presence or absence of coronary artery disease. However , tobacco cessation does not reverse the progression of alcoholic cardiomyopathy (Choices C, D, and G) Patients with alcoholic cardiomyopathy should be managed in the same way as patients with other forms of dilated ca rdiomyopathy: salt and water restriction, diuretics as needed, ACE inhibitors or angiotensin II receptor blockers, beta blockers, mineralocorticoid receptor antagonists, and (if indicated) digoxin However , strict abstinence from alcohol use remains the mainstay of therapy to reverse or halt further progression of cardiomyopathy (Choice E) Niacin deficiency can occur with alcoholism, but supplementation has no role in management of patients with alcoholic ca rdiomyopathy. (Choice F) Glucocorticoid therapy (prednisolone) is occasionally used for patients with alcoholic hepatitis who have a high discriminant function, but it has no role in management of alcoholic cardiomyopathy
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Educational objective: Complete cessation of alcohol consumption is the mainstay of therapy in patients with alcoholic cardiomyopathy and is associated with improvement or normalization of left ventricular function over time. References: 1. Alcoholic cardiomyopathy: a review. 2. Natural history and prognostic factors in alcoholic cardiomyopathy.
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e; A Episcleritis ® B. Dacryocystitis ® C. Hordeolum ® D. Chalazion ® E. Orbital cellulitis
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A 65-year-old woman presents with complaints of pain and swelling over the inner aspect of her right eye for the past two days Examination of the eye reveals tenderness, edema, and redness over the medial canthus. Slight pressure over the area causes expression of purulent materiaL Visual acuity is normaL W hat is the most likely diagnosis?
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C. Hordeolum [14%) D. Chalazion [14%) E. Orbital cellulitis [6%)
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Explanation: Dacryocystitis is an infection of the lacrimal sac. It usually occurs in infants and adults over the age of 40. Acute dacryocystitis is characterized by the sudden onset of pain and redness in the medial canthal region Sometimes, a purulent discharge is noted from the punctum A few patients present with feve r, prostration, and an elevated leukocyte count Staphylococcus aureus and beta-hemolytic Streptococcus are the usual infecting organisms It usually responds to systemic antibiotic therapy. {Choice A) Episcleritis is an infection of the episcleral tissue between the conjunctiva and sclera. Patients complain of an acute onset of mild to moderate discomfort, photophobia, and watery discharge Examination reveals diffuse or localized bulbar conjunctival injection
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{Choice C) Hordeolum refers to an abscess located over the upper or lower eyelid It is usually caused by Staphylococcus aureus. It appears as a localized red, tender swelling over the eyelid (Choice D) Chalazion presents as lid discomfort. It is a chronic , granulomatous inflammation of the meibomian gland It appears as a hard, painless lid nodule. {Choice E) Orbital cellulitis refers to an infection posterior to the orbital septum It is unilateral and more common in children. It is manifested by an abrupt onset of fever , proptosis, restriction of extraocular movements and swollen, red eyelids Educational Objective: Dacryocystitis presents with inflammatory changes in the medial canthal region of the eye Staphylococcus aureus and beta-hemolytic Streptococcus are the usual infecting organisms Time Spent 2 seconds
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e')
A Cataract
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B. Central retinal vein occlu sion
e') C . Macular degeneration
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e') E. Retinal detachment
D. Open-angle glaucoma
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A 65-year-old man comes to the clinic due to gradual onset of blurred vision over the past 2 months. He also has difficulty driving at night and reading fine print His past medical history is notable for diabetes and hype rtension. The patient's medications include ramipril and metformin. His vital signs are normal. His best corrected vision is 00 (right eye) 20/80 and OS (left eye) 20/ 100, with normal findings on visual field testing Ophthalmoscopic examination with pupillary dilation reveals a loss of transparency of the lens in both eyes. The red fundal reflex is normal, but retinal details are difficult to visualize. W hat is the most likely diagnosis?
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A cataract is a vision-impairing opacification of the lens. Oxidative damage of the lens occurs with aging and leads to cataract formation. Risk factors fo r cataract include advancing age, diabetes, smoking, chronic sunlight exposure, and glucocortico id use. Cataracts are usually bilateral, but patients may become symptomatic in one eye before the other. Patients usually report painless blurred vision, glare, and often halos around lights. Ocular examination in early cataract fo rmation may show a normal red reflex and retinal visualization, but as the cataract progresses, the red reflex is lost and retinal detail may not be visible.
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cataract formation may show a normal red reflex and retinal visualization, but as the cataract progresses, the red reflex is lost and retinal detail may not be visible. Cataracts typically follow a slowly progr essive course, and treatment is indicated when loss of vision impairs activities of daily living Definitive treatment is lens extraction with artificial lens implantation. The risk of perioperative complications in cataract surgery is low, and anticoagulants do not need to be held. (Choice B) Central retinal vein occlusion causes acute or subacute loss of vision. Ophthalmoscopy reveals a swollen disc, venous dilation, retinal hemorrhages, and cotton wool spots (Choice C) Macular degeneration (MD) affects central vision. It occurs in 2 primary fo rms atrophic ("dry"), which causes slowly progressive, bilateral vision loss; and exudative/neovascular ("wet"), which causes unilateral, aggressive vision loss. Examination in dry MD shows drusen and patchy depigmentation in the macular region {Choice D) Open-angle glaucoma is characterized by an insidious onset, with gradual loss of peripheral vision and consequent tunnel vision. Intraocular pressures are high Ophthalmoscopic examination reveals cupping of the optic disc. (Choice E) Retinal detachment usually occurs unilaterally and suddenly Patients often describe "a curtain falling in front of the eye" or obscuring of a part of the visual field. Ophthalmoscopic examination reveals an elevated, detached retina.
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Educational objective: A cataract is a vision-impairing opacification of the lens. Patients usually have painless blurred vision, glare, and often halos around lights Treatment with lens extraction and artificial lens implantation is indicated when loss of vision impairs activities of daily living References: 1. The visually impaired patient.
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(:) A Conjunctivitis 10 B. Corneal ulceration
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C. Uveitis
0 D. Postoperative endophthalmitis 10 E. Cavernous sinus thrombosis
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A 60-year-old woman complains of decreasing vision and a dull ache over her left eye for the past 12 hours. She had a successful surgical cataract extraction in her left eye five days ago. Her blood pressure is 140/90 mmHg, pulse is 92/min, respirations are 14/min, and temperature is 38.1 (1 01 .7°F). Examination of the left eye reveals a swollen eyelid, edematous conjunctiva, and exudates in the anterior chamber. Testing with Snellen's chart demonstrates decreased visual acuity in her left eye W hat is the most likely diagnosis?
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D. Postoperative endophthalmitis [69%) E. Cavernous sinus thrombosis [3%)
Explanation: Postoperative endophthalmitis is the most common form of endophthalmitis It usually occurs within six weeks of surgery It is an infection within the eye, particularly the vitreous. Patients usually present with pain and decreased visual acuity Examination reveals swollen eyelids and conjunctiva, hypopyon, corneal edema and infection. The vitreous can be sent for Gram stain and culture. Based on the severity, intravitreal antibiotic injection or vitrectomy is done. (Choice A) Conjunctivitis presents with excessive tearing, burning sensation, mild pain, conjunctival, and eyelid edema. Vision is not affected. {Choice B) Corneal ulce ration presents as a fo reign body sensation, blurred vision, photophobia, and pain A history of contact lens use, recent trauma, or ocular disease may be present The eye is erythematous, and ciliary injection is present Purulent exudates are seen in the conjunctival sac and on the ulcer surface .
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(Choice C) Uveitis presents as blurred vision with moderate pain, conjunctival injection, and constricted pupils. Hypopyon is seen in severe anterior uveitis. Keratic precipitates ("mutton fat") and iris nodules may be seen. It is associated with HLA 827-related conditions. (Choice E) Cavernous sinus thrombosis is characterized by proptosis, ophthalmoplegia, chemosis, and visual loss. It occurs due to hematogenous spread from an infected , inflamed sinus. Educational Objective: Postoperative endophthalmitis is the most common form of endophthalmitis It usually occurs within six weeks of surgery Patients usually present with pain and decreased visual acuity Examination reveals swollen eyelids and conjunctiva, hypopyon, corneal edema and infection. Time Spent 3 seconds
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A 75-year-old African Ame rican man comes to your office for his annual check up He is a known diabetic and hypertensive. His medications include lisinopril and atenolol. His vital signs are normaL Examination of his fundus reveals cupping of the optic disc. Visual field examination reveals constricted peripheral vision. W hat is the most likely diagnosis?
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Open angle glaucoma is usually asymptomatic in the earlier stages It is more common in African Americans, and has an inc reased prevalence in those with a family history of glaucoma and diabetes. There is a gradual loss of peripheral vision over a period of years, and eventual tunnel vision. On examination, the intraocular pressure is high There may be cupping of the optic disc with loss of peripheral vision. Annual examination in high- risk populations is of great benefit in prevention of the condition. Beta-blockers such as Timolol eye drops are effective in the initial management of the patient Laser trabeculoplasty is used as an adjunctive measure. If there is a continuous increase in intraocular pressure, surgical trabeculectomy is done. (Choice A) Diabetic retinopathy is the leading cause of acquired blindness among US adults. It can be classified into non-proliferative and proliferative retinopathy Non-proliferative retinopathy is characterized by the dilation of veins, microaneurysms, retinal hemorrhages, edema, and hard exudates. Proliferative retinopathy is characterized by neovascularization. Most patients with diabetic retinopathy are asymptomatic until very late in the disease, at which point they may present with poor night vision, a curtain falling with a vitreous bleed, or floaters during the resolution of vitreous bleeds.
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(Choice B) Angle closure glaucoma is characterized by a sudden onset of symptoms such as blurred vision, severe eye pain, nausea, and vomiting Examination reveals a red eye with a hazy cornea and a fixed , dilated pupil
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(Choice C) Macular degeneration affects central vision.
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(Choice E) Cataract is a vision-impairing disease characterized by progressive thickening of the lens. Oxidative damage of the lens occurs with aging and leads to cataract formation. Patients usually complain of blurred vision, problems with nighttime driving, and glare. Definitive treatment is lens extraction. Educational Objective: Open angle glaucoma is more common in African-Americans. It is generally asymptomatic in the initial stages, followed by a gradual loss of peripheral vision over a period of yea rs, and eventual tunnel vision.
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A Aspirin and statin B. Compression stockings C. Elevation of head of bed to 45 degrees D. Frequent skin massage E. High-calorie feeding
® F. Pneumatic compression devices
0 G. Pressure redistribution Submit
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A 24-year-old man with hypoxic-ischemic brain injury is sent to the hospital from a nursing facility fo r evaluation of a skin ulcer. The patient has a history of injection drug use, and 6 months ago he was found unresponsive at home with agonal respirations and pulseless electrical activity He required cardiopulmonary resuscitation. endotracheal intubation, and mechanical ventilation. Since then. the patient's neurocognitive functions have not improved, and he receives mechanical ventilation through a tracheostomy and feeding through a gastrostomy tube. Several days ago, the staff noticed a small ulceration over the patient's right heel, which has not healed. Temperature is 37 C (98.6 F) , blood pressure is 110/70 mm Hg, and pulse is 68/min. He moans to painful stimuli but does not follow any instructions. Corneal and gag reflexes are present Heart sounds are normal. Bilateral breath sounds are equal with no added sounds. The abdomen is soft and nontender. Skin examination shows an area of nonblanchable erythema overlying the sacral region. On the posterior aspect of the right heel, there is a skin ulce r that is 2 em x 1 em with exposed dermis. W hich of the following would have been most effective in preventing this patient's skin lesions?
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significant neurologic injury, and now has a stage II pressure ulcer at the heel and a stage I lesion at the sacrum. Besides reduced mobility, risk factors fo r pressure ulcers include malnutrition, abnormal mental status (eg, dementia), decreased skin perfusion, and reduced sensation.
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Standard interventions to prevent pressure ulcers in high-risk patients include:
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Proper patient positioning Mobilization Careful skin ca re Moisture control Maintenance of nutrition
Patients at risk for pressure ulcers should be cared fo r on beds with features that provide pressure redistribution and reduce focal pressure Effective modifications include air-fluidized beds, pressure-relieving overlays (eg, sheepskin), higher-specification foam mattresses, and active repositioning systems or alternating pressure supports. In addition, patients should be repositioned by the nursing staff at regular intervals (eg, every 2 hours), although there is less evidence to support this intervention. (Choice A) Aspirin and statins are effective in reducing the risk of acute coronary events in patients with symptomatic atherosclerotic arterial disease. They do not prevent pressure ulcers. {Choice B) Compression stockings are useful in the prevention and management of venous insufficiency ulcers, which usually occur in the setting of venous stasis dermatitis. They are not beneficial for prevention of pressure ulcers. (Choice C) Elevation of the head of the bed to >30 degrees can cause the patient to slide in the bed, causing skin friction and increasing the risk for pressure ulcers. {Choice D) Tissue overlying bony prominences is particularly susceptible to pressure ulcer formation. Massaging bony prominences is not recommended as it may further inc rease tension on the overlying skin.
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patients with symptomatic atherosclerotic arterial disease. They do not prevent pressure ulce rs. (Choice B) Compression stockings are useful in the prevention and management of venous insuffic iency ulcers, which usually occur in the setting of venous stasis dermatitis. They are not beneficial for prevention of pressure ulcers.
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(Choice C) Elevation of the head of the bed to >30 degrees can cause the patient to slide in the bed, causing skin friction and increasing the risk for pressure ulce rs.
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(Choice D) Tissue overlying bony prominences is particularly susceptible to pressure ulcer fo rmation. Massaging bony prominences is not recommended as it may further increase tension on the overlying skin.
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(Choice E) Malnutrition is associated with an inc reased risk for pressure ulcers. In patients with otherwise normal nutritional status, however , specialized feedings and nutritional supplements have not been shown to reduce the risk fo r pressure ulce rs. (Choice F) Intermittent pneumatic comp ression devices are used to prevent deep venous thrombosis in patients with contraindications to anticoagulant therapy They do not decrease the risk of pressure ulcers. Educational objective: Risk factors fo r pressure ulcers include decreased mobility, malnutrition, abnormal mental status, decreased skin perfusion, and reduced sensation. Interventions that can prevent pressure ulcers include proper positioning fo r pressure redistribution, mobilization, ca reful skin care, moisture control, and maintenance of nutrition. References: 1. Support surfaces for pressur e ulcer prevention. 2. Repositioning for pressure ulcer prevention in adults.
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A 62-year-old female is brought in by EMS due to a severe right-sided headache, nausea and eye pain She was fixing a light bulb, when she suddenly felt pain in her right eye She decided to rest, but the eye pain only got worse. In the next few minutes, she developed loss of vision, photophobia and redness in the same eye. She took medications to relieve the accompanying headache, but the eye pain persisted She denies any trauma. Her past medical history is significant fo r diabetes and hypertension. She appears to be in intense pain with bouts of nausea. Her right eye is red, with conjunctival flushing and visual acuity of 20/200. Her right pupil is mid-dilated and non-reactive to light The same eye feels hard on palpation. The one treatment that should be avoided in this patient is:
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treatment that should be avoided in this patient is:
A Mannitol [4%) B. Acetazolamide [5%]
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C. Pilocarpine [14%) D. Timolol [10%) ..;
E. Atropine [67%)
Explanation: Acute glaucoma is a medical emergency Narcotics are used to control the pain. The increased intraocular pressure is reduced with mannitol, acetazolamide, timolol or pilocarpine Atropine should be avoided since it can dilate the pupil and worsen the glaucoma Sometimes, mydriatic agents such as atropine can precipitate glaucoma {Choice A) The first line of treatment for an acute episode of glaucoma is to administer mannitol intravenously. It is an osmotic diuretic and works immediately (Choice B) Acetazolamide is a ca rbonic anhydrase inhibitor that rapidly reduces further production of aqueous humor , thus decreasing intraocular pressure (Choice C) Pilocarpine rapidly reduces intraocular pressure by opening the canals of Schlemm and allowing for drainage of the aqueous humor. It is applied top ically. (Choice D) Timolol is a beta-blocker that decreases the intraocular pressure by decreasing production of the aqueous humor. It is administered topically Educational objective: Treat acute glaucoma emergently with mannitol, acetazolamide, pilocarpine or timolol. Avo id mydriatic agents such as atropine. Time Spent 2 seconds
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10 A. Choroidal rupture 10 B. Retinal detachment 10 C. Central retinal artery occlusion 10 D. Proliferative diabetic retinopathy 10 E. Exudative macular degeneration
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A 65-year-old female is complaining of seeing a sudden burst of flashing lights and blurred vision in her left eye These symptoms started this morning. She now sees small spots in her field of vision. She felt "like a curtain came down" over her eye She had a successful cata ract extraction in her left eye 4 months ago. Her vital signs are stable. Examination shows a sluggish left pupil Ophthalmoscopy reveals retinal tears and a grayish-appearing retina. W hat is the most probable diagnosis?
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D. Proliferative diabetic retinopathy [ 1%] E. Exudative macular degeneration [2%] Explanation: Retinal detachment refers to the separation of the layers of the retina. It usually occurs in people aged 40-70 years Patients complain of photopsia (flashes of light) and floaters (spots in the visual field.) The most classic description is that of "a curtain coming down over my eyes." Usually , the inc iting event occurs months before retinal detachment Myopia or trauma can cause retinal breaks, through which fluid seeps in and separates the retinal layers In this patient, ocular trauma most likely occurred due to her cataract surgery Ophthalmoscopic examination reveals a grey, elevated retina. Laser therapy and cryotherapy are done to create permanent adhesions between the neurosensory retina, retinal pigment epithelium, and choroid . {Choice A) Choroidal rupture occurs due to blunt ocular trauma. Examination reveals central scotoma, retinal edema, hemorrhagic detachment of the macula, subretinal hemorrhage, and crescent-shaped streak concentric to the optic nerve. The usual complaint is blurred vision following blunt trauma. (Choice C) Central retinal artery occlusion (CRAO) is also characterized by a sudden painless loss of vision in one eye, but its funduscopic findings differ. Ophthalmoscopy of patients with CRAO reveals pallor of the optic disc, cherry red fovea , and boxcar segmentation of blood in the retinal veins. (Choice D) Proliferative diabetic retinopathy in the initial stage is asymptomatic Patients may later complain of decreased visual acuity Neovascularization is the hallmark of proliferative diabetic retinopathy The other findings are vitreous hemorrhage and macular edema. These changes may lead to retinal detachment (Choice E) Exudative macular degeneration typically presents as painless, progressive blurring of central vision, which can be acute or insidious. It occurs bilaterally Testing reveals central scotoma. Ophthalmoscopy reveals growth of abnormal vessels in the retinal space. Sudden visual loss may occur if it is complicated by retinal detachment
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Retinal detachment refers to the separation of the layers of the retina. It usually occurs in people aged 40-70 years Patients complain of photopsia (flashes of light) and floaters (spots in the visual field .) The most classic description is that of "a curtain coming down over my eyes." Usually, the inciting event occurs months before retinal detachment Myopia or trauma can cause retinal breaks, through which fluid seeps in and separates the retinal layers In this patient, ocular trauma most likely occurred due to her cataract surgery Ophthalmoscopic examination reveals a grey, elevated retina. Laser therapy and cryotherapy are done to create permanent adhesions between the neurosensory retina, retinal pigment epithelium, and choroid . (Choice A) Choroidal rupture occurs due to blunt ocular trauma. Examination reveals central scotoma, retinal edema, hemorrhagic detachment of the macula, subretinal hemorrhage, and crescent-shaped streak concentric to the optic nerve. The usual complaint is blurred vision following blunt trauma. (Choice C) Central retinal artery occlusion (CRAO) is also characterized by a sudden painless loss of vision in one eye, but its funduscopic findings diffe r. Ophthalmoscopy of patients with CRAO reveals pallor of the optic disc, cherry red fovea , and boxcar segmentation of blood in the retinal veins.
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(Choice D) Proliferative diabetic retinopathy in the initial stage is asymptomatic Patients may later complain of decreased visual acuity . Neovascularization is the hallmark of proliferative diabetic retinopathy. The other findings are vitreous hemorrhage and macular edema. These changes may lead to retinal detachment (Choice E) Exudative macular degeneration typically presents as painless, progressive blurring of central vision, which can be acute or insidious. It occurs bilaterally Testing reveals central scotoma. Ophthalmoscopy reveals growth of abnormal vessels in the retinal space. Sudden visual loss may occur if it is complicated by retinal detachment Educational Objective: Retinal detachment usually presents with a sudden onset of photopsia and floaters. The most classic description is that of "a curtain coming down over my eyes " Time Spent 2 seconds
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A Central retinal vein occlusion
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e> 0 . Retinal detachment
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A 65-year-old man presents with complaints of decreased vision in both eyes. His visual impairment has been progressively wo rsening over the past five months. He was diagnosed with diabetes ten years ago His current medications are metformin and glyburide His blood pressure is 140/90 mm Hg, pulse is 82/min, respirations are 14/min, and temperature is 98.4° F (36.8° C) Examination shows decreased visual acuity in both eyes Ophthalmoscopy reveals microaneurysms, dot and blot hemorrhages, hard exudates, and macular edema. W hich of the following is the most likely diagnosis?
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Diabetic retinopathy is the leading cause of blindness in the USA It occurs in both insulin dependent and non-insulin dependent diabetes mellitus. There are 3 main categories 1. background or simple retinopathy - consists of microaneurysms, hemorrhages, exudates, and retinal edema, as in this patient 2. pre-prolife rative retinopathy- with cotton wool spots 3. proliferative or malignant retinopathy- consists of newly fo rmed vessels. Patients are usually asymptomatic at first, despite early signs of retinopathy ( e g , microaneurysms). Visual impairment occurs with the development of macular edema. Argon laser photocoagulation is the suggested treatment for the prevention of complications {Choice A) Central retinal vein occlusion is characterized by sudden, unilateral visual impairment that is usually noted upon waking in the morning Diabetics are at inc reased risk for retinal vein occlusion. Ophthalmoscopy reveals disc swelling, venous dilation and tortuosity, retinal hemorrhages and cotton wool spots. (Choice C) Macular degeneration affects central vision. It is characterized by distorted vision and central scotoma. Cigarette smoking increases the risk of macular degeneration Ophthalmoscopy findings vary according to the type (ie , atrophic vs. exudative). The atrophic form is characterized by multiple sores in the macular region, while the exudative form is characterized by new blood vessels that may leak, bleed, and scar the retina.
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(Choice D) Retinal detachment occurs unilaterally It presents as blurred vision that progressively worsens. Ophthalmoscopy reveals the retina hanging in the vitreous. (Choice E) Open angle glaucoma is also seen in diabetics, but is characterized by gradual loss of peripheral vision, resulting in tunnel vision. Ophthalmoscopy shows pathologic cupping of the optic disc. Educational Objective: The 3 main categories of diabetic retinopathy are background or simple (microaneurysms, 1'"'111
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g p py ry and retinal edema, as in th is patient 2. pre-proliferative retinopathy - with cotton wool spots 3. proliferative or malignant retinopathy- consists of newly formed vessels. I
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Patients are usually asymptomatic at first, despite early signs of retinopathy (e.g , microaneurysms) Visual impairment occurs with the development of macular edema. Argon laser photocoagulation is the suggested treatment for the prevention of complications. {Choice A) Central retinal vein occlusion is characterized by sudden, unilateral visual impairment that is usually noted upon waking in the morning Diabetics are at increased risk for retinal vein occlusion. Ophthalmoscopy reveals disc swelling, venous dilation and tortuosity, retinal hemorrhages and cotton wool spots (Choice C) Macular degeneration affects central vision. It is characterized by distorted vision and central scotoma. Cigarette smoking inc reases the risk of macular degeneration Ophthalmoscopy findings vary according to the type (ie., atrophic vs. exudative) The atrophic fo rm is characterized by multiple sores in the macular region, while the exudative form is characterized by new blood vessels that may leak, bleed, and scar the retina.
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(Choice D) Retinal detachment occurs unilaterally It presents as blurred vision that progressively worsens. Ophthalmoscopy reveals the retina hanging in the vitreous. (Choice E) Open angle glaucoma is also seen in diabetics, but is characterized by gradual loss of peripheral vision, resulting in tunnel vision. Ophthalmoscopy shows pathologic cupping of the optic disc. Educational Objective: The 3 main categories of diabetic retinopathy are background or simple (microaneurysms, hemorrhages, exudates, retinal edema), pre-proliferative (cotton wool spots), and proliferative or malignant (neovascularization) Visual impairment occurs with the development of macular edema. Argon laser photocoagulation is performed for the prevention of complications
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e; A Pseudomonas ® B. Cytomegalovirus ® C. Herpes simplex ® D. Candida albicans ® E. Epstein Barr virus
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A 35-year-old HIV-positive male is complaining of deterioration of his vision over the past week. He initially experienced eye pain and mild conjunctivitis, followed by rapid progressive visual loss. Examination of his eyes reveals marked ke ratitis. Funduscopy shows widespread, pale, peripheral retinal lesions and central necrosis of the retina. W hich of the following is the most likely causative organism of this patient's condition?
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Ophthalmologic problems occur in approximately half of patients with advanced HIV infection. Retinitis can occur as a complication of opportunistic infections in A IDS patients Both varicella-zoster (VN) and herpes simplex virus (HSV) can cause severe, devastating intraocular inflammation. Most cases of retinal disease are believed to be a reactivation of a previously acquired infection.
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E. Epstein Barr virus [1%)
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D. Candida albicans [2%)
Explanation:
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In an immunocompromised individual, HSV retinitis may be characterized by rapidly progressing bilateral necrotizing retinitis (referred to as the "acute retinal necrosis syndrome") This patient's clinical presentation is suggestive of acute retinal necrosis most likely due to HSV. The initial symptoms are keratitis and conjunctivitis with eye pain, followed by rapidly progressive visual loss. Funduscopy reveals widespread, pale, peripheral lesions and central necrosis of the retina. HSV infection of the eye is the most common cause of corneal blindness in the United States. (Choice B) CMV retinitis is the most common serious ocular complication of HIV-pos itive patients; however, it is typically painless, and funduscopy shows fl uffy or granular retinal lesions located near the retinal vessels and associated hemorrhages It does not usually cause initial conjunctivitis or keratitis, as in this patient (Choice D) Candida can cause endophthalmitis, especially with disseminated candidiasis infection. Patients with candida fungemia who appear sick should be evaluated by an ophthalmologist for possible endophthalmitis (Choices A and E) Pseudomonas and Epstein-Barr virus are not common causes of retinitis in immunosuppressed patients. Educational Objective: In HIV patients, both HSV and VN can cause severe, acute retinal necrosis associated with
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Ophthalmologic problems occur in approximately half of patients with advanced HIV infection. Retinitis can occur as a complication of opportunistic infections in A IDS patients Both varicella-zoster (VN) and herpes simplex virus (HSV) can cause severe, devastating intraocular inflammation. Most cases of retinal disease are believed to be a reactivation of a previously acquired infection. In an immunocompromised individual, HSV retinitis may be characterized by rapidly progressing bilateral necrotizing retinitis (referred to as the "acute retinal necrosis syndrome") This patient's clinical presentation is suggestive of acute retinal necrosis most likely due to HSV. The initial symptoms are keratitis and conjunctivitis with eye pain, followed by rapidly progressive visual loss. Funduscopy reveals widespread, pale, peripheral lesions and central necrosis of the retina. HSV infection of the eye is the most common cause of corneal blindness in the United States. (Choice B) CMV retinitis is the most common serious ocular complication of HIV-positive patients; however , it is typically painless, and funduscopy shows fluffy or granular retinal lesions located near the retinal vessels and associated hemorrhages It does not usually cause initial conjunctivitis or ke ratitis, as in this patient.
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(Choice D) Candida can cause endophthalmitis, especially with disseminated candidiasis infection. Patients with candida fungemia who appear sick should be evaluated by an ophthalmologist for possible endophthalmitis (Choices A and E) Pseudomonas and Epstein-Barr virus are not common causes of retinitis in immunosuppressed patients. Educational Objective: In HIV patients, both HSV and VN can cause severe, acute retinal necrosis associated with pain, ke ratitis, uveitis, and funduscopic findings of peripheral pale lesions and central retinal necrosis. In contrast, CMV retinitis is painless, not usually associated with keratitis or conjunctivitis, and characterized by funduscopic findings of hemorrhages and fluffy or granular lesions around the retinal vessels. Time Spent 2 seconds
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e; A Orbital cell ulitis ® B. Optic neuritis ® C. Acute anterior uveitis ® D. Open angle glaucoma ® E. Episcleritis
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A 32-year-old woman comes to the office distraught because "the colors look washed out!" She has had this vision impairment since yesterday She also complains of pain on eye movements. Her vital signs are stable, and she is afebrile. Examination reveals decreased visual acuity, sluggish afferent pupillary response to light, and changes in color perception Fundoscopy reveals a swollen disc. W hat is the most likely diagnosis?
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D. Open angle glaucoma [ 11%J E. Episcleritis [3%] Explanation: Optic neuritis typically presents in people aged 20-45 years. Females are more commonly affected. Patients experience rapid impairment of vision in one eye (or rarely both) and pain on eye movement There are marked changes in color perception. Afferent pupillary defect and field loss occur, usually with central scotoma. Optic neuritis is more common in patients with multiple sclerosis; such patients will usually give a history of similar occurrences in the past (Choice A) Orbital cell ulitis refers to infection posterior to the orbital septum These infections are unilateral and more common in children. It presents as an abrupt onset of fever , proptosis, restriction of extraocular movements, and swollen, red eyelids.
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(Choice C) In anterior uve itis, the eye is usually painful and red, with blurring of vision. Typically, the eye has perilimbal injection Examination reveals keratic precipitates. Corneal stromal edema may be present
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(Choice D) Open angle glaucoma is characterized by gradual loss of peripheral vision resulting in tunnel vision. Ophthalmoscopy shows pathologic cupping of the optic disc. (Choice E) Episcleritis is an inflammation of the episcleral tissue between the conjunctiva and sclera. There is an acute onset of mild to moderate discomfort, photophobia, and watery discharge. Examination reveals diffuse or localized bulbar conjunctival injection, and episcleritic nodules may be present Educational Objective: Suspect optic neuritis in a patient with central scotoma, afferent pupillary defect, changes in color perception and decreased visual acuity Remembe r the association between optic neuritis and multiple sclerosis (The USMLE loves this topic!) Time Spent 2 seconds
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0 C. Mitral valve prolapse
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A 62-year-old African American male comes to your office complaining of exertional dyspnea. He denies any shortness of breath at rest, but he can hardly walk half a block without stopping to catch his breath. He has no chest pain, palpitations, or cough Cardiac auscultation findings over the apex are given below. W hich of the following best explains this patient's physical findings?
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B. Long-standing hypertension [60%) C. Mitral valve prolapse [33%) D. Pericardia! effusion [5%)
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Explanation: In addition to the normal S1 and S2, this patient's auscultatory findings demonstrate an additional diastolic sound just prior to S1 known as the fourth heart sound (S4). The presence of the fourth heart sound produces a rhythm that is often referred to as "TEN-nes-see", with S4 co rresponding to the first syllable In adults, the S4 is an indicator of a stiff left ventricle, which occurs in the setting of restrictive cardiomyopathy or left ventricular hypertrophy from prolonged hypertension. Occurring near the end of diastole, S4 corresponds with atrial contraction and is believed to result from the sound of blood striking a stiffened left ventricle.
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This patient's combination of exertional dyspnea and S4 likely indicate the presence of diastolic heart fa ilure, which is most commonly the sequela of left ventricular hypertrophy from prolonged hypertension. (Choice A) An ascending aortic aneurysm is often associated with aortic regurgitation, which would result in a diastolic murmur as opposed to an extra heart sound. (Choice C) Mitral valve prolapse characteristically produces a mid-systolic click and a late systolic murmur heard best over the ca rdiac apex (Choice D) Pericardia! effusions can be associated with acute pericarditis, which typically produces a pericardia! friction rub on cardiac auscultation. Educational objective: The fourth heart sound (S4) is a low frequency sound heard at the end of diastole just before S1 that is commonly associated with left ventricular hypertrophy from prolonged hypertension Time Spent 2 seconds
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A Primary open angle glaucoma
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E. Corneal abrasion
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A 60-year-old woman comes to the emergency department due to a sudden onset of severe pain in her left eye with blurred vision, nausea, and vomiting. The symptoms began a few minutes ago, while she was watching a movie in a nearby theater. Her temperature is 36.8C (984F), blood pressure is 140/90 mm Hg, pulse is 82/min, and respirations are 14/min. Examination reveals decreased visual acuity Her left eye appears red, with a hazy cornea, shallow anterior chamber, and dilated, fixed pupil Her left eye is stony hard to touch. W hat is the most likely diagnosis?
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Explanation: Angle closure glaucoma occurs with closure of a pre-existing narrow anterior chamber angle. It predominantly occurs in people aged 55-70 years. It presents with an acute onset of severe eye pain and blurred vision associated with nausea and vomiting. It usually occurs following pupillary dilation, which may occur in darkened movie theaters, during times of stress, or due to drug intake. Examination reveals a red eye with steamy cornea and moderately dilated pupil that is non reactive to light The anterior chamber is shallow with inflammatory changes. Tonometry reveals inc reased intraocular pressure Intravenous acetazolamide (with subsequent oral administration) may lower the intraocular pressure Permanent cure is offered with laser peripheral iridotomy (Choice A) Open angle glaucoma has an insidious onset, with gradual loss of peripheral vision resulting in tunnel vision. Other characteristic features are persistently increased intraocular pressure and pathologic cupping of the optic disc .
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(Choice B) Conjunctivitis is characterized by very mild pain The cornea is clear. Pupillary size and response to light is normal. Visual acuity is not affected.
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(Choice D) Uveitis presents with moderate pain and blurred vision. Cornea may be hazy The anterior chamber shows flare and cells on slit lamp examination. The pupil is constricted with a poor light response (In acute glaucoma, the pupil is dilated and is nonreactive to light)
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(Choice E) Corneal abrasion presents with severe pain and photophobia There is usually a history of trauma to the eye Slit lamp examination with fl uorescein will reveal the corneal abrasion. Educational objective: Angle closure glaucoma occurs predominantly in people aged 55-70 yea rs It presents with an acute onset of severe eye pain and blurred vision associated with nausea and vom iting Examination reveals a red eye with steamy cornea and moderately dilated pupil that is non reactive to light Time Spent 3 seconds
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A 65-year-old woman comes to the office due to a 3-week history of rash and generalized pruritus. Initially , she attributed the rash to the summer heat and excessive sweating, but it has persisted despite a change to cooler weather. Topical antihistamine creams and calamine lotion have not provided relief. Medical history is notable for hype rtension. hypercholesterolemia, and early Parkinson disease. On physical examination. there are scattered excoriated plaques and small bullae, as shown in the image below.
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A punch biopsy is performed, and immunofluorescence studies of the specimen show linear lgG and C3 deposits at the dermal-epidermal junction W hich of the following is the most appropriate next step in management of this patient?
<0 A Gluten-free diet <0 B. Oral dapsone <0 C. Oral valacyclovir <0 D. Topical clobetasol <0 E. Topical clotrimazole Submit
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Explanation: Bullous pemphigoid is an autoimmune disorder characterized by severe pruritus and tense bullae on an erythematous base. It is most common in patients age >65 and has an increased incidence in those with malignancy or neurological disorders (eg, Parkinson disease, multiple sclerosis) The extent of involvement may range from just a few lesions to hundreds covering a large portion of the body, although mucous membrane involvement occurs only in a minority of patients. A pre-bullous prodrome is common and can present as urticarial or eczematous lesions . Bullous pemphigoid is caused by lgG autoantibodies against the hemidesmosome and basement membrane zone. Antibody binding activates complement and inflammatory mediators, and the resultant inflammation leads to blister formation. The diagnosis is made by skin biopsy; light microscopy shows subepidermal cleavage, and direct immunofluorescence microscopy shows linear lgG and C3 deposits along the basement membrane. First-line treatment for bullous pemphigoid is a high-potency topical glucocorticoid (eg, clobetasol), which is effective even fo r extensive disease. Systemic glucocorticoids are not more effective and are associated with an increased incidence of treatment-related complications, but these can be used when topical agents are not practical {Choices A and B) Dermatitis herpetiformis is characterized by grouped pruritic ves icles on the buttocks and extensor surfaces of the limbs. It represents an autoimmune dermal reaction due to dietary gluten, and biopsy shows microabscesses at the tips of the dermal papillae with deposits of lgA antibodies against epidermal transglutaminase in the dermis. Treatment includes oral dapsone and elimination of dietary gluten (Choice C) Reactivation of varicella zoster virus in the dorsal root ganglia causes erythema and vesicle formation in a dermatomal distribution. Biopsy shows intraepidermal blisters and erosions with multinucleated giant cells. (Choice E) Tinea pedis can occasionally present with a ves iculobullous eruption, usually at the medial/plantar foot Generalized symptoms would not be typical
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y g p ry resultant inflammation leads to blister formation. The diagnosis is made by skin biopsy; light microscopy shows subepidermal cleavage, and direct immunofluorescence microscopy shows linear lgG and C3 deposits along the basement membrane. First-line treatment for bullous pemphigoid is a high-potency topical glucocorticoid (eg, clobetasol) , which is effective even fo r extensive disease. Systemic glucocorticoids are not more effective and are associated with an increased incidence of treatment-related complications, but these can be used when topical agents are not practical I
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{Choices A and B) Dermatitis herpetiformis is characterized by grouped pruritic ves icles on the buttocks and extensor surfaces of the limbs. It represents an autoimmune dermal reaction due to dietary gluten, and biopsy shows microabscesses at the tips of the dermal papillae with deposits of lgA antibodies against epidermal transglutaminase in the dermis. Treatment includes oral dapsone and elimination of dietary gluten (Choice C) Reactivation of varicella zoster virus in the dorsal root ganglia causes erythema and vesicle formation in a dermatomal distribution. Biopsy shows intraepidermal blisters and erosions with multinucleated giant cells. (Choice E) Tinea pedis can occasionally present with a ves iculobullous eruption, usually at the medial/plantar foot Generalized symptoms would not be typical Educational objective: Bullous pemphigoid is an autoimmune disorder characterized by pruritus and tense bullae. A pre-bullous prodrome can present as urtica rial or eczematous lesions. The diagnosis is confi rmed with skin biopsy. First-line treatment is a high-potency topical glucoco rtico id, which is effective fo r even extensive disease. References: 1. A comparison of two regimens of topical corticosteroids in the treatment of patients with bullous pemphigoid: a multicenter randomized study.
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6 A CT scan of the head
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A 62-year-old man comes to the physician due to sudden onset of pain and redness in the left eye He also has photophobia, nausea, and a severe headache that has not responded to ibuprofen There has been no trauma, and he has never had such an episode before. On review of systems, the patient has had "a mild cold" for which he used an over-the-counter oral decongestant Physical examination shows a nonreactive mid-dilated left pupil. The eye appears red with conjunctival flushing W hich of the following is the best next step in evaluating this patient's condition?
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This patient with headache, nausea, eye pain, and a nonreactive mid-dilated pupil, has typical features of acute angle-closure glaucoma (ACG), possibly precipitated by decongestant use. Acute ACG is characterized by an acute rise in intraocular pressure (lOP) due to impaired drainage of aqueous humor into the anterior chamber (which normally occurs through the iridocorneal angle) This increased lOP can damage the optic nerve and lead to permanent vision loss. ACG can occur spontaneously or be triggered by ce rtain medications (decongestants, antiemetics, anticholinergic drugs) in patients with predisposing anatomy. Symptoms include sudden-onset eye pain, headache, nausea, diminished vision, and halos around lights. Patients typically have a nonreactive and mid-dilated pupil; redness and co rneal opacification can also be seen. Urgent ophthalmologic consultation is indicated in patients with suspected ACG. The gold standard for diagnosis is gonioscopy, in which an ophthalmologist uses a specialized prismatic lens with a slit lamp to visualize the iridocorneal angle. Ocular (eg, Schiotz) tonometry measures
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standard for diagnosis is gonioscopy , in which an ophthalmologist uses a specialized prismatic lens with a slit lamp to visualize the iridocorneal angle. Ocular (eg, Schiotz) tonometry measures lOP and can provide additional information if needed or if ophthalmologic consultation is not immediately available. The device is placed against the anesthetized cornea, quantitated pressure is applied, and the resulting indentation is measured. ACG management may include pressure-lowering eye drops and laser or surgical interventions (eg, iridotomy or iridectomy) {Choice A) Urgent non-contrast head CT is indicated fo r suspected intracranial hemorrhage Typical symptoms include sudden-onset severe headache, often accompanied by altered mental status. ACT scan would also be useful to assess for the presence of an intracranial mass in patients with focal neurologic deficits. However, this patient's ocular findings are more consistent with ACG. {Choice B) Duplex studies of the ca rotids are done to evaluate the carotid artery for plaques or stenosis. Emboli released from carotid plaques may cause stroke or transient ischemic attack but are not a common cause of headache. (Choice C) Fluorescein staining of the eye is usually performed to detect corneal abrasions or herpes keratitis. (Choice D) Lumbar puncture is useful to assess fo r subarachnoid hemorrhage or meningitis If subarachnoid hemorrhage is suspected, a head CT scan should be performed first to identify signs of bleeding or increased intracranial pressure Educational objective: Acute angle-closure glaucoma is characterized by sudden-onset eye pain, headache, and nausea. Signs may include conjunctival erythema, co rneal opacification, and a mid-dilated pupil Gonioscopy is the gold standard fo r diagnosis. Ocular tonometry can be helpful if urgent ophthalmological consultation is unavailable. References: 1. Iatrogenic glaucoma secondary to medications.
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6 A Acute angle-closure glaucoma
e; B. Acute anterior uve itis
6 C. Amaurosis fugax e; D. Central retinal vein occlusion
6 E. Optic neuritis Submit
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An 80-year-old man comes to the emergency department due to sudden loss of vision in his left eye that occurred on waking this morning He has no associated pain Past medical history is notable for hypertension Current medications include ramipril and chlorthalidone. He has smoked half a pack of cigarettes a day for the past 60 years His temperature is 36.8 C (98.4 F), blood pressure is 140/90 mm Hg, pulse is 86/min, and respirations are 14/min. Examination of the right eye shows no abnormalities. Funduscopic examination of the left eye reveals swelling of the optic disk, retinal hemorrhages, dilated and tortuous ve ins, and cotton wool spots W hich of the following is the most likely diagnosis?
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Explanation:
Funduscopic findings in central retinal vein occlusion
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• Venous dilation & tortuosity due to venous occlusion • Scattered & diffuse hemorrhages due to backup of blood & increased resistance, leading to ischemic damage
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• Venous dilation & tortuosity due to venous occlusion • Scattered & diffuse hemorrhages due to backup of blood & increased resistance, leading to ischemic damage • "Blood & thunder" appearance due to diffuse hemorrhages • Cotton wool spots • Disk swelling @UWorld
This patient with acute, unilateral, painless loss of vision has findings suggestive of central retinal vein occlusion (CRVO). The characteristic changes on funduscopic examination are sometimes referred to as the "blood and thunder" appearance , and include optic disk swelling, retinal hemorrhages, dilated veins, and cotton wool spots. CRVO should be considered in the differential diagnosis for acute or subacute monocular loss of vision, but it is typically not quite as acute as the vision loss seen in patients with central retinal artery occlusion. CRVO is caused by thrombosis of the central retinal vein and is most common in patients with coagulopathy, hyperviscosity, chronic glaucoma, and atherosclerotic risk factors (eg, age, diabetes, hypertension). The diagnosis can be confirmed with fluorescein angiography. Patients with no significant macular edema or neovascularization are often managed conservatively with -
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sometimes referred to as the "blood and thunder" appearance, and include optic disk swelling, r etinal hemorr hages, dilated veins, and cotton wool spots. CRVO should be considered in the differential diagnosis for acute or subacute monocular loss of vision, but it is typically not quite as acute as the vision loss seen in patients with central retinal artery occlusion. CRVO is caused by thrombosis of the central retinal vein and is most common in patients with coagulopathy, hyperviscosity, chronic glaucoma, and atherosclerotic risk factors (eg, age, diabetes, hypertension) The diagnosis can be confirmed with fluorescein angiography. Patients with no significant macular edema or neovascularization are often managed conservatively with close observation. Significant macular edema can be treated with intravitreal injection of vascular endothelial growth factor inhibitors. No treatment is particularly effective, but some patients may have partial recovery of vision within the first 3 months. (Choice A) Acute angle-closu re glaucoma presents with acute onset of severe eye pain and blurred vision associated with nausea and vomiting Examination shows a red eye with a steamy co rnea and moderately dilated pupil that is non-reactive to light. (Choice B) Patients with anterior uveitis may have vision loss, but the affected eye is usually red and painful {Choice C) Amaurosis fugax is usually caused by atheroemboli from the carotid arteries and causes temporary vision loss as opposed to the persistent vision loss seen in this patient. Swelling of the optic disc may be seen in some cases, but retinal hemorrhage is more consistent with CRVO.
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(Choice E) Optic neuritis is characterized by acute unilateral loss of vision, severe pain, and an afferent pupillary defect. It most commonly occurs in women age <50 and is often an initial presentation of multiple sclerosis. Educational objective: Central retinal vein occlusion presents with acute or subacute painless monocular visual loss. Funduscopic examination shows a "blood and thunder" appearance consisting of optic disk swelling, retinal hemorrhages, dilated veins, and cotton wool spots
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(:) A. Herpes simplex ke ratitis 10 B. Dacryocystitis
e> C. Bacterial keratitis
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D. Trigeminal neuralgia
10 E. Herpes zoster ophthalmicus
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An 85-year-old man presents with a rash over his forehead, tip of nose and left eye He also complains of pain and decreased vision. He has had fever , malaise, and a burning sensation around his left eye fo r the past 5 days. His blood pressure is 140/90 mm Hg, pulse is 92/min, respirations are 14/min, and temperatu re is 38.1 ° C (101 ° F) Physical examination reveals a vesicular rash on the periorbital region and lid margins The left eye is red, with chemosis of the conjunctiva. Dendriform ulcers are seen on the cornea. W hat is the most likely diagnosis?
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Explanation: Herpes zoster ophthalmicus is an infection caused by varicella-zoster virus. Most episodes occur in the elderly or immunosuppressed VZ virus remains latent in the trigeminal ganglion During periods of immunosuppression, the virus travels via the ophthalmic branch to the fo rehead and the eye Symptoms become manifest thereafter with fever , malaise and a burning, itching sensation in the periorbital region. Examination reveals a ves icular rash in the distribution of the cutaneous branch of the first division of the trigeminal nerve. Conjunctivitis and dendriform corneal ulcers characterize the eye involvement Treatment started within 72 hrs after eruption with high dose acyclovir reduces the development of complications {Choice A) Herpes simplex keratitis presents with pain, photophobia, and decreased vision. Dendritic ulcer is the most common presentation. There may also be minute clear ves icles in the corneal epithelium The typical vesicular rash of herpes zoster and systemic symptoms are not seen.
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(Choice B) Dacryocystitis is an infection of the lacrimal sac due to obstruction of the nasolacrimal duct It is characterized by pain, swelling, tenderness, and redness in the tear sac area. Mucous or pus can be expressed
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(Choice C) Bacterial keratitis is usually seen in contact lens wearers, and following co rneal trauma. The co rnea appears hazy with a central ulcer and adjacent stromal abscess. Hypopyon may be present (Choice D) The history is the only facto r by which a diagnosis of trigeminal neuralgia is made clinically It is characterized by a stabbing or shock-like pain over the distribution of the maxillary or mandibular division of the trigeminal nerve. The pain may be triggered by light touch or vibration. Rash is not seen. Educational Objective: Herpes zoster ophthalmicus is characterized by dendriform corneal ulcers and a vesicular rash in the trigeminal distribution. Time Spent 3 seconds
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A Check intraocular pressure B. Refer to ophthalmologist C. Check coagulation parameters D. Observation E. Antibiotics
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A 34-year-old male presents to the emergency department with a red eye He says, "I just woke up this morning and saw that my right eye was red." He denies any itching, pain or discharge He has no known drug or environmental allergies. He takes no medication. His vital signs are stable. The photo of his eye is shown below.
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D. .Observation [75%] E. Antibiotics I1% I
Explanation: This patient has a subconjunctival hemorrhage. He woke up with a red eye, and is entirely asymptomatic Subconjunctival hemorrhage is a completely benign condition. It may be due to simple trauma from rubbing the eyes vigorously , violent coughing spells, hypertensive episodes or coagulopathy In the majority of cases, the condition is from minor bruising and does not require any workup at all. The hemorrhage usually disappears in 24 to 48 hours. Simple observation is the best treatment. The occasional patient with subconjunctival hemorrhage may have an elevated blood pressure In such rare cases, lowering of the blood pressure may be useful (Choice A) The intraocular pressure is usually monitored in individuals with suspected glaucoma Features of glaucoma include visual loss, pupillary dilatation and erythema around the conjunctiva. The eyeball may feel hard to palpation. A tonometer reveals the inc reased intraocular pressure The treatment is a topical cholinergic or beta blocker eye drops
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{Choice B) There is no need fo r an ophthalmology referral at this time. Subconjunctival hemorrhage is a very benign condition. (Choice C) The occasional patient who is on anticoagulation medication may develop a subconjunctival hemorrhage Measurements of coagulation parameters may be indicated in such a case. Therapy is conservative. (Choice E) Antibiotics are not required for subconjunctival hemorrhage because the condition is not infectious. Conjunctivitis can present with discharge and redness of the eye. Topical antibiotic drops are required Educational Objective: Spontaneous subconjunctival hemorrhage is a benign finding, and does not require any treatment. Time Spent 6 seconds
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6 A. Open angle glaucoma @ B. Macular degeneration
6 C. Recurrent cata racts @ D. Central retinal artery occlusion
6 E. Retinal detachment Submit
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A 69-year-old white male presents to your office complaining of progressive bilateral loss of vision over the past several months. He only has problems with his central vision. His peripheral field and navigational vision are not affected. He denies smoking and alcohol intake. He does not have any history of diabetes or hypertension Two years ago, he had cataracts removed from both eyes. W hat is the most likely diagnosis?
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over the past several months. He only has problems with his central vision. His peripheral field and navigational vision are not affected. He denies smoking and alcohol intake. He does not have any history of diabetes or hypertension Two years ago, he had cataracts removed from both eyes W hat is the most likely diagnosis?
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A Open angle glaucoma [4%)
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B. Macular degeneration [84%] C. Recurrent cataracts [7%) D. Central retinal artery occlusion [4%) E. Retinal detachment [2%)
Explanation: Age-related macular degeneration is usually seen in patients above 50 years of age Patients present with progressive and bilateral loss of central vision. Peripheral fields and navigational vision are always maintained, but may become impaired by the development of cataracts. The condition results from degeneration and atrophy of the outer retina, retinal pigment epithelium, Bruch's membrane and choriocapillaries {Choice A) Open angle glaucoma usually presents as a gradual loss of peripheral vision (over a period of yea rs) and consequent tunnel vision. Central vision is spared (Choice C) Cataracts, once removed, do not recur. (Choice D) Central retinal artery occlusion and retinal detachment are ve ry acute conditions with complete vision loss. Educational objective: Age-related macular degeneration is usually seen in patients above 50 yea rs of age with progressive and bilateral loss of central vision. Navigational vision is preserved Time Spent 3 seconds
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e> A
Lens opacity
e; B. Enlarged blind spot (:) C. Increased intraocular pressure
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E. Peripheral retinal degeneration
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A 67-year-old Caucasian male complains of progressive visual loss in his right eye over the past several months. He has a history of hypertension and type 2 diabetes mellitus. Current medications include a daily baby aspirin, hyd rochlorothiazide, lisinopril, and metformin. There is no family history of visual problems. He has a 35 pack yea r smoking history and admits to occasional alcohol use. He is afebrile with a blood pressure of 137/82 mmHg and pulse of 73/min. Cardiac and pulmonary examinations are unremarkable. A neurologic examination demonstrates no focal motor or sensory abnormalities. The patient is asked to cover his left eye and to look at a small spot on a grid made of parallel vertical and horizontal lines. He describes the vertical lines as being bent and wavy W hich of the following is the most likely cause of this patient's complaints?
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E. Peripheral retinal degeneration [14%) Explanation:
The most likely diagnosis in this case is macular degeneration, which is the leading cause of blindness in industrialized countries. One of the earliest findings in macular ·degeneration is distortion of straight lines such that they appear wavy The grid test described above is frequently used to screen fo r patients with macular degeneration The primary risk facto r for macular degeneration is increasing age, although smoking can increase the risk as well. Patients may be asymptomatic , but others complain of visual problems in either one or both eyes Driving and reading are often some of the first activities that are affected since they require fine visual acuity, which is provided primarily by the macula. In addition to the grid test described above, ophthalmologic examination can identify drusen deposits in the macula, which are common lesions seen with this disorder.
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(Choice A) Lens opacification is the cause of visual loss from cataracts. Cataracts, however, should not cause straight lines to appear wavy
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{Choice B) An enlarged blind spot may be seen with papilledema, but this patient has no evidence of inc reased intracranial pressure to result in papilledema
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{Choice E) Visualization of straight lines is a task that requires fine visual acuity, which is controlled primarily by the centrally-located macula as opposed to the more peripheral retina. Educational objective: Macular degeneration is the most common cause of blindness in industrialized nations. Activities that require fine visual acuity are usually the fi rst affected, and patients with this condition may report that straight grid lines appear curved.
Time Spent 3 seconds
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A 30-year-old male comes to the emergency department screaming, "Something blew into my right eye while I was drilling!" He complains of a foreign body sensation in the right eye, photophobia, and excessive lacrimation. Gross examination of the right eye with a penlight after the application of a topical anesthetic is insignificant W hat is the best next step in the management of this patient?
e; A Tonometry
® B. Fluorescein examination ® C. Topical antibiotic ® D. Ultrasonography ® E. MRI of the orbits
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A Tonometry [5%)
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Explanation: This patient most probably sustained a high-velocity eye injury that is commonly associated with drilling, hammering, grinding, etc. In contrast to a low-velocity injury, a high-velocity injury has a greater probability of globe penetration and intraocular fo reign body formation. The clinician should always be cognizant of such a possibility, even if initial presentation is subtle. Although not seen on gross examination, an abrasion or foreign body may be present Fluorescein application following a Wood's lamp or, preferably , slit lamp examination is the most reasonable next step in this case. {Choice D) If a fo reign body is not demonstrated and a strong suspicion remains, CT or ultrasonography can be considered. MRI is never performed fo r the diagnosis of a foreign body; in fact, it is contraindicated, since it can dislodge the fo reign body because of the strong magnetic field. (Choice C) A topical antibiotic is applied after the foreign body has been removed. (Choice A) Tonometry is performed only if penetration of the globe is ruled out Educational Objective: Be overly suspicious for an intraocular foreign body in patients with high-velocity injuries (drilling, grinding, etc) If the initial pen light examination does not reveal any conjunctival and corneal abrasions or fo reign bodies, proceed with fluorescein examination. Time Spent 3 seconds
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0 A Angle-closure glaucoma 0 B. Anterior uve itis 0 C. Episcleritis
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A 32-year-old man complains of right eye pain and discharge His symptoms began acutely on awakening in the morning He uses extended-wear contact lenses and has had difficulty removing the lenses for the last week. His past medical history is significant for obesity, chronic back pain, asthma, and acid reflux disease. On examination, thick, globular yellow discharge is present at the medial eye co rner and on the lid margins. The cornea is edematous, hazy, and ulce rated and there is extensive scleral injection, as shown in the image What is the most likely diagnosis in this patient?
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B. Anterior uve itis C . Episcleritis
D. Pneumococcal conjunctivitis
E. Pseudomonal keratitis F. Subconjunctival hemorrhage
0 G. Viral conjunctivitis Submit
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Explanation: This patient with a painful, red eye and opacification and ulce ration of the cornea has typical features of contact lens-associated keratitis. Most cases are due to Gram-negative organisms such as Pseudomonas and Serratia, but can also be due to Gram-positive organisms as well as certain fungi and amoebas. Contact lens-associated keratitis is a medical emergency and can lead to corneal perforation, scarring, and permanent vision loss if not addressed promptly In addition to removal and discarding of the contact lens, most patients require topical broad-spectrum antibiotics. {Choice A) Acute angle -closure glaucoma, usually seen in older patients (age >40), may also present with a red, painful eye and blurred vision. Corneal opacification can be present, but ulceration is not typ ical. The pupil is fixed and mid-dilated. Extraocular symptoms such as headache and nausea are common.
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(Choice B) Anterior uveitis (iritis) is inflammation of the anterior uveal tract, especially the iris. Patients often have associated conjunctival inflammation adjacent to the co rnea, but the cornea itself is usually spared
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(Choice C) Episcleritis is a common cause of red eye and is distinguished by its localized or patchy distribution and generally mild associated pain and discharge It may occur in association with rheumatoid arthritis and other autoimmune disorders, but many cases are idiopathic Episcleritis is usually self-limited and does not affect vision or involve the co rnea. {Choice D) Patients using extended-wear contact lenses are at risk fo r both bacterial conjunctivitis and keratitis. Involvement of the cornea indicates keratitis, and the cornea is generally spared in uncompl icated conjunctivitis The infection in this patient is likely due to Pseudomonas. (Choice F) Subconjunctival hemorrhage is usually caused by local trauma or Valsalva maneuver (eg, coughing, sneezing, vom iting). Patients will have a well-demarcated patch of extravasated blood beneath the conjunctiva Most cases are benign and require no specific therapy
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Patients often have associated conjunctival inflammation adjacent to the co rnea, but the cornea itself is usually spared {Choice C) Episcleritis is a common cause of red eye and is distinguished by its localized or patchy distribution and generally mild associated pain and discharge It may occur in association with rheumatoid arthritis and other autoimmune disorders, but many cases are idiopathic Episcleritis is usually self-limited and does not affect vision or involve the co rnea. (Choice D) Patients using extended-wear contact lenses are at risk for both bacterial conjunctivitis and keratitis. Involvement of the cornea indicates keratitis, and the cornea is generally spared in uncomplicated conjunctivitis The infection in this patient is likely due to Pseudomonas. {Choice F) Subconjunctival hemorrhage is usually caused by local trauma or Valsalva maneuver (eg, coughing, sneezing, vomiting) Patients will have a well-dema rcated patch of extravasated blood beneath the conjunctiva. Most cases are benign and require no specific therapy
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(Choice G) Viral conjunctivitis ("pink eye") is usually preceded by typical nasopharyngeal symptoms Corneal involvement is uncommon. Viral conjunctivitis is most common in the late summer and fall and may occur in clusters or small epidemics. Educational objective: Contact lens-associated infectious ke ratitis is a medical emergency that causes a painful, red eye and opacification and ulce ration of the co rnea. Most cases are due to Gram-negative organisms but can also be due to Gram-positive organisms as well as certain fungi and amoebas. Most cases require topical broad-spectrum antibiotics. References: 1. Infectious keratitis.
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11) A. Use warm comp resses 11) B. Incision and drainage 11) C. Incision and curettage 11) D. Take biopsy of the lesion 11) E. Oral Penic illin
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A 33-year-old man presents with a 1-day history of localized, small swelling along the margin of the upper eyelid. He feels pain, which does not seem to come from the conjunctival surface . He has a 10-pack year smoking history. He occasionally drinks alcohol. He is sexually active, and does not use condoms regularly He is worried about the swelling What is the best next step in the management of this patient?
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has a 10-pack year smoking history He occasionally drinks alcohol. He is sexually active, and does not use condoms regularly He is worried about the swelling W hat is the best next step in the management of this patient? .;
A Use warm compresses [81%)
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B. Incision and drainage [6%)
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C. Incision and curettage [2%) D. Take biopsy of the lesion [5%) E. Oral Penicillin [7%) Explanation:
This patient has an external hordeolum or stye, which is a common staphylococcal abscess of the eyelid It usually responds to the application of warm compresses
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(Choice B) Incision and drainage is performed if resolution of the lesion does not begin in the next 48 hours. {Choice C) Incision and curettage is the treatment of choice fo r chalazion, which is a granulomatous inflammation of the meibomian gland
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(Choice D) Performing a biopsy is incorrect since the lesion started acutely , and there is no reason to believe at this time that the lesion is cancerous .
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{Choice E) The patient may need antibiotic ointment such as bacitracin or erythromycin, but not oral penicillin
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Educational Objective: External hordeolum or stye is a common staphylococcal abscess of the eyelid It is treated with warm compresses Incision and drainage is performed if resolution does not begin in the next 48 hours.
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<0 A Allergic conjunctivitis <0 B. Anterior uveitis <0 C. Atopic keratoconjunctivitis
e; D. Bacterial conjunctivitis <0 E. Endophthalmitis <0 F. Kawasaki disease
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6 H. Orbital cellulitis <0 I. Viral conjunctivitis
6 J. Viral keratitis Submit
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A 26-year-old man comes to the physician with sudden onset of redness, watery discharge, and itching of both eyes. His vision is slightly distorted from excess tearing but is not blurred. He otherwise feels fine. The patient's past medical history is significant for obesity, asthma, sleep apnea, and chronic back pain. On eye examination, there is bilateral injection with granular appearance of the conjunctiva Mild eyelid swelling and clear discharge are also noted. Pupils are equally round and reactive to light The lungs have a few scattered wheezes, and the heart has a faint systolic murmur at the base. W hat is the most likely diagnosis in this patient?
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a
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Explanation:
Differentiation of conjunctivitis
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Eye involvement
Eye "stuck shut" in morning
Viral
Bacterial
Allergic
Unilateral; often progresses to bilateral
Unilateral; may progress to bilateral
Yes
Yes
Yes
Watery; scant stringy mucus
Purulent; white, yellow, or green in color; thick in consistency
Watery; scant stringy mucus
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Yes
No
Burning, sandy, or gritty feeling in eye; viral prodrome
Unremitting ocular discharge
Itching; history of allergy
Bilateral
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Other complaints
D1ffuse InJeCtion
Diffuse
Diffuse injection; follicular or
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Conjunctival appearance
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Diffuse injection; nonfollicular
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Diffuse injection; follicula r or "bumpy"; conjunctival edema (chemosis)
Red flags that suggest against 1 of the etiologies: copious purulent discharge, decreased visual acuity, photophobia, ciliary flush, foreign body sensation, corneal opacity or infiltrate, fixed or distorted pupil, trouble keeping eye open, and severe headache with nausea © UWorid
Allergic conjunctivitis (AC) is an acute hypersensitivity reaction caused by exposure to environmental allergens such as pollen, animal dander, dust, and mold spores Episodic itching, hyperemia, tearing, and edema of the conjunctiva and eyelids are characteristic. Some patients complain of mild photophobia or a dry-eye sensation. There is often a fam ily or personal history of atopic disorders such as asthma or seasonal allergies The condition usually subsides in 24 hours, even without treatment For persistent or recurrent symptoms, AC can be treated with a variety of topical agents, including antihistamines, vasoconstrictors, mast cell stabilizers, and artificial tears, that are available over the counter or by prescription. Oral antihistamines are less effective for acute episodes but can be helpful if taken seasonally, prior to allergen exposure. {Choice B) Anterior uveitis (iritis) is inflammation of the anterior uveal tract, especially the iris. Discharge is uncommon and, if present, is not profuse Iritis usually has significant pain, miosis, and photophobia; visual loss may be present A gritty sensation and itching are not present in iritis but are common with AC. (Choice C) Atopic keratoconjunctivitis is a severe form of ocular allergy. The most common symptoms are itching, tearing , thick mucus discharge, photophobia, and blurred vision. It can be differentiated from AC by more severe symptoms with a prolonged course, potential visual
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feve r. (Choice E) Endophthalmitis is an invasive infection of the globe (bacterial or fungal) and is due to disruption of the external surface of the eye (eg, trauma) Endophthalmitis may show conjunctival irritation as well, but patients will usually have purulent haziness of the ocular contents and may have a layering-out of pus in the anterior chamber (hypopyon) {Choice F) Kawasaki disease is a vasculitis of medium-sized arteries that affects young children (age usually <5) Symptoms may include conjunctivitis as well as fever, lymphadenopathy , and mucocutaneous inflammation (erythema of lips, tongue, and palate; peripheral edema, desquamation, and generalized rash) (Choice G) Symptoms in optic neuritis typically include visual loss, with or without eye pain Uveitis may occur (uncommonly), but the conjunctiva is not typically affected. (Choice H) Orbital cellulitis is infection of the fat and extraocular muscles surrounding the eye and is a medical emergency Patients usually have erythema, edema, and tenderness of the eyelids, often with impaired extraocular movement (Choice I) Viral conjunctivitis ("pink eye") symptoms are similar to those of allergic conjunctivitis but last longer (several days) and usually are preceded by typical nasopharyngeal symptoms. Viral conjunctivitis is most common in the late summer and fall , and may occur in clusters or small epidemics. {Choice J) Viral keratitis is infection of the co rnea related to herpes simplex virus or varicella zoster. Patients typically have corneal vesicles, opacification, and/or dendritic ulcers. Educational objective: Alle rgic conjunctivitis is an acute hype rsensitivity reaction caused by environmental exposure to allergens It is characterized by intense itching, hyperemia, tearing, and edema of the conjunctiva and eyelids. References: . .
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6 A Bacterial keratitis 10 B. Herpes simplex keratitis 6 C. Herpes zoster ophthalmicus
0 D. Co.rneal abrasion 10 E. Fungal keratitis
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A 32-year-old male construction worker presents with complaints of pain, watering, and redness in his left eye fo r the past 2 days. He reports having similar symptoms in the same eye a few months ago Examination of his left eye reveals vesicles and dendritic ulcers in the cornea. His vital signs are stable. W hat is the most likely diagnosis?
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vo
E. Fungal keratitis [ 1o/o J Explanation:
Herpes simplex keratitis is a frequent cause of corneal blindness in the US. It mostly occurs in adults. These patients usually compla in of pain, photophobia, blurred vision, tea ring, and redness. A history of prior episodes may be present Usually, the recurrences are precipitated by excessive sun exposure, outdoor occupation (as in this patient), fever , or immunodeficiency Corneal vesicles and dendritic ulcers are characteristic . Dendritic ulcers are the most common presentation It is primarily diagnosed cl inically, although epithelial scrapings will show multi-nucleated giant cells. Antiviral therapy (oral or topical) is effective in the treatment of Herpes simplex ke ratitis. (Choice A) Bacterial ke ratitis usually occurs in contact lens wearers, following corneal trauma or entry of a foreign body. The co rnea appears hazy with a central ulcer and adjacent stromal abscess. Hypopyon may be present
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(Choice C) Herpes zoster ophthalmic us is an infection caused by varicella-zoster virus. Most episodes occur in the elderly It presents with fever malaise and a burning, itching sensation in the periorbital region Examination reveals a vesicular rash in the distribution of the cutaneous branch of the first division of the trigeminal nerve. Conjunctivitis and dendrifo rm corneal ulce rs characterize the eye involvement (Choice D) Corneal abrasion presents with severe pain and photophobia. There is usually a history of trauma to the eye. Slit lamp examination reveals corneal abrasion. (Choice E) Fungal keratitis occurs after corneal injury in agricultural worke rs or immunocompromised patients The cornea shows multiple stromal abscesses. Educational objective: Herpes simplex keratitis is characterized by corneal vesicles and dendritic ulcers.
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A 30-year-old man is concerned about "floating spots" and blurred vision in his right eye. He had a penetrating injury to his left eye several weeks ago, which eventually led to vision loss in that eye Inspection reveals a moderate perilimbal fl ush. What is the most probable cause of this patient's condition? 6 A Reagin-mediated disease 10 B. Circulating immune complexes 6 C. Non-caseating granulomas
0 D. Uncovering of 'hidden' antigens 10 E. Non-immune injury
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A Reagin-mediated disease [10%) B. Circulating immune complexes [20%) C. Non-caseating granulomas [3%) ~
D. Uncovering of 'hidden' antigens [38%) E. Non-immune injury [28%)
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Explanation: Sympathetic ophthalmia is also known as "spared eye injury " It is characterized by an immune-mediated inflammation of one eye (the sympathetic eye) after a penetrating injury to the other eye. The typical manifestation is anterior uveitis, but panuveitis, papillary edema, and blindness may develop The pathophys iological mechanism is believed to be the uncove ring of 'hidden' antigens Some antigens contained within the eye are protected from immunologic recognition by natural barriers. Breaking these barriers results in the uncovering of 'hidden' antigens. An immune response against these antigens can involve autoantibodies as well as a cell-mediated reaction. (Choice A) Reagin-mediated ( lgE-mediated) disease is seen in vernal (allergic) conjunctivitis (Choice B) Circulated immune complexes can affect the eye in systemic lupus erythematosus. (Choice C) Ocular injury by non-caseating granulomas is typical for sarcoidosis. (Choice E) Non-immunologic injury is less likely in this case. Educational Objective: Sympathetic ophthalmia is characterized by damage of one eye (the sympathetic eye) after a penetrating injury to the other eye It is due to an immunologic mechanism involving the recognition of 'hidden' antigens. Time Spent 3 seconds
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e; A Retinal detachment
® B. Diabetic retinopathy ® C. Vitreous hemorrhage ® D. Central retinal vein occlusion ® E. Age related macular degeneration Submit
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A 65-year-old man comes to the emergency department due to a sudden loss of vision in his right eye He has had diabetes, and has been treated with metformin and glyburide fo r the past 10 years. Visual acuity is reduced to light perception in his right eye, and normal in his left. His vital signs are normal. Ophthalmoscopy reveals loss of fundus details, floating debris and a dark red glow What is the most likely diagnosis?
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E. Age related macular degeneration [2%) Explanation: Vitreous hemorrhage typically presents as a sudden loss of vision and onset of floaters. The most common cause is diabetic retinopathy An important diagnostic clue is that the fundus is hard to visualize, and even if it is visualized, details may be obscured. Immediate ophthalmologic consultation is required For patients with underlying medical conditions, conservative treatment (i.e , upright position during sleep, which enhances settling of the hemorrhage) is recommended. {Choice A) Retinal detachment refers to the separation of the inner layers of the retina. It may be associated with metabolic disorders (e g , diabetes mellitus) , trauma ( including ocular surgery), vascular disease, myopia, or degeneration Patients typically complain of vision loss, photopsia with showers of floaters. Fundoscopy typically demonstrates an elevated retina with folds and/or a tea r.
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{Choice B) Diabetic retinopathy patients are usually asymptomatic , even though changes in fundoscopy are seen. Vitreous hemorrhage frequently occurs in patients with proliferative diabetic retinopathy. Once a diabetic patient presents with a sudden onset of visual loss with numerous floaters, a vitreous hemorrhage is most likely to have occurred. (Choice D) Central retinal vein occlusion presents as a sudden, painless, unilateral loss of vision. It is also noted in patients with a history of hypertension. Ophthalmoscopic signs are disk swelling, venous dilation and tortuosity, retinal hemorrhages, and cotton wool spots. (Choice E) Patients with macular degeneration typically present with painless progressive blurring of central vision, which can be acute or insidious. It occurs bilaterally Educational objective: Vitreous hemorrhage typically presents as a sudden loss of vision and onset of floaters. Vitreous hemorrhage occurs in patients with diabetic retinopathy. Time Spent 3 seconds
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(:) A Cryotherapy with li quid nitrogen e; B. Excisional biopsy (:) C. Re-exam ination in 3-6 months
e; D. Shave biopsy
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E. Topical fl uorouracil
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A 62-year-old woman comes to the office for evaluation of a pigmented lesion on her left fo rearm. She first noticed the lesion 4 months ago and says it occasionally itches but is otherwise asymptomatic The patient also has numerous "freckles" that she attributes to playing golf during the summer . Medical history includes psoriasis, hypertension, and mild chronic obstructive pulmonary disease. She quit smoking 5 yea rs ago and drinks 2 or 3 glasses of wine a week after golfing. On examination, there is a 5-mm, dark brown lesion at the dorsal surface of her distal left fo rearm; it has a smooth border and a small, eccentric nodule. In addition, multiple scattered, flat, light brown lesions are present on the nose, cheeks, and dorsal surface of the hands. W hich of the following is the most appropriate next step in management of this patient's fo rearm lesion?
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E. Topical fl uorouracil (2%) Explanation: Although this patient's lesion does not have any of the ABCDE characteristics for melanoma, several features are concerning for malignancy and warrant further workup: • In a patient who has multiple pigmented lesions, a lesion with an appearance that is substantially diffe rent from the others (eg, dark brown rather than light brown, nodule rather than flat) may represent melanoma ("ugly duckling sign"). The "ugly duckling sign" has a sensitivity of up to 90% for melanoma. • Ve rtical growth of a melanoma often co rresponds to a palpable nodularity, as in this patient, and increases metastatic risk. The Br eslow depth (distance from the epidermal granular cell layer to the deepest visible melanoma cells) is the most important prognostic indicato r in malignant melanoma. • Benign pigmented lesions are usually asymptomatic ; therefore, biopsy should be considered fo r moles that itch or bleed, particularly in the presence of other conce rning features.
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If melanoma is suspected, the patient should undergo excisional biopsy with initial margins of 1-3 mm of normal tissue. (Choices A and E) Actinic keratoses are indistinct, roughened papules that are most common in sun-exposed areas, such as the face and dorsal surface of the hands. They are usually treated by destruction in situ with c ryotherapy or topical fluorouracil Actinic keratoses are rarely pigmented, and nodularity is more consistent with melanoma. (Choice C) Periodic surveillance is recommended for patients with numerous or atypical nevi, but suspected melanomas warrant tissue confirmation without delay. (Choice D) Shave biopsy is not recommended for most cases of suspected melanoma as partial removal of the primary melanoma may not provide adequate tissue fo r diagnosis and does not allow for accurate depth measurement.
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• Ve rtical growth of a melanoma often co rresponds to a palpable nodularity, as in this patient, and increases metastatic risk. The Breslow depth (distance from the epidermal granular cell layer to the deepest visible melanoma cells) is the most important prognostic indicator in malignant melanoma. • Benign pigmented lesions are usually asymptomatic ; therefore, biopsy should be considered for moles that itch or bleed, particularly in the presence of other conce rning features. If melanoma is suspected, the patient should undergo excisional biopsy with initial margins of 1-3 mm of normal tissue. (Choices A and E) Actinic keratoses are indistinct, roughened papules that are most common in sun-exposed areas, such as the face and dorsal surface of the hands. They are usually treated by destruction in situ with cryotherapy or topical fl uorouraciL Actinic keratoses are rarely pigmented, and nodularity is more consistent with melanoma. (Choice C) Periodic surveillance is recommended for patients with numerous or atypical nevi, but suspected melanomas warrant tissue confirmation without delay (Choice D) Shave biopsy is not recommended for most cases of suspected melanoma as partial removal of the primary melanoma may not provide adequate tissue for diagnosis and does not allow fo r accurate depth measurement Educational objective: A mole may represent melanoma if it appears substantially different from others ("ugly duckling sign"), itches or bleeds, or develops new nodularity . If melanoma is suspected, an excisional biopsy with initial margins of 1-3 mm of normal tissue should be obtained. References: 1. Revised U.K . guidelines for the management of cutaneous melanoma 2010.
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A 28-year-old woman comes to the physician for evaluation of a rash on her left foot A week ago, she noticed multiple lesions on the sole of her foot that are painful with walking or standing. The patient has no other medical conditions. Her only medication is an oral contraceptive She has no history of tobacco or alcohol use. She works as an accountant The patient has had 2 sexual relationships in the past 3 yea rs and has been sexually active with her current boyfriend fo r the past 6 months. Her temperature is 36.1 C (97 F), blood pressure is 128/76 mm Hg, and pulse is 78/min. Skin examination is shown below. The remainder of her phys ical examination is within normal limits.
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W hich of the following is the most likely etiology for this patient's findings? ® A Callus
® B. Human papillomavirus infection ® C. Lichen planus ® D. Poxvirus ® E. Seborrheic keratosis ® F. Squamous cell carcinoma Submit
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Explanation: This patient's skin lesions are consistent with warts (cutaneous verrucae), which are the most common cutaneous manifestation of human papillomavirus (HPV) infection. HPV can cause wa rts in va rious locations including the plantar, palmar, or genital areas. Plantar warts occur most commonly in young adults and patients with decreased cellular immunity (eg, A IDS, organ transplant patients) The virus usually enters through tiny cuts or skin abrasions after direct contact with an HPV-infected individual. Patients can develop lesions weeks to months later; these appear as hyperkeratotic papules on the sole of the foot (sometimes with thrombosed capilla ries and visible skin lines) that can be painful with walking or standing Diagnosis is made clinically based on the appearance and location of the lesions. {Choice A) Calluses are hyperke ratotic lesions that usually occur next to bony prominences on the feet or sometimes on the hands. Calluses may sometimes cause pain and discomfort and occur in response to repeated shear or frictional forces.
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(Choice C) Lichen planus presents as purple flat-topped papules or plaques that are pruritic , planar, or polygonaL The lesions most commonly occur on flexural surfaces of the extremities, trunk, and genitalia. (Choice D) Molluscum contagiosum is a common condition caused by a poxvirus It typ ically presents as single or multiple skin-colored papules with a central punctum (umbilicus or central pit) (Choice E) Seborrheic keratosis usually appears after age 50 as solitary or multiple well-circumscribed hyperpigmented lesions. They can have a "stuck-on" or warty appearance and usually occur on the trunk, face , and upper extremities. (Choice F) Squamous cell carcinoma typically presents with erythematous lesions that are scaly, ulce rate, or grow irregularly . It should be suspected in patients with a slow-growing and non-resolving lesion in sun-exposed areas.
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skin lines) that can be painful with walking or standing. Diagnosis is made clinically based on the appearance and location of the lesions. {Choice A) Calluses are hyperkeratotic lesions that usually occur next to bony prominences on the feet or sometimes on the hands. Calluses may sometimes cause pain and discomfort and occur in response to repeated shear or frictional forces.
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{Choice C) Lichen planus presents as purple flat-topped papules or plaques that are pruritic , planar, or polygonal The lesions most commonly occur on flexural surfaces of the extremities, trunk, and genitalia
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(Choice E) Seborrheic keratosis usually appears after age 50 as solitary or multiple well-circumscribed hyperpigmented lesions. They can have a "stuck-on" or warty appearance and usually occur on the trunk, face , and upper extremities.
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(Choice D) Molluscum contagiosum is a common condition caused by a poxvirus It typ ically presents as single or multiple skin-colored papules with a central punctum (umbilicus or central pit)
(Choice F) Squamous cell carcinoma typically presents with erythematous lesions that are scaly, ulce rate, or grow irregularly It should be suspected in patients with a slow-g rowing and non-resolving lesion in sun-exposed areas. Educational objective: Plantar warts are due to human papillomavirus (HPV) infection and most commonly occur in young adults and immunocompromised individuals. The lesions appear as hyperkeratotic papules on the sole of the foot that can be painful when walking or standing References: 1. Cutaneous human papillomavirus infection: manifestations and diagnosis
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e; A Corneal shape ® B. Lens elasticity ® C. Lens opacity ® D. Macula ® E. Peripheral retina ® F. Intraocular pressure
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A 53-year-old man comes to the office because of difficulty reading fine print over the last year . He now has to hold books, menus, and magazines at an arms length in order to read them. He has never had visual problems before. W hich of the following is most likely abnormal in this patient?
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Explanation: This patient is most likely suffe ring from presbyopia, which is a common age-related disorder that results from the loss of elasticity in the lens. Th is decrease in elasticity prohibits accommodation of the lens, which is required in order to focus on near objects The tendency of patients to hold reading material at a further distance is classic for presbyopia Patients often have no history of eye problems Most patients will report the onset of presbyopia while they are in their forties, and symptoms typically peak at some point in their sixties. The poor near vision associated with presbyopia can easily be improved with reading glasses
{Choice A) A nonspherical co rnea can lead to astigmatism, which typically presents with blurry vision both at a distance and up close. {Choice C) Increased lens opacity is the etiology of cataracts. Patients may have difficulty reading, but a history of difficulty with night vision or driving at night is more characteristic .
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(Choice D) Age-related macular degeneration is a common cause of visual loss in patients over the age of 50, but it is typically associated with central visual field loss.
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(Choice E) Disease located in the peripheral retina is usually secondary to diabetes, which can lead to either proliferative or non-prolife rative retinopathy This patient, however , has no known history of diabetes. {Choice F) Elevated intraocular pressure is the etiology of glaucoma. Primary open-angle glaucoma usually presents with peripheral visual field defects followed by central visual loss. Educational objective: Presbyopia is a common age-related decrease in lens elastic ity that leads to difficulty with near vision. A history of a middle-aged individual who has to hold books at an arms length to read is classic . Time Spent 2 seconds
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0 A. Cytomegalovirus retinitis 0 B. Herpes simplex keratitis
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A 48-year-old homeless man with a history of HIV comes to the emergency department due to floaters and blurred vision in his right eye The symptoms started a week ago and have become "really bothersome." He has not had ocular pain, feve r, or headache. The patient takes combination antiretroviral therapy that includes a protease inhibitor. Six months ago, he was hospitalized with Pneumocystis pneumonia due to medication noncompl iance Temperature is 37.2 C (99 F), blood pressure is 120/70 mm Hg, and pulse is 78/min. BMI is 17 kg/m2 Vision is decreased in the right eye, and funduscopic examination shows several yellow-white exudates immediately adjacent to the fovea and retinal vessels. Several white patches are present on the oropharyngeal mucosa. Neurologic examination shows no focal weakness or sensory loss. W hich of the following is the most likely diagnosis?
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Cytomegalovirus (CMV) is a widely prevalent DNA virus of the herpes fam ily that typically causes an asymptomatic initial infection followed by a life-long latent infection. In patients with significantly compromised cell-mediated immunity (eg, advanced HIV with CD4 count <100/mm•), CMV reactivation may result in viremia or end-organ disease. CMV retinitis is characterized by full-thickness retinal inflammation that moves centripetally along the vasculature, causing edema and scarring. Patients experience blurred vision, floaters , and photopsia (sensation of flashing lights). Lesions near the fovea and optic nerve may cause blindness, and scarring greatly increases the risk of retinal detachment Diagnosis is made by fundoscopy showing yellow-white, fluffy, hemorrhagic lesions along the vasculature. Blood tests for CMV (polymerase chain reaction) are not suffic ient for diagnosis as viremia may develop independently of end-organ disease. Patients are usually treated with oral antivirals (eg, valganciclovi r); if lesions are near the fovea or optic nerve, intravitreal injections are added. All patients should be initiated on antiretroviral therapy (usually 2 weeks after beginning CMV treatment) to prevent recurrence and progression This patient likely developed CMV retinitis due to medication noncompliance (Choice B) Herpes simplex keratitis causes corneal (not retinal) lesions and results in ocular pain, tearing, and discharge (Choice C) Herpes zoster ophthalmicus presents with eye pain and a vesicular eruption usually involving the cornea or iris. This patient did not have a rash, pain, or anterior lesion. (Choice D) HIV retinopathy is marked by cotton-wool retinal lesions that are rarely hemorrhagic and tend to resolve over weeks to months. HIV retinopathy does not commonly cause floaters or blurred vision. (Choice E) Most antiretrovirals are not commonly associated with retinal lesions or the sensation of floaters. (Choice F) Patients with toxoplasmic chorioretinitis present with eye pain and decreased vision. Retinal lesions appear in a nonvascular distribution. This patient does not have eye pain and has lesions in a perivascular distribution.
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"' "' "' "' . "' "'' develop independently of end-organ disease. Patients are usually treated with oral antivirals (eg, valganciclovir); if lesions are near the fovea or optic nerve, intravitreal injections are added. All patients should be initiated on antiretroviral therapy (usually 2 weeks after beginning CMV treatment) to prevent recurrence and progression This patient likely developed CMV retinitis due to medication noncompliance ,
(Choice B) Herpes simplex keratitis causes co rneal (not retinal) lesions and results in ocular pain, tearing , and discharge. (Choice C) Herpes zoster ophthalmicus presents with eye pain and a vesicular eruption usually involving the co rnea or iris. This patient did not have a rash, pain, or anterior lesion. (Choice D) HIV retinopathy is marked by cotton-wool retinal lesions that are rarely hemorrhagic and tend to resolve over weeks to months. HIV retinopathy does not commonly cause floaters or blurred vision.
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(Choice E) Most antiretrovirals are not commonly associated with retinal lesions or the sensation of floaters.
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(Choice F) Patients with toxoplasmic chorioretinitis present with eye pain and decreased vision. Retinal lesions appear in a nonvascular distribution. This patient does not have eye pain and has lesions in a perivascular distribution. (Choice G) Syphilitic chorioretinitis usually presents with uveitis and diminished visual acuity and almost always occurs with syphilitic meningitis. This patient has retinal lesions. Educational objective: Cytomegalovirus retinitis typically presents with blurred vision, floaters, and photopsia (sensation of flashing lights) The major complications are vision loss (including blindness) and retinal detachment Treatment involves antivirals (eg, valganciclovir) and, in severe disease, intravitreal injections All patients should be started on antiretroviral treatment to prevent recurrence and progression. Time Spent 2 seconds
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6 A Adolescent acne
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A 16-year-old girl presents for evaluation of acne, which has been getting progressively worse over the past 2 weeks. Her medical history is significant fo r systemic lupus erythematosus (SLE) for which she has been taking prednisone for a recent exacerbation. Hydroxychloroquine is her only other medicine. She does not use tobacco, alcohol or drugs and her menstrual cycle is regular. On physical examination, her blood pressure is 110/76 mmHg and her pulse is 72/min. Her BMI is 22 kg/m2 Distributed over the face, arms and trunk are monomorphous erythematous papules. There are no open or closed comedones. The remainder of the physical examination is unremarkable. W hich of the following is the most likely cause of her acne?
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A Adolescent acne [12%1 B. Androgen abuse [2% 1 C. Polycystic ovarian disease [1%1 ~
D. Medication side effect [74o/o1 E. Systemic lupus erythematosus [11 %1
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Explanation: This patient has steroid-induced folliculitis, or steroid acne, secondary to the prednisone she is using for her SLE flare. Steroid acne is characterized by monomorphous pink papules and absence of comedones.
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(Choice A) Adolescent acne is characterized by open and closed comedones and inflammatory nodules in differing stages of evolution primarily affecting the face , chest and back.
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{Choice B) Androgen abuse is a possible cause of both acne vulgaris and steroid-induced acne. One of the main pathophysiologic mechanisms underlying acne vulgaris is androgen excess. Given her history, steroid acne is more likely
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{Choice E) Systemic lupus erythematosus itself is not a common cause of acneiform lesions. The skin finding most classic for SLE is an erythematous malar eruption.
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(Choice C) In polycystic ovarian syndrome ( PCOS) there is an underlying excess of serum androgens. As such, it is commonly associated with acne vulgaris Other findings in PCOS incl ude irregular menses, anovulation, and hirsutism.
Educational objective: Systemic and topical corticosteroids can induce an acneiform eruption characterized by monomorphous, erythematous foll icular papules distributed on the face , trunk and extremities. Comedones are characteristically absent Copyright © UWo rld
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e; A Topical pilocarpine
e> B. Ocular massage and high flow oxygen e; C. Systemic corticosteroids
e> D. Topical beta blocker
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A 65-year-old male comes to the emergency department because of a sudden, painless loss of vision in his right eye that occured a half an hour ago Five hours ago, he experienced a similar but transient loss of vision in the same eye, which lasted for five minutes. He has hypertension, diabetes, hypercholesterolemia, and peripheral vascular disease. He had an anterior wall myocardial infarction six yea rs ago. His medications include glyburide, captopril, atenolol, simvastatin, and aspirin. His temperature is 36.7° C (98 ooF), respirations are 16/min, pulse is 88/min, and blood pressure is 146/88 mmHg. Examination of the right eye reveals visual acuity of 20/60 and subtle retinal whitening A right carotid bruit is heard. W hich of the following is the most appropriate next step in the management of this patient?
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Explanation: The most likely diagnosis is central retinal artery occlusion (CRAO) secondary to embolism. Painless loss of monocular vision is the usual presenting symptom. Risk factors include ca rotid artery disease, endocarditis, cardiac valvular disease, long bone fracture, hypercoagulable conditions, vasculitis, atrial myxoma, etc. It occurs when a severe, abrupt diminution of blood flow th rough the central retinal artery causes ischemia of the inner retina. (Remember that the ophthalmic artery is the first intracranial branch of the internal carotid artery It supplies blood to the eye via the (1 ) central retinal artery, which is an end artery that supplies the inner retina, and the (2) ciliary branches, which supply the choroids and anterior portion of globe) Embolism of the retinal artery is the most common cause of ocular stroke. Emboli may travel to the distal branches of the retinal artery, causing loss of only a section of the visual field. It is commonly associated with amaurosis fugax before the occlusion (as in this patient). Visual acuity is typically 20/800 (6/240) or worse. Fundoscopy reveals diffuse ischemic retinal whitening and cherry red spots (typical but not specific for CRAO)
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CRAO is an ophthalmologic emergency A delay in treatment may result in permanent loss of vision. Immediate intervention includes ocular massage, which dislodges the embolus to a point further down the arterial circulation and improves retinal perfusion Medical management and anterior chamber paracentesis to lower the intraocular pressure may be used, but ocular massage has the most rapid action. Carbogen therapy (5 % C02 and 95% 02) or hyperbaric oxygen (HBO) therapy have been shown to be beneficial if given early
(Choice A and D) Topical pilocarpine and beta-blockers are used in the management of acute angle closure glaucoma, which is characterized by a sudden, painful loss of vision with red eye (Choice C) Systemic steroids are used in the management of vision loss associated with temporal arteritis; however, this patient has no signs suggestive of temporal arteritis. (Choice E) Thrombolytics may be useful if initiated within 4-6 hours of visual loss but they are administered intraarterially Their efficacy has not been systematically studied.
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Painless loss of monocular vision is the usual presenting symptom. Risk facto rs include ca rotid artery disease, endocarditis, cardiac valvular disease, long bone fracture, hypercoagulable conditions, vasculitis, atrial myxoma, etc. It occurs when a severe, abrupt diminution of blood flow th rough the central retinal artery causes ischemia of the inner retina. (Remember that the ophthalmic artery is the first intracranial branch of the internal carotid artery It supplies blood to the eye via the (1) central retinal artery, which is an end artery that supplies the inner retina, and the (2) ciliary branches, which supply the choroids and anterior portion of globe) Embolism of the retinal artery is the most common cause of ocular stroke. Emboli may travel to the distal branches of the retinal artery, causing loss of only a section of the visual field. It is commonly associated with amaurosis fugax before the occlusion (as in this patient). Visual acuity is typically 20/800 (6/240) or worse. Fundoscopy reveals diffuse ischemic retinal whitening and cherry red spots (typical but not specific for CRAO) CRAO is an ophthalmologic emergency A delay in treatment may result in permanent loss of vision. Immediate intervention includes ocular massage, which dislodges the embolus to a point further down the arterial circulation and improves retinal perfusion Medical management and anterior chamber paracentesis to lower the intraocular pressure may be used, but ocular massage has the most rapid action. Carbogen therapy (5 % C02 and 95% 02) or hyperbaric oxygen (HBO) therapy have been shown to be beneficial if given early (Choice A and D) Topical pilocarpine and beta-blockers are used in the management of acute angle closure glaucoma, which is characterized by a sudden, painful loss of vision with red eye (Choice C) Systemic steroids are used in the management of vision loss associated with temporal arteritis; however, this patient has no signs suggestive of temporal arteritis. (Choice E) Thrombolytics may be useful if initiated within 4-6 hours of visual loss but they are administered intraarterially Their efficacy has not been systematically studied. Educational objective: Central retinal artery occlusion is emergently treated with an ocular massage and high-flow oxygen administration. Time Spent 2 seconds
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e; A Cataracts e; B. D iabetic retinopathy 6 C. A rterial hypertension
e; D. Hyperosmolarity
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A 57-year-old female with a history of type 2 diabetes mellitus complains of fatigue, urinary frequency, increasingly blurred vision and worsening leg cramps over the past week. She reports that the symptoms all began following an upper respiratory infection 7 or 8 days ago. She does not take any medications, but adheres to a diet low in saturated fat and simple carbohydrates to manage her diabetes. On physical examination, her blood pressure is 160/90 mmHg and her heart rate is 90/min. Her mucous membranes are dry Her urine is positive for glucose but negative for ketones. W hich of the following is the most likely cause of this patient's vision impairment?
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• G. Metabolic acidosis [3%] Explanation: This is a diabetic patient who has developed non-ketotic hyperglycemia (evidenced by glucose present on urinalysis) following a recent upper respiratory infection. Type 2 diabetics are prone to develop nonketotic hyperosmolar syndrome (NKHS) in association with physiologic stressors like infection. Such stress causes elevations in the serum co rtisol and catecholamine levels, substances that serve as insulin counterregulatory hormones. Severe hyperglycemia (serum glucose > 600 mg/dl) in the absence of significant ketosis can result The resultant osmotic diuresis can cause dehydration and serum hyperosmolarity (often >320 mOsm/ L). Altered consciousness ranging from confusion to coma is the main symptom of the metabolic disturbances in NKHS. Acute hype rglycem ia can also cause blurred vision due to a myopic increase in lens thickness and intraocular hypotension secondary to hyperosmolarity {Choice A) Cataracts can be a manifestation of chronic diabetes, especially in patients with suboptimal glycem ic control In these patients, cataracts are thought to result from the gradual accumulation of intralenticular sorbitol This process would take longer than one week to develop (Choice B) Diabetic retinopathy, particularly macular edema during the nonproliferative stage of retinal microangiopathy, can cause blurred vision. However , this would be expected to develop more chronically (usually in association with poor glycemic control over time) than the acute change in vision described above. (Choice C) This patient is hypertensive, but acute vision changes (secondary to retinal hemorrhages, exudates, and/or papilledema) require blood pressure elevations to malignant values ( DBP > 120-130) {Choice E) W hile acute infectious conjunctivitis, uveitis, and/or retinitis can potentially cause blurred vision, the process is usually monocular, and there are generally signs on physical examination.
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{Choice A) Cataracts can be a manifestation of chronic diabetes, especially in patients with suboptimal glycem ic control. In these patients, cataracts are thought to result from the gradual accumulation of intralenticular sorbitol. This process would take longer than one week to develop. {Choice B) Diabetic retinopathy, particularly macular edema during the nonproliferative stage of retinal microangiopathy, can cause blurred vision. However, this would be expected to develop more chronically (usually in association with poor glycemic control over time) than the acute change in vision described above. {Choice C) This patient is hypertensive, but acute vision changes (secondary to retinal hemorrhages, exudates, and/or papilledema) require blood pressure elevations to malignant values (DBP > 120-130) {Choice E) While acute infectious conjunctivitis, uveitis, and/or retinitis can potentially cause blurred vision, the process is usually monocular , and there are generally signs on physical examination. {Choice F) Lacunar strokes typically present with pure motor or pure sensory deficits, ataxia (imbalance) , and/or dysarthria (slurred speech) with hand weakness/cl umsiness. Oftentimes lacunar strokes are clinically silent Visual fields are infrequently affected.
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{Choice G) DKA is rare in patients with Type 2 diabetes. Whereas insulin is inadequate to prevent hyperglycemia in Type 2 diabetics, there is generally sufficient insulin action to avoid metabolic acidosis caused by accumulation of circulating ketones as occurs in Type 1 diabetics with DKA. Educational objective: Type 2 diabetics are prone to the development of a hyperosmolar hyperglycemic state without ketoacidosis. Decreased consciousness is the most common symptom. Other reversible neurologic abnormalities, such as blurred vision, can also be caused be hyperglycemic hyperosmolarity.
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0 A Do you feel down, depr 0 B. Do you have a safety p 0 C. I am going to call the p 0 D. Tell me more about the
o E. These bruises are clea
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A 32-year-old woman comes to the physician with lower back pain for the past week. She developed the pain after lifting some heavy furniture. She has no other symptoms Physical examination shows mild paraspinal muscle tenderness. There is no radiation of pain with straight .. . f h.o I . LJ. leg raise on either side, and no n multiple bruises of various ages [1;] Save are pointed out, the woman begi the following is the most appropr
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A 32-year-old woman comes to the physician with lower back pain for the past week. She developed the pain after lifting some heavy furniture. She has no other symptoms Physical examination shows mild paraspinal muscle tenderness. There is no radiation of pain with straight leg raise on either side, and no neurologic deficits are noted in the lower extremities. However, multiple bruises of various ages are noted on her abdomen, back, and chest W hen the bruises are pointed out, the woman begins to cry. She is also quiet and avoids eye contact W hich of the following is the most appropriate initial response?
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Do you feel down, depressed, or hopeless?
0 B. Do you have a safety plan to leave the situation? 0 C. I am going to call the police to come investigate
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0 E. These bruises are clearly from abuse and you do not deserve to be treated like this.
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Explanation: Physicians should be alert to clues suggesting physical abuse as patients may not always report such incidents spontaneously Multiple bruises, recurrent fractures, or repeated visits to the physician for unexplained injuries are all signs of possible abuse. In cases of possible abuse, the physician must be able to conduct an effective patient interview to provide proper ca re, ensure patient safety, and fulfill legal reporting requirements The initial statement in such cases should be made tactfully and take into account the patient's personality, emotional state, socioeconomic and cultural background, and the broader phys ician-patient relationship Open-ended questions and general statements of observation usually provide the best introduction to such a discussion and allow patients to discuss the issues in their own words. Acknowledging the patient's feelings and/or encouraging further dialogue aboutthe bruises would be good starting points {Choice A) Patients who are victims of abuse may have significant associated emotional symptoms, whether as a result of the abuse itself, from pre-existing affective illness, or from concurrent substance abuse. However, the physician should first gain an understanding of the abuse situation and then ensure immediate patient safety Once immediate safety has been addressed, the physician and patient can discuss what steps may be taken to address concurrent affective symptoms (Choice B) At some point in the conversation, the phys ician should discuss a safety plan with the patient However, before making specific recommendations, it is necessary to understand the nature of the possible abuse and explore what options she may have already considered. (Choice C) Advising the patient to consider reporting the incident to the police may be appropriate in cases of suspected abuse, but this is not a good opening statement The prospect of filing charges may frighten the patient into denying the abuse and discourage a more thorough discussion of the issue. (Choice E) Although the physician may suspect abuse, it is important not to make unfounded assumptions. The possibility of abuse should be explored in an open and ca ring conve rsation
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concurrent substance abuse. However, the physician should first gain an understanding of the abuse situation and then ensure immediate patient safety Once immediate safety has been addressed, the physician and patient can discuss what steps may be taken to address concurrent affective symptoms (Choice B) At some point in the conversation, the physician should discuss a safety plan with the patient However, before making specific recommendations, it is necessary to understand the nature of the possible abuse and explore what options she may have already considered. (Choice C) Advising the patient to consider reporting the incident to the police may be appropriate in cases of suspected abuse, but this is not a good opening statement The prospect of filing charges may frighten the patient into denying the abuse and discourage a more thorough discussion of the issue. (Choice E) Although the physician may suspect abuse, it is important not to make unfounded assumptions. The possibility of abuse should be explored in an open and caring conversation with the patient Value judgments, if any, should originate from the patient rather than the physician
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Educational objective: Patients who are victims of suspected physical abuse should be approached with empathic interviewing techniques. The physician should ask open-ended questions to allow patients to describe their situation on their own terms. The first priorities are to obtain an accurate and thorough understanding of the abuse and take any necessary action to ensure patient safety Additional steps may then be needed to address concurrent emotional symptoms and satisfy legal reporting requirements References: 1. Screening for intimate partner violence and abuse of elderly and vulnerable adults: U.S. preventive services task force recommendation statement.
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A 44-year-old psychology professor with a chronic history of rheumatoid arthritis presents for a follow-up examination. She is currently taking prednisone and infliximab, a regimen that has successfully stabilized her condition. Physical examination reveals no significant changes. Toward the end of the visit, she mentions that she would like to try acupuncture as an adjunct treatment in addition to the medications she is currently taking. What is the most appropriate response to her request?
A ''I'm sorry, but I am not ve ry familiar with acupuncture and am r.eluctant to combine the 6 two therapies " 6 B. "I hope you are aware that acupuncture has its limitations."
e; C. "If you want to try acupuncture, I cannot continue serving as your physician "
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6 D. "Why do you want to try acupuncture?"
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e; E. "How can an educated woman like you suggest something like this?"
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All patients enjoy the right to select treatment plans based on their personal values or preferences W hen a patient expresses interest in alternative medicine, the physician should inquire about the reasons for departing from traditional treatments. It is important to determine if the patient is dissatisfied with the quality of her current care or if she is suffe ring from a bothersome side effect Therefore, it would be most appropriate to ask this patient why she is interested in acupuncture as an adjunct treatment (Choice A) Because alternative medicine is enjoying increasing popularity, physicians have the obligation to become familiar with the most commonly used non-traditional therapies, their side effects, and any potential drug interactions. In this instance, the physician must be prepared to discuss acupunctu re and any contraindications or adverse effects were it to be added to her treatment regimen (Choice B) The physic ian should encourage the patient to obtain relevant literature and educational information about acupuncture from reliable sources. This should not be recommended in an attempt to instill fea r into the patient, but instead to enable the patient to make well-informed decisions. If the physic ian is already aware of potentially harmful interactions, the patient should be told about them. The first step, however, is to discover why the patient is interested in adding this alternative therapy to the treatment regimen
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(Choice C) The physician should not abandon a patient who is interested in exploring an alternative treatment Instead, the patient's preferences should be respected and the patient encouraged to learn more about the available options {Choice E) Ridiculing the patient for an interest in alternative therapy will inevitably undermine all future doctor-patient communication. Instead, physicians should encourage patients to keep them informed about any alternative treatments undertaken. Physicians should also seek to educate themselves about the more popular alternative medicines so that they can properly discuss potential side effects or drug interactions with patients Educational Objective: W hen a patient is interested in alternative therapy, the physician should fi rst inquire as to why
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A 45-year-old woman comes to the physician due to several months of progressively worsening watery diarrhea. She has cramps in her leg muscles and feels very dehydrated She also has mild abdominal discomfort and describes her stools as tea colored. The patient has episodic fl ushing in her face. She follows a normal diet and has no fever or weight loss. There has been no recent travel to unusual places The patient smokes 1-2 cigarettes a day and drinks socially Her temperature is 36.8 C (98.1 F), blood pressure is 108/64 mm Hg, pulse is 118/min, and respirations are 18/min. Abdom inal examination shows a nontender abdomen with normoactive bowel sounds. Laboratory results are as follows . W hite blood cells
5600/~L
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A CT scan of the abdomen shows a 3-cm mass in the panc reatic tail. Which of the following is the most likely diagnosis?
6 A Carcinoid syndrome
6 B. Gastrinoma
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Her temperature is 36.8 C (98 1 F) , blood pressure is 108/64 mm Hg, pulse is 118/min, and respirations are 18/min. Abdominal examination shows a nontender abdomen with normoactive bowel sounds. Laboratory results are as follows .
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20 mEq/L
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A CT scan of the abdomen shows a 3-cm mass in the pancreatic tail. W hich of the following is the most likely diagnosis?
<0 A Carcinoid syndrome <0 B. Gastrinoma <0 C. Pancreatic adenocarcinoma <0 D. Systemic mastocytosis <0 E. VIPoma Submit
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Explanation:
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Clinical features of VIPoma
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Clinical presentation
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Laboratory findings
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• Watery diarrhea • Hypo- or achlorhydria due to l gastric acid secretion • Associated flushing, lethargy, nausea, vomiting, muscle weakness/cramps
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Hypokalemia (jintestinal potassium secretion) Hypercalcemia (increased bone resorption) Hyperglycemia due to increased glycogenolysis Stool studies show secretory diarrhea with j sodium & osmolal gap <50 mOsm/kg
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• Watery diarrhea with VIP level >75 pg/ml • Abdominal CT or MRI to localize tumor in pancreas (usually in pancreatic tail)
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Diagnosis
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@USMLEWorld, LLC
This patient's presentation suggests VIPoma, a rare tumor affecting the pancreatic cells that produce vasoactive intestinal peptide (VIP) Most affected adults are between ages 30-50. VIP binds to intestinal epithelial cells to increase fl uid and electrolyte secretion in the intestinal lumen. Most patients develop VIPoma syndrome (pancreatic cholera) with watery diarrhea (can be tea colored and odorless), muscle weakness/cramps (due to hypokalemia), and hypo- or achlorhydria (due to decreased gastric acid secretion) The stool volume can be greater than 3Uday, leading to significant volume depletion Other findings include facial fl ushing, lethargy, nausea, vomiting, abdominal pain, and weight loss. Patients can also have coexisting
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3U day , leading to significant volume depletion Other findings include fac ial flushing, lethargy , nausea, vomiting, abdominal pain, and weight loss. Patients can also have coexisting hyperparathyroidism as part of multiple endocrine neoplasia (MEN) syndrome. Laboratory studies usually show hypokalemia due to increased intestinal potassium secretion. Other possible findings include hypercalcemia (due to increased bone resorption) and hyperglycemia (due to increased glycogenolysis) Stool studies are consistent with secretory diarrhea and show increased stool sodium and stool osmolal gap <50 mOsm/kg A VIP level >75 pg/ml confirms VIPoma diagnosis. Abdominal imaging (c ross-sectional triple-phase abdominal CT or MRI) can localize the tumor in the pancreas. Nearly 75% of VIPomas are in the pancreatic tail and 60%-80% have metastasized to the liver by the time of diagnosis Treatment involves intravenous volume repletion, octreotide to decrease diarrhea, and possible hepatic resection in patients with metastasis to the liver. (Choice A) Carcinoid syndrome can cause flushing, diarrhea, and bronchospasm. However , nearly 70%-80% of carcinoid tumors occur in the small intestine and do not usually involve the pancreas.
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(Choice B) Gastrinomas can occur in the pancreas and cause diarrhea. However, they cause inc reased gastrin release with multiple gastric ulcers and dyspepsia (Zollinger-EIIison syndrome). In addition, they are not usually associated with facial flushing (seen in this patient)
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{Choice C) Pancreatic adenocarcinoma involving the tail typically presents with abdominal and/or back pain, though it may occasionally cause steatorrhea, jaundice, or weight loss. The severe watery diarrhea with significant hypokalemia is more consistent with a neuroendocrine tumor like VIPoma. (Choice D) Systemic mastocytosis involving the gastrointestinal tract can cause steatorrhea, hepatomegaly, and peptic ulcer disease. Patients also usually develop skin symptoms including pruritus, fac ial flushing, and urticaria. However, mastocytosis would not cause the pancreatic mass seen in this patient Educational objective: VIPoma is a rare tumor affecting the pancreatic cells that produce vasoactive intestinal peptide .. -- - - - - - - - - - •------- --- - ----- - - - -- ---
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involves intravenous volume repletion, octreotide to decrease diarrhea, and possible hepatic resection in patients with metastasis to the liver. {Choice A) Carc inoid syndrome can cause fl ushing, diarrhea, and bronchospasm However , nearly 70%-80% of carcinoid tumors occur in the small intestine and do not usually involve the pancreas. (Choice B) Gastrinomas can occur in the panc reas and cause diarrhea. However , they cause increased gastrin release with multiple gastric ulcers and dyspepsia (Zollinger-EIIison syndrome). In addition, they are not usually associated with facial fl ushing (seen in this patient). (Choice C) Pancreatic adenocarcinoma involving the tail typically presents with abdominal and/or back pain, though it may occasionally cause steatorrhea, jaundice, or weight loss. The severe watery diarrhea with significant hypokalemia is more consistent with a neuroendocrine tumor like V IPoma.
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{Choice D) Systemic mastocytosis involving the gastrointestinal tract can cause steatorrhea, hepatomegaly , and peptic ulcer disease. Patients also usually develop skin symptoms including pruritus, facial flushing, and urticaria. However , mastocytosis would not cause the pancreatic mass seen in this patient Educational objective: VI Poma is a rare tumor affecting the pancreatic cells that produce vasoactive intestinal peptide (V IP) Most patients develop VIPoma syndrome (panc reatic cholera) with watery diarrhea, muscle weakness/cramps (due to hypokalemia), and hypo- or achlorhydria (due to decreased gastric acid secretion) Stool studies are consistent with secretory diarrhea; a V IP level >75 pg/ml confi rms VIPoma diagnosis References: 1. Pancr eatic VIPomas: subject review and one institutional exper ience
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A 35-year-old woman established primary ca re at a clinic 3 months ago. Last month, she arrived unannounced, urgently requesting to see the same physician Due to a cancellation, she was seen later that day for the complaint of a rash on her chest The male physician completed a thorough but unremarkable physical examination in the presence of a female nurse practitioner . Two weeks later , the patient comes to the same physician's office at closing time and without an appointment She complains of "needing to talk to the doctor immediately about a private matter. " She informs the receptionist that it is "absolutely critical" for her to be seen and examined for similar skin complaints that seem to "come and go" and "itch frequently " The patient is calm but insists that an appointment with the female nurse practitioner is not acceptable and instead requests to see the physic ian privately, without the presence of another staff member. W hich of the following would be the most appropriate initial response by the physician?
A Ask the patient to have a seat in the office and proceed with the unscheduled 6 appointment
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C. Have the receptionist instruct the patient to schedule an appointment during normal 6 office hours.
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E. Transfer the patient's care to a partner who is on call for the evening and available by phone
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Explanation: This question addresses the importance of maintaining professional conduct when dealing with patients of all types, ranging from hostile to seductive. Several actions suggest that this patient could have boundary issues. These include • A rrival at unscheduled times and/or at closing time (when others are less likely to be available) • Insistence on seeing the same physician for each visit (for mild conditions) and in private • Frequent return visits fo r nonspecific complaints • Health complaints that necessitate examination of private areas or undressing, despite recent normal findings To maintain a therapeutic distance, the physician should have the receptionist politely inform the woman that patients are seen only when they have scheduled appointments during normal office hours and with the presence of another staff member .
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(Choice A) Having an unscheduled appointment with the patient under these circumstances would only blur the doctor-patient relationship boundary Instead, the physician should maintain a professional demeanor and discuss the patient's medical concerns during a scheduled appointment (Choice B) Although the patient has inappropriate expectations, the situation does not appear to involve imminent concern for impending violence or escalation of her demands. Thus, contacting security is not likely to be necessary (Choice D) The correct approach, even for seductive patients, is to provide the required medical care in a professional manner. This is not an emergency, so having the patient return for a scheduled visit, as opposed to telling her she is not to come back, would be appropriate (Choice E) It is the end of the work day, and there is likely no need for the partner to take any immediate action. Thus, transferring care is not indicated.
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could have boundary issues. These include: • Arrival at unscheduled times and/or at closing time (when others are less likely to be available) • Insistence on seeing the same physic ian fo r each visit (fo r mild conditions) and in private • Frequent return visits fo r nonspecific complaints • Health complaints that necessitate examination of private areas or undressing, despite recent normal findings To maintain a therapeutic distance, the physician should have the receptionist politely inform the woman that patients are seen only when they have scheduled appointments during normal office hours and with the presence of another staff member. (Choice A) Having an unscheduled appointment with the patient under these circumstances would only blur the doctor-patient relationship boundary. Instead, the physician should maintain a professional demeanor and discuss the patient's medical conce rns during a scheduled appointment
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(Choice B) Although the patient has inappropriate expectations, the situation does not appear to involve imminent concern for impending violence or escalation of her demands. Thus, contacting security is not likely to be necessary (Choice D) The co rrect approach, even for seductive patients, is to provide the required medical ca re in a professional manner. This is not an emergency, so having the patient return for a scheduled visit, as opposed to telling her she is not to come back, would be appropriate. (Choice E) It is the end of the work day, and there is likely no need for the partner to take any immediate action. Thus, transferring care is not indicated. Educational objective: W hen dealing with difficult patients, the physician must mainta in professional conduct and responsibilities while addressing their medical and psychological needs. Time Spent 3 seconds
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A 42-year-old woman comes to the emergency department with painful skin lesions. She is unable to eat or drink due to painful blistering and ulceration in her mouth and throat The rash was preceded by feve r, headache, sore throat, cough, nausea, and vomiting. She was treated for acute cystitis with trimethoprim-sulfamethoxazole 5 days ago, but her past history is otherwise unremarkable. Her temperature is 38.3 C (101 F) , blood pressure is 95/60 mm Hg, pulse is 11 0/min, and respirations are 14/min. On examination, the skin is hot and tender with widespread confluent erythematous macules that cover most of the visible skin surface . The oral mucosa shows blistering and erosions. A photograph of her back is shown below.
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What is the most likely diagnosis?
<0 A Erythema multiforme <0 B. Exfoliative dermatitis <0 C. Staphylococcal scalded skin syndrome <0 D. Stevens-Johnson syndrome <0 E. Toxic epidermal necrolysis Submit
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Stevens-Johnson syndrome & toxic epidermal necrolysis <10% of BSA: SJS Nomenclature
>30%: TEN
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Clinical features
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• 4-28 days after exposure to trigger (2 days after repeat exposure) • Acute influenza-like prodrome • Rapid-onset erythematous macules, vesicles, bullae • Necrosis & sloughing of epidermis • Mucosal involvement Drugs
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10%-30%: SJSfTEN overlap
Common triggers
• Allopurinol • Antibiotics (eg, sulfonamides) • Anticonvulsants (eg, carbamazepine, lamotrigine, phenytoin) • NSAIDs (eg, piroxicam) • Sulfasalazine Other • Mycoplasma pneumoniae • Vaccination
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• Anti biotics (eg, sulfonamides) • Anticonvulsants (eg, carbamazepine, lamotrigine, phenytoin) • NSAIDs (eg, piroxicam) • Sulfasalazine
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• Mycoplasma pneumoniae • Vaccination • Graft-vs-host disease BSA = body surface area; NSAIDs = nonsteroidal anti-inflammatory drugs; SJS Stevens-Johnson syndrome; TEN toxic epidermal necrolysis.
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This patient's clinical features - acute mucocutaneous disorder with associated systemic toxicity, following use of sulfonamide antibiotics - are consistent with toxic epidermal necrolysis (TEN) TEN is an inflammatory hypersensitivity reaction to drugs (especially sulfonamides, nonsteroidal antiinflammatory drugs, anticonvulsants and allopurinol) or certain infections (usually Mycoplasma pneumoniae) Clinical features of TEN are variable, but typically include coalesc ing erythematous macules, bullae, desquamation, and mucositis . Patches of skin slide off with light pressure (positive Nikolsky's sign) Systemic signs are common and may include fever, tachyca rdia, hypotension, altered level of consciousness, conjunctivitis, seizures, and coma. The exact pathogenesis is unknown. TEN and Stevens-Johnson syndrome (SJS) are related disorders and may be considered on a continuum of severity By convention, SJS denotes involvement of <10% of body surface area (Choice D), >30% is designated TEN, and 10-30% is referred to as a SJS!TEN overlap syndrome. The treatment of TEN and SJS is primarily supportive, with wound ca re similar to that for burns (and often provided in a designated burn unit) Aggressive fluid support is often needed due to poor oral intake and profound cutaneous fluid loss. Secondary infections are common, and antiseptic precautions are needed. 1•
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TEN and Stevens-Johnson syndrome (SJS) are related disorders and may be considered on a continuum of severity By convention, SJS denotes involvement of <10% of body surface area (Choice D), >30% is designated TEN, and 10-30% is referred to as a SJS!TEN overlap syndrome. The treatment of TEN and SJS is primarily supportive, with wound ca re similar to that fo r burns (and often provided in a designated burn unit) Aggressive fluid support is often needed due to poor oral intake and profound cutaneous fluid loss. Secondary infections are common, and antiseptic precautions are needed. (Choice A) Erythema multiforme (EM) is characterized by sudden onset erythematous rash and target lesions and usually occurs after a herpes simplex virus infection. EM may appear similar to mild SJS!TEN, but bullae and desquamation are less common, mucosal involvement is rare, and systemic symptoms are not as prominent as in SJS!TEN. (Choice B) Exfoliative dermatitis (also known as erythroderma) is a widespread, scaly eruption of the skin. It may be drug-induced, idiopathic , or secondary to an underlying dermatological or systemic disease. {Choice C) Staphylococcal scalded skin syndrome is a syndrome of acute exfoliation of skin caused by a toxin that is produced by Staphylococcus aureus. The skin is tender and wa rm, with a sandpaper-like, diffuse erythematous rash. Other features include bullae, positive Nikolsky's sign, facial edema, perioral crusting, and dehydration It is usually seen in children less than 6 yea rs of age Educational objective: Toxic epidermal necrolysis (TEN) is a severe syndrome characterized by the sudden onset of mucocutaneous lesions and systemic signs of toxicity Typical features include an erythematous eruption that rapidly evolves into exfoliation of the skin. It is most often caused by medications (eg antibiotics, anticonvulsants, allopurinol). TEN and Stevens-Johnson syndrome (SJS) are similar disorders distinguished by the percentage of involved skin SJS involves <1 0% of the body surface area, TEN involves >30, and SJS!TEN overlap syndrome involves 10-30%. Refer ences: 1. The current understanding of Stevens-Johnson syndrome and toxic epidermal
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A 65-year-old heavy smoker with a lengthy history of chronic obstructive pulmonary disease comes to the office due to recent-onset hemoptysis He reports 3-5 episodes of coughing up blood in the past month. He also reports a 9.1-kg (20-lb) weight loss in the past 2 months. Chest radiograph reveals a suspicious lesion, and a bronchoscopy followed by biopsy establishes the diagnosis of squamous cell carcinoma of the lung. W hen the patient is informed of his condition and the prognosis, he asks that no one in his family be told the news yet He seems tearful but cognitively intact His wife , who usually brings him to his visits and is also his health ca re proxy , calls the next day to inquire about the pathology report She says she is deeply concerned because her husband is reluctant to discuss his condition. Which of the following is the most appropriate course of action?
A Ask the wife to come to the office with a copy of the patient's health care proxy fo rm.
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B. In response to the wife's concerns, ask her to come to the office to further review the patient's status.
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C. In response to the wife's concerns, inform her that the patient will receive comprehensive care.
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D. Inform the patient that his wife must eventually be told if the patient refuses to do so himself.
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B. In response to the wife's concerns, ask her to come to the office to further review the patient's status.
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C. In response to the wife's conce rns, inform her that the patient will receive comprehensive care.
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D. Inform the patient that his wife must eventually be told if the patient refuses to do so himself.
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E. Info rm the wife of the pathology report results as she is his health care proxy
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F. Inform the wife that it would not be appropriate to discuss the patient's information.
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himself. [4%) E. Inform the wife of the pathology report results as she is his health ca re proxy [2%) F. Inform the wife that it would not be appropriate to discuss the patient's information. [83%)
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Explanation: Health information cannot be shared with anyone (including family members) without the patient's permission. This patient's wishes must be respected and his confidentiality str ictly maintained. That said, he should be strongly encouraged to discuss his diagnosis with his spouse as she will be significantly impacted by it Moreover, she may be able to provide moral support to her husband, thereby easing his burden. The phys ic ian should encourage an open dialogue between the patient and his wife but should in no way coerce the patient to share the information {Choice D) (Choices A and E) The health care proxy is in effect only if the patient is deemed to have insufficient capacity to make decisions regarding his medical treatment (eg, delirious, nonresponsive) In this case it is not in effect, as there is no indication that the patient lacks capacity (Choices B and C) W ithout the patient's permission, it would be inappropriate to reveal any information to his wife about his condition or ca re over the phone or in person Educational objective: Medical information should be shared with family members only with the patient's permission References: 1. Patient and provider relationships: consent, confidentiality, and managing mistakes in integrated primary car e settings.
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The following vignette applies to the next 2 items. The items in the set must be answered in sequential order. Once you click Proceed to Next Item, you will not be able to add or change an answer.
Item 1 of 2 A tertiary care hospital undergoes an independent review of malpractice claims related to missed or delayed diagnoses that have occurred over the past 10 years in the emergency department A large proportion of these errors led to serious harm, with approximately half resulting in death. The review concludes that the rate of these mistakes in the hospital's emergency department is 25% higher than in compa rable hospitals nationwide. The hospital administration convenes an internal comm ittee to address this issue. W hich of the following is the most likely underlying cause of the majority of these medical errors?
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A. Communication failures between provider s
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E. Lack of detailed signout notes
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C. High emergency department volume (9%) D. Lack of computerized patient handoff tools [3%) E. Lack of detailed signout notes [8%) Explanation: Discontinuity is an unfortunate but unavoidable reality of hospital ca re, with multiple providers assuming responsibility for a patient's care at different times of the day. The process of transferring responsibility for medical care is referred to as a patient handoff, with "signout" referring to the process of transmitting info rmation about the patient and needed follow-up care. Oversights and communication failures during the signout and handoff pr ocess have been linked to adverse clinical events in a range of hospital settings Omission of key information during handoffs often results in near-misses, avoidable escalations in care (eg, transfer to the intensive care unit) , inefficiencies in care, and delays in diagnosis or treatment (Choices B and C) Although high patient volume or acuity can increase the probability of medical errors, these are not the underlying reasons why medical errors occur. (Choice D) Although computerized handoffs have become part of electronic medical record systems, there is minimal evidence supporting their ability to improve handoff quality or patient outcomes. (Choice E) Increasing the level of detail in signout notes has not been found to improve error rates stemming from the patient signout process Overly detailed notes can often lead to difficulty in locating important information in emergencies or inability to see the "big picture " Educational objective: Communication failures between physicians during patient handoffs are a large contributor to medical errors and adverse patient outcomes. References: 1. Missed and delayed diagnoses in the emergency department: a study of closed
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e; A Implementing a signout checklist
® B. Inclusion of nurses and social workers in the signout process ® C. Increasing the length of time allotted for signout ® D. Mandating a face-to-face signout procedure ® E. Minimizing interruptions Submit
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Following a prolonged investigation, the hospital determines that the majority of the missed or delayed emergency department diagnoses are directly linked to communication failures among physicians during the signout process W hich of the following has been found to most effectively improve communication of relevant information during patient transfers?
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D. Mandating a face-to-face signout procedure [27%1 E. Minimizing interruptions [6%I Explanation:
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Medical errors resulting from communication failures between medical providers are most effectively addressed by implementing a systematic signout process that includes checklists to improve efficacy and accuracy. Patient transfers should be conducted verbally and supplemented with an updated and clea r written component Ideally, transfers should occur face to face (with minimal interruptions) , but this has not been found to be as effective as implementing systematic checklists as part of the signout procedure (Choices D and E). Essential components of an effective signout checklist include do not resuscitate/do not intubate status, hospital course and recent events, current condition, and anticipatory info rmation (eg, "if the patient's mental status changes, check a blood gas and consider transfer back to ICU"). During the signout process, physicians should go through each of these categories systematically to ensure that no important info rmation is missed.
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(Choice B) Although conducting signout with other team members could provide additional info rmation or concerns about the patient, this would be impractical. Interdisciplinary rounds would be a more appropriate setting fo r the whole team to discuss the patient at greater length, including discharge planning and follow-up care. (Choice C) Although physicians should designate an appropriate amount of time fo r patient signouts, increased time for patient transfers does not necessarily lead to improved signout quality or better outcomes. Educational objective: Checklists are an important tool to prevent undesired medical outcomes that result from physician communication failures during the patient handoff process References: IJ
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A 70-year-old man is brought to the emergency department after his daughter found him lethargic and confused in his home. He was sick with a "cold" for the past 2 days. The patient lives alone and ambulates with a walker after suffering a stroke 5 years ago. His daughter lives nearby and helps him with his activities. On arrival, his temperature is 38 C (1004 F), blood pressure is 90/65 mm Hg, pulse is 112/min, and respirations are 24/min. Mucous membranes are dry His airway is maintained, and oxygen is administered. Intravenous access is secured, and blood and urine samples are drawn. Laboratory results are as follows: Sodium
134 mEq/L
Potassium
5.9 mEq/L
Chloride
101 mEq/L
Bicarbonate
22 mEq/L
Blood urea nitrogen
110 mg/dl
Glucose
1000 mg/dl
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Serum calcium
9.2 mg/dl
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Amylase
100 U/L
Aspa rtate aminotransferase
15 U/L
Alanine aminotransferase
17 U/L
pH
74 0
PaC02
38 mm Hg
Pa02
90 mm Hg
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Bicarbonate
22 mEq/L
Blood urea nitrogen
110 mg/dl
Glucose
1000 mg/dl
Serum calc ium
9.2 mg/dl
Amylase
100 U/L
Aspa rtate aminotransferase
15 U/L
Alanine aminotransferase
17 U/L
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pH
740
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PaC02
38 mm Hg
Pa02
90 mm Hg
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A rterial blood gases:
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W hich of the following is the best initial treatment for this patient?
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® A 045% saline ® B. Long-acting insulin analogue ® C . Normal saline ® D. Potassium chloride ® E. Sodium bicarbonate ® F. Subcutaneous insulin
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Explanation:
Hyperosmolar hyperglycemic state 11 12
• Type 2 diabetes • Older age
Patient characteristics
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• Gradual hyperglycemic symptoms (eg, polyuria, polydipsia)
Clinical symptom s
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• Altered mentation
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Laboratory studies
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Glucose >1000 mg/dl Normal pH & bicarbonate Normal anion gap Negative or small serum ketones Serum osmolality >320 mOsm/kg
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• Aggressive hydration with norm al saline • Intravenous insulin • Careful monitoring & supplementation of potassium
Initial management
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@UWortd
This patient has severe hyperglycemia associated with acute mental status changes consistent with hyperosmolar hyperglycemic state (HHS) Unlike diabetic ketoacidosis (OKA), HHS is caused by a relative rather than absolute insulin deficiency, and accumulation of ketoacids will be minimal (arterial pH and anion gap are typically normal) However, the plasma glucose is often >1000 mg/dl (compared to 300-500 mg/dl in DKA) and the effective plasma osmolality, (2 x 1 .,
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minimal (arterial pH and anion gap are typically normal) However, the plasma glucose is often >1000 mg/dl (compared to 300-500 mg/dl in DKA) and the effective plasma osmolality, (2 x plasma sodium [mEq/L)) + (plasma glucose [mg/dl) + 18), can be severely elevated (often >320 mOsm/kg) Severe hyperglycemia induces an osmotic diur esis, which can lead to a deficit of 8-10 liters in total body water. In light of this, fluid replacement is the most important initial step in management of HHS, and aggressive hydration will improve tissue perfusion and responsiveness to insulin therapy This patient has prominent evidence of dehydration with hypotension, tachycardia, and dry mucous membranes. Normal saline (NS) is recommended for volume resuscitation in the first few hours of treatment (regardless of sodium levels), with a subsequent change to 0.45% NS if the co rrected sodium (measured sodium in mEq/L + [2 mEq/L sodium for each 100 mg/dl that glucose is above 100 mg/dL)) is normal or high on repeat laboratory testing (Choice A)
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(Choices 8 and F) Glucose can be lowered with ca reful insulin therapy; intravenous regular or short-acting insulin is preferred to subcutaneous insulin, as hypovolem ia and systemic vasoconstriction in HHS can lead to erratic absorption of insulin from subcutaneous tissues. Subcutaneous insulin can sometimes be administered in patients with mild DKA but would not be appropriate fo r this patient with HHS and marked hypovolemia (Choice D) Most patients, including those with normal initial serum potassium levels , will have a total body potassium deficit, and insulin therapy can rapidly cause hypokalemia as it drives potassium into cells. Therefore, potassium should be monitored frequently , with supplemental potassium added to intravenous fluids if levels are between 3.3 and 5.3 mEq/L (Choice E) Infusion of sodium bicarbonate is sometimes used in patients with DKA and severe acidosis (pH <6 9) It is not needed in HHS. Educational objective: Hyperosmolar hyperglycem ic state is characterized by severe hyperglycemia with mental status changes. Severe hyperglycemia induces an osmotic diuresis, which can lead to a deficit of 8-10 liters in total body water. Fluid replacement with normal saline is the most important initial step in management of hyperosmolar hyperglycemic state.
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A 21-year-old woman comes to the office with 5 months of fatigue, excessive sweating, and palpitations The patient is slightly overweight and had previously been unsuccessful in losing weight with caloric restriction and exerc ise. However, she has lost weight during the past 6 months with an over-the-counter weight loss remedy The patient has had no menstrual periods fo r the last 3 months. She is not sexually active. Her blood pressure is 136/70 mm Hg and pulse is 100/min. Her BMI is 26 kg/m2 The patient has lid lag but no proptosis Examination of the thyroid shows a small gland without nodules or tenderness. Laboratory findings are as follows: TSH
low
Free T4
high
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negative
Radioiodine uptake by the thyroid gland is diffusely decreased. Which of the following would most likely be found in this patient?
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ID A Elevated antithyroid peroxidase antibody titer
6 B. Elevated erythrocyte sedimentation rate ID C. Elevated serum alpha-subunit level
6 D. Elevated TSH receptor antibody titer ® E. Low serum thyroglobulin level Submit
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Evaluation of hyperthyroidism Measure TSH, Free T3 & T4
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Primary hyperthyroidism • TSH iow • Free T3 & T4 high
Secondary hyperthyroidism • TSH high • Free T3 & T4 high
Signs of Graves disease (goiter+ ophthalmopathy)?
MRI pituitary gland
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No
Yes
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Low
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1 Gravesdisease
1 • Toxic adenoma • Multinodular goiter
High '
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• Thyroiditis • Iodide exposure
Exogenous hormone
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• Toxic adenoma • Multinodular goiter
• Thyroiditis • Iodide exposure
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@UWorld
This patient, with fatigue, sweating, palpitations, and weight loss, has features of hyperthyroidism The first step in evaluating hyperthyroidism is to measure serum TSH and free T4 levels. In the absence of a TSH-secreting pituitary adenoma (secondary hyperthyroidism), patients with hyperthyroidism will have an elevated T4 and suppressed TSH. The most common cause of hyperthyroidism is Graves' disease, which is caused by an autoantibody to the TSH receptor and is characterized by a diffuse goiter and ocular abnormalities (proptosis, periorbital edema) Patients with clear features of Graves' disease may be managed accordingly, but those without require further investigation. Patients with undiagnosed hyperthyroidism may be evaluated further with radioactive iodine uptake (RAIU), usually with scan. A high RAIU suggests de novo hormone synthesis due to Graves' disease (diffusely increased uptake) or toxic nodular disease (nodular uptake). In contrast, a low RAIU suggests either release of preformed thyroid hormone (ie, thyroiditis) or exogenous thyroid hormone intake. In such cases, the serum thyroglobulin level can make the distinction: elevated thyroglobulin is consistent with endogenous thyroid hormone release whereas decreased thyroglobulin suggests exogenous or factitious thyrotoxicosis. In this patient, it is likely that her weight loss supplement contains thyroid hormone derived from porcine or other animal sources. (Choice A) Antithyroid peroxidase antibodies are seen in autoimmune thyroid disease (eg, Hashimoto thyroiditis) Patients usually present with a palpable goiter and clinical hypothyroidism Occasionally , patients with Hashimoto thyroiditis will present with a transient hyperthyroid phase, but RAIU is usually increased. (Choice B) Subacute thyroiditis (de Quervain's thyroiditis) is characterized by fever, neck pain, thyroid tenderness, and an elevated erythrocyte sedimentation rate. In most cases, hyperthyroid symptoms fade in <8 weeks as the thyroid gland becomes depleted of preformed hormone. (Choice C) TSH is comprised of 2 subunits, an alpha-subunit (common to TSH, FSH, LH, and
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distinction elevated thyroglobulin is consistent with endogenous thyroid hormone release whereas decreased thyroglobulin suggests exogenous or factitious thyrotoxicosis. In this patient, it is likely that her weight loss supplement contains thyroid hormone derived from porcine or other animal sources. {Choice A) Antithyroid peroxidase antibodies are seen in autoimmune thyroid disease (eg, Hashimoto thyroiditis) Patients usually present with a palpable goiter and clinical hypothyroidism. Occasionally, patients with Hashimoto thyroiditis will present with a transient hyperthyroid phase, but RAIU is usually increased. (Choice B) Subacute thyroiditis (de Quervain's thyroiditis) is characterized by fever, neck pain, thyroid tenderness, and an elevated erythrocyte sedimentation rate. In most cases, hyperthyroid symptoms fade in <8 weeks as the thyroid gland becomes depleted of preformed hormone. (Choice C) TSH is comprised of 2 subunits, an alpha-subunit (common to TSH, FSH, LH, and hCG) and a thyroid-specific beta-subunit Many TSH-secreting pituitary adenomas overproduce the alpha-subunit, and an elevated ratio of alpha-subunit to TSH suggests a pituitary adenoma. These patients would have an elevated TSH, elevated free T4, and normal or increased RAIU. (Choice D) This patient's absence of ophthalmopathy (eg, proptosis, periorbital edema) and low RAIU make Graves' disease unlikely Educational objective: In hyperthyroidism, increased radioactive iodine uptake (RAIU) suggests de novo thyroid hormone synthesis, whereas decreased RAIU suggests release of preformed hormone or exogenous hormone intake. Thyrotoxicosis due to exogenous thyroid hormone is characterized by low serum thyroglobulin levels. References: 1. Factitious thyrotoxicosis and herbal dietary supplement for weight reduction .
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A senior resident attends a medical conference at which a table sponsored by a drug company offers free flash drives for attendees. The resident needs a new flash drive for presentations and asks a friend whether it is appropriate to take one. The friend responds, "I think it is okay. It is not an expensive item and it won't affect how you prescribe " According to professional ethical guidelines, which of the following is the most appropriate course of action?
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A Do not take the flash drive as it is unethical to accept any gifts from pharmaceutical companies
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B. Do not take the flash drive as only small gifts that directly benefit patients are acceptable
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ID C. Take the flash drive as the gift costs less than $50, which is acceptable
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6 D. Take the flash drive as this gift will not influence patient care
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@ E. Take the flash drive, but only for personal and not professional use
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Physicians should exercise caution when accepting gifts from external parties, such as pharmaceutical and medical device companies, that have a direct interest in a medical practice. These gifts can influence a physician's prescriptions or practices, even on a subconscious leveL
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To safeguard patients and preserve the reputation of doctors, the American Medical Association (AMA) guidelines (Opinion 8 061 - Gifts to Physicians from Industry) suggest accepting nonmonetary gifts from interested parties only if the gifts directly benefit patient care and are of small monetary value (eg, unbiased educational materials, drug samples) No gifts of cash or high value, or with implied reciprocity , should be accepted The flash drive, although not of high monetary value (Choice C), does not directly benefit patient ca re and should not be accepted. {Choice A) Acco rding to AMA guidelines, nonmonetary gifts may be accepted if they directly benefit patients and are not of high value. Some physicians have decided that accepting any gift from the pharmaceutical industry, regardless of monetary value or alleged purpose, is against their personal ethics. (Choice D) Even when physicians do not consciously believe they are being unduly infl uenced, a gift can affect self-judgment in subtle or subconscious ways and may inadvertently cause harm to patients Acceptance of any gift should be considered with caution. (Choice E) Even if the flash drive is for only personal use, it may still influence practice and it does not directly benefit patient care. Displaying the drive may also promote pharmaceutical marketing Educational objective: Accepting gifts from interested third parties can influence a physician's practice in subtle or subconscious ways Only nonmonetary gifts that are of minimal value and that directly benefit the patient, such as unbiased educational material or drug samples, should be considered. References: 1. Changing interactions between physician trainees and the pharmaceutical
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An unconscious 42-year-old man is brought to the emergency department by ambulance after sustaining a gunshot wound to the chest during an attempted robbery at a convenience store. He is bleeding profusely The patient is minimally responsive to pain and is unable to provide any history The ambulance record indicates that his initial blood pressure was 120/70 mm Hg, pulse was 95/min, and respirations we re 16/min. The patient's current blood pressure is 70/40 mm Hg, pulse is 130/min, and respirations are 28/min. He has an open gunshot wound in the chest and an exit wound in the back. Intravenous fluids and vasopressors are started, and a blood transfusion is ordered. The patient's fiance arrives and states that he should not receive a blood transfusion because he is a devout Jehovah's W itness. No evidence is found in the medical chart of advance directives or a living will documenting the patient's wishes, and examination of his belongings show no blood refusal ca rd. W hich of the following is the most appropriate next step in management of this patient?
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0 A Adm inister high-dose erythropoietin and intravenous iron to stabilize blood loss
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0 B. Continue intravenous fl uids and consult the hospital ethics committee
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0 C. Obtain a court order for approval to administer the blood transfusion
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6 D. Proceed with the blood transfusion 0 E. W ithhold the blood transfusion because of the patient's religious beliefs
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This patient is a presumed Jehovah's Witness who presents with hemorrhagic shock and is likely to benefit from a transfusion that could prevent exsanguination. Because the patient lacks decision-making capacity, providers should determine if he has completed an advance directive that can guide treatment decisions. Most Jehovah's W itnesses carry advance directive cards that explicitly document the individual's refusal of a blood transfusion. In the case of adult patients, courts have consistently supported the right to refuse blood on religious grounds. In this case, no advance directive card is provided and delay in treatment could place the patient in serious harm. The Health Care Consent Act has been applied to Jehovah's W itnesses to allow transfusion to preserve a patient's life in an emer gency when no blood refusal ca rd is present. The patient's fiance is not a legal next of kin and cannot serve as a substituted decision-maker (Choice E) {Choice A) Case reports have shown some success in using high-dose erythropoietin, crystalloids, intravenous iron, and other products to address massive hemorrhage without a blood transfusion. These treatments could be discussed if the patient was conscious and refused a blood transfusion. (Choice B) Ethics committees provide advice if disagreements or ambiguity exist between health ca re providers and a patient/patient's fam ily on decisions involving withholding or withdrawing life-sustaining treatments. This patient needs treatment quickly , with no time for discussion with the ethics committee. (Choice C) Court approval is not needed for a phys ician to proceed with emergency life-saving treatment fo r an unconscious or unresponsive patient.
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Educational objective: In the absence of an advance directive, a life-saving blood transfusion can be given to a Jehovah's W itness who lacks decision-making capacity References: 1. The contemporary approach to the care of Jehovah's w itnesses.
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A 60-year-old man comes to the physician complaining of weight loss and fatigue A review of systems is positive for a change in bowel habits. Further evaluation shows the presence of colon ca rcinoma. The patient is told the diagnosis and is educated about his treatment options and prognosis; he listens politely and does not ask any questions. He is a high school graduate and worked in a car factory until taking extended sick leave in recent weeks. The patient appears to comp rehend the info rmation without difficulty He says he does not want treatment or intervention of any kind. The physician also serves as primary ca re physician for the patient's wife . W hat would be the most appropriate next step in addressing this situation?
6 A Ask the patient why he does not want treatment or intervention of any kind
e; B. Contact his wife and ask her to convince him to receive treatment
6 C. Provide the patient with literature about the benefits of surgery and chemotherapy
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e; D. Respect the patient's decision and do not schedule additional appointments
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6 E. Treat the patient against his wishes, obtaining a court order if necessary
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Explanation: Although this patient likely has the capacity to refuse treatment, his reasoning should first be thoroughly explored and discussed with the physician. He may be in a state of disbelief or denial or afraid of pain or unfamil iar procedures. Patient concerns may sometimes have a more philosophical basis, such as controlling one's destiny, or may be the result of inadequate understanding For example, this patient may have known others with cancer in the past and not be aware of significant advances in prolonging quality and quantity of life . Patients may also have mental health issues such as depression that can diminish their desire for treatment If the patient continues to refuse medical intervention despite cla rification and reassurance from the physician, then this decision should be respected and treatment withheld. (Choice B) This patient appears to have the capacity to make informed decisions about his care. Therefore, it would be inappropriate for the physician to contact family members as a means of pressuring him into compl iance (Choice C) After the matter has been discussed with the patient, he should be given additional literature and verbal information about his disease, its prognosis, and the risks and benefits of the available treatment options This would not be the first step, however, as the physician has already provided initial information.
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(Choice D) The patient's decision should indeed be respected; however, a cancer patient is in need of ongoing support Additional educational efforts and further development of a treatment alliance, family involvement, or change in the patient's condition may lead the patient to reconsider refusing treatment (Choice E) Treating this patient against his wishes would be unethical and would invite criminal charges of battery. It is therefore not an advisable course of action. Educational objective: When a patient refuses potentially life-saving treatment, it is important to fully discuss the specific reasons for the decision before honoring it - -
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A 35-year-old man comes to the physician with a 1-year history of fatigue and weakness. He has had significant loss of appetite and interest in day-to-day activities due to lack of energy. He also reports cold intolerance, a dull constant headache, erectile dysfunction, low libido, and constipation The patient has no fever , neck swelling, skin rash, head injury, or excessive urination. His tempe rature is 36.6 C (97 8 F), blood pressure is 98/72 mm Hg, pulse is 50/min, and respirations are 14/min. His skin is dry and pale. There are delayed deep-tendon reflexes on neurologic examination. His testes are small and soft on palpation. Laboratory results are as follows :
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Hemoglobin
10.2 g/dL
Leukocytes
5,000fi.IL
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Neutrophils
45%
Monocytes
5%
Eosinophils
10%
Lymphocytes
40%
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Sodium
132 mEq/L
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Glucose
56 mg/dL
Potassium
4.0 mEq/L
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Further evaluation in this patient would most likely show which of the following? FreeT.
Serum cortisol
Aldosterone
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I
5,000fi.IL
Neutrophils
45%
Monocytes
5%
Eosinophils
10%
Lymphocytes
40%
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Sodium
132 mEq/L
Glucose
56 mg/dL
Potassium
4.0 mEq/L
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Further evaluation in this patient would most likely show which of the following?
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Free T,
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Aldosterone
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Normal
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Low
Low
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C. Normal
Low
Low
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D. Normal
High
Low
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E. Normal
Normal
Low
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Explanation:
~ [] Clinical features of hypopituitarism
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Pituitary causes
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• Primary (eg, adenoma) or metastatic mass • Infiltration (eg, hemochromatosis, lymphocytic hypophysitis) • Hemorrhage (pituitary apoplexy) or infarction (Sheehan syndrome)
Hypothalamic causes
Etiology
• • • • •
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Mass lesions Radiation therapy Infiltration (sarcoidosis) Trauma to skull base Infections (tuberculosis meningitis)
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ACTH deficiency (secondary adrenal insufficiency)
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• Postural hypotension, tachycardia, fatigue, weight loss, hypoglycemia, eosinophilia
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Hypothyroidism (central) Clinical presentation
• Fatigue, cold intolerance, constipation, dry skin, bradycardia, slowed deep-tendon reflexes
Gonadotropins • Women: Amenorrhea, infertility • Men: Infertility, loss of libido ©UWorld
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©UWorld
This patient's presentation is suggestive of panhypopituitarism due to inadequate production of anterior pituitary hormones. Common causes of hypopituitarism are pituitary or extrapituita ry tumors (by compression), infiltrative diseases (sarcoidosis, hemochromatosis) , trauma, and vascular insults (apoplexy, Sheehan syndrome) Anterior pituitary hormone deficiency can present with variable symptoms depending on the rapidity of onset, severity of hormonal deficiencies, and types of hormonal involvement (single or multiple) Characteristic features of hypopituitarism include • Glucocorticoid deficiency (low ACTH, low cortisol) - fatigue, loss of appetite, hypoglycemia, hyponatremia, eosinophilia • Testosterone deficiency (low/normal FSH and LH, low testosterone) - low libido, erectile dysfunction • Hypothyroidism (low or inappropriately normal TSH, low free T,) - cold intolerance, constipation, bradycardia
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In contrast to the elevated TSH values seen in primary hypothyroidism, TSH deficiency in hypopituitarism is associated with low free T4 and inappropriately normal, low, or even slightly elevated levels of TSH. Aldosterone secretion from the adrenal glands is ACTH-independent and primarily regulated by the renin-angiotensin axis; therefore, serum potassium is normaL Hyponatremia may be present due to an inappropriate inc rease in antidiuretic hormone or from cortisol deficiency Hypoglycem ia is commonly seen due to deficiencies of cortisol and growth hormone. Patients also typically have pale skin due to low ACTH and melanocyte-stimulating hormone levels. Testes are soft and small due to chronic gonadotropin deficiency. Educational objective: Hypopituitarism is characterized by glucocortico id deficiency, hypogonadism, and hypothy roidism. Patients usually present with cold intolerance, hypoglycemia, anorexia, hyponatremia, and/or low libido. In contrast to primary adrenal insufficiency, adrenal insufficiency due to hypopituitarism is not associated with hypoaldosteronism.
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A 56-year-old woman comes to the physician complaining of a "sandy" sensation in her eyes In the last few months, she has also experienced weight loss, fatigue, and palpitations. She smokes a pack of c igarettes a day and has a 25-pack-year history Her eyes are shown in the image below.
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On physical examination, she is unable to maintain eye conve rgence and experiences diplopia on upward gaze Which of the following is the most likely cause of this patient's physical findings?
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ID A. High circulating thyroid hormone levels ID B. Increased intracranial pressure ID C. Inc reased intraocular pressure ID D. Retro-orbital tissue expansion ID E. Sympathetic overactivity Subm it
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Explanation:
This patient has bilateral proptosis and impaired extraocular motion (decreased convergence, diplopia) , which are characteristic findings of Graves' ophthalmopathy Other common symptoms include eye irritation (eg, gritty or sandy sensation), redness, photophobia, pain, and excess tearing Ophthalmopathy in Graves' disease is typically diagnosed at the same time as hyperthyroidism, but some cases may occur before or after the onset of hyperthyroidism. Risk factors fo r Graves' ophthalmopathy include female sex, advancing age, and smoking. Treatment of Graves' disease with radioactive iodine tends to exacerbate ophthalmopathy In Graves' disease, autoantibodies against the thyroid-stimulating hormone (TSH) receptor stimulate thyroid hormone production, with resulting hyperthyroidism. Elevated levels of circulating thyroid hormones, from any thyroid disorder, may cause lid lag and retraction by sympathetic activation and contraction of the superior tarsal muscle. However, true exophthalmos with impaired extraocular motion is seen only in Graves' disease and is due to stimulation of orbital fibroblasts by the same anti-TSH receptor autoantibodies. The result is orbital tissue (connective, adipose, muscular) expansion and lymphocytic infiltration (Choices A and E) Patients with high levels of anti-TSH receptor antibodies are at increased risk for ophthalmopathy. (Choice B) Increased intracranial pressure, as in pseudotumor ce rebri , can cause papilledema but would not cause proptosis. (Choice C) Patients with Graves' ophthalmopathy may develop inc reased intraocular pressure as a secondary effect of retro-orbital tissue expansion and compression of the globe. However , a primary increase in intraocular pressure (eg, glaucoma) does not lead to proptosis. Educational objective: Graves' ophthalmopathy is an autoimmune condition and the most common cause of exophthalmos in adults. Proptosis in Graves' ophthalmopathy results from increased volume of retro-orbital tissues (connective, muscular, and adipose tissue expansion; lymphocytic infiltration) and is a direct result of anti-thyrotrop in receptor autoantibodies.
I References:
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A 55-year-old homeless man comes to the emergency department with muscle cramps and perioral numbness. The patient appears malnourished and says that he has consumed a lot of alcohol recently. His past medical history is significant for chronic-recurrent abdominal pain for which he was advised to quit drinking alcohol. His temperature is 36.7 C (98 F), blood pressure is 110/65 mm Hg, pulse is 80/min, and respirations are 18/min. Examination shows a regular heart rate and clear lung fields. The abdomen is soft without significant tenderness. There are normoactive bowel sounds. Laboratory studies are as follows Hemoglobin
7.2 g/dl
Hematocrit
26%
Mean corpuscular volume
104 fL
Platelets
80,000/!JL
Sodium
136 mEq/L
Potassium
3.1 mEq/L
Chloride
90 mEq/L
Calcium
6.0 mg/dl
Magnesium, serum
0.8 mg/dl
Phosphorus, inorganic , serum
2.0 mg/dl
Album in
3.4 g/dl
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Wh ich of the following is the most probable cause of the hypocalcemia observed in this patient?
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Hemoglobin
7.2 g/dl
Hematocrit
26%
Mean corpuscular volume
104 fL
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Platelets
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80,000/IJL
Sodium
136 mEq/L
Potassium
3.1 mEq/ L
~ []
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Chloride
90 mEq/L
Calcium
6.0 mg/dl
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Magnesium, serum
0.8 mg/dl
Phosphorus, inorganic , serum
2.0 mg/dl
Albumin
3.4 g/dl
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W hich of the following is the most probable cause of the hypocalcemia observed in this patient?
<0 A Extracellular calcium deposition <0 B. Hypoalbuminemia <0 C. Hypomagnesemia <0 D. Hypophosphatemia <0 E. Resistance to parathyroid hormone Submit
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measure ionized calcium (if needed)
. Is it due to a drug? . Recent blood transfusion (j citrate, volume)?
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Yes
• Replete magnesium • Intravenous calcium for severe symptoms
No Measure serum PTH
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I Normal or low PTH I
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. Treal underlying cause
• Low magnesium level?
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serum calcium .LowConf irm with repeat measurement . Correct for serum albumin or
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Approach to hypocalcemia
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+ Hypoparathyroidism Surgical: Parathyroidectomy, thyroidectomy, radical neck surgery Autoimmune: Polyglandular autoimmune syndrome Infiltrative disease: Metastatic cancer, Wilson disease, hemochromatosis Genetic: PTH gene or calcium sensing receptor gene mutations ©UWorld
• Metabolic : Vitamin 0 deficiency, chronic kidney disease Inflammatory: Pancreatitis, sepsis Oncology: Tumor lysis syndrome • PTH resistance: Pseudohypoparathyroidism
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©UWorld
This patient has symptomatic hypocalcem ia associated with significant hypomagnesemia and hypophosphatemia. Hypomagnesemia is very common in hospitalized alcoholics and can cause hypocalcemia by inducing resistance to parathyroid hormone (PTH) as well as by decreasing PTH secretion. The cause of hypomagnesemia in alcoholics is multifactorial, and may include urinary losses, malnutrition, acute panc reatitis, and diarrhea. This patient has additional features of malnutrition/malabsorption including anemia and mild hypoalbuminemia Hypocalcemia due to hypomagnesemia is typically refractory to treatment with calcium unless magnesium is replaced as well. Although PTH levels increase rapidly after magnesium replacement, hypocalcem ia takes longer to improve because PTH resistance persists despite improvement in magnesium levels. Despite PTH deficiency, phosphorus levels are normal or low in magnesium deficiency; this is possibly due to intracellular phosphorus depletion {Choice A) Extracellular deposition of calcium can lead to hypocalcemia. This may occur in patients with hyperphosphatemia, osteoblastic bone metastasis, and acute pancreatitis. This patient has chronic abdominal pain but no specific features of acute pancreatitis.
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(Choice B) About 50% of circulating calcium is protein bound, predominantly to albumin. Consequently, serum total calcium va ries with albumin concentration. Interpretation of serum calcium levels requires correcting for the serum albumin level (serum calcium concentration falls by 0.8 mg/dl for every 1 gm/l decrease in albumin) This patient's serum calcium is low even after co rrecting for the mild hypoalbuminemia. {Choice D) Hypophosphatemia generally coexists with hypomagnesemia in alcoholic patients. Decreased gastro intestinal absorption and increased renal loss of phosphate are causes of hypophosphatemia in alcoholism. Hypophosphatemia itself does not cause hypocalcem ia (Choice E) Resistance to PTH (pseudohypopa rathy roidism) may result in hypocalcemia with high PTH and high phosphate levels. This condition is very rare and is usually associated with characteristic facial features (ie, Alb right hereditary osteodystrophy)
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improvement in magnesium levels. Despite PTH deficiency, phosphorus levels are normal or low in magnesium deficiency; this is possibly due to intracellular phosphorus depletion {Choice A) Extracellular deposition of calcium can lead to hypocalcemia. This may occur in patients with hyperphosphatemia, osteoblastic bone metastasis, and acute pancreatitis. This patient has chronic abdominal pain but no specific features of acute pancreatitis. (Choice B) About 50% of circulating calcium is protein bound, predominantly to albumin. Consequently, serum total calcium va ries with albumin concentration. Interpretation of serum calcium levels requires correcting for the serum albumin level (serum calcium concentration falls by 0.8 mg/dl for every 1 gm/l decrease in albumin) This patient's serum calcium is low even after co rrecting for the mild hypoalbuminemia. {Choice D) Hypophosphatemia generally coexists with hypomagnesemia in alcoholic patients. Decreased gastro intestinal absorption and increased renal loss of phosphate are causes of hypophosphatemia in alcoholism. Hypophosphatemia itself does not cause hypocalcem ia
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(Choice E) Resistance to PTH (pseudohypopa rathy roidism) may result in hypocalcemia with high PTH and high phosphate levels. This condition is very rare and is usually associated with characteristic facial features (ie, Alb right hereditary osteodystrophy)
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Educational objective: Hypomagnesemia is an important cause of hypocalcemia, particularly in alcoholics. Hypomagnesemia causes decreased release of parathyroid hormone (PTH) and PTH resistance. Hypoparathyroidism induced by low magnesium is not associated with elevated phosphorus levels (as seen with other causes of hypoparathyroidism) References: 1. Hypocalcaemia and chronic alcohol intoxication: transient hypoparathyroidism secondary to magnesium deficiency
Time Spent 4 seconds
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l ast updated: [09/02/2016)
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C)
A Clpmiphene citrate therapy
C)
B. Combined hormonal contraceptive therapy
C)
C. Metformin therapy
C)
D. Pelvic ultrasound
C)
E. Spironolactone therapy
Submit
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Lab Values
A 20-year-old woman comes to the physician for evaluation of facial hair. She has had hair on her chin and upper lip for several years and wishes the hair would "stop growing back after plucking" Menses began at age 12 and occur every 2-3 months. The patient has been sexually active with 1 male partner and uses condoms consistently as she does not intend on becoming pregnant Her BMI is 30 kg/m2 . Examination shows coa rse hair on the face and chest Laboratory results show increased serum free testosterone. Glucose tolerance testing shows a 2-hour blood glucose level of 135 mg/dL Serum TSH, 17-hydroxyp rogesterone, and prolactin levels are normal. Urine 13-hCG is negative In addition to recommending weight loss, which of the following is the best next step in the management of this patient?
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Diagnostic criteria
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of 3 of the following:
• Androgen excess: Biochemical or clinical (hirsutism, acne, androgenic alopecia) • Oligo- or anovulation • Polycystic ovaries on ultrasound: ~12 follicles 2-9 mm in diameter and/or ovarian volume >10 ml AND Exclusion of other hyperandrogenic conditions (eg, hypothyroidism, hyperprolactinemia, nonclassic CAH, Cushing syndrome, androgen-secreting tumors)
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Treatment options
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• Weight loss • Combined hormonal contraceptives for hyperandrogenism & menstrual dysfunction • Clomiphene citrate for ovulation induction • Metformin for coexisting type 2 diabetes mellitus
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Comorbidities
• • • • •
Overweight/obesity Glucose intolerance/diabetes mellitus Dyslipidemia Obstructive sleep apnea Endometrial hyperplasia/cancer
CAH = congenital adrenal hyperplasia. ©UWorld
This patient's oligomenorrhea, hirsutism, and elevated testosterone level are consistent with polycystic ovarian syndrome (PCOS) Many patients with PCOS are overweight or obese. The diagnosis is based on clinical or laboratory evidence of hyperandrogenism, a history of
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I I I I I I I p yp g p insulin resistance. Oral contraceptives (OCs) are used to regulate menses, prevent pregnancy, and lower serum androgens. OCs significantly reduce hirsutism by blocking adrenal androgen secretion, luteinizing hormone (LH) secretion, and LH-dependent ovarian androgen production and also by increasing production of sex hormone-binding globulin (SHBG), which binds and decreases free testosterone. In addition, daily exposure to progestin antagonizes the risk of endometrial hyperplasia.
Pharmacotherapy can decrease the frequency of cosmetic hair removal (eg, plucking, shaving, waxing) as hair will be less coarse and grow more slowly . However, it is unlikely to eliminate all hair growth {Choice A) Clomiphene citrate is the first-line treatment fo r ovulation induction in PCOS. It is not indicated in this patient as she is not currently interested in childbearing (Choice C) Insulin resistance is common in PCOS and patients should be screened for glucose intolerance and type 2 diabetes mellitus. A 2-hour glucose level of 140-199 mg/dl (7 8-110 mmoi/L) on glucose tolerance test indicates insulin resistance and ~200 mg/dl (11 .1 mmoi/L) is consistent with diabetes mellitus. Metformin is the first-line treatment for type 2 diabetes mellitus, but it is not routinely recommended in PCOS treatment (Choice D) A diagnostic pelvic ultrasound is not needed when the patient has met the 2 other criteria for PCOS diagnosis (hyperandrogenism and irregular menses). (Choice E) Spironolactone is an aldosterone and androgen receptor antagonist that can reduce hirsutism. However, antiandrogen therapy can impair development of male external genitalia in a fetus. Therefore, it is reserved for women of childbearing age who have contraindications to OCs and use an alternate fo rm of contraception In addition, it does not improve menstrual irregularity. Educational objective: Polycystic ovarian syndrome is characterized by hirsutism and menstrual irregularity, often in an overweight or obese patient The treatment of choice is weight loss and oral estrogen/progestin contraceptives -----------------------------------------------------------------------
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Serum chemistry
19
Sodium
134 mEq/L
Potassium
5.2 mEq/L
Chloride
97 mEq/L
Bicarbonate
12 mEq/L
Glucose
400 mg/dl
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24
Arterial blood gases
25
26
pH
7.19
27 28
Pa02
84 mm Hg
PaC02
25 mm Hg
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A 28-year-old man with type 1 diabetes mellitus comes to the emergency department with a 2-day history of abdominal pain, nausea. and vomiting He has a history of medical noncompliance and has not used insulin for the past 5 days. His temperature is 36.7 C (98 F). blood pressure is 96/62 mm Hg, pulse is 112/min, and respirations are 26/min. Examination shows dry mucus membranes. The abdomen is soft with mild diffuse tenderness. Laboratory studies are as follows.
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Lab Values
Serum and urine ketones are positive W hich of the following is the best index to monitor the response to the treatment of this patient's current condition?
6 A Serum acetoacetate
6 B. Serum anion gap e; C. Serum osmolality
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membranes. The abdomen is soft with mild diffuse tenderness. Laboratory studies are as follows. Serum chemistry
~ [] 9
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Sodium
134 mEq/L
Potassium
5.2 mEq/L
Chloride
97 mEq/L
Bicarbonate
12 mEq/L
Glucose
400 mg/dl
Arterial blood gases
19
20 21
22 23
pH
7.19
Pa02
84 mm Hg 25 mm Hg
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Serum and urine ketones are positive. W hich of the following is the best index to monitor the response to the treatment of this patient's current condition?
1'0 A Serum acetoacetate 1'0 B. Serum anion gap 1'0 C . Serum osmolality ® D. Urine glucose
1'0 E. Urine ketones Submit
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This patient's presentation (hype rglycemia with an anion gap metabolic acidosis) is consistent with diabetic ketoacidosis ( DKA) Treatment of DKA includes insulin to lower serum glucose and ketones, intravenous fluids to correct dehydration, and replacement of electrolytes Patients should have serum glucose measured every hour and electrolytes and anion gap measured every 2-4 hours. Intravenous insulin therapy can lower serum glucose by 50-75 mg/dl per hour but ketosis and acidosis resolve more slowly . The best markers indicating resolution of ketonemia are the serum anion gap and direct assay of beta-hydroxybutyrate (BH), which is the predominant ketone in DKA. The anion gap estimates the unmeasured anion concentration in the blood and returns to normal with the elimination of ketoacid anions. BH is converted to acetoacetate and acetone, wh ich can be measured by the commonly used nitroprusside test, but this test does not detect BH itself. Therefore, either calculation of the anion gap or direct assay of serum BH is recommended to follow ketonemia (Choice A) A rise in serum bicarbonate and arterial pH provides further confi rmation of the improvement in acidosis. (Choice C) Serum osmolality does not need to be measured as it can be estimated accurately from the serum sodium and glucose concentrations ([2 x Na mmoi/L) +glucose) Although serum osmolality may be elevated in DKA, it is not as sensitive fo r monitoring response to treatment (Choice D) Glucosuria typically resolves once serum glucose is corrected below 200-250 mg/dL However, at this level, there is often still significant ketonemia and acidemia. (Choice E) Urine ketone detection uses the nitrop russide test, which detects acetoacetate and acetone only . In addition, urine ketone levels are delayed with respect to serum ketones. Educational objective: The best markers indicating resolution of DKA are the serum anion gap and beta-hydroxybutyrate levels. The serum anion gap estimates the unmeasured anion concentration in the blood and returns to normal with disappearance of ketoacid anions. Refer ences: 1. Management of adult diabetic ketoacidosis
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A 36-year-old man comes to the emergency department compla ining of 2 days of fever , headache, and vomiting He has no other medical problems and takes no medications. He does not use tobacco, alcohol, or illicit drugs He lives with his wife and 2 school-aged children. The patient's temperature is 40 C (104 F) , blood pressure is 100/60 mm Hg, pulse is 100/min, and respirations are 16/min. Physical examination shows petechiae and purpura on his trunk and lower extremities. The patient is unable to bend his neck to touch his chest Examination of cerebrospinal fluid is consistent with meningococcal meningitis. The patient is informed of his diagnosis He is told that management will consist of hospitalization, antibiotic treatment, and isolation precautions However, he refuses hospital admission and insists on being treated at home. The patient is alert and oriented and appears to understand the risk he poses to himself and others by refusing hospitalization. He also declines requests to involve his wife in the decision-making process. W hich of the following is the most appropriate next step in management?
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e> A
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0 B. Hospitalize and isolate the patient against his wishes
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0 C. Info rm the patient's wife and ask her to convince him to accept hospitalization
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0 D. Obtain a court order to proceed with treatment
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6 E. Respect the patient's decision and arrange fo r home antibiotic therapy
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This patient presents with meningococcal meningitis, a highly contagious disease that can lead to devastating complications and outbreaks in the community Treatment involves isolation, intravenous antibiotics, and supportive ca re in an intensive care setting to monitor disease progression Physicians should first encourage the patient to voluntarily comply with treatment by fully explaining the illness, the need for isolation, and the risk he poses to himself and others. The patient should also be educated about the potential harm he could cause if treated at home. A patient who does not comply voluntarily needs to be hospitalized against his/her wishes. It is ethical for the physician to isolate a noncompliant patient until the patient no longer poses a risk. This patient should be placed in an isolation room with droplet precautions until all his contacts receive prophylaxis His wife and children have already been exposed to the disease and will need prophylaxis with antibiotics (eg, rifampin, ciprofloxacin). All other exposed close contacts (including medical staff) will need chemoprophylaxis . In general, adult patients with intact decision-making capacity have the right to refuse treatment, even if it would be life-saving However, protection of individual patient rights (patient autonomy) must be balanced with a physician's duty to protect the health of the public by mandating hospitalization and isolation of patients with a communicable disease.
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(Choice A) The hospital ethics committee should be consulted when there is an ethical dilemma. It is clea r that this patient must be hospitalized to protect the health and welfare of others; the physician should proceed with hospitalization immediately .
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(Choice C) Notifying the patient's wife is necessary, but it is inappropriate to burden her with the responsibility of convincing him to accept hospitalization and treatment (Choice D) A court order is not required in this situation. The medical community has already agreed that it is imperative to isolate a patient with a communicable disease, even against his/her wishes. (Choice E) This is one of the rare instances in which patient autonomy should be overridden due to the grave risk posed to others.
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(including medical staff) will need chemoprophylaxis In general, adult patients with intact decision-making capacity have the right to refuse treatment, even if it would be life-saving. However , protection of individual patient rights (patient autonomy) must be balanced with a physician's duty to protect the health of the public by mandating hospitalization and isolation of patients with a communicable disease. (Choice A) The hospital ethics comm ittee should be consulted when there is an ethical dilemma. It is clea r that this patient must be hospitalized to protect the health and welfare of others; the phys ician should proceed with hospitalization immediately (Choice C) Notifying the patient's wife is necessary, but it is inappropriate to burden her with the responsibility of convincing him to accept hospitalization and treatment (Choice D) A court order is not required in this situation. The medical community has already agreed that it is imperative to isolate a patient with a communicable disease, even against his/her wishes. (Choice E) This is one of the rare instances in which patient autonomy should be overridden due to the grave risk posed to others. Educational objective: Patients have the right to refuse treatment except when doing so poses a serious threat to public health. In these cases, the physician is justified in restricting individual liberties until the public's health is no longer at risk. References: 1. Antibiotics for preventing meningococcal infections 2. Ethical obligations of physicians participating in public health quarantine and isolation measures.
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A 4th-year medical student working in the intensive care unit is helping to care for a 75-year-old man with end-stage lung cance r. The patient suffe rs a cardiac arrest and, despite intensive resuscitation and emergency management, cannot recover and is declared dead 15 minutes later . Team members provide emotional support to his family . The supervising physician reviews the details of the patient's management with the student The physician is aware of the student's interest in critical care and asks if she would like to practice performing procedures, including perica rdiocentesis and intubation, on the deceased patient Which of the following is the most appropriate action by the student? 6 A Defer the procedures until a death certificate is completed
e; B. Defer the procedures until an autopsy is performed 6 C. Do not perform the procedures because they are unethical
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e; D. Perform the procedures only if permission of the family is obtained
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6 E. Practice the procedures, but only under direct supervision
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Explanation: The ethical dilemma of using newly deceased patients for training purposes involves weighing the conflicting considerations of respect for patient integrity with the need to train health care providers to perform lifesaving procedures The consensus of major medical organizations (eg, American Medical Association, American Heart Association's Emergency Cardiovascular Care Committee, Society for Academ ic Emergency Medic ine) is that it is ethical fo r students to perform procedures fo r training purposes as long as the physician obtains permission fr om the family (or the patient prior to death) before the student performs the procedures The training must occur as part of a structured tr aining sequence and be performed under close supervision If the patient's previously expressed consent is not documented and an appropriate fam ily member cannot be found to grant permission, procedures for training purposes should not be performed Physicians should also be aware that approaching a family for permission to perform procedures shortly after a death may be overwhelming and distressing
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{Choices A and B) It is not necessary fo r an autopsy or death certificate to be completed prior to performing a training procedure
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(Choice C) Performing training procedures on newly deceased patients is considered ethical if the family (or the patient prior to death) has provided permission (Choice E) Performing any procedure requires permission of the family (or the patient prior to death) If permission is obtained, the procedure should be performed under direct supervision Educational objective: Acco rding to ethical guidelines, permission must be obtained from the family (or from the patient prior to death) before procedures can be performed on a newly deceased patient for training purposes References: 1. Ethical issues in the emergency department: consent for procedure training on
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A pediatrician in a group practice comes to a colleague to inquire about a patient that the colleague examined earlier that morning. The pediatrician says that he recognized the patient as a former neighbor who is also a good friend of the family The patient was recently diagnosed as HIV positive and is now on antiretroviral medication. The pediatrician asks why the patient is being treated. W hat is the most appropriate response to such an inquiry?
e; A Actually , we've not been able to diagnose his condition.
® B. He is on antiretrovirals because he is HIV positive. ® C. I think you should know he has an infectious disease. ® D. It would be best fo r the patient to tell you the diagnosis ® E. It would be inappropriate for me to discuss this with you. Submit
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Explanation: Confidentiality is one of the key components of a well-run and ethical medical practice. The obligation to maintain confidentiality prohibits the physician from disclosing info rmation about the patient's diagnosis or treatment to anyone not directly involved in, or necessary to, the patient's management. Phys icians should avoid discussing a patient's medical condition in public areas where comments might be overheard. In this case, although the person inquiring is a physician and colleague, he is not involved in the patient's ca re and is therefore not entitled to details regarding that ca re. Moreover, his inquiry is based on personal and not professional curiosity Therefore, the physician should tell the colleague that it would not be appropriate to discuss the patient's condition. Every effort should be made to strictly mainta in the patient's confidentiality (Choice A) The physician should not be dishonest. Instead, the physician should simply respond that it would not be appropriate to discuss the patient's diagnosis or treatment {Choice B) Divulging the diagnosis would be inappropriate as it would be a breach of confidentiality
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(Choice C) Stating that the patient has an infectious disease without further disclosure would also violate the patient's confidentiality and is not appropriate. (Choice D) Although it would be best for the phys ician's colleague to talk directly to the patient to learn of the diagnosis, it is inappropriate to place the patient in a difficult situation should the colleague proceed with this suggestion. Educational objective: Confidential patient information should be disclosed only to fellow health ca re workers who are directly involved in the patient's care. Physicians should avoid discussing a patient's medical condition in public areas where comments might be overheard. Inappropriate inquiries from colleagues curious about a patient's medical condition should be politely but fi rmly rebuffed . Time Spent 4 seconds
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A 58-year-old man comes to the physician with a one-year history of diarrhea. The stools are watery and accompanied by abdominal cramps. He has no fever , blood from the rectum, or foul-smelling stools. He has also experienced frequent episodes of dizziness, flushing, wheezing, and a feel ing of warmth. The patient has taken herbal medicines, which failed to relieve his symptoms. He is depressed about his illness and feels hopeless about diagnosis and treatment He appears ill. Cardiac auscultation shows a 2/6 systolic murmur over the left lower sternal border that increases with inspiration Abdominal examination shows hepatomegaly 3 em below the right costal margin and no abdominal tenderness. Laboratory results are as follows:
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Leukocytes
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Alkaline phosphatase
400 U/L
Aspartate aminotransferase (SGOT)
101 U/L
Alanine aminotransferase (SGPT)
99 U/ L
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This patient is at risk of developing a deficiency of which of the following vitamins or minerals?
e> A
Calcium
6 B. Iron 6 C. Niacin 6 D. Vitamin A
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E. Vitamin C
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The patient's clinical features -episodic flushing and wheezing, diarrhea, and valvular heart disease with tricuspid regurgitation - are consistent with carcinoid syndrome. Carcinoids are slow-growing tumors found most commonly in the distal small intestine, proximal colon, and lung. These tumors can secrete several products, including histamine, serotonin, and vasoactive intestinal peptide, that are metabolized in the liver. Gastrointestinal carcinoid tumors often metastasize to the liver. In such cases, the liver is unable to metabolize these hormones before they are released into the systemic circulation, leading to the carcinoid syndrome. Other clinical features incl ude cutaneous telangiectasias and tricuspid regurgitation. Serotonin is synthesized in carcinoid cells from tryptophan, which is also used in the production of niacin or nicotinic acid. Advanced disease results in increased tryptophan conversion to serotonin and its metabolite 5-hydroxyindoleacetic acid. This may result in tryptophan and niacin deficiency causing pellagra (with diarrhea, dermatitis, glossitis, angular stomatitis, and dementia). (Choices A and E) Neither calcium nor vitamin C deficiency is associated with ca rcinoid syndrome
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(Choice B) Iron deficiency is typically not seen in patients with carcinoid syndrome. In addition, this patient's serum hemoglobin and mean corpuscular volume are within normal limits, making iron deficiency even less likely (Choice D) Vitamin A deficiency is not seen in association with carcinoid syndrome. It occurs most commonly due to dietary deficiency or in association with fat malabsorption (eg, celiac disease, small-bowel Crohn's disease, pancreatic insufficiency) Fatty diarrhea or steatorrhea typically causes pale, greasy , and malodorous stools, unlike the watery diarrhea seen in patients with ca rcinoid syndrome Educational objective: Carcinoid tumors are rare neuroendocrine tumors that cause episodic fl ushing, secretory diarrhea, bronchospasm, and cardiac valvular abnormalities. Carcinoid cells cause increased production of serotonin from tryptophan (required for niacin synthesis), resulting in niacin deficiency (ie, pellagra, with dermatitis, diarrhea, and dementia).
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A 35-year-old white male presents with fatigue, decreased appetite, weight gain, constipation and cold intolerance. He cannot recall any stressful event He does not take any medications. He is a non-smoker and non-alcoholic . His pulse is 47/min and blood pressure is 145/91 mmHg Physical examination reveals cool, pale skin, coarse hair, and brittle nails. There is delayed relaxation of deep tendon reflexes. The thyro id gland is normal on palpation Laboratory studies reveal increased serum free T3 and T4 levels, and normal serum TSH level. W hich of the following is the most likely diagnosis?
e A Primary hypothyro idism e B. Secondary hypothy roidism e c. Subclinical hypothyroidism e D. Generalized resistance to thyroid hormones e E. Graves' disease Submit
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Explanation: Hypothyroidism can result from diseases of the thyroid gland (primary hypothyroidism), pituitary gland (secondary hypothyroidism) and hypothalamus (tertiary hypothyroidism) Rarely, resistance to the action of thyroid hormones may cause hypothyroidism Generalized resistance to thyroid hormones result from receptor defects on the peripheral tissues. Patients usually present at an early age with growth and mental retardation; however, patients with milder defects can present later in life. Elevated circulating thyroid hormone levels with normal to elevated TSH levels are characteristic. Patients typically present with hypothyroidism despite having elevated circulating thyroid hormone levels. (Choice A) Primary hypothyroidism is characterized by low circulating levels of thyroid hormones with TSH levels of more than 10 IU/L Among all the causes of hypothyroidism, primary hypothyroidism from autoimmune thyroid disease is the most common.
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(Choice B) Secondary and tertiary hypothyroidism are characterized by low circulating thyroid hormone levels with low or inappropriately normal TSH levels.
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(Choice E) Graves' disease is characterized by elevated T3 and T4 levels with very low TSH levels. Patients have symptoms and signs of hyperthyroidism. (Choice C) Subclinical hypothyroidism is characterized by mildly elevated serum TSH levels and normal circulating thyroid hormone levels. Patients do not have clinical features of overt hypothyroidism Educational Objective: Patients with generalized resistance to thyroid hormones have high serum T4 and T3 levels with normal to mildly elevated TSH levels. Patients typically have features of hypothyroidism despite having elevated free thyroid hormones. Time Spent 3 seconds
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A 48-year-old woman is admitted to the oncology service for the 4th time in 2 months. She was diagnosed with breast cance r 2 years ago and has endured surgery, chemotherapy, and radiation. She also participated in multiple experimental trials. Unfortunately, her disease has progressed Today, the patient is hospitalized for hemoptysis and shortness of breath . She complains of severe pain in her back and has lost another 5 pounds since she was discharged 2 weeks ago Her body mass index is 17 kg/m2 The patient has expressed a wish to stop all treatment, go home, and enjoy her remaining days. She is found to have the capacity to make this decision. The oncologist, patient, and patient's family decide that hospice care is the most appropriate plan. W hich of the following is considered a requirement for referring a patient for hospice care?
0 A Greater than 75% decline in ability to complete activities of daily living
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0 E. Patient has decision-making capacity 6 F. Patient is actively dying
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Hospice model
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• Focus on quality of life, not cure or life prolongation Symptom control (pain, nausea, dyspnea, agitation, anxiety, depression) • Interdisciplinary team (medi cal, nursing, psychosocial, spiritual, bereavement care) • Services provided at home, assisted living facility, or dedicated facility • Requires survival prognosis of s 6 months @USMLEWorld, LLC
Hospice services provide interdisciplinary palliative care for patients with a pr ognosis of ~6 months. Hospice care involves a patient-centered approach that emphasizes quality of life , comfort, and death with dignity. It is appropriate when aggressive curative treatments are no longer beneficial or desired. The physician must substantiate a prognosis of ~6 months with documentation of irreversible decline in clinical and functional status. Hospice services include comfort measures (eg, control of pain and dyspnea), logistical support (eg, home health care, durable medical equipment), psychological and spiritual counseling, and bereavement support. Hospice services can be provided in a home, nursing home, assisted living facility, or dedicated fac ility Common misunderstandings regarding hospice eligibility include beliefs that the patient must be actively dying and have a do not resuscitate order (Choices C and F) While most patients on hospice care have clear instructions to decline heroic life-sustaining measures, this is not a prerequisite to receive hospice services. (Choice A) Although functional decline is involved in assessing prognosis, it is not a required criterion fo r hospice eligibility (Choice B) Lack of family and caregiver assistance is not a requirement In fact, many hospice
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longer beneficial or desired. The phys ician must substantiate a prognosis documentation of irreversible decline in clinical and functional status.
of~
months with
Hospice services include comfort measures (eg, control of pain and dyspnea), logistical support (eg, home health care, durable medical equipment), psychological and spiritual counseling, and bereavement support. Hospice services can be provided in a home, nursing home, assisted living facility, or dedicated fac ility Common misunderstandings regarding hospice eligibility include beliefs that the patient must be actively dying and have a do not resuscitate order (Choices C and F) W hile most patients on hospice ca re have clear instructions to decline heroic life-sustaining measures, this is not a prerequisite to receive hospice services. (Choice A) Although functional decline is involved in assessing prognosis, it is not a required criterion for hospice eligibility (Choice B) Lack of fam ily and ca regive r assistance is not a requirement services are designed to provide support for families and ca regivers.
In fact, many hospice
(Choice E) Patients should be included in all decisions as long as they have capac ity . In those lacking capacity, decisions regarding hospice care can be made using advanced planning directives or surrogate decision makers. Educational objective: Hospice is a palliative, inte rdisciplinary model of ca re for patients with a prognosis of :56 months. The focus is on symptom control; quality of life ; and psychosocial, spiritual, and bereavement care. Refer ences: 1. Hospice care in the United States.
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A 37-year-old man comes to his primary ca re physician for the evaluation of slightly pruritic skin lesions on his penis and around his anus. He has no fever , malaise, or anorexia. He is sexually active with multiple male partners and uses condoms occasionally The patient has never been tested fo r HIV or other sexually transmitted diseases. He has no drug allergies Examination shows skin-colored, verrucous, papillifo rm lesions as shown in the image below.
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W hich of the following is the most likely cause of this patient's skin condition?
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W hich of the following is the most likely cause of this patient's skin condition?
<0 A Anatomical variation <0 B. Herpes simplex virus <0 C. Human papillomavirus <0 D. Poxvirus <0 E. Treponema palfidum Submit
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Explanation: Condylomata acuminata (anogenital warts) are caused by the human papillomavirus (HPV), which is the most common sexually transmitted disease in the United States. The characteristic lesions are verrucous, papilliform, and either pink or skin-colored. The lesions are usually asymptomatic but may have mild itching or burning Systemic symptoms are usually absent The diagnosis of condyloma acuminata is primarily based on clinical presentation. Biopsy may be considered in atypical cases. HPV infection (especially serotypes 16 and 18) is associated with increased risk for squamous cell carcinoma of the anus, genital organs, and throat HPV is also associated with increased risk for other sexually transmitted diseases, especially HIV. HIV screening should be offered to patients with a new diagnosis of HPV. The condition is self-limited in most cases. If specific treatment is desired, options include: 1. Chemical or physical agents (eg, trichloroacetic acid, podophyllin) 2. Immune therapy (eg, imiquimod) 3. Surgery (eg, cryosurgery, excision, laser treatment)
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{Choice A) Pearly pink penile papules are a common anatomical variant, typically presenting as small papules evenly distributed in a ring around the corona of the glans penis They are a benign non-infectious condition, though patients often request removal to avoid the appearance of having a sexually transmitted disease. (Choice B) Herpes simplex is characterized by small grouped vesicles that erode to form small ulcers. (Choice D) Molluscum contagiosum is a self-limited, localized skin infection caused by a poxvirus It is characterized by small pink or skin-colored papules with indented centers that may occur anywhere except the palms and soles. These lesions may be widely scattered and may occur in a linear pattern due to spread of the virus to adjacent skin via scratching (Choice E) Condyloma lata are a manifestation of secondary syphilis characterized by flattened pink or gray velvety papules These are seen most commonly at the mucous
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1. Chemical or physical agents (eg, trichloroacetic acid, podophyllin) 2. Immune therapy (eg, imiquimod) 3. Surgery (eg, cryosurgery, excision, laser treatment) {Choice A) Pearly pink penile papules are a common anatomical variant, typically presenting as small papules evenly distributed in a ring around the corona of the glans penis They are a benign non-infectious condition, though patients often request removal to avoid the appearance of having a sexually transmitted disease. (Choice B) Herpes simplex is characterized by small grouped ves icles that erode to form small ulcers. {Choice D) Molluscum contagiosum is a self-limited, localized skin infection caused by a poxvirus. It is characterized by small pink or skin-colored papules with indented centers that may occur anywhere except the palms and soles. These lesions may be widely scattered and may occur in a linear pattern due to spread of the virus to adjacent skin via scratching
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{Choice E) Condyloma lata are a manifestation of secondary syphilis characterized by flattened pink or gray velvety papules These are seen most commonly at the mucous membranes and moist skin of the genital organs, perineum, and mouth. Educational objective: Condylomata acuminata (anogenital warts) are ve rrucous papillifo rm lesions located in the anogenital region These lesions are caused by human papillomavirus, which is the most common sexually transmitted disease in the United States. Certain serotypes (especially 16 and 18) are associated with squamous cell carcinoma of the anus, genital organs, and throat References: 1. Genital HPV infection and related lesions in men.
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Last updated: [10/ 14/2016)
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Calcium
12.1 mg/dl
Albumin
3.0 g/dl
Creatinine
1.4 mg/dl
Phosphorus
3.1 mg/dl
Glucose
108 mg/dl
Parathyroid hormone
9 pg/mL
Parathyroid hormone-related protein
undetectable
1,25-dihydroxyvitamin D
19 pg/ml (normal 20-60 pg/ml)
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A 17-year-old boy is brought to the emergency department following a motor vehicle accident He is found to have an extensive cerebral hemorrhage leading to deep coma, as well as fractures of the C4 ve rtebra, pelvis, and right femur. Following admission to the hospital, he is intubated and central lines are placed The patient develops acute renal failure due to rhabdomyolysis, which improves rapidly with treatment He is extubated after regaining consciousness. He also undergoes percutaneous endoscopic gastrostomy tube placement due to persistent problems with swallowing The patient is unable to ambulate due to quadriparesis resulting from cervical co rd injury. Four weeks after his initial injury, he develops nausea and polyuria His laboratory results are as follows
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W hich of the following is the most likely cause of this patient's hypercalcemia? e')
A Hypoalbuminemia
e
B. Immobilization
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Calcium
12.1 mg/dl
Albumin
3.0 g/dl
Creatinine
1.4 mg/dl
Phosphorus
3.1 mg/dl
Glucose
108 mg/dl
Parathyroid hormone
9 pg/ml
Parathyroid hormone-related protein
undetectable
1,25-dihydroxyvitamin D
19 pg/ml (normal 20-60 pg/ml )
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injury Four weeks after his initial injury, he develops nausea and polyuria His laboratory results are as follows
W hich of the following is the most likely cause of this patient's hype rcalcemia?
® A Hypoalbuminemia ® B. Immobilization ® C. Malignancy ® D. Primary hyperparathy roidism ® E. Rhabdomyolysis ® F.. Vitamin D-induced hypercalcem ia Submit
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a
Lab Values
Confirm hypercalcemia • Repeattesting • Correct for albumin concentration or measure ionized calcium
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Measure PTH level
Suppressed PTH (PTH·independent)
High-normal or elevated PTH (PTH-dependent)
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Measure PTHrP, 25-hydroxyvitamin 0, 1,25-dihydroxyvitamin 0
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Causes • Pri mary (or tertiary) hyperparathyroidism • Familial hypercalcemic hypocalciuria • Lithium
Causes • Malignancy • Vitamin 0 toxicity • Granulomatous diseases • Drug-induced (eg, thiazides) • Milk-alkali syndrome • Thyrotoxicosis • Vitamin A toxicity • Immobilization
PTH = parathyroid homlone; PTHrP =parathyroid hormone -related protein. @UWorld
This patient with quadriparesis has a co rrected calcium level of 12.9 mg/dL
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with symptomatic hypercalcemia (nausea, polyuria) and suppressed par athyroid hormone (PTH) level likely due to immobilization. Hypercalcemia of immobilization is likely due to increased osteoclastic bone resorption . The risk is increased in patients with a pre-existing high rate of bone turnover (eg, younger individuals, Paget disease) The onset of hypercalcem ia is usually around 4 weeks after immobilization, although patients with chronic renal insufficiency may develop hypercalcem ia in as little as 3 days The onset of hypercalcemia due to immobilization is often insidious, and the presenting symptoms can be nonspecific Bisphosphonates inhibit osteoclastic bone resorption and are effective in treating hyper calcemia of immobilization and reducing the associated bone loss. {Choice A) Approximately 40% of circulating calcium is bound to proteins (predominantly albumin). Hypoalbuminemia will lower the total serum calcium level; therefore, measured calc ium levels are corrected upward based on the extent of hypoalbuminemia. Conversely, hyperalbuminemia is associated with an inc rease in total calcium. In either case, the ionized fraction is unaffected, and patients will not have calcium-related symptoms directly related to the change in albumin levels.
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(Choices C and F) Hypercalcemia in malignancy can be due to osteolytic metastasis, secretion of PTH-related protein (PTHrP), or increased fo rmation of 1,25-dihydroxyvitamin D. This patient's PTHrP and 1,25-dihydroxyvitamin D levels are low. (Choice D) This patient's PTH level is suppressed, which makes primary hyperparathyroidism unlikely {Choice E) Acute rhabdomyolysis causes hypocalcemia due to precipitation of calcium and phosphorus in damaged muscles. Hypercalcemia can occur due to remobilization of calcium during the diuretic/recovery phase of the illness, often with concurrent hyperphosphatemia However, this patient recovered from rhabdomyolysis several weeks before the onset of hypercalcemia. Educational objective: Hypercalcemia can occur in prolonged immobilization due to increased osteoclastic activity, ..
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can be nonspecific Bisphosphonates inhibit osteoclastic bone resorption and are effective in treating hypercalcemia of immobilization and reducing the associated bone loss.
{Choice A) Approximately 40% of circulating calc ium is bound to proteins (predominantly albumin) Hypoalbuminemia will lower the total serum calcium level; therefore, measured calcium levels are corrected upward based on the extent of hypoalbuminemia. Conversely, hyperalbuminemia is associated with an increase in total calcium. In either case, the ionized fraction is unaffected, and patients will not have calcium-related symptoms directly related to the change in albumin levels. (Choices C and F) Hypercalcemia in malignancy can be due to osteolytic metastasis, secretion of PTH-related protein (PTHrP), or inc reased formation of 1,25-dihydroxyvitamin D. This patient's PTHr P and 1,25-dihydroxyvitamin D levels are low. (Choice D) This patient's PTH level is suppressed, which makes primary hype rparathyroidism unlikely
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(Choice E) Acute rhabdomyolysis causes hypocalcemia due to precipitation of calcium and phosphorus in damaged muscles. Hypercalcem ia can occur due to remobilization of calcium during the diuretic/recovery phase of the illness, often with concurrent hyperphosphatemia. However, this patient recovered from rhabdomyolysis several weeks before the onset of hypercalcem ia Educational objective: Hypercalcemia can occur in prolonged immobilization due to increased osteoclastic activity, especially in individuals with a high baseline rate of bone turnover. Bisphosphonates can reduce this hype rcalcemia and prevent bone loss. References: 1. Immobilization induced hypercalcemia.
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e A Hyperlipidemia e B. Hypernatremia e C. Hypocalcemia e D. Neutropenia e E. Thrombocytopenia Submit
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A 60-year-old man is hospitalized due to pneumonia His other medical problems include hypertension, chronic obstructive pulmonary disease, and degenerative joint disease. The patient has a 60-pack-year smoking history and has consumed 2 12-oz cans of beer daily for the past 15 years His medications include aspirin, metoprolol, enalapril, and albuterol and ipratrop ium inhalers. His temperature is 36.7 C (98 F) , blood pressure is 140/80 mm Hg, pulse is 80/min, and respirations are 16/min. During his hospital stay, several blood tests were ordered and he was found to have hypothyroidism. W hich of the following additional laboratory abnormalities would most likely be directly attributable to hypothyroidism?
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Explanation: Hypothyroidism can cause additional metabolic abnormalities such as hyperlipidemia, hyponatremia and asymptomatic elevations of creatinine kinase (usually <1 0x normal) and serum transaminases (aspartate aminotransferase and alanine aminotransferase) Hypercholesteremia with high low-density lipoprotein (LDL) is due primarily to decreased surface LDL receptors (type 2a hyperlipidemia) and/or decreased LDL receptor activity Hypothyroidism can also decrease lipoprotein lipase activity to cause hypertriglyceridemia. Most hypothyroid patients have either hypercholesterolemia alone or combined hypertriglyceridemia and hypercholesterolemia Isolated hypertriglyce ridemia due to hypothyroidism is rare. The lipid abnormalities may take months to resolve despite adequate treatment of hypothyroidism Statins can increase the risk of myopathy in poorly controlled hypothyroidism and should be given with caution in these patients
{Choice B) Hypothyroidism can cause hyponatremia due to decreased free water clearance. Hypothyroidism and adrenal insufficiency must be ruled out before diagnosing the syndrome of inappropriate antidiuretic hormone. However , hypothyroidism does not usually cause hypernatremia
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(Choice C) Serum calcium is usually normal in hypothyroidism unless a patient has coexisting hypoparathyroidism (eg, polyglandular autoimmune failure or surgical complication during thyroid surgery) . However , thyrotoxicosis can cause hypercalcemia and is due to increased bone resorption {Choices 0 and E) Hypothyroid patients most commonly develop normocytic , normochromic anemia due to decreased red blood cell mass. Chronic autoimmune thyroiditis may cause pernic ious anemia, but some patients can have macrocytosis without megaloblastic anemia. Some hypothyroid patients may develop acquired von Willebrand syndrome with increased bleeding risk; resultant menorrhagia can sometimes cause iron deficiency anemia in women of reproductive age However , hypothyroidism is less commonly associated with thrombocytopenia and neutropenia.
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Hypothyroidism and adrenal insufficiency must be ruled out before diagnosing the syndrome of inappropriate antidiuretic hormone. However , hypothyroidism does not usually cause hypernatremia. (Choice C) Serum calcium is usually normal in hypothyroidism unless a patient has coexisting hypopa rathy roidism (eg, polyglandular autoimmune failure or surgical complication during thyroid surgery) However, thyrotoxicos is can cause hypercalcemia and is due to increased bone resorption {Choices D and E) Hypothyroid patients most commonly develop normocytic , normochrom ic anemia due to decreased red blood cell mass. Chronic autoimmune thyroiditis may cause pernicious anemia, but some patients can have macrocytosis without megaloblastic anemia. Some hypothyro id patients may develop acquired von W illebrand syndrome with increased bleeding risk; resultant menorrhagia can sometimes cause iron deficiency anemia in women of reproductive age. However , hypothyroidism is less commonly associated with thrombocytopenia and neutropenia Educational objective: Hypothyroidism can cause additional metabolic abnormalities such as hyperlipidemia, hyponatremia and asymptomatic elevations of creatinine kinase and serum transaminases (aspartate aminotransferase and alanine aminotransferase) Most patients have hypercholesterolemia alone (due to decreased low-density lipoprotein [LDL] surface receptors and/or decreased LDL receptor activity) or comb ined with hypertriglyce ridemia (due to decreased lipoprotein lipase activity). References: 1. Hyperlipidemia in patients with primary and secondary hypothyroidism. 2. Prevalence and correction of hypothyroidism in a large cohort of patients referred for dyslipidemia.
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A 65-year-old man comes to the office with a 1-year history of erectile dysfunction and decreased libido. He has hypertension that was diagnosed 5 years ago and is controlled with diet The patient has no history of ca rdiac problems, unexpected weight loss, visual changes, or symptoms of neuropathy. Family history is unremarkable. On examination, there is minimal bilateral gynecomastia without galactorrhea. Genitourinary examination shows decreased testicular size. The remainder of the physical examination, including visual fields on confrontation, is unremarkable. Laboratory results are as follows: Serum chemistry Creatinine
1. 1 mg/dl
Alanine aminotransferase
21 U/L
20 21
Endocrine
22 23
Hemoglobin A 1c
5.8%
FSH, serum
5 mU/mL
LH, serum
3 mU/mL
Testosterone, serum
174 ng/dl (normal, 300-800 ng/dl)
TSH
1.3 !JU/mL
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Repeat early-morning testosterone level is 162 ng/dL W hich of the following is the best next step in management of this patient? e')
A Angiography of the deep arteries of the penis
6 B. Measurement of serum prolactin level 6 C. Measurement of transfe rrin saturation
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bilateral gynecomastia without galactorrhea Genitourinary examination shows decreased testicular size. The remainder of the physical examination, including visual fields on confrontation, is unremarkable. Laboratory results are as follows
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Creatinine
1.1 mg/dl
Alanine aminotransferase
21 U/L
Endocrine
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Hemoglobin A 1c
5.8%
FSH, serum
5 mU/mL
LH, serum
3 mU/mL
Testosterone, serum
174 ng/dl (normal, 300-800 ng/dl)
TSH
1.3 IJU/ml
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Repeat early-morning testosterone level is 162 ng/dl Which of the following is the best next step in management of this patient?
<0 A Angiography of the deep arteries of the penis <0 B. Measurement of serum prolactin level <0 C. Measurement of transferrin saturation <0 D. Sildenafil treatment <0 E. Testosterone therapy Submit
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Male hypogonadism Primary (testicular disease)
Findings
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Secondary (pituitary/hypothalamic disease)
• j Energy/libido, j body hair
• j Energy/libido, j body hair
• Gynecomastia more likely
• Gynecomastia less likely
• t LH/FSH
• j/Normal LH/FSH
• j j Testosterone/sperm count
• j Testosterone/sperm count
• Congenital o Klinefelter syndrome
• Congenital o Kallman syndrome
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o Varicocele
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Causes
o Radiation o Infection (eg, mumps) o Trauma o Medications (eg, alkylating agents, glucocorticoids) o Chronic disease
• Gonadotropin suppression o Hyperprolactinemia o Glucocorticoids/opiates • Gonadotroph cell damage o Benign/malignant tumors o Pituitary apoplexy o Infiltration (eg, hemochromatosis) o Systemic disease
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Evaluation
• Karyotype
• Prolactin
• Others based on clinical suspicion
• Transferrin
• +/- MRI
@UWOI!d
This patient has gynecomastia and testicular atrophy His laboratory results show low testosterone levels and inappropriately normal gonadotropin (ie, LH, FSH) levels, indicating secondary (central) hypogonadism Low levels of testosterone normally increase LH and FSH levels due to loss of feedback inhibition. Therefore, low or even normal LH and FSH levels suggest an inappropriate hypothalamic-pituitary response. Secondary hypogonadism can be due to mass lesions in the hypothalamus or pituitary, hyperprolactinemia (due to suppression of gonadotropin-releasing hormone), long-term use of glucocorticoids or opiates, or severe systemic illness. Secondary hypogonadism is also more common in individuals with obesity or type 2 diabetes mellitus. Patients with secondary hypogonadism should have measurement of serum prolactin In men with prolactinoma, gynecomastia is present only in approximately one third of patients, and galactorrhea is uncommon. Visual field defects are present only when the tumor impinges on the optic chiasm. Patients should also have screening for other pituitary hormone deficiencies (eg, TSH) Pituitary imaging with MRI is indicated fo r patients with elevated prolactin, mass-effect symptoms (eg, visual field defects), very low (<150 ng/dl) testosterone levels, or disruptions in other pituitary hormones. (Choice A) Angiography of the penile deep arteries may be indicated when a vascular etiology of erectile impotence is suspected However, th is test is invasive and not routinely performed {Choice C) Hemochromatosis should be suspected when hypogonadism is associated with abnormal skin pigmentation, diabetes mellitus, elevated live r enzymes, and arth ropathy It is unlikely that this patient has hemachromatosis considering his absence of family history, age at presentation, and lack of other clinical features.
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o Systemic disease
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imaging with MRI is indicated for patients with elevated prolactin, mass-effect symptoms (eg, visual field defects), very low (<150 ng/dl) testosterone levels, or disruptions in other pituitary hormones. (Choice A) Angiography of the penile deep arteries may be indicated when a vascular etiology of erectile impotence is suspected. However, this test is invasive and not routinely performed (Choice C) Hemochromatosis should be suspected when hypogonadism is associated with abnormal skin pigmentation, diabetes mellitus, elevated liver enzymes, and arthropathy . It is unlikely that this patient has hemachromatosis considering his absence of family history, age at presentation, and lack of other clinical features. (Choice D) Phosphodiesterase type 5 inhibitors (eg, sildenafil) are useful in patients with erectile dysfunction due to a variety of causes. However, symptomatic treatment may not be needed if a correctable cause is found. (Choice E) Testosterone therapy may be required if serum prolactin and MRI of the pituitary are normal. Dopaminergic agonists are the preferred therapy fo r prolactinoma Educational objective: Secondary hypogonadism can be due to mass lesions in the hypothalamus or pituitary, hyperprolactinemia, long-term use of glucocorticoids or opiates, or severe systemic illness. Patients should have measurement of serum prolactin and screening fo r other pituitary hormone deficiencies. Pituitary imaging is indicated for patients with elevated prolactin, mass-effect symptoms, very low testosterone levels, or disruptions in other pituitary hormones. Refer ences: 1. Testosterone therapy in men with androgen deficiency syndromes: an Endocrine Society clinical practice guideline. 2. Update: hypogonadotropic hypogonadism in type 2 diabetes and obesity.
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An 18-year-old woman is brought to the emergency department with severe abdominal pain Medical history includes asthma, eczema, and multiple episodes of pneumonia Her temperature is 37.2 C (99 F). blood pressure is 90/60 mm Hg, and pulse is 128/min. Physical examination shows pallor and a tender , rigid abdomen. Laboratory studies reveal a hemoglobin concentration of 6.9 mg/dl and platelet count of 378,000/mms Emergency laparotomy reveals a ruptured ectopic pregnancy. The patient receives a transfusion with blood type 0 , Rh-negative. packed red blood cells. During the transfusion, she experiences generalized hives and a drop in blood pressure to 70/40 mm Hg. The transfusion is stopped and intramuscular epinephrine is administered. W hich of the following is the most likely diagnosis?
e> A
Bacterial contamination from transfusion
0 B. Blood group incompatibility 0 C. Cystic fibrosis 0 D. Hyper-lgM syndrome 6 E. Selective lgA deficiency 0 F. W iskott-Aidrich syndrome 0 G. X-linked agammaglobulinemia
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This patient has a history of recurrent pneumonia, atopy (eg, asthma, eczema) , and an anaphylactic reaction during blood transfusion. These findings are highly suggestive of selective lgA deficiency, the most common primary immunodeficiency. Serum lgA levels are low or undetectable due to failure of B cells to differentiate into lgA-secreting plasma cells; serum lgG and lgM levels are normaL Although most patients with lgA deficiency are asymptomatic , some have recurrent sinopulmonary (eg, sinusitis, pneumonia) and gastrointestinal infections (eg, Giardia) due to absence of secretory lgA as a mucosal barrier. Concomitant atopic and autoimmune disorders (eg, systemic lupus erythematosus, celiac disease) are common. Patients with severe lgA deficiency can form lgE antibodies directed against lgA (anti-lgA antibodies) W hen transfused with blood products (eg, red blood cells, platelets, fresh frozen plasma) containing small amounts of lgA , these patients can develop potentially fatal anaphylaxis Therefore, patients with severe lgA deficiency should wear medical alert bracelets and receive blood products that are washed of residual plasma or from an lgA-deficient donor. {Choice A) Bacterial contamination results from bacteria entering the blood component during processing W hen these bacteria are introduced during the transfusion, they can cause septic shock (fever , chills, hypotension) but do not cause anaphylaxis.
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(Choice B) Blood group (eg, ABO, Rh, minor antigen) incompatibility, which is less common with donor 0-negative blood, causes an acute hemolytic reaction. Common findings are fever , flank pain, and hemoglobinuria, but not anaphylaxis. (Choice C) Cystic fibrosis (CF) is characterized by abnormal sodium and chloride transport leading to pancreatic insufficiency and chronic , severe respiratory disease. Abnormal antibody production and transfusion reactions are not associated with CF. (Choices D and G) Patients with hyper-lgM syndrome (high lgM; low lgA, lgG) and X-linked (Bruton) agammaglobulinemia (low lgA, lgG, lgM) can also present with recurrent sinopulmonary infections in childhood. However , they do not develop anti-lgA antibodies and therefore do not experience anaphylaxis during transfusions. {Choice F) W iskott-Aidrich syndrome classically presents in infancy with recurrent sinonulmonFtrv infP.r.fions P.r.7P.mFI Ftnrl th romhor.vtonP.niFI
It is not Ftssor.iFttP.cl with FlnFinhv iFtxis
G
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(Choice A) Bacterial contamination results from bacteria entering the blood component during processing W hen these bacteria are introduced during the transfusion, they can cause septic shock (fever , chills, hypotension) but do not cause anaphylaxis. (Choice B) Blood group (eg, ABO , Rh, minor antigen) incompatibility , which is less common with donor 0-negative blood, causes an acute hemolytic reaction. Common findings are fever , flank pain, and hemoglobinuria, but not anaphylaxis. (Choice C) Cystic fibrosis (CF) is characterized by abnormal sodium and chloride transport leading to pancreatic insufficiency and chronic , severe respiratory disease. Abnormal antibody production and transfusion reactions are not associated with CF. (Choices D and G) Patients with hyper- lgM syndrome (high lgM; low lgA, lgG) and X-linked ( Bruton) agammaglobulinemia (low lgA, lgG, lgM) can also present with recurrent sinopulmonary infections in childhood. However, they do not develop anti- lgA antibodies and therefore do not experience anaphylaxis during transfusions.
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(Choice F) W iskott-Aidrich syndrome classically presents in infancy with recurrent sinopulmonary infections, eczema, and thrombocytopenia It is not associated with anaphylaxis during transfusions. In addition, this patient's platelet count is normal. Educational objective: Selective lgA deficiency is the most common primary immune deficiency, and can present with recurrent sinopulmonary and gastrointestinal infections as well as atopic and autoimmune disease. W ith severe deficiency, production of anti- lgA antibodies can lead to anaphylaxis during blood transfusion. Refer ences:
1 . Selective lgA deficiency.
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A 60-year-old man is brought to the emergency department by his daughter due to a 2-day history of confusion and lethargy. Acco rding to the daughter , he has had a constant dry cough, fatigue, anorexia, polyuria, and constipation for several weeks. In addition, the patient has lost 9.1 kg (20 lb) over the past 3 months. He has no associated pain The patient's medical history is significant fo r hypertension treated with chlorthalidone and for gastroesophageal reflux disease treated with over-the-counter antacids. He smokes 2 packs of cigarettes daily and consumes alcohol occasionally. Blood pressure is 130/90 mm Hg and pulse is 90/min. Temporal wasting is noted. Chest and abdominal examinations are normal. Mental status examination shows somnolence and disorientation to time. Neurologic examination shows decreased deep tendon reflexes. Laboratory results are as follows: Serum chemistry Sodium
140 mEq/L
Potassium
4 mEq/L
Chloride
104 mEq/L
25
Bica rbonate
24 mEq/L
26
C reatinine
1.6 mg/dl
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Calcium
14.4 mg/dl
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Glucose
100 mg/dl
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Alkaline phosphatase, serum
130 U/L
Phosphorus (inorganic) , serum
2.2 mg/dl
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Lab Values
q
Potassium
4 mEq/L
Chloride
104 mEq/L
Bicarbonate
24 mEq/L
Creatinine
1.6 mg/dl
Calcium
14.4 mg/dl
Glucose
100 mg/dl
Alkaline phosphatase, serum
130 U/L
Phosphorus (inorganic) , serum
2.2 mg/dl
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W hich of the following is the most likely cause of this patient's symptoms?
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0 A Elevated parathyroid hormone 0 B. Elevated parathyroid hormone-related protein 0 0 0 0 0
C . Increased 1 ,25-dihydroxyvitamin D production D. Local cytokine production E. Metastatic osteolysis F. Milk-alkali syndrome G. Th iazide-induced hypercalcem ia
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Explanation:
~ [] Malignancy-associated hypercalcemia
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Cause
Tu mor
PTHrP production
• Squamous cell cancers (eg, lung, head, neck, esophagus)
(80% of malignancy-induced hypercalcemia)
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• Renal & bladder cancer • Ovarian & endometrial cancer
Mechanism
Activation of PTH receptor, excessive bone resorption
• Breast cancer
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1,25(0H)2 vitamin D production
• Lymphomas (all types)
Excessive gut absorption of calcium
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• Breast cancer
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Bone metastasis
Ectopic PTH production (very rare)
• Lymphomas
Release of local factors (eg, cytokines) to stimulate bone resorption
• Variable
Bone resorption
• Multiple myeloma
PTH =parathyroid hormone; PTHrP = parathyroid hormone-related protein.
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PTH =parathyroid hormone; PTHrP = parathyroid hormone-related protein. ©UWo~d
This patient has polyu ria and neuropsychiatric symptoms consistent with hype rcalcemia. Severe hypercalcem ia can also cause impaired neuromuscular excitability, leading to weakness, diminished reflexes, and decreased gastrointestinal motility In light of this patient's we ight loss, temporal wasting, dry cough, and smoking history, he most likely has humoral hyper calcemia of malignancy (HHM) due to squamous cell carcinoma of the lung HHM is a paraneoplastic syndrome due to the release of parathyroid hormone-related pr otein (PTHrP) by malignant cells, which is structurally similar to parathyroid hormone (PTH) and acts on the PTH-1 receptor PTHrP causes increased bone resorption and reabsorption of calcium in the distal renal tubule. Increased phosphate excretion leads to hypophosphatemia HHM is characterized by severe (eg, >14 mg/dl) and rapid-onset hypercalcemia. The diagnosis is often suspected on clinical grounds and can be confi rmed by an elevated PTHrP level and suppressed PTH level. HHM is usually seen in advanced malignancy and confers a poor prognosis {Choice A) Primary hype rparathyroidism causes gradual-onset, mild-to-moderate hypercalcemia (usually <14 mg/dL) Symptoms (eg, renal stones, osteoporosis, constipation), if present, are typically chronic and nonspecific (Choice C) Granulomatous diseases (eg, sarcoidosis) and lymphoma can cause hype rcalcem ia due to extrarenal production of 1,25-dihyd roxyvitamin D. However, hype rcalcem ia due to excess 1,25-dihydroxyvitamin D would be associated with hype rphosphatemia rather than hypophosphatemia. Also , sarcoidosis is more common at age <40. (Choices D and E) Osteolytic malignancies (eg, breast cancer, multiple myeloma) cause hype rcalcemia due to stimulation of osteoclasis by local production of cytokines This is significantly less common than HHM, and serum phosphorus levels are usually normal. In addition, most patients have significant associated bone pain.
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pp poor prognosis. I
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(Choice A) Primary hyperparathyroidism causes gradual-onset, mild-to-moderate hypercalcem ia (usually <1 4 mg/dl) Symptoms (eg, renal stones, osteoporosis, constipation), if present, are typ ically chronic and nonspecific (Choice C) Granulomatous diseases (eg, sarco idosis) and lymphoma can cause hypercalcemia due to extrarenal production of 1,25-dihydroxyvitamin D. However, hypercalcemia due to excess 1,25-dihydroxyvitamin 0 would be associated with hyperphosphatemia rather than hypophosphatemia. Also, sarcoidosis is more common at age <40. (Choices D and E) Osteolytic malignancies (eg, breast cancer , multiple myeloma) cause hypercalcem ia due to stimulation of osteoclasi s by local production of cytokines This is significantly less common than HHM, and serum phosphorus levels are usually normal. In addition, most patients have significant associated bone pain. (Choice F) Milk-alkali syndrome is caused by excessive intake of calcium and absorbable alkali. It is characterized by hypercalcemia, metabolic alkalosis, and acute kidney injury Bicarbonate levels are elevated due to increased intake and decreased renal excretion of bica rbonate. {Choice G) Thiazide diuretics cause increased reabsorption of calcium in the distal tubule. The resulting hypercalcem ia is mild (usually <12 mg/dl ) and rarely symptomatic Educational objective: Humoral hypercalcemia of malignancy is characterized by severe, symptomatic hypercalcemia. It is due to the release of parathyro id hormone-related protein by tumor cells, leading to inc reased bone resorption and reabsorption of calcium in the distal renal tubule. References: 1. Cancer-related hypercalcemia.
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You are covering fo r a colleague who is out of town when a 65-year-old woman arrives at the clinic with her son. She has experienced markedly decreased urine output for the past 24 hours. Her medical problems include type 2 diabetes mellitus, hypertension, and ischemic heart disease. The colleague performed coronary angiography on the patient 5 days ago, and she was discharged home the next day in stable condition. Her temperature is 3r C (98 6° F). blood pressure is 140/92 mm Hg, pulse is 88/min, and respirations are 14/min. Laboratory results show creatinine of 3.4 mg/dl and blood urea nitrogen of 40 mg/dl. Acute tubular necrosis secondary to the contrast used during angiography is suspected After reviewing the notes in her medical chart before and after the procedure, you realize that this complication could have been prevented with adequate hydration prior to angiography. The patient has provided consent fo r her case to be discussed with her son. He is very concerned and asks why his mother is unable to urinate. Which of the following is the most appropriate response to this question?
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A I will ask the patient's regular physician to call you and discuss the current condition.
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B. The patient's condition may be related to her recent angiography, but I will discuss it with her regular physician before giving a definitive answer.
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C. This complication could have been prevented if the physician had given intravenous hydration prior to the procedure Unfortunately , the physician fo rgot to do this.
<0
D. The cause of her condition is unlikely to ever be known, but she will be given excellent
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to urinate. Which of the following is the most appropriate response to this question? A I will ask the patient's regular physician to call you and discuss the current condition.
~ [] 9
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B. The patient's condition may be related to her recent angiography, but I will discuss it with her regular physician before giving a definitive answer.
<0
C. This complication could have been prevented if the physician had given intravenous hydration prior to the procedure Unfortunately , the physician fo rgot to do this.
<0
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D. The cause of her condition is unlikely to ever be known, but she will be given excellent treatment
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E. The patient is at high risk fo r complications due to her underlying health issues, and this is an expected event that occurs frequently after angiography
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E. The patient is at high risk for complications due to her underlying health issues, and this is an expected event that occurs frequently after angiography. [6%] Explanation: Handling the aftermath of a mistake made by a colleague can be awkward , especially when the patient's family is pressing for detailed information. Nevertheless, it is the acting physician's obligation to discuss the essential truth with the patient in a tactful and concise manner. The colleague is not available in this case. Therefore, a brief and honest explanation should be provided to the patient with the understanding that a definitive answer will be available once the matter has been fully discussed with the colleague In the meantime, the patient has evidence of acute renal injury likely due to acute tubular necrosis (ATN), and appropriate therapy should be started to treat her acute condition. Physicians should consider admitting a mistake, especially under the following circumstances
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• • • • •
Actual patient harm Clear or potential clinical significance An unwanted treatment, device, or substance reaching the patient An unanticipated outcome An unexpected safety event
(Choice A) For a physician to evade responsibility by saying he/she is not the patient's regular physician is inappropriate The acting physician is obligated to provide care that is in the patient's best interest even if it could expose a mistake made by a colleague (Choice C) Although it is true that intravenous hydration was not given prior to the procedure, it is important to get additional info rmation from the regular physician before admitting this mistake. There might be other reasons for not giving intravenous fluids. Patients can still incur contrast-induced kidney injury despite all precautionary measures. (Choice D) To say that the cause of this patient's condition may never be known could be dishonest, particularly since the sequence of events very likely has a explanation. The acting . . h I h bl' I f t t II th f I t th t th I f t . t tf I b t h t
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started to treat her acute condition. Physicians should consider admitting a mistake, especially under the following circumstances • • • • •
Actual patient harm Clear or potential cl inical significance An unwanted treatment, device, or substance reaching the patient An unanticipated outcome An unexpected safety event
(Choice A) For a phys ic ian to evade responsibility by saying he/she is not the patient's regular physician is inappropriate The acting physician is obligated to provide care that is in the patient's best interest even if it could expose a mistake made by a colleague (Choice C) Although it is true that intravenous hyd ration was not given prior to the procedure, it is important to get additional info rmation from the regular physician before admitting this mistake. There might be other reasons for not giving intravenous fluids. Patients can still incur contrast-induced kidney injury despite all precautionary measures.
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(Choice D) To say that the cause of this patient's condition may never be known could be dishonest, particularly since the sequence of events very likely has a explanation. The acting physician has an obligation to tell the essential truth to the patient in a tactful but honest way. However , the phys ician should fully discuss the matter with the colleague before providing specific details. {Choice E) The patient does have significant risk factors fo r ATN. However, telling this patient and her family that acute ATN is a common complication of angiograms is dishonest This compl ication may have been avoided with adequate precautionary measures, such as hydration Educational objective: A physician has a moral responsibility to act in the patient's best interests. W hen a physician's mistake is discovered, the facts should be clarified and the truth told to the patient Time Spent 5 seconds
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e> A
e; B. Ethics consultation
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C. Medical examiner notification
e; D. No additional steps are necessary
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E. Permission from the patient's next of kin
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Court-appointed legal guardianship
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A 45-year-old man is brought to the emergency department following a serious motor vehicle coll ision on a Califo rnia interstate highway. Despite all attempts to save him, his condition does not improve The physician caring for him believes that he is brain dead. On examination, the patient's temperature is 36.7 C (98 F) and blood pressure is 104/60 mm Hg. He is on mechanical ventilation. Neurologic examination is consistent with brain death. Laboratory and imaging studies are not suggestive of a reversible cause. Apnea testing shows no spontaneous breathing In accordance with local regulations, a second physician confi rms the diagnosis of brain death. The patient's fam ily understands the prognosis Unfortunately , the patient does not have an advanced directive or durable medical power of attorney W hich of the following steps is legally necessary to remove this patient from the ventilator?
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D. No additional steps are necessary [51 % J E. Permission from the patient's next of kin [44%)
Explanation: Brain death is defined as irreversible loss of function of the whole brain, including the brainstem. There are several criteria fo r declaring brain death. Brain death is a legally acceptable definition of death, and artificial life support does not need to be continued. In this patient's case, no further steps are legally required to remove him from the ventilator. Some states, such as New York and New Jersey, have regulations in place in case the declaration of legal death based on brain death is in violation of an individual's religious beliefs. (Choices A and B) A court-appointed legal guardian is sometimes needed when an individual (eg, senior citizen) does not have the capacity to make medical or life decisions and there is no healthca re proxy Involvement of the hospital ethics committee is appropriate when the course of a patient's ca re is unclear , particularly when a family's wishes are at odds with the goals of the healthca re providers However , neither of these interventions is required in a patient with brain death.
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(Choice C) Patients in the hospital who die due to an unknown cause, a medical complication, suspected illegal activities, or within 24 hours of presentation must generally be reported to the coroner or medical examiner. This patient may need to be reported but not until after he has been disconnected from the ventilator . (Choice E) It is important to notify this patient's family members of his condition and to discuss the removal of artificial life support However , family permission is not legally required to discontinue mechanical ventilation in a patient with brain death. Educational objective: Brain death refers to a total loss of brain function and is a legally acceptable definition of death. Time Spent 2 seconds
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130 mg/dl
Sodium
142 mEq/L
Potassium
3.6 mEq/L
Chloride
98 mEq/L
24
Bicarbonate
28 mEq/L
25
Calcium
9.2 mg/dl
TSH
2.2 miU/L
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A 31-year-old woman comes to the office due to a 6 8-kg (15-lb) weight gain over the last few months. She has been unable to lose weight despite rigorous dieting and regular exercise. The patient also has experienced weakness and cannot lift weights that she was able to lift before the onset of her symptoms Her menstrual periods have been irregular for the last few months, and she has had increasing anxiety and insomnia for which she has started seeing a clinical psychologist Medical history is unremarkable. She drinks wine only on rare occasions and quit smoking 7 years ago after a 5-pack-year history On examination, blood pressure is 160/ 100 mm Hg and pulse is 88/min and regular. Neurologic examination shows proximal muscle weakness. Dark terminal hair is present on the lower abdomen. Fasting laboratory results are as follows: Glucose
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Which of the following is the most appropriate next step in evaluating this patient's condition?
6 A Early-morning cortisol level
6 B. Overnight low-dose dexamethasone suppression test e; C. Serum ACTH level 6 D. Serum aldosterone to plasma renin activity ratio 6 E. Serum testosterone level
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Explanation:
~[] 9
Features of Cushing syndrome
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• Central obesity (eg, fat accumulation in the cheeks & dorsocervical & supraclavicular fat pads) • Skin atrophy & wide, purplish striae Clinical manifestations
• Proximal muscle weakness • Hypertension • Glucose intolerance
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• Skin hyperpigmentation (due to ACTH excess)
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• 24-hour urinary cortisol excretion
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Diagnosis
25
• Late-night salivary cortisol assay
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• Low-dose dexamethasone suppression test
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@UWor1d
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This patient has weight gain, psychiatric symptoms, hirsutism, hypertension, and hyperglycemia. This constellation of findings is consistent with hypercortisolism (Cushing syndrome) This condition is most commonly due to exogenous administration of glucocorticoids, but can also be due to an ACTH-producing pituitary tumor (Cushing disease), ectopic ACTH production (eg, small cell lung cancer), or primary adrenal disease. The initial step in the evaluation is to confirm hypercortisolism with a late-night salivary cortisol assay, 24-hour urine free cortisol measurement, and/or overnight low-dose dexamethasone suppression test Two of these first-line tests should be abnormal to establish the diagnosis. If •
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The initial step in the evaluation is to confi rm hypercortisolism with a late-night salivary cortisol assay, 24-hour urine free cortisol measurement, and/or overnight low-dose dexamethasone suppression test Two of these fi rst-line tests should be abnormal to establish the diagnosis If hypercortisolism is confirmed, ACTH levels are measured to diffe rentiate ACTH-dependent (ie, Cushing disease, ectopic ACTH) from ACTH-independent (eg, adrenal adenoma) causes (Choice C) (Choice A) Early-morning cortisol levels will be low or low-normal in patients with primary adrenal insufficiency. However, there is considerable overlap in cortisol levels in normal subjects and those with Cushing syndrome, and this test has low utility in the evaluation of hypercortisolism. (Choice D) The ratio of plasma aldosterone to plasma renin activity is useful to evaluate primary hype raldosteronism, which typ ically presents with hypertension and hypokalemia This patient's hyperglycem ia and psychiatric and menstrual symptoms are more consistent with hype rcortisolism
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(Choice E) Hyperandrogenism can be seen in Cushing syndrome due to ACTH-induced adrenal androgen production or co-secretion of cortisol and testosterone by an adrenal tumor. Testosterone levels may be useful in evaluating hirsutism, but would not explain this patient's constellation of findings consistent with Cushing syndrome. Educational objective: The initial step in the evaluation of Cushing syndrome is to confirm hypercortisolism with a late-night salivary cortisol assay, 24-hour urine free cortisol measurement, and/or overnight low-dose dexamethasone test If hype rcortisolism is confi rmed, ACTH levels are measured to diffe rentiate ACTH-dependent from ACTH-independent causes. References: 1. The diagnosis of Cushing syndrome: an Endocrine Society Practice Guideline.
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A 34-year-old woman comes to the office due to a 6-month history of easy bruising with minimal or no trauma. She also has had difficulty climbing stairs due to muscle weakness and frequent nocturnal muscle cramps The patient has experienced a 7-kg (15-lb) weight gain despite following a restricted-calorie vegan diet Her medical history is notable for an uncompl icated root canal procedure 6 months ago but is otherwise unremarkable. She takes no prescription or over-the-counter medications. The patient is not currently sexually active and has never been pregnant Her last menstrual period was 3 months ago There is no fam ily history of bleeding disorders. Her blood pressure is 146/94 mm Hg and pulse is 78/min. BMI is 29 kg/m2 Examination shows facial plethora with dark terminal hair on her upper lip and chin. There is inflammatory acne on her face and back, extensive tinea ve rsicolor on the trunk, and scattered bruises over the extremities. Fasting laboratory results are as follows Complete blood count Hemoglobin
14 g/dL
Platelets
160,000/mm'
Leukocytes
9,500/mm'
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Neutrophils
80%
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Eosinophils
0%
29
Lymphocytes
17%
Monocytes
2%
Basophils
1%
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Serum chemistry Sodium
140 mEq/L
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Lymphocytes
17%
Monocytes
2%
Basophils
1%
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Serum chemistry Sodium
140 mEq/L
Potassium
3.6 mEq/L
Chloride
100 mEq/L
Bicarbonate
28 mEq/L
20
Creatinine
0.8 mg/dl
21
Calcium
9 mg/dl
Glucose
122 mg/dl
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Which of the following is the most likely cause of this patient's symptoms? ® A Cushing syndrome ® B. Cutaneous small vessel vasculitis
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® C. Polycystic ovary syndrome ® D. Vitamin C deficiency ® E. Vitamin K deficiency ® F. Von Willebrand disease Submit T
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Explanation:
~ []
Features of Cushing syndrome
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face Muscle wasting
Supraclavicular fat pads
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Central obesity
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@UWortd
This patient has several features suggesting Cushing syndr ome (hyperco rtisolism). Weight gain, proximal muscle weakness, and hypertension are common presenting findings. Patients can experience easy bruisability, dermal atrophy , and wide purple striae due to the catabolic effects of cortisol on connective tissue; however , platelet function and coagulation proteins are normal. Dermatologic signs may include hyperpigmentation (in ACTH-dependent Cushing syndrome) and increased incidence of cutaneous fungal infections (eg, tinea ve rsicolor , onychomycosis). Women can have features of hyperandrogenism (eg, menstrual irregularities, acne, hirsutism) due to co-secretion of adrenal androgens with cortisol. Hypergly cemia is common (due to peripheral insulin resistance and hypercortisolism-induced gluconeogenesis) Hypokalemia and alkalosis may be present (due to the partial mineralocortico id effects of cortisol) if co rtisol levels are ve ry high Once there is laboratory confi rmation of hyper cortisolism (eg, late-night salivary cortisol assay, 24-hour urine free co rtisol measurement, overnight low-dose dexamethasone suppression test), ACTH levels are measured to differentiate ACTH-dependent (eg, ACTH-secreting pituitary tumor, ectopic ACTH) from ACTH-independent (eg, adrenal adenoma) causes.
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(Choice B) Cutaneous small-vessel vasculitis can be triggered by infections, medications, inflammatory conditions, or malignancy. It presents with nonblanching violaceous petechiae that can coalesce into palpable purpura. We ight gain, hyperglycem ia, and hyperandrogenic symptoms would not be common. (Choice C) Polycystic ovary syndrome shares a number of features with Cushing syndrome, including obesity , irregular menstrual periods, and hyperandrogenism However , skin atrophy, muscle weakness, and bruisability are not characteristic. (Choices D, E, and F) Vitamin C deficiency causes microvascular bleeding due to impaired synthesis of collagen. Vitamin K deficiency also causes bleeding, due to reduced levels of coagulation factors II, VII, IX, and X. Von W illebrand disease is an autosomal dominant disorder characterized by impaired platelet function and excessive bleeding However , none of these
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confi rmation of hyper cortisolism (eg, late-night salivary cortisol assay, 24-hour urine free co rtisol measurement, overnight low-dose dexamethasone suppression test), ACTH levels are measured to differentiate ACTH-dependent (eg, ACTH-secreting pituitary tumor , ectopic ACTH) from ACTH-independent (eg, adrenal adenoma) causes. (Choice B) Cutaneous small-vessel vasculitis can be triggered by infections, medications, inflammatory conditions, or malignancy. It presents with nonblanching violaceous petechiae that can coalesce into palpable purpura. We ight gain, hyperglycem ia, and hyperandrogenic symptoms would not be common. (Choice C) Polycystic ovary syndrome shares a number of features with Cushing syndrome, including obesity , irregular menstrual periods, and hyperandrogenism However , skin atrophy, muscle weakness, and bruisability are not characteristic. (Choices D, E, and F) Vitamin C deficiency causes microvascular bleeding due to impaired synthesis of collagen. Vitamin K deficiency also causes bleeding, due to reduced levels of coagulation factors II, VII, IX, and X. Von W illebrand disease is an autosomal dominant disorder characterized by impaired platelet function and excessive bleeding. However , none of these conditions would explain this patient's weight gain, muscle weakness, hyperandrogenism, hyperglycem ia, and metabolic alkalosis. In addition, vitamin C or K deficiencies are not common in vegans Educational objective: Cushing syndrome is characterized by weight gain, muscle weakness, and hypertension Patients can experience easy bruisability, dermal atrophy , and striae due to the catabolic effects of cortisol on connective tissue. Women can have features of hyperandrogenism due to co-secretion of adrenal androgens with cortisoL References: 1. The diagnosis of Cushing's syndrome.
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A 43-year-old patient asks the physician to examine his 75-year-old mother, who has been complaining of headaches. When the woman presents for her first appointment, she admits to having a severe , persistent headache for the past 4 weeks. She says the headache is worse in the morning and always lingers throughout the day . She usually feels nauseated but has no vomiting. Her medical history is significant for severe depression and anxiety, and her current medications include an antidepressant. A complete workup shows that she has a brain tumor, likely a glioblastoma. Both she and her son (also the physician's patient) are present at today's appointment to learn of the diagnosis Before the physician has a chance to discuss the findings, the son steps outside the patient's room and requests that the physician not reveal the diagnosis to his mother. Which of the following is the most appropriate response?
<0 A "As a physician, I always tell a patient about a serious diagnosis, as it is my moral responsibility." <0 B. "If you feel this strongly about it, how about I delay giving her info rmation now, but tell her at a later date?"
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<0 C. "Is there a specific reason why you do not want your mother to know the diagnosis?"
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<0 D. "Leave the matter to me as I will determine whether she should know her diagnosis"
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<0 E. "This news would only be upsetting to her and therefore I will not discuss the diagnosis at all."
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E. "This news would only be upsetting to her and therefore I will not discuss the diagnosis at aiL" [0%) Explanation: In general, a patient has the right to know a diagnosis If fam ily members ask for information to be withheld, it is imperative fo r the physician to understand their reasoning Occasionally, it is in the patient's best interest to withhold especially distressing news (eg, if a severely depressed patient might become suicidal). Therefore, it is best to clarify the situation with the concerned family members fi rst before deciding how best to proceed (Choice A) It is indeed accurate (albeit with some qualifications) fo r the physician to tell the patient's son of the moral obligation to inform the patient of her diagnosis However, it is better to first determine the family member's reasoning fo r withholding the diagnosis before deciding how to handle the situation.
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{Choice B) Immediately agreeing to withhold or delay news of the diagnosis is inappropriate as the family member's reasoning should first be explored and discussed.
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(Choice D) Answering the family member's request with a rude, abrupt response is unprofessionaL It is important to provide support to both the mother and her son. (Choice E) W hile the physician may conclude that the news would be upsetting, it would be most appropriate to hear the son's concerns before proceeding For instance, the patient may be relieved to know that the etiology of her headaches has been discovered despite receiving the diagnosis of cancer. Educational objective: Patients have the right to know their diagnoses If family members request that the diagnosis not be revealed to the patient, the underlying reasons should be explored before deciding how to proceed Time Spent 3 seconds
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A 63-year-old man comes to the urgent care center with a 2-week history of an ulcer on his right foot He has no associated pain, fever , chills, or skin rash. The patient was diagnosed with hypertension 5 years ago but did not follow up with a physician, and he has had no surgeries or hospitalizations. He takes ibuprofen for occasional back pain. The patient has a 30-pack year smoking history but quit 2 years ago. He drinks 1 or 2 beers daily and does not eat red meat or processed foods. The patient considers himself to be in good health and walks several miles a day Temperature is 36.7 C (981 F), blood pressure is 156/98 mm Hg, and pulse is 88/min. BMI is 32 kg/m2 . On examination, the feet are warm and dry. A nontender ulcer with a thick surrounding call us is present on the sole of the foot just below the head of the first metatarsal bone. Which of the following will most likely diagnose the underlying cause of this patient's foot ulcer?
<0 A Alcohol screening questionnaire <0 B. Ankle-brachial index <0 C. Culture from the ulcer bed @ D. Duplex venous ultrasound
<0 E. Hemoglobin A1c assay <0 F. Hepatitis C testing <0 G. TSH level Submit
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Explanation:
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Risk factors
• Arterial insufficiency • End-stage renal disease in a patient on dialysis • Smoking
Location
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• Plantar surface, areas under pressure points (eg, bony prominences)
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• Mechanical offloading
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Management
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• Debridement • Wound dressings
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Lab Values
• Antibiotics if infection @UWo~d
Peripheral neuropathy is the most common cause of foot ulcers in patients with diabetes, and diabetes is the most common underlying cause of neuropathic ulcers. Whereas neuropathy involving small nerve fibers typically causes positive symptoms (eg, pain, paresthesias), involvement of large fibers produces primarily negative symptoms (eg, sensory loss) that can cause minor injuries to go unrecognized until the development of a foot ulcer. Autonomic dysregulation can lead to decreased sweating and dry feet (susceptible to skin fissure formation) and further increase the risk for ulceration.
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neuropathic ulcer. He should therefore be screened fo r diabetes with a hemoglobin A1c assay or fasting glucose measurement Poor diabetic control (eg, elevated hemoglobin A1c) inc reases the risk for peripheral neuropathy (Choice A) Peripheral neuropathy due to alcohol use may resemble diabetic neuropathy (eg, symmetric , distal numbness or paresthesias) but is less frequently associated with ulcer development, possibly as perfusion is more preserved. In addition, this patient's moderate alcohol intake is unlikely to cause neuropathy {Choice B) The ankle-brachial index can diagnose peripheral artery disease. Features suggesting an arter ial ulcer include location at the tips of the digits, diminished pulses, skin pallor, loss of hair, and intermittent claudication. This patient has warm feet (preserved perfusion) and walks several miles daily (preserved exercise tolerance), making significant artery disease unlikely (Choice C) Culture from an ulcer bed typically reveals polymicrob ial colonization but would not indicate true infection in the absence of more specific symptoms (eg, fever, erythema, purulent drainage). Culture also would not establish the underlying cause of the ulce r. (Choice D) Duplex sonography can identify venous insufficiency or obstruction. Venous ulcers typically occur on the medial aspect of the leg above the malleolus; they are usually associated with edema and stasis dermatitis. (Choice F) Mild sensorimotor abnormalities can be detected on electrodiagnostic testing in patients with hepatitis C-induced mixed cryoglobulinemia (which can cause a vasculitic rash), but clinically significant neuropathy and ulceration are uncommon. (Choice G) Peripheral neuropathy is an uncommon manifestation of hypothyroidism and is usually seen in patients with severe, untreated hypothyroidism Educational objective: Diabetes is the most common cause of neuropathic ulcers. These ulcers typically occur on the sole of the foot at weight-bearing points.
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0 A. Antithyroid peroxidase antibody assay 0 B. Genetic mutation analysis in fine-needle aspiration biopsy sample
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0 C. Measurement of serum calcitonin
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6 D. Radioactive iodine ablation
0 E. Surgical resection 6 F. Thyroid scintigraphy
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A 33-year-woman comes to the office for follow-up of a thyroid nodule that was discovered incidentally on a routine physical examination 3 weeks ago. The patient feels well and has experienced no weight changes, temperature intolerance, or menstrual irregularities. Medical history is notable for primary hypothyroidism treated with levothyroxine Family history is notable fo r hypertension and hypothyroidism in her mother, but the patient has no relatives with a history of thyroid cancer. TSH is normal. Neck ultrasound reveals a 2.0-cm hypoechoic nodule in the right lobe of her thyroid without any enlarged lymph nodes. Fine-needle aspiration biopsy reveals large cells with ground glass cytoplasm, and pale nuclei containing inclusion bodies and central grooving consistent with papillary thyroid cance r. W hich of the following is the best next step in management of this patient?
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Surgical resection is the primary treatment fo r papillary thyroid cancer. The extent of surgery depends on the tumor size, extrathy roidal invasion, patient age, and lymph node involvement Small tumors (<1-2 em) without evidence of lymph node involvement or contralateral thyro id abnormalities can usually be managed with partial thyro idectomy/lobectomy, whereas larger tumors usually warrant total thy roidectomy. In addition, regional lymph node or central compa rtment lymph node dissection is usually performed for papillary cancer with lymph node metastasis or extrathy roidal invasion. Following surgery, adjuvant therapy with radioiodine ablation is warranted for patients with increased risk of tumor recurrence (eg, large tumors, extrathyroidal invasion, lymph node metastasis, incomplete resection) (Choice D). TSH can stimulate growth of occult residual or metastatic disease. For this reason, patients at increased risk of recurrence should also receive adequate doses of thyroid r eplacement to suppress TSH secretion. (Choice A) Thyroid peroxidase (TPO) antibodies are a marke r fo r chronic lymphocytic (Hashimoto) thyroiditis TPO antibodies are useful in the initial evaluation of hypothyro idism and diffuse goiter but have no utility in evaluation of papillary thyroid cance r.
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(Choice B) Mutations of several genes (eg, BRAF, RET) are common in papillary thyroid cancer. Genetic mutation profiling may be performed when the cytology results from fine-needle aspiration biopsy are indeterminate but are not needed if cytology confirms papillary cancer.
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(Choice C) Calcitonin is a marke r fo r medullary thy roid cancer, which arises from the parafollicular C cells of the thyroid gland Papillary and follicular cancers arise from thyro id epithelial cells. (Choice F) Thyroid scintigraphy is performed in the initial evaluation of thyroid nodules in patients with subnormal TSH levels. A hyperfunctioning ("hot") nodule with increased uptake of the radiomarker is less likely to be malignant than a hypofunctioning ("cold") nodule. Educational objective: Surgical resection is the primary treatment modality for papillary thyro id carcinoma. Postoperative adjuvant therapies for patients at increased risk of recurrence include radioiodine ablation and suppressive doses of thyroid hormone.
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A 68-year-old man is brought to the hospital due to 2 days of progressive shortness of breath and cough He has a history of severe chronic obstructive pulmonary disease and has had multiple recent exacerbations and several hospitalizations over the past year . During his last hospitalization, he had acute respiratory failure requiring endotracheal intubation. This prompted the patient to make a living will specifying that he does not want any resuscitative measures or invasive therapies in the event of a life-threatening emergency. On examination, he is lethargic and arousable only to noxious physical stimuli. His temperature is 37.2 C (99 F), blood pressure is 132/70 mm Hg, pulse is 102/min, and respirations are 32/min. Examination reveals diffusely decreased breath sounds, bilateral expiratory wheezes, and labored breathing It is determined that he lacks decision-making capacity. His daughter says, "I have been taking care of my father fo r many yea rs and I know him better than anyone. He would not want any aggressive measures. Please just make him comfortable." However, the patient's wife demands that everything be done to save her husband's life , including intubation if necessary She insists that she knows what her husband would have wanted and threatens to file a lawsuit W hich of the following interventions is the most appropriate next step?
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<0 B. Meet with all fam ily members to achieve consensus on a course of action
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<0 C. Obtain a court order to proceed with intubation
e; D. Proceed with endotracheal intubation if medically indicated <0 E. Respect the patient's living will and provide comfo rt care only Submit
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C. Obtain a court order to proceed with intubation [0%) D. Proceed with endotracheal intubation if medically indicated [2%)
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E. Respect the patient's living will and provide comfort care only [92%)
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Explanation: A living will (advanced directive) specifies a patient's wishes for health care in advance of losing the ability to communicate or of becoming incapable of making his or her own decisions. In this case, the patient is incapacitated and his family members strongly disagree on the best course of action; both claim to have a better understanding of what the patient would have wanted in the current situation. However, the physician's responsibility is to the patient, and ethically the physician must adhere to the patient's wishes as outlined in the living will. The living will protects the patient's autonomy and overr ules the wishes of any family members. (Choices A, B, and C) Initiating a fam ily meeting would be the first step if the family members disagreed about the course of action and there was no living will and/or no designated health care proxy in place Referral to the hospital ethics committee or the courts for a judgment would become necessary if no consensus was achieved. (Choice D) Proceeding with CPR or intubation would violate the patient's wishes as expressed in his living will. Educational objective: A living will communicates the patient's own wishes if he or she becomes incapacitated, and it overrules the wishes of the family. References: 1. Efficacy of advance care planning: a systematic review and meta-analysis .
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® A. "Although I understand your conce rn , we should address it tomorrow because it is not an emergency "
® B. "I am sorry I would normally see you, but I have another appointment that can't wait." ® C. "I am sorry you drove all this way , but your problem can wait until tomorrow." ® D. "If you feel this is an emergency, you should go to the nearest emergency department fo r evaluation."
® E. "I regret that I cannot see you now; didn't my staff info rm you that it is clos ing time?" ® F. "Let me take a quick look; it's probably nothing to worry about." Subm it
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Lab Values
A 34-year-old man calls the office requesting an urgent appointment due to cough and cold symptoms His temperature is 37.2 C (99 F), but he feels "miserable" and is unsure if he should go to work the next day The patient has a history of seasonal allergies and knee pain from a past sports injury He has no other medical problems but does have a history of frequent office visits. The receptionist info rms him that the physician is preparing to leave as it is near closing time but that an appointment is available for the next morn ing. The patient declines the offer of an appointment and hangs up As the physician leaves the office 30 minutes later to make evening rounds at the hospital, the patient arrives and insists on being seen immediately. He sounds congested and coughs occasionally but is breathing normally He has no other symptoms He again asks to be examined. W hich of the following is the most appropriate response?
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Explanation: This physician is faced with a patient who inappropriately demands to be seen after hours fo r a non-urgent concern . A stable patient who fails to arrive at the appointed time should be advised to reschedule the appointment; the physician is under no obligation to immediately see this patient Performing an examination after hours is inappropriate and reinfo rces the patient's sense of entitlement and poor boundaries. Acquiescing to the patient's demands would only encourage similar behavior in the future and create further tension in the physician-patient relationship due to the patient's lack of respect for the phys ician's time (Choice F) The most appropriate response is to calmly set limits and establish clear professional boundaries. The phys ic ian should explain in a polite yet fi rm tone that the examination will be deferred until the next day because the condition is not an emergency
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(Choice B) Th is response suggests that the patient's behavior is appropriate and offers an excuse not to see the patient rather than explaining that non-emergency concerns can wait
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{Choices C and E) These responses set limits but are dismissive of the patient's conce rns. It is better to acknowledge the concerns but explain that non-urgent issues are addressed during regular office hours. {Choice D) Recommending that the patient go to the emergency department fo r a non-urgent condition is inappropriate and places an unnecessary burden on emergency services. Educational objective: Physicians should respond politely but firmly to inappropriate patient requests Maintaining professional boundaries is an important component of the physician-patient relationship. References:
1. Managing difficult encounters: understanding physician, patient, and situational factors .
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137 mEq/L
Potassium
4.2 mEq/L
Chloride
104 mEq/L
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Bicarbonate
24 mEq/L
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Calcium
11.4 mg/dl
Phosphorus
1 8 mg/dl
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Blood urea nitrogen
21 mg/dl
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Creatinine
1.0 mg/dl
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A 31-year-old woman comes to the office after 3 months of continuous burning, upper abdominal pain that is only partially relieved by over-the-counter ranitidine or antacids. She also has experienced recent-onset constipation and excess urination. The patient reports no weight loss or decreased appetite. Her menstrual periods are regular The patient's father has a history of "many stomach ulcers and multiple kidney stones." Her temperature is 37.1 C (98 8 F), blood pressure is 130/85 mm Hg, pulse is 78/min, and respirations are 14/min. Abdominal examination shows normal bowel sounds, tenderness in the epigastric region, and no palpable masses. Her stools are positive for occult blood. Laboratory results are as follows: Sodium
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Add itional evaluation is most likely to reveal which of the following? e')
A. Ad renal insufficiency
6 B. Glucagonoma 6 C. Medullary thyroid cancer 6 D. Metastatic gastric ca rcinoma e')
E. Milk-alkali syndrome
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Sodium
137 mEq/L
Potassium
4.2 mEq/ L
Chloride
104 mEq/L
Bicarbonate
24 mEq/ L
Calcium
11.4 mg/dl
Phosphorus
1.8 mg/dl
Blood urea nitrogen
21 mg/dl
Creatinine
1.0 mg/dl
Additional evaluation is most likely to reveal which of the following?
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ID A Adrenal insufficiency ID B. Glucagonoma ID C. Medullary thyroid cancer ID D. Metastatic gastric carcinoma ID E. Milk-alkali syndrome ID F. Primary hyper parathyroidism ID G. Sarcoidosis ID H. Thyro id adenoma Submit
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pressure is 130/85 mm Hg, pulse is 78/min, and respirations are 14/min. Abdominal examination shows normal bowel sounds, tenderness in the epigastric region, and no palpable masses. Her stools are positive for occult blood. Laboratory results are as follows
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This patient most likely has type 1 multiple endocrine neoplasia syndrome (MEN1), an autosomal dominant condition characterized by 3 primary tumor types ("the 3 Ps"): • Parathyroid adenomas/hyperplasia Constipation, polyuria, and possibly abdominal pain in the setting of a calcium level of 11.4 mg/dl suggest symptomatic hypercalcemia, likely from primary hyperparathyroidism (PHPT) PHPT is present in >90% of patients with MEN1, usually occurs by age 40, and results from multiglandular parathyroid adenomas or parathyroid hype rplasia • Gastrointestinal/pancr eatic endocr ine tumors (eg, gastrinomas). Burning upper abdominal pain that is only partially responsive to ranitidine and antacids and associated with occult gastro intestinal bleeding is concerning fo r Zollinger-EIIison syndrome, characterized by severe and refractory peptic ulcer disease due to gastrin-producing tumors (gastrinomas) • Pituitary adenomas.
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The patient's father probably also had MEN1 given his history of kidney stones (likely due to hypercalcem ia) and recurrent peptic ulcers.
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{Choice A) Primary adrenal insufficiency presents with fatigue and weight loss. Typical clinical findings include hypotension, hyperpigmentation, and hyperkalemia (Choice B) Glucagonoma is a less common tumor in MEN1 and is characterized by hyperglycemia, necrolytic migratory erythema, weight loss, and anemia. {Choice C) Medullary thyroid cance r is a component of MEN2 and typ ically presents as a thyroid nodule. {Choice D) Gastric cance r can cause abdominal pain with gastro intestinal ulce ration and bleeding However , it is commonly associated with weight loss, early satiety, and dysphagia; would be rare at this patient's age; and is less likely to explain hypercalcemia {Choice E) Milk-alkali syndrome is characterized by hypercalcemia, renal insuffic iency, and II'"'
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findings include hypotension, hyperpigmentation, and hyperkalemia. (Choice B) Glucagonoma is a less common tumor in MEN1 and is characterized by hype rglycemia, necrolytic migratory erythema, weight loss, and anemia. (Choice C) Medullary thyroid cancer is a component of MEN2 and typically presents as a thyroid nodule. {Choice D) Gastric cancer can cause abdominal pain with gastro intestinal ulce ration and bleeding However, it is commonly associated with weight loss, early satiety, and dysphagia; would be rare at this patient's age; and is less likely to explain hypercalcemia (Choice E) Milk-alkali syndrome is characterized by hypercalcemia, renal insufficiency, and metabolic alkalosis. This patient has a normal serum creatinine and bicarbonate. (Choice G) Sarcoidosis causes hype rcalcemia due to increased conversion of 25-hyd roxyvitamin D to 1,25-d ihydroxyvitamin D. However , whereas pulmonary symptoms are common, gastrointestinal manifestations (eg, epigastric pain) are rare. Sarco idosis also would not explain this patient's family history of recurrent kidney stones and peptic ulcers. (Choice H) A toxic thyro id adenoma could cause hypercalcemia due to increased bone turnover. However, this patient has no other manifestations of thyrotoxicosis (eg, weight loss, tachyca rdia) Educational objective: Type 1 multiple endocrine neoplasia is characterized by primary hyperparathy roidism, pituitary tumors, and gastro intestinal/pancreatic endocrine tumors (eg, gastrinomas). Common complications include symptomatic hypercalcemia and recurrent peptic ulcer. References: 1. Multiple endocrine neoplasia type 1.
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Hb MCV Reticulocyte count Serum LDH Haptoglobin Peripheral smear
9 g/dl 75 fl increased increased decreased fragmented RBC
W hich of the following is the most likely cause of this patient's anemia?
® A Bleeding peptic ulce r.
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e; B. Diverticulosis.
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® C. Macrovascular traumatic hemolys is
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® D. Wa rm antibody hemolysis. ® E. G6PD deficiency anemia. Submit
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A 75-year-old Caucasian male comes to the office for his routine medical check-up He complains of fatigue fo r the past month. His previous medical history is significant for calcified aortic valves and hype rtension His vital signs are stable, except for a blood pressure of 150/90 mm Hg Physical examination reveals pallor and a 4+ ejection systolic murmur in the aortic area. Lab reports show
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C. Macrovascular traumatic hemolysis. [92%) D. Warm antibody hemolysis [3%) E. G6PD deficiency anemia. [1%)
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Explanation:
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The laboratory findings (i.e., elevated reticulocyte count, increased LDH level, decreased haptoglobin) of this patient are very suggestive of an intravascular hemolytic anemia. Chronic hemolysis has resulted in iron loss and consequent microcytic anemia. W ith the given history, the most likely cause of hemolysis is mechanical trauma from calcified aortic valves. This phenomenon is also called macrovascular traumatic hemolysis, and is usually seen with artific ial heart valves or markedly calcified valves. The peripheral blood smear of patients with this condition typically reveals helmet cells or fragmented RBCs.
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{Choices A and B) Bleeding peptic ulce r and diverticulosis are common causes of microcytic anemia in the elderly , but these diagnoses cannot explain the signs of hemolysis in this patient {Choice D) Warm, antibody-type, autoimmune hemolytic anemia is most commonly seen in women with some underlying disease affecting the immune system (e g , lymphoid neoplasm, collagen vascular disease, congenital immunodeficiency diseases) It is characterized by a positive Coomb's test However, the clinical presentation of the patient in this vignette is more suggestive of traumatic hemolytic anemia. {Choice E) G6PD deficiency generally causes acute hemolysis precipitated by drugs, infection or metabolic abnormalities, rather than chronic hemolysis. Furthermore, patients typically develop clinical manifestations at an earlier age. Educational Objective: Macrovascular hemolysis can cause microcytic anemia in patients with artificial heart valves or severely calcified aortic valves. Time Spent 5 seconds
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A 36-year-old man comes to the emergency department due to a week of progressive right upper quadrant abdominal pain, malaise, anorexia, and fever . Three months ago, he returned from a vacation to Nepal, where he hiked in the mountains. During his trip, the patient had several self-resolving episodes of diarrhea. He also had unprotected sexual intercourse with a woman he met during the visit. The patient drinks 1 or 2 cans of beer daily but stopped after his recent symptoms began. Temperature is 38.5 C (101 3 F), blood pressure is 120/70 mm Hg, and pulse is 96/min. Breath sounds are decreased in the right lung base. The liver is palpable 3 em below the right costal margin with a tender , smooth edge. Laboratory results are as follows Leukocyte count
13,000/mm'
Neutrophils
67%
Eosinophils
2%
Lymphocytes
31 %
Liver function studies
25
26
Total bilirubin
1.3 mg/dL
27 28
Alkaline phosphatase
320 U/L
Aspartate aminotransferase
87 U/L
Alanine aminotransferase
99 U/L
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Abdominal ultrasonography reveals a solitary cystic lesion on the right lobe of the liver. W hich of the following is the most likely cause of this patient's condition?
6 A. Alcohol-induced liver inflammation 6 B. Gonococcal perihepatitis
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13,000/mm'
Neutrophils
67%
Eosinophils
2%
Lymphocytes
31 %
Total bilirubin
1.3 mg/dL
Alkaline phosphatase
320 U/L
Aspartate aminotransferase
87 U/L
Alanine aminotransferase
99 U/L
Abdominal ultrasonography reveals a solitary cystic lesion on the right lobe of the liver . W hich of the following is the most likely cause of this patient's condition?
® A Alcohol-induced liver inflammation ® B. Gonococcal perihepatitis ® C. Hepatotropic virus infection ® D. Polym icrob ial live r infection ® E. Protozoal infection ® F. Tapeworm infection Submit
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Lab Values
Liver function studies
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Leukocyte count
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the right costal margin with a tender , smooth edge Laboratory results are as follows
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Explanation:
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Entamoeba histolytica
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Risk factors
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Manifestations
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• Developing nations (travel/residence) • Contaminated food/water • Fecal-oral sexual transmission (rare) • 90% of patients asymptomatic • Colitis (diarmea, bloody stool with mucus, abdominal pain) • Liver abscess (RUQ pain, fever) o Complications - rupture of pleura/peritoneum
Diagnosis
• Stool 0 & P, stool antigen testing (colitis) • E histolytica serology (liver abscess)
Treatment
• Metronidazole & intraluminal antibiotic (eg, paromomycin)
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0 & P = ova & parasites; RUQ = right upper quadrant. ©UWorid
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Entamoeba histotytica is a protozoan found in developing countries that is transmitted primarily through the consumption of contaminated food and water. Most infections are asymptomatic, but about 10% of patients have clinical symptoms of colitis or extra intestinal (liver, pleura, brain) disease.
Amebic liver abscess is the most common form of extraintestinal disease and develops when E histolytica spreads from the colonic mucosa to the liver via the portal vein. Symptoms are subacute and include right upper quadrant (RUQ) pain and fever (>38 5 C [101.3 F)), sometimes with recent or concurrent diarrhea (colitis). Hepatomegaly and elevations in -
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Entamoeba histolytica is a protozoan found in developing countries that is transmitted primarily through the consumption of contam inated food and water. Most infections are asymptomatic , but about 10% of patients have clinical symptoms of colitis or extra intestinal (live r, pleura, brain) disease. Amebic liver abscess is the most common form of extraintestinal disease and develops when E histolytica spreads from the colonic mucosa to the live r via the portal vein. Symptoms are subacute and include right upper quadrant (RUQ) pain and fever (>38 5 C [101 .3 F)), sometimes with recent or concurrent diarrhea (colitis). Hepatomegaly and elevations in leukocyte count, alkaline phosphatase, and transaminases commonly occur. A characteristic finding on imaging (CT scan, ultrasound) is the presence of a single subcapsular cyst in the right hepatic lobe. Diagnosis is made with serology; needle aspiration of the live r lesion is not generally needed. Metronidazole and an intraluminal antibacterial (eg, paromomycin) effectively eliminate the infection. A small number of patients may develop complications (eg, pleural infection, peritonitis) due to cyst rupture (Choice A) Alcoholic hepatitis can cause fever, jaundice, and RUQ pain However , it usually develops following years of heavy alcohol use, is characterized by a ~2 1 ratio of aspartate aminotransferase to alanine aminotransferase, and would not cause a cystic lesion on ultrasound.
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(Choice B) Gonococcal perihepatitis occurs in about 10% of women with pelvic inflammatory disease and is marked by RUQ abdominal pain, fever, pleurisy, and mild elevations in aminotransferases. It is rare in men and is not characterized by a single cystic liver lesion. {Choice C) Hepatotrop ic viruses (eg, hepatitis A and B) are often acquired while traveling, and acute infections manifest with vomiting, RUQ pain, jaundice, and elevated aminotransferases (often >1000 U/L) (Choice D) Pyogenic and amebic abscesses have similar clinical and radiographic appearances However, pyogenic abscesses are more common in patients with diabetes or underlying hepatobiliary or pancreatic disease and tend to develop following episodes of infection or from surgical wounds. This patient's recent travel to an endemic E histolytica region also makes an amoebic abscess more likely .
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right hepatic lobe. Diagnosis is made with serology; needle aspiration of the live r lesion is not generally needed. Metronidazole and an intraluminal antibacterial (eg, paromomycin) effectively eliminate the infection. A small number of patients may develop complications (eg, pleural infection, peritonitis) due to cyst rupture (Choice A) Alcoholic hepatitis can cause fever, jaundice, and RUQ pain However , it usually develops following years of heavy alcohol use, is characterized by a ~2 1 ratio of aspartate aminotransferase to alanine aminotransferase, and would not cause a cystic lesion on ultrasound. {Choice B) Gonococcal perihepatitis occurs in about 10% of women with pelvic inflammatory disease and is marked by RUQ abdominal pain, fever, pleurisy, and mild elevations in aminotransferases. It is rare in men and is not characterized by a single cystic liver lesion. {Choice C) Hepatotrop ic viruses (eg, hepatitis A and B) are often acquired while traveling, and acute infections manifest with vomiting, RUQ pain, jaundice, and elevated aminotransferases (often >1000 U/L) (Choice D) Pyogenic and amebic abscesses have similar clinical and radiographic appearances However, pyogenic abscesses are more common in patients with diabetes or underlying hepatobiliary or pancreatic disease and tend to develop following episodes of infection or from surgical wounds. This patient's recent travel to an endemic E histotytica region also makes an amoebic abscess more likely. (Choice F) Echinococcus granulosis can cause a hydatid liver cyst with symptoms of RUQ pain, nausea, vom iting, and hepatomegaly However , fever is rare in the absence of cyst rupture and diarrhea is uncommon. In addition, most patients are asymptomatic fo r yea rs (not months) Educational objective: Entamoeba histotytica is a protozoan that can cause colitis or extraintestinal (live r, pleura, brain) illness in patients who live in or travel to developing countries. Amoebic liver abscess is characterized by right upper quadrant pain, feve r, and (usually) a single subcapsular cyst in the right lobe of the liver. Time Spent 4 seconds
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A 68-year-old man is brought to the emergency department due to 2 days of progressive confusion and lethargy . His symptoms started approximately 4 days ago with malaise, nausea, and vom iting. The patient has hype rtension and chronic back pain due to spinal stenosis. Laminectomy 4 years ago provided limited symptom improvement The patient's medications include daily losartan and as-needed hydrocodone-acetaminophen His wife says that for the past 2 weeks he has been taking additional acetaminophen fo r a severe toothache. The patient smokes a pack of cigarettes and drinks 2 shots of whiskey daily . He has a remote history of intravenous drug abuse. His blood pressure is 110/60 mm Hg, pulse is 108/min, and BMI is 32 kg/m2 The patient is sleepy but wakes when spoken to and follows instructions. He is oriented to person and place. There is mild scleral icterus. Cardiopulmonary examination is unremarkable, and a smooth and tender liver edge is palpable 3 em below the right costal margin. The patient has a mild flapping tremor of both hands. Laboratory results are as follows: Complete blood count Hematocrit
42%
Platelets
160,000/mm'
Leukocytes
9000/mm'
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Serum chemistry Blood urea nitrogen
32 mg/dL
Creatinine
1.9 mg/dL
Live r function studies Total bilirubin
3.3 mg/dL
Alkaline phosphatase
220 U/L
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Blood urea nitrogen
32 mg/dl
Creatinine
1.9 mg/dl
Live r function studies
20
Total bilirubin
3.3 mg/dl
Alkaline phosphatase
220 U/L
Aspartate aminotransferase
3207 U/L
Alanine aminotransferase
4180 U/L
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INR
24 25
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1.6 (normal 0 8-1 2)
W hich of the following is the most likely diagnosis in this patient?
® A. Acute alcoholic hepatitis ® B. Hepatitis C infection ® C . Ischemic hepatitis ® D. Liver cirrhosis ® E. Medication- induced live r injury ® F. Nonalcoholic steatohepatitis Submit
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Etiology
• • • • • •
Viral hepatitis (eg, HSV; CMV; hepatitis A, 8 , D & E) Drug toxicity (eg, acetaminophen overdose, idiosyncratic) Ischemia (eg, shock liver, Budd-Chiari syndrome) Autoimmune hepatitis Wilson disease Malignant infiltration
Clinical presentation
• • • • • •
Generalized symptoms (eg, fatigue , lethargy, anorexia, nausea) Right upper quadrant abdominal pain Pruritus & jaundice due to hyperbilirubinemia Renal insufficiency Thrombocytopenia Hypoglycemia
Diagnostic requirements
• Severe acute liver injury (ALT & AST often > 1000 U/L) • Signs of hepatic encephalopathy (eg, confusion, asterixis) • Synthetic liver dysfunction (INR ;::1.5)
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Acute liver failure
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Explanation:
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ALT =alanine aminotransferase; AST =aspartate aminotransferase; CMV =cytomegalovirus; HSV = herpes simplex virus. IDUWOI1d
This patient has acute liver failure (ALF) likely due to acetaminophen toxicity in the setting of chronic alcohol use. Diagnosis of ALF requires the triad of elevated aminotransferases
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This patient has acute liver failure (ALF) likely due to acetaminophen toxicity in the setting of chronic alcohol use. Diagnosis of ALF requires the triad of elevated aminotransferases (markedly elevated in this patient), signs of hepatic encephalopathy (confusion, somnolence, and flapping tremor consistent with asterixis in this patient), and synthetic liver dysfunction (evidenced by INR 2':1.5). Cirrhosis or underlying liver disease should not be present Acetaminophen toxicity is the most common cause of ALF in many developed countries and can be seen in intentional overdose (suicide attempt) or accidental overdose in patients taking multiple sources of acetaminophen (such as this patient) Toxicity results from overproduction of the toxic metabolite N-acetyl-p-benzoquinone imine (NAPQI), which leads to hepatic necrosis. NAPQI is normally safely detoxified through glucuronidation in the liver, but this pathway becomes overwhelmed in overdose. Chronic alcohol use is thought to potentiate acetaminophen hepatotoxicity by depleting glutathione levels and impairing the glucuronidation process On the other hand, N-acetylcysteine increases glutathione levels and binds to NAPQI, so it is an effective antidote for acetaminophen overdose when given early
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Acute renal insufficiency is common in ALF, especially when acetaminophen induced, due to the drug's direct renal tubular toxicity Hyperbilirubinemia is common as well, but acetaminophen hepatotoxicity is characterized by relatively low serum bilirubin compa red with that in other etiologies of ALF. (Choice A) Acute alcoholic hepatitis typically causes mild to moderate aminotransferase elevation (<500 U/L) in patients who drink heavily (>100 g/day) The AST/ALT ratio is usually >2 1. (Choice B) Hepatitis C causes chronic hepatitis and may to lead to cirrhosis but is not typically associated with ALF. Hepatitis A , B, D, and E are more typical causes of ALF. (Choice C) Ischemic hepatitis can result from severe hypotension (eg, shock live r) or BuddChiari syndrome (hepatic vein thrombosis) and is a potential cause of ALF. This patient has not had significant hypotension and lacks right upper quadrant pain, which is typically severe in Budd-Chiari syndrome {Choices D and F) Nonalcoholic steatohepatitis is a chronic condition that is associated with
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{Choice A) Acute alcoholic hepatitis typically causes mild to moderate aminotransferase elevation (<500 U/L) in patients who drink heavily (>100 g/day). The AST/ALT ratio is usually >2 1. (Choice B) Hepatitis C causes chronic hepatitis and may to lead to cirrhosis but is not typ ically associated with ALF. Hepatitis A , B, D, and E are more typical causes of A LF. {Choice C) Ischemic hepatitis can result from severe hypotension (eg, shock live r) or BuddChiari syndrome (hepatic vein thrombosis) and is a potential cause of ALF. This patient has not had significant hypotension and lacks right upper quadrant pain, which is typically severe in Budd-Chiari synd rome (Choices D and F) Nonalcoholic steatohepatitis is a chronic condition that is associated with metabolic syndrome and may lead to liver cirrhosis. Both nonalcoholic steatohepatitis and cirrhosis are characterized by normal to moderately elevated aminotransferase levels, and elevation >1000 U/L is not consistent with either diagnosis Educational objective: Acute live r failure (ALF) is characterized by elevated aminotransferases, encephalopathy, and INR ::::1 .5. Acetaminophen toxicity is a common cause of ALF that may be potentiated by chronic alcohol use. References: 1. Acute liver failure . 2. Acetaminophen-induced acute liver failure : results of a United States multicenter, prospective study. 3. Influence of acute and chronic alcohol intake on the clinical course and outcome in acetaminophen overdose.
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A 60-year-old man comes to the office for a "check-up " He regularly comes for a preventive visit every year on his birthday in the Fall. The patient feels well, although he frequently experiences a cough productive of white sputum in the morning on waking He has no feve r, chest pain, hemoptysis, or weight loss. The patient's medical history is notable for hypertension that is well controlled with lisinopril. He received a tetanus-diphtheria toxoid booster , pneumococcal polysaccharide vaccine, and influenza vaccine 5 years ago but has not had any vacc ines since then. The patient has smoked a pack of cigarettes a day fo r the last 40 years but does not use alcohol or illicit drugs His temperature is 36.7 C (98 F) , blood pressure is 130/70 mm Hg, pulse is 82/min, and respirations are 12/min. His BMI is 26.2 kg/m2 Physical examination shows an increased anteroposterior chest diameter and a prolonged expiratory phase Chest x-ray reveals a flattened diaphragm with clea r lung fields and a normal mediastinal shadow. W hich of the following vaccines should be given to this patient every year?
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® A 13-valent pneumococcal conjugate vaccine
22
e; B. 23-valent pneumococcal polysaccharide vaccine
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® C. Haemophilus influenzae type 8 vaccine
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® D. Inactivated influenza
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® E. Tetanus-diphtheria toxo id booster
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Recommended vaccines for adults
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Td/Tdap
T dap once as substitute forTd booster, then T d every 10 years
Influenza
Annually
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PPSV23 alone
Sequential PCV1 3 + PPSV23
• Chronic heart, lung, or liver disease
• 1 dose of PCV13 followed by PPSV23 at a later time
• Diabetes, current smokers, alcoholics
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24 25
Age ~65
Age 19-64
Pneumococcus
26
Sequential PCV13 + PPSV23 (very high risk patients)
27
• CSF leaks, cochlear implants
28
• Sickle cell disease, asplenia
29
• lmmunocompromised (eg, HIV, malignancy)
30 31 32
• Chronic kidney disease
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CSF = cerebrospinal fluid; PCV13 = B -valent pneumococcal conjugate vaccine; PPSV23 = 23-valent pneumococcal polysaccharide vaccine; Td = tetanus-diphtheria toxoid booster; Tdap = tetanus-diphtheria-pertussis.
This patient has an extensive smoking history and presents with signs and symptoms of chronic
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This patient has an extensive smoking history and presents with signs and symptoms of chronic obstructive pulmonary disease. In light of this, he requires the influenza and pneumococcal vaccines. Of the vaccines recommended for this patient, only the influenza vaccine is required every year. The Advisory Committee on Immunization Practices (ACIP) of the Centers fo r Disease Control and Prevention (CDC) recommends that the intramuscular inactivated influenza vacc ine be given annually to all adults. The live intranasal influenza vaccine may be given as an alternative to healthy , nonpregnant adults age <50 without high-risk medical conditions or contact with immunocompromised patients The 13-valent pneumococcal conjugate vaccine (PCV13) is recommended fo r all adults age ~65 followed by the 23-valent pneumococcal polysaccharide vaccine ( PPSV23) at least 6-12 months later. Sequential PCV13 and PPSV23 are also recommended fo r adults age <65 with certain very high risk como rbidities (eg, cerebrospinal fl uid leaks, sickle cell disease, cochlear implants, congenital or acquired asplenia, immunocompromised patients) PPSV23 alone is recommended as a one-time vaccine for adults age <65 who are current smokers or have other chronic medical conditions, including heart or lung disease, diabetes, and chronic live r disease {Choices A and B) They should then receive sequential PCV13 and PPSV23 at age 65. {Choice C) Nontypable Haemophilus influenzae is a common cause of exacerbations of chronic bronchitis in adults. However, infection with H influenzae type B is rare in adults and routine vaccination is not recommended. (Choice E) The tetanus-diphtheria toxoid booster (Td) vaccine should be given every 10 yea rs to all adults age >18, with a tetanus-diphtheria-pertussis (Tdap) booster as a one-time dose in place of Td. This patient had a Td booster 5 years ago and would need Tdap as a one-time dose 5 years from now before resuming with Td every 10 years Educational objective: The 13-valent pneumococcal conjugate vaccine (PCV13) is recommended for all adults age ~65 followed by the 23-valent pneumococcal polysaccharide vaccine ( PPSV23) at least 6-12 months
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later. Sequential PCV13 and PPSV23 are also recommended for adults age <65 with certain ve ry high risk como rbidities (eg, cerebrospinal fluid leaks, sickle cell disease, cochlear implants, congenital or acquired asplenia, immunocompromised patients) PPSV23 alone is recommended as a one-time vaccine for adults age <65 who are current smokers or have other chronic medical conditions, including heart or lung disease, diabetes, and chronic live r disease {Choices A and B) They should then receive sequential PCV13 and PPSV23 at age 65. (Choice C) Nontypable Haemophilus influenzae is a common cause of exacerbations of chronic bronchitis in adults. However, infection with H influenzae type B is rare in adults and routine vaccination is not recommended. {Choice E) The tetanus-diphtheria toxoid booster (Td) vaccine should be given every 10 years to all adults age >18, with a tetanus-diphtheria-pertussis (Tdap) booster as a one-time dose in place of Td. This patient had a Td booster 5 years ago and would need Tdap as a one-time dose 5 years from now before resuming with Td every 10 years Educational objective: The 13-valent pneumococcal conjugate vaccine (PCV13) is recommended for all adults age ~65 followed by the 23-valent pneumococcal polysaccharide vaccine (PPSV23) at least 6-12 months later. PPSV23 alone is recommended for adults age <65 who are current smokers or have chronic medical conditions, including heart or lung disease, diabetes, or chronic liver disease. Infl uenza vaccination should be provided annually to all adults.
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References: 1. Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2010. 2. Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine among adults aged =65 years: recommendations of the Advisory Committee on Immunization Practices (ACIP).
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A 66-year-old woman comes to the office due to 2 days of increasing productive cough and low-grade fever . She was treated for community-acquired pneumonia 4 months ago and sinusitis 2 months ago Her review of systems is positive fo r fatigue, generalized weakness, and right-sided chest pain The patient is otherwise healthy and takes no medications. She has never smoked cigarettes and drinks alcohol only on rare social occasions. Temperature is 38.4 C (101 2 F) , blood pressure is 126/72 mm Hg, pulse is 98/min, and respirations are 16/min. Pulse oxymetry is 96%. She is well-appearing. There is mucosal pallor There is no lymphadenopathy in her cervical or supraclavicular chains. Bronchial breath sounds and crackles are present in the left lower lung field. There is point tenderness over the right seventh and eighth ribs at the midclavicular line. The abdomen is soft with no hepatosplenomegaly Laboratory results are as follows Complete blood count
20
Hemoglobin
21
22 23
24
Mean corpuscular volume
25
9.4 g/dL 88 ~Jm'
Platelets
235,000/mm'
Leukocytes
13,500/mm'
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Chest x-rays shows consolidation in the left lower lung and right-sided osteolytic lesions with fractures at the seventh and eighth ribs. This patient is at increased risk fo r recurrent infections due to which of the following abnormalities?
e> A. Complement deficiency 6 B. Defective membrane attack complex 6 C. Destruction of CD4+ T lymphocytes 6 D. Impaired chemotaxis
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never smoked cigarettes and drinks alcohol only on rare social occasions. Temperature is 38.4 C (101 2 F), blood pressure is 126/72 mm Hg, pulse is 98/min, and respirations are 16/min. Pulse oxymetry is 96%. She is well-appearing. There is mucosal pallor There is no lymphadenopathy in her cervical or supraclavicular chains. Bronchial breath sounds and crackles are present in the left lower lung field. There is point tenderness over the right seventh and eighth ribs at the midclavicular line. The abdomen is soft with no hepatosplenomegaly. Laboratory results are as follows Complete blood count Hemoglobin Mean corpuscular volume
9.4 g/dL 881Jm'
Platelets
235,000/mm'
Leukocytes
13,500/mm'
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Chest x-rays shows consolidation in the left lower lung and right-sided osteolytic lesions with fractures at the seventh and eighth ribs. This patient is at increased risk for recurrent infections due to which of the following abnormalities?
® A. Complement deficiency ® B. Defective membrane attack complex ® C. Destruction of CD4+ T lymphocytes ® D. Impaired chemotaxis ® E. Impaired effective antibody production ® F. Impaired phagocytic oxidative metabolism Submit
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Multiple myeloma Pathophysiology
Manifestations
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• Bone pain, fractures • Constitutional symptoms (weight loss, fatigue) • Recurrent infections
Laboratory
• • • •
Rad iology
• Osteolytic lesions/osteopenia (osteoclast activation)
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• Monoclonal plasma cell proliferation
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Normocytic anemia Renal insufficiency Hypercalcemia Monoclonal paraproteinemia
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Multiple myeloma (MM) is a monoclonal plasma cell neoplasm Bone marrow infiltration by neoplastic cells causes osteolytic lesions, fractu res, hypercalcemia (from bone destruction), and anemia. In addition, the excessive production of monoclonal protein can clog the renal tubules, resulting in renal insufficiency.
Patients with MM are prone to infection. Neoplastic infiltration of the bone marrow alters and impairs the normal lymphocyte population, resulting in ineffective antibody production and hypogammaglobulinemia Respiratory (eg, streptococcal pneumonia) and urinary tract infections are the most common infections seen in MM.
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Multiple myeloma (MM) is a monoclonal plasma cell neoplasm. Bone marrow infiltration by neoplastic cells causes osteolytic lesions, fractures , hypercalcem ia (from bone destruction), and anemia. In addition, the excessive production of monoclonal protein can clog the renal tubules, resulting in renal insufficiency Patients with MM are prone to infection. Neoplastic infiltration of the bone marrow alters and impairs the normal lymphocyte population, resulting in ineffective antibody production and hypogammaglobulinemia. Resp iratory (eg, streptococcal pneumonia) and urinary tract infections are the most common infections seen in MM. {Choices A and B) The complement system helps form the terminal membrane attack complex Deficiencies in this system cause problems with the innate immune system, making patients particularly vulnerable to encapsulated bacteria (eg, Neisseria meningitides) These are relatively rare disorders and would not account fo r this patient's osteolytic lesions and fractures.
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(Choice C) CD4+ T lymphocytes are destroyed by HIV. HIV inc reases infection risk but would not account for this patient's osteolytic lesions and pathologic fractures.
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(Choice D) Defective chemotaxis may contribute to recurrent infections in patients with rare genetic conditions, HIV, and bone marrow transplants. It does not contribute significantly to the predisposition to infection in patients with MM. (Choice F) Defects in phagocytic oxidative metabolism impair the ability of phagocytes to produce reactive oxygen intermediaries that aid in the destruction of pathogens and cancerous cells. This may be seen in chronic granulomatous disease. These defects would not explain this patient's osteolytic lesions and laboratory abnormalities. Educational objective: Patients with multiple myeloma are at increased risk for infection due to bone marrow infiltration by neoplastic cells, which alters the normal leukocyte population and causes hypogammaglobulinemia. Time Spent 4 seconds
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A 44-year-old man who has had an extensive small bowel resection for Crohn disease has been on total parenteral nutrition for two years He presented to the hospital with epigastric and right upper quadrant pain His vital signs are within normal limits. Physical examination shows mild right upper quadrant tenderness. An ultrasonogram shows several gallstones; an ultrasonogram performed two years ago did not demonstrate gall stones. Which of the following is the most likely cause of his gallstones?
e A Estrogen-induced increase in cholesterol secretion o B. Gallbladder stasis e; C. Hypertriglyceridemia
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® D. Increased enterohepatic recycling of bile acids
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E. Increased red blood cell destruction
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Explanation: Gallbladder stasis is the most likely cause of gallstone formation in this patient The presence of proteins and fatty acids in the duodenum acts as a stimulus for release of cholecystokinin (CCK), which in turn stimulates the contraction of the gallbladder In patients on total parenteral nutrition or prolonged fasting, the normal stimulus for CCK release and gallbladder contraction is absent This leads to biliary stasis and promotes the formation of bile sludge and gallstones Small-bowel (ileal) resection also contributed to the formation of gallstones in this patient Decreased enterohepatic circulation of bile acids results in altered hepatic bile composition, which becomes supersaturated with cholesterol and promotes gallstone for mation. {Choice A) Estrogen-induced inc rease in cholesterol secretion is the underlying mechanism for the development of cholesterol gallstones during pregnancy and in women taking oral contraceptives. During pregnancy, estrogen causes an increase in cholesterol secretion and progesterone causes a reduction in bile acid secretion, causing increased cholesterol saturation of bile. Progesterone also slows gallbladder emptying and thus facilitates the formation of cholesterol gallstones during pregnancy.
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(Choice C) Hypertriglyceridemia can predispose to gallstones in some patients. However, it is unlikely in th is patient
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(Choice D) Increased enterohepatic recycling of bile acids would not predispose to gallstone fo rmation. Decreased enterohepatic recycling of bile acids, as seen in patients with ileal Crohn disease or ileal resection, can predispose to cholesterol gallstones due to increased concentration of bilirubin conjugates and total calcium in the gallbladder (Choice E) Increased red blood cell destruction (hemolytic anemia) increases the risk of pigmented gallstones by increasing the amount of heme requiring degradation to bilirubin. Educational objective: Total parenteral nutrition causes gallbladder stasis and predisposes to gallstone formation and bile sludging, both of which may lead to cholecystitis
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e> A Haemophilus influenzae and Streptococcus pyogenes 10 B. Mycobacterium tuberculosis and herpes simplex virus
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C. Haemophilus influenzae and Candida species
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D. Streptococcus pyogenes and Klebsiella pneumoniae
10 E. Staphylococcus aureus and Pseudomonas aeruginosa
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A 45-year-old Asian immigrant complains of a progressively wo rsening sore throat and difficulty swallowing for the past 24 hours. You notice that his voice is muffled and he is drooling He also has a harsh shrill associated with respiration. His temperature is 39.3° C (1 03° F) , blood pressure is 120/80 mmHg, pulse is 106/min, and respiratory rate is 22/min. On examination, a few cervical lymph nodes are palpable and there is tenderness to palpation over his larynx. W hich of the following are the two most common organisms that cause this condition?
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E. Staphylococcus aureus and Pseudomonas aeruginosa [3%] Explanation: The abrupt onset and rapid progression of this patient's symptoms should immediately raise conce rn fo r epiglottitis, which is a potentially life-threatening infection that is characteristically associated with a high-grade fever, a severe sore throat with odynophagia (pain on swallowing) and drooling, and progressive airway obstruction. The harsh shrill that this patient has most likely represents stridor , which can occur in some patients with epiglottitis Prior to the widespread use of the Haemophilus influenzae type B (Hib) vaccine in children, Hib caused the vast majority of cases of epiglottitis, followed by Streptococcus pyogenes. In adults, particularly those from other countries as seen in this case, epiglottitis caused by Hib can still occur because many of these individuals have not been properly vaccinated. As a result, clinicians should have a high index of suspic ion of epiglottitis when patients present acutely similar to the patient in this vignette.
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(Choice B) Herpes simplex virus type 1 has rarely been associated with epiglottitis, but Mycobacterium tuberculosis has not
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{Choice C) Certain Candida species may cause epiglottitis in immunocompromised patients This patient, however , has no history of being immunocompromised (Choice D) Strep tococcus pyogenes, as mentioned above, can cause epiglottitis, especially as a complication of varicella infection. Klebsiella pneumoniae, however, does not cause epiglottitis {Choice E) Although Staphylococcus aureus can be the cause of epiglottitis in some individuals, Pseudomonas aeruginosa typ ically only causes epiglottitis in immunocompromised hosts. Educational objective: The most common organisms responsible for the development of epiglottitis, especially in the adult population, are Haemophilus influenzae and Streptococcus pyogenes. Epiglottitis is a medical emergency, and rapid treatment must be initiated in order to prevent obstruction of the airway. Time Spent 2 seconds
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A 57-year-old woman receiving chemotherapy fo r stage IV Hodgkin lymphoma has severe nausea, vom iting, and general malaise. Her last bowel movement was yesterday, and she has had crampy abdominal pain on and off since the vomiting began. The patient's second cycle of chemotherapy ended 3 days ago Her temperature is 36.7 C (98 F), blood pressure is 109/68 mm Hg, pulse is 88/min, and respirations are 18/min. Pulse oximetry reading is 95% on room air. BMI is 18 kg/m2 Physical examination shows dry mucous membranes and enlarged cervical lymph nodes. The chest is clear to auscultation. Mild epigastric tenderness is present on abdominal palpation, but there is no guarding or rebound. Laboratory studies are as follows Complete blood count Hemoglobin
9.5 g/dL
Platelets
98,000/mm'
Leukocytes
5,500/mm' (30% neutrophils)
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Liver function studies
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Total bilirubin
1.2 mg/dL
Alkaline phosphatase
98 U/L
Aspartate aminotransferase (SGOT)
54 U/L
Alanine aminotransferase (SGPT)
23 U/ L 90 U/ L (normal 0-160 U/L)
Lipase .
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Leukocytes
5,500/mm' (30% neutrophils)
Live r function studies
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Total bilirubin
1.2 mg/dl
Alkaline phosphatase
98 U/L
Aspa rtate aminotransferase (SGOT)
54 U/L
Alanine aminotransferase (SGPT)
23 U/L
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Lipase
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90 U/L (normal 0-160 U/L)
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Intravenous fl uids are started. W hich of the following is the best next step in the management of this patient?
® A Anticholinergic agent ® B. Broad-spectrum antibiotics ® C. Dopamine antagonist ® D. Motilin receptor agonist ® E. Opioid antagonist ® F. Serotonin receptor antagonist Submit
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Explanation: This patient's laboratory values are relatively unremarkable aside from mild anemia and thrombocytopenia, two common findings in patients with lymphoproliferative disorders on chemotherapy Her symptoms of vom iting and malaise are likely side effects of chemotherapy. In the setting of normal lipase levels, an abdominal examination without rebound or guarding, and a bowel movement yesterday, other diagnoses such as pancreatitis, perforation, or bowel obstruction are less likely The presence of dry mucous membranes suggests mild volume depletion due to vomiting; therefore, intravenous fluid administration is a good fi rst step in this patient's management. The subsequent step would be to treat her nausea and vomiting. Serotonin (5HT) r eceptor antagonists (eg, ondansetron) that target the 5HT3 r eceptor are considered first-line treatment for chemother apy-induced nausea. They have a low side-effect profile and are highly efficacious. These medications can be used to manage acute emesis but are also useful as prophylaxis, sometimes in combination with corticoste roids.
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(Choice A) The primary anticholinergic agent used to treat vomiting is scopolamine, but this is usually given in the form of a patch to help reduce motion sickness. This drug is not as effective as 5HT3 antagonists for chemotherapy-induced symptoms.
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(Choice B) Patients on chemotherapy, especially in the setting of a lymphoproliferative disorder , are at a higher risk for infection. However, this patient is afebrile and not neutropenic (with absolute neutrophil count > 1500 cells/mm3) , making ongoing infection unlikely (Choice C) Dopamine antagonists such as metoclopramide and prochlorperazine are useful second- or third-line agents for refractory vom iting However, in the setting of recent chemotherapy, 5HT3 antagonists have a better side-effect profile and are more efficacious. (Choice D) Motilin receptors promote gastrointestinal motility Erythromycin is primarily used as an antibiotic , but it also functions as a motilin receptor agonist and can help treat nausea secondary to gastroparesis. (Choice E) Gastro intestinal-specific opioid antagonists such as methylnaltrexone can be used in
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., ., "' ., obstruction are less likely . The presence of dry mucous membranes suggests mild volume depletion due to vomiting; therefore, intravenous fluid administration is a good fi rst step in this patient's management. The subsequent step would be to treat her nausea and vomiting
Serotonin (5HT) receptor antagonists (eg, ondansetron) that target the 5HT3 receptor are considered fi rst-line treatment for chemotherapy-induced nausea. They have a low side-effect profile and are highly efficacious. These medications can be used to manage acute emesis but are also useful as prophylaxis, sometimes in combination with corticosteroids. (Choice A) The primary anticholinergic agent used to treat vomiting is scopolamine, but this is usually given in the form of a patch to help reduce motion sickness. This drug is not as effective as 5HT3 antagonists fo r chemotherapy-induced symptoms (Choice B) Patients on chemotherapy, especially in the setting of a lymphopreliferative disorder , are at a higher risk fo r infection. However , this patient is afebrile and not neutropenic (with absolute neutrophil count >1500 cells/mm'), making ongoing infection unlikely
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(Choice C) Dopamine antagonists such as metoclopramide and prochlorperazine are useful second- or third-line agents for refractory vomiting However, in the setting of recent chemotherapy, 5HT3 antagonists have a better side-effect profile and are more efficacious.
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(Choice D) Motilin receptors promote gastrointestinal motility Erythromycin is primarily used as an antibiotic , but it also functions as a motilin receptor agonist and can help treat nausea secondary to gastroparesis (Choice E) Gastrointestinal-specific opioid antagonists such as methylnaltrexone can be used in patients to reverse opioid-induced constipation. Although severe constipation can cause nausea and vom iting, it is less likely to be a factor in this patient who had a bowel movement yesterday Educational objective: Serotonin (5HT) antagonists that block 5HT3 receptors are the drugs of choice for treating and preventing chemotherapy-induced nausea and vom iting Time Spent 3 seconds
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A 33-year-old woman comes to the office due to a dull, aching pain in the right upper quadrant of the abdomen for several weeks. Her medical history is unremarkable. She takes no medications except an oral contraceptive, which she has used for the past 12 years. The patient drinks 1 or 2 glasses of wine on social occasions but does not use tobacco or illicit drugs. Temperature is 36.7 C (98 F) , blood pressure is 120/80 mm Hg, pulse is 78/min, and respirations are 14/min. BMI is 27 kg/m2 . Examination shows hepatomegaly with moderate discomfort on deep palpation in the right upper quadrant There is no jaundice or ascites. Cardiopulmonary examination shows no abnormalities. Laboratory results are as follows
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Albumin
4.1 g/dl
Total bilirubin
0.9 mg/dl
Alkaline phosphatase
215 U/L
Aspartate aminotransferase (AST, SGOT)
45 U/L
Alanine aminotransferase (ALT, SGPT)
40 U/L
Gamma glutamyl transpeptidase
92 U/L (normal 5-55 U/L)
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Abdom inal ultrasonogram reveals a solitary hyperechoic 7-em lesion in the right lobe of the liver. W hich of the following is the most likely diagnosis in this patient? e')
A Hepatic adenoma
6 B. Hepatocellular carcinoma 6 C. Hydatid cyst
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D. Metastatic adenocarcinoma
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Albumin
4.1 g/dl
Total bilirubin
0.9 mg/dl
Alkaline phosphatase
215 U/L
Aspartate aminotransferase (AST, SGOT)
45 U/L
Alanine aminotransferase (ALT, SGPT)
40 U/L
Gamma glutamyl transpeptidase
92 U/L (normal 5-55 U/L)
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except an oral contraceptive, which she has used for the past 12 years. The patient drinks 1 or 2 glasses of wine on social occasions but does not use tobacco or illicit drugs. Temperature is 36.7 C (98 F) , blood pressure is 120/80 mm Hg, pulse is 78/min, and respirations are 14/min. BMI is 27 kg/m2 Examination shows hepatomegaly with moderate discomfort on deep palpation in the right upper quadrant. There is no jaundice or ascites. Cardiopulmonary examination shows no abnormalities. Laboratory results are as follows
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Abdominal ultrasonogram reveals a solitary hype rechoic 7-em lesion in the right lobe of the liver. W hich of the following is the most likely diagnosis in this patient?
<0 A. Hepatic adenoma <0 B. Hepatocellular carcinoma <0 C. Hydatid cyst <0 D. Metastatic adenocarcinoma <0 E. Regenerating live r nodule Submit
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Explanation:
Solid liver masses Focal nodular hyperplasia Hepatic adenoma Regenerative nodules
• Associated with anomalous arteries • Arterial flow & central scar on imaging • Women on long-term oral contraceptives • Possible hemorrhage or malignant transformation
• Acute or chronic liver injury (eg, cirrhosis)
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Hepatocellular carcinoma
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Li ver metastasis
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Lab Values
• Systemic symptoms • Chronic hepatitis or cirrhosis • Elevated alpha fetoprotein • Single/multiple lesions • Known extrahepatic malignancy
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This young woman has a large, painful hepatic mass. She has elevated alkaline phosphatase and gamma glutamyl transpeptidase (GGT) levels, suggesting biliary compression or obstruction, but otherwise relatively normal liver markers. In light of her minimal alcohol consumption and long-term use of oral contraceptives, this likely represents a hepatic adenoma. Hepatic adenomas are benign epithelial tumors that are most common in young and middle-age women.
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early peripheral enhancement Needle biopsy is not recommended fo r suspected hepatic adenoma due to the risk of bleeding, and surgical excision is preferred. Possible long-term compl ications include progressive growth, rupture, and malignant transformation. Hepatic adenoma can clinically resemble focal nodular hyperplasia (FNH), a common mass lesion in young women caused by hyperperfusion from anomalous arteries. However, FNH is not associated with oral contraceptives, and imaging will show evidence of increased arterial flow and sometimes a central scar. (Choice B) Hepatocellular carcinoma is characterized by a rapidly enlarging liver mass, often with satellite lesions. It usually occurs in patients with cirrhosis or chronic hepatitis (especially hepatitis B) and would be unusual in a young patient without these risk factors. (Choice C) Hydatid cysts are caused by Echinococcus tapeworm infections. In the United States, most cases are seen in immigrants, although occasional cases may be seen in individuals from the Southwest who have been exposed to sheep and dogs It causes cystic, not solid, liver lesions. {Choice D) Most patients with metastatic liver disease will have a known extrahepatic primary malignancy (eg, colon, pancreas) Although the liver lesions may occasionally be found prior to the primary tumor, most patients are older, have systemic symptoms (eg, weight loss), and often have multiple liver lesions. (Choice E) Acute or chronic liver injury can lead to nodular regeneration. This is usually multifocal and occurs most commonly in the setting of cirrhosis. Educational objective: Hepatic adenoma is a benign tumor most often seen in young and middle-age women who take oral contraceptives Possible long-term complications include progressive growth, rupture, and malignant transformation. References: 1. Hepatocellular adenoma: an update.
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e; A. He may have progressed to tuberculous meningitis, so do a CT scan of the brain.
® B. He may be suffering from Jarisch Herxheimer reaction, so start aspirin and sedation. ® C. He may be malingering, so document everything completely. ® D. Stop the ATI immediately since he is having a severe drug reaction to ATI. ® E. Start him on pyridoxine at 1OOmg/day to treat isoniazid-induced peripheral neuropathy
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61
Lab Values
A 26-year-old male comes to the office and complains of a chronic cough, fever and night sweats. He recently migrated from Malaysia to the USA. After the appropriate investigation, he is started on anti-tubercular therapy (ATI) with isoniazid, rifampin, pyrazinamide and ethambutoL After one month, he returns with compla ints of numbness, tingling of extremities and ataxia. W hat is the best next step in the management of this patient?
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E. Start him on pyridoxine at 1OOmg/day to treat i soni azid-induced peripheral neuropathy [96%) Explanation: Peripheral neuropathy may present as tingling in the extremities, numbness and ataxia. It is a known side effect of isoniazid. For this reason, all patients who are started on anti-tubercular therapy are also started on vitamin supplements, especially pyridoxine (10 mg/day) If the peripheral neuropathy has already developed, the dose of pyridoxine is increased to 100 mg/day. Hepatitis is another known side effect of isoniazid. {Choice B) Jarisch-Herxheimer reaction has no association with tuberculosis or its treatment It may develop in the treatment of syphilis. When primary or secondary syphilis is treated with penic illin, the spirochetes die rapidly, thereby leading to the release of antigen-antibody complexes in the blood, and consequent immunologic reaction, which seems like an acute flare-up of syphilis
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{Choice C) There is no reason to suspect that this patient is malingering because there is no indication in the given vignette (Choice D) There are no signs or symptoms (e g , skin eruptions, fever , angioedema, urticaria, etc ) to suggest drug eruption {Choice A) To suspect tuberculous meningitis, there should be meningeal signs or cranial nerve involvement Educational Objective: All patients who are started on anti-tubercular therapy should also be started on vitamin supplements, especially pyridoxine (1 0 mg/day), to avoid peripheral neuropathy and other neurological complications. Hepatitis is another known side effect of isoniazid. Time Spent 2 seconds
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A 43-year-old man is being evaluated for erectile dysfunction, which has been progressive over the past year. He has no other symptoms except some fatigue that he attributes to his intense work schedule. The patient drinks 1-2 beers every day after work and has a 20-pack-year smoking history. He does not use recreational drugs or take over-the-counter medications. Vital signs are normal. BMI is 29 kg/m2 Skin examination shows brownish skin pigmentation, most pronounced over the face and both arms. The abdomen is soft and nontender without organomegaly. Cardiopulmonary examination shows no abnormalities, and there is no peripheral edema. Laboratory results are as follows Hemoglobin
14 g/dL
Platelets
200,000/mm•
Leukocytes
7,500/mm•
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Blood urea nitrogen
14 mg/dL
22
Creatinine
0.8 mg/dL
Fasting glucose
130 mg/dL
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Aspartate aminotransferase
78 U/L
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Alanine aminotransferase
80 U/L
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If untreated, this patient is at increased risk fo r developing which of the following complications? e')
A. Gastric adenocarcinoma
6 B. Hepatocellular carcinoma 6 C. Hypotensive crisis 6 D. Nephrotic syndrome e') E. Pancreatic cancer
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Hemoglobin
14 g/dL
Platelets
200,000/mm'
Leukocytes
7,500/mm'
Blood urea nitrogen
14 mg/dL
C reatinine
0.8 mg/dL
Fasting glucose
130 mg/dL
Aspartate aminotransferase
78 U/L
Alanine aminotransferase
80 U/L
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p ry y y smoking history He does not use recreational drugs or take over-the-counter medications. Vital signs are normal. BMI is 29 kg/m1 Skin examination shows brownish skin pigmentation, most pronounced over the face and both arms. The abdomen is soft and nontender without organomegaly Cardiopulmonary examination shows no abnormalities, and there is no peripheral edema. Laboratory results are as follows I
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If untreated, this patient is at increased risk for developing which of the following complications? ® A Gastric adenocarcinoma ® B. Hepatocellular ca rcinoma ® C. Hypotensive crisis ® D. Nephrotic syndrome ® E. Pancreatic cancer ® F. Skin cancer Submit
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Clinical manifestations of hereditary hemochromatosis
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Skin
Hyperpigmentation (bronze diabetes)
Musculoskeletal
Arthralgia, arthropathy & chondrocalcinosis
Gastrointestinal
Elevated hepatic enzymes with hepatomegaly (early), cirrhosis (later) & increased risk of hepatocellular carcinoma
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Endocrine
Diabetes mellitus, secondary hypogonadism & hypothyroidism
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Cardiac
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Restrictive or dilated cardiomyopathy & conduction abnormalities
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Infections
Increased susceptibility to Listeria, Vibrio vulnificus & Yersinia enterocolitica
@UWorld
This patient's presentation is most consistent with hereditary hemochromatosis (HH) The increased total body iron leads to deposits in various organs (eg, liver, pancreas), resulting in multisystem organ damage Disease progression typically requires decades of increased iron deposition Consequently, patients tend to present in their 30s to 50s, with women presenting later due to therapeutic iron loss through menstruation. Most patients with HH are diagnosed early in the disease due to elevated liver enzymes on routine laboratory studies. However, continued iron deposition can cause hepatic fibrosis and --- -
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The initial evaluation of HH commonly shows elevated iron studies. Diagnosis can be confirmed by genetic analysis of HFE mutations. Serial phlebotomy to deplete excess iron stores can significantly reduce the risk for cirrhosis and HCC. {Choice A) Gastric adenocarcinoma is rarely associated with Leser-Trelat sign (sudden development of seborrheic keratoses) or acanthosis nigricans (thickened, hyperpigmented, velvety skin patches over the neck and folds) In this patient, the distribution of hyperpigmentation and lack of skin thickening are not consistent with acanthosis nigricans. In addition, the combination of ED, skin pigmentation, hyperglycemia, and liver function test abnormalities makes HH more likely. (Choice C) Hypotensive crisis can compl icate Addison disease (primary adrenal insufficiency) Hyperpigmentation (due to increased ACTH leading to increased melanocyte-stimulating hormone) is common; however, Add ison disease is associated with hypoglycem ia, not hyperglycem ia
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(Choice D) Primary systemic amyloidosis, which commonly presents with fatigue, hepatomegaly , and petechiae/ecchymosis on the face , can be compl icated by nephrotic syndrome . However , it is usually not associated with ED or hyperglycemia. (Choice E) Pancreatic cancer can be associated with chronic pancreatitis and certain genetic syndromes (eg, Peutz-Jeghers syndrome), but not HH. (Choice F) Patients with genetic disorders such as xeroderma pigmentosum and albinism are at increased risk for skin cancer. HH does not confe r increased risk. Educational objective: Hereditary hemochromatosis should be considered in patients who have elevated liver enzymes, diabetes mellitus, and skin hyperpigmentation It can progress to cirrhosis and is associated with a significantly increased risk for hepatocellular carc inoma. References: -
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e A C-reactive protein e B. CT scan of the chest e C. D-dimer test e D. Gram sta in and culture of respiratory secretions e E. No further testing required Submit
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A 60-year-old woman undergoes elective co ronary artery bypass surgery and aortic valVe replacement Her postoperative course is complicated by acute renal failure, atrial fibrillation , and pulmonary edema. On the third postoperative day, she cannot tolerate attempted extubation and requires reintubation. On the fifth postoperative day, she develops a fever to 38.9 C (102 F). Her blood pressure is 110/65 mm Hg, pulse is 110-120/min and irregular , and respirations are 36/min. Her chest x-ray shows dense right middle and lower lobe infiltrates. The white blood cell count is 16,200/mm' with 8% bands. Which of the following is the most appropriate next step in management?
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Suspected VAP -Abnormal chest x-ray
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Lower respiratory tract endotraclleal tube sample - Culture - Microscopy
~ Empiric antibiotics• · Gram-positive coverage • Anti-pseudomonal & gram-negative coverage • Consider MRSA coverage
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Negative cultures Discontinue antibiotics & evaluate for other causes
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Positive cultures with clinical improvement • Narrow antibiotics according to culture results
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Eval uation of suspected ventilator -associated pneumonia
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Positive cultures wit hout clinical improvement Likely VAP Consider changing antibiotics Assess for VAP complications (eg, abscess. empyema) Consider evaluating for other causes
MRSA = Methicilln.resislant Staphylococcus 81./reUS.
*Empiric coverage depends on « ug resistance pattern at institution @UWorld
This intubated patient's presentation suggests ventilator-associated pneumonia (VAP) VAP is a type of nosocomial pneumonia that usually develops <::48 hours after endotracheal intubation. It is most commonly caused by aerobic gram-negative bacilli (eg, Pseudomonas aeruginosa,
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This intubated patient's presentation suggests ventilator-associated pneumonia (VAP) VAP is a type of nosocomial pneumonia that usually develops ~48 hours after endotracheal intubation. It is most commonly caused by aerobic gram-negative bacilli (eg, Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae) and gram-positive cocci (eg, methicillin-resistant Staphylococcus aureus, Streptococcus) Patients usually have feve r, purulent secretions, difficulty with ventilation (eg, increased respiratory rate, decreased tidal volume), and leukocytosis The fi rst step is to obtain a chest x-ray. Patients with a normal chest x-ray are unlikely to have VAP and should be evaluated for other causes. Those with an abnormal chest x-ray (eg, alveolar infiltrates, air bronchograms, silhouetting of adjacent solid organs) require lower respi ratory tract sampling (ie, tracheobronchial aspiration) for microscop ic analysis (Gram stain) and culture (Choice E). Patients should receive empiric antibiotics (usually gram-positive, antipseudomonal, and gram-negative coverage) until culture susceptibility results return as treatment delay can increase mortality. However , respiratory tract sampling should be done prior to starting antibiotics as treatment can decrease the sensitivity of both the Gram stain and culture.
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(Choice A) C-reactive protein may be elevated in VAP, but it is nonspecific and not useful fo r diagnosis. (Choice B) CT scan of the chest may be needed to evaluate for VAP complications (eg, empyema) if the patient does not improve clinically. CT scan can also be considered to evaluate fo r alternate causes if the Gram stain and culture are negative fo r VAP. (Choice C) 0-dimer is used as an initial test for deep venous th rombosis and pulmonary embolism. However , it is nonspecific and may be elevated in VAP. This patient's fever , leukocytosis, and lobar infiltrates are more consistent with VAP. Educational objective: Ventilator-associated pneumonia usually occurs within ~48 hours after intubation and presents with feve r, purulent secretions, and abnormal chest x-ray Patients should have lower respiratory tract sampling (Gram stain and culture) and receive empiric antibiotics.
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A 35-year-old man is brought to the emergency department by his roommate, who says that he has been acting "weird" for the past 2 days The patient has spent most of the time in his room and has not been eating much. He has no headaches, focal weakness, or sensory symptoms. His medical history is significant for untreated HIV and hepatitis C infections. Temperature is 37.9 C (1002 F), blood pressure is 140/86 mm Hg, pulse is 96/min. and respirations are 16/min. Mild scleral icte rus is present The oropharynx is normal and there is no nuchal rigidity. Examination of the chest and abdomen are unremarkable. Neurologic examination reveals no focal deficits. Laboratory results are as follows: Complete blood count Hemoglobin
7.6 g/dL
Mean co rpuscular volume
85
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Reticulocytes
8.1 %
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Platelets
45,000/mm>
Leukocytes
4500/mm>
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11m'
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Serum chemistry Blood urea nitrogen
30 mg/dL
Creatinine
2.2 mg/dL
Calcium
9.4 mg/dL
Glucose
98 mg/dL
Total bilirubin
3.6 mg/dL
Indirect bilirubin
2.0 mg/dL
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Serum chemistry Blood urea nitrogen
30 mg/dl
Creatinine
2.2 mg/dl
Calcium
9.4 mg/dl
Glucose
98 mg/dl
Total bilirubin
3.6 mg/dl
Indirect bilirubin
2.0 mg/dl
Alkaline phosphatase
108 U/L
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Alanine aminotransferase
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62 U/ L 64 U/L
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ACT scan of the head with and without contrast reveals no abnormalities. W hich of the following is the most appropriate next step in the management of this patient?
<0 A Bone marrow biopsy <0 B. Flow cytometry of peripheral blood <0 C. Live r biopsy <0 D. Peripheral blood smear <0 E. Right upper quadrant ultrasound Submit
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Explanation:
Thrombotic thrombocytopenic purpura
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• 1ADAMTS13 activity leading to large vWF multimers & resulting in diffuse m icrovascular platelet-rich thrombi
Pathophysiology
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• Acquired (autoantibody) or hereditary • Hemolytic anemia (I LDH, I haptoglobin) with schistocytes • Thrombocytopenia ( 1 bleeding time, normal PT/PTT)
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Sometimes with
Clinical features
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• Renal failure • Neurologic manifestations • Fever
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Management
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LDH = laclale dehydrogenase; PT = prothrombin time; PTT = partial thromboplastin time; vWF = von Willebrand factor.
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• Plasma exchange
@UWorld
Thrombotic thrombocytopenic purpura (TTP) is a life-threatening disorder of the microvasculature characterized by the formation of small vessel thrombi that consume platelets, shear red blood cells, and often cause end organ damage (primarily renal and central nervous system) This patient has the classic pentad of TIP with thrombocytopenia, microangiopathic hemolytic anemia (MAHA), renal insufficiency, feve r, and neurologic changes. TIP is usually due to an acquired autoantibody to ADAMTS13, a plasma protease that cleaves ''
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TIP is typically a disease of young adults (unlike hemolytic uremic syndrome, which primarily affects children) and is often idiopathic but may be triggered by infections (eg, HIV), malignancy, or medications. Diagnosis is based primarily on clinical and laboratory data. Evidence of thrombocytopenia and MAHA (eg, increased levels of indirect bilirubin, aspartate aminotransferase [AST], alanine aminotransferase [ALT], and lactate dehydrogenase) should always raise suspicion for TIP. A manual peripheral blood smear is a crucial test in the diagnostic workup and would show signs of intravascular hemolysis (eg, schistocytes, helmet cells, triangle cells). TIP must be treated emergently with plasma exchange. Glucocorticoids are often added. W ithout treatment, the mortality rate is as high as 90%. (Choice A) Bone marrow biopsy is useful in the workup of unknown causes of anemia and thrombocytopenia However , this patient has evidence of intravascular hemolysis and end organ damage, making TIP far more likely than a bone marrow issue. (Choice B) Flow cytometry can be used to measure CD4 counts in patients with HIV or to identify specific lymphocyte populations when certain types of lymphoma are suspected This patient has the classic pentad of TIP, which should be addressed emergently and takes precedence over measuring the CD4 cell count
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{Choices C and E) Severe live r pathology may cause acute confusion (eg, encephalopathy). However, this patient's mild AST and ALT elevations, indirect hype rbilirubinemia, and significant anemia likely reflect intravascular hemolysis due to TIP, not intrinsic liver pathology requiring ultrasound evaluation or live r biopsy Right upper quadrant ultrasound is also less likely to be useful, given that there is no evidence of gallbladder disease (indirect rather than direct hyperbilirubinemia). Educational objective: Thrombotic thrombocytopenic purpura should be suspected in patients with laboratory evidence of thrombocytopenia and intravascular hemolytic anemia. Neurologic changes and renal failure are often present at diagnosis Peripheral blood smear is c rucial in the diagnostic workup, demonstrating signs of intravascular hemolys is (eg, schistocytes).
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® A Autoimmune disorder
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e; B. D isseminated herpes
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® C. Medication adverse effect
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® D. Multisystem granulomas ® E. Spirochete infection
6 F. Toxin exposure
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A 28-year-old woman comes to the office due to an episode of lightheadedness followed by a syncopal episode. She has had several days of headache, malaise, and myalgia but no vomiting or diarrhea. The patient has no history of similar symptoms. She was diagnosed with chlamydia ce rvic itis 3 weeks ago and received a single dose of azithromyc in The patient has no chronic medical problems or family history of sudden ca rdiac death. She lives in rural Massachusetts and has not traveled recently . Temperature is 37 C (98.6 F) , blood pressure is 120/80 mm Hg, and pulse is 43/min. No orthostatic blood pressure changes are present Cardiopulmonary auscultation reveals no heart murmurs. The right thigh has 2 erythematous skin lesions. EGG shows sinus rhythm with 2:1 atrioventricular block. W hich of the following is the most likely cause of this patient's current condition?
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Epidemiology
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• Endemic to northeastern United States (& Michigan/Wisconsin) • Ixodes scapularis tick transmits Borrelia burgdorferi
• Erythema migrans (80%)
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Early Lyme disease
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• Systemic symptoms - malaise, fatigue, arthralgia, myalgia Manifestations
• Regional lymphadenopathy
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• Neurologic- lymphocytic meningitis, CN palsies, radi culoneuritis
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• Carditis - atrioventricular block
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• Clinical (if erythema migrans)
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Diagnosis
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• B burgdorferi serology (if neurologic/cardiac disease)
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Treatment
• Oral antibiotics (eg, doxycycline) skin/mild disease • IV antibiotics (eg, ceftriaxone) most neurologic/ca rdiac disease
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CN =cranial nerve; IV =intravenous. ©UWo~d
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minority of patients have symptoms of early disseminated disease, including multiple EM lesions, ca rditis, and/or neurologic findings. Lyme carditis typically occurs within the first several weeks or months of 8 burgdorferi infection. The most common manifestation is atrioventricular (AV) conduction block. Symptoms include lightheadedness, syncope, dyspnea, chest pain, and/or palpations Sudden ca rdiac death is rare but may occur. Diagnosis is made with 8 burgdorferi serology ( ELISA and Western blot). Patients typ ically require hospitalization with telemetry and intravenous antibiotics ( eg, ceftriaxone); most recover completely without sequelae. This young patient who lives in a Lyme endemic region has cardiac (lightheadedness, syncope, bradycardia, AV block), systemic (headache, malaise, myalgia) , and skin (likely EM) manifestations, suggesting early disseminated Lyme disease. {Choice A) Dermatomyositis is an autoimmune disorder that may cause AV block, systemic symptoms, skin lesions (eg, Gottron papules, heliotrope eruption), and myalgias. However , most patients have significant symmetric , proximal muscle weakness. This patient in a Lyme endemic area is more likely to have Lyme disease. (Choice B) Disseminated herpes is seen primarily in immunoeompromised hosts (eg, HIV with CD4 <200/mm') and may cause encephalitis, hepatitis, and esophagitis This young patient with new-onset AV block in a Lyme endemic area is more likely to have early disseminated Lyme disease.
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(Choice C) Many medications, including digitalis, amiodarone, and calc ium channel blockers, can cause AV block. However, azithromycin does not typically cause AV block. {Choice D) Sarcoidosis is a multisystem granulomatous disorder that usually causes hilar lymphadenopathy , pulmonary infiltrates, and skin papules but may occasionally cause AV block. Pulmonary and/or skin symptoms are usually prominent
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{Choice F) Some plants (eg, foxglove, oleander) contain digoxin-like compounds that may cause toxicity with AV block. Lyme disease is fa r more common than accidental or purposeful ingestion of these plants
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(Choice B) Disseminated herpes is seen primarily in immunocompromised hosts (eg, HIV with CD4 <200/mm3) and may cause encephalitis, hepatitis, and esophagitis This young patient with new-onset AV block in a Lyme endemic area is more likely to have early disseminated Lyme disease.
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(Choice C) Many medications, including digitalis, amiodarone, and calcium channel blockers, can cause AV block. However, azithromycin does not typically cause AV block.
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(Choice D) Sarcoidosis is a multisystem granulomatous disorder that usually causes hilar lymphadenopathy, pulmonary infiltrates, and skin papules but may occasionally cause AV block. Pulmonary and/or skin symptoms are usually prominent
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{Choice F) Some plants (eg, foxglove, oleander) contain digoxin-like compounds that may cause toxicity with AV block. Lyme disease is far more common than accidental or purposeful ingestion of these plants Educational objective: Lyme disease is caused by the spirochete Borrelia burgdot1eri and is endemic to the northeastern United States. Patients often develop clinical illness without knowledge of a previous tick bite. Early disease typically manifests with erythema migrans (EM), but patients may also present with multiple EM lesions, carditis, and/or neurologic manifestations. Lyme ca rditis most commonly causes atrioventricular block. References: 1. Practice parameter: treatment of nervous system Lyme disease (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. 2. The clinical assessment, treatment, and prevention of Lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America.
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Copyright © UWorld
Last updated: [10/05/2016)
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e; A Ascend ing cholangitis
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e; C. Colorectal cancer
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B. Bile salt diarrhea
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e; E. Osteomalacia
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D. Emphysema
F. Restrictive cardiomyopathy
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A 43-year-old woman comes to the office due to intense generalized pruritus for the past 4 months. She has used several over-the-counter products, including emollients and antihistamines, but did not get any relief and "finally decided to see a doctor." The patient has also felt extremely fatigued and frequently takes naps during the daytime She feels refreshed after waking up and has no dyspnea or nighttime sleep problems The patient does not use tobacco or alcohol. Vital signs are normal. Physical examination is notable for skin excoriations and mild hepatomegaly. Eye examination findings are shown in the exhibit Laboratory testing shows total bilirubin is 1.6 mg/dl and antimitochondrial antibody is positive With her disease progression, this patient is at greatest risk for developing which of the following conditions?
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Primary biliary cholangitis Pathogenesis
• Autoimmune destruction of intrahepatic bile ducts
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• Affects middle-age women • Insidious onset of fatigue & pruritus
Clinical features
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• Progressive jaundice, hepatomegaly, cirrhosis • Cutaneous xanthomas & xanthelasmas
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• Cholestatic pattern of liver injury ( t 1 alkaline phosphatase, t aminotransferases)
Laboratory findings
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• Antimitochondrial antibody
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• Severe hypercholesterolemia
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• Ursodeoxycholic acid (delays progression)
Treatment
• Liver transplantation for advanced disease
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• Malabsorption, fat-soluble vitamin deficiencies
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Complications
• Metabolic bone disease (osteoporosis, osteomalacia) • Hepatocellular carcinoma
~UWortd
This patient has typical features of primary biliary cholangitis (PBC [previously called primary biliary cirrhosis]), including pruritus, fatigue, hepatomegaly, elevated serum bilirubin, and a positive antimitochondrial antibody assay PBC is a progressive autoimmune disease characterized by destruction of the intrahepatic bile ducts, leading to bile stasis and cirrhosis. It I II II I I
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positive antimitochondrial antibody assay PBC is a progressive autoimmune disease characterized by destruction of the intrahepatic bile ducts, leading to bile stasis and cirrhosis. It is commonly associated with sever e hyperlipidemia, which may manifest with xanthelasmas (soft yellow plaques on the eyelids) due to accumulation of lipid-filled macrophages in the dermis. This hyperlipidemia is characterized by elevation of HDL out of proportion to LDL and does not appear to significantly increase the risk for atherosclerosis. Other complications of PBC include malabsorption with associated nutrient deficiencies and hepatocellular carcinoma. In addition, patients may develop metabolic bone disease manifesting as osteoporosis or osteomalacia. Calcium and vitamin D levels in these patients are typ ically normal, suggesting that the bone disease is not due to malabsorption, but the precise etiology is not clea r. {Choice A) Ascending cholangitis is a possible complication of extrahepatic biliary obstruction (eg, common bile duct stone) and typically presents acutely with Charcot triad (eg, fever , jaundice, right upper quadrant pain)
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(Choice B) Bile salt diarrhea occurs in patients with terminal ileal disease (eg, ileal resection, Grahn ileitis) Impaired bile absorption in the ileum leads to increased bile salts in the colon, resulting in diarrhea (cholerheic diarrhea). (Choice C) Primary sclerosing cholangitis (PSG) is an inflammatory disorder of the intrahepatic and extrahepatic biliary tree associated with inflammatory bowel disease. Patients with ulcerative col itis and PSG are at increased risk for colorectal cance r. (Choice D) Alpha-1 antitrypsin deficiency typically causes liver cirrhosis and early-onset emphysema due to excessive elastase activity The absence of pulmonary symptoms/signs makes emphysema unlikely. In addition, xanthelasmas and positive antimitochondrial antibody are not characteristic of alpha-1 antitrypsin deficiency. {Choice F) Restrictive cardiomyopathy and liver c irrhosis may be seen in patients with hemochromatosis due to excessive iron deposition in tissues. Other findings typically include skin hyperpigmentation and diabetes mellitus ("bronze diabetes")
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(Choice A) Ascending cholangitis is a possible complication of extrahepatic biliary obstruction (eg, common bile duct stone) and typically presents acutely with Charcot triad (eg, fever , jaundice, right upper quadrant pain) {Choice B) Bile salt diarrhea occurs in patients with terminal ileal disease (eg, ileal resection, Crohn ileitis) Impaired bile absorption in the ileum leads to increased bile salts in the colon, resulting in diarrhea (cholerheic diarrhea). {Choice C) Primary sclerosing cholangitis (PSC) is an inflammatory disorder of the intrahepatic and extrahepatic biliary tree associated with inflammatory bowel disease. Patients with ulcerative colitis and PSC are at increased risk for colorectal cance r. (Choice D) Alpha-1 antitrypsin deficiency typically causes liver cirrhosis and early -onset emphysema due to excessive elastase activity The absence of pulmonary symptoms/signs makes emphysema unlikely. In addition, xanthelasmas and positive antimitochondrial antibody are not characteristic of alpha-1 antitrypsin deficiency. (Choice F) Restrictive cardiomyopathy and liver cirrhosis may be seen in patients with hemochromatosis due to excessive iron deposition in tissues. Other findings typically include skin hype rpigmentation and diabetes mellitus ("bronze diabetes") Educational objective: Primary biliary cholangitis is a progressive autoimmune disease characterized by destruction of intrahepatic bile ducts. It can be associated with severe hyperlipidemia, leading to xanthelasmas. Other complications include malabsorption, metabolic bone disease (eg, osteoporosis, osteomalacia), and hepatocellular carcinoma. References: 1. Primary biliary cirrhosis. 2. Primary biliary cirrhosis: Clinical and laboratory criteria for its diagnosis.
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A 40-year-old man comes to the office due to progressively worsening shortness of breath and nonproductive cough over the last 3 weeks. He also notes 2 months of fatigue, intermittent fever, and decreased appetite He has lost 6 kg (13 2 lb) during this period He has no other medical problems. He has a history of intravenous drug use and a 20-pack-year smoking history The patient was released from a 2 yea r incarceration 6 months ago. Temperature is 38.3 C (100.9 F), blood pressure is 110/70 mm Hg, pulse is 90/min, and respirations are 18/min. The patient is in no distress but has mild tempo ral wasting. Crackles are present throughout the lung fields. Heart sounds are normal. There is mild hepatomegaly . Chest x-ray is shown below.
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W hat is the most likely diagnosis?
<0 A. Hodgkin disease <0 B. Lung metastasis <0 C. Mycoplasma pneumonia <0 D. Septic embolism <0 E. Tuberculosis Submit
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Explanation: This patient presents with subacute symptoms (fatigue, fever , weight loss, cough) in the setting of intravenous drug use and recent incarce ration. Chest radiograph shows a diffuse reticulonodular pattern (millet seed), raising suspicion for miliary tuber culosis (TB) Miliary TB is caused by the hematogenous spread of Mycobacterium tuberculosis . It may arise during primary infection or with reactivation. Subacute or chronic symptoms are common. Extrapulmonary disease may occur in the lymph nodes, liver, bones, and central nervous system Incar ceration and substance abuse (tobacco and intravenous drug use) put this patient at high risk for TB exposure Other common social risk factors for TB infection include group living and international travel to endemic areas. (Choice A) Hodgkin disease typically presents with painless lymphadenopathy and B symptoms (fatigue, weight loss, night sweats). Mediastinal mass is common. This patient has pulmonary symptoms and a diffuse reticulonodular pattern (not mediastinal mass) on chest x-ray, making TB much more likely
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(Choice B) Metastatic disease to the lung typically presents with multiple masses, although patients occasionally present with a lymphangitic carcinomatosis (which may have a reticulonodular appearance). This patient has subacute fevers (uncommon in metastatic cancer) and multiple risk factors for TB. In addition, lung cancer would be somewhat uncommon at his age (Choice C) Mycoplasma pneumonia can cause subacute feve r, pulmonary symptoms, and a reticulonodular pattern on chest x-ray It would be very rare fo r Mycoplasma to cause symptoms for 2 months; most cases are limited to 2-3 weeks. (Choice D) This patient is an intravenous drug user and is at risk for septic emboli. Septic emboli typically cause nodular and cavitary lesions (not reticulonodular patterns) on chest x-ray In addition, 2 months of symptoms would be less likely than a more acute presentation. Educational objective: '
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TB is caused by the hematogenous spr ead of Mycobacterium tuberculosis . It may arise during primary infection or with reactivation. Subacute or chronic symptoms are common. Extrapulmonary disease may occur in the lymph nodes, liver, bones, and central nervous system Incarceration and substance abuse (tobacco and intravenous drug use) put this patient at high risk for TB exposure Other common social risk factors for TB infection include group living and international travel to endemic areas. (Choice A) Hodgkin disease typically presents with painless lymphadenopathy and 8 symptoms (fatigue, weight loss, night sweats) Mediastinal mass is common. This patient has pulmonary symptoms and a diffuse reticulonodular pattern (not mediastinal mass) on chest x-ray , making TB much more likely {Choice B) Metastatic disease to the lung typically presents with multiple masses, although patients occasionally present with a lymphangitic ca rcinomatosis (which may have a reticulonodular appearance) This patient has subacute feve rs (uncommon in metastatic cancer) and multiple risk factors fo r TB. In addition, lung cancer would be somewhat uncommon at his age
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(Choice C) Mycoplasma pneumonia can cause subacute fever , pulmonary symptoms, and a reticulonodular pattern on chest x-ray It would be very rare fo r Mycoplasma to cause symptoms for 2 months; most cases are limited to 2-3 weeks. (Choice D) This patient is an intravenous drug user and is at risk fo r septic emboli. Septic emboli typically cause nodular and cavitary lesions (not reticulonodular patterns) on chest x-ray In addition, 2 months of symptoms would be less likely than a more acute presentation Educational objective: Miliary tuberculosis typically presents with subacute or chronic feve rs, weight loss, fatigue, and pulmonary symptoms Chest x-ray classically reveals a diffuse reticulonodular pattern (millet seed) The most common behavioral risk factor for tuberculosis in the United States is substance abuse. Time Spent 5 seconds
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® A. Spontaneous pneumothorax ® B. Acute pancreatitis ® C. Perforated duodenal ulcer
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A 51-year-old male with a history of alcoholic pancreatitis presented to the hospital because of sudden onset severe retrosternal and upper abdominal pain. He has been vom iting for the past few hours after consuming alcohol. His temperature is 38.1o C (100 go F), blood pressure is 140/90 mm Hg, pulse is 120/min and respirations are 30/min. Examination shows palpable crepitus in the suprasternal notch. Lungs are clear to auscultation. The abdomen is tender to palpation mostly in the epigastrium W hich of the following is the most likely cause of his current condition?
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Explanation: The constellation of cl inical findings in this patient is most consistent with esophageal perforation First, the patient has chronic pancreatitis resulting from alcohol abuse. Exacerbations of chronic pancreatitis are frequently precipitated by alcohol consumption; such patients should be admonished to never consume alcohoL Exacerbation of the chronic pancreatitis has caused epigastric pain and tenderness as well as vomiting Spontaneous rupture of the esophagus ( Boerhaave syndrome) can occur during episodes of vomiting, particularly when the patient is resisting the vom iting reflex. This results because high intraabdominal pressures are transmitted into the mediastinal esophagus where the transmural difference in pressure is large due to negative intrathoracic pressure Esophageal rupture in this setting typically occurs a few centimeters above the gastroesophageal junction The retrosternal pain and crepitus in the suprasternal notch are the result of pneumomediastinum, which commonly occurs following rupture of the esophagus within the mediastinum. (Choice A) Pneumomediastinum may accompany a pneumothorax, but pneumothorax would have decreased or absent breath sounds on the affected side. (Choice B) Acute pancreatitis causes epigastric pain radiating to the back but would not directly result in pneumomediastinum It may, however , cause a left pleural effusion. (Choice C) A perforated duodenal ulcer would cause epigastric pain, and air would be visualized under the diaphragm on upright abdominal X-ray, but pneumomediastinum is not associated with duodenal perforation. (Choice E) A Mallory-Weiss tear is an incomplete mucosal tear at the gastroesophageal junction usually resulting from protracted vomiting. The common presentation is self-limited hematemesis. Pneumomediastinum does not occur in such tears because the rupture is incomplete (Choice F) Myocardial infa rction presents with c rushing substernal chest pain radiating to the left shoulder and arm typically in a patient with risk factors such as smoking, diabetes, hyperlipidemia, hypertension and a positive family history of coronary artery disease.
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epigastric pain and tenderness as well as vomiting Spontaneous rupture of the esophagus ( Boerhaave syndrome) can occur during episodes of vomiting, particularly when the patient is resisting the vom iting reflex. This results because high intraabdominal pressures are transmitted into the mediastinal esophagus where the transmural difference in pressure is large due to negative intrathoracic pressure. Esophageal rupture in this setting typically occurs a few centimeters above the gastroesophageal junction The retrosternal pain and crepitus in the suprasternal notch are the result of pneumomediastinum, which commonly occurs following rupture of the esophagus within the mediastinum. (Choice A) Pneumomediastinum may accompany a pneumothorax, but pneumothorax would have decreased or absent breath sounds on the affected side. (Choice B) Acute pancreatitis causes epigastric pain radiating to the back but would not directly result in pneumomediastinum It may, however , cause a left pleural effusion. {Choice C) A perforated duodenal ulcer would cause epigastric pain, and air would be visualized under the diaphragm on upright abdominal X-ray, but pneumomediastinum is not associated with duodenal perforation
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(Choice E) A Mallory-Weiss tear is an incomplete mucosal tear at the gastroesophageal junction usually resulting from protracted vomiting. The common presentation is self-limited hematemesis. Pneumomediastinum does not occur in such tears because the rupture is incomplete. (Choice F) Myocardial infarction presents with crushing substernal chest pain radiating to the left shoulder and arm typically in a patient with risk factors such as smoking, diabetes, hype rlipidemia, hypertension and a positive family history of co ronary artery disease. Educational Objective: Esophageal rupture most commonly occurs following instrumentation of the esophagus Less commonly it may occur in patients with protracted vomiting who have been resisting the urge to vom it Rupture in these cases typ ically occurs into the mediastinum resulting in pneumomediastinum. Time Spent 2 seconds
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A 27-year-old woman comes to the physician complaining of joint pain Her symptoms began 10 days ago and consist of bilateral pain in the metacarpophalangeal joints, proximal interphalangeal joints, wrists, knees, and ankles. She describes joint stiffness lasting 10-15 minutes on awakening in the morning The patient has also had associated fatigue and a few episodes of loose bowel movements associated with mild skin itching and patchy redness. She has no fever , weight loss, or lymphadenopathy She has no other medical conditions and takes no medications. The patient is married and has 2 children. She works as an elementary school teacher. On examination, there is tenderness of the involved joints without swelling or redness. The remainder of the physical examination is unremarkable. W hich of the following is most likely elevated in this patient?
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0 A Anti-cyclic c itrullinated peptide antibodies
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6 D. Anti-parvovirus 819 lgM antibodies
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6 F. Cryoglobulin levels
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® G. Rheumatoid factor
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Clinical features of parvovirus 81 9 infection
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• Up to 75% of patients are asymptomatic or have flu like symptoms Signs & symptoms
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• Erythema infectiosum (fifth disease); more common in children with fever, nausea & a malar rash on the cheeks • Acute, symmetrical arthralgia/arthritis usually in the hands, wrists, knees & feet (resembles RA) • Transient aplastic anemia in patients with a history of hematologic disease (eg, sickle cell)
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• Acute infection o 819 lgM antibodies in immunocompetent
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Diagnosis
o NAAT in immunocompromised
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• Previous infection by 819 lgG antibodies (documents immunity)
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• vReactivation of previous infection by NAAT to detect 819 DNA
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NAAT =nucleic acid amplification testing; RA =rheumatoid arthritis. @UWorid
This patient's acute symmetric arthralgias most likely represent viral arthritis secondary to parvovirus 819. Parvovirus is among the most common causes of acute viral arthritis (others include hepatitis 8 and C, HIV, and rubella) Parvovirus infection most commonly affects adults who have frequent contact with children (eg, school teachers, daycare workers) Children with parvovirus infection often develop a "slapped cheek" rash as part of erythema infectiosum. Nearly 75% of adults with parvovirus infection develop a nonspecific rash, but <20% have the characteristic erythema infectiosum rash.
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parvovirus infection often develop a "slapped cheek" rash as part of erythema infectiosum. Nearly 75% of adults with parvovirus infection develop a nonspecific rash, but <20% have the characteristic erythema infectiosum rash. Adults most commonly develop a polyarticular, symmetric arthritis (60% of cases) involving peripheral joints, including the hands (metacarpophalangeal [MCP), proximal interphalangeal [PIP). and wrist), knees, and ankles. Arthritis due to parvovirus 819 typically does not cause joint destruction or chronic arthritis. Other possible nonspecific findings include fever, fatigue, and diarrhea. Parvovirus 819 infection is diagnosed by detecting anti-8 19 lgM antibodies in the serum, which develop within 10-15 days of infection and usually remain positive for 1-6 months. The symptoms typically resolve spontaneously in 2-3 weeks without the need fo r specific treatment (Choices A and G) Anti-cyclic citrullinated peptide antibodies and rheumatoid factor are usually associated with rheumatoid arthritis (RA) RA presents with joint stiffness ::::1 hour in the morning, joint swelling on examination, and symptoms for 2:6 weeks. Although parvovirus can affect similar joints (eg, MCP, PIP, wrist), this patient's acute symptom onset (10 days) and absence of both joint swelling and prolonged joint stiffness in the morning make RA less likely
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(Choices 8 and C) Antinuclea r antibody testing is highly sensitive for systemic lupus erythematosus (SLE); anti-double-stranded DNA antibodies are highly specific for the diagnosis There is significant overlap in the appearance of parvovirus-related arthritis and the arthritis of SLE, but SLE most often causes chronic rather than acute arthritis. Other findings of SLE include malar or discoid rash, hematologic abnormalities (eg, anemia), renal disease, fever , malaise, and weight loss. This patient's short duration of joint pain and absence of other findings make SLE unlikely {Choice E) Anti-streptolysin titers are positive in patients with acute rheumatic fever and indicate recent streptococcal infection. Typical findings include migratory polyarthritis, pancarditis, Sydenham's chorea, erythema marginatum, and subcutaneous nodules. However , the arthritis of rheumatic fever is usually migratory and initially affects lower -extremity joints
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(Choice F) Mixed cryoglobulinemia is usually associated with chronic hepatitis C and can cause arthralgias The arthralgias of mixed c ryoglobulinemia usually occur in association with a chronic
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joint swelling on examination, and symptoms for 2:6 weeks. Although pa tVovirus can affect similar joints (eg, MCP, PIP, wrist), this patient's acute symptom onset (10 days) and absence of both joint swelling and prolonged joint stiffness in the morning make RA less likely
{Choices 8 and C) Antinuclear antibody testing is highly sensitive for systemic lupus erythematosus (SLE); anti-double-stranded DNA antibodies are highly specific for the diagnosis. There is significant overlap in the appearance of patVovirus-related arthritis and the arthritis of SLE, but SLE most often causes chronic rather than acute arthritis. Other findings of SLE include malar or discoid rash, hematologic abnormalities (eg, anemia), renal disease, fever , malaise, and weight loss. This patient's short duration of joint pain and absence of other findings make SLE unlikely {Choice E) Anti-streptolysin titers are positive in patients with acute rheumatic fever and indicate recent streptococcal infection. Typical findings include migratory polyarthritis, panca rditis, Sydenham's chorea, erythema marginatum, and subcutaneous nodules. However , the arthritis of rheumatic fever is usually migratory and initially affects lower-extremity joints
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{Choice F) Mixed cryoglobulinemia is usually associated with chronic hepatitis C and can cause arthralgias The arthralgias of mixed c ryoglobulinemia usually occur in association with a chronic vasculitic syndrome characterized by palpable purpura, lymphadenopathy , nephropathy , and neuropathy . Educational objective: PatVovirus 819 can cause an acute symmetric arthritis of the hands (metacarpophalangeal, proximal interphalangeal, and wrist), knees, and ankle joints. The diagnosis can be confi rmed with anti-patVovirus 819 lgM The syndrome is usually self-limited and does not require specific treatment
References: 1. Parvovirus 819: its role in chronic arthritis.
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<0 A Chronic laxative use <0 B. Cigar ette smoking <0 C. Colonic polyps
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Lab Values
A 62-year-old woman comes to the office due to 4 days of watery diarrhea and abdominal cramps. She has had 4 or 5 loose stools daily with no blood or mucus. She has a history of constipation requiring frequent laxative use but last took a laxative 6 days ago The patient also has a history of hypertension, hyperlipidemia, gastroesophageal reflux, and type 2 diabetes mellitus. Several benign colonic polyps were removed during a colonoscopy 2 years ago She takes omeprazole daily and received oral antibiotics for acute sinusitis 3 weeks ago The patient has not traveled recently She smokes a pack of c igarettes daily Her temperature is 38 C (1004 F) The abdomen is soft with mild distension and mild diffuse tenderness. No guarding or rebound tenderness is present Stool assay for Clostridium difficile is positive In addition to recent antibiotic use, which of the following most likely predisposed this patient to her current condition?
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D. Gastric acid suppression [58% J E. Splanchnic nerve damage [2%]
Explanation:
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Clostridium difficile colitis Risk factors
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Pathogenesis
• Disruption of intestinal flora ~ C difficile overgrowth • Exotoxins cause mucosal inflammation/injury
Clinical p resentatio n
• Watery diarrhea (most common) • Fulminant colitis/toxic megacolon
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• Recent antibiotics • Hospitalization • PPI
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Diagnosis
• Stool PCR
T reatment
• Oral metronidazole or vancomycin
PCR = polymerase chain reaction; PPI = proton pump inhibitor. @UWOI1d
Clostridium diffici/e is a gram-positive, anaerobic bacterium that causes infectious diarrhea in the nosocomial and outpatient setting Hearty, antibiotic-resistant spores are ingested and convert to fully functional bacilli in the colon. Although the organism is noninvasive, pathogenic strains produce exotoxins ("enterotoxin" A and "cytotoxin" B) that penetrate colonic epithelial cells, resulting in apoptosis and the loss of tight junctions Carriage of toxigenic C difficile is
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strains produce exotoxins ("enterotoxin" A and "cytotoxin" B) that penetrate colonic epithelial cells, resulting in apoptosis and the loss of tight junctions Carriage of toxigenic C difficile is common (8%-15%), but extensive prolife ration is usually required to reach exotoxin levels that are pathogenic . The single greatest risk factor for clinical illness is recent antibiotic use (eg, fl uoroquinolones, clindamycin, cephalosporins, penicillins), which disrupts the normal colonic flora (eg, Bacteroides) , freeing nutrients and eliminating a crucial epithelial barrier. Other common risk facto rs include advanced age (>65) and gastric acid suppression (eg, proton pump inhibitor) C difficile colitis usually manifests with watery diar rhea (~3 stools/day), abdominal cramping, vomiting, low-grade feve r, and leukocytosis (-15,000/mm'). Overt melena and bright red blood per rectum are rare. Diagnosis is typically made with stool assay for C difficile exotoxin genes via polymerase chain reaction. Treatment involves the cessation of the inciting antibiotic (if possible), infection control (contact precautions), and antimicrobial therapy with oral metronidazole or vancomycin (Choice A) This patient discontinued laxatives 6 days ago; it is unlikely that laxatives would continue to cause diarrhea several days later. (Choices B and C) Cigarette smoking may increase the risk of colonic polyps Chronic nicotine use and colonic polyps are not typically associated with a direct increase in risk fo r infectious diarrhea. (Choice E) Pelvic splanchnic nerve damage is usually due to abdominal surgery or spinal trauma. Constipation, not diarrhea, is a common consequence Educational objective: Clostridium difficile is a common cause of nosocomial and outpatient infectious diarrhea. Major risk facto rs include recent antibiotic use, age >65, and gastric acid suppression (eg, proton pump inhibitors) Diagnosis is typically made with stool assay for C difficile exotoxins via polyme rase chain reaction. Refer ences:
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e')
A Legionnaires disease
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B. Pulmonary thromboembolism
e') C. Tuberculosis
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e') E. Staphylococcus infection
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D. Bronchiectasis
F. Atypical pneumonia
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A 64-year-old male recovering from an upper respiratory infection develops malaise and productive cough Two days later he presents to the emergency department with confusion and severe dyspnea He reports coughing up copious amounts of yellowish sputum streaked with blood today On physical examination, his temperature is 40° C (104° F), blood pressure is 150/90 mm Hg, pulse is 11 0/min, and respirations are 24/min. Chest x-ray reveals infiltrates in the lung midfields bilaterally as well as multiple thin-walled cavities. W hat is the most likely cause of this patient's condition?
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Explanation:
This patient developed signs and symptoms of severe pneumonia while recovering f rom a simple upper respiratory infection (URI), which was most likely viral. Given his current high fever and purulent sputum, bacterial superinfection, also known as a secondary bacterial pneumonia, is likely Secondary bacterial pneumonia is common in elderly patients, and is most often due to Strep tococcus pneumoniae, Staphylococcus aureus, or Haemophilus influenzae. The patient's blood-streaked sputum and multiple midfield lung cavities on chest x-ray suggest an acute necrotizing pneumonia with secondary pneumatoceles. Of the pathogens listed above, only S. aureus is known to cause post-viral URI necrotizing pulmonary bronchopneumonia with multiple nodular infiltrates that can cavitate to cause small abscesses.
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{Choice B) Pulmonary emboli generally cause either no chest x-ray findings or changes consistent with a single wedge-shaped, parietal pleural-based infa rct {Choice C) Reactivation of pulmonary tuberculosis tends to produce upper lobe fibrocaseous cavitations. {Choice D) Bronchiectasis is necrotizing and can yield blood-tinged, purulent sputum However , bronchiectasis is a chronic bronchopneumonia that produces dilated bronchi, not multiple small abscess cavities. {Choice F ) Atypical pneumonias generally yield diffuse interstitial infiltrates on chest x-ray Educational objective: Of the bacterial pathogens known to cause secondary pneumonia complicating a viral upper respiratory infection, only Staphylococcus aureus is associated with necrotizing bronchopneumonia resulting in pneumatocoeles •
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A 56-year-old man develops fever on the third postoperative day He had undergone co ronary artery bypass surgery fo r multivessel coronary artery disease requiring 4 grafts The patient is still intubated and is receiving mechanical ventilation. He has a history of type 2 diabetes mellitus, hypercholesterolemia, and hypertension His temperature is 38.9 C (102 F) , blood pressure is 130/80 mm Hg, and pulse is 90/min. His BMI is 28 kg/m2 Examination reveals normal breath sounds. Heart sounds are normal. The patient has marked right upper quadrant tenderness to mild palpation Bowel sounds are decreased. Laboratory results are as follows: Hemoglobin
10.8 g/dL
Platelets
150,000/mm'
Leukocytes
17,000/mm'
Total bilirubin
1.0 mg/dL
Alkaline phosphatase
100 U/L
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32 U/L
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Alanine aminotransferase (SGPT)
34 U/L
Amylase
110 U/L
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W hich of the following is the most likely diagnosis in this patient? e') A Acalculous cholecystitis
6 B. A cute cholangitis 6 C. Acute pancreatitis 6 D. Right-sided pneumonia
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Hemoglobin
10.8 g/dL
Platelets
150,000/mm'
Leukocytes
17,000/mm'
Total bilirubin
1.0 mg/dL
Alkaline phosphatase
100 U/L
Aspartate aminotransferase (SGOT)
32 U/L
Alanine aminotransferase (SGPT)
34 U/L
Amylase
110 U/L
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130/80 mm Hg, and pulse is 90/min. His BMI is 28 kg/m2 . Examination reveals normal breath sounds. Heart sounds are normaL The patient has marked right upper quadrant tenderness to mild palpation. Bowel sounds are decreased. Laboratory results are as follows
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W hich of the following is the most likely diagnosis in this patient?
® A Acalculous cholecystitis ® B. Acute cholangitis ® C. Acute pancreatitis ® D. Right-sided pneumonia ® E. Right-sided pyelonephritis ® F. Subphrenic abscess Submi t
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Explanation:
Acalculous cholecystitis
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• Severe trauma, extensive burns, recent surgery (eg, cardiopulmonary, aortic, abdominal) Risk factors
• Prolonged fasting or TPN • Critical illness (sepsis, ICU, mechanical ventilation)
Clinical presentation
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• Unexplained fever, vague/RUQ abdominal discomfort, leukocytosis • Possible jaundice, RUQ mass, abnormal LFTs
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• Abdominal ultrasound (preferred) Diagnosis
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• Cholescintigraphy (HIDA scan) or abdominal CT scan if ultrasound not diagnostic
HIOA = hepatobiliary iminodiacetic acid; ICU = intensive care unit; LFTs = liver function tests; RUQ = right upper quadrant TPN = total parenteral nutrition. @UWorld
This patient's presentation suggests acalculous cholecystitis, an acute inflammation of the gallbladder in the absence of gallstones. Acalculous cholecystitis is most often seen in hospitalized patients who are critically ill. Common predisposing conditions incl ude recent surgery (particularly cardiopulmonary, aortic, or abdominal), severe trauma, extensive burns, sepsis or shock, prolonged fasting or total parenteral nutrition, or critical illness requiring mechanical intubation. These conditions likely cause gallbladder stasis or ischemia with local . fl f th t I d t I llbl dd d. t d d b t . I. f r
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sepsis or shock, prolonged fasting or total parenteral nutrition, or critical illness requiring mechanical intubation. These conditions likely cause gallbladder stasis or ischemia with local inflammation that can lead to gallbladder distension, necrosis, and secondary bacterial infection. Acalculous cholecystitis can present with unexplained fever and diffuse or right upper quadrant (RUQ) abdominal pain Other findings can include jaundice, RUQ mass, leukocytosis, or abnormal liver function tests (normal results do not exclude the diagnosis) Therefore, the diagnosis requires a high degree of suspicion Complications include gangrene, perforation, and emphysematous cholecystitis Abdom inal ultrasound is usually preferred for diagnosis and can reveal signs of acute cholecystitis without gallstones. Patients with unclear ultrasound findings may need abdominal CT scan or cholescintigraphy (hepatobiliary iminodiacetic acid [HIDA)) scans, which are more sensitive and specific for the diagnosis (Choice B) Acute cholangitis is usually due to common bile duct obstruction by a gallstone or malignancy It typically presents with feve r, jaundice, RUQ abdominal pain, and elevated alkaline phosphatase Therefore, acute cholangitis is less likely given this patient's normal alkaline phosphatase and absence of jaundice
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(Choice C) Acute pancreatitis can occur postoperatively in patients with hypotension (similar to acalculous cholecystitis). However , acute pancreatitis is less likely due to this patient's marked RUQ tenderness and normal amylase levels. (Choice D) Right lower lobe pneumonia can present with feve r, cough, right-sided chest pain, and sometimes RUQ pain However, pneumonia is less likely given this patient's normal lung examination. (Choice E) Right-sided pyelonephritis usually presents with fever, nausea, and right flank (not RUQ) pain (Choice F) Subphrenic abscess (rare) can cause fever and abdominal pain However , it usually develops due to peritonitis (eg, perforated ulcer , appendicitis, abdominal surgery) and is unlikely in this patient who did not undergo an abdominal procedure. A right-sided pleural effusion can develop but is unlikely in a patient with normal breath sounds.
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g y g g may need abdominal CT scan or cholescintigraphy (hepatobiliary iminodiacetic acid [HIDAJ) scans, which are more sensitive and specific for the diagnosis. •
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{Choice B) Acute cholangitis is usually due to common bile duct obstruction by a gallstone or malignancy. It typically presents with feve r, jaundice, RUQ abdominal pain, and elevated alkaline phosphatase Therefore, acute cholangitis is less likely given this patient's normal alkaline phosphatase and absence of jaundice (Choice C) Acute pancreatitis can occur postoperatively in patients with hypotension (similar to acalculous cholecystitis). However , acute pancreatitis is less likely due to this patient's marked RUQ tenderness and normal amylase levels. (Choice D) Right lower lobe pneumonia can present with fever , cough, right-sided chest pain, and sometimes RUQ pain. However , pneumonia is less likely given this patient's normal lung examination. (Choice E) Right-sided pyelonephritis usually presents with feve r, nausea, and right flank (not RUQ) pain (Choice F) Subphrenic abscess (rare) can cause fever and abdominal pain However, it usually develops due to peritonitis (eg, perforated ulcer , appendicitis, abdominal surgery) and is unlikely in this patient who did not undergo an abdominal procedure. A right-sided pleural effusion can develop but is unlikely in a patient with normal breath sounds. Educational objective: Acute acalculous cholecystitis is an acute inflammation of the gallbladder in the absence of gallstones that is most commonly seen in hospitalized and severely ill patients. References: 1. Acute acalculous cholecystitis: a review.
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C)
A Calf vein
C)
B. Femoral vein
C)
C. Renal vein
C)
D. Right atrium
C)
E. Upper extremity vein
Submit
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A 66-year-old man comes to the emergency department with acute onset of severe chest pain and shortness of breath. The pain is in the right upper chest and is aggravated by deep breathing and coughing Medical history is significant for hypertension and obstructive sleep apnea The patient quit smoking 10 years ago and drinks beer on weekends. Blood pressure is 110/70 mm Hg, pulse is 116/min and regular, and respirations are 22/min. BMI is 30 kg/m2 Normal vesicular breath sounds are heard on auscultation of the chest Cardiac auscultation reveals tachyca rdia and an accentuated S2. Chest x-ray is unremarkable. ECG shows sinus tachycardia. CT angiogram of the chest reveals an embolus in the right pulmonary artery W hich of the following is the most likely origin of this embolus?
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Explanation:
Proximal & distal deep veins of leg
lit-- - - External iliac vein
=--....:.....- Common femoral vein
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._- --Femoral vein
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l r- - - Popliteal vein
( Proximal
' --------Distal
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#-- - - -Anterior tibial veins
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,___ _ _ _ Posterior tibial veins
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© UWorld
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The finding of a thrombus in the right pulmonary artery on CT angiogram is diagnostic of pulmonary embolus (PE) The deep veins of the lower extremities are the most frequent source. Lower extremity deep vein thrombosis ( DVT) is divided into 2 categories: • Proximal/thigh (eg, iliac, femoral, popliteal) These are the source of >90% of acute PEs, probably due to their large caliber and proximity to the lungs. • DistaVcalf These are less likely to embolize and more likely to spontaneously resolve (Choice A) (Choice C) Thrombi originating from the renal veins are most common in patients with nephrotic syndrome The prevalence of PE in patients with nephrotic syndrome is 10%-30% .
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The finding of a thrombus in the right pulmonary artery on CT angiogram is diagnostic of pulmonary embolus (PE). The deep veins of the lower extremities are the most frequent source. Lower extremity deep vein thrombosis (DVT) is divided into 2 categories: • Proximal/thigh (eg, iliac, femoral, popliteal): These are the source of >90% of acute PEs, probably due to their large caliber and proximity to the lungs • Distal/calf: These are less likely to embolize and more likely to spontaneously resolve (Choice A) (Choice C) Thrombi originating from the renal veins are most common in patients with nephrotic syndrome The prevalence of PE in patients with nephrotic syndrome is 10%-30% . (Choice D) Thromb i originating in the right atrium are more common in patients with intracardiac devices (eg, pacemaker) and are less likely to occur spontaneously.
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(Choice E) Spontaneous upper extremity DVT is generally uncommon (1%-4%) and even less likely to cause PE. Common risk factors for upper extremity DVT include prothrombotic state, indwelling catheter, and anatomical venous obstruction (eg, cervical rib, bony overgrowth after clavicular fracture). Educational objective: The proximal deep leg veins are the most common source of symptomatic pulmonary embolism. Other less common sources of emboli include the calf veins, renal veins, pelvic veins, upper extremity ve ins, and right heart. References: 1. Comparison of the clinical history of symptomatic isolated distal deep-vein thr ombosis vs. proximal deep vein thrombosis in 11 086 patients.
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(:) A Increase warfarin dose and follow up in 3 days e; B. Initiate thrombolytic therapy (:) C. Place inferior vena cava filter
e; D. Start low-dose aspirin (:) E. Start oral rivaroxaban
Subm it
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A 32-year-old man comes to the emergency department with a day of worsening pain and swelling in his right leg He has no fever , chest pain, or shortness of breath. The patient was hospitalized fo r right lower-extremity deep-vein thrombosis 2 weeks ago after a minor sports injury and was discharged on warfarin . W hen he left the hospital, his International Normalized Ratio (INR) value was 2.2 (goal 2- 3) He has been taking warfarin daily ; however, due to a busy work schedule, his dietary intake has been variable and he missed his Coumadin clinic appointment last week. The patient has no other medical problems Today his INR is 1.3. His platelet count, creatinine, and liver function tests are within normal limits. Venous Doppler ultrasound shows a right popliteal vein thrombus extending into the femoral vein that is worse than on previous ultrasound. W hat is the best next step in management of this patient?
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Comparison of rivaroxaban & warfarin Rivaroxaban
Warfarin
Direct factor Xa inhibitor
Vitamin K antagonist
2- 4 hours
5- 7 days
Single agent
Overlap with heparin for
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Mecha nis m of action Therapeut ic effect
Acute DVT t reatment
-5 days
Need for m o nitoring
None
Prothrombin time/INR
A nt idote if hemorrhage
None
Fresh frozen plasma, vitamin K
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@USMLEWorld, LLC
This patient was recently diagnosed with deep-vein thrombosis (DVT) and has had difficulties with warfarin anticoagulation therapy He now has a ovr that has progressed in the setting of a subtherapeutic International Normalized Ratio (INR) value. The risk of pulmonary embolus (PE) is higher with proximal (ie, popliteal, femoral, or iliac vein) than distal (ie, below the knee) ovr, so this patient needs immediate anticoagulation Rivaroxaban is a direct factor Xa inhibitor with a rapid onset of action that can be used as a single agent in the treatment of acute ovr or PE. It does not require laboratory monitoring or overlap therapy with a heparin; however, it exhibits drug interactions and carries a higher risk of irreversible bleeding as no antidote is available in the event of major hemorrhage . Patients may be interested in rivaroxaban if they do not want daily injections (heparin) or if, as with this patient, they have difficulty with dietary restrictions or frequent INR monitoring (warfarin) Rivaroxaban is
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irreversible bleeding as no antidote is available in the event of major hemorrhage. Patients may be interested in rivaroxaban if they do not want daily injections (heparin) or if, as with this patient, they have difficulty with dietary restrictions or frequent INR monitoring (warfarin) Riva roxaban is also a suitable option for patients who have recurrent or refractory DVT. {Choice A) Increasing the patient's warfa rin dose without initially starting anticoagulation with a heparin product (low-molecular weight heparin or intravenous unfractionated heparin) is not recommended when the INR <2.0 as it renders the patient susceptible to a transient hypercoagulable state. {Choice B) Thrombolytic therapy is typ ically reserved for hemodynamically unstable PE patients Less commonly , it is used fo r massive proximal lower-extremity thrombosis or iliofemoral thrombosis associated with significant symptomatic swelling or limb ischemia. {Choice C) Inferior vena cava (IVC) filters may be used in patients with lower-extremity DVT when anticoagulation is contraindicated (eg, hemorrhagic stroke , active bleeding) Anticoagulation failure (recurrent or extending thromboembolism wh ile fully anticoagulated) is another indication for IVC filter placement; however, this patient's INR is grossly subtherapeutic , so he was not fully anticoagulated {Choice D) Aspirin is inadequate for the treatment of acute DVT. Educational objective: Rivaroxaban is an oral anticoagulant (direct factor Xa inhibitor) that has similar efficacy compared to low-molecular-weight heparin and warfarin in the treatment of acute deep-vein thrombosis or pulmonary embolus. It does not require frequent laboratory monitoring or daily injections; however, there is no antidote in the event of major hemorrhage Refer ences: 1. Oral rivaroxaban versus standard therapy for the treatment of symptomatic venous thromboembolism: a pooled analysis of the EINSTEIN-DVT and PE randomized studies. 2. Antithrombotic therapy for VTE disease: antithrombotic therapy and prevention
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Hemoglobin
13 g/dL
Platelets
238,000/mm>
Leukocytes
12,800/mm•
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Chest x-ray reveals bilateral, diffuse reticular opacities Which of the following is the most likely underlying cause of this patient's current condition? 6 A. Cytomegalovirus 6 B. Group A Streptococcus
e; C. Infl uenza virus 6 D. Pneumocystis jiroveci
6 E. Pseudomonas aeruginosa 6 F. Respiratory syncytial virus
e; G. Streptococcus pneumoniae
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A 72-year-old man comes to the hospital due to 12 hours of worsened shortness of breath and nonproductive cough. He was in his usual state of health until 3 days ago, when he abruptly developed fever, headache, sore throat, runny nose, anorexia, and severe body aches. The patient has no known sick contacts but spent a long time in a mall shopping for Christmas presents 5 days ago He has a history of coronary artery disease, hypertension, and diet-controlled type 2 diabetes mellitus. Temperature is 38.9 C (102 F), blood pressure is 140/90 mm Hg, pulse is 102/min, and respirations are 28/min. Oxygen saturation is 91% on 40% supplemental oxygen via mask. Oropharyngeal examination shows mild pharyngeal erythema without exudates. No lymphadenopathy or jugular venous distension is present Chest auscultation reveals scattered bilateral crackles and a fourth heart sound (S4) but no cardiac murmurs. The abdomen is soft and nontender. There is no peripheral edema. Laboratory results are as follows:
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Explanation:
Adults at high risk for influenza complications • Age >65 • Women who are pregnant & up to 2 weeks postpartum • Underlying chronic medical illness (eg, chronic pulmonary, cardiovascular, renal, hepatic) • Immunosuppression • Morbid obesity • Native Americans • Nursing home or chronic care facility residents
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© UWOI1d
Influenza virus is largely a winter infection that attacks the epithelium of the upper and lower respiratory tract Approximately 1-5 days after exposure, patients abruptly develop systemic (fever, malaise, myalgias, headache) and upper/lower respiratory (rhinorrhea, sore throat, nonproductive cough) symptoms Physical and laboratory examinations are often normal but may show pharyngeal erythema (without exudates) and mild alterations in leukocyte count (low early, high later) Most patients recover spontaneously and completely within 1 week of symptom onset However, patients with advanced age (>65) and chronic medical illness (eg, coronary artery disease, diabetes mellitus) are far more likely to develop complications. Pneumonia is the most common complication of infl uenza and is the result of either secondary bacterial infection (eg, Streptococcus pneumoniae) or direct viral attack (influenza pneumonia) Patients with primary influenza pneumonia typically have an acute worsening of symptoms (dyspnea, cough), leukocytosis (<15,000/mm'), hypoxia, and bilateral, diffuse
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pneumonia) Patients with primary influenza pneumonia typically have an acute worsening of symptoms (dyspnea, cough), leukocytosis (<15,000/mm>), hypoxia, and bilateral, diffuse interstitial infiltrates on chest x-ray Hospitalization with supplemental oxygen support and antiviral ( eg, oseltamivir) treatment is usually required Influenza may also cause complications in the muscle (myositis, rhabdomyolysis), heart (myocarditis, pericarditis) , and central nervous system (encephalitis, transverse myelitis) (Choice A) Cytomegalovirus infection may cause a mononucleosis-like illness marked by feve r, malaise, and absolute lymphocytosis Rhinorrhea is uncommon and pulmonary involvement rarely occurs unless there is significant immunocompromise (eg, HIV with CD4 <100/mm>) {Choice B) Group A Streptococcus infection can cause feve r and sore throat with tonsillar exudates (pharyngitis) This patient's pulmonary involvement, rhinorrhea, and myalgias indicate an alternate diagnosis.
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{Choice D) Pneumocystis pneumonia is almost always seen in patients with significant immunocompromise (eg, solid organ transplantation, HIV with CD4 <200/mm>) and is marked by fever , cough, dyspnea, and (often) chest x-ray evidence of bilateral inte rstitial infiltrates. This condition is usually subacute and is not commonly associated with rhinorrhea and myalgias (Choices E and G) Pseudomonas aeruginosa and Streptococcus pneumoniae can cause secondary bacterial pneumonia in patients with influenza. Patients with these infections have high fever , significant leukocytos is (>15,000/mm>) , and lobar infiltrates on chest x-ray This patient with mild leukocytosis and bilateral, diffuse reticular infiltrates on chest x-ray likely has primary influenza pneumonia (Choice F) Respiratory syncytial virus (RSV) infection and influenza share many clinical symptoms, but patients with RSV often have wheezing and rarely (<1 %) have diffuse, bilateral reticular infiltrates. Educational objective: Infl uenza is usually a self-limited infection marked by <1 week of systemic (feve r, malaise, myalgias, headache) and respiratory (rhinorrhea, sore threat, nonproductive cough) symptoms.
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antiviral ( eg, oseltamivir) treatment is usually required Influenza may also cause complications in the muscle (myositis, rhabdomyotysis), heart (myocarditis, pericarditis) , and central nervous system (encephalitis, transverse myelitis) (Choice A) Cytomegalovirus infection may cause a mononucleosis-like illness marked by feve r, malaise, and absolute lymphocytosis Rhinorrhea is uncommon and pulmonary involvement rarely occurs unless there is significant immunocompromise (eg, HIV with CD4 <100/mm') {Choice B) Group A Streptococcus infection can cause feve r and sore throat with tonsillar exudates (pharyngitis) This patient's pulmonary involvement, rhinorrhea, and myalgias indicate an alternate diagnosis. {Choice D) Pneumocystis pneumonia is almost always seen in patients with significant immunocompromise (eg, solid organ transplantation, HIV with CD4 <200/mm') and is marked by fever , cough, dyspnea, and (often) chest x-ray evidence of bilateral inte rstitial infiltrates. This condition is usually subacute and is not commonly associated with rhinorrhea and myalgias (Choices E and G) Pseudomonas aeruginosa and Streptococcus pneumoniae can cause secondary bacterial pneumonia in patients with influenza. Patients with these infections have high fever , significant leukocytos is (>15,000/mm') , and lobar infiltrates on chest x-ray This patient with mild leukocytosis and bilateral, diffuse reticular infiltrates on chest x-ray likely has primary influenza pneumonia (Choice F) Respiratory syncytial virus (RSV) infection and influenza share many clinical symptoms, but patients with RSV often have wheezing and rarely (<1 %) have diffuse, bilateral reticular infiltrates. Educational objective: Infl uenza is usually a self-limited infection marked by <1 week of systemic (feve r, malaise, myalgias, headache) and respiratory {rhinorrhea, sore threat, nonproductive cough) symptoms. Complications (eg, pneumonia) are common in patients with advanced age and chronic illness. Time Spent 2 seconds
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A 45-year-old previously healthy man is brought to the emergency department due to headaches and confusion for 2 days. He has no focal weakness or sensory symptoms The patient has no significant past medical history and does not take any medications. He does not use tobacco, alcohol, or illicit drugs Temperature is 37.9 C (100 2 F), blood pressure is 140/86 mm Hg, pulse is 96/min, and respirations are 16/min. Mild icte rus is present His neck is supple and without rigidity. Cardiopulmonary and abdominal examinations are normal. Neurologic examination shows no focal deficits. Laboratory results are as follows: Complete blood count
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Hemoglobin
8.4 g/dL
Platelets
44,000/mm'
Leukocytes
5,500/mm'
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Blood urea nitrogen
30 mg/dL
Creatinine
2.2 mg/dL
Calcium
10 mg/dL
Glucose
98 mg/dL
A peripheral blood smear shows many fragmented red blood cells. The prothrombin time is normal. Wh ich of the following is the most appropriate next step in the management of this patient?
6 A Cryoprecipitate infusion
6 B. Hemodialysis
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Hemoglobin
8.4 g/dl
Platelets
44,000/mm'
Leukocytes
5,500/mm'
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30 mg/dl
Creatinine
2.2 mg/dl
Calcium
10 mg/dl
Glucose
98 mg/dl
A peripheral blood smear shows many fragmented red blood cells. The prothrombin time is normal. W hich of the following is the most appropriate next step in the management of this patient?
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ID A. Cryoprecipitate infusion ID B. Hemodialys is ID C. MRI of the brain ID D. Packed red blood cell transfusion ID E. Plasma exchange ID F. Platelet transfusion ID G. Urine drug screen ID H. W hole blood transfusion Submit
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Pathophysiology
• Hemolytic anemia (I LDH, I haptoglobin) with schistocytes • Thrombocytopenia ( 1 bleeding time, normal PT/PTT)
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Sometimes with • Renal failure • Neurologic manifestations • Fever
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& resulting in diffuse m icrovascular platelet-rich thrombi
• Acquired (autoantibody) or hereditary
Clinical features
Management
• Plasma exchange
LDH = laclale dehydrogenase; PT = prothrombin time; PTT = partial thromboplastin time; vWF = von Willebrand factor.
@UWorld
Thrombotic thrombocytopenic purpura (TTP) is a life-threatening disorder of the microvasculature characterized by the formation of small vessel thrombi that consume platelets, shear red blood cells, and cause end organ damage Classically, TIP is marked by the pentad of: • • • •
Thrombocytopenia Microangiopathic hemolytic anemia (MAHA) Renal insufficiency Neurologic changes (eg, headache, confusion, coma, stroke)
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• 1ADAMTS13 activity leading to large vWF multimers
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Explanation:
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Micr oangiopathic hemolytic anemia (MAHA) Renal insufficiency Neurologic changes (eg, headache, confusion, coma , stroke) Fever
TIP is caused by a deficiency of plasma protease ADAMTS13 (due to the fo rmation of an autoantibody) In the absence of this protease, long chains of von Willebrand factor accumulate on the endothelial wall, trapping platelets and generating thrombi in areas of high shearing force (eg, arterioles, capilla ries) The diagnosis is based largely on clinical and laboratory findings; evidence of MAHA on peripheral blood smear (schistocytes/red blood cell fragments) is an important diagnostic finding Laboratory markers of coagulation ( eg, prothrombin time [ PT]) are normal in TIP (unlike in disseminated intravascular coagulation [ DIG)) TIP is life threatening and must be treated emergently with plasma exchange ( PEX) PEX removes the patient's plasma and replaces it with donor plasma This replenishes ADAMTS13 and removes the autoantibodies. W ithout emergent PEX, the mortality rate is approximately 90% . TIP is closely related to hemolytic uremic syndrome (HUS) Both cause MAHA and thrombocytopenia Unlike TTP, HUS is typically associated with Escherichia coli 0157:H7 and is primarily a disorder of the renal system; neurologic findings and fever are uncommon. (Choice A) Cryoprecipitate contains clotting factors, fibrinogen, and von W illebrand factor. It is often used in patients with DIG. Th is patient's PT is normal, making DIG unlikely (Choice B) This patient's renal insufficiency is mild. Hemodialysis would not be required (Choice C) This patient has headache and confusion but no focal neurologic deficits. If there was concern for intracranial bleeding (given thrombocytopenia) , a noncontrast head CT scan could be ordered. MRI of the brain is expensive and time consuming, and it would not be a useful next step. (Choices 0 and H) Red blood cell transfusions are considered for life-threatening bleeding or a hemoglobin <7 g/dl (and possibly higher in patients with co ronary artery disease)
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TIP is life threatening and must be treated emergently with plasma exchange (PEX) PEX removes the patient's plasma and replaces it with donor plasma. This replenishes ADAMTS1 3 and removes the autoantibodies. W ithout emergent PEX, the mortality rate is approximately 90%. TIP is closely related to hemolytic uremic syndrome (HUS) Both cause MAHA and thrombocytopenia Unlike TIP, HUS is typically associated with Escherichia coli 0157:H7 and is primarily a disorder of the renal system; neurologic findings and fever are uncommon. (Choice A) Cryoprecipitate contains clotting factors, fibrinogen, and von W illebrand factor. It is often used in patients with DIG. This patient's PT is normal, making DIG unlikely (Choice B) This patient's renal insufficiency is mild. Hemodialysis would not be required (Choice C) This patient has headache and confusion but no focal neurologic deficits. If there was concern for intracranial bleeding (given thrombocytopenia), a noncontrast head CT scan could be ordered. MRI of the brain is expensive and time consuming, and it would not be a useful next step.
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(Choices 0 and H) Red blood cell transfusions are considered for life-threatening bleeding or a hemoglobin <7 g/dl (and possibly higher in patients with co ronary artery disease) (Choice F) There is nothing that suggests this patient has severe bleeding Platelets should not be transfused in TTP unless an invasive procedure or significant bleeding occurs. (Choice G) Urine drug screens are often useful in patients with confusion. However, given this patient's anemia, th rombocytopenia, and evidence of intravascular hemolysis, TIP is likely Emergent PEX is necessary Educational objective: Thrombotic thrombocytopenic purpura (TIP) is caused by autoantibodies to plasma protease ADAMTS13 and is marked by mic roangiopathic hemolytic anemia and thrombocytopenia TIP is life threatening and requires emergent treatment with plasma exchange. Time Spent 4 seconds
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Opening pressure
250mm H,O
Glucose
35 mg/dL
Protein
120 mg/dL
Leukocytes
45/IJL
Red blood cells
0/IJL
Cerebrospinal fluid fungal stain shows encapsulated yeast W hich of the following is the most appropriate next step in management of this patient?
e
A. Amphotericin plus flucytosine
e; B. Griseofulvin
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C. HIV testing and antiretroviral therapy
6 D. ltraconazole
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E. Sulfadiazine-pyrimethamine
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A 38-year-old woman comes to the emergency department with a 2-week history of worsening headaches and low-grade fever. She has no weakness or sensory loss. The patient has lost a significant amount of weight over the last 6 months. Her temperature is 38.1 C (100.5 F) , blood pressure is 115/70 mm Hg, pulse is 100/min, and respirations are 14/min. BMI is 18.7 kg/m2 The patient has neck stiffness and cervical lymphadenopathy. Oropharyngeal examination shows thrush. The neurologic examination is nonfocal , and fundoscopy is within normal limits. CT scan of the head without contrast is normal. Lumbar puncture is performed and results of ce rebrospinal fl uid analysis are as follows:
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Explanation: This patient's presentation is consistent with cryptococcal meningoencephalitis, a subacute invasive fungal infection caused by Cryptococcus neoformans. It is typically seen in immunocompromised patients, especially those with advanced HIV disease (CD4 cell count <100/!JL) Patients will develop fever , lethargy, headache, and altered mentation that may advance to coma if left untreated. An elevated opening pressure on lumbar puncture along with low white blood cell count (<50/IJL), low glucose, and elevated protein on cerebrospinal fluid (CSF) analysis is highly suggestive of cryptococcal meningoencephalitis Treatment consists of induction therapy with 2 weeks of intravenous amphotericin 8 (AmB) and flucytosine , followed by fluconazole for consolidation (8 weeks) and maintenance therapy P-1 year) Intrathecal AmB may be considered as salvage therapy fo r patients who have failed systemic therapy or developed significant adverse effects to intravenous medications. Serial lumbar punctures may be required to reduce increased intracranial pressure, which is associated with increased morbidity and mortality
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(Choice B) GriseofuMn is used to treat dermatophytos is and onychomycosis. C. neoformans is not sensitive to griseofulvin (Choice C) The presence of thrush and an opportunistic infection such as Cryptococcus suggests that the patient is immunocompromised. HIV is a common and treatable cause of immunosuppression in this patient's age group. She should be tested for HIV, but initiation of antiretroviral therapy in the setting of acute infection is not recommended due to risk of immune reconstitution syndrome. Antiretroviral therapy should be deferred until at least 2-8 weeks after completing induction antifungal therapy fo r cryptococcal meningitis (Choice D) ltraconazole can be used as an alternate to fluconazole in the treatment of pulmonary cryptococcal infection. However , it does not cross the blood-brain barrier, making it ineffective in central nervous system infection. (Choice E) Sulfadiazine-pyrimethamine is used in the treatment of ce rebral toxoplasmosis, which typically presents with headache, focal neurologic deficits , and/or seizures. Neuroimaging shows multiple ring-enhancing brain lesions with edema.
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(Choice B) GriseofuMn is used to treat dermatophytosis and onychomycosis C. neoformans is not sensitive to griseofulvin. (Choice C) The presence of thrush and an opportunistic infection such as Cryptococcus suggests that the patient is immunocompromised HIV is a common and treatable cause of immunosuppression in this patient's age group She should be tested for HIV, but initiation of antiretroviral therapy in the setting of acute infection is not recommended due to risk of immune reconstitution syndrome Antiretroviral therapy should be deferred until at least 2-8 weeks after completing induction antifungal therapy fo r cryptococcal meningitis. (Choice D) ltraconazole can be used as an alternate to fluconazole in the treatment of pulmonary cryptococcal infection. However, it does not cross the blood-brain barrier, making it ineffective in central nervous system infection. (Choice E) Sulfadiazine-pyrimethamine is used in the treatment of ce rebral toxoplasmosis, which typically presents with headache, focal neurologic deficits, and/or seizures. Neuroimaging shows multiple ring-enhancing brain lesions with edema. Educational objective: Cryptococcal meningoencephalitis usually develops in patients with advanced HIV disease (CD4 cell count <1 00/IJL) Induction therapy includes amphotericin 8 plus fl ucytosine followed by fluconazole for consolidation and maintenance therapy Serial lumbar punctures may be required to reduce increased intracranial pressure. Antiretroviral therapy should be deferred fo r at least 2 weeks after antifungal therapy is started.
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References: 1. Guidelines for prevention and treatment of opportunistic infections in HIVinfected adults and adolescents. 2. New insights in the prevention, diagnosis, and treatment of cryptococcal meningitis.
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10 A Analgesics, alpha blocker , and baclofen 10 B. Intravenous glucoco rticoids 10 C. Radiation to the spine 10 D. Radionuclide bone scan 10 E. Skeletal survey
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Lab Values
A 75-year-old man is brought to the emergency department with severe back pain that began 3 weeks ago The pain has been significantly worse for the last 12 hours. This morning, the patient also noticed difficulty walking and urinating He has a history of advanced prostate cancer initially treated with local radiation therapy Temperature is 37 C (98 6 F), blood pressure is 122/83 mm Hg, and pulse is 104/min. The patient appears uncomfortable. He has point tenderness over the midline spine near T1 0 and T11. Upper extremity strength and reflexes are normaL Muscle strength in the lower extremities is 3/5 and deep-tendon reflexes are 3+ bilaterally Bilateral plantar reflexes are upgoing Straight urinary catheterization produces 800 ml of urine. W hich of the following is the best initial step in management of this patient?
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Spinal cord compression • Spinal injury (eg, motor vehicle accident) Causes
• Gradually worsening severe local back pain • Pain worse in the recumbent position/at night
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• Malignancy (eg, lung, breast, prostate cancers; myeloma) • Infection (eg, epidural abscess)
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• Early signs: Symmetric lower-extremity weakness, hypoactive/absent deep-tendon reflexes • Late signs: Bilateral Babinski reflex, decreased rectal sphincter tone, paraparesis/paraplegia with increased deep-tendon reflexes, sensory loss
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• Emergency MRI Management
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Lab Values
• Intravenous glucocorticoids • Radiation-oncology & neurosurgery consultations
©UWor1d
This patient with advanced prostate cancer presents with subacute back pain that has now profoundly changed in severity Examination shows lower extremity motor weakness , hyperreflexia, and bladder dysfunction, raising concern for epidural spinal cord compression (ESCC) The thoracic (60%) and lumbosacral (30%) spine are the most common
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profoundly changed in severity Examination shows lower extremity motor weakness, hyperreflexia, and bladder dysfunction, raising concern for epidur al spinal cord compression (ESCC) The thoracic (60%) and lumbosacral (30%) spine are the most common locations for ESCC. Cancers that often metastasize to the spine include lung, breast, and prostate, as well as multiple myeloma
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Early diagnosis of ESCC is crucial in preserving neurologic function; in fact, the primary determinant of outcome is the degree of neurologic involvement at the time of intervention. Pain is typically the first symptom, often present for 1-2 months before additional symptoms appear. Motor findings (bilateral weakness) and ataxia are common as the disease progresses. Bowel and bladder dysfunction are late findings. Although imaging (MRI) plays an important role in the diagnosis of ESCC, intravenous glucocorticoids should be given without delay in a patient with suspected ESCC. Glucocortico ids decrease vasogenic edema (caused by obstructed epidural venous plexus), help alleviate pain, and may restore neurologic function. Once imaging confi rms ESCC, neurosurgical consultation is typically required (Choice A) Analgesics and baclofen are used fo r muscular spasm Alpha blockers may help relieve bladder obstruction from an enlarged prostate. This patient is manifesting signs of significant bilateral motor nerve involvement, making a muscular cause much less likely than a critical neurologic cause . (Choice C) Rad iation to the spine is a useful intervention for painful spinal metastases. It may play a role in this patient's treatment but requires imaging and scheduling. Glucocortico ids should not be delayed (Choices D and E) A radionuclide bone scan and skeletal survey (x-rays of major bones) can detect metastatic bone disease but do not provide useful information about compression of the thecal sac; therefore, they are not recommended for diagnosis of ESCC. In general, glucocorticoids should not be delayed for imaging in this patient as the pretest probability of ESCC is quite high (given patient's neurologic findings, history of prostate cancer , and symptoms)
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Although imaging (MRI) plays an important role in the diagnosis of ESCC, intravenous glucocorticoids should be given without delay in a patient with suspected ESCC. Glucocortico ids decrease vasogenic edema (caused by obstructed epidural venous plexus), help alleviate pain, and may restore neurologic function. Once imaging confi rms ESCC, neurosurgical consultation is typically required {Choice A) Analgesics and baclofen are used fo r muscular spasm Alpha blockers may help relieve bladder obstruction from an enlarged prostate. This patient is manifesting signs of significant bilateral motor nerve involvement, making a muscular cause much less likely than a critical neurologic cause. {Choice C) Rad iation to the spine is a useful intervention for painful spinal metastases. It may play a role in this patient's treatment but requires imaging and scheduling. Glucocortico ids should not be delayed {Choices D and E) A radionuclide bone scan and skeletal survey (x-rays of major bones) can detect metastatic bone disease but do not provide useful information about compression of the thecal sac; therefore, they are not recommended for diagnosis of ESCC. In general, glucocorticoids should not be delayed for imaging in this patient as the pretest probability of ESCC is quite high (given patient's neurologic findings, history of prostate cancer , and symptoms) Educational objective: Epidural spinal co rd compression must be suspected in any patient with a history of malignancy who develops back pain with motor and sensory abnormalities. Bowel and bladder dysfunction are late neurologic findings Intravenous glucocorticoids should be given without delay MRI is then recommended. References: 1. Spinal cor d compression.
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A 45-year-old woman comes to the emergency department due to 3 days of fever , malaise, progressive dyspnea on exertion, dry cough, abdominal pain, and watery diarrhea. Her loose stools this morning were accompanied by bright red blood. The patient underwent allogeneic renal transplantation 6 months ago and is currently taking tacrolimus, mycophenolate, and prednisone Two months ago, she developed severe leukopenia, which resolved after discontinuing trimethoprim-sulfamethoxazole and valganc iclovir. She does not use tobacco, alcohol, or illicit drugs Temperature is 38.9 C (102 F), blood pressure is 110/70 mm Hg, pulse is 11 4/min, and respirations are 22/min. Physical examination shows bilateral lung c rackles and diffuse abdominal tenderness. Gross blood is seen on rectal examination. Laboratory resu~s are as follows: Complete blood count Hematocrit
30%
Platelets
118,000/mm•
Leukocytes
3,800/mm•
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24 mg/dL
Creatinine
1.2 mg/dL
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Live r function studies Total bilirubin
1.3 mg/dL
Alkal ine phosphatase
124 U/L
Aspa rtate aminotransferase
137 U/L
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Serum chem istry
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Blood urea nitrogen
24 mg/dl
Creatinine
1.2 mg/dl
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Total bilirubin
1.3 mg/dl
Alkaline phosphatase
124 U!L
Aspartate aminotransferase
137 U!L
Alanine aminotransferase
11 4UIL
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Urinalysis is normal. Chest x-ray reveals bilateral interstitial infiltrates. Which of the following is the most likely cause of this patient's current condition?
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ID A. Aspergillus fumigatus ID B. Candida albicans ID C. Cryptosporidium
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ID D. Cytomegalovirus
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ID E. Influenza
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ID F. Legionelfa pneumophila ID G. Mycoplasma pneumoniae ID H. Pneumocystis jirovecii Submit
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Explanation: Patients receiving solid organ transplantations require high-dose immunosuppressive medication to prevent organ rejection. This results in systemic immunosuppression, which puts them at risk fo r opportunistic infections, most notably Pneumocystis pneumonia (PCP) and cytomegalovirus (CMV)
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This patient was on prophylaxis fo r PCP (trimethoprim-sulfamethoxazole) and CMV (valganciclovir), but both medications were discontinued 2 months ago due to leukopenia. She now presents with pulmonary symptoms (dyspnea on exertion, dry cough), gastrointestinal symptoms (abdominal pain, diarrhea, hematochezia), pancytopenia, mild hepatitis, and interstitial infiltrates on chest x-ray. This combination of findings strongly suggests tissue-invasive CMV disease (causing pneumonitis, gastroenteritis, and hepatitis) Diagnosis is confirmed by detecting CMV DNA in the blood using polymerase chain reaction ( PCR); tissue biopsy is rarely required Treatment involves discontinuing antimetabolite immunosuppression (eg, mycophenolate) and initiating antiviral ther apy. Intravenous ganciclovir is used fo r patients with severe disease (eg, pneumonitis, meningoencephalitis, high viral loads, significant gastrointestinal disease). Patients with minimal signs and symptoms can take oral valganciclovir. (Choice A) Aspergillosis primarily causes pulmonary disease (fever , pleuritic chest pain, and hemoptysis), although it may involve other organs. Aspe rgillosis tends to cause nodules and focal infiltrates on chest x-ray (not bilateral interstitial infiltrates), and gastro intestinal disease is uncommon. (Choice B) Candida colonizes airways and usually does not cause pneumonia. Gastrointestinal disease is also uncommon. (Choice C) Cryptosporidium causes diarrhea in immunosuppressed patients but usually does not involve the lung (Choice E) Infl uenza typically causes high fever, headache, malaise, and sore throat Pneumonia is a common complication Gastrointestinal disease (colitis), pancytopenia, and hepatitis are uncommon.
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{Choice A) Aspergillosis primarily causes pulmonary disease (fever , pleuritic chest pain, and hemoptysis), although it may involve other organs Aspergillosis tends to cause nodules and focal infiltrates on chest x-ray (not bilateral inte rstitial infiltrates) , and gastro intestinal disease is uncommon. (Choice B) Candida colonizes airways and usually does not cause pneumonia. Gastrointestinal disease is also uncommon. {Choice C) Cryptosporidium causes diarrhea in immunosuppressed patients but usually does not involve the lung. {Choice E) Infl uenza typically causes high fever , headache, malaise, and sore throat Pneumonia is a common complication Gastrointestinal disease (colitis), pancytopenia, and hepatitis are uncommon. (Choice F) Legionella often presents with high fever (> 39 C [ 102.2 F)), gastrointestinal symptoms (eg, diarrhea) , and pulmonary symptoms However, bloody diarrhea is an unusual manifestation of legionellosis and CMV is a far more prevalent infection. If the CMV DNA PCR is negative, other less common causes (eg, Legionella) can be explored
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(Choice G) Mycoplasma causes headache, fever , sore throat, and cough. It typically does not cause gastrointestinal symptoms
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(Choice H) Pneumocystis pneumonia (PCP) is a common infection in solid organ transplant patients who do not receive prophylaxis. PCP presents with pulmonary symptoms (respiratory fa ilure, cough, dyspnea) but typically does not cause gastrointestinal or hepatic issues.
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Educational objective: Patients who receive a solid organ transplant are at risk for opportunistic infections, most notably Pneumocystis pneumonia and cytomegalovirus (CMV). In the absence of prophylaxis, patients who present with a systemic illness involving multiple organ systems (eg, pneumonitis, hepatitis, gastroenteritis) should be tested for CMV viremia. Time Spent 4 seconds
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Sodium
144 mEq/L
Potassium
3.8 mEq/L
Chloride
102 mEq/L
Bicarbonate
24 mEq/L
Blood urea nitrogen
14 mg/dl
Creatinine
0.8 mg/dl
Calcium
11.4 mg/dl
Glucose
146 mg/dl
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A 58-year-old woman undergoing systemic chemotherapy fo r advanced breast cancer with metastases to bone comes to the office for routine follow-up. She has mild, vague bone pain that is relieved by the occasional use of acetaminophen Physical examination shows a well-healed mastectomy scar on the right and a palpable right supraclavicular lymph node. Mucous membranes are moist Laboratory results are as follows:
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Lab Values
Liver function studies Albumin
3.4 g/dl
Which of the following is the best next step in management of this patient?
6 A Bisphosphonate therapy
6 B. Corticosteroid therapy
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Serum chemistry
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Sodium
144 mEq/L
Potassium
3.8 mEq/L
Chloride
102 mEq/L
Bica rbonate
24 mEq/L
Blood urea nitrogen
14 mg/dl
Creatinine
0.8 mg/dl
Calcium
11.4 mg/dl
Glucose
146 mg/dl
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25
3.4 g/dl
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W hich of the following is the best next step in management of this patient?
<0 A Bisphosphonate therapy <0 B. Corticosteroid therapy <0 C. Loop diuretics <0 D. Opioid therapy <0 E. Radiation therapy Submit
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C. Loop diuretics [10%) D. Opioid therapy [4%) E. Radiation therapy [21%) Explanation: This patient presents with mild hypercalcem ia in the setting of metastatic breast cancer to bone. Asymptomatic or mild hypercalcemia (calcium <12 mg/dL) does not require urgent therapy, but hypercalcem ia of malignancy may worsen over time. Bisphosphonates (eg, zoledronic acid) inhibit the osteoclastic activity of bone, stabilizing destructive bony tumors and reducing the risk of skeletal- related events such as pathologic fracture and malignant hypercalcemia. {Choice B) Corticosteroids are useful for hype rcalcem ia related to granulomatous disease as they reduce calcitriol release from activated mononuclear cells. However , they are not effective in hypercalcemia of malignancy, which operates via diffe rent mechanisms.
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{Choice C) Loop diuretics can be used in patients who have moderate or severe hypercalcemia with volume overload from heart fa ilure or renal insufficiency, but these drugs are not recommended fo r routine use otherwise.
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(Choice D) Opioids are the fi rst-line treatment for metastatic bone pain that is not adequately controlled by acetaminophen or nonsteroidal anti-inflammatory drugs This patient is currently achieving adequate pain relief with acetaminophen; therefore, additional pain control is unnecessary. (Choice E) Radiation therapy can treat moderate to severe pain caused by bone metastases. However , it would not be indicated at this time because this patient only has mild pain. Educational objective: Bisphosphonates (eg, zoledronic acid, pamidronate) are the drugs of choice for stabilizing bony metastatic lesions to prevent hypercalcemia of malignancy and pathologic fractures. Time Spent 3 seconds
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Hemoglobin
11.5 g/dL
Mean corpuscular volume
88fL
Platelets
160,000/pL
Leukocytes
7,500/pL
Segmented neutrophils
68%
Bands
1%
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Eosinophils
1%
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Lymphocytes
24%
Monocytes
6%
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A 64-year-old man undergoes an emergency colonic resection for extensive ischemic colitis. He lives alone and consumes large amounts of alcohol. His family history is noncontributory The patient is extubated on the 4th postoperative day. After extubation, he has episodes of confusion and agitation treated with lorazepam and haloperidol. He is also receiving piperacillin with tazobactam. The patient has had nothing by mouth since the surgery. On postoperative day 7, the nurse notices bleeding from a venipuncture site. His temperature is 36.7 C (98 F), blood pressure is 121/76 mm Hg, pulse is 80/min, and respirations are 16/min. Laboratory results are as follows:
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Prothrombin time
24 sec (INR 2 2)
Partial thromboplastin time
44 sec (normal 25-40)
Wh ich of the following is the most likely cause of this patient's current condition? e')
A Acute disseminated intravascular coagulation
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Mean corpuscular volume
88fl
Platelets
160,000/IJL
Leukocytes
7,500/IJL
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Segmented neutrophils
68%
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Bands
1%
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Eosinophils
1%
Lymphocytes
24%
Monocytes
6%
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Prothrombin time
24 sec (INR 2 2)
Partial thromboplastin time
44 sec (normal 25-40)
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Which of the following is the most likely cause of this patient's current condition?
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ID A. Acute disseminated intravascular coagulation ID B. Factor V Leiden ID C. Factor VIII deficiency ID D. Hypersplenism ID E. Lupus anticoagulant I!)
F. Thrombotic thrombocytopenic purpura
ID G. Vitamin K deficiency ID H. von Willebrand disease Submit
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Explanation: This patient's cl inical presentation suggests an acquired bleeding disorder, most likely due to vitamin K deficiency Vitamin K is a fat-soluble vitamin that plays an important role in hemostasis by serving as a cofactor in the enzymatic carboxylation of glutamic acid residues on prothrombin complex proteins The body obtains vitamin K exogenously from intestinal absorption of dietary Vitamin K and endogenously from bacterial production of vitamin K in the intestine. Vitamin K deficiency is most commonly due to inadequate dietary intake, intestinal malabsorption, or hepatocellular disease causing loss of storage sites. The live r can normally store a 30-day supply of vitamin K, but an acutely ill person with underlying liver disease can become vitamin K deficient in as little as 7-10 days. This patient received no enteral nutrition postoperatively and was given a broad-spectrum antibiotic , and so both natural sources of vitamin K were comp romised. In addition, he also likely has alcoholic liver disease, further limiting his vitamin K stores. Vitamin K deficiency decreases plasma levels of all the prothrombin complex proteins (factors 2, 7, 9, 10, and protein C and S) This initially inc reases the prothrombin time ( PT), followed by prolongation of the partial thromboplastin time (PTI) Administration of vitamin K rapidly replenishes the stores in 8-10 hours, and fresh frozen plasma may be used for the management of acute hemorrhage in the interim. (Choice A) Disseminated intravascular coagulation causes depletion of clotting factors and secondary fib rinolysis. This causes bleeding, acute kidney and liver injury, hypotension, and tachycardia Testing shows thrombocytopenia, prolonged PT and PTI, decreased fibrinogen, and schistocytes on peripheral smear. Although this patient's PT and PTI are prolonged, he is hemodynamically stable and has a normal platelet count (Choices B and E) Lupus anticoagulant (LAC) is an antiphospholipid antibody that prolongs the PTI during diagnostic testing However, patients with LAC are actually hypercoagulable with increased risk for venous thrombosis. Factor V Leiden causes a hypercoagulable state due to activated protein C resistance. This patient's inc reased bleeding makes these unlikely . (Choice C) Factor VIII deficiency is an X-linked inherited plasma coagulation disorder that
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(Choice A) Disseminated intravascular coagulation causes depletion of clotting factors and secondary fibrinolysis. This causes bleeding, acute kidney and liver inj ury, hypotension, and tachyca rdia. Testing shows thrombocytopenia, prolonged PT and PTI, decreased fibrinogen, and schistocytes on peripheral smear. Although this patient's PT and PTI are prolonged, he is hemodynamically stable and has a normal platelet count (Choices B and E) Lupus anticoagulant (LAC) is an antiphospholipid antibody that prolongs the PTI during diagnostic testing However , patients with LAC are actually hypercoagulable with inc reased risk for venous thrombosis. Factor V Leiden causes a hype rcoagulable state due to activated protein C resistance. Thi s patient's increased bleeding makes these unlikely (Choice C) Factor VIII deficiency is an X-linked inherited plasma coagulation disorder that primarily prolongs the PTI. It would usually be apparent earlier in life. (Choice D) Hypersplenism can occur in patients with cirrhosis, portal hype rtension, and splenomegaly Splenic sequestration leads to thrombocytopenia, and patients rarely develop clinical bleeding or prolonged PT/ PTI. (Choice F) Thrombotic thrombocytopenic purpura is a rare fo rm of consumptive thrombocytopenia caused by widespread platelet thrombi that form in the microcirculation. It typ ically presents with thrombocytopenia, microangiopathic hemolytic anemia, fever , and neurologic findings ( eg, altered mental status) (Choice H) von W illebrand disease is the most frequently diagnosed inherited bleeding disorder in adults. Laboratory testing usually shows increased bleeding time and PTI. However , the PT will be normaL Educational objective: Vitamin K deficiency is usually due to inadequate dietary intake, intestinal malabsorption, or hepatocellular disease. An acutely ill patient with underlying liver disease can become vitamin K deficient in 7-10 days Laboratory studies usually show prolonged prothrombin time followed by prolonged partial thromboplastin time. Time Spent 4 seconds
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e A Cryptococcal antigen testing of cerebrospinal fluid e B. Cytomegalovirus lgG e C. Herpes simplex virus-1 polymerase chain reaction (PCR) of cerebrospinal fluid e D. JC virus PCR of cerebrospinal fluid e E. Serum Toxoplasma gondii antibody Submit
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Lab Values
A 38-year-old woman comes to the emergency department with 7 days of fatigue and headache that has worsened in intensity today She also reports an episode of vom iting The patient is accompanied by her roommate, who has noted no confusion or personality changes On physical examination she is awake, alert, and conve rsant Her temperature is 38.3 C (101 F) and pulse is 84/min. Her neck is supple Oropharynx examination shows thrush. Lungs and cardiovascular examination is normal. Neurological examination shows no focal deficits. Ophthalmological examination shows bilateral papilledema. An MRI of the brain is normal. A rapid HIV test is positive W hich of the following is most likely to establish a diagnosis?
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Explanation:
Cryptococcal meningoencephalitis
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Presentation
Diagnosis
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• Headache, fever & malaise • Develops over 2 weeks (subacute) • Can be more acute & severe in HIV
Cerebrospinal fluid • High opening pressure • Low glucose, high protein • White blood cells <50/IJL with mononuclear predominance • Transparent capsule seen with India ink stain • Cryptococcal antigen positive • Culture on Sabouraud agar
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Treatment
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Initial • Amphotericin B with flucytosine Maintenance • Fluconazole
@USMlEWorld, LLC
The patient presents with fevers, headaches, and signs of elevated intrac ranial pressure (papilledema) In immunocompromised patients with HIV, this is most consistent with cryptococcal meningitis Typically it is seen in patients with CD4 counts <100/IJL. Cryptococcus neoformans is an invasive fungus acquired by the inhalation of spores that primarily causes pulmonary disease. lmmunocompromised patients can develop central nervous system infection I d. • t • •h IT
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neoformans is an invas ive fungus acquired by the inhalation of spores that primarily causes pulmonary disease. lmmunocompromised patients can develop central nervous system infection leading to meningoencephalitis Diagnosis is established through cryptococcal antigen testing of ce rebrospinal fluid (CSF) CSF India Ink stain or culture on Sabouraud agar may also identify the organism Other features include an elevated opening pressure, low glucose, high protein, and a lymphocytic pleocytosis (although white cells may be reduced in HIV patients) Increased intracranial pressure develops due to the occlusion of CSF flow by the organism Neuroimaging is performed to exclude mass lesions. A lumbar puncture is not contraindicated in the absence of mass lesions and offers therapeutic value in the relief of elevated intracranial pressure. {Choice B) Cytomegalovirus typically causes retinitis in patients with HIV who have CD4 counts <50/IJL Papilledema is usually not seen and MRI may show periventricular enhancement (Choice C) Herpes simplex virus 1 (HSV-1) infection can cause encephalitis in both immunocompetent and immunocompromised patients. Cognitive and personality changes, as well as focal neurological deficits and/or seizures, are more common in HSV infection due to the temporal lobe involvement (seen on MRI) Absence of these features suggests c ryptococcal meningoencephalitis as the more likely diagnosis in this patient
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(Choice D) JC virus causes progressive multifocal leukoencephalopathy , an opportunistic infection seen in patients with HIV that can be detected on polymerase chain reaction testing of cerebrospinal fluid. Neuroimaging usually shows patchy areas of white matter consistent with demyelination (Choice E) Serum toxoplasma antibody tests fo r prior exposure to Toxoplasma gondii Reactivation of T gondii in patients with A IDS most commonly presents with a ring-enhancing mass lesion seen on neuroimaging Educational objective: Patients with HIV who have subacute-onset of low-grade feve r, headache, and signs of inc reased intracranial pressure should be evaluated for cryptococcal meningitis Diagnosis is established by detection of the cryptococcal antigen or isolation of the organism in cerebrospinal fluid.
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0 A. Coronary artery spasm 0 B. Costochondritis
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0 C. Diffuse esophageal spasm
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0 E. Globus sensation (hystericus)
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A 50-year-old woman comes to the office with a several-month history of intermittent, substernal chest pain Her pain is not related to activity, does not radiate, and occurs in episodes lasting from a few seconds to a few minutes. During the episodes, she has difficulty swallowing both liquids and solids. She has no associated weight loss or change in appetite The patient was recently seen in the emergency department due to sudden worsening of the pain; her evaluation included a normal ECG, normal cardiac biomarke rs, and a negative myocardial perfusion scan. Past medical history is notable fo r hypertension, for which she takes chlorthalidone. The patient does not use tobacco, alcohol, or illicit drugs Vital signs are normal. Physical examination and upper gastrointestinal endoscopy reveal no abnormalities. W hich of the following is the most likely diagnosis?
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E. Globus sensation (hystericus) (4%)
F. Zenke r diverticulum [0%) Explanation:
Diffuse esophageal spasm Pathophysiology
• Uncoordinated, simultaneous contractions of esophageal body
Symptoms
• Intermittent chest pain • Dysphagia for solids & liquids
Diagnosis
• Esophagram: "Corkscrew" pattern • Manometry: Intermittent peristalsis, multiple simultaneous contractions
Treatment
• Calcium channel blockers • Alternate: Nitrates, tricyclics
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©UW011d
This patient with intermittent non-cardiac chest pain and dysphagia has typical symptoms of diffuse esophageal spasm (DES) DES is characterized by uncoordinated, simultaneous contractions of the esophageal body, likely related to impaired inhibitory innervation in the esophagus. DES is frequently seen in association with emotional factors and functional gastrointestinal disorders. Symptoms often resemble those in achalasia (impaired esophageal motility with incomplete relaxation at the lower esophageal sphincter) and nutcracker esophagus
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gastrointestinal disorders. Symptoms often resemble those in achalasia (impaired esophageal motility with incomplete relaxation at the lower esophageal sphincter) and nutcracker esophagus (excessive tone at the lower esophageal sphincter) . The diagnosis of DES is challenging due to the episodic nature of clinical features. Esophageal manometry reveals intermittent peristalsis and multiple simultaneous contractions of the middle and lower esophagus. The lower esophageal sphincter usually shows normal relaxation. Esophagram may show nonperistaltic contractions producing a "corkscrew esophagus" pattern , although this is neither sensitive nor specific Endoscopy is usually normal. First-line treatment includes calcium channel blockers (eg, diltiazem), which relieve pain and reduce dysphagia. (Choice A) Variant (Prinzmetal) angina is due to coronary artery spasm Typical symptoms include episodic chest pain at rest Patients may have normal ECG findings between attacks, with variable ST abnormalities during acute events. Variant angina does not explain the patient's dysphagia (Choice B) Costosternal syndrome (costochondritis) usually occurs after repetitive activity It is characterized by pain that is reproducible with palpation and worsened with movement or position changes. It would not cause dysphagia (Choice D) Eosinophilic esophagitis is characterized by food impaction, dysphagia, or heartburn that does not respond to standard medications. Endoscopy usually reveals esophageal rings or strictures. (Choice E) Globus sensation is a functional disorder of the esophagus characterized by the sensation of a foreign body in the throat It is often worse when swallowing saliva and is frequently associated with anxiety Pain, dysphagia, dysphonia, or systemic symptoms are not typical for globus and suggest another condition. (Choice F) Zenker diverticulum is a disorder of the proximal esophagus and is generally asymptomatic , although it can cause a sensation of food sticking in the throat, halitosis, and regurgitation. Chest pain is not a typical symptom Educational objective:
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include episodic chest pain at rest Patients may have normal ECG findings between attacks, with variable ST abnormalities during acute events. Variant angina does not explain the patient's dysphagia (Choice B) Costosternal syndrome (costochondritis) usually occurs after repetitive activity It is characterized by pain that is reproducible with palpation and worsened with movement or position changes It would not cause dysphagia. (Choice D) Eosinophilic esophagitis is characterized by food impaction, dysphagia, or heartburn that does not respond to standard medications. Endoscopy usually reveals esophageal rings or strictures. (Choice E) Globus sensation is a functional disorder of the esophagus characterized by the sensation of a foreign body in the throat It is often worse when swallowing saliva and is frequently associated with anxiety Pain, dysphagia, dysphonia, or systemic symptoms are not typical for globus and suggest another condition.
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(Choice F) Zenker diverticulum is a disorder of the proximal esophagus and is generally asymptomatic, although it can cause a sensation of food sticking in the throat, halitosis, and regurgitation Chest pain is not a typical symptom
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Educational objective: Diffuse esophageal spasm is characterized by uncoordinated contractions of the esophagus and presents with chest pain and dysphagia Esophageal manometry reveals multiple simultaneous contractions of the middle and lower esophagus Esophagram may show a "corkscrew" pattern First-line treatment incl udes calcium channel blockers. References: 1. Physiology of diffuse esophageal spasm (DES)--when normal swallows are not normal.
Time Spent 2 seconds
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A 42-year-old woman comes to the office in October fo r a hospital follow-up She has occasional fatigue but is otherwise feeling well. The patient was hospitalized 3 weeks ago for abdominal swelling but cannot remember all the details of her ca re. She was started on lactulose, spironolactone, and furosemide with some improvement in her symptoms. The patient drank 12 beers daily for 15 years but has been sober for the last 3 months. She does not use tobacco or illicit drugs The patient received all appropriate childhood vaccines and a tetanus-diphtheria toxoid booster following a traumatic injury at age 31 ; she does not recall receiving any other vaccines since then. Physical examination shows mild jaundice, palmar erythema, a slightly distended abdomen, and spider angiomata Serologies are as follows: Hepatitis A lgM
negative
Hepatitis A lgG
negative
Hepatitis B surface antigen
negative
Anti-hepatitis B surface antibody
negative
Hepatitis C antibody
negative
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W hich of the following immunizations are recommended for this patient? HAV = hepatitis A vaccine HBV = hepatitis B vaccine PCV13 = 13-valent pneumococcal conjugate vaccine PPSV23 = 23-valent pneumococcal polysaccharide vaccine Tdap = tetanus-diphtheria-acellular pertussis vaccine 1D A. HAV, HBV, and Tdap 1D B. HAV, HBV, infl uenza, and PPSV23 1D C. HAV, HBV, infl uenza, PCV13, and Tdap
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Hepatitis A l.gG
negative
Hepatitis 8 surface antigen
negative
Anti-hepatitis 8 surface antibody
negative
Hepatitis C antibody
negative
Which of the following immunizations are recommended for this patient? HAV = hepatitis A vaccine HBV = hepatitis 8 vaccine PCV13 = 13-valent pneumococcal conjugate vaccine PPSV23 = 23-valent pneumococcal polysaccharide vaccine Tdap = tetanus-diphtheria-acellular pertussis vaccine
<0 A HAV, HBV, and Tdap
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<0 D. HAV, HBV, infl uef'Za, PPSV23, and Tdap
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negative
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beers daily fo r 15 yea rs but has been sober for the last 3 months. She does not use tobacco or illicit drugs. The patient received all appropriate childhood vaccines and a tetanus-diphtheria toxoid booster following a traumatic injury at age 31 ; she does not recall receiving any other vaccines since then. Physical examination shows mild jaundice, palmar erythema, a slightly distended abdomen, and spider angiomata. Serologies are as follows :
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<0 B. HAV, HBV, influenza, and PPSV23 <0 C. HAV, HBV, infl uenza, PCV13, and Tdap <0 E. Influenza, PPSV23, and Tdap Submit
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Explanation:
Recommended vaccines for chronic liver disease Tdap!Td
Tdap once as substitute for Td booster, then T d every 10 years
Influenza
Annually
Pneum ococcal vaccines
PPSV23 once, then revaccination with sequential PCV13 & PPSV23 at age 65
Hepatitis A
2 doses 6 months apart with initial negative serologies
Hepatitis B
3 doses at 0 months, 1 month & at least 4 months with initial negative serologies
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PCV13 = 13-valent pneumococcal conjugate vaccine; PPSV23 = 23-valent pneumococcal polysaccharide vaccine; Td = tetanus-diphtheria toxoid booster; Tdap = tetanus-diphtheria-acellular pertussis. @UWorld
This patient has cl inical features consistent with cirrhosis along with risk factors for chronic live r disease (alcohol abuse) Patients with chronic live r disease require immunizations similar to the general population as well as additional disease-specific vaccines. Influenza vaccine is recommended annually in all adults (Choice A) The intramuscular inactivated influenza vaccine appears to be more effective than the live attenuated intranasal
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9
years Adults should also receive the tetanus-diphther ia-acellular pertussis (Tdap) vaccine as a one-time dose in place of Td. If a patient has not received Tdap as an adult, or if the prior vaccine history is unknown, the US Centers for Disease Control and Prevention (CDC) recommends that Tdap be given, followed by Td every 10 yea rs thereafter. This patient is not confi rmed to have had Tdap and would need the one-time dose before resuming Td every 10 yea rs (Choice B)
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Sequential vaccination with the 13-valent pneumococcal conjugate vaccine (PCV13) followed (at a later time) by the 23-valent pneumococcal polysaccharide vaccine (PPSV23) is recommended for all adults age ~65 and for those age <65 with certain very high-risk comorbid conditions (eg, cerebrospinal fluid leaks, sickle cell disease, cochlear implants, congenital or acquired asplenia, immunocompromised patients) For adults age <65 with other chronic medical conditions that inc rease the risk of invasive pneumococcal disease (eg, heart or lung disease, diabetes, smoking, chronic live r disease), PPSV23 alone is recommended, followed by sequential PCV13 and PPSV23 at age 65 (Choice C)
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Patients with chronic live r disease who contract viral hepatitis are at increased risk for compl ications For this reason, they should receive vaccination against hepatitis A and B unless they have documented evidence of immunity The hepatitis A vaccine (HAV) is given as a series of 2 doses, and the hepatitis 8 vacc ine (HBV) in 3 doses. Because this patient's hepatitis serologies do not indicate immunity, HAV and HBV vaccines should be administered {Choice E). Educational objective: Patients with chronic liver disease require immunizations similar to the general population as well as additional disease-specific vaccines, incl uding hepatitis A and 8 vaccines as well as the 23valent pneumococcal polysaccharide vaccine. References: 1. Advisory committee on immunization practices recommended immunization schedule for adults aged 19 years or older: United States, 2014.
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0 A Asp irin e; B. Clopidogrel
0 C. Heparin
o o
D. Simvastatin E. Warfarin
Submit
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Lab Values
A 42-year-old mildly overweight man is being evaluated for his second episode of deep vein thrombosis in 2 years Both episodes appear to have been unprovoked . He has no recent prolonged immobility , long-distance travel, or lower-extremity trauma. The patient has no past medical history of diabetes, cancer , or liver disease. A thrombophilia workup is ordered. Use of which of the following drugs is most likely to lead to low protein S levels?
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Anticoagulants & their mechanism of action !Intrinsic pathway
I
IExtrinsic pathway I
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XII
--111~
Tissue factor
IXIIa I
~
lI
XI --111~
IJI ----4~ lvua
Xla
I
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lEI-----.
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Factor Xa inhibitors
24
Direct • Rivaroxaban (oral) • Apixaban (oral) Indirect • Fondaparinux
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Areas of intervention: Direct thrombin inhibitors
Cl Heparins •
Vitamin K antagonists
•
Direct thrombin inhibitors
•
Factor Xa inhibitors
(Thrombin)
• Argatroban • Bivalirudin • Dabigatran (oral)
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Areas of intervention: Direct thrombin inhibitors
Cl Heparins •
Vitamin K antagonists
•
Direct thrombin inhibitors
•
Factor Xa inhibitors
~UWorld
• Argatroban • Bivalirudin • Dabigatran (oral)
(Thrombin)
Fibrinogen
~
Fibrin
Warfarin is a coumarin anticoagulant most commonly used in the setting of thrombophilia and ca rdiac conditions that predispose to intracardiac thrombus formation. Warfarin functions by inhibiting synthesis of the vitamin K-dependent clotting factors II, VII, IX, and X, as well as the vitamin K-dependent anticoagulant proteins C and S. As a result, it can cause a decrease in measured levels of protein S. This may lead to an incorrect diagnosis of inherited protein S deficiency If possible, vitam in K antagonists such as warfarin should be discontinued for 2 weeks prior to evaluating protein S levels. (Choice A) Asp irin is an antiplatelet agent that inhibits cyclooxygenase-1 , thereby inhibiting thromboxane A, synthesis. (Choice B) Clopidogrel is an antiplatelet agent that prevents platelet activation by blocking adenosine diphosphate receptors on the surface of platelets (Choice C) Heparin activates antithrombin Ill, which in turn inactivates factor I Ia (thromb in), factor IXa, and factor Xa. {Choice D) Simvastatin is a lipid-lowering agent that functions by inhibiting 3-hyd roxy-3-methylglutaryl-coenzyme reductase. Educational objective: Warfarin is an anticoagulant agent that functions by inhibiting the synthesis of vitamin K-dependent facto rs II, VII, IX, and X , protein C, and protein S.
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Fibrinogen ----t~ Fibrin
Warfarin is a coumarin anticoagulant most commonly used in the setting of th rombophilia and cardiac conditions that predispose to intracardiac thrombus fo rmation. Warfarin functions by inhibiting synthesis of the vitamin K-dependent clotting factors II, VII, IX, and X, as well as the vitamin K-dependent anticoagulant proteins C and S. As a result, it can cause a decrease in measured levels of protein S. This may lead to an inco rrect diagnosis of inherited protein S deficiency If possible, vitamin K antagonists such as warfarin should be discontinued for 2 weeks prior to evaluating protein S levels. (Choice A) Aspirin is an antiplatelet agent that inhibits cyclooxygenase-1 , thereby inhibiting thromboxane A, synthesis {Choice B) Clopidogrel is an antiplatelet agent that prevents platelet activation by blocking adenosine diphosphate receptors on the surface of platelets.
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(Choice C) Heparin activates antithrombin Ill, wh ich in turn inactivates factor I Ia (thrombin), factor IXa, and factor Xa.
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{Choice D) Simvastatin is a lipid-lowering agent that functions by inhibiting 3-hydroxy-3-methylglutaryl-coenzyme reductase. Educational objective: Warfarin is an anticoagulant agent that functions by inhibiting the synthesis of vitamin K-dependent factors II, VII, IX, and X , protein C, and protein S. References: 1. Pitfalls in special coagulation testing: three illustrative case studies. 2. Protein S abnormalities: a diagnostic nightmar e.
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8.9 g/dL
Platelets
134,OOOfi.IL
Total bilirubin
6.3 mg/dL
Lactate dehydrogenase
740 U/L
Haptoglobin
30 mg/dL (50-150 mg/dL)
Further workup, including MRI of the abdomen, shows hepatic vein thrombosis. Which of the following is the most likely diagnosis? e')
A Acute intermittent porphyria
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0 B. Aplastic anemia
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0 D. Hereditary spherocytosis
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6 E. Paroxysmal nocturnal hemoglobinuria
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Hemoglobin
22 24
A 43-year-old woman comes to the emergency department with abdominal pain and dark urine. Physical examination shows right upper-quadrant tenderness without guarding or rebound. Laboratory results are as follows
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Explanation:
Clinical features of paroxysmal nocturnal hemoglobinuria
Clinical manifestations
• Hemolysis -? fatigue • Cytopenias (impaired hematopoiesis) • Venous thrombosis (intraabdominal, cerebral veins)
Workup
• Complete blood count (hypoplastic/aplastic anemia, thrombocytopenia, leukopenia) • Elevated lactate dehydrogenase & low haptoglobin (hemolysis) • Indirect hyperbilirubinemia • Urinalysis (h emoglobinuria) • Flow cytometry (absence of CD55 & CD59)
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Treatment
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• Iron & folate supplementation • Eculizumab (monoclonal antibody that inhibits complement activation)
@USMLEWorld, UC
The most likely diagnosis in this case is paroxysmal nocturnal hemoglobinuria (PNH). PNH is an autoimmune hemolytic disorder characterized by intravascular and extravascular hemolysis and hemoglobinuria The disease is due to an acquired genetic defect that results in lack of the glycosylphosphatidylinositol anchor, which connects proteins, including CD55 and CD59, to the cell surface. These proteins normally inhibit the activation of complement on red blood cells, but their absence allows the complement membrane attack complex to form and results in hemolysis
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CD59, to the cell surface . These proteins normally inhibit the activation of complement on red blood cells, but their absence allows the complement membrane attack complex to form and results in hemolysis On average, patients have manifestations in the fourth decade of life resulting from one of the following 1. Hemolysis leading to hemoglobinuria 2. Cytopenias- fatigue and dyspnea from anemia 3. Hyper coagulable state (eg, portal vein th rombosis) - acute abdominal pain that may be due to severe hemolys is or portal vein thrombosis This patient's anemia and low haptoglobin accompanied by elevated bilirubin and lactate dehydrogenase (LDH) are all consistent with intravascular hemolysis. The key to the diagnosis is the patient's hepatic vein thrombosis in conjunction with these signs of hemolysis. Patients with autoimmune hemolytic anemia have a tendency fo r venous thromboembolism, but those with PNH are at particular risk, especially within intraabdominal or cerebral veins. Flow cytometry tests are used to confirm the diagnosis by assessing for the absence of the CD55 and CD59 proteins on the surface of the red blood cells.
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{Choice A) Acute intermittent porphyria may also present with abdominal pain and dark red/brown urine. However , the pigmented urine is due to porphyrins and/or porphyrin precursors (not hemoglobinuria) , and hematologic abnormalities and thromboembolism are rare. {Choice B) The elevated LDH and bilirubin accompanied by the low haptoglobin make a hemolytic anemia much more likely than an aplastic anemia. {Choice C) G6PD deficiency can cause hemolytic anemia but is more common in male patients, particularly those of African descent Patients are generally asymptomatic when there is no anemia, but disease can be triggered by medications or infections. Venous thrombosis is unlikely {Choice D) Symptomatic hereditary spherocytosis would likely have led to some symptoms in this patient before age 43, and it is not usually associated with venous thromboses .
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autoimmune hemolytic anemia have a tendency for venous thromboembolism, but those with PNH are at particular risk, especially within intraabdominal or ce rebral ve ins. Flow cytometry tests are used to confirm the diagnosis by assessing for the absence of the CD55 and CD59 proteins on the surface of the red blood cells. (Choice A) Acute intermittent porphyria may also present with abdominal pain and dark red/brown urine. However, the pigmented urine is due to porphyrins and/or porphyrin precursors (not hemoglobinuria), and hematologic abnormalities and thromboembolism are rare. (Choice B) The elevated LDH and bilirubin accompanied by the low haptoglobin make a hemolytic anemia much more likely than an aplastic anemia. (Choice C) G6PD deficiency can cause hemolytic anemia but is more common in male patients, particularly those of African descent Patients are generally asymptomatic when there is no anemia, but disease can be triggered by medications or infections. Venous thrombosis is unlikely. (Choice D) Symptomatic hereditary spherocytosis would likely have led to some symptoms in this patient before age 43, and it is not usually associated with venous th romboses . Educational objective: Paroxysmal nocturnal hemoglobinuria should be suspected in patients who have a combination of hemolytic anemia, cytopenias, and hypercoagulable state (intraabdominal or cerebral venous thrombosis) Flow cytometry tests are used to confirm the diagnosis by assessing for absence of the CD55 and CD59 proteins on the surface of red blood cells. References: 1. Baseline characteristics and disease burden in patients in the International Paroxysmal Nocturnal Hemoglobinuria Registry. 2. Thrombosis in paroxysmal nocturnal hemoglobinuria.
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An 18-year-old man is undergoing evaluation for a 4-day history of fatigue, malaise, fever, and sore throat. The patient plays rugby for his college and missed several days of practice His temperature is 38.8 C (101 F), blood pressure is 135/70 mm Hg, pulse is 90/min, and respirations are 18/min. Physical examination shows ce rvical lymphadenopathy , pharyngeal hyperemia, and mild splenomegaly A rapid streptococcal antigen test is negative and a heterophile antibody test is positive. W hich of the following is the most appropriate recommendation for this patient?
A You can return to school and sports after
e
~24
hours of antibiotics
B. You can return to school and sports when your symptoms subside
® C. You should refrain from playing sports for
~3
weeks
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e; D. You should refrain from playing sports until your heterophile antibody test is negative
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® E. You should refrain from playing sports until your physical examination is normal
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Infectious mononucleosis
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Etiology
Epstein-Barr virus most common
Clinical features
• • • • •
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Diagnostic findings
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Fever Tonsillitis/pharyngitis +/- exudates Posterior or diffuse cervical lymphadenopathy Significant fatigue +/- Hepatosplenomegaly
• Positive heterophile antibody (Monospot) test (25% false negative rate during first week of illness) • Atypical lymphocytosis • Transient hepatitis
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Management
Avoid contact sports for ;::3 weeks due to the risk of splenic rupture
CVUWorld
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Infectious mononucleosis (IM) has a wide spectrum of severity, with most patients experiencing high fever , pharyngitis, adenopathy, and exhaustion. Splenomegaly is seen in more than half of patients, and splenic ruptu re is a rare but potentially dangerous complication that is most likely to occur in male patients within 3 weeks of symptom onset Manifestations of splenic rupture include abdominal pain and anemia.
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All athletes should refrain from playing sports for 2!3 weeks until all symptoms resolve. As the spleen may not be palpable until it is 2-3 times the normal size, physical examination (Choice E) is not a reliable indicator of resolution. In addition, splenic palpation and percussion is
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All athletes should refrain from playing sports for ~3 weeks until all symptoms resolve. As the spleen may not be palpable until it is 2-3 times the normal size, physical examination (Choice E) is not a reliable indicator of resolution. In addition, splenic palpation and percussion is particularly unreliable in athletes with firm abdominal musculature. Ultrasonographic measurement of the spleen can be considered fo r return to play in athletes participating in strenuous sports (eg, basketball, diving, football , gymnastics, hockey, lacrosse, rugby, wrestling) or activities that increase intraabdominal pressure (eg, weightlifting) (Choice A) Patients with streptococcal pharyngitis are not contagious after 24 hours of antibiotics. However, streptococcal pharyngitis does not usually cause splenomegaly or significant fatigue In addition, antibiotics are not used in IM as it is caused by a virus. Antibiotics can also cause a maculopapular rash in patients with IM. (Choice B) Patients with IM should refrain from sports for at least ~3 weeks regardless of symptoms, as this is the period of highest risk for splenic rupture. In addition, most patients with IM experience prolonged fatigue and some take months to return to normal energy leveL (Choice D) Epstein-Barr virus (EBV) heterophile antibodies peak 2-6 weeks after primary EBV infection and can remain positive for up to 1 yea r This test is useful for diagnosis but irrelevant for return to play guidelines
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Educational objective: Patients with infectious mononucleosis are at risk fo r splenic rupture. Sports, especially those involving significant contact, should be avoided fo r ~3 weeks. Splenomegaly can be difficult to palpate in athletic patients with firm abdominal musculature. References: 1. Return to play after infectious mononucleosis. 2. Common questions about infectious mononucleosis.
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White blood cells
5,500/IJL
Hemoglobin
7.0 g/dl
Hematocrit
22%
Platelets
196,000/IJL
Red blood cells
1.7 million
Mean corpuscular volume
114 fL
Mean corpuscular hemoglobin
36 pg/cell
Reticulocytes
0.4%
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A 50-year-old man comes to the physician complaining of feeling fatigued and weak for a year. He becomes tired early in the day and also finds it difficult to remember things. He is currently unemployed and lives on Social Security benefits. The patient says that he drinks 2-3 beers a day but has been charged multiple times with driving under the influence. His parents died of old age He lives with 4 friends. His vital signs are within normal limits. Laboratory results are as follows:
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Peripheral smear shows anisocytosis, poikilocytosis, and basophilic stippling Which of the following is the best next step in management of this patient? e')
A Blood lead levels
6 B. Bone marrow biopsy 6 C. Direct antiglobulin test 6 D. I ron studies e') E. Serum B12 and folate levels
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He becomes tired early in the day and also finds it difficult to remember things. He is currently unemployed and lives on Social Security benefits. The patient says that he drinks 2-3 beers a day but has been charged multiple times with driving under the influence. His parents died of old age He lives with 4 friends. His vital signs are within normal limits. Laboratory results are as follows:
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W hite blood cells
5 ,500/~L
Hemoglobin
7.0 g/dl
Hematocrit
22%
Platelets
196 ,000/~L
Red blood cells
1.7 million
Mean corpuscular volume
11 4 fL
Mean corpuscular hemoglobin
36 pg/cell
Reticulocytes
0.4%
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Peripheral smear shows anisocytosis, poikilocytosis, and basophilic stippling W hich of the following is the best next step in management of this patient?
<0 A Blood lead levels <0 B. Bone marrow biopsy <0 C. Direct antiglobulin test <0 D. Iron studies <0 E. Serum B12 and folate levels Submit
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Acute myeloid leukemias Drug-induced (eg, hydroxyurea, zidovudine, Liver disease
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Alcohol abuse
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Hypothyroidism
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€> V SMLEV1<>~1<1. LLC
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Myelodysplastic syndromes
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Vitamin 812 deficiency
chemotherapy agents)
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Folate deficiency
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Common causes of macrocytic anemia (MCV > 100 fl)
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Explanation:
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This patient's presentation is consistent with macrocytic anemia, wh ich is usually confirmed by abnormal red blood cell (RBC) indices (elevated mean corpuscular volume [MCV]. elevated mean corpuscular hemoglobin, and normal mean corpuscular hemoglobin concentration) Macrocytic anemia can be due to megaloblastic (eg, impaired DNA synthesis due to 812 or folate deficiency) or non-megaloblastic (eg, alcoholism, hypothyroidism, drugs, liver disease) etiologies The next step is examining the peripheral blood smear and measuring the reticulocyte count. Megaloblastic anemia is typically associated with MCV >1 10 fl, low reticulocyte count, macroovalocyte RBCs, hypersegmented neutrophils (mean lobe count >5), anisocytosis, and poikilocytosis Non-megaloblastic anemia can have increased, normal, or decreased reticulocyte I
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levels usually require further testing to elucidate the underlying disorder. Pernicious anemia is the most important cause of 812 deficiency, and patients may also develop neurologic deficits (eg, memory loss) and achlorhydria (Choice A) Lead poisoning can be associated with basophilic stippling, but it causes microcytic anemia (MCV <80 fl) Alcoholism (as in this patient) can also cause basophilic stippling, ribosomal precipitates that form va rying sizes of blue granules in the RBC cytoplasm However, basophilic stippling is nonspecific and can also be due to thalassemias. (Choice B) Bone marrow biopsy is helpful for diagnosing myelodysplasia, which usually causes cytopenias in ~1 cell lines. Although patients can develop macrocytosis, bone marrow biopsy is usually reserved for evaluating patients with normal 812 and folate levels. (Choice C) Direct antiglobulin test can help diagnose autoimmune hemolytic anemias. Patients typ ically have hemoglobin of 7-10 g/dL with elevated reticulocyte count, bilirubin, and lactate dehydrogenase The haptoglobin is also markedly decreased, and peripheral smear usually shows spherocytes However , there is only mild macrocytosis (<110 fl) rather than the significantly elevated MCV seen in this patient (Choice D) Measuring iron levels is useful for evaluating patients with microcytic anemia (MCV <80 fL) Educational objective: Macrocytic anemia can be due to megaloblastic (eg, impaired DNA synthesis due to 812 or folate deficiency) or non-megaloblastic (eg, alcoholism, hypothyroidism, drugs, liver disease) etiologies Peripheral smear, reticulocyte count, and 812 and folate levels can aid diagnosis and distinguish between 8 12 and folate deficiency References: 1. Macrocytic anemia.
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Hemoglobin
8.6 g/dl
Mean corpuscular volume
74 fl
Platelets
440,000/mm'
Leukocytes
4,100/mm>
Ferritin, serum
8 ng/ml
Iron studies
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Iron , serum
26 IJg/dl
Iron-binding capacity
474 IJg/dl
Which of the following is the most appropriate next step in management of this patient?
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e> A
Bone marrow biopsy
6 B. Colonoscopy and endoscopy 6 C. Echocardiography 6 D. Endomysia! and tissue transglutaminase lgA antibody
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E. Isotope-labeled erythrocytes scintigraphy
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A 65-year-old woman comes to the office with a 2-month history of fatigue and dyspnea on exertion . She takes no medications. Her temperature is 36.7 C (98 F), blood pressure is 162/83 mm Hg, pulse is 100/min, and respirations are 21 /min. Auscultation shows a 2/6 mid-systolic murmur in the second left intercostal space with normal S2 splitting No peripheral edema is noted. Rectal examination shows guaiac-negative brown stooL Electrocardiogram shows sinus tachycardia and nonspecific ST-T changes Subsequent laboratory results are as follows
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... . -.
Explanation: This patient's laboratory values are consistent with a mic rocytic anemia from iron deficiency (low serum iron and ferritin with an elevated total iron-binding capacity). The evaluation of iron deficiency anemia (IDA) varies according to age group and patient-specific factors such as family history of colon cancer or presence of associated symptoms (eg, diarrhea in celiac disease). This patient has only nonspecific symptoms of anemia (dyspnea and tachyca rdia from hypoxemia, and a systolic murmur due to hyperdynamic circulation). New IDA in elderly patients should be considered to be from gastrointestinal (GI) blood loss (eg, polyps, cance r, angiodysplasia) until proven otherwise. In the clinical setting fecal occult blood tests (FOBTs) are frequently performed in patients before a diagnosis of iron deficiency is established with laboratory testing When positive, FOBTs may guide the decision to perform colonoscopy and endoscopy in elderly patients, regardless of iron levels. However, a single negative FOBT is not sufficient to exclude occult Gl bleeding Elderly patients with IDA should be evaluated with colonoscopy and endoscopy despite a single negative FOBT, especially if no other obvious source of chronic blood loss is identified. (Choice A) Bone marrow biopsy is usually not required in the workup of IDA Appropriate workup includes a search for the cause of iron deficiency (eg, chronic blood loss, malabsorption, poor dietary intake) (Choice C) Aortic stenosis may also present with a systolic murmur. When severe, it is associated with Gl angiodysplasia causing occult Gl bleed. However, normal S2 splitting essentially excludes severe aortic stenosis. (Choice D) Endomysia! and tissue transglutaminase lgA antibodies are found in celiac disease. Patients usually present at a younger age (typically <40) and have associated symptoms such as chron ic or intermittent diarrhea, foul-smelling stools, and flatulence. (Choice E) Radioisotope scans are useful in determining the source of active bleeding but are not diagnostic in the absence of an active bleed. They are typically used in acute (not chronic)
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colonoscopy and endoscopy in elderly patients, regardless of iron levels. However, a single negative FOBT is not sufficient to exclude occult Gl bleeding Elderly patients with IDA should be evaluated with colonoscopy and endoscopy despite a single negative FOBT, especially if no other obvious source of chronic blood loss is identified. (Choice A) Bone marrow biopsy is usually not required in the workup of IDA Appropriate workup includes a search for the cause of iron deficiency (eg, chronic blood loss, malabsorption, poor dietary intake) (Choice C) Aortic stenosis may also present with a systolic murmur. When severe, it is associated with Gl angiodysplasia causing occult Gl bleed. However, normal S2 splitting essentially excludes severe aortic stenosis. (Choice D) Endomysia! and tissue transglutaminase lgA antibodies are found in celiac disease. Patients usually present at a younger age (typically <40) and have associated symptoms such as chronic or intermittent diarrhea, foul-smelling stools, and flatulence. (Choice E) Radioisotope scans are useful in determining the source of active bleeding but are not diagnostic in the absence of an active bleed. They are typically used in acute (not chronic) Gl blood loss when the source of bleeding remains unidentified on colonoscopy and endoscopy. Educational objective: The most common cause of iron deficiency anemia in the elderly is gastrointestinal blood loss. The next step in evaluation would be colonoscopy and endoscopy. A single negative occult blood test does not exclude the possibility of gastrointestinal bleeding References: 1. Iron status and colorectal cancer in symptomatic elderly patients. 2. Iron deficiency anemia in the elderly: prevalence and endoscopic evaluation of the gastrointestinal tract in outpatients.
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A 67-year-old woman is hospitalized for sepsis secondary to a urinary tract infection. Her past medical history is significant for hypertension, gout, and chronic obstructive pulmonary disease. She is placed in the intensive ca re unit and treated with intravenous fl uids and antibiotics. Blood and urine cultures grow Escherichia coli. Ultrasound examination of the abdomen reveals a non-obstructing right-sided kidney stone. She improves clinically with treatment and is continued on ciprofloxacin after the bacterial antibiotic sensitivities are reviewed. On the sixth day of hospitalization, the patient becomes confused. She has no pain or shortness of breath but has 6 or 7 watery bowel movements with lower abdominal pain She has a low-grade fever. Her blood pressure is 111/89 mm Hg, pulse is 112/min, and oxygen saturation is 94% on room air. There are occasional wheezes bilaterally . The patient's abdomen is soft and mildly tender in the left lower quadrant with normoactive bowel sounds. She has an indwelling Foley catheter but no central venous lines. Chest x-ray reveals no new infiltrates. Laboratory evaluation shows a white blood cell count of 14 ,200/IJL compared to 8,700/IJL 2 days ago W hich of the following is the best next step in management of this patient?
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0 A Change Foley catheter and start fl uconazole
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6 D. Stop ciprofloxacin and start intravenous vancomycin 0 E. Urgent surgical consult
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a
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Severe
• WBC <15,000/mm3 • Creatinine <1.5x baseline
• WBC :2:15,000/mm3 • Creatinine :2:1.5x baseline • Serum albumin <2.5 g/dl
Oral metronidazole
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Mild-moderate
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• • • •
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I Ileus? I
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WBC :2:20,000/mm3 Lactate :2:2.2 mg/dl Toxic megacolon Severe ileus
Yes
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Options
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• Add IV metronidazole • Switch to rectal vancomycin
• Subtotal colectomy • Diverting loop ileostomy with colonic lavage
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I Clostridium difficile colitis I
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Explanation:
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This patient presents with new-onset white blood cell (WBC) elevation and confusion while in the hospital. Infection is a common source of confusion in hospitalized patients, particularly those in the intensive care unit or with new-onset fever or WBC elevation. This patient's recent antibiotic use, watery bowel movements, and mild abdominal tenderness suggest possible Clostridium f
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colitis with toxic megacolon Diagnosis is usually confirmed with stool studies for C difficile toxin (eg, polyme rase chain reaction) Patients with mild to moderate (WBC <15,000/IJL, as in this patient) C difficile colitis should receive empiric oral metronidazole while awaiting stool studies. Patients with negative studies may require sigmoidoscopy or colonoscopy with biopsy to document pseudomembranous colitis. Severe colitis usually requires oral vancomycin with or without IV metronidazole or a possible switch to intracolonic vancomycin Fidaxomicin is a bacteric idal antibiotic usually reserved fo r recurrent colitis or as initial therapy fo r patients with severe colitis who cannot tolerate oral vancomycin {Choice A) Asymptomatic funguria is common in patients with longstanding indwelling urinary catheters, but actual symptomatic fungal urinary tract infections are unusuaL In cases of uncomplicated asymptomatic funguria, catheters can be replaced, but empiric antifungal agents are generally unnecessary.
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{Choice B) Aminoglycosides (eg, gentamicin) can treat resistant Gram-negative bacteria. However , this patient was improving clinically and had Escherichia coli sensitive to ciprofloxacin This patient's antibiotic use and gastro intestinal symptoms make C difficile colitis more likely than worsening urinary tract infection. {Choice D) Intravenous vancomycin is generally used empirically for bacteremia secondary to a cutaneous source (eg, central line) or infection (eg, pneumonia) due to resistant Gram-positive organisms However, this patient has no central venous lines or new infiltrate on chest x-ray In addition, intravenous vancomycin is not excreted into the colon and is not effective against C difficile colitis. In contrast, oral vancomycin is effective for C diffici/e colitis. {Choice E) Surgical consult would be required in patients with acute peritoneal signs or severe C difficile colitis (toxic megacolon or severe ileus, WBC >20,000/IJL, lactate ~2 . 2 mEq/L) However , this patient has mild to moderate colitis without acute peritoneal signs on examination. Educational objective: Clostridium difficile colitis should be suspected in any patient who has been on antibiotics and
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{Choice A) Asymptomatic funguria is common in patients with longstanding indwelling urinary catheters, but actual symptomatic fungal urinary tract infections are unusual In cases of uncomplicated asymptomatic funguria, catheters can be replaced, but empiric antifungal agents are generally unnecessary. (Choice B) Aminoglycosides (eg, gentamicin) can treat resistant Gram-negative bacteria. However, this patient was improving clinically and had Escherichia coli sensitive to ciprofloxacin This patient's antibiotic use and gastrointestinal symptoms make C difficile colitis more likely than wo rsening urinary tract infection. (Choice D) Intravenous vancomycin is generally used empirically fo r bacteremia secondary to a cutaneous source (eg, central line) or infection (eg, pneumonia) due to resistant Gram-positive organisms However, this patient has no central venous lines or new infiltrate on chest x-ray In addition, intravenous vancomycin is not excreted into the colon and is not effective against C difficite col itis. In contrast, oral vancomycin is effective for C difficile colitis.
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(Choice E) Surgical consult would be required in patients with acute peritoneal signs or severe C difficile col itis (toxic megacolon or severe ileus, WBC >20,000/!JL, lactate ~2 . 2 mEq/L) However, this patient has mild to moderate colitis without acute peritoneal signs on examination. Educational objective: Clostridium difficile colitis should be suspected in any patient who has been on antibiotics and complains of diarrhea and/or abdominal pain Stool studies for C diffici/e toxin should be sent to confi rm the diagnosis Patients with suspected colitis should receive empiric metronidazole while awaiting results of stool studies. References: 1. Clostridium difficile infection in patients with unexplained leukocytosis.
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Item: 40 of 40 0. ld : 4384
e')
A Clopidogrel
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6 D. Estrogen
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e') E. Simvastatin
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A 34-year-old woman comes to the ER because of right lower leg swelling, redness, and pain She has no significant past medical history and does not use any medications. Her mother has a history of pulmonary embolism. Her temperature is 36.7o C (98° F) , pulse is 80/min, respirations are 16/min, and blood pressure is 120/76 mmHg. Examination shows tenderness to palpation in the right calf. Compressive ultrasonogram shows a deep vein th rombosis of the right leg. Further evaluation reveals an elevated plasma homocysteine level. She is started on heparin and warfarin therapy W hat other additional therapy is indicated in this patient?
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C. Vitamin E [9%) D. Estrogen [1%) E. Simvastatin (13%) ~
F. Pyridoxine [58%)
Explanation:
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This patient has deep venous thrombosis ( DVT) in the setting of increased homocysteine levels. Homocysteine is a highly reactive amino acid. Increased levels predispose to venous thrombosis as well as atherosclerosis, presumably due to a combination of direct vascular damage, activation of clotting mechanisms, and inhibition of antithrombotic pathways Thus, this patient's DVT treatment should include an attempt to co rrect her homocysteine level
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Homocysteine can be metabolized to cysteine or methylated to form methionine. If either of these pathways is disrupted by an enzyme or cofactor deficiency, elevated homocysteine levels result The homocysteine to cysteine pathway is catalyzed by cystathionine 13-synthase (CBS) using the cofactor pyridoxine ( 86). The homocysteine to methionine pathway is catalyzed by methylenetetrahydrofolate reductase (MTHFR) and methionine synthase (MS), with folate and cobalam in ( 812) as essential cofactors (see figure).
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Independent of the underlying cause, homocysteine levels can usually be normalized by administration of pyridoxine (86) and folate . Vitamin 8 12 should be added if a 812 deficiency is documented. Although this treatment does correct homocysteine levels, it is still unclear whether it reverses hypercoagulability Tetrahydrofolate
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MS + 812
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Homocysteine
1
CBS ' "
Cystathionine
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Cysteine
(Choice A) Clopidogrel and ticlopidine inhibit platelet aggregation by blocking the ADP receptors on platelets. Clopidogrel is used in the treatment of arterial thrombosis (e g, Ml, stroke) but is not used in the treatment of venous thrombosis. (Choice B) The use of thrombolytics in DVT is limited to patients with extensive iliofemoral involvement. (Choice C) Vitamin E, an antioxidant, acts to protect cell membranes from free radical damage It has no effect on homocysteine metabolism. (Choice D) Estrogen use in oral contraceptive pills and hormone replacement therapy increases
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5-methyl tetrahydrofolate
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CBS • 86
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Homocysteine
Cystathionine
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Cysteine (Choice A) Clopidogrel and ticlopidine inhibit platelet aggregation by blocking the ADP receptors on platelets Clopidogrel is used in the treatment of arterial thrombosis (e.g., Ml, stroke) but is not used in the treatment of venous thrombosis. {Choice B ) The use of thrombolytics in DVT is limited to patients with extensive iliofemoral involvement
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(Choice C) Vitamin E, an antioxidant, acts to protect cell membranes from free radical damage It has no effect on homocysteine metabolism.
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(Choice D) Estrogen use in oral contraceptive pills and hormone replacement therapy increases the risk for thromboembolism. (Choice E) Simvastatin acts to lower LDL levels through inhibition of HMG CoA reductase. Although research suggests that statins have antithrombotic properties, they are not used as treatment for DVT. Educational Objective: Vitamin 86, folate, and vitamin 812 are involved in the metabolism of homocysteine Vitamin 86 lowers homocysteine levels by acting as a cofactor for the enzyme cystathionine 13-synthase, which metabolizes homocysteine into cystathionine. Time Spent 2 seconds
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Blood pH Pa0 2 PaC02 HC03-
e> A. Respiratory acidosis 6
B. Respiratory alkalosis
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7.53 70 mmHg 30 mmHg 22 mEq/L
W hich of the following best describes his primary acid-base status?
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C. Metabolic acidosis D. Metabolic alkalosis
e'> E. Normal acid base status
Subm it
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A 56-year-old male comes to the emergency room because of a 2-day history of fever, chills, shortness of breath and productive cough. He also threw up once in the emergency room. He has been smoking for several years and occasionally drinks alcohoL On admission, his BP was 90/60, but with one liter of normal saline it improved to 120/80 mm Hg. His temperature is 38.8° C (102° F) His arterial blood gas (ABG) analysis is as follows
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Explanation: Human blood pH is normally maintained at 7.35-7.45. HC03- is normally 24 meq/ L, and PaC02 is normally 40 mm Hg Any deviation from these normal values is indicative of an acid-base disorder. Metabolic acid-base disorders are due to a primary change in the concentration of HC03-, whereas respiratory acid-base disorders are due to a primary change in PC02. A primary rise in PaC02 (respiratory acidosis) or fall in plasma HC03- (metabolic acidosis) reduces the pH, whereas a primary fall in PC02 (respiratory alkalosis) or a rise in plasma HC03(metabolic alkalosis) increases the pH In this case, the patient has a respiratory alkalosis because his pH is greater than 7.45 and he has a primary decrease in his PaC02. He is suffering from pneumonia, which has caused tachypnea due to hypoxia Hyperventilation results in C02 loss and a consequent decrease in PaC02. Because C02 is an acid, C02 loss causes alkalosis. The slightly decreased bicarbonate level is due to early renal compensation
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(Choice A) Respiratory acidosis is most commonly caused by respiratory suppression Potential causes include narcotic overdose, neurologic diseases causing airway muscle weakness and COPD.
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(Choice C) Classic causes of metabolic acidosis can be recalled using the mnemonic MUDPILES (anion-gap) Methanol, Uremia (renal fa ilure), DKA, Paraldehyde, INH, Lactic acidosis, Ethylene glycol, Salicylates Diarrhea and renal tubular acidosis are other causes (non-anion gap) (Choice D) Metabolic alkalosis is most commonly caused by vom iting Hyperaldosteronism and volume contraction are other causes. Educational Objective: Respiratory alkalosis is characterized by an increased pH and a primary decrease in the PaC02. Typical causes include hyperventilation due to pneumonia, high altitude or salicylate intoxication. Time Spent 12 seconds
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A 47-year-old woman, gravida 4, para 4, comes to the physician with lower abdominal pain that is relieved with urination. The pain has been present for over 2 months. The patient has also been vo iding more frequently than usuaL She is occasionally sexually active with her husband, but intercourse is painfuL The woman has a history of 4 uncomplicated vaginal deliveries during her 30s. She has no fever or chills. On examination, the patient has mild lower abdominal pain with no rebound or guarding Her external genitalia appear normaL On bimanual examination, palpation of the anterior vaginal wall elicits severe pain No cervical motion tenderness is present The rest of the examination is normaL Urinalysis results are as follows: Specific gravity
1.013
Protein
None
Blood
Negative
Glucose
Negative
Ketones
Negative
Leukocyte esterase
Negative
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Nitrites
Negative
29
Bacteria
None
W hite blood cells
1-2/hpf
Red blood cells
0/hpf
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Which of the following is the most likely diagnosis? 6 A Cystocele 6 B. Interstitial cystitis
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1.013
Protein
None
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Blood
Negative
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Glucose
Negative
Ketones
Negative
Leukocyte esterase
Negative
Nitrites
Negative
Bacteria
None
W hite blood cells
1-2/hpf
Red blood cells
0/hpf
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no rebound or guarding Her external genitalia appear normal. On bimanual examination, palpation of the anterior vaginal wall elicits severe pain No cervical motion tenderness is present The rest of the examination is normal. Urinalysis results are as follows: Specific gravity
27 28
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W hich of the following is the most likely diagnosis?
<0 A Cystocele <0 B. Interstitial cystitis <0 C. Pelvic inflammatory disease <0 D. Stress incontinence <0 E. Urinary tract infection Submit
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Epidemio logy
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• Associated with psychiatric disorders (anxiety) & pain syndromes (fibromyalgia) • Bladder pain with filling, relief with voiding
Clinical presentation
• t frequency, urgency • Dyspareunia
Diagnosis
• Bladder pain with no other attributable cause for ;?:6 weeks duration • Normal urinalysis
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• Not curative; focus is on quality of life
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• More common in women
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Interstitial cystitis (painf ul bladder syndrome)
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Explanation:
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Treatment
• Behavioral modification & trigger avoidance • Amitriptyline • Analgesics for exacerbations
@UWOI1d
Interstitial cystitis (also known as painful bladder syndrome) is a chronic, painful bladder condition of uncertain etiology The pelvic pain in interstitial cystitis is classically exacerbated by bladder filling and relieved by voiding The onset of the symptoms is typically gradual, and - - - ·- - - -- - - - - - - - - - - - -- - - . -- -. - - -- - - --- - - - -- -
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Interstitial cystitis (also known as painful bladder syndrome) is a chronic , painful bladder condition of uncertain etiology The pelvic pain in interstitial cystitis is classically exacerbated by bladder filling and relieved by voiding The onset of the symptoms is typically gradual, and the symptoms worsen over a period of months. Other characteristic symptoms include urinary urgency and frequency, and chronic pelvic pain. The pain can be exacerbated by exercise, sexual intercourse (dyspareunia), and alcohol consumption.
The diagnosis of interstitial cystitis is primarily clinical. Urinalys is is obtained to exclude other causes of bladder pain (eg, urinary tract infection, sexually transmitted disease, cancer); results are normal in interstitial cystitis. Treatment is palliative and includes trigger avoidance, amitriptyline, and analgesics for pain flares. {Choice A) A cystocele refers to bladder prolapse into the anterior vaginal wall, which can cause vaginal pressure, dyspareunia, urinary frequency and urgency, and incontinence. This patient has no evidence of a prolapse on examination. {Choice C) Pelvic inflammatory disease is characterized by pelvic pain, cervical motion tenderness, and feve r. Urinary symptoms are usually not present (Choice D) Stress incontinence refers to involuntary leakage of urine with exertion, sneezing, or coughing Pain is typically not a symptom of stress incontinence. {Choice E) Urinalysis (and urine culture, if urinalysis is abnormal) is performed to rule out urinary tract infection. The normal urinalys is in this patient excludes a urinary tract infection. Educational objective: Interstitial cystitis (painful bladder syndrome) is an idiopathic , chronic condition characterized by bladder pain that is worsened by filling and relieved by vo iding. Dyspareunia, urinary frequency and urgency can also be present References:
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A 72-year-old man comes fo r evaluation of shortness of breath, headache, and fatigue He has a history of hypertension, lives alone, and is not compliant with his medications. The patient drinks 1 or 2 glasses of wine daily but does not smoke. Blood pressure is 184/ 128 mm Hg, pulse is 96/min, and oxygen saturation is 90% by pulse oximetry on room air. He has early papilledema on funduscopic examination. Pulmonary examination shows bibasilar coarse crackles. Cardiac examination shows a grade 2/6 systolic ejection murmur along the left sternal border. There is trace pedal edema. Chest x-ray reveals mild pulmonary edema. An ECG is unchanged from prior tracings Laboratory studies are normal except for serum creatinine of 2.0 mg/dl. The patient is given oxygen and furosem ide and is started on a nitroprusside drip After 36 hours, his blood pressure is 140/80 mm Hg and he is no longer dyspneic ; however , he is confused and disoriented and has diffuse hyperreflexia. There are no other focal neurologic findings Repeat laboratory results are as follows
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Sodium
140 mEq/L
Potassium
4.4 mEq/L
Chloride
100 mEq/L
Bica rbonate
14 mEq/L
Creatin ine
2.5 mg/dL
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W hich of the following is the most likely cause of this patient's symptoms? e')
A Alcohol withdrawal
6 B. Cyanide toxicity 6 C. Ischemic brain injury 6 D. Lacunar infarcts e')
E. Uremic encephalopathy
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• Central nervous system: Headache, altered mental status, seizures, coma
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• Gastrointestinal: Abdominal pain, nausea, vomiting
• Cardiovascular: Arrhythmias
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• Renal: Metabolic acidosis (from lactic acidosis), renal failure
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• Skin: Flushing (cherry-red color), cyanosis (occurs later)
• Respiratory: Tachypnea followed by respiratory depression, pulmonary edema
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Manifestations of cyanide accumulation & toxicity
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Explanation:
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This patient's presentation suggests cyanide toxicity Common etiologies include combustion of carbon- and nitrogen-conta ining compounds (eg, wool, silk), industrial exposure (eg, metal extraction in mining), and medications (eg, sodium nitroprusside). Cyanide binds to cytochrome oxidase and inhibits mitochondrial oxidative phosphorylation Cells then shift to anaerobic metabolism with decreased ATP production and eventual lactic acidosis. Patients can develop symptoms affecting the central nervous (eg, headache, confusion), cardiovascular (eg, arrhythmias), respiratory (eg, tachypnea followed by respiratory depression), and gastrointestinal (eg, vomiting) systems, and skin (eg, flushing) Sodium nitroprusside is a potent arterial and venous vasod ilator often used for hypertensive emergencies The drug contains 5 cyanide groups and undergoes rapid conve rsion to cyanide and eventually thiocyanate, which is eliminated by the kidneys Prolonged infusion (>24 hours) .,
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emergencies The drug contains 5 cyanide groups and undergoes rapid conve rsion to cyanide and eventually thiocyanate, which is eliminated by the kidneys Prolonged infusion (>24 hours) at high rates (5-10 1,1g/kg/min) can lead to cyanide toxicity, especially in patients with chronic kidney disease. As a result, low infusion rates (<2 JJg/kg/min), short-term use. and close monitoring are recommended. Treatment includes sodium thiosulfate . {Choice A) Alcohol withdrawal can cause agitation. tachyca rdia, hype rtension, and mental status changes However, withdrawal is more common in patients with heavy alcohol use who stop suddenly . This patient's moderate alcohol use and absence of tachyca rdia make this less likely (Choice C) Cerebral vessels may not auto-regulate in chronic hype rtension Significant decreases in blood pressure with failed autoregulation may significantly lower cerebral blood flow and cause ischemia. However , this patient's symptoms after sodium nitrop russide use are more concerning for cyanide toxicity. (Choice D) Lacunar infarcts are small strokes from occluded penetrating arteries, usually located in deep brain structures. Lacunar infarcts usually present with sensory or motor deficits, impaired cognition. or dysarthria. This patient's absence of focal neurological findings makes this less likely (Choice E) Uremic encephalopathy can present with altered mentation and occasional myoclonus and usually occurs in patients with advanced renal failure. This patient's mild creatinine rise from 2.0 mg/dL to 2.5 mg/dL is unlikely to cause uremic encephalopathy Educational objective: Prolonged infusion of sodium nitrop russide at high rates can lead to cyanide toxicity, especially in patients with chronic kidney disease. Typical findings include headache, confusion. arrhythmias. flushing, and respiratory depression References: 1. Sodium nitr opr usside in 2014: A clinical concepts review.
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A 31-year-old woman comes to the office with a 6-week history of periorbital edema and abdominal distention. Her temperature is 37.1 C (989 F), blood pressure is 125/75 mm Hg, pulse is 80/min, and respirations are 14/min. Examination shows moderate ascites and lower extremity edema. Urinalysis shows proteinuria and 24-hour urinary protein excretion is 4 g/day, total serum protein is 5 g/dl , and serum albumin is 2.5 g/dL Renal ultrasound is unremarkable. A renal biopsy is performed The patient is started on diuretics and salt and protein intake is restricted. The edema begins to improve However. the patient suddenly develops severe right-sided abdominal pain, feve r. and gross hematuria. W hich of the following is the most likely diagnosis revealed by renal biopsy? 11)
A Focal segmental glomerulosclerosis
11)
B. lgA nephropathy
11)
C. Membranous glomerulopathy
11)
D. Minimal change disease
11)
E. Systemic amyloidosis
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D. Minimal change disease [5%] E. Systemic amyloidosis [10%]
8 9
Explanation:
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Renal vein thrombosis (RVT) and other thromboembolism are important complications of nephrotic syndrome. Loss of antithr ombin Ill (an inhibitor of multiple coagulation factors) in the urine increases the risk of venous and arterial thrombosis. Thrombosis of the renal vein can be acute and present with abdominal pain, fever , and hematuria, as in this patient However, RVT is more commonly progressive, causing gradual worsening of renal function and proteinuria in an asymptomatic patient RVT can occur in any etiology of nephrotic syndrome, but it is most commonly seen with membranous glomerulopathy .
20 21
(Choices A, D, and E) Focal segmental glomerulosclerosis, minimal change disease, and systemic amyloidosis can all cause nephrotic syndrome and subsequent renal ve in thrombosis; however, RVT is less frequent with these disorders.
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{Choice B) lgA nephropathy usually presents with gross or microscopic hematuria with minimal proteinuria after an upper respiratory tract infection. Patients rarely develop rapidly progressive glomerulonephritis or nephrotic syndrome. This patient's presentation of nephrotic syndrome and symptoms of renal infarction is not consistent with lgA nephropathy. Educational objective: Renal ve in thrombosis is an important compl ication of all causes of nephrotic syndrome However, it is most commonly associated with membranous glomerulopathy References: 1. Disease-specific risk of venous thromboembolic events is increased in idiopathic glomerulonephritis .
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A 34-year-old man comes to the office due to fever, dry cough, and fatigue for 2 weeks. He has allergic rhinitis and uses a nasal glucocorticoid but has no other medical history. The patient works as a park ranger in Arizona and recently returned from a trip to a state park in New England He is an accomplished spelunker and spends a great deal of time exploring caves. The patient does not use tobacco, alcohol, or illicit drugs. He has 2 cats. Temperature is 37.7 C (100 F), blood pressure is 128/72 mm Hg, pulse is 86/min, and respiratory rate is 15/min. Lung auscultation reveals bilateral crackles. Chest x-ray shows bilateral alveolar opacities and hilar lymphadenopathy . Bronchoscopic biopsy reveals granulomas with yeast forms. W hich of the following is the most likely risk factor for this patient's current condition?
e; A A rea of residence
e> B. Medication use e; C. Pet exposure
22
e> D. Recent travel
23
e; E. Recreational activity
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Explanation: Histoplasma capsulatum is the most common endemic mycosis in the United States, accounting fo r approximately 500,000 new infections each yea r Exposure occurs primarily in the Midwest (particularly the Ohio and Mississippi river valleys) and, to a lesser extent, the Northeast. The organism prolife rates most readily in soil contaminated with bat or bird droppings; therefore, patients often have a history of interacting with chicken coops, farm buildings, bird roosts, or caves. Small dose inoculation is rarely symptomatic (<5% become ill); patients who inhale larger doses (eg, exposure in enclosed areas such as a cave) are at higher risk for symptomatic infection. Symptoms usually present 2-4 weeks after exposure with subacute fever, chills, malaise, headache, myalgias, and dry cough Chest x-ray typically reveals mediastinal or hilar lymphadenopathy (LAD) with focal , reticulonodular, or miliary infiltrates (depending on the degree of exposure) Diagnosis is usually made with Histoplasma antigen testing of the urine or blood, plus serology. Some patients may require tissue diagnosis, which often reveals granulomas with narrow-based budding yeasts Most cases resolve completely (over weeks) without intervention. For patients with moderate or severe disease, oral itraconazole or intravenous liposomal amphoteric in B can be used. {Choice A) Coccidioidomycosis is common in Arizona and often presents with chest pain, cough, fatigue, and feve r Chest x-ray is usually normal but may reveal a unilateral infiltrate with ipsilateral hilar LAD. Biopsy reveals spherules with endospores This patient had bilateral infiltrates and biopsy evidence of granulomas with yeast, making histoplasmosis more likely (Choice B) Intranasal corticosteroids have minimal systemic absorption and extensive fi rst-pass metabolism in the liver Side effects include nosebleeds, decreased growth curves (in children), and, occasionally, nasal septum perforation Significant immunosuppression is unlikely. (Choice C) Cats may transmit Toxoplasma gondii, a protozoan that rarely causes symptomatic disease in immunocompetent individuals but may occasionally present with a mononucleosis-like illness (eg, LAD, fevers, malaise). Pulmonary infection is rare, and biopsy would not reveal
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g ranulomas with narr ow-based budding yeasts Most cases resolve completely (over weeks) without intervention. For patients with moderate or severe disease, oral itraconazole or intravenous liposomal amphotericin 8 can be used. {Choice A) Coccidioidomycosis is common in Arizona and often presents with chest pain, cough, fatigue, and feve r. Chest x-ray is usually normal but may reveal a unilateral infiltrate with ipsilateral hilar LAD. Biopsy reveals spherules with endospores This patient had bilateral infiltrates and biopsy evidence of granulomas with yeast, making histoplasmosis more likely (Choice B) Intranasal co rticostero ids have minimal systemic absorption and extensive fi rst-pass metabolism in the live r. Side effects include nosebleeds, decreased growth curves ( in children), and, occasionally, nasal septum perforation Significant immunosuppression is unlikely. (Choice C) Cats may transmit Toxoplasma gondii, a protozoan that rarely causes symptomatic disease in immunocompetent individuals but may occasionally present with a mononucleosis-like illness (eg, LAD, fevers, malaise). Pulmonary infection is rare, and biopsy would not reveal granulomas with yeast (Choice D) Although there are pockets of endemic H capsulatum in New England, caving in endemic areas is a much stronger risk factor than travel alone. Educational objective: Histoplasma capsulatum is prevalent in the central, midwestern , and northeastern United States. Inoculation typ ically occurs when patients are exposed to soil contaminated by bird or bat droppings. Infections are usually subclinical in immunocompetent hosts; however , some patients (especially with high dose exposure) may have subacute pulmonary illness. References: 1. Diagnosis and management of pulmonary nodules 2. Pulmonary histoplasmosis
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A 59-year-old woman is hospitalized due to lower gastrointestinal bleeding. Her past medical history includes hypertension, chronic obstructive pulmonary disease with cor pulmonale, and diverticulosis. She takes albuterol, aspirin, furosemide, and lisinopril. On admission, her blood pressure was 80/50 mm Hg and hemoglobin was 6.5 g/dl Her condition stabilized with fluid resuscitation, blood transfusions, and by withholding her home medications. The patient's urine output has been 300-400 mL per day for the past 3 days On the fourth day of hospitalization, she is found lethargic and difficult to arouse. Her blood pressure is 110/70 mm Hg and pulse oximetry is 93% on 6 L per minute oxygen. Laboratory testing reveals Hemoglobin
10.2 g/dL
Leukocytes
14,300/IJL
Blood glucose
93 mg/dL
21
Blood urea nitrogen
62 mg/dL
22
Creatinine
2.7 mg/dL
Sodium
132 mEq/L
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Potassium
5.0 mEq/L
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Chloride
100 mEq/L
Bicarbonate
18 mEq/L
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Arterial blood gases pH
7.15
Pa02
80 mm Hg
PaC02
60 mm Hg
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Blood urea nitrogen
62 mg/dl
Creatinine
2.7 mg/dl
Sodium
132 mEq/ L
Potassium
5.0 mEq/L
Chloride
100 mEq/ L
Bicarbonate
18 mEq/L
Arterial blood gases
20
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pH
7. 15
Pa02
80 mm Hg
PaC02
60 mm Hg
W hich of the following is most likely contributing to this patient's lethargy?
® A Alveolar diffusion block ® B. Decreased anion gap ® C. Hypoventilation ® D. Low tubular ammonia production ® E. Poor tubular bica rbonate reabsorption ® F. Renal tubular chloride loss Submit
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Explanation: This patient has acidemia (pH <7 35) She has a mixed acid-base disor der with elevated PaC02 (>40 mm Hg) indicating respiratory acidosis and low serum bica rbonate (<24 mEq/L) consistent with metabolic acidosis. Acidemia by itself does not lead to central nervous system depression, but often, the underlying cause of acidemia results in lethargy and altered mental status. In this case, she likely has C02 retention due to her underlying chronic obstructive pulmonary disease (COPD), leading to C02 narcosis (usually seen at PaC02 >60 mm Hg). Acute hyperca rbia can be differentiated from chronic C02 retention in COPD by the associated acidosis and low bicarbonate level (chronic C02 retainers have normal pH and high serum bicarbonate) This patient also has acute kidney injury (AKI) most likely due to hypotension during her gastrointestinal (GI) bleed. AKI can cause a non-anion gap metabolic acidosis from impaired H+ excretion, ammonia generation, or bica rbonate reabsorption Her anion gap (serum [Na') - (CI· + HCO;]) is 14 mEq/L, indicating a non-anion gap metabolic acidosis (normal10-1 4 mEq/L) {Choice B) AKI can also cause an anion gap acidosis due to retention of unmeasured uremic toxins which can also cause encephalopathy. However in this patient, the normal anion gap suggests that the elevated blood urea nitrogen is due to her Gl bleed (ie, metabolism of blood proteins to urea) and there is not likely to be an excessive concentration of other unmeasured uremic toxins. Her mental status changes are therefore less likely to be due directly to her AKI. {Choice A) A decrease in alveolar diffusing capacity is characterized by hypoxia and tachypnea Tachypnea would cause lowering of the pC02 because C02 is more readily diffusible than 0 2 . (Choice D) Hepatic encephalopathy is associated with elevated levels of ammonia in the blood. The impaired generation of ammonia in AKI decreases renal acid excretion but does not raise blood ammonia levels or cause changes in mental status. (Choice E) Defective tubular bica rbonate reabsorption in the proximal tubules is the defect in type 2 renal tubular acidosis (RTA) also known as proximal RTA Type 2 RTA is often times inherited and may be a component of Fanconi syndrome . Type 2 RTA can also occur with use
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toxins which can also cause encephalopathy However in this patient, the normal anion gap suggests that the elevated blood urea nitrogen is due to her Gl bleed (ie, metabolism of blood proteins to urea) and there is not likely to be an excessive concentration of other unmeasured uremic toxins. Her mental status changes are therefore less likely to be due directly to her AKI. (Choice A) A decrease in alveolar diffusing capac ity is characterized by hypoxia and tachypnea Tachypnea would cause lowering of the pC02 because C02 is more readily diffusible than 0 2 . (Choice D) Hepatic encephalopathy is associated with elevated levels of ammonia in the blood. The impaired generation of ammonia in AKI decreases renal acid excretion but does not raise blood ammonia levels or cause changes in mental status. (Choice E) Defective tubular bicarbonate reabsorption in the proximal tubules is the defect in type 2 renal tubular acidosis (RTA) also known as proximal RTA Type 2 RTA is often times inherited and may be a component of Fanconi syndrome Type 2 RTA can also occur with use of carbonic anhydrase inhibitors (acetazolamide)
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(Choice F ) Renal tubular chloride loss as seen in aggressive loop or thiazide diuretic use causes metabolic alkalosis, not acidosis. This is due to loss of extracellular volume that accompanies chloride loss, thus stimulating renin-angiotensin-aldosterone activity and increasing urinary excretion of H•. Educational objective: Alveolar hypoventilation with C02 retention can lead to respiratory acidosis along with C02 narcosis. Acute kidney injury can cause a non-anion gap metabolic acidosis due to impaired acid excretion or an anion gap acidosis due to retention of unmeasured uremic toxins. References: 1. Serum anion gap: its uses and limitations in clinical medicine.
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e A Abdominal muscle weakness e B. Bladder sphincte r contraction e C. Detrusor weakness e D. Overactive bladder e E. Urethral obstruction Submit
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A 75-year-old man comes to the office due to lower abdominal discomfort and difficulty voiding fo r the past 24 hours. The patient has never had urinary difficulty before. He has had a nonproductive, hacking cough for over a week, and yesterday his neighbor advised him to try an over-the-counter medication containing diphenhydramine to improve the symptoms. The patient's past medical history is significant for an ischemic stroke 3 yea rs ago with mild left-sided residual weakness, and he uses a cane to ambulate. He is anxious on examination. Temperature is 36.7 C (98 F), blood pressure 150/80 mm Hg, and pulse is 105/min. Abdominal examination reveals a lower abdominal mass. Cardiac examination reveals regular rhythm A mildly enlarged prostate is palpated on rectal examination. W hich of the following most likely accounts for this patient's current symptoms?
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E. Urethral obstruction [20%) Explanation:
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This elderly patient with difficulty vo iding and a palpable lower abdominal mass (likely representing an overfilled bladder) has acute urinary retention due to an adverse effect of diphenhydramine First-generation H1-antihistamines (eg, diphenhydramine, chlorpheniramine, hydroxyzine) also have significant anticholinergic effects (eg, at muscarinic receptors of the parasympathetic nervous system) , which can manifest as dryness of the eyes, dryness of the oral mucosa and respiratory passages, or urinary retention. Urinary retention caused by anticholinergic agents results from failure of detrusor muscle contraction and, to a lesser extent, impaired bladder sphincter relaxation, both of which are controlled by parasympathetic input from the pelvic splanchnic nerves. Elderly men, who are likely to have some degree of underlying urinary obstruction due to benign pr ostatic hyperplasia (BPH), are at increased risk of developing urinary retention due to anticholinergic agents
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(Choice A) The abdominal musculature may be used in an accessory fashion to increase intraabdominal pressure and facilitate urination or defecation; however , a solitary defect in the strength of the abdominal musculature would be insufficient to cause urinary retention. (Choice B) The bladder sphincter normally relaxes when the detrusor muscle contracts to allow free passage of urine into the urethra and out of the body Spinal cord injury or stroke may lead to detrusor sphincter dyssynergia in which the bladder sphincter contracts during detrusor muscle contraction and prevents voiding This patient's acute-onset urinary retention following diphenhydramine ingestion makes detrusor muscle weakness more likely . (Choice D) Overactive bladder is clinically defined by symptoms of urgency , frequency , and nocturia. Difficulty initiating urination is not a typical feature. (Choice E) Urethral obstruction commonly occurs in older men due to BPH. Common symptoms include urinary urgency, difficulty with initiating and maintaining urinary stream, and feeling of •
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hyperplasia (BPH), are at increased risk of developing urinary retention due to anticholinergic agents.
8
{Choice A) The abdominal musculature may be used in an accessory fashion to increase intraabdominal pressure and facilitate urination or defecation; however , a solitary defect in the strength of the abdominal musculature would be insufficient to cause urinary retention.
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(Choice B) The bladder sphincter normally relaxes when the detrusor muscle contracts to allow free passage of urine into the urethra and out of the body. Spinal cord injury or stroke may lead to detrusor sphincter dyssynergia in which the bladder sphincter contracts during detrusor muscle contraction and prevents voiding This patient's acute-onset urinary retention following diphenhydramine ingestion makes detrusor muscle weakness more likely . {Choice D) Overactive bladder is clinically defined by symptoms of urgency, frequency , and nocturia. Difficulty initiating urination is not a typical feature.
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{Choice E) Urethral obstruction commonly occurs in older men due to BPH. Common symptoms incl ude urinary urgency , difficulty with initiating and maintaining urinary stream, and feeling of incomplete bladder emptying This patient likely has some component of BPH-related obstruction. However, he had not been having significant symptoms of urinary obstruction, and his acute urinary retention is most likely due to anticholinergic-mediated detrusor weakness. Educational objective: First-generation H1-antihistamines have potent anticholinergic effects and may cause eye and oropharyngeal dryness as well as urinary retention. Due to a high prevalence of benign prostatic hyperplasia, elderly men are at inc reased risk of urinary retention due to anticholinergic activity References: 1. Adverse effects of medications on urinary symptoms and flow rate : a community-based study.
37
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A 33-year-old woman is brought to the emergency department after an episode of generalized tonic-clonic seizures. She is confused and unable to provide further history. Review of the medical record indicates that she has schizophrenia but stopped taking all her psychiatric medications 3 weeks ago Temperature is 36.7 C (98 F) , blood pressure is 130/76 mm Hg, pulse is 80/min, and respirations are 14/min. Examination shows normal pupils. The patient's lungs are clear to auscultation and her heart sounds are normal. Her abdomen is soft. Extremities examination shows no edema. Laboratory results are as follows: Serum sodium
118 mEq/L
Serum potassium
3.4 mEq/L
Serum creatinine
0.8 mg/dl
Serum calcium
8.4 mg/dl
Serum glucose
98 mg/dl
Serum osmolality
252 mOsm/kg
Urine osmolality
78 mOsm/kg
Urine specific gravity
1 002
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Lab Values
Which of the following is the most likely cause of this patient's electrolyte abnormalities?
6 A. Adrenal insufficiency 6 B. Fluoxetine-mediated hypothalamic antidiuretic hormone production e; C. Idiopathic central diabetes insipidus 6 D. Idiopathic nephrogenic diabetes insipidus 6 E. Primary polydipsia 6 F. Syndrome of inappropriate antidiuretic hormone secretion due to lung cance r
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Serum sodium
118 mEq/L
Serum potassium
3.4 mEq/L
Serum creatinine
0.8 mg/dl
Serum calcium
8.4 mg/dl
Serum glucose
98 mg/dl
Serum osmolality
252 mOsm/kg
Urine osmolality
78 mOsm/kg
Urine specific gravity
1 002
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I I I I p ry • medical record indicates that she has schizophrenia but stopped taking all her psychiatric medications 3 weeks ago Temperature is 36.7 C (98 F) , blood pressure is 130/76 mm Hg, pulse is 80/min, and respirations are 14/min. Examination shows normal pupils The patient's lungs are clear to auscultation and her heart sounds are normal. Her abdomen is soft Extremities examination shows no edema. Laboratory results are as follows
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Lab Values
W hich of the following is the most likely cause of this patient's electrolyte abnormalities?
® A Adrenal insufficiency ® B. Fluoxetine-mediated hypothalamic antidiuretic hormone production ® C. Idiopathic central diabetes insipidus ® D. Idiopathic nephrogenic diabetes insipidus ® E. Primary polydipsia ® F. Syndrome of inappropriate antidiuretic hormone secretion due to lung cance r Submit
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Explanation:
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Evaluation of hyponatremia
9
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r - - - - - - - - - - - - - - - - - , Yes
Serum osmolality >290 mOsm/kg
• Marked hyperglycemia • Advanced rena l failure
No r-----------------,
Yes
Urine osmolality <100 mOsm/kg
• Primary polydipsia • Malnutriti on (beer d rinker's potomania)
No
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I Urine sodium <25 mEq/L I
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No
Yes
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• SIADH · Adrenal insufficiency • Hypothyroidism
• Volume depletion • Congestive heart failure • Cirrhosis
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This patient has had seizures due to severe hyponatremia Hyponatremia is often due to excess antidiuretic hormone (AOH) secretion leading to impaired renal water excretion. However, hyponatremia can also be due to significantly increased water intake that overwhelms the kidney's
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• SIADH • Adrenal insufficiency • Hypothyroidism
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• Volume depletion • Congestive heart failure • Cirrhosis
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This patient has had seizures due to severe hyponatremia Hyponatremia is often due to excess antidiuretic hormone (AOH) secretion leading to impaired renal water excretion. However, hyponatremia can also be due to significantly increased water intake that overwhelms the kidney's ability to excrete water. One approach to evaluate hyponatremia is to measure the serum osmolality. A serum osmolality >290 mOsm/kg suggests either marked hyperglycemia or advanced renal failure as likely causes of the hyponatremia The next step in evaluating patients with serum osmolality <290 mOsm/kg is to measure the urine osmolality A urine osmolality <100 mOsm/kg, as in this patient, suggests either primary polydipsia or malnutrition (eg, beer potomania). Primary polydipsia is more common in patients with psychiatric conditions (eg, schizophrenia) , possibly due to a central defect in thirst regulation These patients continue to drink water despite a decreased serum osmolality that should normally inhibit the thirst reflex. The kidney increases water excretion, which dilutes the urine maximally to an osmolality <100 mOsm/kg. However, hyponatremia can develop if the water intake is higher than the kidney's ability to excrete water. Patients with significant hyponatremia can develop confusion, lethargy, psychosis, and seizures. (Choice A) Adrenal insufficiency typically presents with hypovolemia, which leads to increased ADH and hyponatremia. However, the increased ADH would lead to concentrated urine with urine osmolality greater than the serum osmolality {Choices C and D) Diabetes insipidus can be central (decreased ADH release from the pituitary) or nephrogenic (normal ADH levels with renal ADH resistance). The decreased ADH action in both types leads to decreased renal water reabsorption , water loss with polyuria, and dilute urine. However, patients typically develop hypernatremia. (Choices Band F) Many drugs (eg, carbamazepine, cyclophosphamide, selective serotonin reuptake inhibitors such as fl uoxetine) can stimulate hypothalamic ADH production and cause
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hyponatremia can develop if the water intake is higher than the kidney's ability to excrete water. Patients with significant hyponatremia can develop confusion, lethargy, psychosis, and seizures. (Choice A) Adrenal insufficiency typically presents with hypovolemia, which leads to increased ADH and hyponatremia However, the increased ADH would lead to concentrated urine with urine osmolality greater than the serum osmolality (Choices C and D) Diabetes insipidus can be central (decreased ADH release from the pituitary) or nephrogenic (normal ADH levels with renal ADH resistance). The decreased ADH action in both types leads to decreased renal water reabsorption, water loss with polyuria, and dilute urine. However, patients typically develop hypernatremia. (Choices 8 and F) Many drugs (eg, carbamazepine, cyclophosphamide, selective serotonin reuptake inhibitors such as fluoxetine) can stimulate hypothalamic ADH production and cause syndrome of inappropriate antidiuretic hormone secretion (SIADH). Lung cancer (eg, small cell cancer) can also cause SIADH due to ectopic ADH production by the tumor cells. The excess ADH in both cases leads to water retention in the kidney and hyponatremia However, the urine is inappropriately concentrated (instead of dilute) As a result, the urine osmolality is higher than the serum osmolality Educational objective: Causes of hyponatremia include syndrome of inappropriate antidiuretic hormone secretion and primary polydipsia. Primary polydipsia is more common in patients with psychiatric conditions (eg, schizophrenia), possibly due a central defect in thirst regulation Patients typically develop hyponatremia and dilute urine with urine osmolality <100 mOsm/kg. Those with significant hyponatremia can develop confusion, lethargy, psychosis, and seizures. References: 1. Hyponatremia and hypernatremia: disorders of water balance. 2. Psychogenic polydipsia review: etiology, differential, and treatment.
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A 20-year-old man is found to have an elevated calcium level on pre-employment screening blood tests. He feels well and has no polyuria, polyd ipsia, or constipation. His medical history is unremarkable. He takes no prescription medications, although he has been consuming "protein shakes and vitamin supplements" in preparation for running a marathon. The patient does not use tobacco, alcohol, or illicit drugs. Temperature is 37 C (98 6 F), blood pressure is 110/70 mm Hg, and pulse is 82/min. Physical examination is unremarkable. Laboratory results are as follows: Sodium
140 mEq/L
Potassium
4.0 mEq/L
Chloride
103 mEq/L
Bicarbonate
24 mEq/L
Blood urea nitrogen
18 mg/dl
Serum c reatinine
0.8 mg/dl
Calcium
11 .2 mg/dl
Glucose
98 mg/dl
Albumin
4.2 g/L
Serum parathyroid hormone level
65 pg/ml (normal 10-65 pg/ml)
Urine calcium/creatinine clea rance ratio
<0.01
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W hich of the following conditions is most consistent with this patient's findings? I
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e
Potassium
4.0 mEq/L
Chloride
103 mEq/L
Bicarbonate
24 mEq/L
Blood urea nitrogen
18 mg/dl
Serum creatinine
0.8 mg/dl
Calcium
11 .2 mg/ dl
Glucose
98 mg/dl
Albumin
4.2 g/ L
Serum parathyroid hormone level
65 pg/ml (normal 10-65 pg/ml)
Urine calcium/creatinine clearance ratio
<0.01
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W hich of the following conditions is most consistent with this patient's findings?
® A Familial hypocalciuric hypercalcem ia ® B. Multiple myeloma ® C . Primary hyperparathyro idism ® D. Renal cell carcinoma ® E. Sarcoidosis ® F. Vitamin D toxicity Submit
61
Lab Values
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c 0
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Decreased sensitivity to ca2• (familial hypocalciuric hypercalcemia)
Increased sensitivity to Ca2•
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4 ©UWorld
6
8
10
12 mg/dL
Serum ca2+ concentration
This patient has mild, asymptomatic hypercalcemia and normal renal function. In light of a high-normal parathyroid hormone (PTH) level and low urinary calcium excretion, this presentation is consistent with familial hypocalciuric hypercalcemia ( FHH). FHH is a benign autosomal dominant disorder caused by a mutation of the calcium-sensing receptor (CaSR). Normally ,
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is consistent with familial hypocalciuric hypercalcemia (FHH) FHH is a benign autosomal dominant disorder caused by a mutation of the calcium-sensing r eceptor (CaSR). Normally , high-normal calcium levels suppress PTH secretion by the parathyroid glands, but in FHH, higher calcium concentrations are required to suppress PTH release. Concurrently , the defective CaSR leads to increased reabsorption of calcium in renal tubules.
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In the evaluation of hype rcalcemia, an elevated (or inappropriately normal) PTH level suggests either primary hyperparathyroidism or FHH. However. patients with primary hyperparathy roidism have increased urinary calcium excretion due to excessive mobilization of calcium from bones, whereas patients with FHH usually have very low urinary calcium levels (typically <100 mg/24 hr) Urine calcium excretion can be more precisely assessed using the urine calcium/creatinine clearance r atio (UCCR) UCCR = (Ca•.JCa,......)/(Creat,"j Creat,.= ) UCCR is usually <0.01 in FHH compared to >0.02 in primary hyperparathyroidism (Choice C)
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Most patients with FHH are asymptomatic , although potential complications include pancreatitis and chondrocalcinosis. In the absence of complications, no specific treatment is required (Choices 8 , D, E, and F) Patients with multiple myeloma. renal cell carc inoma, sarcoidosis, and vitamin 0 toxicity may also present with hypercalcemia, but PTH levels are typically suppressed due to feedback inhibition. Educational objective: Familial hypocalciuric hypercalcemia is caused by a mutation in the calcium-sensing receptor It is a benign disorder characterized by asymptomatic hypercalcemia, elevated or inappropriately normal parathyro id hormone levels, and low urinary calcium excretion. It can be differentiated from primary hyperparathyroidism. which has increased urinary calcium excretion. by the urine calcium/c reatinine clearance ratio. References: 1. Familial hypocalciuric hypercalcaemia: a review.
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A 72-year-old woman with poorly controlled type 2 diabetes mellitus presents to your clinic one week after being discharged from the hospital She had been admitted with pyelonephritis secondary to a multi-drug resistant organism, and received several days of intravenous antibiotics. Her serum creatinine on admission had been 2 1mg/dL Today it is found to be 4.9 mg/dL Urinalysis reveals rare epithelial casts and no white blood cells. FENa is greater than 2% . What antibiotic did she most likely receive during her hospitalization?
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A. Nafcillin
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B. Vancomycin
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C. Levofloxacin
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D. Amikacin E. Doxycycline F. Azithromycin
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This patient has acute renal failure (ARF) in the setting of chronic kidney disease. Of the drugs listed, amikacin is the most likely causative agent There are several indications that amikacin or another aminoglycoside is the cause of this patient's acute renal failure. First, she had pyelonephritis with a multidrug-resistant organism, probably a gram-negative rod . Aminoglycosides are commonly used in this setting Second, her urine sediment does not contain any white blood cells. If she had acute interstitial nephritis (A IN), eosinophils and white blood cell casts would be present in her urine. Third, her elevated FENa is not consistent with a
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F. Azithromycin [5%]
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E. Doxycycline [4%]
Explanation:
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pre-renal etiology of acute renal failure. Am inoglycosides may be used in patients with renal dysfunction, but their serum levels and the patient's renal function must be followed closely. Because of their adverse effects and need fo r monitoring, aminoglycosides are being used with decreasing frequency, particularly in older patients. (Choice A) Nafcillin is a common cause of acute renal failure due to A IN. This drug is used to treat infections caused by methicillin-sensitive Staphylococcus aureus (MSSA) Nafcillin would not have been used to treat multidrug-resistant pyelonephritis and her urinary sediment is not consistent with A IN. (Choice B) Vancomycin is used to treat infections with methicillin-resistant S. aureus (MRSA) MRSA pyelonephritis is uncommon but may occur in patients who are chronically ill, are institutionalized, or have indwelling bladder catheters. Vancomycin can be nephrotoxic at high doses and it must be dosed according to serum levels. This woman is more likely to have been infected with a gram-negative organism than a gram-positive one, so is unlikely to have received vancomycin (Choice C) Levofloxacin is a fl uoroquinolone antibiotic often used to treat pyelonephritis Levofloxacin must be renally dosed but is not a common cause of ARF.
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pre-renal etiology of acute renal failure. Aminoglycosides may be used in patients with renal dysfunction, but their serum levels and the patient's renal function must be followed closely . Because of their adverse effects and need fo r monitoring, aminoglycosides are being used with decreasing frequency, particularly in older patients (Choice A) Nafcillin is a common cause of acute renal failure due to A IN. Thi s drug is used to treat infections caused by methicillin-sensitive Staphylococcus aureus (MSSA) Nafcillin would not have been used to treat multidrug-resistant pyelonephritis and her urinary sediment is not consistent with A IN. (Choice B) Vancomycin is used to treat infections with methicillin-resistant S. aureus (MRSA) MRSA pyelonephritis is uncommon but may occur in patients who are chronically ill, are institutionalized, or have indwelling bladder catheters. Vancomycin can be nephrotoxic at high doses and it must be dosed according to serum levels. This woman is more likely to have been infected with a gram-negative organism than a gram-positive one, so is unlikely to have received vancomycin.
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{Choice C) Levofloxacin is a fluoroquinolone antibiotic often used to treat pyelonephritis Levofloxacin must be renally dosed but is not a common cause of ARF.
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(Choice E) Doxycycline is most often used to treat community acquired pneumonia, some zoonotic infections (e g., Lyme disease), Chlamydia, and acne. It is not strongly associated with renal dysfunction and is not likely to have been used for multidrug-resistant pyelonephritis (Choice F) Azithromycin is a macrolide antibiotic typically used to treat community acquired pneumonia, sinus infections, streptococcal pharyngitis, and Chlamydia It has approximately 20% renal clearance but is not strongly associated with acute renal failure. Educational Objective: Aminoglycosides are antibiotics used to treat serious gram-negative infections. They are potentially nephrotoxic and drugs levels and renal function must be monitored closely during therapy Time Spent 2 seconds
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A 57-year-old man comes to the physician fo r 2 episodes of blood in his urine. He also complains of fatigue and fever fo r the last 4 weeks. He has no other medical problems and takes no medications. The patient has a 50-pack-year smoking history but does not use alcohol or illicit drugs. His father died from a blood disorder, but the patient is unsure of the specific name. Vital signs are within normal limits. Examination shows a left-sided varicocele that fa ils to empty when the patient is recumbent The remainder of the examination shows no abnormalities. Laboratory results are as follows
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Hemoglobin
180 g/dl
WBCs
7 ,400/IJL
Platelets
580,000/IJL
Urinalysis
>10 RBCs/hpf
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W hich of the following is the most appropriate diagnostic procedure?
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OA
Chest x-ray
() B. Abdominal CT scan () C . Urine cytology () D . Serum alpha-fetoprotein levels
() E. Ultrasound of the testicles () F. Bone marrow biopsy
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E. Ultrasound of the testicles (14%) F. Bone marrow biopsy [19%) Explanation:
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Renal cell carcinoma • Flank pain, hematuria & a palpable abdominal renal mass • Scrotal varicoceles (left-sided) • Paraneoplastic symptoms o Anemia or erythrocytosis o Thrombocytosis o Fever o Hypercalcemia o Cachexia @UWor1d
This patient most likely has renal cell carcinoma (RCC) Most RCC patients are asymptomatic until the disease is advanced. The classic triad of RCC (flank pain, hematuria, and a palpable abdominal renal mass) is found in only 10% of patients; when present, it strongly suggests advanced/metastatic disease. Hematuria is seen in about 40% of patients and signifies tumor invasion of the collecting system. Scrotal varicoceles (most are left-sided) are observed in about 10% of patients Varicoceles typically fail to empty when the patient is recumbent due to tumor obstruction of the gonadal vein where it enters the renal vein. Presence of this finding should always raise suspicion for mass obstruction to venous flow, as is seen in RCC. Twenty percent of patients may also have constitutional symptoms such as feve r, night sweats, anorexia, weight loss, or easy fatigability Ectopic production of erythropoietin by the tumor can produce polycythemia, although most advanced tumors are associated with anemia. CT scan of fhn _,h~r\1'"1"\nn. i r fhn ("' f"\l"'l.t"'jfj\1"' ., .... ,.4 t"' J'"..,"'\I"jfi ,.. fn r f fr. r ,..i.,("lnt"\t"' in.n orr .,nrl t"hl"''lllrl hi"'\ nht_,j..,,...._,-t n"'U"\("'f
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invasion of the collecting system. Scrotal varicoceles (most are left-sided) are observed in about 10% of patients Varicoceles typically fail to empty when the patient is recumbent due to tumor obstruction of the gonadal vein where it enters the renal vein. Presence of this finding should always raise suspicion for mass obstruction to venous flow, as is seen in RCC. Twenty percent of patients may also have constitutional symptoms such as feve r, night sweats, anorexia, weight loss, or easy fatigability Ectopic production of erythropo ietin by the tumor can produce polycythemia, although most advanced tumors are associated with anemia. CT scan of the abdomen is the most sensitive and specific test for diagnosing RCC and should be obtained when the index of suspicion is high (Choice A) Chest x-ray is important to check fo r metastasis but will not indicate the diagnosis in this patient (Choice C) The combination of fever , scrotal varicocele, and polycythemia would virtually exclude bladder cancer, although this patient is at risk due to his smoking history and presence of hematuria. Urine cytology is not helpful in diagnosing RCC. (Choices 0 & E) This patient's findings are unlikely to indicate testicular ca rcinoma; therefore, an ultrasound of the testicles or serum alpha-fetoprotein measurements would not be helpful (Choice F) Erythrocytosis and thrombocytosis are seen as paraneoplastic manifestations of RCC. Bone marrow biopsy is not indicated at this time. Educational objective: Unilateral va ricoceles that fail to empty when a patient is recumbent raise suspicion for an underlying mass pathology, such as renal cell carcinoma (RCC), that obstructs venous flow. CT scan of the abdomen is the most sensitive and specific test for diagnosing RCC. References: 1. Paraneoplastic manifestations of renal cell carcinoma
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A 57-year-old homeless man with known HIV infection comes to the emergency department complaining of shortness of breath and a nonproductive cough over the past week. He has a history of type 2 diabetes mellitus with poor follow-up and medication compliance His last CD4 count was 120 cells/IJL 3 months ago His temperature is 38 go C (102° F), pulse is 11 0/min, respirations are 24/min, and blood pressure is 120/80 mm Hg Oxygen saturation is 86% on room air. Lung examination is notable for diffuse rales bilaterally The abdomen is soft and nontender. Laboratory results are as follows Creatinine
1.2 mg/dL
Potassium
4.2 mEq/L
Chest x-ray shows bilateral patchy opacities in the lower lungs. The patient is treated with azithromycin, ceftriaxone, trimethoprim-sulfamethoxazole, prednisone, and albuterol. He is also given insulin before meals for his diabetes mellitus. On the third day of hospitalization, his serum potassium is 5.9 mEq/L and his c reatinine is 1.5 mg/dL W hich of the following medications is most likely responsible for these laboratory changes?
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<0 A Albuterol
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<0 C. Ceftriaxone ® D. Insulin
<0 E. Prednisone <0 F. Trimethoprim Submit
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Explanation:
Medications that can ca use hyperkalemia
Medication
Mechanism
Nonselect ive beta-
Interferes with bet a-2-mediated intracellular
adrenergic blockers
potassium uptake
ACE inhibitor, ARB, K• sparing diuretics
Inhibition of aldost erone or the ENaC channel
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Digitalis
Inhibition of the Na-K-ATPase pump
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Cyclosporine
Heparin
NSAIDs
Succinylcholine
Blocks aldosterone activit y
Blocks aldosterone production Decreases renal perfusion resu lting in decreased K• delivery t o the collecting ducts Causes extracellular leakage of pot assium through acetylcholine receptors
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Trimethoprim (TMP) and sulfamethoxazole (SMX) work sequentially to block the bacterial synthesis of tetrahydrofolic acid. TMP-SMX is commonly used for treating uncomplicated urinary tract infections (Gram-negative rods), Pneumocystis jirovecii pneumonia, community-acquired MRSA skin infections, and nocardiosis. Trimethoprim can cause hyperkalemia by blocking the epithelial sodium channel in the collecting tubule, similar to the action of the potassium-sparing diuretic amiloride. This occurs more commonly in HIV-infected patients who are treated with high doses of trimethoprim, but even normal doses can produce a modest elevation in the plasma potassium concentration. Thus, patients treated with high-dose trimethoprim require serial monitoring of potassium to avoid serious complications. Trimethoprim also competitively inhibits renal tubular creatinine secretion and may cause an artificial increase in serum creatinine; however , glomerular filtration rate is unchanged
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(Choices A and D) Albuterol (a selective beta-2 agonist) and insulin lower serum potassium temporarily by driving potassium intracellularty. They are used to treat hyperkalemia
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{Choices 8 and C) Macrolide antibiotics (eg, azithromycin) can cause prolonged QT and cholestasis. Ceftriaxone is also associated with cholestasis and is contraindicated in neonates at high risk of developing cholestasis. Neither drug affects potassium levels. (Choice E) Prednisone has some mineralocorticoid activity, but it would cause potassium loss, not retention. Educational objective: Trimethoprim can cause hype rkalemia due to blockade of the epithelial sodium channel in the collecting tubule. Trimethoprim also competitively inhibits renal tubular creatinine secretion and may cause an artificial increase in serum creatinine without affecting the glomerular filtration rate. References: II .
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A 73-year-old man with dementia is brought to the emergency department by nursing home staff because he has been moaning continuously and gripping his lower abdomen for the past 36 hours. The patient is unable to give any history, but staff members say that he refused oral intake the previous day. He has had no vom iting or diarrhea. His last bowel movement was 2 days ago. The patient uses adult diapers, which were last changed 2 days ago He has a history of benign prostatic hyperplasia, external hemorrhoids, hypertension, and hyperlipidemia One year ago, he was hospitalized for diverticular bleeding that resolved spontaneously. His medications review shows that his primary care physician started amitriptyline 8 days ago for chronic neck pain. On physical examination, the patient is afebrile. His blood pressure is 160/70 mm Hg and his pulse is 100/min. The mucous membranes are moist His lung fields are clear to auscultation. Palpation of the abdomen shows fullness and tenderness along the midline below the umbilicus without guarding or rigidity Bowel sounds are heard in all 4 quadrants W hich of the following is the best initial management for this patient?
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<0 A Abdominal CT scan
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<0 B. Barium enema
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® C. Intravenous fluids, analgesics, and observation
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<0 D. Upright abdominal x-ray
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<0 E. Urgent surgical consultation
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<0 F. Urinary catheterization
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Explanation: This patient's abdominal pain and suprapubic fullness are consistent with amitriptyline-induced urinary retention. Amitriptyline is a tricyclic antidepressant with anticholinergic properties The bladder empties under muscarinic control with both detrusor muscle contraction and internal urethral sphincter relaxation. Anticholinergic agents can cause urinary retention by reducing detrusor contraction and preventing urethral sphincter relaxation. In addition, elderly male patients often have some degree of underlying benign prostatic hyperplasia and are at risk for urinary retention. Both the anticholinergic properties of amitriptyline and pressure from urinary retention could have caused this patient's constipation as well. This patient's cl inical presentation is sufficient to initiate prompt urinary catheterization for suspected urinary retention. Bedside ultrasound or bladder scan (if available) can also help in diagnosis but should not delay urinary catheterization. Urinary catheterization can document a postvoid residual bladder volume (>50 ml is considered diagnostic fo r urinary retention) and provides symptomatic relief by draining urine from the distended bladder. This patient should also discontinue amitriptyline therapy. (Choice A) An abdominal CT scan would reveal a distended bladder in this patient and may also show hydronephrosis and hydroureter. However, CT scans are more expensive and time-consuming than urinary catheterization and will not provide symptomatic relief. {Choice B) Barium enemas are used to diagnose luminal abnormalities of the colon, such as colon cancer or diverticulosis. (Choice C) Intravenous fluids, analgesics, and observation are the treatment for nephrolithiasis (kidney stones) Patients with kidney stones typically present with intense flank pain and hematuria instead of suprapubic fullness. Intravenous fluids could potentially worsen this patient's obstructive urinary symptoms (Choice D) Upright abdominal x-ray is not as reliable fo r evaluating urinary retention as it may not show a distended bladder (unless obstructed by a bladder stone). Abdom inal x-rays are more useful for diagnosing ileus or small-bowel obstruction. Amitriptyline may cause ileus, but these
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(Choice B) Barium enemas are used to diagnose luminal abnormalities of the colon, such as
colon cancer or diverticulos.is. (Choice C) Intravenous fluids, analgesics, and observation are the treatment for nephrolithiasis (kidney stones) Patients with kidney stones typically present with intense flank pain and hematuria instead of suprapubic fullness. Intravenous fl uids could potentially worsen this patient's obstructive urinary symptoms. (Choice D) Upright abdominal x-ray is not as reliable for evaluating urinary retention as it may not show a distended bladder (unless obstructed by a bladder stone). Abdom inal x-rays are more useful fo r diagnosing ileus or small-bowel obstruction. Amitriptyline may cause ileus, but these patients typically develop nausea, vomiting, hypoactive bowel sounds, distended abdomen, diffuse mild abdominal pain, and abdominal imaging showing dilated bowel loops without air/fluid levels. This patient's normal bowel sounds, infraumbilical fullness, and lack of wet diapers for 2 days make urinary retention more likely than ileus. (Choice E) Surgical consultation is indicated fo r suspected acute abdomen (eg, bowel perforation, mechanical obstruction) Obstruction typically presents with vomiting, moderate-to-severe abdominal pain, hyperactive bowel sounds, possible peritoneal signs (eg, guarding), and dilated bowel loops with air fl uid levels on imaging Perforation usually has absent bowel sounds. This patient's absence of guarding/rigidity or gastrointestinal symptoms (eg, vomiting) makes these less likely Educational objective:
Drugs with anticholinergic properties can cause acute urinary retention by preventing detrusor muscle contraction and urinary sphincter relaxation. The treatment involves urinary catheterization and discontinuing the medication. References:
1. Management of acute urinary retention.
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A 32-year-old Caucasian male presents to the ER with a 12-hour history of anorexia and vomiting He says that he feels 'a little dizzy'. He denies abdominal pain or diarrhea. His past medical history is insignificant His blood pressure is 110/70 mmHg while supine and 100/60 mmHg while sitting. His heart rate is 90/min. His laboratory values are:
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139 mEq/L
Serum potassium
3.1 mEq/L
Serum calcium
8.9 mEq/L
Serum chloride
88 mEq/L
Serum bica rbonate
33 mEq/L
Blood glucose
95 mg/dl
BUN
20 mg/dl
Serum c reatinine
1.1 mg/dl
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W hich of the following is the most likely cause of the decreased chloride level in this patient? e')
A. Gastrointestinal loss
e
B. Bicarbonate reabsorption in the kidney
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Serum potassium
3.1 mEq/L
Serum calcium
8.9 mEq/L
Serum chloride
88 mEq/L
Serum bicarbonate
33 mEq/L
Blood glucose
95 mg/dl
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20
20 mg/dl
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23
1.1 mg/dl
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W hich of the following is the most likely cause of the decreased chloride level in this patient?
® A Gastrointestinal loss ® B. Bicarbonate reabsorption in the kidney ® C. Metabolic alkalosis ® D. Intracellular shift ® E. Volume depletion ® F. Hypokalemia Submit
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Explanation: The chemistry values obtained fo r this patient demonstrate hypochloremia, hypokalemia, and an elevated bicarbonate level. These findings are all consistent with gastrointestinal losses due to vomiting (Choice A) . Gastrointestinal fl uid is rich in both hydrogen chloride and potassium chloride. Therefore, any process by which excessive gastric contents are lost (vomiting, nasogastric suctioning), may result in loss of hydrogen, chloride, and potassium ions. The results include hypochloremia and hypokalemia, as seen in this patient. Furthermore, the loss of hydrogen ions increases the concentration of bicarbonate. An arterial blood gas would be expected to confi rm metabolic alkalosis in this patient by demonstrating a pH>74 in addition to the elevated bica rbonate. {Choice B & E) For each hydrogen chloride ion lost due to vomiting, a bica rbonate ion is produced In addition, the volume contraction caused by vomiting leads to activation of the renin-angiotensin system which stimulates bicarbonate reabsorption It is important to realize that while volume contraction and bicarbonate reabsorption are inc reased in this patient, they are the result of hydrogen chloride loss; not the cause of it. These answer choices reverse cause and effect (Choice C) This answer choice again reverses cause and effect. In this patient, vomiting has caused significant loss of hydrogen chloride, resulting in metabolic alkalosis. Metabolic alkalosis is the consequence - not the cause - of vomiting (Choice D & F) Hypokalemia accompanies, but does not cause this patient's hypochloremia. It is the result of gastrointestinal loss of potassium, the intracellular shift of potassium caused by alkalosis, and increased renal excretion of potassium caused by aldosterone. The aldosterone is ramped up by the renin-angiotensin system as a means to retain fluid. Educational objective: Gastric contents are rich in hydrogen, chloride, and potassium Therefore vomiting causes hypochloremic metabolic alkalosis and hypokalemia Bicarbonate levels rise as a result of hydrogen loss and activation of the renin-angiotensin system The administration of isotonic sodium chloride and potassium is used to reverse these electrolyte abnormalities.
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A 50-year-old man comes to the emergency department due to sudden onset of severe, colicky pain in the right flank. He was admitted twice previously for similar symptoms. On both occasions, the patient was managed conservatively and sent home. He has no other medical problems and no history of urinary infections. He usually eats precooked food from a local store and has a soda with each meaL The patient does not use tobacco, alcohol, or illicit drugs. His vital signs are stable. He is given intravenous fl uids and pain medications. Laboratory results are as follows Hemoglobin
14.5 g/dL
Leukocytes
13,000/mm'; no bands
Platelets
300,000/mm'
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Blood urea nitrogen
16 mg/dL
22
Creatinine
0.8 mg/dL
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CT scan of the abdomen without contrast reveals renal calculi. Urinalysis shows moderate levels of blood and calcium oxalate crystals W hich of the following is the best recommendation for the prevention of future stones in this patient?
e> A
Calcium supplements
6 B. Decreased dietary calcium intake 6 C. Decreased potassium intake 6 D. High dietary animal protein
e>
E. High doses of vitam in C
6 F. High-fructose diet 6 G. Limited sodium intake
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occasions, the patient was managed conservatively and sent home. He has no other medical problems and no history of urinary infections. He usually eats precooked food from a local store and has a soda with each meal. The patient does not use tobacco, alcohol, or illicit drugs His vital signs are stable. He is given intravenous fluids and pain medications. Laboratory results are as follows
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Hemoglobin
145g/dL
Leukocytes
13,000/mm'; no bands
Platelets
300,000/mm'
16 17 18 19
Blood urea nitrogen
16 mg/dL
Creatinine
0.8 mg/dL
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CT scan of the abdomen without contrast reveals renal calculi. Urinalysis shows moderate levels of blood and calcium oxalate c rystals W hich of the following is the best recommendation for the prevention of future stones in this patient?
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ID A. Calcium supplements ID B. Decreased dietary calcium intake ID C. Decreased potassium intake ID D. High dietary animal protein ID E. High doses of vitamin C ID F. High-fructose diet ID G. Limited sodium intake ID H. Low-fat diet Submit
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Explanation: The most common renal stones are calcium stones. Increased sodium intake enhances calcium excretion (hypercalciuria) , and low sodium intake promotes sodium and calcium reabsorption through its effect on the medullary concentration gradient Reabsorption of sodium and calcium is coupled via complex mechanisms involving the calcium-sensing receptor in the thick ascending limb of the loop of Henle. Therefore, patients with recurrent renal calculi should be advised to restrict sodium intake. If these patients continue to develop renal stones, their urine sodium levels may be checked to evaluate adherence to a sodium-restricted diet {Choices A and F) Excessive calcium intake (>2 g/day) and inc reased fructose intake may worsen hypercalciuria and calc ium oxalate precipitation in urine. Hydrochlorothiazide reduces urinary calcium excretion and may be used in recurrent stone formers with hypercalciuria {Choices 8 and E ) Calcium binds oxalate to fo rm inabsorbable calcium oxalate in the gastrointestinal tract Calcium restriction may increase free oxalate absorption, leading to hyperoxaluria and urinary calc ium oxalate stone fo rmation. Increased vitamin C intake also promotes hyperoxaluria Patients should be advised to restrict oxalate-containing foods (eg, chocolate, tea, peanuts).
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(Choice C) A high-potassium diet decreases urinary calcium excretion. Foods rich in potassium enhance urinary citrate excretion (likely from urinary alkalization), forming soluble calcium citrate and thereby preventing stone formation. {Choice D) Diets rich in animal protein are associated with an increased risk of nephrolithiasis in men. Increased acid resulting from protein metabolism is excreted in urine, leading to calcium salt precipitation (Choice H) Patients with malabsorption syndromes (eg, Crohn disease, cystic fibrosis) have increased amounts of intestinal fatty acids that form salts with calcium. Less calcium is available to bind oxalate, resulting in hyperoxaluria. This patient has no evidence of malabsorption
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worsen hypercalciuria and calc ium oxalate precipitation in urine. Hydrochlorothiazide reduces urinary calcium excretion and may be used in recurrent stone formers with hypercalciuria {Choices 8 and E) Calcium binds oxalate to fo rm inabsorbable calcium oxalate in the gastrointestinal tract Calcium restriction may increase free oxalate absorption, leading to hyperoxaluria and urinary calc ium oxalate stone fo rmation. Increased vitamin C intake also promotes hyperoxaluria Patients should be advised to restrict oxalate-containing foods (eg, chocolate, tea, peanuts). (Choice C) A high-potassium diet decreases urinary calcium excretion. Foods rich in potassium enhance urinary citrate excretion (likely from urinary alkalization), forming soluble calcium citrate and thereby preventing stone formation. {Choice D) Diets rich in animal protein are associated with an increased risk of nephrolithiasis in men. Increased acid resulting from protein metabolism is excreted in urine, leading to calcium salt precipitation
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(Choice H) Patients with malabsorption syndromes (eg, Crohn disease, cystic fibrosis) have increased amounts of intestinal fatty acids that form salts with calcium. Less calcium is available to bind oxalate, resulting in hyperoxaluria. This patient has no evidence of malabsorption Educational objective: The dietary recommendations for patients with renal calculi are: 1. Increased fluid intake 2. Decreased sodium intake 3. Normal dietary calcium intake References: 1. Diet and fluid pr escription in stone disease.
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A 68-year-old man with a history of type 2 diabetes mellitus and co ronary artery disease (status post triple-vessel coronary artery bypass surgery 5 years ago) undergoes a left total knee replacement for significant degenerative joint disease. He has an uncomplicated perioperative course and is undergoing physical therapy starting on postoperative day 3. On postoperative day 5, the patient complains of new-onset abdominal discomfort. Over the past 12 hours. he has spontaneously voided 200 mL of urine. Review of the medical chart shows infrequent record ing of fl uid input/output over the previous 4 days. His temperature is 37.0° C (98 6° F) , blood pressure is 110/70 mm Hg, pulse is 80/min, and respirations are 14/min. His body mass index is 40 kg/m2 Abdom inal examination shows diffuse discomfort and difficulty in appreciating masses due to obesity. Portable bladder scan is inconclusive. Laboratory results are as follows Hemoglobin
12.5 g/dL
Platelets
170,000/IJL
Leukocytes
9,700/IJL
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Serum sodium
130 mEq/L
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Serum potassium
5.0 mEq/L
Chloride
101 mEq/L
Bicarbonate
21 mEq/L
Blood urea nitrogen
70 mg/dL
Serum creatin ine
3.5 mg/dL
Calc ium
9.6 mg/dL
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His renal function was normal prior to the surgery W hich of the following is the most appropriate next step in management of this patient?
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Platelets
170,000/!JL
Leukocytes
9,700/!JL
Serum sodium
130 mEq/L
Serum potassium
5.0 mEq/L
Chloride
101 mEq/L
Bicarbonate
21 mEq/L
Blood urea nitrogen
70 mg/dl
Serum creatin ine
3.5 mg/dl
Calcium
9.6 mg/dl
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His renal function was normal prior to the surgery. W hich of the following is the most appropriate next step in management of this patient?
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0 A Bladder catheterization 0 B. Computed tomography angiography of the abdomen 0 C. Immediate hemodialys is 0 D. Intravenous fluid bolus 0 E. Intravenous loop diuretic 0 F. Urine culture 0 G. Urine sediment analysis Submit
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Explanation:
Management of acute oliguria
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History & physical examination (eg, assess for benign prostatic hyperpla sia)
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b iochemistry
No significant urine retention
Significant Bedside bladder
-+-- - - - - - ; scan to assess for
±imaging
u rinary retention
urine retention
Urethral catheter to decompress b ladder
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22 Pre-renal causes:
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. Hypovolemia
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- Sepsis
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Low cardiac output
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Renal causes: Acute tubular necrosis
b iochemistry
Interstitial nephritis
± imaging
Glomerular d isease
!
(eg, heart failure)
29 30 31 32 33 34 35 36 37 38
Serum & uri ne
Treat underlying Fluid administration if
0
ITreat underlying cause I
cause (eg, benign prostatic hyperplasia,
appropriate or treat
malignancy) with
underlying cause
urologic consultation
USML~Wodd, l lC
This patient presents with acute abdominal pain, oliguria (<250 ml urine in 12 hours), increased blood urea nitrogen, and increased serum creatinine in the postoperative setting Acute kidney
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This patient presents with acute abdominal pain, oliguria (<250 ml urine in 12 hours) , increased blood urea nitrogen, and inc reased serum c reatinine in the postoperative setting Acute kidney injury (AKI) with oliguria can be due to pre-renal, intrinsic renal disease, or post-renal causes. Postoperative urinary retention (PUR) is a common complication of surgery and anesthesia. A precipitating event (eg, bladder distention during general anesthesia, epidural anesthesia use) can lead to inefficient detrusor muscle activity and acute urinary retention (the most likely cause in this patient) The risk of PUR also increases with advancing age, high fluid intake during surgery, and concomitant use of other medications (eg, opiates, anticholinergics). Postoperative oliguria (~ 0.5 mU kg/hr) requires immediate assessment with initial portable bladder scan (if available) to assess bladder volume. Patients with significant urinary retention and likely distal obstruction require Foley catheterization to restore normal urine output and resolve or prevent hydronephrosis, tubular atrophy, and renal injury If catheterization does not relieve the patient's oliguria or if there is no significant urinary retention, the patient's AKI may be due to other etiologies (ie, intrinsic , pre-renal). This patient recently had surgery, and the oliguria and abdominal discomfort suggest urinary retention. Because the portable bladder scan is inconclusive (due to obesity), bladder catheterization is the appropriate next step.
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(Choice B) Computed tomography (CT) angiography of the abdomen is useful for diagnosing renovascular disease due to atherosclerosis (unilateral or bilateral renal artery stenosis) Progressive renal vascular disease can cause chronic kidney disease but is an unlikely cause of acute renal failure. Moreover , the use of intravenous contrast for CT angiography is contraindicated in acute renal failure. {Choice C) Urgent hemodialysis is indicated in patients with severe acidemia, hyperkalemia, vol ume overload, certain drug toxicities and overdoses, or uremic encephalopathy (Choice D) Intravenous fluids are critical for treating pre-renal AKI due to hypovolemia. However, administering fluids without first placing a bladder catheter in patients with suspected post-renal obstruction would further increase the strain on the kidneys and bladder and potentially worsen symptoms (Choice E) Patients with heart fa ilure can have volume overload but low cardiac output (ie,
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angiography is contraindicated in acute renal fa ilure.
(Choice C) Urgent hemodialysis is indicated in patients with severe acidemia, hyperkalemia, volume overload, certain drug toxicities and overdoses, or uremic encephalopathy (Choice D) Intravenous fluids are c ritical for treating pre-renal AKI due to hypovolemia. However , administering fl uids without first placing a bladder catheter in patients with suspected post-renal obstruction would further increase the strain on the kidneys and bladder and potentially worsen symptoms (Choice E) Patients with heart fa ilure can have volume overload but low cardiac output (ie, cardiorenal syndrome). Renal perfusion in these patients can be improved with intravenous loop diuretics. They should not be used in those with oliguria due to suspected bladder outlet obstruction. (Choices F and G) Urine sediment analysis is helpful for diffe rentiating between pre-renal and intrinsic renal disease. Muddy brown casts are present in acute tubular necrosis; urine eosinophils suggest acute interstitial nephritis. Urinary tract infections and/or pyelonephritis would be suggested by a positive urine culture. However, this patient's presentation is more concerning fo r urinary retention and requires bladder catheterization before other etiologies are considered. Educational objective: Urgent bladder scan and catheterization should be performed in all patients with oliguria and acute renal failure due to suspected bladder outlet obstruction in the postoperative setting Placement of bladder catheter in a timely fashion can rapidly improve symptoms, reverse acute renal failure, and prevent long-term renal damage References: 1. Postoperative urinary retention .
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A 56-year-old man comes to the emergency department complaining of 3 days of progressively worsening shortness of breath. He recently had a cold, and his symptoms have gradually exacerbated since then. He now has a mild productive cough but no fever or chills. The patient has a 25-pack-year smoking history and has been diagnosed with mild emphysema , type 2 diabetes mellitus, hypertension, hyperlipidemia, and hypothyroidism He takes glipizide, lisinopril, furosemide, aspirin, atorvastatin , levothyroxine, and uses an albuterol inhaler as needed. Physical examination shows decreased breath sounds with diffuse wheezes bilaterally The re is trace bilateral lower extremity edema. Arterial blood gas results are as follows
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pH
7.23
Pa02
88 mm Hg
PaC02
40 mm Hg
Serum HCO,·
16 mEq/L
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W hich of the following best describes the acid-base status of this patient? ID A Mixed metabolic acidosis and respiratory alkalos is ID B. Mixed metabolic and respiratory acidosis ID C . Normal acid-base balance ID D. Primary metabolic acidosis ID E. Primary respiratory acidosis
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Acid-base disorders
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Primary disorder
-
Appropriate compensation
Metabolic acidosis
PaC02 = 1.5 (serum HC03-) + 8 ± 2
Metabolic alkalosis
I PaC0 2 by 0.7 mm Hg for every 1 mEq/L lise
18 19
in serum HC03-
t Serum HC03- by 1 mEq/L for every 10 mm Hg
Acute respiratory acidosis
20 21
lise in PaC02
22 23
I Serum HC03-by 2 mEq/L for every 10 mm Hg
Acute respiratory alkalosis
24
decrease in PaC02
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~UWor1d
The first step in assessing a patient's acid-base status is to analyze the arterial pH, which indicates the overall acid-base state. Arterial pH :>7 35 indicates acidemia while pH ~7 45 indicates alkalemia. This patient's arterial pH of 7.23 is consistent with acidemia. The next step is to check pC02 and serum HCO,- to determine if the cause is respiratory or metabolic . The serum HCO,- is low, indicating that the primary disorder is metabolic acidosis. The lungs try to compensate for the acidosis by increasing respirations to lower pC0 2 in the same direction as the serum HCO,-. W inter's formula (arterial pC02 = 1.5 [HCO,-) + 8 ± 2) can help determine appropriate respiratory compensation. This patient's expected arterial pC02 would be 32 mm Hg ± 2 ([1.5 • 16 mm Hg + ;
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indicates the overall acid-base state. A rterial pH :::7 35 indicates acidemia while pH ~7 .45 indicates alkalemia. This patient's arterial pH of 7.23 is consistent with acidemia. The next step is to check pC02 and serum HCO,· to determine if the cause is respiratory or metabolic . The serum HCO; is low, indicating that the primary disorder is metabolic acidosis. The lungs try to compensate for the acidosis by inc reasing respirations to lower pC02 in the same direction as the serum HCO;. W inter's formula (arterial pC0 2 = 1.5 [HCO;J + 8 ± 2) can help determine appropriate respiratory compensation This patient's expected arterial pC02 would be 32 mm Hg ± 2 ([ 1 5 • 16 mm Hg + 8) ± 2). As a result, a pC02 of 30-34 mm Hg in this patient would be interpreted as primary metabolic acidosis with respiratory compensation However, this patient's higher than expected pC02 (40 mm Hg) suggests that an independent primary respiratory acidosis is causing a mixed (~2 primary disturbances) acid-base disorder. He likely has lactic acidosis (due to pneumonia) This causes metabolic acidosis and chronic obstructive pulmonary disease (COPD) exacerbation, which leads to respiratory acidosis. This patient's COPD at baseline causes chronic respiratory acidosis (pC02 >40 mm Hg), and his body is unable to mount the required respiratory response to combat metabolic acidosis and lower pC02 to the expected range. Educational objective: Mixed acid-base disorders refer to ~2 primary acid-base disturbances in a patient After identifying a primary acid-base disorder, the calculated expected pC02 or HCO; should be compared to measured values to distinguish between appropriate compensation and a mixed disorder. References: 1. A stepwise approach to acid-base disorders. Practical patient evaluation for metabolic acidosis and other conditions. 2. A practical approach to acid-base disorders
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6 A Hemodialysis @ B. Peritoneal dialysis
6 C. Renal transplantation from a cadaver @ D. Renal transplantation from a living related donor C)
E. Renal transplantation from a living unrelated donor
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A 34-year-old man is being evaluated for possible end-stage renal disease. He has a long history of diabetes, type 1. He previously developed chronic renal insufficiency despite being on enalapril and insulin. His renal function is getting worse day by day A nephrologist is currently managing his renal condition. W hich of the following long-term treatments would give the best survival rate for this patient?
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D. Renal transplantation from a living r elated cjon0r [89%) E. Renal transplantation from a living unrelated donor [2%)
Explanation:
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End stage renal disease is a progressive condition that is fatal if left untreated. Once end stage renal disease develops, there are only two treatment options available: dialysis or renal transplantation The choice depends on the patient and co-morbid conditions; however , if both options are available, renal transplantation is preferred, as it is associated with better survival and quality of life . The advantages of renal transplantation over dialysis are: 1. Better survival and quality of life . 2. Anemia, bone disease, and hypertension persist in spite of dialysis; these are better controlled with transplantation 3. Transplant patients have a return of normal endocrine, sexual, and reproductive functions, and enhanced energy levels; thus, returning to fulltime employment and more strenuous physical activity is possible. 4. In diabetics, autonomic neuropathy persists or worsens after dialysis; whereas, it stabilizes or improves with transplantation. 5. Expected survival rate after transplantation is 95% at one yea r and 88% at five years. The major disadvantages of renal transplantation are difficulty in finding a donor, surgical risk and cost, and side effects of immunosuppression Transplantation from a living related donor has the least graft rejection and best graft survival, followed by a living non-related donor, and cadaver graft (Choices C and E). (Choices A and B) Dialysis options include hemodialysis (home or in-center) or peritoneal dialys is (chronic ambulatory or cyclic peritoneal dialysis). In the US, 85% of patients have in-center hemodialysis, 15% have peritoneal dialysis, and approximately 1% have home hemodialysis The choice depends on the patient. Peritoneal hemodialysis provides the patient with more control and mobility , but the risk of peritonitis is high. The five-yea r survival rate in
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The advantages of renal transplantation over dialysis are: 1. Better survival and quality of life . 2. Anemia, bone disease, and hypertension persist in spite of dialysis; these are better controlled with transplantation 3. Transplant patients have a return of normal endocrine, sexual, and reproductive functions, and enhanced energy levels; thus, returning to fulltime employment and more strenuous physical activity is possible 4. In diabetics , autonomic neuropathy persists or worsens after dialysis; whereas, it stabilizes or improves with transplantation 5. Expected survival rate after transplantation is 95% at one year and 88% at five years The major disadvantages of renal transplantation are difficulty in finding a donor , surgical risk and cost, and side effects of immunosuppression. Transplantation from a living related donor has the least graft rejection and best graft survival, followed by a living non-related donor , and cadaver graft {Choices C and E).
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(Choices A and B ) Dialysis options include hemodialysis (home or in-center) or peritoneal dialysis (chronic ambulatory or cyclic peritoneal dialysis) In the US, 85% of patients have in-center hemodialysis, 15% have peritoneal dialysis, and approximately 1% have home hemodialysis The choice depends on the patient Peritoneal hemodialysis provides the patient with more control and mobility, but the risk of peritonitis is high. The five-year survival rate in non-diabetic patients who are on dialysis is 30-40% ; whereas, in diabetics , it is 20% . Educational Objective: Patients with end stage renal disease have only two treatment options dialysis or renal transplantation Renal transplantation is always preferred due to better survival rates and quality of life. A living related donor is always preferred, followed by a living non- related donor, and lastly , a cadaveric donor. Time Spent 2 seconds
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A 36-year-old man recently diagnosed with Hodgkin lymphoma comes to the physician due to fatigue and generalized edema. Laboratory results are shown below:
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... 20
Sodium
145 mEq/L
Potassium
3.8 mEq/L
Creatinine
0.9 mg/dl
Albumin
2.0 g/dl
Total bilirubin
0.9 mg/dl
Globulin
4.6 g/dl
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Urinalysis shows 4+ proteinuria with no hematuria. Vital signs are with in normal limits. W hich of the following glomerular diseases is most likely to be present in this patient?
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<0 A Amyloidosis
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<0 B. Crescentic glomerulonephritis
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<0 C. Focal segmental glomerulosclerosis <0 D. Membranoprolife rative glomerulonephritis <0 E. Minimal change disease Submit
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E. Minimal change disease [28%) Explanation:
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Primary renal causes of nephrotic syndrome
...
Etiology
Clinical associations
Focal segmental glomerulosclerosis
African American & Hispanic ethnicity; obesity; HIV & heroin use
20
21
Adenocarcinoma (eg, breast, lung); nonsteroidal antiinflammatory drugs (NSAIDs); hepatitis B; systemic lupus erythematosus
Membranous nephropathy
22 23
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Membranoproliferative g lomerulonephritis
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29 30 31 32 33 34 35 36 37 38
Minimal change disease lgA nephropathy
Hepatitis B & C; lipodystrophy
NSAIDs; lymphoma Upper respiratory tract infection
©USMLEWorld. UC
A variety of glomerular diseases may be seen in the setting of malignancy This patient has nephrotic syndrome (indicated by the high degree of proteinuria, hypoalbuminemia, and edema) following a recent diagnosis of Hodgkin lymphoma Minimal change disease (MCD) is I ... Ill
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nephrotic syndrome (indicated by the high degree of proteinuria, hypoalbuminemia, and edema) following a recent diagnosis of Hodgkin lymphoma Minimal change disease (MCD) is the most common form of nephrotic syndrome in patients with Hodgkin lymphoma. Nephrotic syndrome will usually resolve with successful treatment of the lymphoma.
Overall, membranous glomerulopathy is the most common form of nephrotic synd rome associated with malignancies However , these are usually solid cancers (lung, colon, prostate, breast), unlike in the case of the association between MCD and Hodgkin lymphoma Awareness of these disease associations may help guide the screening and detection of underlying conditions in patients with nephrotic syndrome (Choice A) Nephrotic syndrome due to amyloidosis is usually seen in multiple myeloma (deposition of immunoglobulin light chains) , not Hodgkin lymphoma Weight gain and lower extremity edema can occur at a slow pace and may initially go unnoticed by the patient or physician
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(Choice B) This patient is unlikely to have crescentic glomerulonephritis as he does not have acute kidney injury (present in almost all cases), hematuria, or hypertension In addition, crescentic glomerulonephritis is usually associated with autoimmune disorders and not with malignancies {Choice C) Focal segmental glomerulosclerosis is associated with HIV, heroin, obesity, and some medications; it is not classically associated with malignancies. (Choice D) Membranoproliferative glomerulonephritis is associated with hepatitis B and C infections, chronic bacterial infections (eg, endocarditis) , and some autoimmune conditions. It is uncommonly associated with leukemias (chronic lymphocytic leukem ia) or lymphomas (non-Hodgkin lymphoma, B-cell lymphoma) and is not typically seen in Hodgkin lymphoma. Educational objective: Membranous nephropathy is the most common form of nephrotic syndrome associated with carcinoma. However , minimal change disease is usually seen in patients with Hodgkin lymphoma.
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A 32-year-old man comes to the clinic due to a week of escalating low back pain The pain is dull, achy, present at rest, and worse with activity The patient has no significant medical history He smokes a pack of cigarettes daily and drinks alcohol occasionally He recently began using intravenous heroin due to significant psychosocial stress at home. There is a fam ily history of prostate cancer in his father. Temperature is 36.7 C (98 F), blood pressure is 120/80 mm Hg, pulse is 90/min, and respirations are 16/min. Gentle percussion over the lumbar ve rtebrae (L3 and L4) elicits exquisite pain A full neurologic examination, including straight leg raise, is normal. Laboratory results are as follows: Complete blood count
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W hich of the following is the most likely diagnosis?
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A Ankylosing spondylitis
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6 B. Lumbar disk herniation 6 C. Lumbar spinal stenosis 6 D. Prostate cancer
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6 F. Vertebral osteomyelitis Submit
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This patient has vertebral osteomyelitis. Injection drug users, patients with sickle cell anemia, and immunosuppressed patients are at highest risk fo r osteomyelitis The spine is a frequent site of osteomyelitic infection in injection drug users. In this group, Staphylococcus aureus is the most common pathogen, but infections with gram-negative organisms also occur. Most cases of vertebral osteomyelitis are chronic (>6 weeks) and insidious with minimal symptoms Many patients have back pain unrelieved by rest; fever is present in <50%. Physical examination often shows few findings, but tenderness to gentle per cussion over the spinous process of the involved ve rtebra can be an important clue. Leukocytes may be elevated or normal Platelet count is often high as a marke r of inflammation/stress. The eryth rocyte sedimentation rate is often significantly elevated (>1 00 mm/hr) MRI is the most sensitive diagnostic study Treatment is long-term intravenous antibiotics with or without surgery {Choice A) Ankylosing spondylitis is characterized by pain and progressive limitation of back motion. It occurs most often in young men. Symptoms are usually most severe in the morning and improve as the day progresses. Exquisite tenderness to palpation is not a classic finding {Choice B) Lumbar disk herniation typically presents with the acute onset of back pain with or without radiation down a leg Patients can usually recall an inciting event. The pain is worse with activity and improves with rest. The spine is not typically tender to palpation {Choice C) Lumbar spinal stenosis is a narrowing of the spinal canal with comp ression of one or more of the spinal roots . Most affected patients are >60. Patients experience back pain that radiates to the buttocks and thighs. Symptoms often worsen with walking and lumbar extension and improve with lumbar flexion. Numbness and paresthesias may occur. The diagnosis is confirmed with MRI. {Choice D) Although prostate cancer is a possibility, this patient's young age, localized pain on palpation, lack of night pain, and lack of urinary symptoms make this a less likely diagnosis {Choice E) Vertebral compression fractures can cause local tenderness to palpation, but this usually occurs in elderly patients with a history of osteoporosis Educational objective:
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process of the involved vertebra can be an important clue. Leukocytes may be elevated or normal. Platelet count is often high as a marker of inflammation/stress. The erythrocyte sedimentation rate is often significantly elevated (>100 mm/hr) MRI is the most sensitive diagnostic study. Treatment is long-term intravenous antibiotics with or without surgery. (Choice A) Ankylosing spondylitis is characterized by pain and progressive limitation of back motion. It occurs most often in young men. Symptoms are usually most severe in the morning and improve as the day progresses. Exquisite tenderness to palpation is not a classic finding {Choice B) Lumbar disk herniation typ ically presents with the acute onset of back pain with or without radiation down a leg. Patients can usually recall an inciting event The pain is worse with activity and improves with rest The spine is not typ ically tender to palpation {Choice C) Lumbar spinal stenosis is a narrowing of the spinal canal with compression of one or more of the spinal roots . Most affected patients are >60. Patients experience back pain that radiates to the buttocks and thighs. Symptoms often wo rsen with walking and lumbar extension and improve with lumbar flexion. Numbness and paresthesias may occur. The diagnosis is confi rmed with MRI.
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(Choice D) Although prostate cance r is a possibility, this patient's young age, localized pain on palpation, lack of night pain, and lack of urinary symptoms make this a less likely diagnosis
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(Choice E) Vertebral comp ression fractures can cause local tenderness to palpation, but this usually occurs in elderly patients with a history of osteoporosis
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Educational objective: Tenderness to gentle percussion over the spinous process of the involved ve rtebra is the most reliable sign for spinal osteomyelitis Pain is not relieved with rest Fever and leukocytosis are unreliable findings The erythrocyte sedimentation rate is grossly elevated. MRI is the most sensitive diagnostic study. There should be a ve ry high index of suspicion fo r vertebral osteomyelitis in patients with a history of injection drug use or recent distant site infection (eg, urinary tract infection). Time Spent 2 seconds
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W hat is the most appropriate next step in the management of this patient?
0 A Oral free water 0 B. IV 0.9% saline
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6 D. IV 5% dextrose in 0.45% saline
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0 E. IV free water
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A 71-year-old man with inclusion body myositis is brought to the emergency department from his nursing home after becoming less interactive. His temperature is 37.1°C, blood pressure is 90/60, heart rate is 98/min, and respiratory rate is 16/min. He has orthostatic vital signs Physical examination reveals a frail man with dry oral mucosa and decreased axillary perspiration Laboratory studies reveal the following
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Explanation: Hypernatremia reflects a water deficit in relation to sodium, and occurs when there is inc reased hypotonic fluid loss and decreased access to free wate r. It most often occurs in people who are debilitated or have altered levels of consciousness and cannot access free water .
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Inclusion body myositis is a condition involving adult-onset distal muscular weakness and atrophy . Majority of patients may also present with dysphagia. In the above vignette, the patient's medical condition/disability has most likely resulted in poor free water intake, thereby causing severe hypovolemic hypernatremia (mental status changes, severe volume depletion). The initial treatment fo r severe hypovolem ic hypernatremia is isotonic 0.9% saline, which acts to gradually correct the hyperosmolality while normalizing the patient's volume status. Isotonic saline is usually hypoosmola r in compa rison to the hypernatremic plasma Once the volume deficit has been restored, such patients are then switched to half-normal (0.45%) saline in order to better replace the free water deficit. The goal rate of plasma sodium correction is no more than 1 mEq/Uh A greater rate of correction may result in cerebral edema.
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Patients with less severe hypovolem ic hypernatremia are initially treated with 5% dextrose in 0.45% saline.
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(Choice A) Oral free water is reasonable therapy for otherwise well-functioning patients who have been free water depleted (e g , euvolemic and hype rvolemic hypernatremia) Free water will not restore this patient's volume status, and should not be used. (Choice C) 5% dextrose in water (05W) is the treatment of choice fo r patients with euvolemic and hypervolemic hypernatremia. (Choice D) 5% dextrose in 0.45% saline is the treatment of choice for mild hypovolemic hypernatremia. (Choice E) IV free water may cause red blood cell lysis due to osmotic shock when given to patients with euvolem ic or hypervolemic hypernatremia; therefore, 5% dextrose should be used instead.
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• The initial treatment for severe hypovolemic hypernatremia is isotonic 0.9% saline, which acts to gradually co rrect the hype rosmolality while normalizing the patient's volume status. Isotonic saline is usually hypoosmolar in comparison to the hypernatremic plasma. Once the volume deficit has been restored, such patients are then switched to half-normal (045%) saline in order to better replace the free water deficit. The goal rate of plasma sodium correction is no more than 1 mEq/Uh. A greater rate of correction may result in ce rebral edema. Patients with less severe hypovolemic hypernatremia are initially treated with 5% dextrose in 045% saline. (Choice A) Oral free water is reasonable therapy for otherwise well-functioning patients who have been free water depleted (e.g , euvolemic and hype rvolemic hypernatremia) Free water will not restore this patient's volume status, and should not be used. {Choice C) 5% dextrose in water ( D5W) is the treatment of choice for patients with euvolem ic and hypervolemic hypernatremia.
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(Choice D) 5% dextrose in 045% saline is the treatment of choice fo r mild hypovolemic hypernatremia.
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(Choice E) IV free water may cause red blood cell lysis due to osmotic shock when given to patients with euvolemic or hypervolemic hypernatremia; therefore, 5% dextrose should be used instead. {Choice F) Colloid solutions are effective in co rrecting hypovolem ia; however , these are not more successful, and are significantly more expensive, than normal saline. For these reasons, collo id solutions are not recommended as the fi rst-line therapy fo r hypovolemia Educational Objective: The most common cause of hypernatremia is hypovolemia. Mild cases can be treated with 5% dextrose in 04 5% saline. Severe cases should be initially treated with 0.9% saline. Time Spent 2 seconds
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e; A Hyperthyroidism
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F. Right ventricular failure
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A 45-year-old man comes to the emergency department complaining of dyspnea, fatigue, poor appetite, and weight gain over the past 2 weeks. His symptoms started with worsening shortness of breath with exertion. He has been waking up at night breathless for the past few days. He also finds it difficult to open his eyes in the morning due to facial edema. The patient has no other medical problems and takes no medications. His blood pressure is 200/ 120 mm Hg and pulse is 100/min. Physical examination shows anasarca with distended jugular ve ins while sitting upright Lung auscultation shows bibasilar crackles. Urinalysis shows 1+ protein, no nitrite, trace leukocyte esterase, >50 red blood cells, red blood cell casts, and occasional neutrophils. W hich of the following is the most likely mechanism of this patient's edema?
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F. Right ventricular fa ilure [17%) Explanation:
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Causes of peripheral edema Primary mechanism
Clinical examples • Heart failure (left ventricular & cor pulmonale)
Increased capillary hydrostatic pressure
• Primary renal sodium retention (renal disease & drugs) • Venous obstruction (eg, cirrhosis & venous insufficiency)
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Decreased capillary oncotic pressure (hypoalbuminemia)
• Protein loss (eg, nephrotic syndrome & protein-losing enteropathy) • Decreased albumin synthesis (eg, cirrhosis & malnutrition) • Bums, trauma & sepsis
Increased capillary permeability
• Allergic reactions • Acute respiratory distress syndrome • Malignant ascites
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• Bums, trauma & sepsis
Increased capillary permeability
• Allergic reactions • Acute respiratory distress syndrome • Malignant ascites
Lymphatic obstruction/increased interstitial oncotic pressure
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• Malignant ascites • Hypothyroidism • Lymph node dissection
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This patient's presentation (anasarca, pulmonary and facial edema, hypertension, and abnormal urinalysis with proteinuria and microscopic hematuria) suggests acute nephritic syndrome with fluid overload. The table summarizes the primary mechanisms of the most common causes of peripheral edema. Acute nephritic syndrome is primary glomerular damage due to causes such as poststreptococcal glomerulonephritis, lgA nephropathy, lupus nephritis, membranoprolife rative glomerulonephritis, and rapidly progressive glomerulonephritis Primary glomerular damage leads to decreased glomerular filtration rate with eventual development of significant volume overload (eg, pulmonary edema, distended neck veins, anasarca) Abnormal urinary sediment (red blood cells, red blood cell casts) and variable degrees of proteinuria are present on urinalysis Serum creatinine can also be elevated. The increased volume also leads to hypertension Significant proteinuria (3+) eventually leads to hypoalbuminemia, which further contributes to the edema. Decreased glomerular filtration rate is also the cause of edema in patients with end-stage renal disease.
{Choice A) Pretibial myxedema is a localized nonpitting thickening and induration of the skin over the lower legs, pretibial area, or the dorsum of the feet in patients with Graves' disease. However, anasarca and abnormal urinalysis are usually not seen in patients with hyperthyroidism.
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protein-losing enteropathy) or decreased albumin synthesis (eg, cirrhosis or severe malnutrition) It can cause significant peripheral edema but usually does not cause pulmonary edema. Alveolar capillaries have a higher permeability to albumin at baseline (reducing oncotic pressure difference) and greater lymphatic flow than skeletal muscle, protecting the lungs from edema. (Choice C) Cirrhosis can cause portal hypertension as the scarred liver limits blood flow th rough the sinusoidal network. Cirrhotic patients develop ascites and edema in the lower extremities due to increased venous pressure below the liver. However , the venous pressure above the hepatic ve ins (eg, jugular venous pressure) is usually reduced or normaL Pulmonary edema typically does not occur in patients with cirrhosis. (Choice E) Renal hypoperfusion can occur in heart failure (decreased ca rdiac output), which leads to increased renal sodium and water retention and edema. However , the urinalysis in patients with heart fa ilure does not show red blood cells or casts, as seen in this patient (Choice F) Right ventricular failure is usually due to underlying left heart fa ilure or severe pulmonary disease. It usually manifests with elevated jugular venous pressure and peripheral edema. Patients with severe cases can also develop hepatosplenomegaly , ascites, and anasarca. However, abnormal urinalysis with hematuria would not be expected in patients with right heart failure. Educational objective: Nephritic glomerulonephritis usually presents with urinary sediment containing red blood cells, occasional white blood cells, and red cell or mixed cellular casts. Edema in these patients is due primarily to decreased glomerular filtration rate and retention of sodium and water by the kidneys. Refer ences: 1. Acute glomerulonephritis
Time Spent 2 seconds
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Hb WBC Platelets BUN Serum Creatinine
6 A Broad cast
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9.5 g/dl 15,000/cmm 130,000/cmm 34 mg/dl 2.2 mg/dl
Which of the following is the most likely microscopic finding on urinalysis?
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A 57-year-old woman is admitted to the ICU after being involved in a highway motor vehicle accident. She was hypotensive at the scene and received 7 liters of fl uids, wh ich included crystalloids, blood, and fresh frozen plasma She apparently had significant external blood loss from multiple fractures and skin loss. She undergoes surgery, after which she is transferred to the ICU and receives continuous IV fl uids and vasopressors. Her laboratory studies 24 hours after the accident show the following:
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® D. WBC casts e; E. Fatty casts
0 F. Eosinophils Subm it
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p Explanation: The clinical picture of this patient is highly suggestive of acute tubular necrosis (ATN) following hypovolemic shock. Her serum BUN and Cr ratio is less than 20 1. Other findings that support this diagnosis are 1. Urine osmolality of 300-350 mOsm/L (but never <300) 2. Urine Na of >20 mEq/L 3. FE--Na -->2% Prolonged hypotension from any cause can lead to ATN. The hallmark findings on urinalys is are muddy brown granular casts consisting of renal tubular epithelial cells; this is a nonspecific , but very sensitive finding for ATN.
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(Choice A) Broad casts are seen in patients with chronic renal failure (CRF) These arise in the dilated tubules of enlarged nephrons that have undergone compensatory hypertrophy in response to the reduced renal mass. Waxy casts, which are shiny and translucent, are also generally seen in chronic renal disease. {Choice C) RBC casts are indicative of glomerular disease or vasculitis. (Choice D) WBC casts are definitive evidence that urinary WBCs originate in the kidney These are seen in cases of interstitial nephritis, pyelonephritis, etc. (Choice E) Fatty casts are seen in conditions causing nephrotic syndrome Hyaline casts are composed almost entirely of protein and pass unchanged along the urinary tract; these may be seen in asymptomatic individuals and in patients with pre-renal azotemia. Educational Objective: Muddy brown granular cast - Acute tubular necrosis RBC casts - Glomerulonephritis WBC casts - Interstitial nephritis and pyelonephritis
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support this diagnosis are 1. Urine osmolality of 300-350 mOsm/L (but never <300) 2. Urine Na of >20 mEq/L 3. FE--Na -->2%
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Prolonged hypotension from any cause can lead to ATN. The hallmark findings on urinalys is are muddy brown granular casts consisting of renal tubular epithelial cells; this is a nonspecific , but very sensitive finding for ATN. (Choice A) Broad casts are seen in patients with chronic renal failure (CRF) These arise in the dilated tubules of enlarged nephrons that have undergone compensatory hypertrophy in response to the reduced renal mass. Waxy casts, which are shiny and translucent, are also generally seen in chronic renal disease. {Choice C) RBC casts are indicative of glomerular disease or vasculitis. (Choice D) WBC casts are definitive evidence that urinary WBCs originate in the kidney These are seen in cases of interstitial nephritis, pyelonephritis, etc. (Choice E) Fatty casts are seen in conditions causing nephrotic syndrome Hyaline casts are composed almost entirely of protein and pass unchanged along the urinary tract; these may be seen in asymptomatic individuals and in patients with pre-renal azotemia. Educational Objective: Muddy brown granular cast - Acute tubular necrosis RBC casts - Glomerulonephritis WBC casts - Interstitial nephritis and pyelonephritis Fatty casts - Nephrotic syndrome Broad and waxy casts - Chronic renal failure • Extremely high yield question fo r the USMLE!!! Time Spent 2 seconds
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® A Careful allergy history taking ® B. Monitoring the blood drug levels ® C. Pre-treatment with allopurinol
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® E. Agg ressive intravenous hyd ration Submit
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A 23-year-old male hospitalized fo r confusion and seizures is treated with intravenous high-dose acyclovir. On the third day of hospitalization, his serum c reatinine level inc reases to 3.4 mg/dl from a baseline of 0.9 mg/dl at admission. The observed finding could have been potentially prevented by which of the following?
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B. Monitoring the blood drug levels [5%) C. Pre-treatment with allopurinol [3%) D. Pre-treatment with prednisone [4%) .;
E. Aggressive intravenous hydration [86%)
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Explanation: The acute elevation of thi s patient's serum creatinine is most likely secondary to acyclovir nephrotoxicity, a phenomenon that occurs in 5-10% of patients who receive the drug intravenously Acyclovir is excreted principally in the urine via glomerular filtration and tubular secretion . When the acyclovir concentration in the collecting duct exceeds its solubility, crystallization, crystalluria, and renal tubular damage may result In most cases, this toxic complication is transient and can be prevented (as well as treated) with adequate hydration and dosage adjustment, which includes slowing the rate of intravenous infusion. {Choice A) Allergic reaction is not the most common cause of acyclovir-induced renal failure.
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{Choice B) Monitoring of acyclovir blood levels is not always effective in preventing nephrotoxicity During states of low intravascular volume (eg, dehydration), nephrotoxicity can develop secondary to drug crystallization within the collecting duct even when acyclovir blood levels are not within the established toxic range (Choice C) Allopurinol pre-treatment may be used in lymphoma and leukemia to prevent tumor lysis-associated urate crystal nephropathy (Choice D) Pre-treatment with prednisone may be used to minimize radiocontrast-induced allergic reactions. Educational Objective: Acyclovir can cause crystalline nephropathy if adequate hydration is not also provided Time Spent 3 seconds
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e; A 24 hr urine collection fo r metabolic evaluation
6 B. Reassurance e; C. Fluid intake greater than 2 U day
6 D. Intake of potassium citrate
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A 26-year-old man comes to the emergency department because of a sudden onset of severe right-sided flank pain The pain is col icky and radiates from the flank to the scrotum. He also has nausea, vom iting and dark-colored urine. He has never had these symptoms before. His temperature is 37° C (98 6° F), blood pressure is 126/70 mm Hg, pulse is 90/min, and respirations are 18/min. Examination shows no abnormalities. He is given adequate analgesia Non-contrast helical CT shows a 4 mm radiopaque stone in the right upper ureter. Laboratory studies show serum calcium of 9.8 mg/dl, serum creatinine of 0.9 mg/dl , and BUN of 15 mg/dl. Urinalys is shows hematuria but no casts. W hich of the following is the most appropriate next step in management?
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Explanation: This patient has the classic clinical presentation of nephrolithiasis The following are important concepts in the management of such patients 1. Imaging study - CT scan of the abdomen without contrast is the investigation of choice because of its high sensitivity and specificity It has the advantage over the plain abdominal x-ray (KUB) in detecting the radiolucent stones. 2. Narcotics and NSAIDs- These are equally effective in relieving the pain of acute renal colic ; however , in patients with normal renal function, NSAIDs are preferred over narcotics because the latter can exacerbate nausea and vom iting 3. Size of the stone - Stones measuring less than 5mm in diameter typ ically pass spontaneously with conservative management. This includes a fluid intake of greater than 2L daily . Increased hyd ration increases the urinary flow rate and lowers the urinary solute concentration, thus preventing stone formation. 4. Urology referral - Urgent urologic evaluation is warranted in patients with anuria, urosepsis, or acute renal fa ilure. (Choice A) A detailed metabolic evaluation is not needed when a patient presents with his first renal stone. In patients with recurrent renal stones, 24-hr urine is collected to identify any underlying metabolic disorder. A complete urinary evaluation includes measurement of calcium, citrate, c reatinine, uric acid, oxalate, pH and sodium levels. (Choice B) Reassurance alone is not appropriate Although his renal stone is relatively small, he still requires conservative management (ie , adequate hydration). (Choice D) Potassium citrate is the appropriate treatment when a patient presents with a history of recurrent stone formation due to citrate deficiency. (Choice E) Restriction of dietary oxalate is helpful when a patient presents with a history of
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g g y g because of its high sensitivity and specificity It has the advantage over the plain abdominal x-ray (KUB) in detecting the radiolucent stones. 2. Narcotics and NSAIDs- These are equally effective in relieving the pain of acute renal col ic ; however, in patients with normal renal function, NSA IDs are preferred over narcotics because the latter can exacerbate nausea and vom iting 3. Size of the stone - Stones measuring less than 5mm in diameter typically pass spontaneously with conservative management This includes a fluid intake of greater than 2L daily. Increased hydration increases the urinary flow rate and lowers the urinary solute concentration, thus preventing stone formation. 4. Urology referral - Urgent urologic evaluation is warranted in patients with anuria, urosepsis, or acute renal failure. {Choice A) A detailed metabolic evaluation is not needed when a patient presents with his first renal stone. In patients with recurrent renal stones, 24-hr urine is collected to identify any underlying metabolic disorder. A complete urinary evaluation includes measurement of calcium, citrate, c reatinine, uric acid, oxalate, pH and sodium levels. (Choice B) Reassurance alone is not appropriate Although his renal stone is relatively small, he still requires conservative management (ie , adequate hydration). (Choice D) Potassium citrate is the appropriate treatment when a patient presents with a history of recurrent stone fo rmation due to citrate deficiency . (Choice E) Restriction of dietary oxalate is helpful when a patient presents with a history of recurrent calcium stone formation due to hyperoxaluria Educational Objective: Hydration is the cornerstone of therapy for renal stone disease. A detailed metabolic evaluation is not needed when a patient presents with his first renal stone. Time Spent 2 seconds
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Hb WBC Platelets Serum Na Serum K BUN Serum creatinine
10.5 g/dl 7,400/cmm 160,000/cmm 135 mEq/L 5.0 mEq/L 50 mg/dl 3.0 mg/dl
Ultrasonogram of the abdomen shows bilateral small kidneys and no evidence of hydronephrosis. Kidney biopsy shows intimal thickening and luminal narrowing of renal arterioles with evidence of sclerosis. Which of the following is the most likely cause of this patient's findings?
6 A Hypertension <0 B. Diabetes mellitus
6 C. Multiple myeloma ® 0 . Analgesic abuse Submit
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A 70-year-old man is brought to the hospital by his son because of worsening fatigue His son states that his father does not like seeing doctors and has not seen a physician in the past 20 yea rs. He has no medical problems Physical examination of the prostate shows no abnormalities. Laboratory studies show:
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Explanation: This patient most likely has benign nephrosclerosis secondary to hypertension. Hypertension is the second leading cause of end stage renal disease in the United States. It is inter-related with kidney disease; hypertension causes nephropathy, and vice versa. In particular, it is the renal vasculature that is exquisitely sensitive to damages incurred by sy stemic hypertension. Arteriosclerotic lesions of afferent and efferent renal arterioles and glomerular capillary tufts are the most common renal vascular lesions seen. As the hypertension progresses, there is a progressive decrease in renal blood flow and glomerular filtration rate. The sequence of kidney damage evolves from nephrosclerosis to glomerulosclerosis. Nephrosclerosis is characterized by hypertrophy and intimal medial fibrosis of renal arterioles; whereas, glomerulosclerosis is characterized by progressive loss of the glomerular capillary surface area with glomerular and peritubular fibrosis. Microscop ic hematuria and proteinuria occur due to these glomerular lesions. The kidneys generally decrease in size.
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(Choice B) Diabetic nephropathy is the leading cause of end stage renal disease in the United States. Increased extracellular matrix, basement membrane thickening, mesangial expansion, and fibrosis characterize diabetes mellitus nephropathy The sequence of pathological changes in the kidneys of a patient with diabetes mellitus is as follows 1. Within the first year of diabetes mellitus - Glomerular hyperperfusion and renal hypertrophy with inc rease in glomerular filtration rate. 2. First five years of diabetes mellitus - Glomerular basement membrane thickening, glomerular hypertrophy, and mesangial volume expansion with glomerular filtration rate returning to normaL 3. Within 5-10 years of diabetes mellitus- Microalbuminuria, which later progresses to overt nephropathy (Choice C) Some degree of renal insufficiency is seen in approximately 50% of patients with multiple myeloma along the course of their disease. This is due to obstruction of the distal and collecting tubules by large laminated casts consisting mainly of Bence-Janes proteins Amyloid deposition and infiltration of the kidney by plasma cells are commonly seen.
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hypertrophy and intimal medial fibrosis of renal arterioles; whereas, glomerulosclerosis is characterized by progressive loss of the glomerular capillary surface area with glomerular and peritubular fibrosis. Microscopic hematuria and proteinuria occur due to these glomerular lesions. The kidneys generally decrease in size. (Choice B) Diabetic nephropathy is the leading cause of end stage renal disease in the United States. Increased extracellular matrix, basement membrane thickening, mesangial expansion, and fibrosis characterize diabetes mellitus nephropathy The sequence of pathological changes in the kidneys of a patient with diabetes mellitus is as follows 1. W ithin the first year of diabetes mellitus - Glomerular hyperperfusion and renal hypertrophy with increase in glomerular filtration rate. 2. First five years of diabetes mellitus - Glomerular basement membrane thickening, glomerular hypertrophy , and mesangial volume expansion with glomerular filtration rate returning to normal. 3. W ithin 5-10 years of diabetes mellitus- Microalbuminuria, which later progresses to overt nephropathy
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(Choice C) Some degree of renal insufficiency is seen in approximately 50% of patients with multiple myeloma along the course of their disease. This is due to obstruction of the distal and collecting tubules by large laminated casts consisting mainly of Bence-Janes proteins. Amyloid deposition and infiltration of the kidney by plasma cells are commonly seen. (Choice D) Analgesic abuse nephropathy is primarily a tubulointerstitial disease characterized by focal glomerulosclerosis Educational Objective: The most common renal vascular lesions seen in hypertension are arteriosclerotic lesions of afferent and efferent renal arterioles and glomerular capillary tufts . Diabetes mellitus nephropathy is characterized by increased extracellular matrix, basement membrane thickening, mesangial expansion, and fibros is. Time Spent 3 seconds
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Complete blood count Hematocrit
34%
Serum chemistry
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22
Sodium
117 mEq/L
Potassium
5.4 mEq/L
Bicarbonate
22 mEq/L
Creatinine
1.3 mg/dl
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Rapid correction of this patient's metabolic abnormalities puts him at highest risk of which of the following? e')
A Cerebral edema
e
B. Embolic stroke
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A 67-year-old man with mild chronic obstructive pulmonary disease is brought to the emergency department by his daughter with the chief complaint of seizure. The patient has had episodes of confusion and lethargy over the past week. He complains of some exertional shortness of breath and nonproductive cough. His daughter believes that he is losing weight and has decreased appetite His temperature is 37.2 C (99 F), blood pressure is 134/88 mm Hg, and pulse is 104/min and irregular The mucous membranes are moist and there is no peripheral edema. Neurologic examination is unremarkable. Laboratory results are as follows:
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104/min and irregular The mucous membranes are moist and there is no peripheral edema. Neurologic examination is unremarkable. Laboratory results are as follows: Complete blood count Hematocrit
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34%
Serum chemistry
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Sodium
117 mEq/L
Potassium
5.4 mEq/ L
Bica rbonate
21
22 Creatinine
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22 mEq/L
1.3 mg/dl
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Rapid correction of this patient's metabolic abnormalities puts him at highest risk of which of the following?
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<0 A Cerebral edema <0 B. Embolic stroke <0 C. Hydrocephalus <0 D. Osmotic demyelination <0 E. Ventricular arrhythmias Submit
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Explanation: This patient presents with a provoked seizure in the setting of severe hyponatremia This is considered a medical emergency and requires prompt correction of the serum sodium concentration with 3% saline solution. However, correction of the serum sodium should not exceed 0.5 mEq/Uhr to avoid causing irreversible brain damage from osmotic demyelination or central pontine myelinolysis. Rapid correction of serum sodium in the setting of hyponatremia results in excess wate r being moved by osmosis from the intracellular compartment (neurons and glia) into the extracellular compa rtment This in turn leads to disruption of cellular metabolic activity and subsequent cell damage. The opposite is true when rapidly correcting a patient with hypernatremia, when cerebral edema can occur {Choice A) This patient's hyponatremia could be from lung cancer-associated syndrome of inappropriate antidiuretic hormone given his euvolemic status, recent weight loss, and smoking history.
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{Choice B) This patient has an irregular heart rhythm, which may be secondary to atrial fib rillation, and therefore is at increased risk of an embolic stroke. However , rapid correction of his hyponatremia will not contribute to that risk.
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{Choice C) Rapid co rrection of hyponatremia results in increased water movement out of brain tissue and so would not contribute to the formation of hydrocephalus. Hydrocephalus can be either obstructive (noncommunicating) or nonobstructive (communicating), resulting from excess cerebrospinal fluid production or impaired ce rebrospinal fluid absorption {Choice E) Electrolyte abnormalities can result in cardiac arrhythmias However , rapid co rrection of hyponatremia is more likely to result in osmotic demyelination in the central nervous system than to cause a ventricular arrhythmia Educational objective: Acute, symptomatic hyponatremia (impaired mental status/seizures) is a medical emergency. It requires a prompt inc rease in the serum sodium concentration with 3% or hypertonic saline at a rate of no more than 0.5 mEq/Uhr to avoid causing central nervous system osmotic demyelination syndrome .
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Sodium
140 mEq/L
Potassium
6.8 mEq/L
Bicarbonate
18 mEq/L
Blood urea nitrogen
24 mg/dl
Creatinine
1.6 mg/dl
Calcium
8 mg/dl
Glucose
160 mg/dl
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A 58-year-old man with Burkitt lymphoma is admitted to the hospital for chemothe rapy Medical history includes hypertension, stable angina, and hyperlipidemia Two days after starting chemotherapy, the patient reports nausea and generalized weakness. Laboratory results are as follows:
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EGG shows peaked T waves. Which of the following interventions should be employed next to rapidly lower serum potassium in this patient?
6 A Calcium carbonate
6 B. Furosemide e; C. Hemodialysis 6 D. High-dose inhaled beta-2 agonist 6 E. Insulin and glucose 6 F. Normal saline e; G. Sodium polystyrene sulfonate
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Explanation:
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Clinical features of hyperkalemia
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Sequence of ECG changes
Cardiac membrane stabilization
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Tall peaked T waves with shortened QT interval PR prolongation & QRS widening Disappearance of P wave Conduction blocks, ectopy, or sine wave pattern
• Calcium infusion
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Rapidly acting treatment options
• Insulin with glucose • Beta-2 adrenergic agonists • Sodium bicarbonate
Removal of potassium from the body (slow-acting)
• Diuretics • Cation exchange resins • Hemodialysis
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This patient with Burkitt lymphoma has hyperkalemia likely due to tumor lysis syndrome from chemotherapy Indications for emergent treatment of hyperkalemia include presence of hyperkalem ia-related ECG changes or marked elevation (>6 5 mEq/L) or rapid rise in serum potassium level. Hyperkalemia is life threatening due to its adverse cardiac effects, including significant bradycardia (sinus node dysfunction, atrioventricular block) and ventricular
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removing potassium from the body. Insulin (administered intravenously) can move potassium intracellularly within minutes. Glucose is given along with insulin to avoid hypogly cem ia Inhaled beta agonists are also rapidly acting agents that shift potassium intracellularly However, their use in patients with active coronary artery disease (eg, stable angina) can cause tachycardia and precipitate angina Therefore, insulin is the preferred agent in this patient (Choice D) Intracellular shifts are usually transient, so efforts to decrease total body potassium must still be made, although this occurs over a longer time frame. {Choice A) Administration of intravenous calcium chloride or gluconate (not calcium carbonate, which is used as an oral calcium supplement) helps stabilize the ca rdiac membrane, making it resistant to the effects of hype rkalemia However , calcium has no effect on serum potassium level. {Choice B) Furosem ide is a loop diuretic that promotes renal potassium excretion. Onset of action is delayed by approximately 30 minutes. (Choice C) Hemodialysis is the most definitive way to remove potassium from the body in patients with renal failure. However, the process often takes time to prepare (eg, catheter placement, dialysis machine setup)
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(Choice F) Normal saline may be used to manage pre renal azotemia with or without hyperkalemia. Normal saline has no direct effect on serum potassium (Choice G) Sodium polystyrene sulfonate is a potassium-binding resin that decreases total body potassium content Sodium is exchanged for potassium in the gut Sodium polystyrene sulfonate takes at least 1-2 hours to take effect Educational objective: Hyperkalemia is a medical emergency Therapy involves 3 goals: Stabilizing the ca rdiac membrane with calcium, shifting potassium intracellularly , and decreasing the total body potassium content Insulin/glucose administration is the quickest way to lower serum potassium concentration. - -
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pH Pa0 2
7.54 124 mmHg
PaC0 2
20 mmHg
Bica rbonate
17 mEq/L
W hich of the following additional findings do you most expect in this patient? C)
A. Low urine bicarbonate excretion
C)
B. High urine pH
C)
C. High serum aldosterone level
C)
D. High serum anion gap
C)
E. High serum albumin level
Submit
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Lab Values
A 34-year-old male is recovering from head trauma sustained in a motor vehicle accident He is currently in the intensive care unit on mechanical ventilation. His most recent arterial blood gas analysis shows
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E. High serum albumin level [2%) Explanation: While being mechanically ventilated this patient is vulnerable to forced hyper- or hypoventilation Ventilation is defined as the tidal volume multiplied by the respiratory rate. Hyperventilation (caused by increased tidal volume and/or respiratory rate) results in excessive C0 losses and 2 respiratory alkalosis, while hypoventilation (caused by decreased tidal volume and/or respiratory rate) results in co retention and respiratory acidosis. The patient described is experiencing 2 respiratory alkalosis as evidenced by his increased arterial blood pH (normal = 74) and his decreased PaC0 (normal = 40 mmHg). His serum bicarbonate level is decreased due to 2 attempted renal compensation fo r the respiratory alkalosis. Specifically, the kidneys retain increased amounts of H+ (protons) and excrete increased amounts of bicarbonate (HC0 -) in an 3 attempt to normalize the serum pH The increased amount of HC0 - in the urine alkalinizes the 3 urine.
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(Choice A) Renal compensation for respiratory or metabolic acidosis involves low urine bicarbonate excretion. {Choice C) Increased serum aldosterone would result in increased H+ and K+ losses in the urine and serum alkalosis. "Contraction alkalosis" occurs in states of intracellular volume contraction, where inc reased levels of aldosterone function to restore intravascular volume but also cause increased urinary proton loss. (Choice D) A high serum anion gap occurs in metabolic acidoses resulting from diabetic ketoacidosis, renal fa ilure, lactic acidosis, and methanol, ethylene glycol or salicylate poisoning. {Choice E) A high serum albumin level may indicate hemoconcentration, as occurs in dehydration
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Ventilation is defined as the tidal volume multiplied by the respiratory rate. Hyperventilation (caused by increased tidal volume and/or respiratory rate) results in excessive C0 losses and 2 respiratory alkalosis, while hypoventilation (caused by decreased tidal volume and/or respiratory rate) results in co retention and respiratory acidosis. The patient described is experiencing 2 respiratory alkalosis as evidenced by his increased arterial blood pH (normal = 74) and his decreased PaC0 (normal = 40 mmHg). His serum bicarbonate level is decreased due to 2 attempted renal compensation for the respiratory alkalosis. Specifically , the kidneys retain increased amounts of H+ (protons) and excrete increased amounts of bicarbonate (HC0 -) in an 3 attempt to normalize the serum pH The increased amount of HC0 - in the urine alkalinizes the 3 urine. (Choice A) Renal compensation fo r respiratory or metabolic acidosis involves low urine bicarbonate excretion.
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(Choice C) Increased serum aldosterone would result in increased H+ and K+ losses in the urine and serum alkalosis. "Contraction alkalosis" occurs in states of intracell ular volume contraction, where inc reased levels of aldosterone function to restore intravascular volume but also cause increased urinary proton loss. (Choice D) A high serum anion gap occurs in metabolic acidoses resulting from diabetic ketoacidosis, renal failure, lactic acidosis, and methanol, ethylene glycol or salicylate poisoning . {Choice E) A high serum albumin level may indicate hemoconcentration , as occurs in dehydration Educational objective: The kidney compensates fo r respiratory alkalosis by preferentially excreting bicarbonate in the urine. The result is an alkalinized urine (increased urine pH) Time Spent 2 seconds
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A 24-year-old woman is brought to the emergency department due to feeling lightheaded every time she stands up The patient has no significant medical problems. She left her boyfriend 4 months ago as he was "eating too much" and has since had decreased appetite and lost 5 kg (11 lb). The patient has also missed her last 2 menstrual periods. She does not use tobacco, alcohol, or illicit drugs Family history is significant for coronary artery disease and congestive heart fa ilure. Her temperature is 36.7 C (98 F), blood pressure is 100/70 mm Hg, and pulse is 88/min while supine. On standing, blood pressure is 80/55 mm Hg and pulse is 120/min. Other than dry skin and mucous membranes, the patient's physical examination is unremarkable. Initial laboratory resu~s are as follows Serum chemistry
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Sodium
132 mEq/dL
Potassium
2.8 mEq/dL
Chloride
88 mEq/dL
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Urine electrolytes
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Sodium
73 mEq/L (-20 mEq/L)
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Potassium
68 mEq/L (5-15 mEq/L)
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Which of the following is the most likely underlying etiology for this patient's symptoms?
6 A. Cerebral salt wasting 6 B. Diuretic abuse e; C. Laxative abuse 6 D. Low caloric intake
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Item: 30 of 38 0. ld : 3085 I
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Sodium
132 mEq/dL
Potassium
2.8 mEq/dL
Chloride
88 mEq/dL
Urine electrolytes
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alcohol, or illicit drugs Family history is significant for co ronary artery disease and congestive heart fa ilure. Her temperature is 36.7 C (98 F) , blood pressure is 100/70 mm Hg, and pulse is 88/min while supine On standing, blood pressure is 80/55 mm Hg and pulse is 120/min. Other than dry skin and mucous membranes, the patient's physical examination is unremarkable. Initial laboratory results are as follows :
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Sodium
73 mEq/L (-20 mEq/L)
Potassium
68 mEq/L (5-15 mEq/L)
W hich of the following is the most likely underlying etiology for this patient's symptoms?
® A Cerebral salt wasting ® B. Diuretic abuse ® C. Laxative abuse ® D. Low calo ric intake ® E. Mineralocorticoid defici ency ® F. Self-induced vom iting Submit
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Explanation: This young woman has dizziness due to orthostatic hypotension. In addition, she has abnormal serum and urine electrolytes, including hyponatremia, hypokalemia, hypochloremia, and inc reased urinary sodium and potassium. Diuretic abuse, which leads to hypovolemia, best explains the laboratory findings in this patient as follows: • Normally, dehydrated patients with hyponatremia are expected to have low urine sodium (<20 mEq/L) ; however, this patient has elevated urine sodium, which suggests salt wasting (eg, diuretic use, ce rebral salt wasting [CSW), adrenal insufficiency) • Normally, patients with hypokalemia respond by reducing urine potassium exc retion, except in cases of renal potassium wasting (eg, diuretic use, hyperaldosteronism, renal tubular acidosis). • Hypochloremia is likely a result of diuresis and contraction alkalosis; urine chloride levels can vary.
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Surreptitious diuretic use is sometimes employed as a means to lose weight Patients may gain access to these medications from fam ily members who have been appropriately prescribed these medications. {Choice A) CSW presents with hypovolemia and hyponatremia with high urine sodium (>20 mEq/L) However, CSW always occurs due to a neurologic insult (injury or surgery) (Choice C) Laxative abuse will also lead to hypotension and hypovolemia. However, elevated urine sodium indicates that sodium loss is through the urinary tract (eg, diuretic use) rather than the gastrointestinal tract ( eg, laxative use) (Choice D) Low caloric intake causes weight loss secondary to wasting of muscle mass and fat and could also lead to electrolyte abnormalities. However, elevated urine sodium and potassium are not expected {Choice E) Mineralocorticoid deficiency can lead to wasting of sodium and water, but serum potassium levels are increased in such patients.
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Surreptitious diuretic use is sometimes employed as a means to lose weight Patients may gain access to these medications from fam ily members who have been appropriately prescribed these medications. {Choice A) CSW presents with hypovolemia and hyponatremia with high urine sodium (>20 mEq/L) However, CSW always occurs due to a neurologic insult (injury or surgery). (Choice C) Laxative abuse will also lead to hypotension and hypovolemia However , elevated urine sodium indicates that sodium loss is through the urinary tract (eg, diuretic use) rather than the gastro intestinal tract (eg, laxative use) (Choice D) Low caloric intake causes weight loss secondary to wasting of muscle mass and fat and could also lead to electrolyte abnormalities. However, elevated urine sodium and potassium are not expected (Choice E) Mineralocortico id deficiency can lead to wasting of sodium and water, but serum potassium levels are increased in such patients (Choice F) Self-induced vomiting may lead to hypovolemia, hypokalemia, and hyponatremia However, urinary sodium will be low as the kidneys try to conserve water by maximally resorbing sodium and water. Educational objective: Diuretic abuse leads to increased excretion of water and electrolytes by the kidneys, resulting in dehydration, weight loss, orthostatic hypotension, hyponatremia, and hypokalemia Urinary sodium and potassium will be elevated. Patients sometimes abuse diuretics to induce weight loss. References: 1. Diuretic abuse and central pontine myelinolysis.
Time Spent 5 seconds
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Item: 31 of 38 0. ld : 2633
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Sodium
144 mEq/dL
Potassium
4.3 mEq/dL
Chloride
98 mEq/dL
Bicarbonate
21 mEq/dL
Calcium
14.5 mg/dl
Blood urea nitrogen
48 mg/dl
Creatinine
2.0 mg/dl
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A 54-year-old man comes to the emergency department due to a cough He has a 44-pack-year smoking history but quit a month ago. The patient has also experienced weight loss, anorexia, constipation, inc reased thirst, and fatigue, which he attributes to depression He lost his wife to breast cancer 4 months ago and says that "life hasn't felt the same since then." Blood pressure is 104/68 mm Hg, pulse is 95/min, and respirations are 24/min. Oxygen saturation is 92% on room air. The patient appears thin, pale, and short of breath. Laboratory results are as follows
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Chest x-ray reveals a hilar mass in the left lung W hat is the best next step in management of this patient?
6 A CT scan of the head
6 B. Emergency hemodialysis
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ee -, II ... • .. I ... I ,. I ,. ... • • ,,.. ,. I ,. I • • I room air. The patient appears thin, pale, and short of breath. Laboratory results are as follows: 1 ~
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Sodium
144 mEq/dL
Potassium
4.3 mEq/dL
Chloride
14 15 16 17 18 19
Bicarbonate
20 21
22 23
24
98 mEq/dL
21 mEq/dL
Calcium
14.5 mg/dL
Blood urea nitrogen
48 mg/dL
Creatinine
2.0 mg/dL
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Chest x-ray reveals a hilar mass in the left lung What is the best next step in management of this patient?
<0 A CT scan of the head <0 B. Emergency hemodialysis <0 C. Glucoco rticoids <0 D. Loop diuretics <0 E. Saline hydration Submit
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Management of hypercalcemia Short-term (immediate) treatment Severe (calcium >14 mg/d l ) or symptomatic
• Normal saline hydration plus calcitonin • Avoid loop diuretics unless volume overload (heart failure) exists Long-term treatment • Bisphosphonate (zoledronic acid)
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Moderate (calcium 12-14 mg/dl)
• Usually no immediate treatment required unless symptomatic • Treatment is similar to that for severe hypercalcemia
Asymptomatic or mild (calcium <12 mg/d l )
• No immediate treatment required • Avoid thiazide diuretics, lithium, volume depletion & prolonged bed rest
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Explanation:
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This patient has severe symptomatic hypercalcemia In light of his smoking history and associated lung mass, this likely represents humoral hypercalcemia of malignancy due to secretion of parathyroid hormone-related protein Severe hypercalcemia (serum calcium >14 mg/dl), especially with a rapid rise in serum calcium, can cause weakness, gastrointestinal distress, and neuropsychiatric symptoms (eg, confusion, stupor, coma) Patients are typically volume depleted (as suggested by this patient's blood urea nitrogen to creatinine ratio >20) due
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Management of hypercalcemia Short-term (immediate) treatment Severe (calcium >14 mg/d l ) or symptomatic
• Normal saline hydration plus calcitonin • Avoid loop diuretics unless volume overload (heart failure) exists Long-term treatment • Bisphosphonate (zoledronic acid)
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Moderate (calcium 12-14 mg/dl)
• Usually no immediate treatment required unless symptomatic • Treatment is similar to that for severe hypercalcemia
Asymptomatic or mild (calcium <12 mg/d l )
• No immediate treatment required • Avoid thiazide diuretics, lithium, volume depletion & prolonged bed rest
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Explanation:
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@UWorlcl
This patient has severe symptomatic hypercalcemia In light of his smoking history and associated lung mass, this likely represents humoral hypercalcemia of malignancy due to secretion of parathyroid hormone-related protein Severe hypercalcemia (serum calcium >14 mg/dl), especially with a rapid rise in serum calcium, can cause weakness, gastrointestinal distress, and neuropsychiatric symptoms (eg, confusion, stupor, coma) Patients are typically volume depleted (as suggested by this patient's blood urea nitrogen to creatinine ratio >20) due
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normal saline) to restore intravascular volume and promote urinary calc ium excretion. Calcitonin, by inhibiting osteoclast-mediated bone resorption, quickly reduces serum calcium concentrations and may be administered concurrently with saline. Bisphosphonates (eg, pamidronate, zoledronic acid) also inhibit bone resorption and provide a sustained reduction in calcium levels. However, the calc ium-lowering effect of bisphosphonates is delayed, usually occurring over 2-4 days, and they are typically given after initial administration of saline and calcitonin. (Choice A) This patient may have metastatic carcinoma of the lung, which warrants additional imaging However, the hypercalcemia and hypovolemia must be co rrected urgently, especially before administration of radiographic contrast agents. (Choice B) Hemodialysis is an effective treatment for hypercalcemia. However, it is typically reserved for patients with renal insufficiency or heart fa ilure in whom aggressive hydration cannot be administered safely (Choice C) Glucocorticoids inhibit the formation of 1,25-dihydroxyvitamin D by activated mononuclea r cells in the lungs and lymph nodes. Glucocortico ids can be used to treat hypercalcemia due to excessive vitamin D intake, granulomatous diseases (eg, sarcoidosis), and certain lymphomas However , most cases of malignancy-related hypercalcemia are not due to vitamin D excess. (Choice D) Although loop diuretics can promote diuresis and reduce calcium levels, their routine use in hypercalcemic patients is not recommended as they can worsen the volume depletion Educational objective: Severe hypercalcem ia can cause weakness, gastrointestinal distress, and neuropsychiatric symptoms. Patients are typically volume depleted due to polyuria and decreased oral intake. Initial treatment includes saline hydration to restore intravascular volume and calcitonin to inhibit bone resorption Bisphosphonates further reduce calcium levels and are given after initial administration of saline. References:
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® A Cystoscopy ® B. Finasteride ® C. Prostate biopsy
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® D. Urine culture
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® E. Urine flow rate testing
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A 74-year-old African American man complains of urinary frequency over the last 2 months. He wakes up to use the bathroom several times during the night He also complains of mild straining during urination. Over the last few weeks, he has had 2 episodes of bloody urine that cleared spontaneously. The patient otherwise considers himself in good health. He had right knee replacement for severe osteoarthritis 7 years ago His father died of colon cancer. He has a 30-pack-year smoking history but quit 15 years ago Rectal examination shows an enlarged and smooth prostate with no nodules, and normal rectal sphincter tone. Serum creatinine is 0.8 mg/dl and prostate-specific antigen level is 3.8 ng/ml (normal <4 ng/ml) Urinalysis shows 0-1 white blood cells/hpf, 2-3 red blood cells/hpf, and trace protein Which of the following is the best next step in management of this patient?
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E. Urine flow rate testing [3%] Explanation:
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Indications for cystoscopy • Gross hematuria with no evidence of glomerular disease or infection • Microscopic hematuria with no evidence of glomerular disease or infection but increased risk for malignancy • Recu rrent urinary tract infections
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• Obstructive symptoms with suspicion for stricture, stone
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• Irritative symptoms without urinary infection
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• Abnormal bladder imaging or urine cytology
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(!)UWOI1d
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This patient's presentation is consistent with benign prostatic hyperplasia ( BPH) BPH usually affects men age >50. Patients typically develop lower urinary tract symptoms (eg, increased urinary frequency , hesitation, dribbling, nocturia) and a feeling of incomplete vo iding Rectal examination shows a smooth and symmetrically enlarged prostate without nodules. However , this patient also has gross and microscopic hematuria. Causes of microscopic hematuria include renal (eg, renal cell cance r, lgA nephropathy), ureteral (eg, stricture, stone) , bladder (eg, cancer , cystitis), and prostate/urethral (eg, BPH, prostate cancer, urethritis) abnormalities. Cystoscopy is recommended for all patients with unexplained gross hematuria or with microscopic hematuria and other risk factors for bladder cancer . Risk factors for bladder cancer include c igarette smoking, certain occupational exposures (eg, painters, metal worke rs) , chronic I
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microscopic hematuria and other risk factors for bladder cancer. Risk factors for bladder cancer include c igarette smoking, certain occupational exposures (eg, painters, metal workers), chronic cystitis, iatrogenic causes (eg, cyclophosphamide), and pelvic radiation exposure. Cigarette smoking is the most important risk factor for bladder cancer. While smoking cessation decreases this risk, patients still have a higher risk than nonsmokers even up to 20 years after smoking cessation. Although BPH can cause hematuria, this patient should first be evaluated with cystoscopy to exclude bladder cancer. If negative, he can receive BPH treatment with alpha adrenergic antagonists (eg, terazosin, tamsulosin) with or without 5-alpha reductase inhibitors (eg, finasteride) (Choice B) (Choice C) Prostate biopsy is generally indicated to evaluate for prostate cancer. Although prostate cancer can present with obstructive vo iding symptoms and hematuria, rectal examination usually shows an asymmetrically enlarged prostate that can be firm or have nodules. In this patient with a normal PSA and benign features on prostate exam, biopsy is not needed. (Choice D) Urine culture is generally recommended to rule out infections (eg, cystitis) as the cause of microscop ic hematuria. Cystitis usually presents with acute onset of hematuria, lower urinary tract symptoms, and abnormal urinalysis (eg, pyuria, red blood cells) However, this patient's symptom duration (2 months) and absence of significant pyuria make this less likely. (Choice E) Maximal urinary flow rate testing can also diagnose BPH. Flow rates >15 mU sec usually exclude significant bladder outlet obstruction. This is considered an optional test for most patients Educational objective: Cystoscopy is recommended for patients with gross hematuria or with microscop ic hematuria and other risk factors for bladder cancer. Risk facto rs for bladder cancer include cigarette smoking, ce rtain occupational exposures (eg, painters, metal workers), chronic cystitis, iatrogenic causes (eg, cyclophosphamide), and pelvic radiation exposure References: 1. Indication of cystoscopy in patients with asymptomatic microscopic haematuria. 2. Diagnosis and treatment of bladder cancer: how can we improve?
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A 62-year-old woman presents to your office complaining of urinary frequency and burning during urination. She denies fever, chills, nausea, back pain or abdominal pain Her past medical history is significant for a long history of diabetes mellitus and hypertension She does not use tobacco or consume alcohol. Her blood pressure is 160/ 100 mmHg and her heart rate is 70/min. Her hematocrit is 43% and her WBC count is 8,500/mm 3. Urinalysis reveals the following:
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Glucose
negative
Ketones
negative
Nitrites
positive
Protein
2+
WBC
20-25/hpf
RBC
3-5/hpf
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She is given a three day course of levofloxacin. Urinalysis two weeks later reveals 2+ protein but no nitrites, W BCs, or RBCs. W hich of the following is most likely responsible for her persistent urinalysis abnormality?
e> A Atherosclerotic narrowing of the renal arteries 6 B. Glomerular basement membrane changes 6 C. Cystic transformation of the renal parenchyma 6 D. Parench¥mal atrophy due to calyceal dilation
e> E. Insoluble crystal precipitation in the tubular lumen Submit
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This patient's findings on urinalysis are a reflection of two disease processes Initially she presents with a urinary tract infection characterized by urinary frequency, dysuria, pyuria, and positive nitrites. After the UTI is treated, however , the proteinuria persists This is most likely a reflection of diabetic nephropathy secondary to her longstanding diabetes mellitus. Diabetes mellitus is the leading cause of end stage renal disease in the United States, occurring in 30-40% and 20% of patients with type I and type II diabetes mellitus after 20 years, respectively. The most common histologic lesion in diabetic nephropathy is diffuse glomerulosclerosis. Nodular glomerulosclerosis (with Kimmelstiei-Wilson nodules) is pathognomonic Disease progression can be slowed with strict glycemic control, treatment of hypertension, and angiotensin axis blockade. (Choice A) Renal artery stenosis is typically due to atherosclerotic vascular disease. It presents as difficult-to-control hypertension with or without renal dysfunction Renal artery stenosis is the most common cause of secondary hypertension in adults. It does not typically cause proteinuria.
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(Choice C) Autosomal dominant polycystic kidney disease is the leading cause of inherited renal disease in adults. It typically presents as abdominal or flank pain with mic roscopic or gross hematuria. There is a positive family history in 75% of cases and over half of patients have hypertension at presentation Proteinuria is not a classic finding
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{Choice D) Parenchymal atrophy due to calyceal dilation occurs in obstructive nephropathy. This patient does not have any symptoms of urinary obstruction. Urinary obstruction is much more common in men than in women.
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{Choice E) Insoluble crystal deposition resulting in acute renal fa ilure is seen with hyperuricemia (tumor lysis syndrome), indinavir, acyclovir, and sulfonamide therapy.
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Educational objective: Diabetic nephropathy is characterized by proteinuria and a progressive decline in GFR The pathologic hallmark is nodular glomerulosclerosis but diffuse glomerulosclerosis is more common. Time Spent 3 seconds
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Sodium
132 mEq/L
Potassium
2.4 mEq/L
Calcium
10.1 mg/dL
Chloride
90 mEq/L
Bica rbonate
40 mEq/L
Urine chloride
14 mEq/L
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A 21-year-old woman comes to the physician with progressive weakness and loss of energy She nearly collapsed yesterday while performing one of her routine 3-hour workouts. She is not doing well academically in college despite persistent attempts to improve her grades Her blood pressure is 102/58 mm Hg and pulse is 113/min. Her body mass index is 21 kg/m2 . Fine hair is noted on her scalp. Examination shows dental erosions with slightly enlarged cheeks. There is no edema. Laboratory results are as follows:
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In addition to potassium supplementation, which of the following is the best treatment to co rrect the laboratory abnormalities in this patient? 6 A Acetazolamide 6 B. Breathing in a paper bag
e; C. Calcium gluconate infusion 6 D. Hyperventilation 6 E. Insulin therapy 6 F. Loop diuretics
e; G. Normal saline infusion 6 H. Sodium bica rbonate infusion
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She nearly collapsed yesterday while performing one of her routine 3-hour workouts. She is not doing well academically in college despite persistent attempts to improve her grades. Her blood pressure is 102/58 mm Hg and pulse is 113/min. Her body mass index is 21 kg/m2 Fine hair is noted on her scalp Examination shows dental erosions with slightly enlarged cheeks. There is no edema. Laboratory results are as follows
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Sodium
132 mEq/L
Potassium
2.4 mEq/L
Calcium
10.1 mg/dL
Chloride
90 mEq/L
Bica rbonate
40 mEq/L
Urine chloride
14 mEq/L
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In addition to potassium supplementation, which of the following is the best treatment to co rrect the laboratory abnormalities in this patient?
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ID A Acetazolamide ID B. Breathing in a paper bag ID C. Calcium gluconate infusion ID D. Hyperventilation ID E. Insulin therapy ID F. Loop diuretics ID G. Normal saline infusion ID H. Sodium bicarbonate infusion Submit
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Clinical features of metabolic alkalosis Saline-responsive
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• Vomiting • Gastric suctioning • Diuretics Causes
• Laxative abuse • Decreased oral fluid intake (volume depletion) Saline-resistant • Primary hyperaldosteronism
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• Cushing's syndrome
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• Severe hypokalemia (<2 mEq/L)
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• Volume depletion: Easy fatigability, postural dizziness, muscle cramps
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Clinical presentation
• Hypokalemia: Muscle weakness, arrhythmias
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• Urine chloride: <20 mEq/L (saline-responsive), >20 mEq/L (saline-resistant)
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• Treat underlying cause to reverse generation phase in all cases
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Treatment
• Saline-responsive: Also give normal saline to correct maintenance phase
©UWorld
This patient's presentation (age, exercise, fine hair, dental erosions) is consistent with likely
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©UWorld
This patient's presentation (age, exercise, fine hair, dental erosions) is consistent with likely bulimia nervosa. Bulimia is more common in younger women and leads to binge eating followed by induced vomiting The body mass index tends to be normal or slightly low. Patients can present with hypotension, tachyca rdia, dry skin, hair loss, parotid gland hypertrophy with puffy cheeks, and dental erosions due to periodic induced vomiting The chronic vomiting can lead to volume depletion causing metabolic alkalosis (MA) , hypokalemia, and hypochloremia MA is due to an underlying disorder producing excess bicarbonate (generation phase) combined with a process preventing renal bica rbonate excretion (maintenance phase) MA is further classified as saline responsive or resistant The generation phase in saline-responsive MA can be due to urinary or gastrointestinal hydrogen loss (eg, diuretics, vomiting) or decreased oral intake. The maintenance phase (eg, hypovolemia) prevents the normal kidney from excreting the excess bica rbonate in the urine. The kidneys perce ive a decreased effective arterial blood volume from the underlying etiology (eg, vomiting with volume depletion) and increase renin and aldosterone release. This leads to sodium reabsorption, potassium exc retion, and hydrogen excretion. There is also decreased bicarbonate excretion. If the history cannot provide the etiology , urine chloride can diffe rentiate between saline-resistant and saline-responsive MA Saline-resistant MA has excess mineralocorticoid causing hydrogen and potassium loss and increased sodium retention leading to increased extracellular volume. The kidneys respond by excreting both sodium and chloride to result in high urine chloride. Saline-responsive MA has low urine chloride (<20 mEq/L) due to hypovolemia and hypochloremia Treatment fo r both types focuses on the underlying cause to reverse generation and inc rease renal bica rbonate excretion. In saline-responsive MA , normal saline administration restores arterial volume, corrects hypochloremia, and increases urinary bica rbonate excretion. (Choice A) Acetazolamide is a diuretic that works by inhibiting carbonic anhydrase, which leads to decreased reabsorption of bica rbonate, sodium, and chloride. This may improve her alkalosis somewhat; however, this will worsen her volume depletion. Additionally , acetazolamide causes hypokalemia, an undesirable side effect in this woman who already has a low serum potassium concentration. It can be considered in edematous patients with metabolic alkalosis.
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and inc rease renal bicarbonate excretion. In saline-responsive MA, normal saline administration restores arterial volume, corrects hypochloremia, and increases urinary bicarbonate excretion. {Choice A) Acetazolamide is a diuretic that works by inhibiting ca rbonic anhydrase, which leads to decreased reabsorption of bicarbonate, sodium, and chloride. This may improve her alkalosis somewhat; however, this will worsen her volume depletion Additionally, acetazolamide causes hypokalemia, an undesirable side effect in this woman who already has a low serum potassium concentration. It can be considered in edematous patients with metabolic alkalosis. {Choices 8 and D) Hyperventilation decreases pC02 and causes respiratory alkalosis. Breathing into a bag inc reases pC0 and decreases pH slightly , but it does not reverse the 2 underlying metabolic alkalosis. (Choices C and E) Calcium gluconate and insulin can be used as acute therapy for hyperkalemia This patient has hypokalemia (Choice F) Loop diuretics increase distal sodium delivery and the secretion of aldosterone, which would further worsen metabolic alkalosis, hypokalemia and volume depletion (Choice H) Sodium bicarbonate infusion would not be needed in a patient who already has excess serum bicarbonate. It is used primarily in those with metabolic acidosis, hyperkalemia, and renal failure. Educational objective: The pathogenesis of metabolic alkalosis requires generating excess bicarbonate (generation phase) and preventing excretion of excess bicarbonate (maintenance phase) Treatment involves addressing the underlying cause and promoting urinary bicarbonate excretion. Refer ences: 1. Rational treatment of acid-base disorders.
Time Spent 6 seconds
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Serum sodium Serum potassium Serum calcium Serum creatinine BUN
145 mEq/L 5.5 mEq/L 8.6 mg/dl 3.2 mg/dl 30 mg/dl
His serum cyclosporine level is normaL Renal ultrasonography does not detect dilatation of the calyces. Biopsy of the transplant shows heavy lymphocyte infiltration and vascular involvement with swelling of the intima. Which of the following is the most appropriate next step in management?
6 A. Decrease the dose of cyclosporine <0 B. Give IV steroids
6 C. Order ureterography ® D. Administer IV diuretics e; E. Prepare for surgery
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A 56-year-old man develops oliguria three days after having a kidney transplantation His postoperative course was uncomplicated. His blood pressure is 160/ 100 mm Hg and heart rate is 90/min. Palpation of the transplant reveals mild tenderness. Laboratory studies show
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Explanation:
Renal transplant dysfunction in the early post-operative period manifests as oliguria, hypertension, and increased c reatinine/ BUN. It can be explained by a number of causes, which include ureteral obstruction, acute rejection, cyclosporine toxicity , vascular obstruction, acute tubular necrosis, etc. In this case, the patient's clinical signs, symptoms, and laboratory findings are suggestive of acute rejection. Rapid institution of anti-rejection therapy, including high-dose IV steroids, is important {Choice A) Cyclosporine toxicity does not present with graft tenderness. The transplant's function is usually restored when the dose of cyclosporine is decreased. In this case, the patient's clinical features (i e., normal serum cyclosporine level, renal biopsy findings) are more consistent with acute rejection.
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{Choice C) Renal ultrasound helps to rule out ureteral obstruction.
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{Choice E) Surgery is not appropriate in this case.
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Educational Objective: Renal transplant dysfunction in the early post-operative period can be explained by a va riety of causes, including ureteral obstruction, acute rejection, cyclosporine toxicity, vascular obstruction, and acute tubular necrosis. Radioisotope scanning, renal ultrasound, MRI, and renal biopsy can be employed in conducting a differential diagnosis. Acute rejection is best treated with intravenous steroids.
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• Extremely high yield question fo r the USMLE!!!
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{Choice D) Adm inistration of IV diuretics may be employed in acute tubular necrosis, but the patient's renal biopsy findings are not consistent with this condition.
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A 72-year-old man is hospitalized for right femoral fracture after a motor vehicle accident Six days after the surgical repair, he is found to be lethargic . He has hypertension and osteoarthritis. His medications include hydrochlorothiazide, lisinopril, and naproxen These medications were continued in the hospital On examination, he is drowsy but awakens to commands. His tempe rature is 36.7 C (98 F), blood pressure is 144/76 mm Hg, pulse is 88/min, respirations are 16/min, and pulse oximetry is 95% on room air. Multiple contusions in the anterior abdominal wall and thighs are seen. Physical examination findings are shown in the exhibit Laboratory studies reveal
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Hemoglobin
8.4 g/dl
Blood urea nitrogen
78 mg/dl
Albumin
3.8 g/dl
Total Bilirubin
0.4 mg/dl
Aspartate aminotransferase
112 U/L
Alanine aminotransferase
42 U/L
Creatine kinase, serum
32000 U/L
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W hich of the following is the most appropriate next step in management of this patient?
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C)
A. Blood transfusion
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61
Lab Values
•
Laboratory studies reveal
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Hemoglobin
8.4 g/dl
Blood urea nitrogen
78 mg/dl
Albumin
3.8 g/dl
Total Bilirubin
0.4 mg/dl
Aspartate aminotransferase
112 U/L
Alanine aminotransferase
42 U/ L
Creatine kinase , serum
32000 U/L
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Which of the following is the most appropriate next step in management of this patient?
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I ® A Blood transfusion ® B. Hemodialysis ® C. Intravenous lorazepam ® D. Intravenous morphine ® E. Lactulose ® F. Stress test Submit
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a
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Explanation:
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Indications for urgent dialysis (AEIOU)
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Acidosis
17
Electrolyte abnormalities
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• Metabolic acidosis o pH <7 .1 refractory to medical therapy • Symptomatic hyperkalemia o ECG changes or ventricular arrhythmias • Severe hyperkalemia o K >6.5 mEq/L refractory to medical therapy
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!ngestion
• • • •
Overload
Volume overload refractory to diuretics
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Uremia
Toxic alcohols (methanol, ethylene glycol) Salicylate Lithium Sodium valproate, carbamazepine
• Symptomatic: o Encephalopathy o Pericarditis o Bleeding
This patient demonstrates asterixis in the video clip Bilateral, non-rhythmic, alternate flexion and -~-······
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" This patient demonstrates asterixis in the video clip Bilateral, non-rhythmic , alternate flexion and extension movements at the wrist (also called the "flap") are classically seen when the patient is asked to extend his arms and hands and spread the fingers This occurs likely as a result of interruption of the neural pathways that sustain muscle contraction. Asterixis is seen in hepatic encephalopathy, uremic encephalopathy, and C02 retention. This patient has numerous factors that together can cause a severe degree of acute kidney injury, including rhabdomyolysis from trauma, use of nonsteroidal antiinflammatory drugs (eg, naproxen), anemia, diuretic use, and loss of glomerular autoregulation with lisinopril Reduced renal clearance of uremic toxins is seen as high levels of blood urea nitrogen (BUN) and symptoms of lethargy and somnolence. The diagnosis of uremia is based on clinical symptoms/signs and not on an absolute BUN level Typically symptoms appear at BUN level >100 mg/dl Uremic encephalopathy is an indication fo r urgent hemodialysis. Lactulose is used for the management of hepatic encephalopathy in decompensated cirrhosis (Choice E). W hile asterixis may be seen in this condition, this patient does not have acute liver failure as only the AST is mildly increased from skeletal muscle injury Furthermore, bilirubin and albumin levels are normal, suggesting normal liver synthetic function.
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(Choice A) This patient has anemia but does not need a blood transfusion as his hemoglobin is >8 g/dl; he is asymptomatic and does not have ongoing bleeding.
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(Choice C) Intravenous lorazepam can be used to treat an ongoing seizure.
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(Choice D) Intravenous morphine is an opioid analgesic that may worsen this patient's drowsiness and lethargy It may occasionally cause seizures or myoclonus. (Choice F) The high creatinine phosphokinase level is due to rhabdomyolysis associated with the motor vehicle accident and is not typically seen in acute coronary syndrome Educational objective: Asterixis is the flapping movements of hands wh ich occurs when the wrist is extended with arms out stretched. Common causes include hepatic encephalopathy, uremic encephalopathy, and hypercapnia Treating the underlying cause will improve neurological status and resolve asterixis.
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<0 C. Increased central venous pressure
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<0 A Age-related renal functional decline <0 B. Hypertensive arteriolosclerosis
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<0 F. Renal arteriolar vasoconstriction <0 G. Renal artery stenosis <0 H. Renal tubular dysfunction <0 I. Suppression of antidiuretic hormone release
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An 80-year-old woman is brought to the emergency department from a nursing home with 3 days of poor oral intake. At baseline, the patient would lie in bed most of the day and respond to questions She is now unable to answer questions and has been more irritable. The patient has hypertension, diabetes mellitus, coronary artery disease, and Alzheimer disease. Medications include aspirin, amlodipine, metoprolol, metformin, and memantine. On examination, blood pressure is 95/60 mm Hg, pulse is 11 0/min, and respirations are 20/min. Mucus membranes are dry. Lung examination shows midinspiratory coarse crackles at the left lower lung field . Laboratory findings are significant for white blood cell count of 15,000/mm', creatinine of 2.1 mg/dL, and blood urea nitrogen is 61 mg/dL Her creatinine was 0.9 mg/dL last month. Chest x-ray reveals a dense, left lower lobe infiltrate. W hich of the following underlying pathophys iologic mechanisms is most likely associated with the laboratory findings in th is patient?
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I. Suppression of antidiuretic hormone release [7% J Explanation: This patient has pneumonia, complicated by hypotension, tachycardia, and prerenal azotemia (reduced kidney perfusion) Decreased effective renal blood flow (RBF) activates the renin-angiotensin-aldosterone axis. Initially, angiotensin constricts the glomerular arterioles. The effe rent arteriole constricts significantly more than the afferent arteriole, which maintains intraglomerular pressure and glomerular filtration rate (GFR) despite reduced RBF. Low RBF also causes release of prostaglandins that dilate the afferent arteriole to maintain GFR Continued volume depletion overwhelms this adaptive response, and intraglomerular pressure falls , reducing GFR despite maximal efferent arteriolar vasoconstriction. Factors that may aggravate prerenal azotemia include decreased fluid intake (common in elderly patients), ACE inhibitors (prevent the action of angiotensin on arterioles) , and aspirin (inhibits the effects of prostaglandins).
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In prerenal azotemia, the renal tubules avidly reabsorb sodium and water in response to a high antidiuretic hormone level (Choice I) Urea reabsorption also inc reases, causing a high blood urea nitrogen to creatinine (BUN/Cr) ratio of >20: 1. Persistent untreated renal hypoperfusion leads to intrinsic renal failure due to ischemia. Tubules undergo acute ischemic necrosis (Choice H), and reabsorption of solutes is impaired. The blood urea level, and BUN/Cr ratio fall (<20:1) Other causes of intrinsic renal fa ilure also reduce the BUN/Cr ratio. The exact mechanism is disease-dependent • Age-related renal functional decline (progressive loss of renal mass and thickening of the glomerular basement membrane) causes a gradual decline in renal function (Choice A) • Hypertensive arteriolosclerosis from uncontrolled hypertension (Choice B) • Nodular glomerulosclerosis in diabetic nephropathy (Choice D) (Choice C) Patients with poor cardiac output from congestive heart fa ilure may have hypotension with inc reased intravascular volume, elevated central venous pressure, and reduced RBF. Clinical findings may include bibasilar crackles, elevated jugular venous pressure, peripheral edema, and bilateral pulmonary edema on x-ray
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(<20 1) Other causes of intrinsic renal fa ilure also reduce the BUN/Cr ratio. The exact mechanism is disease-dependent • Age-related renal functional decline (progressive loss of renal mass and thickening of the glomerular basement membrane) causes a gradual decline in renal function (Choice A) • Hypertensive arteriolosclerosis from uncontrolled hype rtension (Choice B) • Nodular glomerulosclerosis in diabetic nephropathy (Choic·e D) (Choice C) Patients with poor cardiac output from congestive heart failure may have hypotension with increased intravascular volume, elevated central venous pressure, and reduced RBF. Clinical findings may include bibasilar crackles, elevated jugular venous pressure, peripheral edema, and bilateral pulmonary edema on x-ray (Choice E) Obstructive uropathy is typically seen in males, mostly due to benign prostatic hyperplasia Postrenal acute kidney injury requires obstruction of both ureters or an obstruction at or distal to the bladder. The BUN/Cr ratio may be high, but patients are euvolemic and normotensive. (Choice G) Renal artery stenosis is characterized by hypertension and chronic renal insufficiency
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Educational objective: Elderly patients with impaired thirst response are predisposed to prerenal azotemia due to intravascular volume depletion and poor renal perfusion Diuretics worsen volume depletion Nonsteroidal anti- inflammatory drugs and angiotensin 11-conve rting enzyme inhibitors impair the normal physiologic response of renal arterioles, worsening glomerular filtration rate and renal function. References: 1. Management of acute renal failure in the elderly patient: a clinician's guide
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A 51-year-old man is admitted to the hospital because of renal fa ilure. His past medical history is significant for recurrent episodes of bilateral flank pain over the past several yea rs as well as nocturia 2 to 3 times per night for the past 10 years. He has no weight loss. On physical examination, his blood pressure is 164/ 100 mm Hg The liver is enlarged and a mass is felt at the right flank on deep palpation W hich of the following is the most likely diagnosis?
e A Horseshoe kidney o B. Nephrolithiasis e; C. Papillary necrosis
® D. Polycystic kidney disease
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E. Renal cell ca rc inoma
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Explanation: This man most likely has autosomal dominant polycystic kidney disease (ADPKD) ADPKD is one of the most common hereditary diseases in the United States and accounts for 10% of dialys is patients Patients will often have hype rtension and palpable kidneys on exam. Please note the enlarged right kidney is easier to palpate because it lies lower than the left kidney! The live r might be enlarged due to cystic involvement (Choice A) Horseshoe kidney is a congenital abnormality that can cause compl ications such as ureteropelvic junction obstruction, renal stones, ves icoureteric reflux, and chronic urinary tract infections. Horseshoe kidney does not typ ically cause pain and would not be palpable on physical examination. (Choice B) Nephrolithiasis is a common complication of PKD, occurring in 20% of affected patients. It can cause pain but would not produce a palpable renal mass unless it has caused severe hydronephrosis Severe hydronephrosis usually causes acute renal failure, whereas the abnormalities in the patient described above have been more chronic in nature.
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(Choice C) Papillary necrosis refers to ischemic necrosis in the renal papillae. Analgesic overuse is the most common cause, but diabetes mellitus, infections, urinary tract obstruction, hemoglobinopathies, cirrhosis, congestive heart failure, shock, and hemophilia can also be associated. There would not be a palpable mass on physical examination. (Choice E) Renal cell ca rcinoma does not seem to occur with increased frequency in patients with APKD when compared to the general population Also , it is less likely given no other symptoms such as we ight loss or loss of appetite. RCC alone would not give renal failure. Educational objective: Autosomal dominant polycystic kidney disease is a heritable form of renal disease characterized by multiple renal cysts and intermittent flank pain, hematuria, urinary tract infections, and nephrolithiasis Time Spent 3 seconds
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0 A Endometriosis 0 B. Estrogen deficiency 0 0 0 0 0
C. Inadequate lubrication D. Interstitial cystitis E. Lichen sclerosus F. Vaginismus G. Vulvodynia
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A 44-year-old woman comes to the office with a 6-month history of painful sexual intercourse. She has no associated itching or abnormal vaginal discharge The patient has never had these symptoms before and has had no problems with sexual desire or orgasm She has been monogamous with her husband fo r 15 years The patient's menstrual periods are regular and are not associated with unusual pain She has no urinary or gastrointestinal symptoms. Her medical history is notable fo r mild hypertension that has been well controlled with dietary changes and exercise. The patient has no history of pelvic inflammatory disease or gynecologic surgery Her only medications include a daily multivitamin and saline eye drops for chronic dry eyes. The patient does not use tobacco, alcohol, or illicit drugs. Temperature is 36.5 C (97 7 F), blood pressure is 136/88 mm Hg, pulse is 72/min, and respirations are 12/min. The neck is supple. The patient has mild dental caries. Chest auscultation reveals no abnormalities. The abdomen is soft and nontender. Pelvic examination shows normal-appearing external genitalia and dry vaginal mucosa. The uterus and adnexa are normal with no cervical motion tenderness. W hich of the following is the most likely cause of this patient's current condition?
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G. Vulvodynia [2%) Explanation:
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Sjogren syndrome • Keratoconjunctivitis sicca Exocrine features
• Xerosis of skin
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• Dry mouth, salivary hypertrophy
Extraglandular features
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• Cutaneous vasculitis • Arthralgia/arthritis • Interstitial lung disease
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• Objective signs of decreased lacrimation (eg, Schirmer test) Diagnostic findings
• Positive anti-Ro (SSA) &/or anti-La (SSB) • Salivary gland biopsy with focal lymphocytic sialoadenitis • Classifi cation: primary if no associated CTD, secondary if comorbid CTO (eg, SLE, RA, scleroderma)
CTD = connective tissue disease; RA SSAISSB = SjOgren syndrome.
= rheumatoid arthritis; SLE = systemic lupus erythematosus;
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Sjogren syndrome (SS) is an autoimmune disorder characterized by inflammation of the
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• Salivary gland btopsy wtth focal lymphocyttc staloadenttts • Classification: primary if no associated CTD, secondary if comorbid CTD (eg, SLE, RA, scleroderma)
CTD = connective tissue disease; RA = rheumatoid arthritis; SLE = systemic lupus erythematosus; SSAISSB = SjOgren syndrome. @UWorld
Sjogren syndrome (SS) is an autoimmune disorder characterized by inflammation of the exocrine glands. It can occur as an isolated phenomenon or as a manifestation of another autoimmune disease (eg, rheumatoid arthritis). Impaired function of salivary and other exocrine glands (eg, lacrimal glands) can produce sicca syndrome, characterized by generalized dryness of mucous membranes, leading to dry mouth with increased risk of dental caries, irritated/itchy eyes, and cough Dryness of the vaginal mucosa commonly causes dyspareunia. Extraglandular features of SS may include arthritis, Raynaud phenomenon, and cutaneous vasculitis. SS can also cause manifestations along the entire respiratory tract, including nonallergic rhinitis, bronchiectasis, large and small airway disease with impaired mucociliary clearance, and interstitial lung disease. In addition, SS is associated with a significant risk for non-Hodgkin lymphoma (Choice A) Endometriosis causes deep dyspareunia but is unlikely in a patient without dysmenorrhea Vaginal dryness is not a feature of this condition. (Choice B) Estrogen deficiency is a common cause of dyspareunia in postmenopausal patients. This patient is premenopausal with regular menses and does not have a lack of estrogen. (Choice D) Interstitial cystitis, also referred to as painful bladder syndrome, presents with chronic peMc pain, urinary urgency, and dyspareunia It is less likely to cause dry vaginal mucosa and would not affect the eyes or oral mucosa. (Choice E) Lichen sclerosis may present with dyspareunia but more typically causes vulvar itching. Physical examination findings include white vulvar plaques rather than normal external
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{Choice A) Endometriosis causes deep dyspareunia but is unlikely in a patient without dysmenorrhea. Vaginal dryness is not a feature of this condition. {Choice B ) Estrogen deficiency is a common cause of dyspareunia in postmenopausal patients This patient is premenopausal with regular menses and does not have a lack of estrogen. {Choice D) Inte rstitial cystitis, also referred to as painful bladder syndrome, presents with chronic pelvic pain, urinary urgency, and dyspareunia It is less likely to cause dry vag inal mucosa and would not affect the eyes or oral mucosa. (Choice E) Lichen sclerosis may present with dyspareunia but more typically causes vulvar itching. Physical examination findings include white vulvar plaques rather than normal external genitalia with dry vaginal mucosa. (Choice F) Vaginismus (eg, genitopelvic pain/penetration disorder) is dyspareunia due to muscle spasm that prevents vag inal penetration. Pelvic examination demonstrates involunta ry muscle contraction but may be limited as muscle spasm may prevent speculum entry (Choice G) Vulvodynia, fo rmerly termed vestibulodynia, is a cause of painful entry dyspareunia Physical examination shows pain to superficial touch of the vaginal vestibule rather than dryness. Educational objective: Sjogren syndrome is an autoimmune disorder characterized by inflammation of the exocrine glands. Typical features include dry mouth, auto immune sialoadenitis, and keratoconjunctivitis sicca. Extraglandular features include arthritis, Raynaud phenomenon, dyspareunia, cutaneous vasculitis, interstitial lung disease, and non-Hodgkin lymphoma References: 1. Diagnosis and management of Sjogren syndrome.
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A 22-year old college student comes to the student health service due to sleep problems for the past 3 months. The patient says, "School has become more stressful, and I have been feeling more fatigued since my girlfriend broke off our relationship last month." He is very sleepy during the day and also feels embarrassed in front of other students as he often falls asleep during classes. The patient goes to bed at 1 AM and awakens at 8 AM. After classes, he avoids socializing and frequently returns straight to his dorm room and naps The patient also describes "weird things happening when I fall asleep, like hearing whispering voices and seeing colorful animals." He reports other unusual experiences such as suddenly feeling weakness in his face and knees, as if he has lost control of his body The patient drinks beer socially but does not use illicit drugs He has a history of depression as a teenager that responded to psychotherapy. He is 170.2 em (5 ft 7 in) tall and weighs 83.9 kg (185 lb); BMI is 29 kg/m2 Physical examination is normal. Which of the following is the most likely diagnosis for this patient?
0 A Brief psychotic disorder
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6 D. Major depression with psychotic features
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0 E. Narcolepsy 0 F. Obstructive sleep apnea ® G. Sleep deprivation Submit
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DSM-5 d iagnostic criteria
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o Cataplexy: Brief loss of muscle tone precipitated by strong emotion (eg, laughter, excitement) o Shortened REM sleep latency
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• At least 1 of the following:
o Low cerebrospinal fluid levels of hypocretin-1
Associated features
• Hypnagogic or hypnopompic hallucinations • Sleep paralysis
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This patient's excessive daytime sleepiness, hallucinations while fall ing asleep, and cataplexy (transient loss of muscle tone in response to intense emotion) are suggestive of narcolepsy. Intrusions of REM sleep phenomena during sleep-wake transitions may include hypnagogic (on falling asleep) and hypnopompic (on awakening) hallucinations and sleep paralysis (inability to move immediately after awakening). Narcolepsy is associated with low cerebrospinal fluid levels of orexin-Nhypocretin-1. Onset typically occurs during adolescence or the early 20s. Diagnostic evaluation includes polysomnography to rule out other sleep disorders and a multiple sleep latency test that demonstrates decreased sleep latency and sleep-onset REM periods. (Choice A) A brief psychotic disorder involves
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• Recurrent lapses into sleep or naps (minimum 3 times per week for 3 months)
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Narcolepsy
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periods. (Choice A) A brief psychotic disorder involves ~1 positive psychotic symptoms that last a day to a month and are not due to another medical disorder or substance use. This patient is experiencing the hypnagogic hallucinations characteristic of narcolepsy {Choices 8 and F) A diagnosis of narcolepsy requires ruling out other sleep disorders that can present with excessive daytime sleepiness The circadian rhythm sleep-wake disorder with delayed sleep phases involves inability to fall asleep for ~2 hours and awakening later than the desired time. This patient goes to sleep late (at 1 AM) but does not describe difficulty initiating sleep or inability to awaken at a preferred time. Obstructive sleep apnea is characterized by loud snoring, gasping, and apneas (Choice C) Hypersomnolence disorder is characterized by persistent daytime sleepiness (not sleep attacks) and is diagnosed only when excessive sleepiness is not better explained by another sleep disorder. (Choice D) This patient has insufficient symptoms for a current major depressive episode, and his hallucinations are related to narcolepsy (Choice G) This patient is getting 7 hours of sleep plus naps Sleep deprivation may lead to excessive daytime sleepiness, napping, and quicker REM onset, but it is not associated with cataplexy. Educational objective: Narcolepsy is characterized by excessive daytime sleepiness, cataplexy , and REM sleep-related phenomena (eg, hypnagogic/hypnopompic hallucinations, sleep paralysis) References: 1. Central disorders of hypersomnolence: focus on the narcolepsies and idiopathic hypersomnia. 2. Narcolepsy: a clinical review.
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<0 A Alcohol cessation <0 B. Discontinue atorvastatin <0 C. Discontinue losartan
e; D. Low-dose prednisone <0 E. Moderation of coffee intake <0 F. Smoking cessation
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A 53-year-old man comes to the emergency department at 6 00 AM due to severe pain in his right great toe for the past 3 hours. His pain began suddenly as a dull ache, and rapidly worsened to severe throbbing that is not relieved by acetaminophen Medical history is notable fo r hypertension, type 2 diabetes mellitus, and hypercholesterolemia. The patient has smoked 2 packs of cigarettes daily for 30 yea rs. He drinks 2-3 beers and 3-4 cups of coffee daily , consumes fast food often, and does not exerc ise regularly Current medications include metformin, losartan, amlodipine, sitagliptin, and atorvastatin. The patient's temperature is 36.8 C (982 F) , blood pressure is 160/90 mm Hg, pulse is 88/min, and respirations are 16/min. On examination, the right great toe appears markedly swollen, red, and warm to the touch. W hich of the following interventions would be most appropriate to prevent development of further similar episodes in this patient?
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and seafood but is reduced in diets emphasizing protein from vegetarian and low-fat dairy sources. Risk is also increased by heavy intake of beverages and foods containing f ructose and other refined sugars Heavy alcohol intake, especially from beer and distilled spirits, is also associated with an increased risk of gout attack. Ethanol increases uric acid production and may also decrease renal elimination of uric acid. (Choices B and C) A number of medications, including thiazide and loop diuretics, aspirin, and beta blockers, can increase the risk of gouty attacks. Losartan and calcium channel blockers lower uric acid levels and likely reduce the risk of an attack. Atorvastatin and rosuvastatin also lower serum uric acid slightly (Choice D) Glucocorticoids may be used for acute treatment of gout as well as short-term prevention of flare-ups in patients starting urate-lowering therapy. Otherwise, glucoco rtico ids are not recommended for routine gout prophylaxis and would be relatively contraindicated in patients with diabetes. (Choice E) Higher consumption of coffee (but not tea) is associated with lower uric acid levels and a decreased risk of gout attack. (Choice F) Smoking is associated with a lower risk of gout due to decreased endogenous production of uric acid. Educational objective: Lifestyle modifications, including alcohol cessation and weight loss, are recommended to prevent recurrent gout attacks. Medications for lowering serum urate are indicated fo r patients with repeated attacks of gouty arthritis or complicated disease (eg, tophi, uric acid kidney stones) References: 1. Alcohol quantity and type on risk of recurrent gout attacks: An internet-based case-crossover study.
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A 16-year-old girl comes to the emergency department with fever , joint pain, and a rash that started on her face this morning and has quickly spread down her body. She also has pain in her fingers and wrists. The patient feels tired but has no neck stiffness, nausea, or vomiting She has one male sexual partner and uses condoms intermittently Her immunization status is unknown but she does not think she has received many . Temperature is 38.2 C (100 8 F), blood pressure is 125/75 mm Hg, pulse is 86/min, and respirations are 14/min. Physical examination shows a blanching, erythematous maculopapular rash on the face , chest, back, and extremities that spares the palms and soles. Posterior auricular and suboccipital lymphadenopathy is present The oropharynx is clea r. W hich of the following organisms is the most likely cause of this patient's symptoms?
0 A. Epstein-Barr virus
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6 D. Rickettsia rickettsii
0 E. Rubella virus 6 F. Treponema pallidurn ® G. Varicella-zoster virus
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Rubella (German measles)
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• Congenital o Sensorineuralhearingloss o Cataracts o Patent ductus arteriosus Clinical presentation
• Children o Fever o Cephalocaudal spread of maculopapular rash • Adolescents/Adults o Same as ch ildren + arthralgias/arthritis
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• Serology
Prevention
• Live attenuated rubella vaccine
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This patient has a maculopapular rash with a cephalocaudal spread, postauricular and suboccipital adenopathy, and arthralgia. These findings are consistent with rubella infection. After a prodrome of mild fever, lymphadenopathy, and malaise, a blanching, erythematous, maculopapular rash erupts on the face and spreads caudally within 24 hours, sparing the palms and soles. Adolescents, particularly females, may have polyarthralgia and/or arthritis. Although most symptoms resolve in a few days, joint pain can last up to a month. Rubella is no longer endemic in the United States due to widespread vaccination, but sporadic or imported cases do occur. Vaccination with the live attenuated rubella vaccine is important as active infection in women during the first trimester of pregnancy can cause congenital rubella
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imported cases do occur. Vaccination with the live attenuated rubella vaccine is important as active infection in women during the first trimester of pregnancy can cause congenital rubella syndrome {Choice A) Fever and ce rvical lymphadenopathy are features of infectious mononucleosis, but exudative pharyngitis is usually prominent The presence of a maculopapular rash is less common unless there is a history of beta-lactam antibiotic administration. {Choice B) The prodrome and rash of measles are very similar to rubella. However, measles usually features higher feve r (eg, >40 C [104 FJ), cephalocaudal spread of the rash over multiple days, and cervical rather than posterior auricular or suboccipital adenopathy In addition, arthritis does not occur in measles. (Choice C) Disseminated gonococcal infection can present with rash, fever, and polyarthralgias in a sexually active patient However, the rash of disseminated gonococcus is usually vesiculopustular and rarely involves the face.
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(Choice D) Rocky Mountain spotted feve r is characterized by a febrile prodrome followed by an erythematous macular rash that starts over the wrists and ankles, involves the palms and soles, and spreads centrally {Choice F) Secondary syphilis usually presents with fever and a maculopapular rash involving the entire trunk and extremities. It includes the palms and soles, which are spared in rubella. (Choice G) The rash of varicella (chickenpox) follows a prodrome of fever and malaise. In contrast to rubella, it is vesicular , appears in successive crops, and c rusts after several days. Educational objective: Rubella presents with low-grade fever , a maculopapular rash with rapid cephalocaudal spread, and posterior auricular and suboccipital lymphadenopathy. Adolescents, especially females , may also present with arthralgias or arthritis that can persist after the rash resolves. Refer ences:
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A 35-year-old man comes to the office due to poor sleep and impaired concentration at work. He used to "sleep like a baby," but since returning from his last tour of military duty 6 months ago, he has had difficulty fall ing and staying asleep. He also describes frequent nightmares and awakening in a state of panic , sweating profusely and short of breath. During the day, he feels tired and distracted by unusual experiences He says, "I am worried that I'm going crazy because I see images of explosions and hear my friend's voice call ing to me fo r help I also keep checking the doors in case anyone is breaking into the house." Over the past several months, the patient has increased his use of alcohol from 2 to 4 drinks a day to help him fall asleep. He takes ibuprofen for knee and back pain He has no other medical problems There is a family history of hypertension, colon cancer , and bipolar disorder. Temperature is 37 C (98 6 F) , blood pressure is 130/80 mm Hg, pulse is 84/min, and respirations are 16/min. Physical examination is unremarkable. Mental status examination shows a visibly tense and restless man who jumps in response to a telephone ringing and whose eyes frequently scan the room . W hich of the following is the most appropriate pharmacotherapy?
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A A ripiprazole B. Bupropion C. Clonazepam D. Escitalopram E. Lorazepam F. Valproate G. Zolpidem
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G. Zolpidem (2%) Explanation:
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Post-traumatic stress disorder
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• Exposure to life-threatening trauma
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• Nightmares, flashbacks, intrusive memories Clinical features
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• Avoidance of reminders, amnesia for event • Emotional detachment, negative mood, decreased interest in activities
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• Sleep disturbance, hypervigilance, irritability
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• Duration ~1 month
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Treatment
• Trauma-focused cognitive-behavioral therapy • Antidepressants (SSRi s, SNRis)
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SNRI = serotonin-norepinephrine reuptake inhibrtor; SSRI = selective serotonin reuptake inhibitor. ©UWorld
This patient's sleep disturbance and impaired concentration are most likely due to post-traumatic stress disorder (PTSD). His experience of seeing images and hearing his friend's voice are likely flashbacks that should be distinguished from hallucinations that may occur in psychotic disorders. Other common PTSD symptoms include anxiety, irritability, emotional detachment, avoidance, exaggerated startle response, and hypervigilance. First-line treatment of PTSD includes trauma-focused cognitive-behavioral psychotherapy
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SNRJ = serotonin-norepinephrine reuptake inhibitor; SSRI = selective serotonin reuptake inhibitor. ©UWorid
This patient's sleep disturbance and impaired concentration are most likely due to post-traumatic stress disorder (PTSD). His experience of seeing images and hearing his friend's voice are likely flashbacks that should be distinguished from hallucinations that may occur in psychotic disorders. Other common PTSD symptoms include anxiety, irritability, emotional detachment, avoidance, exaggerated startle response, and hypervigilance First-line treatment of PTSD includes trauma-focused cognitive-behavioral psychotherapy and antidepressant medication. Selective serotonin reuptake inhibitors (SSRis), such as escitalopram, and serotonin-norepinephrine reuptake inhibitors (SNRis) have the best evidence. Although anxiety and severe insomnia are common PTSD symptoms, there is little evidence to support the long-term use of benzodiazepines and non-benzodiazepine hypnotics (Choices C, E, and G) Benzodiazepines should particularly be avoided in patients with a como rbid substance use disorder. The alpha-adrenergic receptor blocker prazosin has been used as an augmentation to antidepressants to decrease nightmares and improve sleep in PTSD. {Choice A) Second-generation antipsychotics such as aripiprazole are not first-line treatment for PTSD. They have a role as augmentation in patients with inadequate response to an SSRI/SNRI. (Choice B) Bupropion is a norepinephrine dopamine reuptake inhibitor that can be stimulating and cause insomnia. It is commonly used to treat major depression but is not a first-line choice in PTSD. (Choice F) Valproate is an anticonvulsant mood stabilizer that is used to treat bipolar disorder , but it has not proven effective in treating PTSD. Educational objective: Trauma-focused cognitive-behavioral therapy and selective serotonin reuptake inhibitors/serotonin-norepinephrine reuptake inhibitors are first-line treatments for post-traumatic stress disorder.
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in psychotic disorders. Other common PTSD symptoms include anxiety, irritability, emotional detachment, avoidance, exaggerated startle response, and hypervigilance First-line treatment of PTSD includes trauma-focused cognitive-behavioral psychotherapy and antidepressant medication. Selective serotonin reuptake inhibitors (SSRis), such as escitalopram, and serotonin-norepinephrine reuptake inhibitors (SNRis) have the best evidence. Although anxiety and severe insomnia are common PTSD symptoms, there is little evidence to support the long-term use of benzodiazepines and non-benzodiazepine hypnotics (Choices C, E, and G) Benzodiazepines should particularly be avoided in patients with a como rbid substance use disorder. The alpha-adrenergic receptor blocker prazosin has been used as an augmentation to antidepressants to decrease nightma res and improve sleep in PTSD. (Choice A) Second-generation antipsychotics such as aripiprazole are not fi rst-line treatment fo r PTSD. They have a role as augmentation in patients with inadequate response to an SSRI/SNRI. (Choice B) Bupropion is a norepinephrine dopamine reuptake inhibitor that can be stimulating and cause insomnia. It is commonly used to treat major depression but is not a fi rst-line choice in PTSD.
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(Choice F) Valproate is an anticonvulsant mood stabilizer that is used to treat bipolar disorder , but it has not proven effective in treating PTSD.
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Educational objective: Trauma-focused cognitive-behavioral therapy and selective serotonin reuptake inhibitors/serotonin-norepinephrine reuptake inhibitors are fi rst-line treatments for post-traumatic stress disorder. References: 1. Pharmacotherapies for posttraumatic stress disorder: a meta-analysis.
2. Evidence-based pharmacotherapy of post-traumatic stress disorder (PTSD).
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6 A Antibiotic instillation into the catheter
e; B. Echocardiography 6 C. Hepar in instillation into the catheter
e; D. Portable chest x-ray 6 E. Repeat 12-lead ECG
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A 34-year-old woman is admitted to the hospital because of septic shock secondary to a urinary tract infection. In the intensive care unit, she receives intravenous fluids and antibiotics. Her initial ECG shows sinus tachyca rdia but is otherwise unremarkable. Chest x-ray shows no abnormalities. An internal jugular vein catheter is placed on the right side using ultrasound guidance to locate the vein. The patient is properly draped, and the skin is cleaned with chlorhexidine solution. Blood is freely aspirated from all ports after insertion. Vital signs are stable, and oxygenation is maintained. W hich of the following is the most appropriate next step in managing this patient?
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Explanation: Central venous catheters are commonly used for access in patients with difficult vascular access and for long-term administration of medications. Complications from central venous catheter placement occur in 1o/o-5% of the cases and include arterial puncture, pneumothorax, hemothorax, thrombosis, air embolism, sepsis, vascular perforation, and myocardial perforation leading to tamponade A chest x-ray should always be obtained to confi rm proper placement of the catheter and absence of complications To avoid myocardial perforation, the catheter tip should be located proximal to either the cardiac silhouette or the angle between the trachea and the right mainstem bronchus. Ideally , the catheter tip should lie in the superior vena cava. Tip placement in smaller veins (e g , subclavian, jugular, azygous, and internal mammary) predisposes to vascular perforation Proper placement is essential prior to administering medications and other agents due to the possibility of administration into the wrong anatomic space (Choices A and C) (Choice B) Echocardiography can detect fl uid in the perica rdium but is not useful in determining the placement of a catheter tip or showing pneumothorax
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(Choice E) Repeat 12-lead ECG is not as accurate as chest x-ray in showing the proper placement of a central venous catheter or monitoring the complications Educational objective: A chest x-ray should be obtained in all patients who undergo central venous catheterization to confi rm proper placement of the catheter tip and absence of complications before administering drugs or other agents through the catheter. Refer ences: 1. Aberrant locations and complications in initial placement of subclavian vein catheters 2. Central venous catheters. Placement and monitoring tips.
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® G. Nortriptyline
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A 25-year-old graduate student comes to the student health clinic for a routine physical examination. He has been concerned about his health since a close friend died suddenly in a motor vehicle collision several weeks ago, but he has otherwise been feeling well. The patient's medical history reveals no major problems except for a recent history of bulimia. He has smoked a pack of c igarettes daily for the past 7 years. He tried varenicl ine fo r smoking cessation but had mood changes and stopped the medication. He takes no medications currently . The patient's mother has asthma and his father died of a heart attack at age 56. Physical examination is unremarkable, and vital signs are normal. At the end of the visit, he asks for assistance with smoking cessation. In addition to proper counseling and support, which of the following would be considered an appropriate first-line treatment for the patient at this time?
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Explanation: Nicotine replacement therapy (NRT) , varenicline, and bupr opion are the 3 available FDA-approved, first-line pharmacological treatments for smoking cessation. NRT replaces the nicotine from tobacco to decrease nicotine withdrawal and aid in smoking cessation. It can be delivered in multiple ways (eg, transdermal patch, gum, lozenge, inhaler , nasal spray) The combination of patch and gum or lozenge is commonly used to control both shorter-term and longer-term nicotine withdrawal symptoms. Va renicline, an alpha-4 beta-2 nicotinic acetylcholine receptor partial agonist, can diminish nicotine c ravings However , varenicline has been associated with mood changes and suicidality as well as ca rdiovascular events in patients with pre-existing ca rdiovascular disease. The antidepressant bupropion is a norepinephrine and dopamine reuptake inhibitor that has been found to be an effective smoking cessation aid. However, it is contraindicated in patients with bulimia or seizures {Choice B) (Choices A, E , and H) Beta-blockers (eg, atenolol) , selective serotonin reuptake inhibitors (eg, fluoxetine) , and monoamine oxidase inhibitors (eg, selegiline) have not been found to be effective fo r smoking cessation. {Choice C) Buspirone is an anti-anxiety medication. The re is limited evidence that it may be of benefit as a short-term adjuvant for smoking cessation, but it is not FDA-approved for this indication.
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{Choice D) Electronic cigarettes provide nicotine in an aerosolized fo rm. Dosing can be inconsistent They have not been shown to have clear efficacy fo r smoking cessation and should not be considered fi rst-line treatment (Choice G) Nortriptyline, a tricycl ic antidepressant, may have modest efficacy as a smoking cessation aid, but it is not considered fi rst-line treatment and is not FDA-approved for this indication. Educational objective: N. f I I t th
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antidepressant bupropion is a norepinephrine and dopamine reuptake inhibitor that has been found to be an effective smoking cessation aid. However, it is contraindicated in patients with bulimia or seizures (Choice B) (Choices A, E, and H) Beta-blockers (eg, atenolol), selective serotonin reuptake inhibitors (eg, fluoxetine), and monoamine oxidase inhibitors (eg, selegiline) have not been found to be effective for smoking cessation. (Choice C) Buspirone is an anti-anxiety medication. There is limited evidence that it may be of benefit as a short-term adjuvant for smoking cessation, but it is not FDA-approved for this indication. (Choice D) Electronic cigarettes provide nicotine in an aerosolized form. Dosing can be inconsistent They have not been shown to have clear efficacy for smoking cessation and should not be considered fi rst-line treatment (Choice G) Nortriptyline, a tricycl ic antidepressant, may have modest efficacy as a smoking cessation aid, but it is not considered fi rst-line treatment and is not FDA-approved for this indication. Educational objective: Nicotine replacement therapy, bupropion, and va renicline are first-line treatments for smoking cessation. They should be used in conjunction with counseling and supportive therapy
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References: 1. Nicotine replacement therapy for smoking cessation. 2. Antidepressants for smoking cessation. 3. Pharmacotherapy for smoking cessation: pharmacological principles and clinical practice.
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A 25-year-old woman comes to the office due to abdominal bloating, headache, fatigue, weight gain, mood swings, and decreased libido. She says, "The symptoms last about a week and then seem to subside, but they always come back again." During these episodes, her appetite increases and she c raves sweet and salty foods. The episodes have been occurring for years. The patient has a history of depression as a teenager that responded well to cognitive-behavioral therapy and a family history of bipolar disorder in a maternal uncle. She has no recent change in sleep pattern or interest in activities, or feelings of hopelessness or guilt. She takes no medications and physical examination is normal. Complete blood count, serum chemistries, pregnancy test, and TSH levels are within normal limits. W hich of the following is the most appropriate next step in management of this patient?
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This patient's presentation is suggestive of premenstrual syndrome (PMS) The most common physical manifestations of PMS are bloating, fatigue, headaches, and breast tenderness. Psychological symptoms may include mood swings, anxiety, difficulty concentrating, decreased libido, and irritability Symptoms usually begin a week prior to menses and resolve within a few days after menses start Patients are symptom free during the foll icular phase. Premenstrual dysphoric disorder (PMDD) is a severe variant of PMS, with prominent irritability , hopelessness, depressed mood, self-critical thoughts, anger , and greater psychosocial impairment
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Prior to recommending a treatment approach, a clea r diagnosis of PMS/PMDD must be established. This requires ruling out an underlying psychiatric disorder that may be exacerbated during the premenstrual phase but is still present at other times (eg, dysthymia, cyclothymia, personality disorder) . A detailed menstrual history (diary) with prospective charting of daily mood and physical symptoms over the course of 2 or 3 menstrual cycles is commonly used. Demonstration that symptoms occur repeatedly and predictably prior to menstruation and resolve with menses confi rms the diagnosis If symptoms occur irregularly or throughout the menstrual cycle, a primary mood or personality disorder is more likely . Mild PMS can be managed with exercise and stress reduction. Selective serotonin reuptake inhibitors (SSRis) (eg, fluoxetine) are fi rst-line treatment for moderate to severe PMS/ PMDD. (Choice A) Studies have shown mixed results with cognitive-behavioral therapy in PMS. It may be helpful in reducing affective symptoms and the preoccupation with physical symptoms in patients who wish to avoid medication. However , in this patient, the optimal approach would be to fi rst confirm the diagnosis with a symptom diary and then present treatment options {Choices 8 , D, and F) It is premature to recommend treatment without first confi rming the diagnosis using a menstrual diary Both continuous and late luteal-phase-only (starting on cycle day 14) SSRI treatments are effective in PMS/ PMDD. Valp roate is an anticonvulsant mood stabilizer used in bipolar disorder ; it is not used to treat PMS/PMDD. (Choices C and G) There is no evidence that special diets or vitamin supplements are effective in PMS/ PMDD.
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Demonstration that symptoms occur repeatedly and predictably prior to menstruation and resolve with menses confirms the diagnosis If symptoms occur irregularly or throughout the menstrual cycle, a primary mood or per sonality disorder is more likely Mild PMS can be managed with exercise and stress reduction. Selective serotonin reuptake inhibitors (SSRis) (eg, fl uoxetine) are first-line treatment for moderate to severe PMS/ PMDD.
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(Choice A) Studies have shown mixed results with cognitive-behavioral therapy in PMS. It may be helpful in reducing affective symptoms and the preoccupation with physical symptoms in patients who wish to avoid medication. However, in this patient, the optimal approach would be to first confirm the diagnosis with a symptom diary and then present treatment options (Choices 8 , D , and F) It is premature to recommend treatment without first confirming the diagnosis using a menstrual diary Both continuous and late luteal-phase-only (starting on cycle day 14) SSRI treatments are effective in PMS/PMDD. Valproate is an anticonvulsant mood stabilizer used in bipolar disorder; it is not used to treat PMS/ PMDD. (Choices C and G) There is no evidence that special diets or vitamin supplements are effective in PMS/ PMDD. Educational objective: Premenstrual syndrome and premenstrual dysphoric disorder are characterized by physical (eg, fatigue, bloating, breast tenderness) and psychological (eg, mood swings, irritability) symptoms that occur in the week prior to menses and resolve during the foll icular phase. Assessment should begin with a menstrual diary to determine the relationship of symptoms to menstrual cycle phase References: 1. Premenstrual syndrome and premenstrual dysphoric disorder. 2. Daily symptom ratings for studying premenstrual dysphoric disorder: A review.
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A 75-year-old woman comes to the emergency department due to 1 day of severe low back pain The pain started after lifting a turkey from the freezer and worsens with standing, walking, and lying on her back. She had no recent falls, lower extremity weakness, or sensory loss in the legs The patient has a history of temporal arteritis, which was diagnosed several months ago and is being treated with prednisone. She does not use tobacco or alcohoL Her temperature is 36.7 C (98 F) , blood pressure is 140/70 mm Hg, pulse is 80/min, and respirations are 16/min. Physical examination reveals midline tenderness with palpation or percussion of the lumbar spine. Ankle jerk reflexes are absent bilaterally Knee reflexes are 2+ in both legs Babinski's reflex is downgoing bilaterally Muscle strength is 5/5 in both legs Bilateral straight leg raise to 90 degrees does not inc rease the pain W hich of the following is the most likely diagnosis in this patient?
<0 A Ankylosing spondylitis <0 B. Epidural abscess <0 C. Herniated disk
e; D. Lumbosacral strain <0 E. Metastatic tumor <0 F. Multiple myeloma <0 G. Spinal stenosis
6 H. Vertebral compression fracture Submit
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Explanation:
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Clinical features of vertebral compression fracture
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• • • • • •
Etiologies
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Clinical presentation
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Trauma Osteoporosis, osteomalacia Infection (eg, osteomyelitis) Bone metastases Metabolic (eg, hyperparathyroidism) Paget disease
Chronic/gradual VCF • Painless • Progressive kyphosis • Loss of stature Acute VCF • Low back pain &decreased spinal mobility • Pain increasing with standing, walking, lying on back • Tenderness at affected level
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• Increased risk for future fractures • Hyperkyphosis, possibly leading to protuberant abdomen, early satiety, weight loss, decreased respiratory capacity
Complications
VCF =vertebral compression fracture.
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This patient's presentation - acute back pain and point tenderness after lifting - suggests a vertebral compression fracture (VCF), which occurs most commonly in the elderly Risk factors fo r VCF include trauma (eg, falls), osteoporosis/osteomalacia, infection (eg, osteomyelitis) , malignancy with bone metastases, and metabolic abnormalities (eg, hyperparathyroidism) Patients with gradual onset VCF can be asymptomatic However , an acute VCF can present with low back pain and decreased spinal mobility after sudden bending, coughing, or lifting The pain typically increases with standing, walking, or lying on the back. Examination can show tenderness at the affected leveL Repeated VCF can lead to kyphosis and loss of stature. Nontraumatic VCF is most commonly due to osteoporosis, which decreases bone density and increases fracture risk. Although metastatic cance r can cause VCF, this patient's chronic steroid use and postmenopausal status make advanced osteoporosis more likely (Choice E) Her absent ankle reflexes can be due to normal aging (most common after age 70) and are not clinically significant {Choice A) Ankylosing spondylitis (AS) typically presents with pain and progressively limited back motion. AS is more common in younger men (age <40) In addition, the pain of AS is typically worse in the morning and improves throughout the day (Choice B) Spinal epidural abscess classically presents with the triad of fever , severe localized back pain, and neurologic deficits (eg, motor weakness, paresthesias, bowel/bladder dysfunction). (Choice C) Herniated disk usually presents with radicular pain radiating along the thigh to below the knee (ie, sciatica) Patients can have a positive straight leg raise test due to the nerve root compression. (Choice D) Lumbosacral strain is usually seen after a specific event or action. Patients typically have increased pain with movement and decreased pain with rest In addition, the pain is typ ically in the paraspinal area without significant tenderness to palpation of the vertebra as seen in this patient (Choice F) Multiple myeloma typically presents with anemia, bone pain (usually back or chest),
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back pain, and neurologic deficits (eg, motor weakness, paresthesias, bowel/bladder dysfunction) (Choice C) Herniated disk usually presents with radicular pain radiating along the thigh to below the knee (ie, sciatica). Patients can have a positive straight leg raise test due to the nerve root compression (Choice D) Lumbosacral strain is usually seen after a specific event or action. Patients typically have inc reased pain with movement and decreased pain with rest In addition, the pain is typically in the paraspinal area without significant tenderness to palpation of the vertebra as seen in this patient (Choice F) Multiple myeloma typically presents with anemia, bone pain (usually back or chest), fatigue, and weight loss. Laboratory findings also show elevated creatinine and hype rcalcemia However, the back pain tends to be chronic rather than acute as seen in this patient
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(Choice G) Lumbar spinal stenosis (LSS) refers to a narrowing of the intraspinal (central) canal, lateral recess, or neural foramen. Patients typically develop low back pain with neurological symptoms (eg, sensory loss, weakness in the legs) that is worse with spinal extension (eg, walking, standing) but improved with leaning forward or lying down. This patient's lack of significant neurological findings makes this less likely Educational objective: A vertebral compression fracture is a common complication of advanced osteoporosis Patients with osteoporosis can develop a compression fracture with acute back pain following minimal trauma (eg, bending, coughing, lifting) Examination may show point tenderness, but neurological examination is usually normal. References: 1. Evaluation and management of vertebral compression fractures
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A 54-year-old man comes to the physician complaining of morning facial puffiness and bilateral leg swelling His other medical problems include recurrent pulmonary infections due to bronchiectasis and psoriasis. His blood pressure is 143/92 mm Hg and pulse is 92/min. His body mass index is 24 kg/m2 . Examination shows a fourth heart sound. Hepatomegaly , palpable kidneys, and 2+ pitting edema of the lower extremities to the knees bilaterally are present on examination. Urinalysis shows 4+ proteinuria and normal urinary sediment W hich of the following is the most likely diagnosis in this patient?
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A Amyloidosis
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B. Hepatorenal syndrome
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e') E. Polycystic renal disease
D. lgA nephropathy
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A 54-year-old man comes to the physician complaining of morning facial puffiness and bilateral leg swelling His other medical problems include recurrent pulmonary infections due to bronchiectasis and psoriasis. His blood pressure is 143/92 mm Hg and pulse is 92/min. His body mass index is 24 kg/m2 . Examination shows a fourth heart sound. Hepatomegaly , palpable kidneys, and 2+ pitting edema of the lower extremities to the knees bilaterally are present on examination. Urinalysis shows 4+ proteinuria and normal urinary sediment W hich of the following is the most likely diagnosis in this patient?
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Clinical features of secondary amyloidosis
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• Extracellular deposit of insoluble polymeric protein fibrils in tissues & organs, elevated amyloid A
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• Can be secondary to chronic inflammatory conditions Epidemiology
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Inflammatory arthritis (eg, rheumatoid arthritis)
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Chronic infections (eg, bronchiectasis, tuberculosis, osteomyelitis)
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Inflammatory bowel disease (eg, Crohn's disease)
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Malignancy (eg, lymphoma)
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Vasculitis
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• Asymptomatic proteinuria or nephrotic syndrome
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• Cardiomyopathy with heart failure
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• Hepatomegaly
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Clinical presentation
• Mixed sensory & motor peripheral neuropathy &/or autonomic neuropathy • Visible organ enlargement (eg, macroglossia) • Bleeding diathesis • Waxy thickening, easy bruising of skin
Diagnosis
Treatment
• Abdominal fat pad aspiration biopsy • Treatment of underlying condition
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• Bleeding diathesis • Waxy thicken ing, easy bruising of skin Diagnosis
T reatment
• Abdominal fat pad aspiration biopsy • Treatment of underlying cond ition • Colchicine for prevention & treatment
@UWortd
This patient's cl inical presentation of facial swelling, bilateral lower-extremity edema, and massive proteinuria are consistent with nephrotic syndrome. The presence of nephrotic syndrome with palpable kidneys, hepatomegaly , and ventricular hypertrophy (suggested by an audible fourth heart sound) in the setting of chronic inflammatory disease (recurrent pulmonary infections, bronchiectasis) is suggestive of secondary amyloidosis (AA) as a common unifying diagnosis. Treatment is usually directed at the underlying inflammatory disease. Colchicine is approved fo r both the treatment and prophylaxis of AA. {Choice B ) Hepatorenal syndrome refers to acute renal failure in patients with acute or chronic liver disease and portal hypertension. It usually presents in patients with severe liver disease with progressively rising serum creatinine with minimal proteinuria ( <500 mg/day) {Choice C) Hypertensive nephrosclerosis is seen in patients with chronic hypertension and is associated with retinopathy, left ventricular hypertrophy, progressive renal fail ure, and mild proteinuria (generally <1 g/day) Kidneys are usually small, and hepatomegaly is not present (Choice D) lgA nephropathy is a type of nephritis that typically presents with hematuria on urinalysis Unlike in this patient, lgA nephropathy is usually restricted to the kidneys (Choice E) Patients with polycystic kidney disease typically present with flank pain, hematuria, renal failure, hypertension, and large palpable kidneys Hepatomegaly can also be present due to co-occurrence of hepatic cysts in some patients However , they usually do not have the
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heart sound) in the setting of chronic inflammatory disease (recurrent pulmonary infections, bronchiectasis) is suggestive of secondary amyloidosis (AA) as a common unifying diagnosis. Treatment is usually directed at the underlying inflammatory disease. Colchicine is approved fo r both the treatment and prophylaxis of AA. {Choice B) Hepatorenal syndrome refers to acute renal failure in patients with acute or chronic live r disease and portal hypertension It usually presents in patients with severe live r disease with progressively rising serum creatinine with minimal proteinuria ( <500 mg/day) (Choice C) Hypertensive nephrosclerosis is seen in patients with chronic hypertension and is associated with retinopathy , left ventricular hypertrophy , progressive renal failure, and mild proteinuria (generally <1 g/day). Kidneys are usually small, and hepatomegaly is not present {Choice D) lgA nephropathy is a type of nephritis that typically presents with hematuria on urinalysis Unlike in this patient, lgA nephropathy is usually restricted to the kidneys
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{Choice E) Patients with polycystic kidney disease typically present with flank pain, hematuria, renal failure, hypertension, and large palpable kidneys Hepatomegaly can also be present due to co-occurrence of hepatic cysts in some patients. However, they usually do not have the proteinuria or generalized edema seen in this patient
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Educational objective: Secondary amyloidosis is a compl ication of a chronic inflammatory condition (eg, chronic infections, inflammatory bowel disease, rheumatoid arthritis) resulting in extracellular tissue deposition of fib rils into tissues and organs. Patients can develop multi-organ dysfunction (eg, kidneys, liver, gastrointestinal tract) Treatment usually involves treating the underlying inflammatory disease. References: 1. AA amyloidosis: basic knowledge, unmet needs and future tr eatments.
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A Alprazolam B. Diphenhydramine C. Melatonin D. Paroxetine E. Ramelteon F. Reassurance G. Zolpidem
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A 79-year-old woman comes to the office for her yearly check-up She reports feeling well physically, but mentions some sleep difficulties and being worried about her grandson who was recently admitted to a drug rehabilitation program The patient says she used to sleep 8-9 hours a night Now she wakes up in the middle of the night and rises an hour earlier than she would like to, around 5:30AM. The patient has little difficulty falling asleep and does so most evenings while sitting and watching television. She gets a total of 6% to 7 hours of sleep and often awakens 1-2 times to go to the bathroom, returning to sleep within 10-15 minutes. During the day, she has energy in the morning but often feels sleepy and takes a 30-45 minute nap in the afternoons. The patient reports no persistent anxiety or panic attacks. She has good appetite and is able to follow television programs, concentrate on crossword puzzles, and go out with friends as long as it is earlier in the day The patient has a history of depression, which responded well to paroxetine. in her fifties following her divorce. Her medical problems include osteoporosis and arthritis. Her medications include alendronate and ibuprofen as needed. She does not use alcohol or illicit drugs Which of the following is the most appropriate intervention regarding her sleep?
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G. Zolpidem (6%) Explanation: This patient's sleep pattern (decreased total sleep time, peak sleepiness earlier in the evening, nocturnal awakenings, reduced sleep during early morning hours, and daytime napping (reduced daytime sleep latency) is consistent with normal aging. Changes in sleep architecture include increased sleep latency, decreased REM latency , and decreased slow wave sleep Due to these changes, elderly patients may complain of difficulty falling asleep and/or maintaining sleep. Provided that patients do not feel a significant impairment in activities of daily living or cognition, no further workup is necessary and patients should be reassured that these changes are normaL W hen insomnia is impairing, nonpharmacologic interventions such as sleep hygiene measures and cognitive behavioral therapy are used fi rst line. Pharmacotherapy is generally limited to short-term management (Choice A) Benzodiazepines such as alprazolam should be avoided in elderly patients due to the inc reased risk of cognitive impairment, delirium, and falls. (Choice B) Diphenhyd ramine, an antihistamine with strong anticholinergic effects, should be avoided in the elderly as it has the potential to cause urinary retention and confusion. (Choices C, E, and G) Melatonin, ramelteon, and zolpidem would not be indicated for this patient with normal, age-related sleep changes Ramelteon, a melatonin agonist used for sleep-onset insomnia, has demonstrated safety in older adults and requires no dosage adjustment. The nonbenzodiazepine hypnotic , zolpidem, should be use cautiously and in lowest possible doses due to the increased risk of delirium, falls, and fractures. (Choice D) Paroxetine is a selective serotonin reuptake inhibitor used in the treatment of anxiety and depressive disorders. This patient has insufficient anxiety or depressive symptoms to warrant its use.
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I I I I p • p g p y g cognition, no further workup is necessa ry and patients should be reassured that these changes are normal.
When insomnia is impairing, nonpharmacologic interventions such as sleep hygiene measures and cognitive behavioral therapy are used first line. Pharmacotherapy is generally limited to short-term management {Choice A) Benzodiazepines such as alprazolam should be avoided in elderly patients due to the increased risk of cognitive impairment, delirium, and falls . (Choice B) Diphenhydramine, an antihistamine with strong anticholinergic effects, should be avoided in the elderly as it has the potential to cause urinary retention and confusion. {Choices C, E, and G) Melatonin, rametteon, and zolpidem would not be indicated for this patient with normal, age-related sleep changes Ramelteon, a melatonin agonist used for sleep-onset insomnia, has demonstrated safety in older adutts and requires no dosage adjustment The nonbenzodiazepine hypnotic, zolpidem, should be use cautiously and in lowest possible doses due to the increased risk of delirium, falls , and fractures. (Choice D) Paroxetine is a selective serotonin reuptake inhibitor used in the treatment of anxiety and depressive disorders. This patient has insuffic ient anxiety or depressive symptoms to warrant its use. Educational objective: Normal age-related sleep changes include decreased total sleep time, increased nighttime awakenings, sleepiness earlier in the evening with earlier morning awakening, and increased daytime somnolence (napping) References: 1. Aging and sleep: physiology and pathophysiology.
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0 A Acetylcholine receptor autoantibody test 0 B. Discontinuation of lisinopril 0 C. Electromyogram 6 D. Erythrocyte sedimentation rate
0 E. MRI of the spine 6 F. Muscle biopsy
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® G. Serum electrolyte assay
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A 52-year-old woman comes to the clinic with gradual-onset weakness of the leg muscles. For several months, she has had increasing difficulty climbing stairs and rising from a chair. The patient initially attributed her symptoms to being "out of shape " She has no problem chewing food , changes in bowel or bladder function, morning stiffness, or joint pain Medications include lisinopril and amlodipine for hypertension. She does not use tobacco, alcohol, or illicit drugs. Vital signs are normal. Examination shows 4/5 strength in the thigh muscles of both legs, and distal muscle strength is 5/5. Repeated muscle contractions do not alter the weakness. Mild tenderness is noted in the proximal thigh muscles. Deep tendon reflexes and sensory examination are normal, and Babinski sign is absent W hich of the following would establish a diagnosis in this patient?
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Polymyositis
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Clinical presentation
• Symmetrical proximal muscle weakness • No/mild pain or muscle tenderness
• Elevated m uscle enzymes (eg, CK, aldolase) Diagnostic tests
• Autoantibodies (eg, ANA, anti-Jo-1)
• Biopsy: Endomysia! mononuclear infiltrate, patchy necrosis
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• Interstitial lung disease
Associated conditions
• Malignancy
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• Myocarditis
• Systemic glucocorticoids
Treatment
• Glucocorticoid-sparing agents (eg, methotrexate, azathioprine)
ANA = antinuclear antibodies; CK = creatine kinase. ©UWo~d
Polymyositis is an inflammatory muscle disease that presents with slowly progressive proximal weakness of the lower extremities (eg, difficulty negotiating stairs or rising from a seated position) Proximal arm weakness usually follows, leading to difficulty working with the arms overhead. Patients may develop dysphagia due to involvement of the striated muscles of the
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(eg, methotrexate, azathioprine) ANA= antinuclear antibodies; CK = creatine kinase. ©UWo~d
Polymyositis is an inflammatory muscle disease that presents with slowly progressive proximal weakness of the lower extr emities (eg, difficulty negotiating stairs or rising from a seated position) Proximal arm weakness usually follows, leading to difficulty working with the arms overhead. Patients may develop dysphagia due to involvement of the striated muscles of the upper pharynx. Mild pain or tenderness can develop due to inflammation; however, significant pain or a lack of weakness should prompt consideration of other diagnoses. Polymyositis is similar to dermatomyositis but without skin findings Muscle enzymes (eg, creatine kinase) are inva riably elevated, and autoantibodies (eg, antinuclear antibodies, anti-Jo-1 antibodies) are present in most cases. A muscle biopsy is the most definitive diagnostic test and shows a mononuclear infiltrate surrounding necrotic and regenerating muscle fibers. {Choice A) Acetylcholine receptor antibodies are present in myasthenia gravis, which is characterized by muscle fatigability (weakness increases with repeated activity) and involves oculobulbar muscles in addition to proximal limb muscles. (Choices B and G) ACE inhibitors (eg, lisinopril) can cause hyperkalemia, leading to flaccid paralysis. However, this is unlikely to evolve over months and is uncommon in patients without underlying renal insufficiency or additional medications that cause hyperkalemia. Hypercalcem ia can also cause weakness, but significant hypercalcemia would likely be associated with additional symptoms (eg, nausea, constipation, polydipsia). (Choices C and D) Erythrocyte sedimentation rate and C-reactive protein are inflammatory markers often used in the assessment of polymyalgia rheumatica, a syndrome characterized by proximal muscle pain and stiffness out of proportion to weakness. It most often affects the shoulders. In polymyositis, weakness is typically more prominent than pain Erythrocyte sedimentation rate and C-reactive protein may be elevated but are nonspecific Electromyography is useful for differentiating polymyositis from other causes of weakness (eg,
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characterized by muscle fatigability (weakness increases with repeated activity) and involves oculobulbar muscles in addition to proximal limb muscles. (Choices B and G) ACE inhibitors (eg, lisinopril) can cause hyperkalemia, leading to flaccid paralysis However, this is unlikely to evolve over months and is uncommon in patients without underlying renal insuffic iency or additional medications that cause hyperkalemia Hypercalcemia can also cause weakness, but significant hypercalcemia would likely be associated with additional symptoms (eg, nausea, constipation, polydipsia) (Choices C and D) Erythrocyte sedimentation rate and C-reactive protein are inflammatory
markers often used in the assessment of polymyalgia rheumatica, a syndrome characterized by proximal muscle pain and stiffness out of proportion to weakness. It most often affects the shoulders. In polymyositis, weakness is typically more prominent than pain Erythrocyte sedimentation rate and C-reactive protein may be elevated but are nonspecific . Electromyography is useful for differentiating polymyositis from other causes of weakness (eg, amyotrophic lateral sclerosis) but is also nonspecific (Choice E) This patient has no findings to warrant an MRI, such as back/radicular pain
(herniated disk), bowel/bladder dysfunction (cauda equina syndrome), abnormal sensory examination (cord compression), or feve r or intravenous drug use (epidural abscess)
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Polymyositis is characterized by chronic proximal weakness. Muscle enzymes (eg, creatine kinase) are elevated, and autoantibodies (eg, antinuclear antibodies, anti-Jo-1 antibodies) are present in most cases. Muscle biopsy is the most definitive test and shows a mononuclear infiltrate surrounding necrotic and regenerating muscle fibe rs.
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References:
1. Idiopathic inflammatory myopathies. 2. The diagnosis and classification of polymyositis.
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® G. Tetrahydrocannabinol
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A 24-year-old man is brought to the emergency department by his wife after he began threatening her at home. She reports that he has been increasingly irritable and abusive over the last several months and becomes angry fo r no clear reason. He was recently involved in a fist fight at work. His wife also adds that they have been unsuccessful in their attempts to conceive over the past 2 years. The husband states that there is nothing wrong He is otherwise healthy and exercises frequently . The patient reports occasional alcohol use and past marijuana use. On examination, blood pressure is 148/92 mm Hg and pulse is 102/min; he has a receding hairline. There is palpable tissue underneath his nipples bilaterally Heart and lung examinations are normaL W hich of the following substances most likely explains the patient's symptoms and findings?
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This patient's increased aggression, accelerated male pattern baldness, and gynecomastia are concerning for anabolic {androgenic) steroid use. Anabolic steroids (eg, testosterone, trenbolone, boldenone, stanozolol, nandrolone) are popular among young people and athletes looking to improve their physical appearance and performance Anabolic steroid side effects include impaired endogenous testicular function and decreased testicular size and sper m count Hepatic dysfunction may occur, and patients can develop erythrocytosis due to androgen-stimulated erythropoiesis HDL levels decrease, and high doses may even cause ca rdiac dysfunction Gynecomastia can develop when excess testosterone is converted to estradiol, leading to breast enlargement Skin changes include acne and premature or accelerated male pattern baldness. Psychiatric effects include aggression and mood disturbances that are often complicated by concurrent alcohol use. {Choice A) Growth hormone may be taken to improve athletic ability . It can lead to hyperglycem ia, sodium retention, hypertension, swollen hands, and joint and muscle pain.
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{Choice B) Inhalants can produce short-lived psychotic episodes. There are numerous possible side effects, including hypoxia, brain damage, and bone marrow suppression. Agg ression and gynecomastia are not strongly associated with inhalant abuse. {Choice C) Methamphetamine is a central nervous system stimulant associated with a number of complications, including hypertension, tachycardia, severe agitation or aggressiveness, and psychosis Patients might have acne or fac ial sores due to skin picking. Male pattern baldness may be seen. However, gynecomastia is absent {Choice D) Phencycl idine ( PCP) causes brief dissociative psychotic episodes. Patients taking PCP may be aggressive and less sensitive to pain but do not develop acne, baldness, or gynecomastia {Choice E) Tamoxifen, a nonsteroidal anti-estrogen, competes with estrogen at estrogen receptors in the breast and is taken by users of anabolic steroids to treat gynecomastia
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{Choice G) Tetrahydrocannabinol (THC) may cause increased appetite, red eyes, slowed - '- -- - - - - - - - -- - - - - - - - - - - -- ---- - - -- - --- - -
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(Choice B) Inhalants can produce short-lived psychotic episodes There are numerous possible side effects, including hypoxia, brain damage, and bone marrow suppression Agg ression and gynecomastia are not strongly associated with inhalant abuse. (Choice C) Methamphetamine is a central nervous system stimulant associated with a number of compl ications, including hypertension, tachycardia, severe agitation or aggressiveness, and psychosis Patients might have acne or facial sores due to skin picking. Male pattern baldness may be seen. However, gynecomastia is absent. {Choice D) Phencyclidine (PCP) causes brief dissociative psychotic episodes Patients taking PCP may be aggressive and less sensitive to pain but do not develop acne, baldness, or gynecomastia (Choice E) Tamoxifen, a nonsteroidal anti-estrogen, competes with estrogen at estrogen receptors in the breast and is taken by users of anabolic steroids to treat gynecomastia. (Choice G) Tetrahydrocannabinol (THC) may cause increased appetite, red eyes, slowed reflexes, dizziness, and impaired coordination. THC use may lead to gynecomastia but is unlikely to cause aggression. Educational objective: Anabolic-androgenic steroids are used to improve physique and athletic performance but are associated with numerous adverse effects, including acne, baldness, gynecomastia, hepatic dysfunction, altered lipid profiles, virilization, testicular failure, and possible mood and behavior changes References: 1. Adverse health effects of anabolic-androgenic steroids.
2. Anabolic steroids and male infertility: a comprehensive review.
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A healthy 62-year-old woman comes to the physician with pain behind her right heel for a day The pain is worse with activity and partially relieved with rest She has no fever, back pain, swelling, or skin rash. She eats a healthy diet and walks 2 miles every morning The patient has no chronic medical problems but was diagnosed with a urinary tract infection 4 days ago and has been taking ciprofloxacin Her 55-year-old brother has gout Her vital signs are within normal limits. Examination shows tenderness 3 em above the posterior calcaneus. There is no leg swelling Which of the following is the most likely cause of th is patient's leg pain?
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This patient's presentation suggests Achilles tendinopathy likely due to recent fluoroquinolone use. Continued use of this medication can lead to rupture of the tendon. Risk factors include age >60, female, normal body mass index, concurrent oral corticosteroid use, and history of organ transplant. Tendinopathy most commonly involves the Achilles tendon but can also occur in the rotator cuff, hand, biceps, thumb, and other tendon sites. Pain/tenderness is present 2-6 em above the posterior calcaneus in Achilles tendinopathy. Drug manufacturers are required to include a boxed warning notifying patients of the increased risk of tendinopathy and tendon rupture associated with fluoroquinolones Patients should stop the drug at the onset of symptoms, avoid exercise and/or use of the affected area, and seek medical care for symptom evaluation and changing to a non-fluoroquinolone antibiotic. {Choice B) Crystal- induced synovitis (e g , gout, pseudogout) typically presents with acute-onset monoarthritis with severe pain, redness, swelling, and pain with movement. The typically affected joints include first metatarsophalangeal joint, knee, ankle, hands, elbow, and wrist. However, crystal-induced synovitis usually does not affect the heel or the Achilles tendon, as seen in this patient.
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(Choice C) Deep venous thrombosis (DVT) typically presents with unilateral calf or thigh pain and leg swelling with warmth, tenderness, or erythema. This patient is very active and does not have significant DVT risk factors (eg, oral contraceptive use, family history, malignancy) (Choice D) Osteonecrosis (also known as aseptic , avascular, atraumatic or ischemic necrosis) typically presents with gradual onset of pain in the weight-bearing joints (hip most common) It occurs less commonly in the foot and ankle. This patient also does not have the usual osteonecrosis risk factors such as corticosteroid use, excessive alcohol intake, systemic lupus erythematosus, or sickle cell disease. (Choice E) Septic arthritis usually presents as an acute monoarthritis most commonly in the knees, wrists, ankles , and hips Patients typically develop systemic findings (eg, fever, chills) and restricted movement in the joint with pain, swelling, or warmth. This patient's absence of systemic findings or joint swelling makes this less likely
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JOtnts tnclude fi rst metatarsophalangeal JOtnt, knee, ankle, hands, elbow, and wnst However, crystal-induced synovitis usually does not affect the heel or the Achilles tendon, as seen in this patient {Choice C) Deep venous thrombosis (OVT) typically presents with unilateral calf or thigh pain and leg swelling with warmth, tenderness, or erythema. This patient is ve ry active and does not have significant DVT risk factors (eg, oral contraceptive use, family history, malignancy). {Choice D) Osteonecrosis (also known as aseptic , avascular, atraumatic or ischemic necrosis) typically presents with gradual onset of pain in the weight-bearing joints (hip most common) It occurs less commonly in the foot and ankle. This patient also does not have the usual osteonecrosis risk factors such as corticosteroid use, excessive alcohol intake, systemic lupus erythematosus, or sickle cell disease. {Choice E) Septic arthritis usually presents as an acute monoarthritis most commonly in the knees, wrists, ankles, and hips Patients typically develop systemic findings (eg, fever , chills) and restricted movement in the joint with pain, swelling, or warmth. This patient's absence of systemic findings or joint swelling makes this less likely Educational objective: Fluoroquinolone use is associated with tendinopathy and tendon rupture (Achilles most common) Patients can develop tendon pain within 24 hours with a median of 8 days after starting the drug. Patients should stop the drug at onset of symptoms, avoid exercise and/or use of the affected area, and seek medical care for symptom evaluation and changing to a non-fluoroquinolone antibiotic. References: 1. Impact of age, sex, obesity, and steroid use on quinolone-associated tendon disorders. 2. Fluoroquinolone-associated tendinopathy: a critical review of the literature.
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0 A Acute stress disorder
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A 23-year-old woman comes to the office due to anxiety, sad mood, and difficulty sleeping. Her symptoms began 2 weeks ago following a rape by a former male friend at a party She feels anxious all the time and has nightmares and difficulty fall ing asleep. The patient describes having a panic attack when she walked past the house where the rape occurred and has since avoided the street as well as any of her friends who attended the party. Her sister commented that she is irritable and "hard to be around" lately . The patient also has difficulty concentrating on her school work and says, "I feel like I'm in a daze and this is a bad dream." She is reluctant to discuss the attack and says, "I can't even remember what happened anyway " The patient does not use alcohol or illicit drugs. Temperature is 36.9 C (984 F), blood pressure is 125/70 mm Hg, pulse is 78/min, and respirations are 14/min. Physical examination shows no abnormalities. On mental status examination, she is anxious and occasionally tearful. Which of the following is the most likely diagnosis?
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• Intrusive memories, nightmares, flashbacks with intense psychological/physiological reactions Clinical features
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• Amnesia for event, detachment, avoidance of reminders • Negative mood • Arousal with sleep disturbance, irritability, hypervigilance, exaggerated startle, impaired concentration
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• Trauma-focused, brief cognitive behavioral therapy • Consider pharmacotherapy for insomnia, intense anxiety • Monitor for development of post-traumatic stress disorder
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• Exposure to actual or threatened trauma
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This patient's 2-week history of anxiety, avoidance of reminders, and dissociative symptoms (feelings of unreality, amnesia) following sexual trauma is consistent with acute stress disorder (ASD) Her negative mood, irritability, sleep disturbance, nightmares, and impaired concentration are also characteristic . Other ASD symptoms include intrusive memories and flashbacks. Symptoms must last for 2:3 days and S1 month following trauma exposure. If the symptoms persist for >1 month and meet criteria for post-traumatic stress disorder (PTSD), the diagnosis is changed from ASD to PTSD (Choice F). Early recognition and intervention are important as patients with ASD are at higher risk for subsequent PTSD.
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This patient's 2-week history of anxiety, avoidance of reminders, and dissociative symptoms (feelings of unreality, amnesia) following sexual trauma is consistent with acute stress disorder (ASD) Her negative mood, irritability, sleep disturbance, nightmares, and impaired concentration are also characteristic . Other ASD symptoms include intrusive memories and flashbacks. Symptoms must last for ~3 days and S1 month following trauma exposure. If the symptoms persist for >1 month and meet criteria for post-traumatic stress disorder (PTSD), the diagnosis is changed from ASD to PTSD (Choice F). Early recognition and intervention are important as patients with ASD are at higher risk for subsequent PTSD. {Choice B) In adjustment disorder , the stressor can be of any severity (eg, moving, divorce) and results in symptoms of anxiety and depression that do not meet the criteria fo r another psychiatric disorder. This patient experienced severe trauma, and her avoidance behavior and dissociative symptoms are characteristic of ASD. (Choice C) Patients with ASD may have difficulty recalling part or all of a specific traumatic event; this does not require a como rbid diagnosis of dissociative amnesia unless the amnesia extends beyond the immediate time of the trauma. (Choice D) This patient's sad mood, sleep disturbance, and impaired concentration are a response to trauma and better explained as symptoms of ASD than as major depression. (Choice E) This patient's panic attack is triggered by reminders of the trauma. She does not experience recurrent, unexpected panic attacks necessary fo r the diagnosis of panic disorder. {Choice G) Specific phobia involves <::6 months of excessive fea r and avoidance of a specific object or situation and can develop after a traumatic event (eg, being attacked by an animal) This woman's avoidance of place and people, however , is more than a simple phobia. It is accompanied by other symptoms of ASD (poor sleep, anxiety, irritability), making it the appropriate diagnosis Educational objective: Acute stress disorder is a severe anxiety response characterized by re-experiencing of trauma, dissociation, negative mood, avoidance, and hyperarousallasting <::3 days and ~1 month after exposure to a traumatic event
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A 68-year-old woman is brought to the clinic by her daughter due to severe pain in her fingers Her daughter says, "Mom has had horrible problems with her joints for a long time, but she has never tried to get help " The patient adds that her fingers have become more swollen and painful over the last few weeks. She had similar symptoms in her foot last year . She was given an unknown pain pill, but it was ineffective. Medical history is notable for hypertension. hypothyroidism. and early Alzheimer dementia. Vital signs are normal. Examination findings of the hands are shown in the image below.
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W hat is the most likely diagnosis in this patient? ® A Calcinosis cutis ® B. Chondrosarcoma ® C. Gout ® D. Osteoarthritis ® E. Psoriatic arthritis ® F. Rheumatoid nodules Submit T
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W hat is the most likely diagnosis in this patient? ® A Calcinosis cutis ® B. Chondrosarcoma ® C. Gout ® D. Osteoarthritis ® E. Psoriatic arthritis ® F. Rheumatoid nodules Submit T
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Explanation: This patient with multiple white nodules in the hands and a history of painful arthritis in the fingers and feet has tophaceous gout In most cases, gout is characterized by hyperuricemia and precipitation of uric acid crystals in the joints, leading to episodic monoarticular arthritis (especially in the fi rst metatarsophalangeal joint and knee). The diagnosis is confi rmed with arthrocentesis showing an inflammatory effusion with uric acid crystals. Urate crystals may also deposit in the soft tissues, fo rming tumors known as tophi Tophi can ulcerate and drain a chalky material. Uric acid tophi are virtually pathognomonic for gout, and even in the absence of microscopic confirmation of crystals, the diagnosis can be made provisionally in patients with visible tophi and a history of episodic monoarthritis. An elevated serum ur ic acid level is nonspecific but can also contribute to the diagnosis. {Choice A) Calcinosis cutis is characterized by deposition of calcium and phosphorus in the skin. It presents with scattered whitish papules, plaques. or nodules. This patient's history of painful arthritis is more typical for gout
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(Choice B) Chondrosarcomas are bone tumors occurring in the 5th or 6th decade of life . They most commonly affect the pelvis, femur. or proximal humerus and would likely not be as multifocal and bilateral as the disease pictured (Choice D) Severe osteoarthritis can produce Heberden and Bouchard nodes, which are hard, bony nodules over the distal and proximal interphalangeal joints, respectively This patient's tophi involving several joint spaces and soft tissue structures are more consistent with gout (Choice E) Psoriatic arthritis can present with distal interphalangeal joint arthritis, asymmetric oligoarthritis, symmetric polyarthritis, spondyloarthropathy , or aggressively destructive arthritis mutilans. Most patients have established psoriasis, and nail changes (eg, pitting) are common. (Choice F) Rheumatoid nodules are firm, flesh-colored, and nontender. They typically occur over pressure points such as the elbow and extensor surface of the proximal ulna. Educafonal ob'ecfve·
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.,.,. precipitation of uric acid crystals in the joints, leading to episodic monoarticular arthritis (especially in the first metatarsophalangeal joint and knee) The diagnosis is confirmed with arthrocentesis showing an inflammatory effusion with uric acid crystals "'
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Urate crystals may also deposit in the soft tissues, forming tumors known as tophi. Tophi can ulce rate and drain a chalky materiaL Uric acid tophi are virtually pathognomonic for gout, and even in the absence of microscopic confirmation of crystals, the diagnosis can be made provisionally in patients with visible tophi and a history of episodic monoarthritis. An elevated ser um uric acid level is nonspecific but can also contribute to the diagnosis (Choice A) Calcinosis cutis is characterized by deposition of calcium and phosphorus in the skin. It presents with scattered whitish papules, plaques, or nodules. This patient's history of painful arthritis is more typical fo r gout (Choice B) Chondrosarcomas are bone tumors occurring in the 5th or 6th decade of life . They most commonly affect the pelvis, femur, or proximal humerus and would likely not be as multifocal and bilateral as the disease pictured .
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(Choice D) Severe osteoarthritis can produce Heberden and Bouchard nodes, which are hard , bony nodules over the distal and proximal interphalangeal joints, respectively This patient's tophi involving several joint spaces and soft tissue structures are more consistent with gout (Choice E) Psoriatic arthritis can present with distal interphalangeal joint arthritis, asymmetric oligoarthritis, symmetric polyarthritis, spondyloarthropathy, or aggressively destructive arthritis mutilans. Most patients have established psoriasis, and nail changes (eg, pitting) are common. (Choice F) Rheumatoid nodules are fi rm, flesh-colored, and nontender. They typically occur over pressure points such as the elbow and extensor surface of the proximal ulna. Educational objective: In chronic tophaceous gout, urate crystals can be deposited in the skin, resulting in the formation of tumors with a chalky white appearance Time Spent 16 seconds
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6 A Dementia, Alzheimer type <0 B. Frontotemporal dementia
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® D. Normal aging
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0 F. Pseudodementia due to depression Submit
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A 76-year-old woman comes to the office for a routine checkup Her medical history is significant fo r hypertension, type 2 diabetes mellitus, and hypothyroidism that are controlled with oral agents. She had a stroke a year ago and has mild residual right arm weakness. Otherwise, she has no physical symptoms but mentions that she is concerned about becoming more fo rgetful She says, "Sometimes I can't remember people's names and occasionally during conversations I can't seem to find the right word." The patient is widowed and lives alone. She drives herself to the grocery store weekly and has no difficulty managing her finances. She describes her mood as "just okay" and mentions that she misses her husband and feels badly that she lives far from her children and grandchildren. She plays ca rds with her close friends regularly and is looking forward to a trip to visit her family. Her appetite is good, but she describes fall ing asleep earlier in the evening, awakening earlier in the morning, and having less energy during the day than she had before. Blood pressure is 135/76 mm Hg and pulse is 65/min. Finger stick glucose and TSH levels are normal Which of the following is the most likely diagnosis in this patient?
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Cognitive impairment in elderly patients
Normal aging
• Slight decrease in fluid intelligence (ability to process new information quickly) • Normal functioning in all activities of daily living • Mild decline in ~1 cognitive domains
Mild neurocognitive disorder
• Normal functioning in all activities of daily living with compensation
Major neurocognitive disorder (dementia)
• • • •
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Significant decline in ~1 cognitive domains Irreversible global cognitive impairment Marked functional impairment Chronic & progressive, months to years
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Major depression
• Reversible mild-moderate cognitive impairment (pseudodementia) • Features of depression (mood, interest, energy) • Episodic, weeks to months
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This patient, who has well-controlled diabetes, hypertension, and hypothyroidism and no new focal neurologic deficits (baseline right arm weakness due to prior stroke), is experiencing
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This patient, who has well-controlled diabetes, hypertension, and hypothyroidism and no new focal neurologic deficits (baseline right arm weakness due to prior stroke), is experiencing occasional forgetfulness, word-finding difficulty , and changes in sleep pattern that are most likely due to normal age-related changes
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As patients age, they tend to have a lower energy level and slower process ing speed that affects memory and executive functioning (eg, planning, working memory, mental flexibility) to a small degree They have occasional word-finding difficulty (expressive aphasia) or memory loss but are able to provide details about incidents of forgetfulness. Changes in sleep pattern , including lighte r sleep and phase advance (ie, falling asleep earlier in the evening and awakening earlier), are also common with advancing age Normal age-related changes, as seen in this patient, should not impair daily functioning (eg, self-care, finances, medication management) This helps distinguish normal aging from mild neurocognitive disorder (NCO). In mild NCO, there is a modest but notable decline in cognitive function (eg, complex attention, executive function, learning and memory, language, perceptual-motor, social cognition) Capacity for independence in everyday activities is generally preserved but takes greater effort, time, and/or compensatory strategies Major NCO (dementia) involves significant cognitive decline and clea rly impaired functioning that necessitates assistance in everyday activities.
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(Choices A, B , and C) These conditions are etiological subtypes of NCO that can be diffe rentiated by their characteristic cognitive and behavioral features. Different sources may refer to them using diffe rent terminologies Alzheimer disease presents with insidious onset and gradual progression of memory impairment (particularly memory for recent events or of specific events at specific times) and deficits in executive functioning In frontotemporal dementia, behavioral changes (eg, disinhibition, apathy) are prominent. In vascular (multi-infarct) dementia, cognitive deficits are temporally related to one or more cerebrovascular events and often present in a stepwise fashion. (Choice E) Normal-pressure hydrocephalus is characterized by a triad of dementia, gait apraxia, and urinary incontinence. This woman does not manifest any of these classic signs.
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self-care, finances , medication management) This helps distinguish normal aging from mild neurocognitive disorder (NCO). In mild NCO, there is a modest but notable decline in cognitive function (eg, complex attention, executive function, learning and memory, language, perceptual-motor, social cognition) Capacity for independence in everyday activities is generally preserved but takes greater effort, time, and/or compensatory strategies. Major NCO (dementia) involves significant cognitive decline and clearly impaired functioning that necessitates assistance in everyday activities. (Choices A, B , and C) These conditions are etiological subtypes of NCO that can be differentiated by their characteristic cognitive and behavioral features. Different sources may refer to them using different terminologies Alzheimer disease presents with insidious onset and gradual progression of memory impairment (particularly memory for recent events or of specific events at specific times) and deficits in executive functioning In frontotemporal dementia, behavioral changes (eg, disinhibition, apathy) are prominent. In vascular (multi-infarct) dementia, cognitive deficits are temporally related to one or more cerebrovascular events and often present in a stepwise fashion. {Choice E) Normal-pressure hydrocephalus is characterized by a triad of dementia, gait apraxia, and urinary incontinence. This woman does not manifest any of these class ic signs. {Choice F) Depression is a common cause of reversible cognitive impairment in the elderly (pseudodementia) This patient's social engagement and enjoyment of her fam ily make this unlikely Educational objective: Normal age-related cognitive changes include occasional forgetfulness and word-finding difficulty that do not impact activities of daily living References: 1. Normal cognitive aging.
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<0 A Acute manic episode with psychotic features <0 B. A lcohol withdrawal <0 C. Delusional disorder
e; D. Methamphetamine abuse <0 E. Opioid abuse <0 F. Schizophrenia
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A 42-year-old man is brought to the emergency department after assaulting his wife . She says he has not slept or eaten fo r days; he became agitated and started accusing her of plotting with her former boyfriend to murder him. He also believes that the FBI is out to get him and that there are "bugs" under his skin. The patient had a prior psychiatric hospitalization 8 months ago when he was admitted fo r paranoid delusions and visual hallucinations. The patient was formerly a successful stockbroker but has been unemployed for the past 2 years He is uncoope rative with the evaluation, speaks rapidly and loudly , gets up to pace during the interview, and shouts, "I don't trust any of you; you're in this together " Examination shows a thin, diaphoretic man with poor grooming and dentition. He picks at his skin and has multiple sores on his face and body Temperature is 37.8 C (100 F) , blood pressure is 140/90 mm Hg, pulse is 104/min, and respirations are 20/min. W hich of the following is the most likely diagnosis?
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This patient's paranoid delusions, tactile hallucinations (bugs crawling under the skin), aggressive behavior, severe insomnia, and physical findings of poor dentition and skin sores are suggestive of chronic methamphetamine abuse. Methamphetamine is a highly addictive and ve ry potent central nervous stimulant also known as "meth," "crystal meth," "ice," and "glass " Heavy use frequently causes marked weight loss, psychotic symptoms, and excoriations due to chronic skin picking. Severe dental problems ("meth mouth") can include brown discoloration, tooth decay, and cracked teeth due to severe clenching Other features of intoxication include mood disturbances, anxiety, irritability, confusion, violent behavior, and signs of sympathetic over-activity (eg, elevated pulse and blood pressure, hyperthermia, sweating, pupillary dilation) Some chronic methamphetamine users can develop persistent psychosis that may be difficult to distinguish from primary psychiatric disorders. Visual and tactile hallucinations tend to be more common in substance-induced psychotic disorders. Long-term management includes both cognitive-behavioral treatment to prevent relapse and antipsychotic medication.
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(Choices A, C, and F) Methamphetamine intoxication can resemble a manic episode as users experience increased energy and talkativeness, and can go for days without eating or sleeping They may also experience psychotic symptoms (eg, delusions, paranoia, hallucinations) that are seen in primary psychotic disorders. However , this patient's history of tactile and visual hallucinations and physical findings (sympathetic over-activity , skin sores due to picking, and tooth decay) make methamphetamine abuse more likely than a primary mood or psychotic disorder. {Choice B ) Alcohol withdrawal can present with hallucinations and elevated vital signs but is usually associated with marked tremulousness. The extent of this patient's paranoid delusions is more suggestive of chronic methamphetamine abuse. {Choice E) Signs of opioid intoxication include slurred speech, sedation, and pinpoint pupils Educational objective: Chronic methamphetamine abuse can cause psychotic symptoms, including paranoid delusions and auditory, visual, and tactile hallucinations (bugs crawling under the skin) Other signs incl ude
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Some chronic methamphetamine users can develop persistent psychosis that may be difficult to distinguish from primary psychiatric disorders. Visual and tactile hallucinations tend to be more common in substance-induced psychotic disorders. Long-term management includes both cognitive-behavioral treatment to prevent relapse and antipsychotic medication. {Choices A, C, and F) Methamphetamine intoxication can resemble a manic episode as users experience increased energy and talkativeness, and can go for days without eating or sleeping They may also experience psychotic symptoms (eg, delusions, paranoia, hallucinations) that are seen in primary psychotic disorders. However, this patient's history of tactile and visual hallucinations and physical findings (sympathetic over-activity, skin sores due to picking, and tooth decay) make methamphetamine abuse more likely than a primary mood or psychotic disorder. (Choice B) Alcohol withdrawal can present with hallucinations and elevated vital signs but is usually associated with marked tremulousness. The extent of this patient's paranoid delusions is more suggestive of chronic methamphetamine abuse. {Choice E) Signs of opioid intoxication include slurred speech, sedation, and pinpoint pupils Educational objective: Chronic methamphetamine abuse can cause psychotic symptoms, including paranoid delusions and auditory, visual, and tactile hallucinations (bugs c rawling under the skin) Other signs include marked weight loss, severe tooth decay, and excoriations due to skin picking
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References: 1. The profile of psychiatric symptoms exacerbated by methamphetamine use. 2. Methamphetamine psychosis: epidemiology and management. 3. Differences in Clinical Features of Methamphetamine Users with Persistent Psychosis and Patients with Schizophrenia.
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<0 A Bradycardia <0 B. Decreased appetite <0 C. Diarrhea <0 D. Hypersomnia
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6 H. Weight gain
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A 7-year-old boy is brought to the office by his mother for a routine checkup Physical examination is normal, but the mother says that her son's behavior over the past year has been poor The boy is always running around (even during dinner), does not listen to instructions, and keeps his room a mess. He is unable to follow a morn ing routine to get ready for school and frequently misses the bus as a result The mother also says that the boy's second-grade teacher has reported that he answers questions impulsively and out of turn and cannot sit at his desk for very long without fidgeting He also frequently forgets to bring in his homework and loses his books. The physician recommends a trial of methylphenidate. Which of the following side effects is the patient most likely to experience while taking this medication?
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This patient's behavioral problems both at home and at school (hyperactivity, impulsivity, disorganization) are consistent with attention-deficit hyperactivity disorder (ADHD) The stimulant methylphenidate is a first-line treatment fo r school-age children with ADHD. Common side effects of methylphenidate include decreased appetite, weight loss, and insomnia. Stimulants commonly cause a mild reduction in appetite that can usually be managed by encouraging the child to eat favorite nutrient-dense foods and take the medication after meals. Weight should be monitored regularly during treatment Other common side effects include jitteriness, gastro intestinal symptoms, and tachyca rdia {Choice A) Methylphenidate can cause tachycardia, not bradyca rdia {Choice C) Diarrhea can occur, but it is less common than decreased appetite {Choices D and H) Methylphenidate more commonly causes insomnia and weight loss.
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{Choices E, F, and G) Rash and seizures are rare side effects of methylphenidate Although new-onset tics have been reported with stimulants, these are uncommon. Methylphenidate should be used cautiously in patients with Tourette syndrome or other tic disorders. Educational objective: Methylphenidate is a central nervous system stimulant that is frequently used to treat attention-deficit hype ractivity disorder. Common side effects include decreased appetite, weight loss, and insomnia. References: 1. Effect of stimulants on height and weight: a review of the literature. 2. Psychopharmacology of attention-deficit hyperactivity disorder: effects and side effects. 3. Treatment of attention deficit hyperactivity disorder in children and adolescents: safety considerations.
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6 A Avascular necrosis
e; B. Bacterial infection 6 C. Bone demineralization
e; D. Hyperuricemia 6 E. Nerve damage
e; F. Rheumatoid arthritis
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A 51-year-old man complains of difficulty walking and mild right-sided foot pain fo r the past several weeks. The patient's medical history is significant fo r type 1 diabetes mellitus, hypertension, and hype rcholesterolemia Physical examination shows a significantly deformed right foot and a mildly deformed left foot X-rays of the right foot suggest effusions in several of the tarsometatarsal joints, large osteophytes, and several extra-articular bone fragments. W hich of the following is the most likely cause of this patient's complaints?
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Charcot joint (neurogenic arthropathy) • Vitamin 812 deficiency • Diabetes Associated conditions
• Deformed joints
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• Arthritis or arthropathy • Mild pain • Fractures (may be unsuspected by patient)
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• Spinal cord injury • Tabes dorsalis (tertiary syphilis)
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• Degenerative joint disease & loose bodies on joint imaging • Treat underlying condition Management
• Mechanical devices (assist in weight bearing, decrease further trauma) • X-rays (if trauma is present)
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• X-rays (if trauma is present) UWortd
This patient has neurogenic arthropathy (Charcot joint) due to diabetes. Pathogenesis involves decreased proprioception, pain, and temperature perception, which can occur due to diabetes, peripheral nerve damage, syringomyelia, spinal cord injury, vitamin B12 deficiency, or tabes dorsalis. As normal neurologic input is lost, patients unknowingly traumatize their weight-bearing joints This causes secondary degenerative joint disease, joint deformation, and functional limitation. X-rays will reveal loss of ca rtilage, osteophyte development, and loose bodies. In diabetes, vasculopathy also contributes to disease pathogenesis. Associated pain is typically mild. Management of a Charcot joint involves treating the underlying disease and providing mechanical devices (eg, special shoes) to assist in weight bearing and decrease further trauma. (Choice A) Avascular necrosis refers to bone destruction due to poor vascular supply. It is a complication of corticosteroid use, trauma, systemic lupus erythematosus, sickle cell disease, and a number of other processes. It generally affects the proximal and distal femur with pain as the main symptom {Choice B) Bacterial infection is an important cause of acute monoarticular arthritis (septic joint) It is exquisitely painful and rapidly destructive. Fever may be present An x-ray will reveal joint destruction but not osteophytes or loose bodies. A septic joint is diagnosed by joint fluid aspiration (Choice C) Bone demineralization is the hallmark of osteoporosis This disease predisposes patients to pathologic fractures, particularly of the hip and ve rtebrae. However , it does not cause joint destruction. (Choice D) Gout results from uric acid deposition within joints It is exquisitely painful and generally affects the great toes, ankles, wrists, and elbows. X-rays of joints affected by chronic gout reveal punched-out erosions with an overhanging rim of co rtical bone known as a "rat bite" lesion.
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compl ication of corticosteroid use, trauma, systemic lupus erythematosus, sickle cell disease, and a number of other processes. It generally affects the proximal and distal fem ur with pain as the main symptom (Choice B) Bacterial infection is an important cause of acute monoarticular arthritis (septic joint) It is exquisitely painful and rapidly destructive. Fever may be present An x-ray will reveal joint destruction but not osteophytes or loose bodies. A septic joint is diagnosed by joint fluid aspiration. (Choice C) Bone demineralization is the hallmark of osteoporosis. This disease predisposes patients to pathologic f ractures, particularly of the hip and vertebrae. However, it does not cause joint destruction. (Choice D) Gout results from uric acid deposition within joints It is exquisitely painful and generally affects the great toes, ankles, wrists, and elbows. X-rays of joints affected by chronic gout reveal punched-out erosions with an overhanging rim of cortical bone known as a "rat bite" lesion. (Choice F) Rheumatoid arthritis is a common cause of polyarticular inflammatory arthritis. It typically affects the hands, wrists, feet, and ankles, generally in a symmetric fashion. X-rays of patients with long-standing, poorly controlled disease will reveal periarticular osteoporosis, joint erosions, and joint space narrowing Educational objective: Neurogenic arthropathy (Charcot joint) is a complication of neuropathy and repeated joint trauma. It affects weight-bearing joints and manifests with functional limitation, deformity , and degenerative joint disease and loose bodies on joint imaging References: 1. Charcot neuroarthropathy: An often overlooked complication of diabetes.
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0 A Ankylosing spondylitis 0 B. Central spinal canal stenosis 0 C. Disc herniation 6 D. Iliac artery thrombosis
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e; H. Vertebral osteomyelitis
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A 54-year-old retired schoolteacher comes to the physician due to worsening low back pain The pain started 3 weeks ago It is continuous, does not improve with rest, and is worse at night The patient has had little relief with over-the-counter nonsteroidal analgesics He has no other symptoms He had a surgical resection of a lung tumor 1 year ago for non-small cell carc inoma of the lung. At that time, preoperative positron emission tomography (PET) scanning did not reveal any evidence of metastasis. His vital signs are within normal limits. Examination shows local spinal tenderness at the L4-L5 leveL W hat is the most likely cause of this patient's back pain?
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Common causes of low back pain
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Condition
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Mechanical (muscle strain, spasm, degenerative arthritis)
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Herniated nucleus pulposus/ disk disease
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Clinical clues • Normal neurologic examination • Negative straight leg raise • Possible paraspinal tenderness • Radiculopathy (usually L4-L5) • Possible positive straight leg raise • Possible neurologic deficits
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Musculoskeletal
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• Pseudoclaudication
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Spinal stenosis
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• Better with spine flexion • Worse with extension • Older age
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• Older age
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Compression fracture
• More common in women • Trauma/fall (may be minor)
Inflammatory
Ankylosing spondylitis, reactive arthritis, psoriatic arthritis,
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• Better with activity or exercise • No improvement with rest • Gradual onset
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• No improvement with rest • Gradual onset
• HLA-827 present
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• History of malignancy
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• Age >50 • Worse at night
Malignancy
Metastatic cancer to bone
• Cauda equina syndrome (weakness, urine retention/incontinence, saddle anesthesia)
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Osteomyelitis, discitis, abscess
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• IV drug abuse • Diabetes
• Fever, exquisite point tenderness
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©UWorld
Metastatic disease of the vertebrae is the most likely cause of back pain in this patient with a history of non-small cell carcinoma of the lung. Bony metastases are much more common than primary bone tumors and the most common tumors that metastasize to bone include lung, breast, prostate, thyroid, and kidney cancers. Bony metastases typically cause pain that is constant and worse at night, with point tenderness on examination. In contrast, the pain caused by degenerative disease is typically exacerbated by exercise and relieved by rest. Although the initial positron emission tomography (PET) scan was negative 1 year ago, a history of known I 1 rI d th h t · r f th I t t r b d. h ·I h t th r t
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{Choice A) Ankylosing spondylitis is an HLA-827-associated seronegative spondyloarthropathy that most commonly affects men in the second or third decade of life .
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(Choice B) Spinal stenosis typically occurs in the lumbar spine and causes low back pain that is relieved with rest but aggravated with activity
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degenerative disease is typically exacerbated by exercise and relieved by rest. Although the initial positron emission tomography (PET) scan was negative 1 year ago, a history of known malignancy and the characteristics of the pain place metastatic bone disease highest on the list of differential diagnoses in this patient.
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{Choice C) Disc herniation presents as low back pain radiating down the buttock and below the knee in a dermatomal distribution due to irritation of a nerve root. Positive straight leg and crossed straight leg tests are specific for disc herniation. (Choice D) Iliac artery thrombosis can cause low back pain associated with claudication of the hip muscles and possibly impotence {Choice E) Lumbar strain usually occurs acutely following twisting of the back while lifting heavy weights It is typically exacerbated by activity and relieved by rest, and there is usually no point tenderness. (Choice G) Ve rtebral compression fractures can result from trauma or (more commonly) can occur in the setting of osteoporosis without any history of trauma. However , osteoporosis is uncommon in men, particularly under age 65. (Choice H) Ve rtebral osteomyelitis may cause chronic progressive pain with point tenderness over the affected vertebrae. However , it is typically accompanied by a low-grade fever and generally occurs in patients with recent overlying soft tissue infection or bacteremia. The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels are usually elevated. Educational objective: Low back pain in patients with a history of malignancy should always raise suspicion for bone metastasis. Tumors metastatic to bone typically cause progressive pain that is constant and k th I r t t ' hI t
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r() A Muscle fibers
6 B. Peripheral nerves (() C. Postsynaptic membrane
6 D. Presynaptic membrane
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A 60-year-old man comes to the physician complaining of fatigue and muscle weakness in his extremities. He has also lost 7 kg (15 lb) during the last 3 months. He has no other medical conditions. The patient smokes 2 packs of cigarettes daily and consumes alcohol occasionally. His muscle strength is 3/5 in the proximal muscle groups symmetrically. His reflexes are 2+ bilaterally No sensory abnormality is present There are erythematous to violaceous papules involving the dorsum of his fingers. Chest x-ray reveals an ill-defined mass in the right lower lobe. His muscle weakness is most likely due to a lesion involving which of the following?
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Paraneoplastic syndrome
Involved site
Myasthenia gravis
Acetylcholine receptor in postsynaptic membrane
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Fluctuating muscle weakness • Ocular (ptosis, diplopia) • Bulbar (dysphagia, dysarthria) • Facial, neck & limb muscles • Proximal muscle weakness
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Lambert-Eaton syndrome
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• Autonomic dysfunction (eg, dry mouth) • Cranial nerve involvement (eg, ptosis) • Diminished or absent deep-tendon reflexes
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Dermatomyositis/ polymyositis
Muscle fiber injury
• Interstitial lung disease, esophageal dysmotility, Raynaud phenomenon
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Polyarthritis
• Esophageal dysmotility • Skin findings (eg, Gottron papules, heliotrope rash) in dermatomyositis @UWOI!d
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@UWOI!d
This patient's smoking history, weight loss, and right lower lobe mass are concerning fo r lung cancer. Patients with suspected malignancy can develop a paraneoplastic syndrome due to the tumor producing hormones and/or cytokines. Paraneoplastic syndromes are not directly related to the cancer's invasion. They are most commonly seen in cancers of the lung, breast, and ovaries, and lymphomas. Symptoms typically resemble those of primary endocrine, metabolic , hematologic , or neuromuscular disorders. Paraneoplastic syndromes affecting the peripheral nerve and/or muscle (eg, myasthenia gravis, Lambert-Eaton syndrome, dermatomyositis) most commonly present with muscle weakness, as seen in this patient. Dermatomyositis is an idiopathic inflammatory myopathy with immune-mediated muscle injury Dermatomyositis patients typically present with symmetrical proximal muscle weakness and erythematous rash on the dorsum of the fingers (Gottron's sign) and/or upper eyelids (heliotrope eruption) Diagnosis is usually confirmed by muscle biopsy (Choice B) Peripheral nerve involvement usually causes neuropathies presenting with sensory and/or motor abnormalities and abnormal reflexes on physical examination. This patient's normal reflexes and sensory examination make this unlikely
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(Choice C) Myasthenia gravis is due to autoantibodies against acetylcholine receptors in the postsynaptic membrane. It is characterized by fl uctuating ocular (ptosis, diplopia), facial and/or bulbar muscle weakness that becomes worse with repetitive tasks. This patient's absence of eye findings and the presence of skin findings make this less likely (Choice D) Lambert-Eaton myasthenic syndrome involves antibodies targeted against the presynaptic membrane. Although patients can also present with proximal limb muscle weakness, they usually have other autonomic dysfunction (eg, dry mouth, erectile dysfunction) and absent or diminished deep-tendon reflexes. Repeat isometric contraction can lead to temporary improvement of muscle weakness and reappearance of absent deep-tendon reflexes. This patient's preserved reflexes and skin findings are more consistent with dermatomyositis
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biopsy (Choice B) Peripheral nerve involvement usually causes neuropathies presenting with sensory and/or motor abnormalities and abnormal reflexes on physical examination. This patient's normal reflexes and sensory examination make this unlikely (Choice C) Myasthenia gravis is due to autoantibodies against acetylcholine receptors in the postsynaptic membrane. It is characterized by fluctuating ocular (ptosis, diplopia), facial and/or bulbar muscle weakness that becomes worse with repetitive tasks. This patient's absence of eye findings and the presence of skin findings make this less likely (Choice D) Lambert-Eaton myasthenic syndrome involves antibodies targeted against the presynaptic membrane. Although patients can also present with proximal limb muscle weakness, they usually have other autonomic dysfunction (eg, dry mouth, erectile dysfunction) and absent or diminished deep-tendon reflexes. Repeat isometric contraction can lead to temporary improvement of muscle weakness and reappearance of absent deep-tendon reflexes. This patient's preserved reflexes and skin findings are more consistent with dermatomyositis. (Choice E) Paraneoplastic myelopathy of the spinal cord typ ically presents with flaccid or spastic paraplegia or quadriplegia, sensory deficits, and/or urinary or fecal retention/ incontinence. Educational objective: Dermatomyositis is an idiopathic inflammatory myopathy with immune-mediated muscle injury that can be due to a paraneoplastic syndrome in malignancy Patients typically have symmetrical proximal muscle weakness and erythematous rash over the dorsum of the fingers (Gottron's sign) and/or upper eyelids (heliotrope eruption)
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References: 1. Paraneoplastic muscle disease
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A 10-year-old boy is brought to the emergency department due to sudden-onset nausea, abdominal cramps, and several episodes of vomiting over the last 2 hours. He has not had diarrhea. His mother notes that the patient's 6-year-old sister has similar symptoms The ch ildren ate barbecued chicken with potato salad at a community lunch 4 hours before the symptoms began. They also swam in the community pool and played with a pet turtle. The patient has a history of upper respiratory infections and received antibiotics a month ago for acute otitis media. Temperature is 36.8 C (98 2 F), blood pressure is 112/70 mm Hg, and pulse is 88/min. Abdomen is soft and nontender. Which of the following is the most likely cause of this patient's symptoms?
<0 A Bacillus cereus <0 B. Campylobacter jejuni <0 C. Clostridium difficile
® D. Clostridium pet11'ingens <0 E. Enterotoxigenic Escherichia coli <0 F. Giardia Iambiia
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® H. Nontyphoidal salmonella
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<0 J . Staphylococcus aureus
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py Explanation:
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Foodborne disease
Watery diarrhea predominant
Vomiting predominant
Nongastrointestinal symptoms
l • Staphylococcus aureus
• Clostridium perfringens
• Salmonella (both typhi & non-typhi)
• Botulism (descending paralysis)
• Bacillus cereus
• Enterotoxic Escherichia coli
• Campylobacter
• Ciguatera toxin (paresthesia)
• Noroviruses (eg, Norwalk)
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Inflammatory diarrhea predominant
• Enteric viruses
• Shiga toxin producing Escherichia coli
• Cryptosporidium
· Shigella
• Scombroid (flushing, urticaria)
• Cyc/ospora
• Enterobacter
• Listeria (meningitis)
• Intestinal tapeworms
• Vibrio (usually parahaemolyticus)
• Vibrio vulnificus (cellulitis, sepsis)
• Yersinia • Hepatitis A Oaundice) • Brucellosis (fever, arthralgias) ©UWor1d
This boy and his sister developed concomitant acute gastrointestinal symptoms after attending a • •• ••
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This boy and his sister developed concomitant acute gastrointestinal symptoms after attending a community lunch, suggesting a foodborne illness. Approximately 50 million cases of foodborne illness occur in the United States each year Pathogens include bacteria, viruses, and parasites. Suspicion for a specific etiologic organism is often suggested by the food consumed, length of time to symptoms, and symptom complex.
Staphylococcus aureus is found in the nose and on the skin of -25% of the population. Most people are asymptomatic, but colonized food handlers can transmitS aureus to food during preparation. Dairy items (eg, mayonnaise in potato salad) , meats, eggs, produce, and salads are particularly vulnerable. S aureus produces enterotoxins in the contaminated food that rapidly cause symptoms after ingestion (often within 1-6 hours). Vomiting is the primary symptom; diarrhea may or may not be present Illness is usually self-limited, resolving completely within 24-48 hours.
(Choice A) Bacillus cereus also causes rapid-onset vomiting due to a toxin formed outside of the body However, B cereus is usually transmitted via starch products (particularly rice that has been reheated or left at room temperatures for extended periods) The mayonnaise in this patient's potato salad was likely the culprit (Choices B and H) Campylobacter jejuni and nontyphoidal salmonella directly attack colonic epithelial cells and usually cause watery diarrhea (with blood/mucus), severe abdominal pain, and fever Both organisms are transmitted by poultry (salmonella is also associated with turtles) This patient had a vomiting-predominant illness (not diarrhea-predominant). {Choice C) Clostridium difficile causes antibiotic-associated colitis (watery diarrhea, abdominal pain) Although this patient had antibiotics a month ago, vomiting is his primary symptom (not diarrhea) (Choices 0 , E, and I) Clostridium petiringens, enterotoxigenic Escherichia coli (ETEC), and Shiga toxin-producing E coli (STEC) produce toxins after the organism is ingested. As such, symptoms are typically delayed >1 day (not 4 hours) Both C petiringens and ETEC cause watery diarrhea; STEC causes watery diarrhea that becomes bloody, often with renal failure
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feve r. Both organisms are transmitted by poultry (salmonella is also associated with turtles). This patient had a vomiting-predominant illness (not diarrhea-predominant) (Choice C) Clostridium difficile causes antibiotic-assoc iated colitis (watery diarrhea, abdominal pain) Although this patient had antibiotics a month ago, vomiting is his primary symptom (not diarrhea) (Choices 0 , E, and I) Clostridium perfringens, enterotoxigenic Escherichia coli (ETEC), and Shiga toxin-producing E coli (STEC) produce toxins after the organism is ingested As such, symptoms are typically delayed >1 day (not 4 hours) Both C perfringens and ETEC cause watery diarrhea; STEC causes watery diarrhea that becomes bloody, often with renal failure (0157 H7) (Choice F) Giardia is transmitted primarily by contaminated water. Incubation takes 7-1 4 days, and symptoms include foul-smelling, watery diarrhea. {Choice G) Listeria monocytogenes is a foodborne illness that occasionally causes self-limited, febrile gastroenteritis (watery diarrhea). Patients who are immunocompromised, pregnant, or at the extremes of age (<2, >50) may develop invasive disease (bacteremia, meningoencephalitis) This patient did not have diarrhea or fever. Educational objective: Staphylococcus aureus causes foodborne illness due to the ingestion of preformed toxins. Vomiting is the preeminent symptom and usually begins 1-6 hours after exposure Diarrhea may or may not be present Food containing mayonnaise is often implicated in staphylococcal food poisoning References: 1. Diagnosis and management offoodborne illnesses: a primer for physicians. 2. Staphylococcal enterotoxins.
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A 60-year-old man comes to the office due to a 6-month history of constant back pain, thigh pain, and headache. He has moderate, deep, achy pain in the mid lumbar area that does not radiate and is worse with changes in position such as rolling over in bed. The patient has no significant history of trauma, and the course of his symptoms has been stable but persistent He has been taking acetaminophen without relief. There is no associated nausea, vomiting, weight loss, fever, difficulty walking, leg numbness, or urinary symptoms Medical history is notable for hype rtension treated with chlorthalidone and lisinopriL He also uses a hearing aid for recently acquired, left-sided hearing loss. Blood pressure is 138/85 mm Hg, pulse is 76/min, and respirations are 12/min. BMI is 29 kg/m2 The patient appears comfortable and in no acute distress. Cardiopulmonary examination is normaL The abdomen is soft and nontender with no organomegaly. He has mild thoracic dextroscoliosis and a decrease in the normal lumbar lordosis. The lower extremities show mild anterolateral femoral bowing Upper and lower motor strength, sensation, and reflexes are normaL W hich of the following is the most likely cause of this patient's current condition?
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0 A Calcium malabsorption 0 B. Osteoblast apoptosis
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6 D. Parathyroid hormone/calcitonin imbalance 0 E. Plasma cell dyscrasia
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0 F. Vitamin D overproduction Submit
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Osteolytic phase (osteoclast dominant) Osteoclasis
Mixed phase (osteoclast + osteoblast)
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Osteosclerotic phase (osteoblast dominant) Weak, thickened woven bone
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© UWortd
This patient with bone pain, headaches, unilateral hearing loss, and femoral bowing has typical symptoms of Paget disease of bone. Paget disease is the most common bone disorder after osteoporosis, affecting approximately 3% of adults age >40. It is characterized by a focal increase in bone turnover, in which osteoclast dysfunction leads to bone breakdown and a compensatory inc rease in bone formation. The pelvis, skull, spine, and long bones are most commonly involved. Microscopic findings include increased numbers of abnormal-appearing osteoclasts, with a disorganized "mosaic" pattern of lamellar bone. Early-stage lesions will have a predominance of osteoclast activity, later progressing through a mixed osteoclastic/osteoblastic phase, a predominantly osteoblastic phase, and a residual sclerotic phase. Most patients with Paget disease are asymptomatic and are identified incidentally by radiographic findings or elevated alkaline phosphatase levels. Symptoms may include skeletal deformities, bone or joint pain, and fractures. Enlarging cranial bones may lead to increased hat size, headaches, and hearing loss due to entrapment of c ranial nerve VII I or encroachment on the cochlea. Additional compl ications include benign giant cell tumors of bone and osteosarcoma.
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(Choice A) Osteomalacia due to malabsorption of calcium and vitamin D causes abnormal mineralization of bone with muscular weakness, bone pain, and deformity However, it would not lead to unilateral hearing loss, and this patient has no history of a malabsorptive disorder (eg, celiac disease) {Choice B) Glucoco rticoids can cause osteoporosis, in part due to induction of apoptosis in osteoblasts. Osteoblast activity is inc reased in Paget disease. (Choice D) Hyperparathyroidism can present with weakness, abdominal pain, and bone pain or fractures. Hearing loss would not be seen. {Choice E) Multiple myeloma (a plasma cell dyscrasia) can cause osteolytic lesions, I I I t I df t H b ·1 t Ih d b f
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predominance of osteoclast activity, later progressing through a mixed osteoclastic/osteoblastic phase, a predominantly osteoblastic phase, and a residual sclerotic phase Most patients with Paget disease are asymptomatic and are identified incidentally by radiographic findings or elevated alkaline phosphatase levels. Symptoms may include skeletal deformities, bone or joint pain, and fractures. Enlarging cranial bones may lead to increased hat size, headaches, and hearing loss due to entrapment of cranial nerve VIII or encroachment on the cochlea. Additional complications include benign giant cell tumors of bone and osteosarcoma. (Choice A) Osteomalacia due to malabsorption of calcium and vitamin D causes abnormal mineralization of bone with muscular weakness, bone pain, and deformity However, it would not lead to unilateral hearing loss, and this patient has no history of a malabsorptive disorder (eg, cel iac disease) (Choice B) Glucocorticoids can cause osteoporosis, in part due to induction of apoptosis in osteoblasts. Osteoblast activity is increased in Paget disease.
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{Choice D) Hyperparathyroidism can present with weakness, abdominal pain, and bone pain or fractures. Hearing loss would not be seen. (Choice E) Multiple myeloma (a plasma cell dyscrasia) can cause osteolytic lesions, osteoporosis, and fractures. However , bowing, unilateral hearing loss, and absence of systemic symptoms are more typical of Paget disease. (Choice F) Overproduction of calcitriol (the active form of vitamin D) is seen in granulomatous diseases such as sarcoidosis and tuberculosis. Hypercalciuria and hypercalcemia may occur, leading to kidney stones, nephrocalcinosis, and renal failure. Educational objective: Paget disease of bone is characterized by osteoclast dysfunction with a focal inc rease in bone turnover. Most patients are asymptomatic , but symptoms may include skeletal deformities, bone pain, and fractures. Involvement of cranial bones may lead to headaches and hearing loss. Time Spent 2 seconds
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A 48-year-old man with an extensive smoking history is evaluated for cough and an episode of mild hemoptysis After the patient ignored his symptoms fo r weeks, his wife finally convinced him to make an appointment Chest x-ray shows a mass lesion in the right upper lobe. A chest CT scan and bronchoscopy with biopsy are scheduled fo r that afternoon, and the patient is instructed to schedule a follow-up visit with the physician 3 days later to discuss the results. The patient agrees to have the tests done but declines the follow-up appointment, saying that he and his wife are leaving for a previously scheduled 2-week anniversary celebration and vacation the next day Despite education about diagnostic possibilities, he is convinced that his symptoms are stress-related and that he will feel better by the time he returns. The physician is highly concerned that the workup may show lung cancer although the patient clinically appears to be stable. Which of the following is the most appropriate response by the physician?
A I am concerned that you may be in denial about the seriousness of your condition.
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B. I recommend that you postpone your trip because I think you probably have cancer.
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C. I recommend that you postpone your trip so that we can discuss your test results. e')
D. Please give me permission to speak to your wife . (:)
E. Please leave your info rmation and I will contact you by phone with the results. e') T
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I I I I p g p pp y g his wife are leaving fo r a previously scheduled 2-week anniversary celebration and vacation the next day. Despite education about diagnostic possibilities, he is convinced that his symptoms are stress-related and that he will feel better by the time he returns. The physician is highly concerned that the workup may show lung cancer although the patient clinically appears to be stable. Which of the following is the most appropriate response by the physician?
A. I am concerned that you may be in denial about the seriousness of your condition. C)
B. I recommend that you postpone your trip because I think you probably have cancer. C)
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C. I recommend that you postpone your trip so that we can discuss your test results.
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D. Please give me permission to speak to your wife . C)
E. Please leave your information and I will contact you by phone with the results.
F. Please set up an appointment as soon as you return so we can discuss your results.
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Explanation: In this situation, it is likely that the patient will subsequently receive bad news about his health from the physician Due to the likely severity and possible life-threatening nature of the diagnosis (ie, cancer) , the phys ician should recommend timely treatment; delays could increase the risk of harm. Therefore, the physician should recommend that the patient adhere to the plan fo r timely in-person follow-up It is premature, however , to provide the patient with a "probable" diagnosis of cancer before the workup is complete (Choic·e B). Steps for delivering bad news should include assuring a comfortable and private setting, assessing the patient's understanding of the condition and cultural/educational/religious issues, making medical information understandable to the patient, providing empathy, and formulating a collaborative treatment plan ( SPIKES protocol)
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(Choice A) Attributing his symptoms to stress may be the patient's initial way of cop ing with expected bad news. It would be inappropriate to confront the patient with his denial at this point If and when a cance r diagnosis is confi rmed, the news should be delive red in a sensitive manner.
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(Choice D) It is premature and inappropriate to bypass communication with the patient and call his spouse All preliminary communication should still be directed to the patient (Choice E) Contacting the patient by phone would not be the most appropriate method for communicating serious news. Face-to-face meetings are more appropriate fo r delivering bad news. (Choice F) Given the potential seriousness of the patient's condition, delaying treatment until he returns is inappropriate Educational objective: It is important that physicians have an appropriate strategy fo r delive ring bad news. Helpful steps may include setting up a face-to-face meeting, assessing how the patient perce ives the medical condition and wants to receive the information, providing understandable information, addressing
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of cancer before the workup is complete (Choice B). Steps for delivering bad news should include assuring a comfo rtable and private setting, assessing the patient's understanding of the condition and cultural/educational/religious issues, making medical information understandable to the patient, providing empathy, and formulating a collabo rative treatment plan ( SPIKES protocol) (Choice A) Attributing his symptoms to stress may be the patient's initial way of cop ing with expected bad news. It would be inappropriate to confront the patient with his denial at this point If and when a cancer diagnosis is confirmed, the news should be delivered in a sensitive manner. (Choice D) It is premature and inappropriate to bypass communication with the patient and call his spouse All preliminary communication should still be directed to the patient (Choice E) Contacting the patient by phone would not be the most appropriate method for communicating serious news. Face-to-face meetings are more appropriate for delivering bad news. (Choice F) Given the potential seriousness of the patient's condition, delaying treatment until he returns is inappropriate. Educational objective: It is important that physicians have an appropriate strategy for delive ring bad news. Helpful steps may include setting up a face-to-face meeting, assessing how the patient perceives the medical condition and wants to receive the information, providing understandable info rmation, addressing patient's emotional reaction to serious news, and formulating a treatment plan. References: 1. SPIKES: a framework for breaking bad news to patients with cancer. 2. Physician-patient communication: breaking bad news.
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0 C. Giant cell arteritis 6 D. Kawasaki disease 0 E. Polymyos itis 0 F. Takayasu arteritis ® G. Thromboangiitis obliterans Submit
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A 29-year-old woman comes to the office due to a 6 month history of numbness and pain in her upper arms. The pain is worse on the left side and is exacerbated by lifting or other activity. Associated symptoms incl ude fatigue, fleeting joint pains, and a 5-kg (11-lb) weight loss. The patient's medical history is unremarkable, and she does not use tobacco or illic it drugs. She emigrated from Vietnam 5 years ago and works in a furniture repair shop The patient's blood pressure is 140/90 mm Hg in the right arm and 90/55 mm Hg in the left arm, and her pulse is 78/min and regular. Conjunctival and oral mucosa are moist and without lesions. Cardiopulmonary examination shows clear lung fields and no heart murmurs; however , a bruit is heard in the right supraclavicular fossa , and the left radial and brachial pulses are decreased. Abdominal examination is unremarkable. No skin lesions are present Complete blood count, electrolytes, and renal function are normaL Eryth rocyte sedimentation rate is 40 mm/hr. W hich of the following is the most likely diagnosis fo r this patient?
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Takayasu arteritis • Female Risk factors
• Asian • Age 10-40 • Constitutional (eg, fever, weight loss)
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• Arterio-occlusive (eg, claudication, ulcers) in upper extremities
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• Arthralgias/myalgias
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Symptoms
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• Blood pressure discrepancies Examination findings
• Pulse deficits • Arterial bruits
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• Elevated inflammatory markers (eg, ESR, CRP) Diagnosis
• Chest x-ray: Aortic dilation, widened mediastinum • CT/MRI: Wall thickening, narrowing of lumen
Treatment
• Systemic glucocorticoids
CRP = C-reactive protein; ESR = erythrocyte sedimentation rate.
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CRP = C-reactive protein; ESR = erythrocyte sedimentation rate. (i)UWorld
This patient with exertional arm pain (likely claudication), systemic symptoms, and pulse deficits has typ ical features of Takayasu arter itis, a chronic large artery vasculitis that predominantly affects Asian women age <40. It primarily involves the aorta and its branches and is characterized by mononuclear infiltrates and granulomatous inflammation of the vascular media, leading to arterial wall thickening with aneurysmal dilation or narrowing and occlusion. Initial symptoms are nonspecific (eg, fever, arthralgias, weight loss). As the disease progresses, vascular involvement with arterio-occlusive manifestations (eg, claudication, distal ulcers) may develop, particularly in the upper extremities. Examination findings include blood pressure discrepancies, pulse deficits, and bruits. Patients commonly have anemia and elevated inflammatory markers (eg, erythrocyte sedimentation rate, C-reactive protein) Chest x-ray can reveal aortic dilation and a widened mediastinum, and CT and MRI may reveal thickening of large artery walls and lumenal narrowing Initial treatment includes systemic glucocorticoids {Choice A) Ao rtic dissection presents with acute chest pain radiating to the back. It is most common in patients with underlying hypertension. {Choice B ) Aortic coarctation can cause pulse deficits and blood pressure discrepancies but is more likely to be found in the lower rather than the upper extremities. Also , coarctation is more commonly diagnosed in neonates and young children and is not typically associated with constitutional symptoms or elevated inflammatory markers. (Choice C) Giant cell arteritis is a large artery vasculitis similar to Takayasu arteritis. However , it occurs almost exclusively in patients age >50. Typ ical findings include temporal or scalp tenderness, and most patients have chronic pain and stiffness of the shoulders and hips (ie, polymyalgia rheumatica) (Choice D) Kawasaki disease is an acute illness of children characterized by fever, mucositis, conjunctivitis, cervical adenopathy , rash, and edema of the hands and feet It is a self-limited disorder and resolves within 1-2 weeks.
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(Choice B) Aortic coarctation can cause pulse deficits and blood pressure discrepancies but is more likely to be found in the lower rather than the upper extremities. Also, coarctation is more commonly diagnosed in neonates and young children and is not typically associated with constitutional symptoms or elevated inflammatory marke rs. (Choice C) Giant cell arteritis is a large artery vasculitis similar to Takayasu arteritis. However , it occurs almost exclusively in patients age >50. Typical findings include temporal or scalp tenderness, and most patients have chronic pain and stiffness of the shoulders and hips (ie, polymyalgia rheumatica) {Choice D) Kawasaki disease is an acute illness of children characterized by feve r, mucositis, conjunctivitis, cervical adenopathy , rash, and edema of the hands and feet It is a self-limited disorder and resolves within 1-2 weeks. (Choice E) Polymyositis is characterized by painless proximal muscle weakness with elevated serum levels of muscle enzymes (eg, creatine kinase). It does not cause arteria-occlusive manifestations. (Choice G) Thromboangiitis oblite rans (Buerger disease) occurs primarily in men who are heavy smoker s. Findings include superficial thrombophlebitis and ischemia and gangrene of the digits Educational objective: Takayasu arteritis is a large artery vasculitis that is most common in young Asian women. Initial symptoms include fever, arthralgias, and weight loss. Later features include arteria-occlusive symptoms, blood pressure discrepancies, and pulse deficits. CT and MRI can reveal aneurysm fo rmation or lumenal narrowing. Treatment includes systemic glucocorticoids. References: 1. Update on Takayasu arteritis. 2. Diagnostic and classification criteria of Takayasu arteritis.
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r() A Reactive arthritis
6 B. Sarcoidosis (() C. Inflammatory bowel disease
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A 44-year-old white male presents with a long history of joint pains in several joints He has seen a physician before but no diagnosis was made. He has been taking ibuprofen with partial relief. He has now developed fever, diarrhea and weight loss. He denies any genitourinary or eye symptoms He does not use tobacco, alcohol or drugs He is a farmer. On examination, he has generalized lymphadenopathy and non-deforming arthritis. Small intestinal biopsy reveals periodic acid-Schiff (PAS)-positive macrophages W hich of the following is the most likely diagnosis?
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Explanation: The patient described is most likely suffering from W hipple disease. W hipple's disease is a multisystem disease that is characterized by a multitude of possible manifestations. Most commonly, patients with W hipple disease present with a history of chronic malabsorptive diarrhea (steatorrhea, flatulence, abdominal distention), protein-losing enteropathy , we ight loss, migratory non-deforming arthritis, lymphadenopathy and a low-grade feve r. The disease may also cause damage to the eye, CNS and myocardium. W hipple's disease is caused by infection with the gram-positive bacillus Tropheryma whippelii, but a mechanism whereby patients contract this infection has yet to be determined. The diagnosis is made with a small intestinal biopsy and PCR in patients with clinical symptoms consistent with the disease. Small intestinal biopsy shows PASpositive macrophages in the lamina propria containing non-acid-fast gram-positive bacilli. (Choice A) Reactive arthritis class ically occurs following an infection. The classic example is HLA-827-associated reactive arthropathy characterized by conjunctivitis, urethritis and arthritis. It typically follows infections by Chlamydia, Shigella, Salmonella, Yersinia, Campylobacter and C. difficile. (Choice B) In sarco idosis biopsy shows non-caseating granulomas. (Choice C) On histopathology, ulcerative colitis shows acute and chronic inflammation of the mucosa leading to c rypt abscess formation. Crohn disease shows full-thickness inflammation with granuloma and lymphoid aggregate formation and skip regions
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(Choice E) Celiac disease (celiac sprue, gluten-sensitive enteropathy) is an autoimmune disease characterized by malabsorptive diarrhea. Serologic testing shows anti-endomysia! and antitransglutaminase antibodies, and histopathology shows effacement of small intestinal villi. (Choice F) Intestinal lymphoma usually presents with abdominal pain, weight loss, nausea and vomiting, distention, and occult blood in the stool. Malabsorption is not a typical feature, and histopathology would show a diffuse infiltrate by atypical lymphocytes
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"' ' ., . "' ... "' "' in patients with clinical symptoms consistent with the disease. Small intestinal biopsy shows PASpositive macrophages in the lamina propria containing non-acid-fast gram-positive bacilli.
(Choice A) Reactive arthritis class ically occurs following an infection. The classic example is HLA-827-associated reactive arthropathy characterized by conjunctivitis, urethritis and arthritis. It typically follows infections by Chlamydia, Shigella, Salmonella, Yersinia, Campylobacter and C. difficile. {Choice B) In sarcoidosis biopsy shows non-caseating granulomas. (Choice C) On histopathology, ulce rative colitis shows acute and chronic inflammation of the mucosa leading to crypt abscess formation. Crohn disease shows full-thickness inflammation with granuloma and lymphoid aggregate fo rmation and skip regions. (Choice E) Celiac disease (celiac sprue, gluten-sensitive enteropathy) is an autoimmune disease characterized by malabsorptive diarrhea. Serologic testing shows anti-endomysia! and antitransglutaminase antibodies, and histopathology shows effacement of small intestinal villi. (Choice F) Intestinal lymphoma usually presents with abdominal pain, weight loss, nausea and vom iting, distention, and occult blood in the stool. Malabsorption is not a typical feature, and histopathology would show a diffuse infiltrate by atypical lymphocytes.
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(Choice G) HIV Infection may be associated with a similar syndrome of fever, malabsorptive diarrhea and weight loss when Mycobacterium avium-intracellulare infects the small intestinal wall. This would also cause PAS-positive macrophages on small intestinal biopsy, but these bacilli would also be acid-fast
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Educational objective: W hipple disease is a multisystem disorder with a va ried presentation caused by infection with the gram-positive bacillus Tropheryma whippelii Chronic malabsorptive diarrhea, weight loss, migratory non-deforming arthritis, lymphadenopathy and a low-grade fever are the most common presenting symptoms Time Spent 2 seconds
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(:) A. Alveolar hemorrhage
e; B. Aortic aneurysms (:) C. Carpal tunnel syndrome
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E. Malignancy
e; F. Sudden visual loss
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A 52-year-old woman comes to the physician with a rash over her face that began a few weeks ago. Lately , the patient has also been having difficulty rising from a seated position and climbing stairs. On examination, an erythematous rash on the upper chest and violaceous periorbital edema are present Her vital signs are within normal limits. Examination shows symmetric proximal muscle weakness in the legs. This patient's condition is most often associated with which of the following?
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Clinical features of dermatomyositis
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Muscle weakness
Skin findings
• Proximal, symmetric • Weakness in UE = LE • Gottron's papules • Heliotrope rash • Interstitial lung disease
Extramu scular findings
• Dysphagia • Myocarditis
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• I CPK, aldolase, LDH
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• Diagnostic uncertainty o EMG o Biopsy (skin/muscle)
Management
• High-dose glucocorticoids PLUS glucocorticoid-sparing agent • Screening for malignancy
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CPK creatinine phosphokinase; EMG electromyography; LDH = lactate dehydrogenase; LE = lower extremity; UE = upper extremity.
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CPK creatinine phosphokinase; EMG electromyography; LDH = lactate dehydrogenase; LE = lower extremity; UE = upper extremity. ©UWorld
This woman with proximal muscle weakness and rash has features consistent with dermatomyositis Der matomyositis is an autoimmune condition that is 6 times more common in women. In its most classic form, it causes a proximal extensor muscle inflammatory myopathy and characteristic cutaneous findings ( eg, violaceous poikiloderma over va rious regions of the body). On the face , the eruption is most often accompanied by periorbital edema and is known as the heliotrope sign On the chest and lateral neck it is called the shawl sign On the knuckles, elbows, and knees it is referred to as Gottron's sign Violaceous, slightly scaly papules overlying the joints are known as Gottron's papules; these are pathognomonic for dermatomyositis. Patients have an elevated creatine phosphokinase (CPK) that is generally 10 times the upper limit of normaL The classic autoantibodies associated with dermatomyositis are anti-Jo-1 (antisynthetase antibody) and anti-Mi-2 (against helicase)
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Internal malignancies are more common in patients with dermatomyositis (>15% of adult patients) compared to the general population The most common malignancies are ovarian, lung, pancreatic , stomach, or colorectal cancers, and non-Hodgkin lymphoma Regular , age-appropriate cancer screening is essential in these patients (Choice A) Inflammatory diseases associated with alveolar hemorrhage include Goodpasture syndrome, granulomatosis with polyangiitis (formerly Wegener's), microscopic polyangiitis, eosinophilic granulomatosis with polyangiitis (fo rmerly Churg-Strauss syndrome), Beh9et syndrome, systemic lupus erythematosus, and antiphospholipid antibody syndrome Dermatomyositis can cause pulmonary fibrosis in roughly 10% of patients (Choice B) Inflammatory diseases associated with aortic aneurysms include Beh9et syndrome, Takayasu arteritis, giant cell arteritis, ankylosing spondylitis, rheumatoid arthritis, psoriatic arthritis, relapsing polychondritis, lgG4-related disease, and reactive arthritis. (Choice C) Inflammatory or depositional diseases associated with ca rpal tunnel syndrome include rheumatoid arthritis, sarco idosis, hypothyroidism, and amyloidosis.
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patients) compa red to the general population. The most common malignancies are ovarian, lung, pancreatic , stomach, or colorectal cancers, and non-Hodgkin lymphoma. Regular, age-appropriate cancer screening is essential in these patients. {Choice A) Inflammato ry diseases associated with alveolar hemorrhage include Goodpasture syndrome, granulomatosis with polyangiitis (fo rmerly Wegener's), microscopic polyangiitis, eosinophilic granulomatosis with polyangiitis (formerly Churg-Strauss syndrome), Behfiet syndrome, systemic lupus erythematosus, and antiphospholipid antibody syndrome Dermatomyositis can cause pulmonary fibrosis in roughly 10% of patients. (Choice B) Inflammatory diseases associated with aortic aneurysms include Behfiet syndrome, Takayasu arteritis, giant cell arteritis, ankylosing spondylitis, rheumatoid arthritis, psoriatic arthritis, relapsing polychondritis, lgG4-related disease, and reactive arthritis. (Choice C) Inflammato ry or depositional diseases associated with carpal tunnel syndrome include rheumatoid arthritis, sarcoidosis, hypothy roidism, and amyloidosis (Choice D) Autoimmune diseases associated with glomerulonephritis include systemic lupus erythematosus, Goodpasture syndrome, relapsing polychondritis, cryoglobulinemia, granulomatosis with polyangiitis (formerly Wegener's), and microscopic polyangiitis, among others. It is not common for the elevated CK in dermatomyositis to cause a myoglobin-induced acute kidney injury, but when it does it is due to direct injury to the tubular cells rather than to glomerulonephritis (Choice F) Autoimmune diseases associated with sudden visual loss include temporal arteritis, multiple sclerosis, and, rarely, systemic lupus erythematous. Educational objective: Dermatomyositis is characterized by classic cutaneous findings accompanied by proximal muscle weakness. Over 15% of adult patients will have or develop an internal malignancy, most commonly ovarian, lung, pancreatic , stomach, or colorectal cancers, or non-Hodgkin lymphoma. Regular , age-appropriate cance r screening is essential in these patients Time Spent 2 seconds
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e') E. Osteosarcoma
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A 43-year-old woman comes to the physician complaining of bilateral joint pain and swelling in her hands fo r the past few months. She reports easy fatigability and loss of energy that has worsened insidiously. It is especially ·difficult for her to perform daily activities in the morning due to prolonged stiffness. The patient also describes frequent knee pain accompanied by a low-grade feve r. She takes over-the-counter ibuprofen to relieve her symptoms. Her hematocrit is 33% and c reatinine is normal. This patient is at greatest risk fo r which of the following?
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Clinical features of rheumatoid arthritis
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Symptoms • Insidious onset, multiple joint pain, stiffness & swelling • Morning stiffness lasting hours, improves with activity • Small joints (eg, PIP, MCP, MTP) commonly involved • Monoarthtitis (eg, knees, elbows) can also occur later Clinical presentation
• Spares the DIP joint, unlike osteoarthritis Examination
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• Tenosynovitis of the palms
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Laboratory/ imaging studies
• • • •
Positive anti-CCP antibodies (diagnostic testing) High lgM rheumatoid factor High C-reactive protein & ESR correlate with disease activity X-ray: Soft-tissue swelling, joint space narrowing & bony erosions
Anti-CCP =anti-cyclic citrullinated peptide; DIP = distal interphalangeal joints; ESR =erythrocyte sedimentation rate; lgM = Immunoglobulin M; MCP = metacarpophalangeal; MTP = metatarsophalangeal. ©UWo~d
This patient has a characteristic presentation of rheumatoid arthritis (RA). RA affects women
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©UWo~d
This patient has a characteristic presentation of rheumatoid arthritis (RA). RA affects women more often than men and has a typical onset at age 30-50. Morning stiffness for 2:1 hour is typ ical of RA and would explain this patient's difficulty with morning activities. Symmetric joint swelling is characteristic . The most commonly affected joints include the metacarpalphalangeal joints, proximal interphalangeal joints, wrists, and knees. Due to the autoimmune nature of the disease, systemic symptoms such as fatigue, fever, and anemia often occur. Patients are started on treatment (including disease-modifying agents) based on the severity of their symptoms Increased levels of proinflammatory cytokines, corticosteroid therapy , and lack of physical activity may contribute to local (around inflamed joints) o r generalized loss of bone mass in RA patients There is an increased risk of osteopenia, osteoporosis, and bone fractures, especially if other risk factors (eg, low body weight, female sex, fam ily history of osteoporosis, cigarette smoking, postmenopausal state, excessive alcohol use, other comorbidities) are present The degree of bone loss generally co rrelates with disease activity Strategies to prevent bone loss (adequate physical activity, optimization of vitamin 0 and calcium intake, minimization of glucocortico id dose) should be implemented Most experts suggest a low threshold fo r starting bisphosphonate therapy in RA patients Although there may be associations between RA and some of the other answer options, the risk of osteoporosis is the greatest (up to a 2-fold inc rease, with one study showing a prevalence of 22%) (Choice A) Avascular necrosis of bone is most commonly seen in patients with systemic co rticosteroid therapy, heavy alcohol use, systemic lupus erythematosus, or sickle cell disease. Corticosteroids are often used in patients with RA. Avascular necrosis is therefore possible in this patient, but osteoporosis would be more likely . (Choice B) Paget disease of bone (osteitis deformans) is a condition of increased bone turnover due to osteoclast overactivity , leading to the replacement of lamellar bone with abnormal woven bone. The risk of Paget disease is not increased in RA.
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corticosteroid therapy, heavy alcohol use, systemic lupus erythematosus, or sickle cell disease. Corticosteroids are often used in patients with RA. Avascular necrosis is therefore possible in this patient, but osteoporosis would be more likely (Choice B) Paget disease of bone (osteitis deformans) is a condition of increased bone turnover due to osteoclast overactivity, leading to the replacement of lamellar bone with abnormal woven bone. The risk of Paget disease is not increased in RA. (Choice C) Osteitis fibrosa cystica (Von Reckl inghausen disease of bone), which presents with bony pain, is characterized by excessive osteoclastic resorption of bone, leading to replacement with fibrous tissue (brown tumors). It is very rare and is seen primarily in patients with parathyroid carcinoma. It can also occur in primary and secondary/tertiary (advanced renal disease) hype rparathyro idism Renal injury may occur in RA (from use of nonsteroidal antiinflammatory drugs and some disease-modifying agents or from amyloidosis due to inflammation), but the risk of osteoporosis is far greater than the risk of osteitis fib rosa cystica
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{Choice E) Osteosarcoma is a primary malignant bone tumor. Risk factors include Paget disease and radiation and chemotherapy exposure.
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Educational objective: Patients with rheumatoid arthritis are at inc reased risk of developing osteopenia, osteoporosis, and bone fractures, especially if additional risk factors for osteoporosis are present Management includes adequate physical activity, optimization of calcium and vitamin 0 intake, minimization of corticosteroid therapy, and consideration for bisphosphonate treatment References: 1. Clinical decision rules in rheumatoid arthritis: do they identify patients at high risk for osteoporosis? Testing clinical criteria in a population based cohort of patients with rheumatoid arthritis recruited from the Oslo Rheumatoid Arthritis Register.
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0 A Forgetting to take her medication without reminders
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6 D. Patient's awareness of forgetfulness
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A 74-year-old woman comes to the office accompanied by her husband for a routine checkup The patient has a history of hypertension and hypercholesterolemia She has no other medical problems or physical limitations. At today's visit, her blood pressure is elevated and her husband says that she often forgets to take her blood pressure pills The patient says, "It's hard to remember to take them every day " Her husband believes that her speech has changed as she occasionally struggles to find appropriate words and sometimes cannot recall people's names. Two days ago, she drove to a nearby groce ry store and was unable to find her way back. She naps during the day , has difficulty fall ing asleep at night, and always wakes up early in the morning. Her appetite is good Physical examination is within normal limits. On mental status examination, the patient is calm and cooperative She says her mood is good and scores 25/30 on the Mini-Mental State Examination. W hich of the following is the most specific indicator of dementia (major neurocognitive disorder) as opposed to normal aging in this patient?
0 B. Getting lost in familiar territory 0 C. Mini-Mental State Examination score
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Explanation:
Normal aging
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Dementia (major cognitive disorder)
• Can provide details about incidents of forgetfulness
• Cannot remember specific instances of forgetfulness
• Patient is concerned about memory loss
• Family is more concerned than patient
• Recent memory for important events & conversations is intact
• Has notable decline in memory for recent important events & conversations
• Occasional (expressive aphasia) • No receptive aphasia
• Frequent, with substitutions • Some receptive aphasia
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• Maintains independence in ADLs
• Becomes dependent on others for ADLs
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• Is able to operate common appliances
• Is unable to operate common appliances
• Maintains interpersonal social skills
• Loses interest in social activities
• Does not get lost in familiar territory (may have to pause briefly to reorient)
• Can get lost for hours in familiar territory while driving or walking
Memory loss
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Independence & functioning
ADL =activities of daily living. © UWond
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ADL =activities of daily living.
©uwond This elderly patient has forgetfulness, word-finding aphasia, impairment of daily functioning , and insomnia. Of these symptoms, the most specific fo r dementia (major neurocognitive disor der) is her impaired functioning in daily activities as demonstrated by getting lost in familiar surroundings Other areas of impaired functioning in dementia can include difficulties with dressing, maintaining personal hygiene, food acquisition and intake, self-administration of medications, social interactions, and operating common appliances. (Choices A, E, and F) Normal age-related cognitive decline involves nonprogressive, mild memory impairment and decreased rate of info rmation processing that does not result in interference with daily function. Sometimes forgetting to take medication without reminders, occasional word-finding aphasia, and sleep disturbance can also occur with normal aging and are therefore less specific for dementia. In contrast, patients with age-related memory loss will not get lost in fam iliar settings
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{Choice C) The Mini-Mental State Examination is a widely used screening test fo r delirium or dementia. However, scores ~23 are usually considered suggestive of these conditions, and higher cutoff scores are associated with lower specificity The test is also much less sensitive fo r mild dementia as performance can be influenced by educational level and age (eg, this patient's score of 25 could be normal or significant depending on her education level). (Choice D) Patients with dementia are more commonly unaware of their deficits and do not complain of memory loss. Informant-reported memory loss is a better predictor of dementia. Educational objective: Cognitive deficits that interfere with independence in everyday activities are a key feature that distinguishes dementia (major neurocognitive disorder) from normal age-related changes Patients with dementia have functional impairments that necessitate assistance. Refer ences:
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e; A Bartonella henselae e; B. Mycobacterium tuberculosis 6 C. Pasteurella multocida
e; D. Salmonella enteritidis
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() E. Staphylococcus aureus
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e; F. Streptococcus pyogenes
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A 4-year-old girl is brought to the clinic by her parents due to painful swelling in her groin, which began 2 weeks ago and has gradually become red and tender. Cool compresses and over-the-counter analgesics have not improved her symptoms The patient attends preschool 3 times a week and returned from a fam ily trip to China 2 months ago. The family has 2 dogs, a cat, and a turtle. Temperature is 37.4 C (99 3 F); other vital signs are normal. Examination shows a small, nontender papule on the anterior left thigh There is a 4-cm, tender, soft, and freely mobile left inguinal lymph node with overlying erythema Which of the following is the most likely causative organism of this patient's condition?
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Cat-scratch disease Etiology
Clinical manifestations
• Bartonella henselae
• Papule at scratch/bite site • Regional adenopathy • +/- Fever of unknown origin
(~14
days)
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Diagnosis
• Usually clinical • +/- Serology
Treatment
• Azithromycin
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(!)UWond
A localized papule with ipsilateral regional lymphadenopathy in the setting of cat exposure raises concern for cat-scratch disease (CSD). CSD, caused by Bartonella henselae, is a fastidious gram-negative bacillus carried by the majority of cats, especially kittens. B henselae can be transmitted by a cat scratch or bite, or (rarely) by a flea. However, the majority of patients do not recall a specific scratch or bite. Classically, patients present with a localized papular or nodular skin lesion that may initially go unnoticed. Additional presenting symptoms may include fever of unknown origin and/or regional lymphadenopathy in the subsequent 1-2 weeks. Affected lymph nodes are enlarged, tender , and have overly ing erythema; suppuration is less common. Lymphadenopathy may take 1-2
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lymphadenopathy in the subsequent 1-2 weeks. Affected lymph nodes are enlarged, tender, and have overlying erythema; suppuration is less common. Lymphadenopathy may take 1-2 months to resolve. Cat exposure and symptoms consistent with CSD are usually sufficient to make a clinical diagnosis. Although many mild cases will self-resolve, treatment with azithromycin is typically recommended. (Choice B) Mycobacterium tuberculosis should be considered in patients with lymphadenopathy (especially cervical) or who have traveled to an endemic region (eg, China) Similar to CSD, the onset may be gradual; however , adenitis due toM tuberculosis is strikingly nontender. (Choice C) Pasteurella multocida, normal oral flora in dogs and cats, can cause cellulitis and other soft tissue infection within 1-2 days of a dog or cat bite. This patient's adenopathy with indolent onset is inconsistent with P multocida. (Choice D) Salmonella enteritidis is carried by reptiles (including turtles) and can cause severe mesenteric adenitis in conjunction with enteritis. Cutaneous lesions are inconsistent with Salmonella infection.
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Educational objective: Cat-scratch disease, caused by Bartonella henselae, most commonly presents with a mild papular or nodular skin lesion and ipsilateral lymphadenitis of gradual onset These symptoms in the setting of cat exposure are sufficient to make a clinical diagnosis of cat-scratch disease. References: 1. Cat-scratch disease.
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0 A Bacterial infection of the proximal femur 0 B. Gonococcal infection of the synovial fluid 0 C. Opioid drug-seeking behavior 6 D. Osteonecrosis of the proximal femur 0 E. Slippage of the femoral head epiphyseal plate S ubm it
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A 21-year-old African American man comes to the office requesting a refill of an opioid medication for new-onset left hip pain. The pain started 3 weeks ago and was initially only with weightbearing, but has progressively worsened and is now present at rest and overnight He has no history of trauma. Medical history is notable for sickle cell disease with several hospitalizations for acute pain crisis. His last hospitalization was 3 months ago The patient has been taking some leftover opioid pain medications from that hospitalization, in addition to regularly scheduled folic acid and hydroxyurea. He is sexually active with a new female partner The patient does not use alcohol, tobacco, or illicit drugs His temperature is 37.2 C (99 F), blood pressure is 100/70 mm Hg, pulse is 80/min, and respirations are 16/min. Physical examination reveals no local tenderness, but there is restriction of abduction and internal rotation of the left hip The right hip and other joints are normal. Hip x-rays and eryth rocyte sedimentation rate are normal. W hich of the following is the most likely diagnosis?
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Etiology
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Clinical manifestations
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• • • • • • • •
Steroid use Alcohol abuse Systemic lupus erythematosus Antiphospholipid syndrome Hemoglobinopathies (eg, si ckle cell) Infections (eg, osteomyelitis, HIV) Renal transplantation Decompression sickness
• Groin pain on weight bearing • Pain on hip abduction & internal rotation • No erythema, swelling, or point tenderness
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Laboratory findings
• Normal white blood cell count • Normal ESR & CRP
Radiologic imaging
• Crescent sign seen in advanced stage • MRI is most sensitive modality
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Avascular necrosis
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CRP = C-reactive protein; ESR = erythrocyte sedimentation rate. «lUWO
This patient has features typical of osteonecrosis (aseptic necrosis) of the femoral head, including progressive hip pain, limited internal rotation and abduction, and normal x-rays and inflammatory markers (eg, erythrocyte sedimentation rate [ESR)). Osteonecrosis is caused by occlusion of end arteries supplying the femoral head, leading to necrosis and collapse of the
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including progressive hip pain, limited internal r otation and abduction, and normal x-rays and inflammatory markers (eg, erythrocyte sedimentation rate [ESRJ). Osteonecrosis is caused by occlusion of end arteries supplying the femo ral head, leading to necrosis and collapse of the periarticular bone and ca rtilage Osteonecrosis is common in patients with sickle cell disease due to disruption of microcirculation in the bone by sickling as well as increased intraosseous pressure due to bone marrow hype rplasia. The femoral head has 2 main sources of blood - the ascending arteries and the foveal artery, which lies within the ligamentum teres. The foveal artery is patent early in life , but may become obliterated in older patients. For this reason, aseptic necrosis of the femoral head is uncommon in children but the risk rises in older patients. (Choice A) Osteomyelitis is a recognized compl ication of sickle cell disease, and is usually due to Staphylococcus aureus or Salmonella. It is most common in children, often multifocal, and typically accompanied by fever, malaise, and elevated ESR (Choice B) Neisseria gonorrhoeae can cause acute purulent arthritis (usually without associated skin lesions or fever). However, involvement of the distal large joints (eg, knees, wrists, ankles) is more common, and it would usually be associated with elevated ESR {Choice C) Features that suggest drug-seeking behavior include "lost" or "stolen" medication, premature refill requests, and pain inconsistent with examination findings or known pathology This patient's pain is easily explainable by osteonecrosis, which is a recognized complication of his underlying disease.
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(Choice E) Slipped capital femo ral epiphysis (SCFE) is characterized by pain and altered gait Obesity is an important risk factor. SCFE most often occurs in early adolescence and is usually visible on x-rays. Educational objective: Osteonecrosis (aseptic necrosis) of the femo ral head is a common complication of sickle cell disease and presents with hip pain, reduced range of motion, and normal findings on initial x-rays. It is due to occlusion of end arteries supplying the femoral head, leading to necrosis and collapse of the periarticular bone and cartilage.
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A 27-year-old African American woman comes to the office due to 6 weeks of pain and swelling of her hands and wrists. The pain worsens in the morn ing and is associated with stiffness for 10-15 minutes. She has also had easy fatigability and muscle aches. The patient has no significant past medical history and does not take any medications. She has been sexually active with a new partner Her temperature is 37.9 C (100 2 F), blood pressure is 140/90 mm Hg, and pulse is 76/min. Physical examination reveals slightly swollen, tender metacarpophalangeal and proximal interphalangeal joints. There is a nontender ulcer on the buccal mucosa. Mild ce rvical and axillary lymphadenopathy is present Cardiopulmonary auscultation is normal. The abdomen is soft and nontender The tip of the spleen is palpable with exhalation. Laboratory resu~s are as follows:
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Hemoglobin
11 0 g/dL
Platelets
90,000/mm>
Leukocytes
4,500/mm'
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An x-ray of the hands and wrists reveals no bony erosions. Urinalysis shows 2+ protein and 20-30 red blood cells/hpf Which of the following is the most likely diagnosis?
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6 A Beh!fet disease
6 B. Disseminated gonococcal infection e; C. Fe~y syndrome 6 6 6 e;
D. Hodgkin disease E. Parvovirus 819 infection F. Sarcoidosis G. Systemic lupus erythematosus
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Manifestations of systemic lupus erythematosus
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• Constitutional: Fever, fatigue & weight loss • Symmetric, migratory arthritis Clinical symptoms
• Skin: Butterfly rash & photosensitivity • Serositis: Pleurisy, pericarditis & peritonitis • Thromboembolic events (due to vasculitis & antiphospholipid antibodies)
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• Neurologic: Cognitive dysfunction & seizures
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• Hemolytic anemia, thrombocytopenia & leukopenia
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• Hypocomplementemia (C3 & C4)
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Laboratory findings
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• Renal involvement: Proteinuria & elevated creatinine
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• Antibodies: o ANA (sensitive) o Anti-dsDNA & anti-SM (specific)
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Explanation:
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This patient's presentation strongly suggests systemic lupus erythematosus (SLE) Young African American women are at greatest risk for developing SLE and fatigue, painless oral ulcers, nondeforming arthritis, renal abnormalities (eg, hematuria, proteinuria, glomerulonephritis), and cytopenias are amongst the most common manifestations of active disease. Arthritis and arthralgias affect 95% of patients with SLE and tend to be migratory, symmetric, polyarticular,
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often exceeds the objective findings on examination, and x-rays usually show no evidence of joint destruction or erosion (unlike other inflammatory arthritides such as RA) {Choice A) Behfiet disease typically presents with multiple oral and genital ulcers that are recurrent and painfuL Uveitis is common. This patient has a nonpainful oral ulcer and hematologic and renal abnormalities, which are findings not typically seen with Behfiet disease. {Choice B) Disseminated gonococcal infection is associated with polyarthralgia, skin lesions, and tenosynovitis. Morning stiffness, oral ulcers, and glomerulonephritis (hematuria and proteinuria) would be unusuaL {Choice C) Felty syndrome is defined as advanced RA associated with splenomegaly and neutropenia. Advanced RA is characterized by marked morning stiffness. Oral ulcers and renal disease are not typical of Felty syndrome {Choice D) Hodgkin lymphoma can cause systemic symptoms and adenopathy; it is also associated with minimal change disease and nephrotic syndrome However, oral ulcers, synovitis, and glomerulonephritis (red cells on urinalysis) would be uncommon.
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{Choice E) Most adult patients with parvovirus infection are asymptomatic or have flu-like symptoms, but a minority may develop a symmetric , nonerosive arthritis or aplastic anemia. The prolonged duration of the symptoms (>3-4 weeks) and the renal abnormalities (hematuria, proteinuria) make SLE more likely than parvovirus infection in this patient {Choice F) Sarcoidosis typically presents with pulmonary and skin findings and can cause interstitial nephritis However, glomerulonephritis and oral ulcers are unusuaL Educational objective: Systemic lupus erythematosus is a multisystem inflammato ry disease that often presents with arthritis and arthralgias. Joint involvement tends to be symmetric, migratory, and nonerosive with brief morning stiffness. The knees, carpal joints, and joints of the fingers are most commonly affected. Time Spent 2 seconds
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® A Exercise program with aerobic conditioning ® B. High-dose prednisone ® C. Hydroxychloroquine ® D. Low-dose prednisone ® E. Methotrexate ® F. Oxycodone/acetaminophen
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A 35-year-old woman comes to the clinic complaining of aching pain and stiffness over her entire body for the past 3 months. She also has easy fatigability, poor sleep, and frequent headaches. The patient has had difficulty performing her daily tasks and feels that her work performance as an accountant has worsened. She has used over-the-counter pain medications with no relief. On examination, she has tenderness to gentle palpation over the muscles of her neck, shoulders, and back. Vital signs are within normal limits. Laboratory results show normal electrolytes, complete blood count, erythrocyte sedimentation rate, and thyroid function tests. Which of the following is the best initial therapy to improve this patient's symptoms?
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Explanation: This patient's presentation is consistent with likely fib romyalgia (FM) FM presents most commonly in young to middle-aged women with widespread pain, fatigue, and cognitive/mood disturbances. Patients tend to have a fairly normal physical examination except for point muscle tenderness in areas such as the mid trapezius, lateral epicondyle, costochondral junction in the chest, and greater trochanter. FM has no specific diagnostic laboratory findings Revised 2010 American College of Rheumatology criteria suggest using the widespread pain index and symptom severity scale, rather than trigger points, for diagnosis The index and scale better emphasize cognitive problems, fatigue, and severity of somatic symptoms Initial management of FM involves a multidisciplinary approach including patient education about FM, regular aer obic exercise, and good sleep hygiene Education requires validating that FM is a benign condition with a favo rable prognosis Although patients may complain of increased short-term pain during or after activity, a regular exercise program (eg, aerobic conditioning, strength training, stretching) improves long-term pain Water exercises also can greatly reduce the pain. Medications (eg, tricyclic antidepressants) are reserved for patients failing initial measures. There is limited evidence for other approaches, incl uding trigger-point injections, analgesics, and alternative therapy (eg, tai chi, yoga) {Choices 8 , 0 , and E) High-dose prednisone is effective for giant cell arteritis; low-dose prednisone is used for polymyalgia rheumatica. Methotrexate is effective for inflammatory conditions such as rheumatoid arthritis. All of these conditions usually have an elevated erythrocyte sedimentation rate. However , FM is not an inflammatory condition (normal erythrocyte sedimentation rate) and does not respond significantly to methotrexate or corticosteroids. {Choice C) Hydroxychloroquine is effective for treating patients with systemic lupus erythematosus (SLE) or rheumatoid arthritis (RA) However, it is not effective fo r FM. This patient does not have other findings to suggest SLE or RA (eg, malar rash, joint abnormalities) {Choice F) Acetaminophen and tramadol (alone or combined) are effective in patients requiring
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the pain. Medications (eg, tricyclic antidepressants) are reserved for patients failing initial measures. There is limited evidence for other approaches, including trigger-point injections, analgesics, and alternative therapy (eg, tai chi, yoga) {Choices 8 , D, and E) High-dose prednisone is effective for giant cell arteritis; low-dose prednisone is used for polymyalgia rheumatica. Methotrexate is effective for inflammatory conditions such as rheumatoid arthritis. All of these conditions usually have an elevated erythrocyte sedimentation rate. However , FM is not an inflammatory condition (normal erythrocyte sedimentation rate) and does not respond significantly to methotrexate or corticosteroids. (Choice C) Hydroxychloroquine is effective for treating patients with systemic lupus erythematosus (SLE) or rheumatoid arthritis (RA). However, it is not effective for FM. This patient does not have other findings to suggest SLE or RA (eg, malar rash, joint abnormalities). (Choice F) Acetaminophen and tramadol (alone or comb ined) are effective in patients requiring additional treatment fo r acute pain or fa iling to respond to fi rst line drug therapies However , there is insufficient evidence on the effectiveness of opioids such as oxycodone Educational objective: Fibromyalgia most commonly presents in young to middle-aged women with widespread pain, fatigue, and cognitive/mood disturbances. Patients have point muscle tenderness in areas such as the mid trapezius, lateral epicondyle, costochondral junction in the chest, and greater trochanter. Exercise is the foundation of management, with medications (eg, duloxetine, tricyclic antidepressants) reserved for patients who fail initial measures. References: 1. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. 2. Exercise for fibromyalgia : a systematic review.
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0 A. Anorexia nervosa 0 B. Avoidant/restrictive food intake disorder
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0 C. Bipolar II disorder
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6 D. Bulimia nervosa 0 E. Cocaine use disorder 0 F. Marijuana use disorder ® G. MDMA (ecstasy) use disorder
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A 17-year-old girl is brought to the office by her mother, who is conce rned about her daughter's weight loss and mood changes The girl has lost 4.5 kg (10 lb) in the last 2 months and has been uncharacteristically irritable. The mother says that she has suddenly become a "picky eater" and that she now often refuses to eat, insisting that she is "just not hungry." She also worries that her daughter is not sleeping enough W hen questioned about these conce rns, the patient denies having any problems and says that she feels "fine" and just has lots of energy. She adds, "Isn't it healthy to be thin and fit? I don't understand what my mother is worried about" The patient's height is 157.5 em (5 ft 2 in) and her weight is 47.6 kg (105 lb) Physical examination shows a thin girl with erythema of the turbinates and nasal septum and mild facial acne. Which of the following is the most likely diagnosis?
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Cocaine is a stimulant that produces incr eased ener gy and decreases appetite and need for sleep. Individuals who abuse coca ine often present with mood changes (eg, euphoria, irritability) and weight loss secondary to decreased appetite The diagnostic hallmark in this scenario is erythema of the turbinates and nasal septum, which is a common finding in individuals who snort cocaine. In severe cases, perforation of the nasal septum can occur. In addition to mood disturbance, other psychiatric complications of coca ine use include anxiety, panic attacks, grandiosity, and psychosis (delusions and hallucinations) {Choices A, B , and D) The physical finding of erythema of the turbinates and nasal septum and the lack of other characteristic features of eating disorders make these diagnoses less likely. Anorexia nervosa is associated with intense fear of gaining weight and distorted body image despite a significantly low weight Diagnosis of bulimia nervosa requires evidence of binge eating and compensatory behaviors. Avoidant/restrictive food intake disorder involves lack of interest and avoidance of eating based on the sensory characteristics of food , with typical onset in infancy or early childhood. {Choice C) This girl's mood changes are consistent with cocaine use. Diagnosis of bipolar II disorder requires evidence of at least one major depressive episode and hypomanic episodes unrelated to substance use.
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(Choice F) Marijuana use is usually associated with an inc rease, not decrease, in appetite Phys ical findings include injected conjunctivae, but erythema of the turbinates and nasal septum would not be expected
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(Choice G) MDMA (ecstasy) is a commonly abused drug with stimulant and hallucinogenic properties Due to its stimulant properties, users can present with decreased appetite, increased energy, euphoria, and disinhibition similar to that seen in coca ine use. However, it is taken in oral form and would not cause nasal erythema
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Educational objective: Cocaine abuse should be suspected in an individual with we ight loss, behavioral changes, and erythema of the turbinates and nasal septum.
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A 7-year-old girl is brought to the office by her mother, who is concerned about her behavior. Over the past month, the girl has awakened almost every night, come into her parents' room, and insisted on sleeping the remainder of the night in their bed. The girl wakes up abruptly in a panicky sweat, crying and screaming, "I'm so scared; monsters are chasing me." She breathes rapidly and shakes but is able to calm down after being consoled by her parents and hugging a favo rite stuffed animal. She started a new school 2 months ago Although the girl is shy, she enjoys school and has several good friends. She is eating normally and plays on a soccer team. Examination shows no abnormalities. Which of the following is the most likely diagnosis? 6 A Acute stress disorder
e; B. Adjustment disorder 6 C. Nightmare disorder
e; D. Nocturnal panic attack 6 E. REM sleep behavior disorder
e; F. Separation anxiety disorder 6 G. Sleep terror disorder
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G. Sleep terror disorder [16%) Explanation: This girl's recurrent awakenings with associated dream content and ability to be consoled are most consistent with nightmare disorder. Diagnosis requires recurrent episodes of awakening from sleep with recall of highly disturbing and frightening dream content. On awakening, the child is fully alert, remembers the dream, and can usually be consoled. Although frightening, nightmares are typically transient and developmentally normal for most children. Nightmares occur during rapid eye movement (REM) sleep and are more frequent in the second half of the night Sleep terro r disorder, in contrast, is a non-REM arousal disorder characterized by incomplete awakenings, unresponsiveness to comfort, and no recall of dream content (Choice G). Sleep terrors typically occur in the first third of the night and are characterized by marked autonomic arousal and amnesia for the episode in the morning. (Choice A) Nightmares are common in acute stress disorder, but there is no history of trauma exposure or characteristic symptoms of hype rarousal or intrusive symptoms while awake. (Choice B) Although starting a new school can sometimes be stressful, this girl is not displaying any emotional or behavioral problems apart from nightmares (she enjoys school, has friends, eats well), making an adjustment disorder unlikely (Choice D) Although panic attacks can occur during sleep and produce abrupt awakenings, they are not typically associated with nightmares (Choice E) REM sleep behavior disorder involves repeated episodes of complex motor behaviors or vocalization during REM sleep. (Choice F) Separation anxiety disorder is characterized by excessive fear or anxiety conce rning separation from home or attachment figures. Although this girl turns to her parents for comfort following a nightmare, there is no evidence that she has difficulty separating in general
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awakenings, unresponsiveness to comfort, and no recall of dream content {Choice G). Sleep terrors typically occur in the first third of the night and are characterized by marked autonomic arousal and amnesia for the episode in the morning. {Choice A) Nightmares are common in acute stress disorder , but there is no history of trauma exposure or characteristic symptoms of hyperarousal or intrusive symptoms while awake. {Choice B) Although starting a new school can sometimes be stressful, this girl is not displaying any emotional or behavioral problems apart from nightmares (she enjoys school, has friends, eats well), making an adjustment disorder unlikely {Choice D) Although panic attacks can occur during sleep and produce abrupt awakenings, they are not typically associated with nightmares {Choice E) REM sleep behavior disorder involves repeated episodes of complex motor behaviors or vocalization during REM sleep. {Choice F) Separation anxiety disorder is characterized by excessive fear or anxiety concerning separation from home or attachment figures Although this girl turns to her parents for comfo rt following a nightmare. there is no evidence that she has difficulty separating in general Educational objective: Nightmare disorder involves recurrent awakenings from REM sleep associated with full alertness and dream recall It should be differentiated from non-REM sleep terrors, which are characterized by partial arousals, unresponsiveness, and lack of dream content Refer ences: 1. Just a scary dream? A brief review of sleep terrors, nightmares, and rapid eye movement sleep behavior disorder. 2. Prevalence and correlates of disturbed dreaming in children.
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<0 A Nightmares <0 B. Nocturnal panic attacks <0 C. Nocturnal seizures
e; D. REM sleep behavior disorder <0 E. Sleep terrors <0 F. Sleep walking
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A healthy 5-year-old girl is brought to the office for evaluation of night awakenings. She has awakened screaming during each of the past 3 nights about an hour after going to sleep. W hen her parents go to her room , she is short of breath, crying, and sweating Her face is flushed and she looks frightened The girl does not respond to her parents and jumps out of bed as if running away from something. W hen her parents hold her, she continues to cry She eventually goes back to sleep. The next morning, the girl does not mention the incident Her parents report that she started kindergarten last week and has begun to go all day without taking a nap. Her mother wonders if she is having nightmares due to anxiety about starting school. Developmental milestones are normal. Temperature is 36.7 C (98 F), blood pressure is 100/60 mm Hg, pulse is 96/min, and respirations are 20/min. A complete phys ical examination is unremarkable. W hich of the following is the most likely diagnosis?
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This child's awakenings are suggestive of sleep terr ors, a type of parasomnia that occurs during nonrapid eye movement (NREM) sleep Sleep terrors are characterized by episodes of screaming or c rying during which the child is inconsolable and cannot be fully awakened. A flushed face, sweating, and tachycardia are common. These episodes usually last a few minutes and then the child settles back down to sleep The next morning, the child usually has no memory of the incident. Sleep terrors are most commonly seen in children age 2-12, with a peak incidence at age 5-7. They can be triggered by acute stress, sleep deprivation, illness, or medications that affect the central nervous system. Sleep terrors usually resolve spontaneously as the child ages (Choice A) Nightmares are frightening dreams that occur during REM sleep They usually occur in the middle of the night or early morning when REM sleep is typically reached. W hen awakened, the child is fully alert and can usually recall the nightmare. (Choice B) Nocturnal panic attacks are characterized by an abrupt awakening from NREM sleep with a sensation of chest tightness and choking This child has no history of daytime episodes of anxiety, is inconsolable at night, and does not mention the incident the next day, making nocturnal panic attacks much less likely.
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{Choice C) Epilepsy can present with nocturnal seizures that can resemble sleep terrors. As with sleep terrors, the patient may not be able to be fully roused and will not remember the episode However, vocalizations are less likely with seizures and instead the child may have tonic-clonic movements and/or incontinence. Seizures occur randomly th roughout the night, whereas sleep terrors usually occur in the fi rst third of night sleep (Choice D) REM sleep behavior disorder is characterized by repeated episodes of aggressive motor behaviors (dream enactment) It is rare in children, and patients are able to recall their dream content, unlike sleep terrors, in which there is no memory of the incident. {Choice F) Sleep walking, another type of NREM parasomnia, involves walking or running around. The child has a blank stare and is unresponsive and not fully awake. This patient jumps out of bed, which can be seen in sleep terrors, but does not move around as in sleep walking
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(Choice B) Nocturnal panic attacks are characterized by an abrupt awakening from NREM sleep with a sensation of chest tightness and choking This child has no history of daytime episodes of anxiety, is inconsolable at night, and does not mention the incident the next day, making nocturnal panic attacks much less likely.
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{Choice C) Epilepsy can present with nocturnal seizures that can resemble sleep terrors. As with sleep terrors, the patient may not be able to be fully roused and will not remember the episode However, vocalizations are less likely with seizures and instead the child may have tonic-clonic movements and/or incontinence. Seizures occur randomly th roughout the night, whereas sleep terrors usually occur in the fi rst third of night sleep (Choice D) REM sleep behavior disorder is characterized by repeated episodes of aggressive motor behaviors (dream enactment) It is rare in children, and patients are able to recall their dream content, unlike sleep terrors, in which there is no memory of the incident. {Choice F) Sleep walking, another type of NREM parasomnia, involves walking or running around. The child has a blank stare and is unresponsive and not fully awake. This patient jumps out of bed, which can be seen in sleep terrors, but does not move around as in sleep walking She also has a panicky scream that does not occur in sleep walking. Educational objective: Sleep terro rs are a common, and usually benign, parasomnia of childhood. They occur during non-REM sleep and are characterized by fear, crying or screaming, decreased level of consciousness, and amnesia of the event References: 1. Just a scary dream? A brief review of sleep terrors, nightmares, and rapid eye movement sleep behavior disorder. 2. Parasomnias of childhood.
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6 A Apophyseal joint arthritis
e; B. Intervertebral disk degeneration
6 C. Ligamentous sprain e; D. Loss of bone mineral density
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6 E. Nerve root demyelinization
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A 67-year-old man comes to the physician due to 2 days of back pain He was moving boxes in his garage when the pain started. The pain is not relieved by lying down and inc reases in intensity when straining and coughing. He cannot sleep during the night due to pain, and has taken several acetaminophen tablets without relief. He has never had such pain before. Physical examination shows 2+ symmetrical knee and ankle jerk reflexes. Straight leg raise is negative. He has point tenderness to palpation and percussion along the midline at the fourth lumbar ve rtebra. W hich of the following is the most likely underlying etiology of th is patient's current condition?
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Etiologies
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Clinical features of vertebral compression fracture
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Clinical presentation
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Trauma Osteoporosis, osteomalacia Infection (eg, osteomyelitis) Bone metastases Metabolic (eg, hyperparathyroidism) Paget disease
Chronic/gradual VC F • Painless • Progressive kyphosis • Loss of stature Acute VCF • Low back pain &decreased spinal mobility • Pain increasing with standing, walking, lying on back • Tenderness at affected level
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Complications
• Increased risk for future fractures • Hyperkyphosis, possibly leading to protuberant abdomen, early satiety, weight loss, decreased respiratory capacity
VCF = vertebral compression fracture.
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This patient's presentation-acute back pain and point tenderness after strenuous activitysuggests a vertebral compression fracture (VCF) Patients with gradual onset VCF can be
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This patient's presentation- acute back pain and point tenderness after strenuous activitysuggests a vertebr al compression fr acture (VCF) Patients with gradual onset VCF can be asymptomatic However, an acute VCF can present with sudden onset of low back pain and decreased spinal mobility after bending, coughing, or lifting The pain typically increases with standing, walking, or lying on the back. Examination can show tenderness at the affected level Each VCF can decrease a patient's height by <::1 em and lead to kyphosis, which is associated with decreased respiratory capacity and increased risk fo r atelectasis pneumonia Kyphosis can also cause a protuberant abdomen, early satiety , and weight loss. VCF is associated with a significantly increased risk for future vertebral and nonvertebral fractures. The most common cause of nontraumatic VCF is osteoporosis, which is characterized by progressive loss of bone mineral density and loss of normal bony architecture. VCF can also be due to osteomalacia, which is usually caused by inadequate levels of vitamin D, calcium, or phosphorus and results in decreased bone mineralization and inc reased fracture risk. Other risk factors for VCF include trauma, infection (eg, osteomyelitis), malignancy with bone metastases, and metabolic abnormalities (eg, hyperparathyroidism) (Choice A) Apophyseal joint arthritis indicates spondyloarthropathy, such as ankylosing spondylitis (AS). AS typically presents with pain and progressively limited back motion, and is more common in younger men(< age 40). In addition, the pain of AS is typically worse in the morning and improves throughout the day {Choice B ) Lumbar disk degeneration can cause low back pain in the elderly , but the pain usually worsens with activity and is relieved with rest This patient's nighttime pain makes this less likely {Choice C) Ligamentous back sprain usually occurs after a specific event or action. Patients usually have pain that increases with movement and decreases with rest In addition, the pain is typically in the paraspinal area without significant tenderness to palpation of the vertebra, as seen in this patient (Choice E) Nerve root demyelination can be due to immune-mediated (eg, Guillain-Barre), toxin d. f . d d t b I' h d't . f f I P f t II d I I
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(Choice A) Apophyseal joint arthritis indicates spondyloarthropathy, such as ankylosing spondylitis (AS) AS typically presents with pain and progressively limited back motion, and is more common in younger men(< age 40) In addition, the pain of AS is typically worse in the morning and improves throughout the day (Choice B) Lumbar disk degeneration can cause low back pain in the elderly , but the pain usually worsens with activity and is relieved with rest This patient's nighttime pain makes this less likely (Choice C) Ligamentous back sprain usually occurs after a specific event or action. Patients usually have pain that increases with movement and decreases with rest In addition, the pain is typically in the paraspinal area without significant tenderness to palpation of the vertebra, as seen in this patient
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(Choice E) Nerve root demyelination can be due to immune-mediated (eg, Guillain-Barre), toxin or medication-induced, metabolic , hereditary, or infectious processes Patients usually develop neurologic deficits that correspond to the affected nerve roots (eg, paresthesias, lower extremity weakness) In addition, nerve root demyelination does not typically cause back pain or tenderness to palpation Educational objective: Risk factors for vertebral compression fracture include trauma, osteoporosis or osteomalacia, infection (eg, osteomyelitis), malignancy with bone metastases, and metabolic abnormalities (eg, hyperparathyroidism) The most common causes of nontraumatic vertebral comp ression fractures are osteoporosis and osteomalacia. References: 1. Evaluation and management of vertebral compression fractures.
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6 A Anticitrullinated peptide antibodies
e; B. Antismooth muscle antibodies
6 C. Live r biopsy e; D. Serum iron studies
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6 E. Serum uric acid level
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e; F. Slit-lamp eye examination
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A 43-year-old man comes to the physician reporting acute-onset right knee pain He was diagnosed with type 2 diabetes mellitus a year ago and takes metformin. He does not use tobacco, alcohol, or illicit drugs. The patient is in a monogamous relationship His father also has diabetes. His temperature is 37 C (98 6 F) , blood pressure is 134/86 mm Hg, pulse is 86/min, and respirations are 16/min. BMI is 26 kg/m' Physical examination shows a slightly swollen and tender right knee and mild hepatomegaly . Right knee x-ray reveals chondrocalcinosis and a moderate effusion. App ropriate analgesic is administered for joint pain. Which of the following is the best next step in management of this patient?
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Clinical manifestations of hereditary hemochromatosis Skin
Hyperpigmentation (bronze diabetes)
Musculoskeletal
Arthralgia, arthropathy & chondrocalcinosis
Gastrointestinal
Elevated hepatic enzymes with hepatomegaly (early), cirrhosis (later) & increased risk of hepatocellular carcinoma
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Diabetes mellitus, secondary hypogonadism & hypothyroidism
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Restrictive or dilated cardiomyopathy & conduction abnormalities
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Increased susceptibility to Listeria, Vibrio vu/nificus & Yersinia enterocolitica
This patient has acute monoarticular arthritis with chondrocalcinosis (calcified articular cartilage on radiographs), diagnostic of calcium pyrophosphate dihydrate crystal deposition (CPPD) disease (pseudogout) Patients with pseudogout should be evaluated for secondary causes such as hyperparathyroidism, hypothyroidism, and hemochromatosis. Given this patient's recently diagnosed type 2 diabetes mellitus and hepatomegaly, hereditary hemochromatosis (HH) is highly likely HH-induced iron deposition in the synovial fluid appears to promote CPPD.
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patient's recently diagnosed type 2 diabetes mellitus and hepatomegaly, hereditary hemochromatosis (HH) is highly likely HH-induced iron deposition in the synovial fluid appears to promote CPPD. The initial evaluation of HH includes serum iron studies, which will show increased levels of serum iron, ferritin , and transferrin saturation. The diagnosis can be confirmed with genetic testing for hemochromatosis-associated mutations (eg, HFE) Liver biopsy is not required but may be useful to stage the extent of liver involvement (eg, in patients with significant live r function test abnormalities) or to confi rm the diagnosis in patients who have iron studies indicating iron overload but negative resu~s on the classic HFE gene markers (Choice C) Long-term management of hemochromatosis involves serial phlebotomy to deplete excess iron stores. (Choice B) Antismooth muscle antibodies are seen in autoimmune hepatitis (AH), characterized by a range of liver disorders (eg, asymptomatic mild aminotransferase elevations, acute live r failure, cirrhosis) AH is associated with type 1 diabetes mellitus, not type 2, and joint compl ications are less common and result in arthralgia of the small joints (Choices A and E) Chondrocalcinosis is not a typical feature of gout or rheumatoid arthritis (which is associated with anticitrullinated peptide antibodies) (Choice F) Slit-lamp eye examination is helpful in identifying the Kayser-Fleischer rings of W ilson disease. W ilson disease can cause hepatomegaly; however , it typically presents with neuropsychiatric manifestations, and almost all patients are diagnosed before age 35. Educational objective: Hereditary hemochromatosis is commonly associated with calcium pyrophosphate dihydrate crystal deposition in joints, leading to chondrocalcinosis, pseudogout, and chronic arthropathy Patients commonly also have diabetes and live r disease. Diagnosis is suggested by iron overload on serum iron studies and can be confi rmed by genetic tests. References: 1. Hereditary hemochromatosis. 2. Characteristics of the arthropathy described in hereditary hemochromatosis.
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