MOCK PANCE EXAM-Block 5

One Step Further Question: What is the goal blood pressure for a patient with chronic kidney disease?

Answer: < 140/90 mm Hg.

One Step Further Question: What is the definitive diagnostic modality for pyloric stenosis?

Answer: Abdominal ultrasound.

One Step Further Question: What is the number one cause of acute liver failure in the United States?

Answer: Acetaminophen poisoning.

One Step Further Question: What type of esophageal malignancy is associated with untreated or uncontrolled gastroesophageal reflux disease?

Answer: Adenocarcinoma.

One Step Further Question: What is the most commonly implicated class of antibiotics in sensorineural hearing loss?

Answer: Aminoglycosides.

One Step Further Question: Which medication classes are commonly used in the short term to treat the symptoms of akathisia?

Answer: Antihistamines and benzodiazepines.

One Step Further Question: What occupations place individuals at greater risk of developing lung cancer?

Answer: Asbestos processing, welding, and pesticide manufacturing

One Step Further Question: How much pericardial fluid must accumulate before cardiac silhouette enlargement may be seen on a chest radiograph?

Answer: At least 200 mL.

One Step Further Question: What type of cells found on a peripheral blood smear are characteristic of mononucleosis infection?

Answer: Atypical lymphocytes (Downey cells).

One Step Further Question: What is the next diagnostic study after a non-reactive fetal nonstress test?

Answer: Biophysical profile.

One Step Further Question: A cavernous sinus thrombosis first causes a palsy of which cranial nerve?

Answer: CN VI based on its anatomic location within the cavernous sinus.

One Step Further Question: In which phase is a patient most infectious?

Answer: Catarrhal stage.

One Step Further Question: What is the most common cause of pelvic inflammatory disease?

Answer: Chlamydia trachomatis.

One Step Further Question: Chronic eustachian tube dysfunction places patients at risk for development of what more serious otic complication?

Answer: Chronic eustachian tube dysfunction is a major risk factor for development of cholesteatomas

One Step Further Question: Which joints in the hands are typically spared from rheumatoid arthritis?

Answer: Distal interphalangeal joints

One Step Further Question: What parasitic infection is a risk factor for development of vitamin B12 deficiency?

Answer: Fish tapeworm, Diphyllobothrium latum.

One Step Further Question: What are some foods that can aggravate the symptoms of carcinoid syndrome in patients with a carcinoid tumor?

Answer: Foods high in tyramines, such as blue cheese and chocolate, or ethanol, such as red wine, can elicit the symptoms of carcinoid syndrome.

One Step Further Question: How long should an inhaled corticosteroid be continued after a seasonal allergy exposure?

Answer: Four weeks after the end of exposure.

One Step Further Question: How is sickle cell disease diagnosed?

Answer: Hemoglobin electrophoresis.

One Step Further Question: What is the most commonly found hereditary abnormality associated with allergic reaction and anaphylaxis in a patient receiving a blood transfusion?

Answer: Hereditary IgA deficiency.

One Step Further Question: Where is the most common area to find Koplik spots?

Answer: In the buccal mucosa opposite of the premolar teeth.

One Step Further Question: What is the leading disease-related cause of death in patients with hemophilia?

Answer: Intracranial hemorrhage.

One Step Further Question: What is the name given to an enlarged left axillary lymph node associated with metastatic abdominal cancer?

Answer: Irish node.

One Step Further Question: What are Pastia's lines?

Answer: Linear petechiae seen in the elbows and axilla associated with scarlet fever.

One Step Further Question: What bacterial infection is the most common trigger of Erythema multiforme?

Answer: Mycoplasma pneumoniae.

One Step Further Question: After careful examination of vocal folds and technique, what medication may offer expedited resolution of laryngitis in professional vocalists to permit normal working function?

Answer: Oral or intramuscular corticosteroids can speed recovery, but patients should be thoroughly assessed beforehand to reduce use that may increase risk of vocal cord hemorrhage

One Step Further Question: Mutation of what gene is responsible for the majority of cases of polycystic kidney disease?

Answer: PKD1.

One Step Further Question: Cultures should be obtained during a rigid bronchoscopy if what complication of foreign body aspiration is suspected?

Answer: Postobstructive pneumonia.

One Step Further Question: What is the first-line treatment for polymyositis?

Answer: Prednisone.

One Step Further Question: What are solitary, fleshy perianal protrusions that occur in prepubertal children that are found anterior to the anus and are less than 2 cm in diameter?

Answer: Pyramidal perianal papules (infantile perianal pyramidal protrusions).

One Step Further Question: What types of cells are pathognomonic for Hodgkin's lymphoma?

Answer: Reed-Sternberg cells.

One Step Further Question: What is the name of the most common, autosomal-dominant form of congenital long QT syndrome?

Answer: Romano-Ward syndrome

One Step Further Question: What is the most common complication of a measles infection?

Answer: Secondary bacterial infection of the respiratory tract.

One Step Further Question: What is lanugo?

Answer: The growth of fine, light hair on the body as a result of anorexia nervosa

One Step Further Question: What is Cushing's disease?

Answer: The most common cause of Cushing's syndrome, an ACTH-producing pituitary tumor.

One Step Further Question: Which artery supplies blood to the scaphoid bone?

Answer: The radial artery.

One Step Further Question: What is the treatment for a pregnant patient with tick exposure and no erythema migrans?

Answer: The treatment is watchful waiting. If the patient is symptom free, it is appropriate to inform her of symptoms to watch for and then treat with antimicrobials should she develop symptoms.

One Step Further Question: What is the treatment for asbestosis or other forms of pneumoconiosis?

Answer: The treatment of asbestosis requires prompt antimicrobial therapy for respiratory infections, as well as immunization against influenza and pneumococcal pneumonia. Supplemental oxygen may be required as well.

One Step Further Question: What is a suitable prophylaxis for patients who experience frequent recurrences of tinea versicolor?

Answer: Topical selenium sulfide 2.5% or ketoconazole 2% shampoo.

One Step Further Question: True or false: Individuals with varicose veins are at a greater risk of developing deep vein thrombosis?

Answer: True

One Step Further Question: What is the test of choice used to diagnose syphilis in cerebrospinal fluid?

Answer: Venereal disease research laboratory (VDRL) test

One Step Further Question: Is there a genetic predisposition to hypertrophic obstructive cardiomyopathy?

Answer: Yes, it is an inherited autosomal-dominant disorder.

A 15-year-old girl admits that she has a fear of gaining weight and will do anything to make her high school swim team. She has been skipping meals for the past three months in an attempt to lose weight. What are you most likely to find on physical examination? Body mass index of 17 kg/m2 Body mass index of 20 kg/m2 Eroded tooth enamel Hypertension

Correct Answer ( A ) Explanation: A body mass index of 17 kg/m2 is a sign of anorexia nervosa, an eating disorder characterized by restriction of caloric intake, fear of gaining weight, and a distorted sense of body size and shape. Patients present with either restrictive anorexia nervosa where they lose weight by dieting or excessive exercise or with purging anorexia nervosa when they vomit after eating. Women are most commonly affected by anorexia nervosa, and this disorder is typically accompanied by suicidal thoughts and other psychiatric diseases. Patients present with a low body mass index (< 17.5 kg/m2), dry scaly skin, and hair loss. Symptoms include amenorrhea, dizziness, abdominal pain, and fatigue. Complications of anorexia nervosa include cardiovascular changes, gastrointestinal disorders, endocrinological changes, and gynecologic changes. Treatment is aimed toward behavioral therapy, medical management, and prevention of complications, and pharmacologic treatment, as needed.

A 62-year-old man with diabetes mellitus and hypertension presents with sudden onset of binocular diplopia. On examination, he has horizontal diplopia on gaze toward the affected side. What cranial nerve and muscle are responsible for this abnormality? Abducens nerve, lateral rectus muscle Oculomotor nerve, inferior oblique muscle Oculomotor nerve, medial rectus muscle Trochlear nerve, superior oblique muscle

Correct Answer ( A ) Explanation: A unilateral palsy of one or more of the oculomotor cranial nerves can result in binocular diplopia. The abducens nerve (cranial nerve VI), which innervates the lateral rectus muscle, is the nerve most commonly affected and will result in horizontal diplopia on gaze toward the affected side. Causes of an isolated neuropathy in cranial nerves III, IV or VI include demyelinating disease such as multiple sclerosis, hypertensive or diabetic vasculopathy, or compression. The abducens nerve is also the most likely of the three oculomotor nerves to be affected by tumor or increased intracranial pressure.

A 78-year-old woman with a history of tobacco abuse presents with dyspnea on exertion and cough that has been worsening over the last three days. A chest X-ray demonstrates a left-sided pleural effusion. A computed tomography scan of the chest is ordered and shows a 3.5 cm spiculated mass in the peripheral left lower lobe. What is the most likely diagnosis? Adenocarcinoma Bacterial pneumonia Small cell carcinoma Squamous cell carcinoma

Correct Answer ( A ) Explanation: Adenocarcinoma is the most common form of lung cancer. Smoking is a major risk factor for the development of adenocarcinoma. The lesions associated with adenocarcinoma are typically in the peripheral lung, frequently with pleural involvement. These masses can cause little to no symptoms for a period of years before being found incidentally or causing local invasion of surrounding tissue. The treatment of lung cancer is based on staging, cell type, and physical location of the tumor. If the patient is found to have an adenocarcinoma larger than 3 cm or mediastinal adenopathy, an MRI of the brain is recommended to rule out metastasis. Pain medication, chemotherapy, and smoking cessation are all adjuvant treatments of lung cancer. Surgery and radiation is recommended for resectable tumors. Prognosis is dependent on the stage of cancer at the time of diagnosis. Small cell carcinoma (C) and squamous cell carcinoma (D) tend to present as a central mass with symptoms of hemoptysis, cough, and dyspnea.

A 67-year-old man presents with gradually worsening fatigue and intermittent fevers over the last three months. A review of systems reveals an unintentional weight loss of 15 pounds that he attributes to a loss of appetite over the past few months and easy bruising with little or no trauma. Physical exam reveals bruises in various stages of healing, hepatosplenomegaly, and sternal tenderness. Labs reveal a severe normocytic anemia, thrombocytopenia, and a leukocyte count of 3500/μL. Which of the following findings on bone marrow biopsy would be consistent with the suspected diagnosis? Auer rods Basophilic stippling Heinz bodies Reed-Sternberg cells

Correct Answer ( A ) Explanation: Auer rods are abnormal rod-shaped granules in the cytoplasm of a malignant cell. They are not always present in acute myeloid leukemia (AML), but when they are, they suggest a myelogenous etiology and help confirm the diagnosis. Anemia and thrombocytopenia are usually severe at the time of diagnosis accompanied by a decreased reticulocyte count. Physical findings include fever, organomegaly, lymphadenopathy, sternal tenderness, and easy bruising or bleeding tendencies. Significant GI bleeding and retinal hemorrhages can also be present. Many patients have symptoms for more than three months at the time of initial presentation. Fatigue is also common. Replacement of the deficient blood components may be necessary. Treatment includes two phases: induction and postremission. Induction regimens typically include a combination therapy of cytarabine and an anthracycline. Post-remission treatment may include several cycles of cytarabine Basophilic stippling (B) is present in sideroblastic anemias and thalassemia among other conditions. Heinz bodies (C) are denatured particles of hemoglobin and are seen as a result of oxidative denaturation of hemoglobin from glucose-6-phosphate dehydrogenase deficiency or certain drugs. Reed-Sternberg cells (D) on biopsy indicate Hodgkin's lymphoma..

An 11-month-old boy presents with fever, cough, coryza, and conjunctivitis. He is visiting from Costa Rica and has had symptoms for the past three days. Physical exam reveals an erythematous, macular rash behind his ears, on his neck, and in his hairline. Which of the following physical exam findings is most consistent with the suspected diagnosis? Bluish-white spots on his buccal mucosa Circumoral pallor Desquamation of his hands and feet Dry, fissured, and erythematous lips

Correct Answer ( A ) Explanation: Bluish-white spots on the buccal mucosa describe Koplik spots associated with rubeola (measles) infection. Rubeola is a highly contagious, viral illness caused by a single-stranded RNA virus. The signs and symptoms include fever and general malaise that begin approximately 10 days after exposure to the virus. Koplik spots then develop and are pathognomonic of measles. A rash develops as the oral manifestations fade and looks like erythematous macules behind the ears, on the neck, and in the hairline. The rash spreads to the face, trunk, and extremities and fades in the same distribution as the initial appearance, eventually involving desquamation. Diagnosis is clinical; however, there are serologic tests available that detect antibodies. Treatment is generally supportive consisting of analgesics, antipyretics, and fluids. Administration of Vitamin A can reduce morbidity and mortality. Circumoral pallor (B) is associated with scarlet fever. Other physical exam findings include a "strawberry tongue" and a "sandpaper" rash, involving the bilateral axilla and groin. Desquamating rash of the hands and feet (C) and dry, fissured, and erythematous lips (D) are both associated with Kawasaki disease.

What is the first line treatment for a pregnant patient with known tick exposure and erythema migrans? Amoxicillin Azithromycin Cefuroxime Doxycycline

Correct Answer ( A ) Explanation: Early lyme disease in pregnancy is best treated with oral amoxicillin 500 mg three times daily for 14 days. Lyme disease is a bacterial infection caused by Borrelia burgdorferi that is transmitted by tick species Ixodes scapularis and Ixodes pacificus found in North America and Europe. Erythema migrans is an erythematous bullseye rash that is a cutaneous sign of early lyme disease. If lyme disease is left untreated, patients may go on to develop arthritis or more severe neurologic and cardiovascular symptoms such as meningitis, atrioventricular heart block, and myopericarditis. Late Lyme disease with severe symptoms typically requires hospitalization and treatment with IV antibiotics.

A 65-year-old man presents to your office with complaints of urinary frequency, hesitancy and nocturia. Which of the following findings would suggest a diagnosis of prostate cancer rather than benign prostatic hypertrophy? Asymmetric areas of induration on digital rectal exam Elevated serum prostate specific antigen Presence of hematuria on urinalysis Symmetric enlargement and firmness of the prostate on digital rectal exam

Correct Answer ( A ) Explanation: In the United States, prostate cancer is the most frequently diagnosed type of cancer in men after skin cancer. Prostate cancer is seen more commonly in African-American men and the likelihood of developing this type of cancer increases with age. It is uncommon in men younger than 50 years old. Risk factors include a family history of prostate cancer, cigarette smoking, and a diet high in animal fat. Most patients diagnosed with prostate cancer are asymptomatic, and the cancer is found on digital rectal exam (DRE) or because of an elevated serum prostate specific antigen (PSA). A physical exam finding of asymmetric areas of induration or nodules on DRE is suspicious for prostate cancer and further workup should be initiated. Diagnosis is made with biopsy. Treatment decisions are determined after discussion with the patient about the severity of disease and quality of life related to treatment side effects. Treatment options include active surveillance, prostatectomy, radiation therapy, and hormonal therapy.

Which of the following is considered first-line treatment for hypertension in patients with polycystic kidney disease? Angiotensin-converting enzyme inhibitors Beta blockers Calcium channel blockers Thiazide diuretics

Correct Answer ( A ) Explanation: Polycystic kidney disease (PKD) is the most common genetic cause of chronic kidney disease and is most commonly inherited in an autosomal dominant pattern. Presenting symptoms can include flank discomfort (which can be due to enlarging cysts, hemorrhage into cysts, infection, or renal calculi), hematuria, and hypertension. Hypertension is present in the majority of patients with normal renal function who are 40 years and older and nearly universal in patients with evidence of renal insufficiency. Adequate treatment of hypertension in patients with PKD can slow the progression of renal dysfunction and decrease the risk of cardiovascular morbidity. Angiotensin-converting enzyme (ACE) inhibitors (e.g. captopril, lisinopril) and angiotensin II receptor blockers (ARBs) are considered the drugs of choice in this population. In patients with advanced renal disease, these medications may exacerbate renal failure and increase serum potassium levels, so patients must be monitored closely

A 16-year-old boy is in clinic because of a rash. He noticed an itchy rash on his abdomen that is close to his umbilicus. He is a previously healthy boy and is not on any medications. On physical examination vital signs are normal. On skin examination there is a well-demarcated and pruritic area at the subumbilical region with weeping and vesiculation. Which of the following is the most likely diagnosis? Allergic contact dermatitis Cellulitis Herpes zoster Impetigo

Correct Answer ( A ) Explanation: The boy has findings that are suspicious for allergic contact dermatitis from the nickel of the metal fasteners of his pants. Allergic contact dermatitis is an acquired, inflammatory reaction of the skin that requires absorption of antigen from the skin surface and recruitment of previously sensitized, antigen-specific T lymphocytes into the skin. An intact immune system is required for the development of allergic contact dermatitis, which occurs in two phases: the sensitization phase and the elicitation phase. Contact allergens are found in both the natural and man-made environment. The most common contact allergen is urushiol, a pentadecylcatechol found in plants of the Toxicodendron species, such as poison ivy, poison oak, and poison sumac. Other common childhood contact allergens in the United States and Europe include metals such as nickel, cobalt, and potassium dichromate. Acute allergic contact dermatitis lesions consist of erythematous, indurated, scaly plaques. Vesiculation and bullae may be seen in severe cases. Edema may be prominent in areas in which the skin is thin. Repeated or continued exposure to allergens results in chronic disease. The skin becomes dry, scaly, and thicker as a result of acanthosis, hyperkeratosis, edema, and cellular infiltration in the dermis. Lichenification and fissuring may develop later. Secondary changes include excoriation or impetiginization. A history of allergen exposure and the pattern of the eruption are important factors in making the correct diagnosis. Patterns of dermatitis that are suggestive of allergic contact dermatitis include persistent, localized dermatitis that has not responded as expected to therapy, and dermatitis in an unusual pattern or distribution.

A four-year-old boy is brought by his mother to the clinic because of a lesion in the genital area. The mother noted the skin lesion about a month ago. She found the lesion in the anal area that started small but now some have coalesced. The boy does not complain of pain or bleeding with defecation. On skin examination, there are multiple flesh-colored papules measuring 2 to 3 mm in diameter with some larger plaques that have a "cauliflower appearance" in the perianal area. Which of the following is the most likely diagnosis? Condyloma accuminata Condyloma lata Epidermal nevi Molluscum contagiosum

Correct Answer ( A ) Explanation: The boy has lesions in the perianal area that are consistent with condyloma accuminata. It is also known as anogenital warts or venereal warts and is a manifestation of human papillomavirus (HPV) infection. The possibility of sexual abuse is a major concern in the evaluation of children with condyloma acuminatum. However, other modes of viral transmission may account for the majority of pediatric cases. The potential methods for human papillomavirus (HPV) acquisition in children are heteroinoculation (transmission of HPV may occur during nonsexual contact with a caregiver, such as bathing or diaper changing), autoinoculation (children may acquire anogenital lesions from self due to transmission of HPV from other cutaneous or mucosal sites of infection), and sexual abuse. Condylomata acuminata initially appear as flesh-colored, pink or brown soft moist papules that are a few millimeters in diameter. Over the course of weeks to months, the papules may coalesce into larger plaques that often demonstrate a cauliflower appearance. In boys, condylomata acuminata are most commonly detected in the perianal area and are less frequently found on the penile shaft. Girls may present with lesions on the perianal area, vulva, hymen, vaginal vestibule, or periurethral areas. Anogenital warts may also occur on the internal mucosal surfaces of vagina or rectum. Condyloma acuminatum is usually asymptomatic although occasional lesions are pruritic or painful. Rarely, bleeding occurs. Since most condylomata acuminata in children resolve within a few years, treatment is not required for most children with asymptomatic lesions. Condyloma lata (B) of secondary syphilis are highly infectious, moist papules and small plaques that may develop in the anogenital region. Serologic testing is useful for diagnosis. Epidermal nevi (C) are uncommon skin lesions that present at birth or in early childhood as skin-colored to hyperpigmented verrucous plaques. A linear distribution or a distribution that follows Blaschko's lines is suggestive of an epidermal nevus. Molluscum contagiosum (D) is a cutaneous viral infection commonly seen in children. The recognition of round, smooth, skin-colored papules with central umbilication supports a diagnosis of molluscum contagiosum

A 65-year-old woman presents to the ED with generalized weakness. Recent history includes upper GI bleed secondary to peptic ulcer disease. Her hemoglobin was found to be 6.4 g/dL. While receiving a packed red blood cell transfusion, she developed headache, joint pain, fever, wheezing, and hypotension. Which of the following is the most likely cause of these symptoms? Acute transfusion reaction Febrile transfusion reaction Graft-versus-host reaction Transfusion-related acute lung injury

Correct Answer ( A ) Explanation: This patient is suffering from an acute transfusion reaction or hemolytic crisis. This is most commonly caused by ABO incompatibility and may result in activation of the coagulation cascade (DIC). Signs and symptoms include headache, back pain, joint pain, anxiety, fever, tachycardia, hypotension, wheezing, pulmonary edema, and renal failure. Delayed reactions can occur in extravascular spaces, most commonly the spleen, liver, or bone marrow. Hemolytic crisis may also present with pink serum or urine due to severe hemolysis. Management includes discontinuing the transfusion immediately and starting IV fluids to maintain urine output at 30-100 cc/hour. Laboratory analysis should include a repeat type and screen with crossmatching, serum haptoglobin, CBC, and direct Coombs testing to confirm the diagnosis. Transfusion-related acute lung injury (D) is non-cardiogenic pulmonary edema leading to bilateral patchy infiltrates within four hours of transfusion. Patients may have rapid progression to ARDS and require ventilatory support with non-invasive positive pressure ventilation or endotracheal intubation.

A 48-year-old man presents to clinic today for his yearly checkup. He has a history of asthma and gastroesophageal reflux disease. His current medications include an albuterol inhaler and omeprazole. He describes having asthma symptoms two times per week that he treats with his albuterol rescue inhaler. Which of the following should be initiated to better control his asthma? Fluticasone HFA Fluticasone/salmeterol Montelukast Prednisone

Correct Answer ( A ) Explanation: This patient's asthma can be classified as mild intermittent, and he can benefit by the addition of a low dose inhaled corticosteroid, such as fluticasone, to his regimen. Low dose inhaled corticosteroids are effective at controlling asthma symptoms not adequately controlled with a short-acting beta-agonist (e.g. albuterol). Inhaled corticosteroids are effective at decreasing symptoms associated with asthma, increasing lung function, as well as decreasing the risk of exacerbation, hospitalization, and death.

A 45-year-old man is complaining of progressive dysphagia. He states he doesn't see a healthcare provider often and first noticed dysphagia developing two or three years ago. He denies difficulty swallowing liquids. He admits that he has heartburn symptoms nearly all day every day. He is unable to sleep lying flat because it makes his symptoms worse. He agrees that he is not able to eat very well because everything seems to make the heartburn worse. He does not take any chronic medications but recently completed a three-day course of levofloxacin. Which of the following is the most likely cause of his dysphagia? Achalasia Peptic stricture Pill esophagitis Zenker's diverticulum

Correct Answer ( B ) Explanation: A peptic stricture causes esophageal dysphagia and is most commonly caused by uncontrolled or untreated gastroesophageal reflux disease. Along with Schatzki's rings and eosinophilic esophagitis, it is one of the most common structural causes of dysphagia. The stricture forms as a result of collagen deposition in the esophagus as an ulcerative area begins to heal. Over time, the collagen fibers will contract resulting in narrowing of the esophageal lumen and the clinical manifestation of solid food dysphagia. Liquid dysphagia is uncharacteristic of a peptic stricture. Treatment of a peptic stricture includes esophageal dilation followed by proton pump inhibitor therapy to minimize the risk of recurrence. Achalasia (A) is an esophageal dysmotility disorder that causes a solid and liquid food dysphagia and is associated with the classic "bird's beak" appearance on imaging. Pill esophagitis (C) is characterized by sudden onset of odynophagia following ingestion of a medication commonly associated with pill esophagitis such as bisphosphonates or NSAIDs. Tetracycline, doxycycline, and clindamycin have been shown to cause a direct irritation to the esophageal tissue, but this has not been shown in other antibiotics. Zenker's diverticulum (D) is considered an oropharyngeal cause of dysphagia in which food is diverted into the diverticulum rather than down the esophagus resulting in halitosis and the regurgitation of undigested food or medications.

An 18-year-old woman is brought in by her parents for a suspected overdose. Her parents found an empty bottle of acetaminophen in her room after the patient threatened suicide. The patient admits to taking approximately 12,000 milligrams of acetaminophen approximately two hours prior to arrival. She weighs 58.2 kilograms. Which of the following is the most appropriate next step in managing this patient? Administer acetylcysteine therapy Administer activated charcoal Order and await a serum acetaminophen level Order liver function tests to determine treatment

Correct Answer ( B ) Explanation: Administering activated charcoal is the first step in treatment of a patient who presents to the emergency department within four hours of acetaminophen overdose. Acetaminophen is one of the most common toxic ingestions. Poisonings can be intentional or unintentional. The recommended dosing of acetaminophen for children is 15 mg/kg every four to six hours in children two to 12 years of age (maximum 24-hour dose for children is 75 mg/kg/day) and in adults is 650 to 1000 mg every four to six hours (maximum 24-hour dose for adults is 3000 mg). A toxic exposure in adults is > 200 mg/kg as a single ingestion or over a 24-hour period. It is also considered a toxic dose with > 150 mg/k per 24-hour period for at least two consecutive days. Peak serum levels are usually achieved within 30 minutes to two hours. The drug is primarily metabolized by the liver. In an overdose, hepatic metabolism of the drug may be saturated causing subsequent hepatic necrosis. Hepatocyte injury can begin to occur within 12 hours of exposure. There are four clinical stages of acetaminophen toxicity. During stage I, patients may be asymptomatic or may have mild symptoms of anorexia, nausea, vomiting, or malaise. In stage II (which occurs 48-72 hours following toxic ingestion) clinical signs of hepatotoxicity (e.g., right upper quadrant abdominal pain and tenderness and elevated serum transaminases) may occur. Stage III is associated with fulminant hepatic failure. Stage IV is associated with complete recovery and can take place anywhere from four days to two weeks after overdose. Treatment is guided by the Rumack-Matthew nomogram, which plots the plasma acetaminophen concentration against the hours since ingestion. Treatment guidelines are based on time to presentation after ingestion. If the patient presents between four to 24 hours from ingestion, acetaminophen levels should be drawn to guide treatment. If the time to presentation is unknown or > 24 hours, gastrointestinal decontamination should still be considered. Acetylcysteine therapy should be administered if there is a risk of liver damage as indicated by the nomogram.

A 36-year-old woman was prescribed a selective serotonin reuptake inhibitor and an atypical antidepressant for treatment of depression one week ago. The patient presents today with complaints of restlessness and increased anxiety. During the interview, she is constantly pacing. Vital signs are normal. Which of the following is the most likely cause of her symptoms? Acute dystonia Akathisia Serotonin syndrome Tardive dyskinesia

Correct Answer ( B ) Explanation: Akathisia is a subjective feeling of restlessness, which often manifests with a compelling need to move constantly. Examples of symptoms of akathisia include anxiety, an inability to relax, rocking motions, and jitteriness. Akathisia is associated with starting a new psychotropic medication, including antidepressants and antipsychotics. A patient presenting with akathisia should have their psychotropic dosage reduced to the minimum effective level. Acute dystonia (A) presents with slow, sustained, involuntary contractions of muscles, which results in slow, repetitive movements or abnormal postures. Serotonin syndrome (C) is an emergent condition due to toxic serotonin levels. Symptoms include variable mental status, hyperreflexia, mydriasis, tachycardia and hypertension. Tardive dyskinesia (D) is an emergent complication of antipsychotic use. Symptoms include muscular rigidity, hyporeflexia, hypertension, and tachycardia.

A 52-year-old woman presents with amenorrhea and weight gain, especially in the centripetal area and in the dorsocervical fat pad. Physical exam reveals striae on the abdomen and a ruddy facial complexion. Blood pressure is 153/88 mm Hg. What is the most likely diagnosis? Addison's disease Cushing's disease Grave's disease Pheochromocytoma

Correct Answer ( B ) Explanation: Cushing's syndrome occurs due to hypercortisolism. The causes of Cushing's syndrome may be due to adrenocorticotropic hormone (ACTH), including an ACTH-secreting pituitary tumor (the most common cause) or other non-pituitary ACTH secreting neoplasms, such as small cell lung carcinoma. Alternatively, Cushing's syndrome may be ACTH-independent, including adrenal adenoma, adrenal carcinoma, and exogenous administration of glucocorticoids. Patients may present with amenorrhea, central obesity, easy bruising and purple striae, "moon face" (facial adiposity), "buffalo hump" (increased adipose tissue in the neck and upper back), hypertension, and depressive symptoms. Diagnosis is confirmed by elevated cortisol levels, using a dexamethasone suppression test, and testing ACTH levels. Further CT or MRI imaging may then be used to localize any suspected tumor. Treatment is by surgical removal of any tumor, followed by hormone replacement. Adrenal inhibitors of cortisol include ketoconazole and metyrapone.

A patient is diagnosed with hemophilia B. Which of the following is the mainstay of therapy? Desmopressin acetate Factor IX concentrate Factor VIII concentrate Platelet transfusion

Correct Answer ( B ) Explanation: Factor IX concentrate is the mainstay of therapy for individuals with hemophilia B (Christmas disease). Hemophilia B is a genetically inherited deficiency in factor IX. It is associated with a prolonged activated partial thromboplastin time (aPTT). The prothrombin time (PT) and thrombin time will be normal. Diagnosis is made by examining factor IX activity. Patients with hemophilia have spontaneous bleeding episodes involving skin, mucous membranes, and joints. Minor trauma can cause large amounts of bleeding. Complications include compartment syndrome from intramuscular hematoma, joint destruction from recurrent hemarthroses, or the development of antibodies to exogenous factor IX.

A 21-year-old man presents to the emergency room after a syncopal episode while playing soccer. Physical examination reveals a holosystolic apical murmur. The patient's electrocardiogram shows left ventricular hypertrophy. Echocardiogram indicates thickness of the mid-septal region. What is the most likely diagnosis? Dilated cardiomyopathy Hypertrophic obstructive cardiomyopathy Restrictive cardiomyopathy Takosubo cardiomyopathy

Correct Answer ( B ) Explanation: Hypertrophic obstructive cardiomyopathy leads to an increased risk of sudden death in young athletes. Most patients are asymptomatic; those patients with symptoms commonly present with dyspnea on exertion, angina, or syncope. Physical examination reveals a loud S4, prominent apical impulse and mitral regurgitation murmur, which increases with a Valsalva maneuver. Septal wall thickness leads to obstruction of left ventricular outflow and diastolic filling dysfunction. ECG commonly shows left ventricular hypertrophy (LVH) and the echocardiogram is diagnostic, showing septal wall thickness and an increased ejection fraction. Beta-blockers are the initial treatment of choice to slow the heart rate and assist with diastolic filling. Calcium channel blockers also improve diastolic function but may cause hypotension due to their vasodilatory effect. Patients who present with unexplained syncope, especially with family history, are managed with an implantable defibrillator.

A 15-year-old boy presents with sore throat, pain with swallowing, fatigue, and cervical lymphadenopathy for the past week. He developed a rash two days ago after beginning amoxicillin. Physical exam reveals a diffuse, morbilliform rash. What is the most likely diagnosis? Herpangina Infectious mononucleosis Streptococcal pharyngitis Viral pharyngitis

Correct Answer ( B ) Explanation: Infectious mononucleosis causes nausea, anorexia, malaise, cervical adenopathy, and exudative pharyngitis. Splenomegaly is present in about 50 to 75 percent of patients. Treatment with penicillins or cephalosporins will almost universally cause a diffuse, pruritic, morbilliform rash. Mononucleosis is caused by an infection with the Epstein-Barr virus (EBV); therefore, antibiotics are not helpful. Treatment is supportive and includes rest, analgesics, antipyretics, and hydration. Fatigue and malaise can sometimes last for several months, although most patients recover fully within several weeks. Patients with splenic enlargement should be cautioned to avoid activities that may result in abdominal trauma (i.e. contact sports) for a period of six to eight weeks after infection to avoid the risk of splenic injury. Herpangina (A) due to coxsackie virus presents with painful oropharyngeal ulcerations and vesicles. Streptococcal pharyngitis (C) is a possibility with this patient as the signs and symptoms of mononucleosis and streptococcal infection are very similar. However, the history of developing a rash following the administration of amoxicillin and the lack of clinical improvement with amoxicillin suggests a diagnosis of mononucleosis. Viral pharyngitis (D) typically presents with an injected posterior oropharynx. Again, the history of developing a rash following the administration of amoxicillin suggests a diagnosis of mononucleosis.

A seven-year-old boy with a history of bone marrow transplant at age five presents for a low-grade fever, shortness of breath, and wheezing. Viral antigen testing of his nasal washings confirms diagnosis with respiratory syncytial virus. In addition to hydration and humidification of his inspired air, which of the following interventions is most appropriate for this patient? Intravenous corticosteroids Nebulized ribavirin Oral oseltamivir Supplemental surfactant administration

Correct Answer ( B ) Explanation: Nebulized ribavirin is appropriate in this patient with respiratory syncytial virus (RSV), since he is at greater risk of complications from the illness due to his history of bone marrow transplantation. RSV is a paramyxovirus that causes respiratory infections, most commonly in the autumn and early winter in the United States. Though RSV is generally considered an infection of children, affecting children between six months and five years of age, elderly and immunocompromised adults can also be affected with high mortality rates. RSV bronchiolitis causes illness by contributing to proliferation and necrosis of bronchial epithelium. The resulting sloughed epithelium leads to respiratory obstruction and heavy mucus production. Most patients present with rapid breathing rates, cough, wheezing, and low-grade fever. Apnea and hyper-inflated lungs often result. Though the gold standard of diagnosing RSV is with a culture of nasopharyngeal or lower respiratory tract secretion, rapid diagnosis is more commonly made by using viral antigen identification of nasal washing with an immunofluorescence or ELISA assay. Most patients will recover from RSV infection with supportive care that can include humidification of inspired air, hydration, and ventilatory support, if necessary. However, patients at risk for complications, including patients who are immunocompromised, patients with history of bone marrow transplants, patients with congenital heart disease, and patients with chronic lung diseases, may benefit from receiving nebulized or intravenous ribavirin. Some patients with high risk factors for RSV infection may also benefit from prophylaxis against RSV during the autumn and winter months by getting palivizumab intramuscularly monthly.

A six-year-old girl presents with sore throat and fever for the past three days. Physical exam reveals a faint, generalized rash on the face and chest that feels rough upon palpation. The rash spares the circumoral area. Exam of the oral cavity reveals a bright red tongue with white papillae. What is the most likely diagnosis? Kawasaki disease Scarlet fever Staphylococcal scalded skin syndrome Viral exanthem

Correct Answer ( B ) Explanation: Scarlet fever is caused by toxin-producing group A beta-hemolytic streptococci. Symptoms include a fine, papular rash that blanches with pressure and spares the circumoral area that is often described as a "sandpaper rash." A "strawberry tongue" is another symptom that may develop within the first two to three days of illness. At first, the tongue may appear to have a whitish coating that eventually precedes the development of a reddened tongue with white papillae. Other symptoms include headache, sore throat, cervical lymphadenopathy, mild abdominal pain, nausea, malaise, and fever. Scarlet fever is most prevalent in school-age children. A rapid strep test or throat culture is usually indicated to confirm infection. An oral penicillin or a macrolide is the potential first-line antibiotic therapy. Treatment also includes supportive care with hydration, analgesics, and antipyretics. Prognosis for recovery is usually good. It is rarely complicated by sepsis but can be complicated by the development of a peritonsillar abscess or rheumatic fever.

A 50-year-old woman presents to her primary care physician's office with a chief complaint of one year of morning stiffness in her joints, swelling in her fingers, knees, and ankles, and new nodules on her fingers. What is the most effective pharmacologic treatment for the suspected diagnosis? Hydrocortisone Ibuprofen Methotrexate Tocilizumab

Correct Answer ( C ) Explanation: Methotrexate is a type of disease-modifying antirheumatic drug (DMARD) that is used in the treatment of rheumatoid arthritis. Rheumatoid arthritis is a chronic rheumatologic disease characterized by arthritis and swelling of joints, morning stiffness, extra-articular manifestations such as finger nodules, and radiographic changes of joint erosion and demineralization. Disease-modifying antirheumatic drugs include hydroxychloroquine, sulfasalazine, and methotrexate and should be started as soon as rheumatoid arthritis is suspected. Early intervention with DMARDs has been proven to decrease symptom duration, improve disease activity, and alter the course of the disease.

A 19-year-old African American man presents to your office with questions about his diagnosis of sickle cell anemia. He has been managing his condition since childhood by treating his symptoms and having occasional blood transfusions. Now he is experiencing more frequent painful episodes and wants to know if there are other treatment options. Which of the following is the most appropriate pharmacologic treatment? Ferrous sulfate Hydroxyurea Oxycodone Prednisone

Correct Answer ( B ) Explanation: Sickle cell anemia is an autosomal recessive genetic disorder that causes a mutated form of hemoglobin S. This mutation leads to chronic vaso-occlusive crises in affected individuals and causes a number of other health problems. It is most commonly found in persons of African ancestry. Individuals may be carriers of the sickle cell trait, meaning that they carry one mutated gene for hemoglobin S and one normal gene. Carriers generally do not experience the painful or vaso-occlusive crises that those with the disease experience and have some resistance to malaria. Generally diagnosed in early childhood, patients with sickle cell disease experience clinical manifestations that include acute and chronic pain, anemia, splenic sequestration, infection and involvement of multiple organ systems. Aspects of treatment include prevention of infection through immunizations, prevention of vaso-occlusive crises with hydroxyurea and management of painful episodes with rest, analgesia, and hydration. Hydroxyurea increases fetal hemoglobin (HbF) production and slightly raises the total hemoglobin concentration in the body. Fetal hemoglobin reduces the chance that red blood cells will sickle in a person who has sickle cell disease. So increased production of HbF can reduce the occurrence of sickling-related complications. Treatment and management of the disease is best provided by a sickle cell disease specialist.

Following a motor vehicle accident, a 24-year-old man is brought to the emergency department by paramedics. He has a pulse of 110 beats/min, respiratory rate of 22 breaths/min, blood pressure of 98/55 mm Hg, and temperature of 98.6°F. He is in obvious distress. He has jugular venous distention, faint heart sounds, and bilateral breath sounds. Which of the following is the most likely diagnosis? Acute pericarditis Cardiac tamponade Pulmonary embolism Tension pneumothorax

Correct Answer ( B ) Explanation: The man in this case most likely has acute cardiac tamponade. Cardiac tamponade is caused by accumulation of fluid within the pericardial sac. The fluid restricts diastolic filling resulting in hemodynamic compromise. Trauma can cause acute bleeding into the pericardium leading to the rapid development of cardiac tamponade. Other causes of cardiac tamponade include aortic dissection, pericarditis, neoplasms, tuberculosis, and iatrogenic causes. Symptoms depend on how rapidly the fluid accumulates. Acute tamponade can develop in minutes and is associated with dyspnea, chest pain, tachypnea, and symptoms of cardiogenic shock. Sinus tachycardia is the most common finding. Beck's triad is commonly observed in acute cardiac tamponade. Beck's triad is composed of jugular venous distension, hypotension, and diminished heart sounds. Acute tamponade is life-threatening if not recognized and treated quickly. Suspected cardiac tamponade is evaluated with an ECG, echocardiography, and chest radiograph. ECG typically shows sinus tachycardia. Electrical alternans is a relatively specific finding, but is not sensitive for cardiac tamponade. Electrical alternans is beat-to-beat QRS complex alterations. Chest radiographs are generally nonspecific for cardiac tamponade, but may help rule out dissection as a possible cause. In cardiac tamponade, echocardiography plays a major role in the diagnosis and assessment of hemodynamic compromise. Moderate to large effusions are present in most cases of cardiac tamponade. The heart may appear to be swinging within the effusion. Removal of the pericardial fluid is the definitive treatment and can be accomplished either emergently through subxiphoid percutaneous drainage, echocardiographically guided pericardiocentesis, or surgically. The fluid obtained from the pericardium should be sent for analysis if the etiology is uncertain. Relative contraindications for pericardial fluid drainage are severe pulmonary hypertension and coagulopathies.

A 72-year-old retired shipyard worker received a chest X-ray as part of a routine medical work-up. The radiologist reported incidental findings of fibrocalcified pleural plaques which are suggestive of an occupational lung disease. Which one of the following is true regarding the suspected disease? It has a high correlation with tuberculosis It has an increased risk for lung cancer It presents as enlarged lymph nodes and noncaseating granulomas It primarily affects the upper lobes of the lung

Correct Answer ( B ) Explanation: This patient most likely has asbestosis, which is a type of pneumoconiosis. Pneumoconiosis refers to the inhalation of small dust particles from environmental substances such as coal, asbestos, silica, or beryllium that all result in interstitial fibrosis and cause an increased incidence of cor pulmonale. This particular patient was exposed to a shipyard, which has a high asbestos exposure, and therefore this patient most likely has developed asbestosis. The classic chest x-ray findings include fibrocalcified pleural plaques predominantly of the posterio-lateral mid lung and diaphragm. It is common to discover these lesions in asymptomatic patients during routine chest x-rays. Later, it can result in fibrotic lung disease, mesothelioma or other lung malignancies. Bronchogenic carcinoma is more common than mesothelioma since mesothelioma takes a longer time to develop (25-40 years). Keep in mind that smoking has no effect on mesothelium, but amplifies the risk of bronchogenic carcinoma when combined with asbestos.

Which of the following medications is the most appropriate initial treatment for a patient with chronic kidney disease and hypertension? Furosemide 20 mg once daily Lisinopril 10 mg once daily Metoprolol succinate 25 mg once daily Spironolactone 25 mg once daily

Correct Answer ( B ) Explanation: Treatment of hypertension with an angiotensin-converting-enzyme (ACE) inhibitor has been shown to improve kidney-related outcomes in patients with chronic kidney disease. The main benefit of ACE inhibitors is that they're more effective at slowing the glomerular filtration rate decline compared to beta-blockers or calcium channel blockers. This benefit can be seen in chronic kidney disease patients with and without proteinuria.

A five-week-old boy is brought to the clinic for evaluation of non-bilious, projectile vomiting after eating. Which of the following physical examination findings is most highly associated with a diagnosis of pyloric stenosis? Abdominal distension Jaundice Olive-shaped mass Sausuage-shaped mass

Correct Answer ( C ) Explanation: Non-bilious projectile vomiting in an infant is the most common symptom of pyloric stenosis and palpation of an olive-shaped mass is the most commonly associated physical exam finding. Pyloric stenosis is caused by the hypertrophy of the pylorus, and it classically causes projectile vomiting followed by the infant demanding to be re-fed. The olive-shaped mass is present in up to 92 percent of cases and can be palpated along the lateral edge of the rectus abdominis muscle in the right upper quadrant of the abdomen.

A 34-year-old woman presents to the clinic with a chief complaint of "I hurt all over." She complains of fatigue, widespread pain, and difficulty sleeping for over six months. She has a past medical history of irritable bowel syndrome and depression. On physical examination, vital signs are normal. Musculoskeletal examination reveals multiple tender points, but no synovitis or muscle weakness. The remainder of the examination is normal. Laboratory studies, including erythrocyte sedimentation rate, C-reactive protein level, and thyroid-stimulating hormone level, are normal. Which of the following is the most likely diagnosis? Chronic fatigue syndrome Complex regional pain syndrome Fibromyalgia Polymyalgia rheumatica

Correct Answer ( C ) Explanation: Patients with symptoms of chronic widespread pain should be suspected of fibromyalgia and undergo evaluation to confirm or exclude the diagnosis. Symptoms of fibromyalgia, including chronic, widespread musculoskeletal pain lasting at least three months but often for many years; a history of tenderness to touch; fatigue; sleep, cognitive, and psychiatric disturbances; paresthesias; problems with balance; and sensitivity to noises, light, odors, and cold. Typical patient complaints that should raise suspicion of fibromyalgia are "I hurt all over" or "It feels like I always have the flu." The diagnosis of fibromyalgia is based primarily upon the patient's symptoms of widespread pain, typically reported in the muscles and joints, and findings of multiple tender points in characteristic soft tissue locations, in the absence of evidence on physical examination and laboratory testing of joint or muscle inflammation that would explain the patient's symptoms. A specific number of tender points is not required to make the diagnosis in clinical practice. Other common features supporting the diagnosis include fatigue and nonrestorative sleep, cognitive disturbances, and the coexistence of other disorders often seen in association with fibromyalgia, including depression, anxiety, irritable bowel syndrome, bladder irritability, obstructive sleep apnea, and restless legs syndrome. Patients with chronic fatigue syndrome (A) often have fatigue, cognitive disturbances, generalized allodynia, and hyperalgesia similar to fibromyalgia and other functional somatic syndromes. However, chronic fatigue syndrome does not include the presence of chronic widespread musculoskeletal pain. Complex regional pain syndrome (B) is a form of chronic pain in a body region, but it most commonly affects the extremities. It is characterized by pain, swelling, skin changes, vasomotor instability, limited range in motion, and patchy bone demineralization. Polymyalgia rheumatica (D) is characterized by severe stiffness in the morning and when sedentary and the onset is usually in those over 60 years of age. Additionally, ESR and CRP levels are usually elevated. However, like fibromyalgia there are often no abnormal physical findings on exam.

Which of the following fetal heart rate acceleration patterns is considered a reassuring fetal nonstress test after 32 weeks of gestation? Accelerations that last ≥ 10 minutes Accelerations that last ≥ 10 seconds and peak ≥ 10 bpm above baseline Accelerations that last ≥ 15 seconds and peak ≥ 15 bpm above baseline Accelerations that last ≥ 2 minutes, but < 10 minutes

Correct Answer ( C ) Explanation: A fetal heart rate pattern with accelerations that last ≥ 15 seconds and peak ≥ 15 bpm above baseline is considered reactive or reassuring. The fetal nonstress test is reactive from 32 weeks to term if there are two or more fetal heart rate accelerations reaching a peak of at least 15 bpm above the baseline rate and lasting at least 15 seconds from onset to return to baseline in a 20-minute period. A reactive test is reassuring of fetal well-being and is reassuring regardless of the length of observation time needed to demonstrate reactivity. The fetal nonstress test is the most common cardiotocographic method of antepartum fetal assessment. It is noninvasive and can be performed in any setting with an electronic fetal monitor. There is no direct risk of maternal or fetal injury associated with nonstress testing. Fetal nonstress tests are initiated when fetal neurologic maturity enables fetal heart rate acceleration, which typically occurs at 26 to 28 weeks, and the fetus is believed to be at increased risk of death. Testing is performed at daily to weekly intervals as long as the indication for testing persists. The frequency of testing is based on clinical judgment, taking into consideration whether the test is being performed to screen for fetal hypoxemia in a high-risk pregnancy or to monitor a fetus with suspected, but compensated, fetal hypoxemia.

24-year-old man presents to the emergency department with rectal pain for the past three days. The pain is exacerbated with movement, sitting, and defecation. He denies this ever occurring in the past. Physical exam shows swelling and erythema at the anal verge. A rectal examination demonstrates induration that can be palpated through the rectal wall. What is the most likely diagnosis? Anal fistula Internal hemorrhoid Perirectal abscess Pilonidal cyst

Correct Answer ( C ) Explanation: A perirectal abscess is typically characterized by pain and discomfort with bowel movements. They are almost always caused by obstruction of an anal gland causing infection and abscess formation. Individuals with Crohn's disease, ulcerative colitis, trauma, Hodgkin's disease, immunocompromise, or a history of radiation are more risk for developing abscesses. A complete blood count, if performed, may show leukocytosis. Tender inguinal adenopathy may also be present. Treatment should include incision and drainage. Typically, deep infections should be drained in the operating room. Antibiotics are typically not necessary after adequate drainage but should be considered in cases with associated cellulitis or in patients with co-morbidities.

Which of the following would an agoraphobic most likely have a fear of? Getting or having a specific illness Public speaking Public transportation Spiders

Correct Answer ( C ) Explanation: Agoraphobia is an anxiety disorder characterized by extreme anxiety in situations where the person perceives the environment to be dangerous, uncomfortable, or unsafe. Individuals describe avoiding situations for fear of experiencing panic symptoms and consequent embarrassment or feelings of helplessness. Individuals may fear being overwhelmed by symptoms of anxiety to the point that they lose control or die. Common agoraphobic situations include public transportation, waiting in line, crowds, grocery stores, shopping malls, restaurants, and wide-open spaces. These individuals may go to extreme, irrational lengths to avoid these situations. The fear of getting or having a specific illness (A) is called illness anxiety disorder. The fear of public speaking (B) is characterized as a social anxiety disorder. Social anxiety disorder (ie, social phobia) is a common disorder characterized by excessive fears of scrutiny, embarrassment, and humiliation in social or performance situations, leading to significant distress or impairment in functioning. The fear of spiders (D) is referred to as arachnophobia.

A 45-year-old woman presents with a painful tongue. Physical exam reveals decreased vibratory sensation. Laboratory studies are notable for a mean corpuscular volume of 112 fL and hypersegmented neutrophils. Chronic use of which of the following medications is most likely? Acetaminophen Amiodarone Omeprazole Prednisone

Correct Answer ( C ) Explanation: Chronic omeprazole use is a risk factor for the development of vitamin B12 deficiency. Vitamin B12, or cobalamin, is an essential biomolecule that is critical in DNA synthesis in hematopoietic cells. Meat and dairy products are the only dietary sources of vitamin B12 in humans. The minimum daily requirement of vitamin B12 is 6-9 mcg per day; the average Western diet contains 5-7 mcg. Causes of vitamin B12 deficiency include gastric abnormalities (e.g. pernicious anemia, gastrectomy), small bowel disease (e.g. Crohn's disease, ileal resection, malabsorption syndrome), pancreatitis, strict vegetarians and vegans, and drugs (e.g. biguanides, proton pump inhibitors, histamine 2 receptor antagonists). Vitamin B12 and folate deficiency both produce megaloblastic anemia but only vitamin B12 deficiency results in neurological symptoms. Neurologic symptoms are caused by defects in myelin formation due to unknown mechanisms. Patients with vitamin B12 deficiency may complain of paresthesias, numbness, weakness, dexterity loss, ataxia, impaired memory, and atrophic glossitis. Elevated mean corpuscular volume is the hallmark laboratory abnormality seen in vitamin B12 deficiency. Once vitamin B12 is suspected, serum B12 levels can be used to confirm the diagnosis. Treatment typically involves parenteral vitamin B12 although high-dose oral formulations are as effective.

33-year-old man with sinusitis presents for right-sided ear fullness, ear "popping," and a sense of muffled hearing for four weeks. He has tried over-the-counter ceruminolytics with no improvement. Physical exam shows bilaterally normal ears, and his exam is otherwise unremarkable. Which of the following is the most likely diagnosis? Cholesteatoma Chronic otitis media Eustachian tube dysfunction Tympanic membrane perforation

Correct Answer ( C ) Explanation: Eustachian tube dysfunction is the most likely diagnosis in this patient with several weeks of unilateral ear fullness and sense of impaired hearing. Eustachian tube dysfunction occurs when the eustachian tube, which normally opens only in swallowing and yawning, becomes less coordinated in its movements. As a result, air gets trapped within the middle ear and leads to development of negative pressure. The most common causes of eustachian tube dysfunction are viral upper respiratory infections and allergic rhinitis. When abnormalities are seen on physical exam, they might include retraction of the tympanic membrane and decreased tympanic membrane mobility. As noted in this patient, sinus congestion may be an associated factor. Medications that offer relief are treatments aimed toward correcting the imbalance in negative pressure, such as acute treatment with oral and intranasal decongestants and long-term management with intranasal corticosteroids. Patients should also be counseled to avoid activities such as air travel and underwater diving to minimize pressure changes during flares of eustachian tube dysfunction. A cholesteatoma (A) would typically be visualized on physical exam as a retraction pocket overlaying the tympanic membrane or a tympanic membrane perforation that exudes keratin debris. Chronic otitis media (B), or chronic middle ear infection, is more likely to present with purulent aural discharge, which is not present in this patient. A tympanic membrane perforation (D) usually presents as acute pain and may be seen as a hemotympanum on exam, which is also inconsistent with this patient's presentation.

22-year-old woman presents to your office with complaints of pelvic pain and vaginal discharge. She admits to having recent unprotected intercourse with a new partner, and her last menstrual period ended three days ago. Which of the following is the most appropriate pharmacologic treatment? Azithromycin Ceftriaxone Ceftriaxone plus doxycycline Metronidazole

Correct Answer ( C ) Explanation: Pelvic inflammatory disease (PID) is an acute infectious condition of the upper female genital tract that causes significant inflammation. The most common areas of infection include the uterus and fallopian tubes, although adjacent pelvic structures or areas in the abdomen may also be affected. Risk factors for PID include age younger than 25 years, multiple sexual partners, unprotected intercourse, and a past history of sexually transmitted infections (STIs). Neisseria gonorrheae and Chlamydia trachomatis are the pathogens most commonly identified in patients with PID. The most common presenting symptom is lower abdominal pain. Patients may also complain of abnormal bleeding, vaginal discharge, fever, chills, nausea, or vomiting, depending on the severity of disease. Physical exam findings include cervical motion tenderness, also referred to as chandelier sign. Delay in diagnosis and treatment can lead to sequelae such as infertility; therefore, empiric treatment for PID should be initiated in sexually active women younger than age 25 years or at risk for STIs who present with lower abdominal pain. Empiric, broad-spectrum coverage of the pathogens most likely to be causing the infection should be given. Outpatient treatment for women with mild to moderate symptoms of PID includes a regimen of ceftriaxone plus doxycycline.

A nine-month-old boy presents with fever, cough, coryza, and conjunctivitis for three days. He recently returned from a family trip to Pakistan 10 days ago. Physical exam reveals small, bluish-white papules with erythematous bases on the buccal mucosa. What is the most likely diagnosis? Kawasaki disease Rubella Rubeola Scarlet fever

Correct Answer ( C ) Explanation: Rubeola (measles) is a highly contagious, viral illness caused by a spherical, single-stranded RNA virus in the family Paramyxoviridae. The signs and symptoms include fever and general malaise that begins approximately 10 days after infection. These symptoms are followed by the development of Koplik spots, which consist of bluish-white spots on the buccal mucosa. These are pathognomonic of measles. The rash begins as the Koplik spots start to fade and appears as erythematous macules behind the ears, on the neck, and around the hairline. The rash spreads to the face, trunk, and extremities and fades in the same distribution as the initial appearance, eventually involving desquamation. Diagnosis is mainly clinical; however, there are some serologic tests available to detect antibodies. Treatment is generally supportive consisting of analgesics, antipyretics, and fluids. Administration of Vitamin A can reduce morbidity and mortality.

A 51-year-old man presents to the outpatient clinic complaining of a painless rash to his bilateral palms and soles for the last four weeks. He denies pain, odynophagia, arthralgias, cough or constitutional symptoms. He takes no medications. His physical exam is negative with the exception of generalized nontender lymphadenopathy and a diffuse macular rash with some fine scaling on bilateral palms and soles as seen in the image above. Which if the following is the most likely diagnosis? Erythema nodosum Hand, foot and mouth disease Secondary syphilis Stevens-Johnson syndrome

Correct Answer ( C ) Explanation: Secondary syphilis, caused by Treponema pallidum, is one of a few conditions that causes lesions involving the palms and soles. It most commonly occurs five to eight weeks after the hallmark of primary syphilis, a painless chancre, spontaneously heals although a small percentage still have a healing chancre at the time of secondary syphilis presentation. Because primary syphilis is commonly unnoticed by the patient, secondary syphilis is often the presenting stage of syphilis. The rash is bilateral and painless. It may be macular, papular, or occasionally pustular. Lesions may be pink, red, or brown. Some fine scaling may be associated with the lesions and surrounding skin. Eighty-five percent of patients with secondary syphilis present with diffuse nontender lymphadenopathy. Associated clinical manifestations of secondary syphilis include constitutional symptoms, alopecia, and uveitis. Rapid plasma reagin (RPR) is the test of choice for diagnosing syphilis at any stage. A single IM injection of benzathine penicillin G remains the treatment of choice for the primary, secondary, and early latent stages of syphilis, and no antibiotic resistance has been observed. Erythema nodosum (A) typically presents as a painful, erythematous, nodular lesion or series of lesions located primarily in the pretibial area

A 50-year-old man complains of increased fatigue and unintentional weight loss occurring over the last three months. He reports having a loss of appetite prior to the unintentional weight loss but has no other specific complaints. On physical exam, you palpate a mass above the umbilicus. Which of the following is the most likely finding? How should this mass be documented? Blumer's shelf Leser-Trelat sign Sister Mary Joseph nodule Virchow's nodes

Correct Answer ( C ) Explanation: Sister Mary Joseph nodule is a firm periumbilical mass caused by the presence of metastatic cancer. The majority of Sister Mary Joseph nodules arise from cancers of the gastrointestinal tract and ovaries. Gastric cancer is the most common cause in men and ovarian cancer in women. Primary cancer cells are thought to spread to the periumbilical region via arterial and venous networks or via the lymphatic draining system. The lesions are often the first and only presenting sign of abdominal or pelvic carcinoma. Lesions are typically < 5 cm, firm to hard and may be painful. The presence of a Sister Mary Joseph nodule is a poor prognostic sign with most patients dying within 10 months of its discovery. Blumer's shelf (A) is associated with cancers that have metastasized to the peritoneal cul-de-sac and is described as a palpable mass detected on rectal or vaginal exam. Leser-Trelat sign (B) can be an ominous sign of any internal malignancy most commonly caused by gastrointestinal adenocarcinoma. It is characterized by the sudden onset of diffuse seborrheic keratosis with an inflamed base. Virchow's node (D) is the presence of a left supraclavicular lymphadenopathy associated with a metastatic abdominal malignancy.

A 36-year-old man presents to the emergency room with mouth sores, eye pain, and fever. Upon questioning, he admits to recently starting allopurinol. Physical exam reveals an ill-appearing man with hemorrhagic erosions on his vermilion border and severe conjunctivitis. Approximately 35% of his skin is sloughing, although his palms and soles are spared. Which of the following is the most likely diagnosis? Erythema multiforme Staphylococcal scalded skin syndrome Stevens-Johnson syndrome Toxic epidermal necrolysis

Correct Answer ( D ) Explanation: This man most likely has toxic epidermal necrolysis. Toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS) are a spectrum of severe mucocutaneous reactions characterized by extensive necrosis and epidermal detachment. Stevens-Johnson syndrome is defined as < 10% body surface involvement. TEN involves > 30% of the body surface area. SJS is more common than TEN. SJS and TEN are commonly induced by drugs and infections. Some of the drugs most frequently associated with SJS and TEN include allopurinol, anticonvulsants, sulfonamide antibiotics, and certain nonsteroidal anti-inflammatory drugs. SJS and TEN are 100-times more common in human immunodeficiency virus-positive individuals. SJS and TEN are thought to be caused by cell-mediated reaction against keratinocytes, which leads to massive apoptosis. High fever, malaise, and myalgias typically precede mucocutaneous lesions by one to three days. Key clinical features of SJS/TEN include mucositis, skin tenderness, and blistering. Skin lesions are often symmetric and begin on the face and trunk before spreading to the extremities. The scalp, palms, and soles are typically spared. 90% of patients with SJS/TEN have mucosal involvement. Anemia and lymphopenia are common laboratory abnormalities seen in SJS/TEN. Treatment of SJS/TEN involves withdrawing any potentially causative drugs, wound care, fluid and electrolyte management, nutritional support, pain control, and monitoring for secondary infections. Patients with SJS/TEN often require care in a burn unit. Sepsis is one of the main causes of mortality. Erythema multiforme (A) is characterized by target-like lesions that consist of three concentric zones. Lesions typically begin on the extremities and spread centrally. Herpes simplex virus is the most common causative agent. Staphylococcal scalded skin syndrome (B) is usually seen in neonates and infants. Staphylococcal scalded skin syndrome (SSSS) typically presents with generalized erythema that quickly progresses to blister development and desquamation. Mucous membranes are spared in SSSS. Histologically, only the upper layer of the epidermis is involved in SSSS, in contrast to SJS/TEN, which involves full thickness epidermal necrosis. Stevens-Johnson syndrome (C) and TEN are considered to be variants of the same disease, however this patient had 35% of his skin sloughing. This is consistent with TEN, not SJS.

A three-year-old previously healthy boy presents to the emergency department with a chief complaint of sudden onset of wheezing and coughing. He was playing by himself in a separate room when he suddenly started to cry out for his babysitter. What is the most likely diagnosis? Acute bronchiolitis Asthma Croup Foreign body aspiration

Correct Answer ( D ) Explanation: Foreign body aspiration is the most likely diagnosis in an unwitnessed patient who has a sudden onset of wheezing and coughing. Aspiration of a foreign body is more common in infants and children and should always be suspected in an unsupervised child if they are in sudden respiratory distress. Signs and symptoms include wheezing, coughing, stridor, hoarseness, and complete airway obstruction, which may lead to cyanosis and even altered mental status. An expiratory chest X-ray may demonstrate a mediastinal shift away from the lung containing the foreign body or may demonstrate hyperinflation in the region distal to the foreign body. Diagnostic and therapeutic test of choice is a rigid bronchoscopy as this will provide a definitive diagnosis as well as allow removal of the foreign object

A patient presents with hearing loss involving the right ear. The Weber test lateralizes to the right ear. The patient notes hearing better when the tuning fork is on the mastoid during the Rinne test. Which of the following is the likely cause of his hearing loss? Furosemide use Meniere's disease Mumps Otitis media

Correct Answer ( D ) Explanation: Hearing loss can be divided into conductive loss due to a problem localized to the external ear, tympanic membrane, or ossicles and sensorineural loss which is caused by a problem with the cochlea, auditory nerve, or central auditory processing. The Weber and Rinne tests can help to differentiate between the two possible causes of hearing loss. The Weber test is performed by placing a vibrating tuning fork on the patient's forehead. Patients with normal hearing should hear it equally well in both ears. If the sound is heard better in one ear it indicates either a conductive loss in that ear or a sensorineural loss in the opposite ear. The Rinne test is performed by placing a vibrating tuning fork on the mastoid and then moving it to the entrance of the ear canal. A patient with a conductive loss will hear it better when the fork is on the mastoid, whereas a patient with normal hearing will hear it better when the fork is at the entrance of the canal. This patient has evidence of a conductive hearing loss. Common causes include otitis media, serous otitis, and cerumen impaction.

A 62-year-old female with a history of congenital long QT syndrome presents to the emergency room complaining of fatigue and a racing heart. She is just getting over an acute gastrointestinal infection with vomiting and diarrhea. She is placed on the cardiac monitor as seen above. Which of the following is the most appropriate next step in management? Defibrillation Intravenous adenosine Intravenous atropine Intravenous magnesium sulfate

Correct Answer ( D ) Explanation: Intravenous magnesium sulfate is first-line therapy in patients with hemodynamically stable torsades de pointes (TdP). TdP is a type of polymorphic ventricular tachycardia. Torsades de pointes occurs in patients with acquired or congenital long QT interval syndrome. A prolonged corrected QT is generally defined as > 0.45 seconds in adult males and > 0.47 seconds in adult females. Common causes of acquired long QT syndrome include hypokalemia, anorexia nervosa, antiarrhythmic drugs, macrolide antibiotics, hydroxyzine, methadone, certain antipsychotics, certain antiemetics, and diuretics due to electrolyte changes. Females are at a higher risk for drug-induced long QT. Other risk factors include bradycardia, impaired renal function, underlying heart disease, ischemic stroke, and advanced age. The diagnosis of torsades de pointes is made primarily on electrocardiogram findings (ECG). The classic ECG findings are a rhythm > 100 beats per minute and frequent variation in the QRS axis and morphology. The name torsades de pointes comes from the twisting of QRS complexes around the isoelectric line. Urgent defibrillation is the first-line therapy for hemodynamically unstable patients with torsades de pointes. Intravenous magnesium sulfate and stopping the offending drug are first-line therapy in the treatment and prevention of torsades de pointes. The woman in the question most likely has hypokalemia due to vomiting and diarrhea, which in addition to her congenital long QT syndrome has caused torsades de pointes.

A 48-year-old woman presents with weakness that has progressively worsened over the last several weeks. An autoimmune myopathy is suspected, and autoantibody tests are ordered. Anti-Jo-1 and rheumatoid factor (RF) are positive. Which of the following physical exam findings is most consistent with the diagnosis? Exercise-induced muscular cramping Heliotrope rash and a "shawl sign" Presence of scapular winging Proximal muscle weakness of the hip flexors

Correct Answer ( D ) Explanation: Proximal weakness of the hip flexors and the deltoids bilaterally is a symptom of polymyositis. Many patients will complain of progressively worsening weakness in the proximal muscles over a period of weeks or months. They will often describe this as difficulty getting out of a chair without using the armrests or as difficulty washing their hair in the shower. Polymyositis is an autoimmune myopathy that typically affects individuals over the age of 45. Approximately 30 percent of patients will test positive for Anti-Jo-1 autoantibody. A small percentage of patients may also have a positive rheumatoid factor. The mainstay of therapy is reducing inflammation through immunosuppression and increasing quality of life through physical therapy and exercise to increase muscle strength and endurance.

A 63-year-old man presents for hoarseness, which has been worsening over six months. He works as a landscaper, and his past medication history is significant for hypertension and smoking since age 14. His exam is unremarkable except for a raspy voice quality. Which of the following initial steps is most appropriate? Advise one to two weeks of strict voice rest Empiric trial of a proton pump inhibitor Prescribe Augmentin Referral for laryngoscopy

Correct Answer ( D ) Explanation: Referral to otolaryngology for a laryngoscopy is most appropriate for this patient, whose chronic hoarseness may indicate laryngeal or lung cancer. This possibility should always be entertained in patients who present with hoarseness beyond two weeks duration, and patients who have a history of tobacco use. However, most cases of acute laryngitis are fairly benign in nature, and typically occur in the setting of an upper respiratory infection. These patients usually have resolution of hoarseness within two weeks. However, these patients should be cautioned to avoid vigorous voice use until their voice returns to normal. This is to minimize the risk of developing traumatic vocal cord hemorrhage or polyps, which can lead to prolonged courses of laryngitis. Another common cause of laryngitis is gastroesophageal reflux (GERD). Patients with chronic hoarseness, in addition to cough, throat clearing, or post-nasal drip, should be considered for GERD that is affecting the larynx, known as laryngopharyngeal reflux. These patients may see improvement of symptoms after three to six months on a maximal daily dose of a proton pump inhibitor. Regardless, chronic laryngitis should not be assumed to be benign until other causes, such as tumors, nodules, or spastic conditions of the larynx, are ruled out.

A 45-year-old woman presents with several months of a worsening, daily cough that recently resulted in hemoptysis. She also endorses frequent episodes of diarrhea, hives, and "hot flushes." A physical exam is normal with the exception of focal wheezing over her right upper lobe. Which of the following interventions is typically curative of her most likely condition? Inhaled aminoglycoside antibiotics Inhaled corticosteroids Long-acting inhaled bronchodilators Surgical resection

Correct Answer ( D ) Explanation: Surgical resection of the lesion generally gives patients very favorable outcomes when managing bronchial carcinoid tumors, the most likely diagnosis in a patient with these symptoms. Bronchial carcinoid tumors commonly cause persistent coughing with hemoptysis and focal wheezing. As these tumors begin to secrete hormonal mediators, they may cause carcinoid syndrome during which symptoms can include diarrhea, flushing, head and neck edema, bronchospasm, or hives. Specific manifestations depend on the type of hormone released, because this can vary. Carcinoid tumors should also be suspected in patients with recurrent pneumonia. Most diagnosed carcinoid tumors grow in the central bronchi. Peripherally located bronchial carcinoid tumors are rare and usually do not produce symptoms. Suspicion of a bronchial carcinoid tumor should prompt work-up with imaging. A CT scan may help localize the lesion and assess growth over time. Octreotide scintigraphy can also aid in localization. Fiberoptic bronchoscopy usually allows for biopsy in centrally located tumors. However, bleeding often complicates biopsy, since these tumors are generally very well vascularized. Though bronchial carcinoid tumors rarely metastasize, they commonly compromise respiratory function through bleeding and airway obstruction. These tumors are often resistant to radiation and chemotherapy. Fortunately, surgical excision generally gives a favorable prognosis.

An eight-year-old Caucasian boy is brought by his mother to clinic because of a rash on his chest and back. The mother noticed the rash as he was playing outside with his shirt off. The boy says that the rash might have been present for a few months now and he would experience occasional itching. He has no history of atopy. On physical examination there are multiple mildly erythematous macules, patches, and thin plaques on the neck, chest and back. Which of the following is the most likely diagnosis? Pityriasis alba Pityriasis rosea Seborrheic dermatitis Tinea versicolor

Correct Answer ( D ) Explanation: The boy has skin findings that are consistent with tinea versicolor. Tinea versicolor (or pityriasis versicolor) is a common superficial fungal infection. The causative organisms are saprophytic, lipid-dependent yeasts in the genus Malassezia. The term "versicolor" refers to the variable changes in cutaneous pigmentation that may occur in this disorder. The macules, patches, and thin plaques of tinea versicolor can be hypopigmented, hyperpigmented, or mildly erythematous. In light-skinned individuals, hyperpigmented tinea versicolor is often light brown. Hyperpigmented tinea versicolor may present as dark brown to gray-black macules and patches in those with dark skin. A fine scale is often present on affected skin, which becomes more apparent when the lesion is scraped for microscopy. Individual lesions are typically small, but frequently coalesce into larger patches. While most patients are asymptomatic, some complain of mild pruritus. Although spontaneous remission has been reported, the disorder can be persistent if untreated. The variable clinical features of tinea versicolor and the existence of other skin disorders with similar findings make it preferable to confirm the diagnosis with a potassium hydroxide (KOH) preparation. Both hyphae and yeast cells are evident in a pattern that is often described as "spaghetti and meatballs". Additionally, in approximately one-third of cases, examination with a Wood's lamp will reveal yellow to yellow-green fluorescence. Pityriasis alba (A) is a mild form of eczematous dermatitis that presents with hypopigmented macules and small patches on the face, and less frequently on the upper extremities. Fine scale may be visible. The disorder is most common in children with an atopic history. Pityriasis rosea (B) presents with inflammatory macules and small patches in a "Christmas tree-like" distribution on the trunk. A larger herald patch that precedes the widespread eruption is often noted. Lesions are erythematous and exhibit a collarette of scale. Seborrheic dermatitis (C) on the trunk is usually more erythematous than tinea versicolor, and typically has thicker scale. Patients often exhibit other areas of involvement such as the scalp, eyebrows, and nasolabial folds.

A five-year-old girl is brought by her mother to the clinic because of bumps on her face. For the past few days, she had three red bumps below her nose that later became filled with fluid with redness on the surrounding skin. The mother is worried that the bumps seem to be getting worse. On physical examination, there are multiple areas of perinasal erythema, erosions, and gold-colored crusts. There is no fever and no lymphadenopathy noted. Which of the following is the most likely diagnosis? Acne vulgaris Contact dermatitis Eczema herpeticum Impetigo

Correct Answer ( D ) Explanation: The girl has history and examination findings that are suspicious for impetigo. Impetigo is a contagious superficial bacterial infection observed most frequently in children ages two to five, although older children of any age and adults may also be affected. The infection usually occurs in warm, humid conditions and is easily spread among individuals in close contact. Risk factors include poverty, crowding, poor hygiene, and underlying scabies. Non-bullous impetigo is the most common form of impetigo. Lesions begin as papules that progress to vesicles surrounded by erythema. Subsequently, they become pustules that enlarge and rapidly break down to form thick, adherent crusts with a characteristic golden appearance. This evolution usually occurs over about one week. Lesions usually involve the face and extremities. Multiple lesions may develop but tend to remain well localized. Regional lymphadenitis may occur, although systemic symptoms are usually absent. The diagnosis of impetigo often can be made on the basis of clinical manifestations. A Gram stain and culture of pus or exudate is recommended to identify whether Staphylococcus aureus or a beta-hemolytic Streptococcus is the cause. However, treatment may be initiated without these studies in patients with typical clinical presentations.

A five-year-old boy presents with severe vigorous coughing fits followed by deep, high-pitched inspiration. What phase of the underlying disease is this patient most likely experiencing? Catarrhal phase Convalescent phase Early phase Paroxysmal phase

Correct Answer ( D ) Explanation: The paroxysmal phase of pertussis is defined as a paroxysmal cough of severe vigorous coughing during expiration, followed by a vigorous inspiration that causes a "whooping" sound. Pertussis is also known as "whooping cough" and is caused by Bordetella pertussis. The disease course is divided into three phases: the catarrhal phase, the paroxysmal phase, and the convalescent phase. The paroxysmal phase typically occurs in the second week of illness and can last up to three months if left untreated. The coughing may be worse at night and is triggered by deep breathing as initiated by yawning, laughing, yelling, or exercising. Pertussis can affect all ages but most commonly affects infants and children. Treatment includes supportive care and the use of a macrolide antibiotic (e.g., azithromycin) to shorten the duration of symptoms. Catarrhal phase (A) is the first phase of the disease course of pertussis and is characterized by nonspecific symptoms such as generalized malaise, cough, and rhinorrhea. Early signs of pertussis that can occur in this phase include excessive lacrimation and conjunctival redness. Fever is uncommon, and this phase typically lasts one week. The convalescent phase (B) is the final phase of pertussis and is defined as the gradual reduction of the frequency and severity of the cough. This phase typically lasts two to four weeks. Early phase (C) is not one of the three phases of pertussis.

A 24-year-old woman was snowboarding when she fell onto her right wrist. On physical examination, a positive scaphoid compression test is elicited, but wrist X-rays are negative for fracture. What is the best initial treatment for this patient? Follow up in one month for repeat imaging Non-steroidal anti-inflammatory medication Referral to an orthopedic surgeon Thumb spica splint with follow-up in 10 days

Correct Answer ( D ) Explanation: The patient should be placed in a thumb spica splint and provided with follow-up in 10 days; this is the most appropriate initial treatment for a patient exhibiting signs and symptoms of an occult scaphoid fracture. The typical sign of a scaphoid fracture is pain over the anatomic snuffbox or the dorsal web space between the thumb and pointer finger. Compression of this space elicits a positive scaphoid compression test. X-rays of the wrist, including anteroposterior, lateral, and scaphoid views, must be performed. Scaphoid fractures may not reveal themselves on initial imaging, and therefore, it is imperative that the imaging be repeated in 10 to 14 days from the initial injury. The unique blood supply to the scapula leads to risk of avascular necrosis if a fracture is not treated properly with immobilization and early detection. Because the majority of scaphoid fractures will heal with immobilization, if there is any suspicion of a fracture without radiographic evidence, the injury should still be treated as a fracture until follow-up imaging is performed. Therefore, a thumb spica splint with follow-up is the best initial treatment.

A 60-year-old woman presents to your office with complaints of bilateral lower extremity pain that worsens throughout the day with prolonged standing. Physical exam reveals distended veins in both legs distal to the knees. Which of the following is the most appropriate diagnostic test to confirm the suspected diagnosis? Ankle-brachial index Computed tomography Direct contrast venography Duplex ultrasound

Correct Answer ( D ) Explanation: Varicose veins are a form of chronic venous disease characterized by dilated, elongated subcutaneous veins. Women are affected more than men, and prolonged standing is a risk factor for their development. Symptoms of varicose veins include pain or tenderness in the lower extremities, pruritus, burning sensations, leg cramps, paresthesias, edema, and skin changes. The physical exam of the venous system is difficult, and examination of the superficial system is used as a guide to the deep system. Visible distension of the veins generally indicates the presence of chronic venous disease. Duplex ultrasound is the standard imaging modality used in the diagnosis of varicose veins and other venous disorders due to its accuracy and cost, and it is noninvasive. Initial treatment of varicose veins is with conservative measures, including leg elevation and compression stockings. The ankle-brachial index (A) is used to exclude arterial disease in patients with symptoms of claudication or ulceration. Computed tomography (B) does not play a role in the diagnosis of varicose veins or other chronic venous diseases. Direct contrast venography (C) is considered the "gold standard" for diagnosing deep vein thrombosis but has been essentially replaced by duplex ultrasound due to the invasive and labor intensive nature of the procedure

Hyperuricemia is most likely in which of the following patients? A 29-year-old woman with human immunodeficiency virus currently taking indinavir A 36-year-old man with tuberculosis currently taking rifampin A 41-year-old man with Burkitt lymphoma currently receiving chemotherapy A 55-year-old woman with breast cancer currently undergoing radiation therapy

orrect Answer ( C ) Explanation: Chemotherapy for high-grade lymphomas (especially Burkitt lymphoma) and leukemias can lead to tumor lysis syndrome. This phenomenon usually follows chemotherapy and leads to electrolyte abnormalities from the breakdown of dying cells, therefore a 41-year-old man with Burkitt lymphoma currently receiving chemotherapy is most likely to have hyperuricemia. It may also develop after steroid administration. This manifests with the classic quartet of hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia. Symptoms occur as a result of these metabolic derangements and begin within one to five days of initiating chemotherapy or radiation therapy. Management is aimed at prevention by delaying chemotherapy or radiation therapy if an underlying medical condition (e.g. renal failure) exists. For hyperuricemia, IV fluids, allopurinol, urine alkalinization, and electrolyte monitoring is indicated. Dialysis may be indicated based on severity of symptoms or toxic electrolyte levels.