V3, Block 4

You are evaluating an 18-year-old Caucasian male freshman starting pitcher on his college's baseball team. He is looking to bulk up without the side effects of androgenic anabolic steroids; he also wants to speed up tissue repair concerning his occasional elbow soreness. He has been taking 5 IU of recombinant human growth hormone (HGH) orally once per day for 4 months in combination with a training program emphasizing the use of moderate weights. While he believes he appears more muscular, he is uncertain whether this regimen is safe and asks for your opinion. Past medical history is unremarkable and there is no history of tobacco, alcohol, or street drug use. Growth and development have been normal and immunizations are current. Vital signs are normal. Examination is unremarkable. No elbow pathology was noted. Muscle mass appears slightly greater than average. How would you address his concerns? A. "HGH has been shown to improve on-field performance." B. "There is no concern regarding the safety of HGH, and it is a legal substance for use in competition." C. "While HGH is legal for use in competition, concerns regarding safety exist." D. "HGH poses significant health risks and has been banned by many athletic regulatory agencies." E. "Intramuscular administration of HGH should be performed under a physician's supervision."

"HGH poses significant health risks and has been banned by many athletic regulatory agencies." Human growth hormone (HGH) is a powerful anabolic agent that promotes bone growth in children and adolescents, increases muscle mass, and contributes to the regulation of water, carbohydrate, and lipid metabolism, among other functions. As a purported performance-enhancing drug (PED), it is claimed to further increase lean muscle mass, decrease fat stores, quicken healing of soft tissue injuries, and improve overall athletic performance; however, claims of improved overall athletic performance have not been substantiated.

A child crawls up stairs, builds a tower of 3 cubes, follows simple commands, and hugs his parents. They cannot yet walk up and down stairs one step at a time, build a tower of 7 cubes, or use a spoon well. What is the age of the child? A. 6 months B. 15 months C. 24 months D. 30 months E. 36 months

15 months; The concept of developmental milestones highlights how complex skills build on simpler ones. Development in each of the 4 domains (gross motor, fine motor, cognitive, and emotional) affects functioning in all of the others. An average 15-month-old can crawl up stairs, build a tower of 3 cubes, follow simple commands, and hug their parents.

An 11-year-old girl with no significant past medical history presents with an increase in the frequency of her nosebleeds. She has experienced 3 episodes in the last week. Her mother was able to control and stop the bleeding by applying direct pressure to her external nasal area. Past medical history shows no significant issues with bleeding discrepancies or coagulopathies; she had a tonsillectomy when she was 8 years old; there were not any postoperative complications. Physical examination reveals a raw and irritated anterior right nare; the presence of dried crusted blood is noted. What is the most likely cause of this patient's anterior epistaxis? A. digital trauma B. deviated septum C. genetic clotting disorder D. atherosclerotic disease E. hypertension

A. Digital trauma; Anterior epistaxis is an extremely common presenting complaint in pediatric patients in a primary care office. Common factors are usually due to local trauma that predisposes patients to developing anterior epistaxis; they include (but are not limited to) nose digital trauma (nose picking), forceful nose-blowing/rubbing, administration of supplemental nasal oxygen, or low humidity.

A woman presents with an otherwise healthy 12-month-old boy because she noticed that his eyes that appear to be crossed as well as each one being different colors. The mother sheepishly admits to smoking for about 10 years and she smoked during her entire pregnancy. She is worried because she had a brother die when he was 3 because he had a tumor in both his eyes. Physical exam reveals heterochromia iridis and leukocoria bilaterally, as well as evidence of severe strabismus. What is the main risk factor for the most likely diagnosis of this child? A. Hereditary B. Leukocoria C. Smoking D. Heterchromia iridis E. Strabismus

A. Hereditary; The correct response is heredity. The child most likely has inherited retinoblastoma. Retinoblastoma is a rapidly developing cancer that generally affects children under 6. It is most commonly diagnosed in children 1-2 years old. Genetic counseling is especially important when more than one family member has had the disease or if the retinoblastoma occurs in both eyes.

A 38-year-old male patient with HIV develops diabetes; he takes stavudine. What diabetes medication is most likely to exacerbate potential acid-base disorders of his antiviral therapy? A. Metformin B. Glyburide C. Glipizide D. Exenatide E. Insulin

A. Metformin; Lactic acidosis is a serious and potential complication of both metformin and stavudine use. Lactic acidosis is a form of elevated anion gap metabolic acidosis.

An 8-year-old boy presents with his father on a Sunday afternoon with left ear pain. His father reports that he had 2 ear infections as a baby, but he cannot remember in which ear. The visit occurs during the summer months, and the patient's father says that the boy has been swimming almost daily in a neighbor's pool. Physical examination of the ears bilaterally reveals left ear canal erythema and edema, and pain with manipulation of the left pinna. No other physical examination findings are abnormal. What is the most likely treatment? A. Neomycin/polymyxin B/hydrocortisone topical solution B. Clotrimazole 1% topical solution C. Ciprofloxacin oral suspension D. Triamcinolone 0.1% topical solution E. Amoxicillin oral suspension

A. Neomycin/polymyxin B/hydrocortisone topical solution; Neomycin/polymyxin B/hydrocortisone (Cortisporin) solution is the correct answer. In this case, the patient has the diagnosis of acute left bacterial otitis externa. Initially, removal of any desquamated epithelium and moist cerumen should be performed. Topical solutions are usually adequate to treat the infection and should be chosen based on the most likely causative organism. Bacterial cases of otitis externa are usually caused by Pseudomonas aeruginosa or Staphylococcal species. Cortisporin has broad-spectrum coverage, including a steroid to reduce inflammation. It is usually given 3-4 times daily for 7-10 days. This is not the first choice, however, if the patient has a perforation of the tympanic membrane in the infected ear.

A 43-year-old Caucasian woman presents with a 1-day history of burning sensation during urination and foul-smelling urine. She says that she has the habit of frequently voiding her bladder about once every 2-3 hours. She is hypertensive and on treatment with thiazides. She is sexually active with 1 partner (her husband); they use condoms for contraception. Fluid intake and blood glucose are normal. Leukocyte esterase dipstick test is positive, and urinalysis reveals 10 WBC/mL and bacteria. What is the most applicable risk factor for the patient's diagnosis? A. length of the urethra B. repeated voiding of the bladder C. condom use D. her hypertension E. treatment with thiazides

A. length of the urethra; The correct answer is the length of the urethra. The diagnosis in this patient is a urinary tract infection (UTI). The female urethra is shorter, about 4 cm, compared to the male urethra, which is 22.3 cm (mean) (SD 2.4 cm) in length. The short length favors easy ascent of uropathogens to the bladder. Other risk factors for UTI in women include recent sexual activity, urinary obstruction, instrumentation, and uterine or bladder prolapse.

A 41-year-old man presents with right upper quadrant pain. His pain began gradually, following a meal, but it has now become constant. He notes that he has had previous episodes of similar pain, but it has never been quite this severe. The pain radiates to his right shoulder and is worsened with inspiration. He has experienced nausea and vomiting, and he notes feeling chilled. Examination reveals an overweight man in moderate distress. He develops rigors during the physical exam. He has scleral icterus, and his skin has a yellow hue. Heart and lungs are clear. His abdomen is soft and non-distended with positive Murphy's sign. Vital signs reveal BP 109/62 mm Hg, pulse 112, respirations 18, and temperature 102.3°F. Laboratory studies include: WBC 15.66 k/uL Glucose 104 mg/dL Hemoglobin 15.5 g/dL BUN 11 mg/dL Hematocrit 43.80% Creatinine 1.05 mg/dL Platelets 128 k/uL Sodium 139 mmol/L Albumin 3.4 g/dL Potassium 4.3 mmol/L Total Bilirubin 6.3 mg/dL Chloride 102 mmol/L Conjugated Bilirubin 4.5 mg/dL CO2 27 mmol/L Alkaline Phosphatase 114 U/L Calcium 8.5 mg/dL AST 97 U/L Amylase 36 U/L ALT 132 U/L Lipase 23 U/L Total Protein 5.6 g/dL What is the most appropriate initial diagnostic study for this patient? A. Abdominal x-ray B. Abdominal MRI C. Abdominal ultrasound D. HIDA scan E. Liver biopsy

Abdominal ultrasound; The above patient is suffering from right upper quadrant pain, jaundice, and fever, which are all part of the Charcot triad associated with cholangitis. Cholangitis is defined as infection of the bile ducts. It typically occurs when the bile ducts are obstructed, leading to infection. Given his history of postprandial right upper quadrant pain, the patient likely has cholelithiasis. His laboratory data is suggestive of biliary obstruction. The best initial testing for gallstones is abdominal ultrasound. (Given that this patient has all three components of Charcot's triad as well as mildly elevated liver enzymes, some clinicians might also choose to proceed directly to ERCP, since this procedure is both diagnostic and therapeutic, and drainage of the bile ducts is a life-saving procedure in acute cholangitis. However, this is not one of the answer choices.)

A 32-year-old Hispanic woman, previously in good health, was brought to the emergency department by paramedics after she was found unresponsive in her home. It is unknown if she had a seizure. Past medical history is not significant, and she has no known allergies. She is not on any medications and is Gravida 4, Para 4, Ab 0. She is married and recently emigrated to the U.S. from Central America. Vital signs: temperature 100.4°F, pulse 112, respirations 24, blood pressure 110/62, O2 sat 96% on room air. Physical exam reveals a well-developed woman with obtunded mental status. Cardiac exam reveals normal S1 and S2 without rub, murmur, or gallop. Lungs are clear to auscultation and percussion. Spinal tap is thought to be contraindicated. The patient is admitted to the ICU. After consultation with specialists, a tentative diagnosis is made; the patient is treated with a therapeutic trial of medication. The following morning, the patient is found to be alert, oriented, and afebrile. Lab and imaging studies show: WBC - 17.2 K/mcL ESR - 25 mm/hr Hgb - 12.4 gm/dL Electrolytes - normal Hct - 37% BUN - 12 mg/dL Platelets - 305 K/mcL Creatinine - 1.2 mg/dL Neutrophils - 68% Pregnancy test - Negative Lymphocytes - 20% HIV immunoassay - Negative Monocytes - 2% Blood cultures - No growth (preliminary) Eosinophils - 10% EKG - NSR, 1 PAC Basophils - 1% Transthoracic Echocardiogram - Normal heart size and structure. Chest X-ray - Normal heart size. No infiltrates or edema. CT Brain without contrast - Multiple cystic lesions. Cyst with dot sign noted. MRI Brain with contrast - Multiple cystic lesions. Cyst with dot sign present. What is the treatment of choice (the successful therapeutic trial) for this patient's disease? A. Albendazole with IV prednisolone B. Heparin IV C. Interferon alpha 2-b D. Isoniazid, rifampin, pyrazinamide, and ethambutol E. Pyrimethamine with sulfadiazine

Albendazole with IV prednisolone; Albendazole with concomitant steroid therapy (dexamethasone or prednisolone) is currently the treatment of choice for neurocysticercosis of the brain parenchyma due to active lesions caused by larval forms of the pork tapeworm Taenia Solis. Neurocysticercosis, the most common parasitic disease of the brain worldwide, most commonly presents with seizure, but other neurologic manifestations (double vision, stroke, neuropsychiatric syndrome, or hydrocephalus) may occur. CT and MRI of the brain in this case showed multiple cystic lesions with a "dot sign", which represents larval cysts with scolex ("head").

A 70-year-old African American man presents with gradual but progressive dyspnea and fatigue on exertion. He notes difficulty in climbing stairs; there is associated lightheadedness, increased abdominal girth, and swollen bilateral lower extremities. He admits to chronic alcohol use, but he denies any heart disease, chest pain or pressure, diaphoresis, palpitations, a history of diabetes, cigarette smoking, or claudication. His physical exam reveals sinus tachycardia, bibasilar rales, a laterally-displaced PMI, an elevated JVP, an S3 gallop, a mitral regurgitation murmur, peripheral edema, and abdominal ascites. A bedside echocardiogram noted four-chamber dilatation, increased left ventricle end-diastolic diameter and volume, thinning left ventricle walls, left atrial enlargement, and limited mitral and aortic valve opening. What is correct regarding this patient? A. In temperate zones, Trypanosoma cruzi is the most common infectious etiology. B. There is no genetic association of this illness. C. Atrophy and hypertrophy of myocardial fibers occur histologically. D. Prolonged bradycardia is a known precipitant of acute episodes. E. Endomyocardial biopsy is an essential element in the diagnosis.

Atrophy and hypertrophy of myocardial fibers occur histologically; This patient's diagnosis is most consistent with dilated cardiomyopathy (DCM). Atrophy and hypertrophy of the myocardial fibers occur histologically.

A 45-year-old woman presents with worsening symptoms. She was diagnosed with idiopathic pulmonary hypertension about 2 years ago and she is on home oxygen therapy. She has longstanding fatigue and dyspnea; she is now experiencing worsening dyspnea with exertion, some swelling in her ankles, and the inability to breathe well when lying down. Although she has always been thin, she notes her weight has increased by 10 pounds in the last month. She denies fever and chills. The patient's vitals are shown in the table. Weight 152 lb Height 66" Pulse 95 Blood pressure 132/86 Temperature 98.4°F/36.9°C Pulse oximetry 91% On physical exam, the patient is in no apparent distress; she is using her portable oxygen by nasal cannula. Her ankles have visible edema, and her neck veins are mildly distended. Lung sounds are diminished bilaterally, but no rales or crackles are heard. A gallop is auscultated on her cardiac exam. What is the next most appropriate intervention for this patient? A. Call an ambulance for immediate transport to the emergency department. B. Initiate diuretics and refer to a pulmonologist this week. C. Initiate a macrolide antibiotic and cough syrup; follow up in 2 days. D. Prescribe an albuterol inhaler for use as needed when shortness of breath occurs. E. Send the patient to the hospital for immediate admission.

B. Initiate diuretics and refer to a pulmonologist this week; This patient with pulmonary hypertension (which may be progressing into cor pulmonale) needs specialist care. It would be most appropriate to initiate diuretics and refer her to a pulmonologist this week. Treatment medications for pulmonary hypertension are complex; they can include endothelin receptor antagonists, phosphodiesterase inhibitors, intravenous prostacyclins, and others.

A family friend calls you for medical advice. She just gave birth to her third child 1 week ago. She is worried after a nurse from the hospital called her. The nurse said the baby tested high on a newborn screening for phenylalanine and that she would set up an appointment at a specialty center for the family. Your friend could not remember the name of the disorder, but she was told that it could prevent the infant from normal neurological development if left untreated. The friend reports that her pregnancy was uncomplicated and that the infant appears healthy so far. No one in the infant's immediate family has any health problems. What will most likely be recommended treatment for the newborn's condition? A. Administration of growth hormone B. Cognitive behavioral therapy C. Dietary control D. Oxygen therapy E. Surgery

C. Dietary Control; This newborn most likely has phenylketonuria (PKU), which is an autosomal recessive metabolic disorder that causes abnormal metabolism of phenylalanine and results in elevated serum phenylalanine. Dietary control, primarily by restriction of phenylalanine, is the mainstay of treatment. PKU is rare and is diagnosed by routine newborn screening. A strict diet low in phenylalanine can prevent complications of the disease, and afflicted patients can lead a relatively normal life. Neurologic deficits, such as intellectual disability and seizures, can occur if untreated. If an afflicted patient does not adhere to the special diet, they may begin having cognitive deficits and/or seizures.

A 23-year-old woman presents with fatigue and the recent onset of a yellowing of her skin. Her physical examination is remarkable for the presence of splenomegaly. Laboratory results are as follows: TEST RESULTS Hematocrit 38 Hemoglobin 12.6 gm/dL RBC 3.3 x 106/µl MCHC37 Platelets 258,000/mm3 WBC 5.4 x 103/mm3 Neutrophils 57 Lymphocytes 37 Monocytes 4 Eosinophils 2 Basophils 0 Comments: Red blood cells are spherocytes. Red blood cells demonstrate increased osmotic fragility. What would be an appropriate treatment for this patient? A. Hemodialysis B. Phlebotomy C. Splenectomy D. B12 Injection E. Iron supplements

C. Splenectomy; Splenectomy can be used to treat hereditary spherocytosis This patient has hereditary spherocytosis. Consistent with hereditary spherocytosis are spherocytes on the peripheral blood smear, anemia, an elevated MCHC, increased osmotic fragility, and splenomegaly. The primary pathology is located within the red blood cell membrane that leads to the abnormal spherical shape of the cells. The abnormal red blood cells are subsequently removed by the spleen, resulting in increased hemolysis. In approximately 2/3 of the cases, hereditary spherocytosis is inherited in an autosomal dominant manner.

A 25-year-old male basketball player presents with acute onset shortness of breath associated with right-sided chest pain. The pain is unaffected by position and is worse with inspiration. He was grocery shopping when it started. He denies chest trauma. He had an upper respiratory infection earlier in the month that had resolved without incident. He smokes 1 pack of cigarettes per day and has no significant past medical history. On PE, he is afebrile; BP is 138/80 mm Hg, and pulse is 124; R is 24; and pulse oximetry is 94% on room air with mild respiratory distress. Trachea is midline. Lungs are clear to auscultation bilaterally with no wheezing or rhonchi; tactile fremitus and percussion are equal throughout posterior lung fields. Heart is tachycardic with normal S1 and S2, no murmur, rubs, or gallops. What is the most likely diagnosis? A. Pericarditis B. Pulmonary embolism C. spontaneous pneumothorax D. Acute chest syndrome E. community-acquired pneumonia

C. spontaneous pneumothorax; The patient has a primary spontaneous pneumothorax (PSP). There is a higher incidence in male patients and it usually occurs in age 20-40. PSP is heavily associated with smoking. Patient presentation and physical exam findings will vary depending on the size of the pneumothorax. Most commonly, patients present with unilateral chest pain, dyspnea, and cough occurring with minimal activity in addition to tachycardia and tachypnea. A large PSP may become a tension pneumothorax, and the patient may have a deviated trachea and no breath sounds on affected side with increased resonance to percussion with respiratory distress and shock. Imaging of choice for a PSP is a chest radiograph, usually an upright inspiratory film. A white visceral pleural line is diagnostic. Supine or lateral decubitus views can also be used.

A 55-year-old woman presents with a 2-month history of gross hematuria. She states she has no pain with urination, but the hematuria is persistent. Upon questioning, she states that she does have some progressively worsening left flank pain. The pains are not debilitating, but they are nagging. She has no chronic medical problems. She admits to a 50 pack-year smoking history, and she states she is currently retired from her job as a teacher. Vital signs are within normal limits, and physical exam reveals a left side abdominal mass. Urine dipstick only shows too numerous to count RBCs, and urine cultures are negative. What test would best confirm your diagnosis? A. Kidney, ureters, bladder X-ray B. Intravenous pyelogram C. Cystoscopy D. CT scan with and without contrast kidney protocol E. MRI of abdomen and pelvis

CT scan with and without contrast kidney protocol; Hematuria is the most common presenting sign of urinary tract cancer. Silent or painless hematuria suggests tumor or renal parenchymal disease. Renal cell carcinoma can present with flank pain, hematuria, persistent back pain, and an abdominal mass; also, it can be found incidentally on CT scan. So the clinical picture points to cancer, with renal cell carcinoma as the most likely diagnosis. The study of choice to evaluate the kidneys for masses is a CT scan with and without contrast kidney protocol. Any mass that enhances with IV contrast should be considered RCC until proven otherwise.

A 22-year-old primiparous woman at 10 weeks gestation presents to the office. Though she currently works as a graphic design consultant, she was a competitive swimmer in college and still maintains a regimen of endurance and resistance training 3-4 times per week. She has had no vaginal spotting, and the pregnancy is progressing normally. She would like to continue with her exercise routine but is concerned about reports from friends that exercise has an adverse effect on pregnancy. Past medical history is otherwise unremarkable. Vital signs are normal, and examination is consistent with a 10-week gestation. What advice would you give? A. Adopt a sedentary lifestyle during pregnancy. B. Vigorous activity increases the risk of miscarriage. C. Exercise increases the risk of prematurity. D. Continue current exercise regimen. E. Limit activity to normal activities of daily living.

Continue current exercise regimen;Exercise during pregnancy provides benefits to both the mother and child. Pregnant women should engage in 2.5 hours of moderate intensity exercise per week during pregnancy. They may safely engage in vigorous exercise as well. Maternal benefits include increased pain tolerance, lower total weight gain, and a decreased risk of preeclampsia and gestational diabetes. Fetal benefits include decreased incidences of preterm birth, cesarean section, and large-for-gestational-age births. These recommendations apply to a normal pregnancy.

A 64-year-old man presents with a 3-day history of insidious chest pain. He has a past medical history of hypertension, coronary artery disease, and poorly controlled left ventricular congestive heart failure due to medication noncompliance. Pain is made worse when he takes a deep breath and when he coughs. He denies any relation of pain to position, activity, or food intake. He denies fever, chills, palpitations, sputum production, wheezing, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, and peripheral edema. He denies any relation of pain to position, activity, or food intake and is able to perform his normal daily activities. His physical exam reveals no respiratory distress, cyanosis, or accessory muscle usage. There are bibasilar thoracic friction rubs upon inspiration, an absence of lung fremitus, dullness to percussion, and reduced lung sounds. A chest X-ray is performed. What health maintenance approach should be recommended at this time? A. Aggressive restriction of dietary fat intake B. Explaining the necessity of an emergent and repeated thoracentesis C. Counseling regarding compliance with heart failure medications D. Prophylactic use of broad-spectrum antibiotics E. No need to reevaluate onset of shortness of breath in this patient's chronic condition

Counseling regarding compliance with heart failure medications; The patient should be counseled regarding compliance with heart failure medications. This patient's underlying condition is a transudative pleural effusion, most likely due to poorly controlled congestive heart failure. Transudative effusions are usually managed by treating the underlying medical disorder. Observation of pleural effusion is reasonable when benign etiologies are likely, as in the setting of overt congestive heart failure, viral pleurisy, or recent thoracic or abdominal surgery.

A 68-year-old man with a past medical history of type 2 diabetes mellitus, hypothyroidism, and hyperlipidemia presents with intermittent bouts of moderate to severe "squeezing, pressure, and tight" left-sided chest pain that has been occurring over the last 3 months. Additionally, he admits to associated shortness of breath and nausea during these episodes, which are provoked upon exposure to cold weather, during times of emotional stress, and following the consumption of a meal. Chest pain lasts approximately 10-15 minutes and resolves spontaneously. He denies diaphoresis, fever, chills, abdominal pain, reflux, regurgitation, diarrhea, cough, and pleurisy. What pharmacologic agent has a significantly high risk of adverse effects and even mortality in this patient? A. Sublingual nitroglycerin B. Enteric-coated aspirin C. Atorvastatin (Lipitor) D. Immediate release nifedipine (short-acting) E. Metoprolol (Lopressor)

D. Immediate release nifedipine (short-acting); This patient's most likely diagnosis is angina pectoris. Short-acting agents, such as short-acting nifedipine, should be avoided due to increased cardiovascular and mortality risks in some patients, as well as significant adverse effects such as reflex tachycardia. Amlodipine, oral nicardipine, and long-acting nifedipine are effective treatment options for chronic stable angina.

A 45-year-old woman presents with a 2-week history of daily headaches. She describes feeling as if a rubber band is around her temples, making it extremely hard to concentrate when trying to complete tasks at work or at home. Further questioning reveals that the patient is under a significantly increased amount of stress at work due to a new, extremely rigid boss who started last month. She denies any auras, nausea, vomiting, or specific neurological issues, but she does admit to some sensitivity to excessive noise and glaring lights. She has always treated these with two 500 mg tablets of acetaminophen as needed, but this current episode has had little or no relief with this regimen. What is the most likely diagnosis? A. Cluster headache B. Migraine headache C. Post-traumatic headache D. Tension headache E. Giant Cell Arteritis headache

D. Tension Headache; the most likely diagnosis is tension headache. Tension headaches are the most common type of primary headache disorders, often referred to as stress headaches. Patients will describe pericranial tenderness, which is typically described as vice-like or tight and is exacerbated by emotional stress, fatigue, noise, or glare. The headaches are usually general, and they are not associated with focal neurological symptoms.

A 16-year-old boy with no significant past medical history presents to learn the results of a lipid panel that was performed. The lipid panel was ordered due to periorbital and extensor tendon xanthomas on the patient's body. The patient consumes a low-fat and low-calorie diet, and he exercises daily. He denies any bothersome symptoms, and his physical exam is otherwise unremarkable. What is the most likely mechanism for this patient's metabolic disorder? A. Increased production of HDL B. Undiagnosed diabetes mellitus C. Hypersecretion of triglyceride-carrying chlyomicrons from the small intestine D. reduction in the amount of LDL receptors on hepatocytes E. increased VLDL synthesis by the liver

D. reduction in the amount of LDL receptors on hepatocytes; LDL (low-density lipoprotein) is removed from the circulation by either LDL receptors on hepatocytes or by scavenger cells such as monocytes or macrophages. When there is a decrease in LDL receptors on hepatocytes, or when LDL levels exceed receptor availability, the amount of LDL that is removed by scavenger cells is greatly increased. The LDL receptors are deficient or defective in the genetic disorder known as familial hypercholesterolemia (type 2A). Patients with this primary hypercholesterolemia disorder may be heterozygotes or homozygotes, with homozygotes developing cutaneous xanthomas and myocardial infarctions in childhood.

A 74-year-old man presents with a 1-hour history of constant moderate to severe "squeezing, pressure, and tight" left-sided chest pain, accompanied by nausea. He has a past medical history of type 2 diabetes mellitus, hypothyroidism, and hyperlipidemia. He also has a 1-week history of similar recurrent chest pain about 10 minutes in duration; the pain occurs following exposure to cold weather and consumption of a meal. He denies fever, chills, abdominal pain, diarrhea, cough, pleurisy, and shortness of breath. What additional findings would be most consistent with his most likely diagnosis? A. The chest pain is relieved by sitting forward. B. This pain will be relieved with antacids and belching. C. Movement of the chest, trunk, and arms are provocative factors. D. Vomiting, diaphoresis, and weakness are associated findings. E. There is localized tenderness to the chest wall.

D. vomiting, diaphoresis, and weakness are associated findings; this patient's most likely diagnosis is acute myocardial infarction. His symptoms prior to this episode represent angina pectoris. Common symptoms associated with myocardial infarction include dyspnea, nausea, vomiting, diaphoresis, and weakness.

A 6-year-old boy presents for evaluation of what his mother describes as "odd behaviors." The family recently moved and the boy started public school. Although the mother had asked her previous health provider for testing, none was done. She now reports that her son's teacher agrees that the child exhibits odd behaviors. The boy has limited language skills. Even when he correctly verbalizes words, the content often does not make sense. He also repeats words and phrases. He does not socialize appropriately. He prefers to watch his hand wave in front of his face repeatedly. He seems particularly obsessed with rubber bands, collecting them and studying them. He does not play with his toys. The child throws tantrums when his daily routine is disrupted and covers his ears when there is even a moderately loud noise. The mother has noted these problems since his infancy. The boy is an only child. The mother denies pregnancy or birth complications. He has been healthy (other than common childhood illnesses), with no identified health conditions. The history is not suspicious for abuse, and the psychosocial environment appears stable. The mother reports she has an uncle with some type of intellectual disability, but she does not know any details. On physical exam, the same behavioral abnormalities are observed, but the remainder of the exam is normal. What test would be most appropriate for the evaluation of this boy's condition? A. DNA test for fragile X syndrome B. Karyotyping for trisomy 21 C. MRI or CT of the head D. Rubella antibody testing E. Sweat chloride test

DNA test for fragile X syndrome; This boy's behaviors suggest an autism spectrum disorder (which includes Asperger syndrome). Autistic disorder is characterized by impaired social functioning, communication/language problems, and restricted and/or repetitive behaviors. There is no laboratory or imaging test to confirm autistic disorder, but the patient should be evaluated for other similar disorders, especially with a family history of intellectual disabilities. A DNA test for fragile X syndrome would be appropriate, as about 1/4 of those with fragile X have autistic disorder. Fragile X syndrome is the most common genetic disease associated with intellectual disabilities; it is most often seen in male patients. Affected individuals may appear physically normal or have prominent foreheads, jaws, and ears. Young boys may have macroorchidism after puberty.

A healthy 37-year-old woman sustained a hairline fracture of the left tibia. Her leg is put in a cast and immobilized. Six weeks later, the cast is removed from her leg. A repeat X-ray shows healing of the fracture line. What histological changes would be most likely to be observed in this patient's gastrocnemius muscle? A. Increased fibrosis in the muscle tissue B. Increased fat deposition in the muscle C. Decrease in mitochondrial enzyme activity D. Increase in calcium levels E. Increase in number of satellite cells

Decrease in mitochondrial enzyme activity; Due to long-term restriction of activity, the gastrocnemius muscle is expected to undergo disuse atrophy. The muscle fibers decrease in size and there is a decrease in the number of myofibrils. Histologically, there is a decrease in mitochondrial enzyme activity, signaling a change in the muscle's oxidative capacity.

The mother of a 3-year-old boy states that her child does not walk normally. The mother feels that the child has been falling more frequently; she also tells you that his symptoms are worsening quickly. On exam, the child uses his hands to push himself into an upright position from sitting on the ground. He walks with a waddling gait. There is hypertrophy of the bilateral calves, lumbar lordosis, and hyporeflexia. There is also cognitive delay. His labs reveal an increased creatine kinase. What is the most likely diagnosis? A. Facioscapulohumeral muscular dystrophy B. Myotonic muscular dystrophy C. Duchenne muscular dystrophy D. Becker muscular dystrophy E. Limb-girdle muscular dystrophy

Duchenne muscular dystrophy symptoms are usually noted at age 3-5 in boys. The disease is present at birth, but symptoms often are not noted until the child starts walking. A waddling gait, hypertrophy of the calves, lumbar lordosis, and hyporeflexia are all common exam findings with this disease. The way the child pushed himself into an upright position is known as Gower's sign. There is also an increase in creatine kinase. This is the most common form of muscular dystrophy in children.

A 1-month-old infant is being evaluated for rapid breathing, feeding difficulty, lethargy, and poor weight gain. The physical exam is notable tachypnea, tachycardia, a cardiac gallop, and a medium-pitched systolic murmur that is best heard posteriorly in the interscapular area with radiation to the left axilla, apex, and anterior precordium. A prominent anterior chest heave is also observed. The lower extremities demonstrate a 12 mm Hg pressure difference compared to the upper extremities. Additionally, there are delayed femoral pulsations; upper extremity pulsations are normal. What is correct regarding the long-term management of this patient? A.Continued monitoring of blood pressure is unnecessary. B. Evaluation by a cardiovascular surgeon is essential for definitive treatment. C. Cardiac catheterizations are required in the non-surgical approach to this patient. D. Medical management of this patient is not expected to be of any benefit. E. Routine antibiotic prophylaxis may be omitted prior to any surgical procedures.

Evaluation by a cardiovascular surgeon is essential for definitive treatment; This patient's manifestations suggest a diagnosis of coarctation of the aorta. There is general agreement that symptomatic children under 6 months should undergo surgical repair, and those who develop significant recurrent stenosis at any age should undergo balloon dilation or stent placement. The optimal therapy for the treatment of native coarctation in children over 1 remains somewhat controversial.

A 42-year-old man presents for evaluation of a growth on his tongue. He thinks the lesion has been present for a few months, and it has not changed; however, he generally prefers to avoid healthcare, and he has not been concerned. He is only here at the urging of his family member. The patient denies oral symptoms and changes in taste sensation; he states that he generally feels fine. The patient denies the use of chew tobacco and cigarettes. On physical exam, there is a white patch of tissue, which does not scrape off; there is a "shaggy" appearance on the left lateral tongue. No erythema is noted. No other lesions are identified. The remainder of his exam is normal. A biopsy of the lesion is obtained. The pathology shows hyperkeratosis and "balloon" cells in the upper cell layer. What additional test should be ordered on this patient? A. C-reactive protein B. Fungal culture C. Heterophile antibodies D. HIV Elisa E. MRI of the head and neck

HIV Elisa; This patient has oral hairy leukoplakia, which is often associated with HIV-infection or other immunocompromised states (such as post-transplant). It is rare in immunocompetent individuals. Therefore, this patient should have an HIV Elisa test in order to screen for HIV. The oral hairy leukoplakia is a benign neoplasm of the tongue; in and of itself, it is not of great significance. However, due to its association with an immunocompromised state, it can be a harbinger of a more significant condition.

A 24-year-old man is brought in by his roommates for a seizure. The patient has alternative episodes of consciousness and is not currently seizing. The roommates give a history of the patient being in previously excellent health, no known seizure disorder, and studying exercise science in college. He first complained of feeling ill about 3-4 days ago after returning from a spring break caving expedition, with headache, fever, and malaise. By last night, the roommates noted the man was not making sense in conversation, had trouble swallowing, and appeared more lethargic. Early this morning, he also had a witnessed seizure. Vitals are shown in the table. Weight 182 lb Height 72" Pulse 106 Blood pressure 102/58 Temperature 104.1°F/40.1°C On physical exam, the patient appears lethargic and intermittently responds to loud voice stimulus. He does not verbalize any answers and appears to have a hemiparesis. Other than his abnormal neurologic status and mild tachycardia, the remainder of his physical exam is normal. Multiple tests are done and results are shown in the table. Urinalysis - normal Complete blood count - Mildly elevated white blood cell count (WBC) Comprehensive metabolic panel - Normal C-reactive protein - Elevated Toxicology screen - Negative Cerebrospinal fluid analysis - Increased lymphocytes and protein, normal glucose MRI of head - Some areas of increased signal, no masses Brain biopsy - Edema, inflammation, Negri bodies If the patient was able to supply an accurate, complete history by himself, which of the following aspects of this patient's history would best explain his current condition? A. He had experienced multiple concussions while playing football as a teen. B. He had recently started a new oral medication for acne. C. He was the victim of a bat bite while spelunking. D. His father had Huntington's disease. E. His mother consumed large amounts of alcohol throughout his fetal gestation.

He was the victim of a bat bite while spelunking; This patient presents a very concerning clinical picture for encephalitis. Encephalitis classically presents with fever, headache, altered mental status, and a variety of other neurologic signs and symptoms. It is caused by a variety of viral organisms: herpesvirus, influenza, HIV, adenovirus, and many others. It can be transmitted by a variety of vectors worldwide, and history is vital to establishing possible etiologies. If this patient was able to report he was the victim of a bat bite while spelunking, that history would be most supportive of a diagnosis of rabies encephalitis. Encephalitis is a complicated condition with a variety of findings, but the Negri bodies on brain biopsy are pathognomonic for rabies.

A 39-year-old woman presents with a rash. The rash started 5 days ago; it is pruritic and located primarily on her arms and legs, with a few sores in her mouth. Her husband described the rash as like a "bullseye." She has felt mildly "flu-like," but she denies fevers. She denies any changes in soaps, detergents, or diet. She has not been around anyone with a similar condition, and she denies travel. Otherwise, she reports feeling better than usual, with more improved control of her migraines since her neurologist started her on topiramate about 3 weeks ago. She has not needed to use her sumatriptan for over 1 month. Her review of systems is negative. She suffers from migraines, but she has no other chronic health conditions. Her current medications are topiramate daily, with sumatriptan as needed. She is allergic to amoxicillin. She has regular menses; she had a tubal ligation as contraceptive. On physical exam, a few small oral lesions are noted. The lesions on the extremities are primarily on the dorsal surfaces, with a ringed appearance, similar to a target. The remainder of her exam is normal, including vital signs. What is the most important and appropriate intervention in this case? A. Admission to burn unit for skin management B. High-dose oral antihistamines C. High-dose oral steroids D. Immediate discontinuation of the new medication E. Topical steroid cream

Immediate discontinuation of the new medication; This patient is presenting with a target lesion rash; it is typical of erythema multiforme, which is a relatively common type IV hypersensitivity reaction. In about 50% of cases of erythema multiforme, no cause is identified. Other causes are infection and medications, including anticonvulsants. This patient's rash occurrence suspiciously followed the initiation of a new medication. Erythema multiforme is an acute, self-limited condition; it can range in severity from a rash, mild malaise, and pruritus (erythema multiforme minor) to a much more severe condition, involving mucosal surfaces and possible desquamation with erythema multiforme major. The most important treatment of erythema multiforme when a medication is attributed as the cause is immediate discontinuation of the new medication.

A 33-year-old G2P2 who delivered a baby two weeks ago via uncomplicated vaginal delivery presents to the office due to fever, malaise, and nausea. She is currently breastfeeding her baby. Perineum and vagina are healing well without signs of infection, uterine fundus is firm and is located midway between the mons pubis and the umbilicus. Her right breast shows a few reddish streaks radiating up from the nipple in the upper outer quadrant, and the skin appears edematous. The nipple-areola complex has some minor crusting with a few abrasions. The breast is engorged; she is concerned about feeding baby from the affected breast. The breast is tender to palpation, although it is not fluctuant. In addition to prescribing oral antibiotics, what is the next best step in management? A. Bind breasts and use analgesia for comfort B. Incision and drainage of the abscess C. Increase frequency of breastfeeding D. Pump and dump milk from affected breast E. Wean baby and begin formula feeding

Increase frequency of breastfeeding; Increase frequency of breastfeeding is the correct answer. Puerperal mastitis is a common problem faced by newly breastfeeding mothers. Infection typically ascends from the nipple-areola complex through small breaches in the skin. Patients typically present with localized, unilateral breast tenderness and erythema accompanied by fever, malaise, and fatigue. However, systemic signs of infection may be absent. The key to treatment and the prevention of an abscess forming is to continue breastfeeding from both breasts and to increase the frequency of the feeding sessions in order to keep the breasts as empty of milk as possible. If instead breastfeeding is stopped, the stagnant milk acts as a reservoir for multiplying bacteria and abscess formation may ensue. Studies have shown that the baby is not adversely affected by latching on and breastfeeding from both breasts, as the mother and infant are usually colonized with the same organisms at the time mastitis develops.

A 32-year-old man presents due to occasional shortness of breath and associated cough, especially when he is working outside. He has associated chest tightness that resolves within minutes when he sits down and rests. These symptoms occur 1-2 days a month. He is otherwise healthy and does not smoke. Blood pressure is 128/74 mm Hg, and pulse is 76, respiration is 14, and pulse oximetry is 100% on room air. His FEV1 is 96%. What is the treatment of choice? A. Inhaled corticosteroid B. Inhaled short-acting beta agonist C. Inhaled long-acting beta agonist D. Inhaled anticholinergic E. Oral beta agonist

Inhaled short-acting beta agonist; This patient has intermittent asthma, which is defined as symptoms ≤2 days per week, nighttime awakenings ≤2 times a month, and no interference of normal activities with a normal FEV1 between exacerbations. The treatment of choice is inhaled short-acting beta agonist (SABA), albuterol, when needed. If the asthma occurs due to an allergen or in a predictable manner, the patient can use the SABA prior to exposure to avoid triggers as much as possible.

A 70-year-old woman with a history of hypertension, hyperlipidemia, and myocardial infarction presents with a 3-day history of shortness of breath at rest. She has found it difficult to walk short distances due to shortness of breath and is experiencing orthopnea and nocturnal dyspnea. She denies cough, fever, chills, nausea, abdominal pain, vomiting, diarrhea, or rashes. Upon physical examination, the patient is short of breath, requiring numerous pauses during conversation. General assessment reveals the patient is tachycardic and diaphoretic Cool extremities. Heart exam reveals a diminished first heart sound, S3 gallop, and laterally displaced PMI. Lung exam reveals dullness to percussion, bibasilar rales, and expiratory wheezing. 2+ pitting edema of the lower extremities to the level of the mid-calf. There is no JVD noted. What intervention will provide the greatest symptomatic relief to this patient? A. Pericardiocentesis B. Intravenous beta blocker C. Intravenous diuretic D. Oral calcium channel blocker E. Subcutaneous Lovenox

Intravenous diuretic; In the Framingham classification, a patient is diagnosed with congestive heart failure if two major criteria are met or one major and two minor criteria are met. This patient exhibits the following major criteria: paroxysmal nocturnal dyspnea rales (bibasilar rales) S3 gallop She also exhibits the following minor criteria: nocturnal cough dyspnea with minor exertion tachycardia bilateral pedal edema Patient is in congestive heart failure. The bibasilar rales indicate fluid, so the patient also has pulmonary edema. Loop diuretics (furosemide) remain the mainstay and first line of therapy in congestive heart failure. IV diuretic therapy is indicated for the treatment of acute pulmonary edema.

A 55-year-old woman with no significant medical problems presents with a CC of pink urine, stating, "I think I have blood in my urine." She states she has no pain with urination, but the hematuria is persistent. On questioning, she states that she has had a 1-month history of some progressively worsening left flank pain. The pains are not debilitating, but they are nagging. She admits to a 50 pack-year smoking history, and she states she is currently retired from her job as a teacher. Vital signs: T 98.6°F, BP 118/76 mm Hg, P 78/min, R 14/min. Abdominal exam reveals a left side abdominal mass. Urine dipstick only shows too numerous to count RBCs, and urine cultures are negative. CT scan of the abdomen and pelvis with and without contrast reveals a 4.2 cm solid enhancing lesion in the left renal parenchyma. What is the most ? A. Antibiotics for 10 days B. Chemotherapy C. Left nephrectomy D. Hormonal therapy E. Observation

Left nephrectomy;This patient is exhibiting the classic triad of renal cell carcinoma (RCC): Hematuria Flank pain A palpable flank or abdominal mass This is uncommon in patients with renal cell carcinoma (10%) and usually indicates advanced disease. The patient admits to a history of smoking, which is a risk factor for RCC. The acceptable treatment options for RCC include: Surgery, either partial or complete nephrectomy—the only curative treatment. Radiation therapy Immunotherapy Molecular targeted therapy

A 50-year-old woman presents for her annual pelvic examination; her previous examination took place about 18 months ago. She tells you that her last menstrual period was over 12 months ago; the last few occurrences of menses were extremely irregular. The patient also describes having multiple daily episodes of severe intense heat in her face and trunk that is accompanied by sweating. She further states that these "heat episodes" have been occurring 4-6 times a day for the last 4 weeks. They have been interfering with her everyday activities and her sleep. She reports no other issues at this time. She has received her annual pelvic examinations yearly as well as clinical breast exams and mammograms; there have been no significant findings. During the pelvic examination, you note obvious vaginal thinning and excessive dryness; there is also apparent vaginal wall atrophy. What pharmacologic intervention can be prescribed in order to assist in ameliorating the patient's symptoms? A. Menopausal hormone therapy B. Low-dose oral contraceptives C. Phytoestrogens D. Progestin-releasing intrauterine devices E. Testosterone replacement therapy

Menopausal hormone therapy;This patient scenario is most likely the result of menopause. There is usually a 1-3 year period that women adjust physiologically to diminished hormonal and menstrual actions and the effects this has on their bodies. These effects may include hot flashes, night sweats, vaginal dryness, and, in later stages, osteoporosis. In western societies, the average age at which women achieve menopause is about 51. This patient has from moderate-to-severe symptoms of the physiological menopausal transition. Given that this patient does not have any obvious risk factors, menopausal hormone therapy (MHT) is the best pharmacological option. At one time, MHT was referred to as hormone replacement therapy. MHT can reduce hot flashes, night sweats, poor sleeping, and irritability. MHT will also treat vaginal symptoms related to menopause, such as vaginal dryness and discomfort. It can also slow bone loss and ease mood swings and depressive symptoms.

A 50-year-old woman with no significant past medical history presents for an annual pelvic examination. She states her last menstrual period was over 6 months ago; the last few occurrences of menses were extremely irregular. The patient also describes having the sensation of intense heat in her face and trunk, and the sensation is accompanied by sweating. She also states that her "heat episodes" have been occurring 1 or 2 times a week for the last several months. Patient denies any other symptoms at this time. She has received her annual pap and pelvic examination yearly, as well as a clinical breast exam, without any issues. On pelvic examination, you note obvious vaginal thinning, excessive dryness, and apparent vaginal wall atrophy. Based on this history and physical examination findings, what is most likely occurring in this patient? A. ovarian cancer B. menopause C. pregnancy D. cervical cancer E. polycystic ovary syndrome

Menopause; The patient in this case is most likely experiencing menopause. Menopause is defined as a cessation of menstruation due to either natural aging or an external cause (surgical). There is usually a 1-3 year time period in which women will typically adjust physiologically to the diminished hormonal and menstrual actions as well as the effects they have on their body. These effects may include hot flashes, night sweats, vaginal dryness, and in the later stages, osteoporosis. In western societies, the average age at which a woman experiences menopause is roughly 51.

A 7-year-old boy presents with his parents for evaluation of behavior problems in school; the problems have been ongoing for over 6 months. The boy's teacher recommended he be evaluated. The teacher reports that he tests at grade level, but he seems to make careless mistakes on schoolwork and has trouble maintaining attention to instruction; he does not finish his homework, and he often loses his homework, pencils, and books. The boy is seen often fidgeting at his desk; he blurts out answers and has difficulty waiting his turn. The parents agree that they have seen similar traits at home for several years, such as forgetting to do daily activities and being easily distracted. They view him as a bright happy boy who is very active. He has had normal vision and hearing screenings. The father reports that he was very similar as a child and still struggles with focus and concentration as an adult, but he never received any help. The parents deny any major changes in the family situation. They would like medical help to improve their son's performance in school. The boy has been seen regularly for his well-child exams and has always met milestones and had normal exams. Today, he is quickly moving about the exam room; he looks at a book for a few moments, and he then looks to the window for a short while before interrupting his parents.In addition to behavioral intervention, and assuming the parents agree to medication for their son, what medication is the most appropriate initial treatment? A. amitriptyline B. bupropion C. clonazepam D. methlyphenidate E. sertraline

Methylphenidate; This child meets criteria for attention deficit hyperactivity disorder (ADHD), and it would be most appropriate to start methylphenidate, a central nervous system stimulant. This medication is considered a first-line therapy for ADHD; it works by regulating dopamine and norepinephrine levels.

A 74-year-old man with a past medical history of hyperlipidemia, myocardial infarction, rheumatic heart disease, and hypertension presents for a routine evaluation. He states that he has no complaints and feels well. The physical exam reveals an elderly man in no apparent distress whose vital signs are within normal limits. The cardiac exam is noteworthy for a soft S1 to auscultation, a systolic thrill palpable at the cardiac apex, lateral displacement of the point of maximal impulse, and a holosystolic murmur of IV/VI intensity, which is loudest at the apex and radiates to the axilla. The intensity of the murmur does not increase with inspiration. The remainder of the exam is normal. What EKG finding would be most likely associated with this patient's presentation? A. Wide QRS complexes B. Diffuse ST elevations C. Prolonged PR intervals D. Negative P-wave deflection in V1 E. Large P-wave amplitude in II

Negative P-wave deflection in V1; This patient's murmur is identified as mitral regurgitation (MR). The murmur of MR is caused by turbulent flow through incompetent mitral valves from the left ventricle (LV) into the left atrium during ventricular systole. It is a high-pitched, "blowing" holosystolic murmur best heard at the apex, and it usually radiates to the axilla. The intensity of an MR murmur does not increase with inspiration, which helps distinguish it from the murmur tricuspid regurgitation. The S1 heart sound is a combination of the mitral and tricuspid valves closing. In MR, valve closure is incomplete and S1 may be noticeably quieter. A grade 4 murmur is loud and has a palpable thrill. The point of maximum impulse (PMI) is normally felt at the left fifth intercostal space, a half-inch medial to the left midclavicular line (precordium). Complications of MR include LV enlargement. Eventually, the heart decompensates and gradually the left atrium (LA) will enlarge. Lateral displacement of the PMI usually indicates cardiomegaly. In patients with MR in sinus rhythm, evidence of LA enlargement is characterized in lead V1 by a P-wave that is initially positive but is followed by a negative deflection at the wave's terminus. There may be a bimodal P-wave in some leads. LA depolarization will last longer than normal, so duration of the P-wave is longer than normal. P-wave amplitude and PR interval remain unchanged.

A 30-year-old man presents with a 1-week history of a painful tongue. He has been having diarrhea and forgetting things more easily. He recently emigrated from India and lives alone on a maize-based diet. On examination, you note that the tip and margins of his tongue are a bright scarlet color. He also has a symmetrical erythematous rash on his forearms. What is the most likely diagnosis? A. Vitamin A deficiency B. Pyridoxine deficiency C. Vitamin C deficiency D. Niacin deficiency E. Vitamin E deficiency

Niacin deficiency; Niacin deficiency causes pellagra, which is characterized by: Symmetrical dermatitis, usually on parts of the body exposed to sunlight Scarlet glossitis and stomatitis Diarrhea Mental aberrations, such as memory impairment, depression, and dementia These may appear alone or in combination. Causes include inadequate dietary intake, especially in patients with corn-based diets or alcoholism. Dietary sources include legumes, yeast, meat, and enriched cereal products.

A 32-year-old man presents with severe headaches. He reports that he had experienced 2 of these severe headaches about a month ago, and now has had 2 more, which have woken him from sleep. The headaches lasted anywhere from 15 minutes to an hour, then resolved entirely. His wife urged him to seek care for this one, as she was worried about a stroke. He complains of severe head pain, and his left eye appears droopy, slightly swollen, and it is watering. His nose is runny. He denies history of head trauma, memory loss, gait disturbances, muscle weakness, nausea, and vomiting. Over-the-counter acetaminophen and ibuprofen have not been helpful. He has no known medical conditions, takes no regular medications, and has no known allergies. He has never had surgery. He denies any family history of headaches or neurological conditions. He smokes 1 pack/day and drinks alcohol 3-4 times/week. He denies the use of drugs. On physical exam, the patient appears restless. Ptosis and pupillary constriction are observed in his left eye, and some clear nasal discharge is noted. The remainder of his exam is normal. What test results best support this patient's likely diagnosis? A. Inflammation on temporal artery biopsy B. Normal magnetic resonance imaging (MRI) C. Polyspikes and slow wave pattern on electroencephalogram (EEG) D. Positive toxicology for cocaine E. Thickened sinus mucosa on computed tomography (CT)

Normal MRI; this patient is most likely experiencing cluster headaches, in which he would be expected to have normal magnetic resonance imaging (MRI). Cluster headaches are intense, episodic headaches that occur more commonly in men than women. Symptoms are unilateral, often accompanied by rhinorrhea and lacrimation, miosis, and ptosis of the eye.

A 42-year-old Hispanic man presents because his employee health fair lab results returned with several "out of normal" range results. He is an established patient in your practice; you have seen him 4 times for illness or minor injury over the past 10 years. He reports that he is in generally good health and feels well; he does not see any other healthcare providers. A summary of his past medical history includes: Medications: occasional over-the-counter ibuprofen for joint pain Allergies: denies allergies to medication, food, environmental agents, or latex Surgical history: open reduction of left ankle at age 22 Medical history: mild osteoarthritis Social history: denies the use of tobacco or illicit drugs. He drinks 3-4 beers per week. He is married and has five children; he works in industrial hygiene at a lab facility. He plays rugby on the weekends as a hobby. Family history: no chronic diseases are known to the patient. His vital signs at check-in: Temp. 98.6°F, BP 118.76 mm Hg, P. 72/ min, R. 14/ min This patient's laboratory results from the health fair are shown in the chart. Test Result Complete blood count (CBC) WBC 6.1 RBC 4.78 Hemoglobin 15.4 Hematocrit 45.2 MCV 94.6 MCH 32.2 MCHC 34.1 RDW 11.7 Platelets 462 MPV 9.9 WBC differential Normal Complete Metabolic Panel (CMP) Sodium 132 Potassium 3.3 Chloride 100 HCO3 26 Glucose 94 Bun 16 Creatinine 1.1 Calcium 9.9 Albumin 3.5 Total Protein 6.3 AST (SGOT) 21 ALT (SGPT) 17 Alk Phosphatase 55 Total Bilirubin 0.8 Anion Gap 6 eGFR >60 Lipid Panel Cholesterol 226 Triglyceride 1280 HDL 42 LDL Unable to calculate VLDL 37 Thyroid TSH 1.96 Based on the history and test values presented, what is this patient's most significant risk? A. dehydration B. hemorrhage C. malnutrition D. pancreatitis E. renal failure

Pancreatitis; This patient has significant hypertriglyceridemia and is at risk for pancreatitis. While elevated triglycerides play a role in arteriosclerosis and cardiovascular risk, dramatically elevated triglycerides (>500, and even more so with levels over 1000) put the patient at risk for inflammation of the pancreas. (The elevated triglyceride level >400 mg/dL is also the reason the laboratory was unable to calculate the low-density lipoprotein (LDL) cholesterol level. LDL levels can be measured directly, but most screening tests use a calculation. It is common for a patient to have 1 or more lab results out of the normal range for routine screening, and it is important that the practitioner quickly recognize those with clinical importance.

A 34-year-old woman presents Monday morning with knee pain. She states that she was playing with her two children in their backyard over the weekend and fell onto solid ground, landing directly on her knees. She noted immediate and significant right knee pain. She notes significant swelling; it accompanies the knee pain, which she rates as an 8/10 on a numerical pain scale. Physical examination reveals significant obvious joint effusion and exquisite focal tenderness to palpation over the patellar area of the right knee; the left knee has no obvious abnormalities. Results of the anterior drawer, McMurray, and varus/valgus stress testing are within normal limits. Given the history and physical examination findings, what is the most likely diagnosis? A. Bone cyst B. Patellar fracture C. Ligament tear D. Tibial fracture E. Femoral shaft fracture

Patellar fracture; The patient above has most likely experienced a right patellar fracture. Many fractures of the patella are the result of direct forces, such as striking the dashboard in a motor vehicle accident, or in the patient's scenario, falling onto a flexed knee. Patellar fractures should be high on the differential diagnosis list if a patient presents with acutely swollen knee and patella pain following trauma to that area. There will be presence of joint effusion and focal tenderness to palpation of the patella. Another feature is that the patient will be unable to extend the knee against gravity, which requires surgical repair if present. Our patient had all these signs and symptoms, minus the inability to extend the knee.

A G3P3 37-year-old Hispanic woman presents because she only menstruates a few times per year. Her family is concerned, but she is not because her menses have demonstrated this pattern most of her life. Menses last about 10 days. Her last menstrual period occurred 4 months prior to presentation. She denies dysmenorrhea, pelvic pain, nausea, vomiting, breast tenderness, fatigue, and vasomotor symptoms. She is not breastfeeding, and she delivered her last child 3 years prior to presentation. She and her husband are considering another child. The review of systems and past medical history is unremarkable. She takes a prenatal vitamin daily, but no other medications. The patient is a homemaker; she is married and lives with her husband, 3 children, and mother-in-law. She denies tobacco, drug, and alcohol use. Urine specimen and vitals are collected. Results are shown in the table. Weight 226 lb Height 64" Pulse 90 Blood pressure 132/85 Urine hCG Negative Physical exam reveals a pleasant, obese woman. Her uterus and adnexa are not palpable on physical exam due to obesity. The remainder of the physical exam is normal. You have recommended weight loss and ordered several labs, which are pending. Assuming the patient's lab results are all within normal ranges, what is the most appropriate clinical intervention for this patient's amenorrhea? A. Have the patient monitor her menstrual cycle and return if she develops pain. B. Insert levonorgestrel intrauterine system (Mirena). C. Order brain MRI to evaluate pituitary gland. D. Perform ultrasound and endometrial biopsy. E. Refer for endometrial ablation.

Perform ultrasound and endometrial biopsy; This patient should have an ultrasound and endometrial biopsy; she is at risk for prolonged stimulation to the endometrium, resulting in endometrial hyperplasia. Other risks factors for endometrial hyperplasia include obesity and being over 35. The classic anovulatory menstrual pattern presents with a history of infrequent (but heavy and long) menses. An ultrasound can evaluate the endometrial thickness, and an endometrial biopsy can determine histologically if hyperplasia is present.

A 51-year-old Caucasian woman presents to the clinic to follow up on multiple tests she had requested from another practitioner. She has had what she describes as "episodes," in which she feels overheated and diaphoretic. Her coworkers note that her face turns red. These episodes seem to occur multiple times during the day; they have been occurring for the last 2-3 months, and they last 1-2 minutes before they resolve. She is also very warm when sleeping at night. She denies weight changes, palpitations, headaches, galactorrhea, acne, bowel changes, hair loss, and any changes to her skin or nails. Overall, she reports some mild malaise and irritability, but she denies depression and fatigue. Her past medical history is unremarkable, with no known medical conditions, allergies, medications, or prior surgeries. She denies the use of alcohol, tobacco, and drugs. Her method of contraception is her husband's vasectomy. Her last menstrual period was about 4 months ago, but periods had been regular and monthly prior to that. Physical exam and vitals are normal. Test results are shown. Complete blood count (CBC) - Normal Thyroid-stimulating hormone (TSH) - Normal Urinalysis - Normal Complete Metabolic Panel (CMP) - Normal Follicle-stimulating hormone (FSH) - Elevated Quantitative hCG - Negative Prolactin - Normal Free/total testosterone - Normal What is the most likely diagnosis? A. perimenopause B. menopause C. pituitary adenoma D. polycystic ovarian syndrome E. pregnancy

Perimenopause; This patient is experiencing the climacteric stage of life, which is often referred to as menopause. Technically, menopause is defined as the point in time in which a woman has had no menstrual periods for 1 year, which is due to decreased ovarian function, and the average age at which menopause occurs is 51.5 years. This woman would be considered perimenopausal.

Mandatory newborn screening has been completed on a Caucasian infant who was born 36 hours ago. The birth was relatively benign without any complications; the newborn was born at exactly 40 weeks gestation. An abnormal result found in the screening tests has resulted in you ordering required counseling for the parents due to the fact that they must initiate lifelong modification in their child's diet to decrease the incidence of abnormal intellectual development. What disease state was most likely found during this patient's screening? A. Classic galactosemia B. Congenital hypothyroidism C. Phenylketonuria D. Sickle cell disease E. Tyrosinemia (of the newborn)

Phenylketonuria; Phenylketonuria is an extremely well-known amino acid metabolism disorder that can be found in newborns. In classic phenylketonuria, there is decreased activity of phenylalanine hydroxylase, which is the enzyme that converts phenylalanine to tyrosine; this leads to excessively high levels of phenylalanine accumulating in the patient. It is an autosomal recessive trait and it has an incidence in Caucasian infants of around 1:10,000 live births. Patients with untreated phenylketonuria can develop issues such as severe intellectual disability, hyperactivity, seizures, or eczema. Treatment requires a meal plan that is low in phenylalanine; it should be started as early as possible, usually within the first 7 - 10 days of life. If this treatment plan is put into place and followed throughout the patient's life, there is a very high likelihood that little or no issues will be seen in terms of the complication due to this condition.

A 24-year-old man with no significant PMH presents due to increasing pain in his right groin and buttock and difficulty walking. The pain has been present and worsening for about 1 month. He further reports that he had significantly injured himself (also near his right hip) in a fall while snowboarding about 3 months ago. He did not seek immediate care and had difficulty ambulating for a week, then saw a chiropractor to "put his lower back back in." The pain and gait problems eventually improved. Now he is concerned because the pain has returned with no new history of trauma. He denies any family history for musculoskeletal and rheumatologic conditions. On physical exam, the patient was noted to walk with a slight limp. Examination of the hip, buttock, and groin region reveals no edema, erythema, or ecchymosis. The exam does not produce one particular point of tenderness with palpation, passive range of motion is limited and painful, especially with forced internal rotation. A straight-leg raise against resistance elicits pain. What diagnostic study would confirm this patient's condition? A. arthroscopy B. Bone biopsy C. Nuclear bone scan D. Plain radiography (X-ray) E. Ultrasound

Plain radiography (x-ray);This patient's condition is suspicious for avascular necrosis (or the more preferred term, osteonecrosis) of the hip. Avascular necrosis (AVN) is a relatively common complication, following a traumatic hip dislocation, when the vascular supply to the femoral head is damaged and bone death occurs. There are many theories about the exact mechanism; other causes such as vascular, congenital, and autoimmune diseases have been implicated with osteonecrosis. Plain radiography (X-ray) is the preferred initial test, and if the "crescent sign" is seen, AVN is confirmed. The crescent sign is a lucent (dark-appearing) crescent-shaped region of the femoral head, usually just a sliver beneath a more opaque (white-appearing) bone edge, which indicates some sclerosis and bone structure collapse upon itself.

A 72-year-old man presents with a 2-hour history of a nosebleed that will not stop. The patient's nose began dripping blood at breakfast; there is no known trauma. He denies pain. He has tried applying nasal pressure and laying down to rest. Until the bleeding began, the patient had not been experiencing any nasal symptoms, such as congestion, impaired nasal patency, or rhinitis. The patient has no diagnosed medical conditions, and he takes no medications. He denies prior episodes of severe nosebleeds, easy bruising, and any known bleeding disorder. The patient's vitals are shown in the table. Weight 148 lb Height 69" Pulse 98 Blood pressure 166/96 mm Hg Temperature 97.4°F/36.3°C On physical exam, the man is holding a large towel to his nose; there is continued brisk bleeding. He is otherwise in no apparent distress. On rhinoscopy, bleeding is observed from bilateral nares. No foreign body, mass, lesions, or abrasions are visualized. The bleeding site cannot be identified. A stat CBC is obtained; results are shown in the table. Test Result Normal range Units WBC 7.2 3.6-9.0 K/μL RBC 5.1 4.18-5.22 M/μL Hemoglobin 13 12.9-15.5 g/dL Hematocrit 38.1 34.6-50.1 % MCV 82.4 80.0-100.0 fL MCH 30.2 27.0-34.0 pg MCHC 32.8 30.0-37.0 g/dL RDW 16.1 11.0-17.0 % Platelets 348 140-440 K/μL MPV 9.9 6.5-12.0 fL WBC differential Normal A nasal tampon is placed, but it is unsuccessful in stopping the brisk nasal bleeding. What is the most likely diagnosis? A. Anterior epistaxis B. Neoplasm C. Posterior epistaxis D. Thrombocytopenia E. Underlying coagulopathy

Posterior epistaxis; Based on this patient's history, his physical, and his unresponsiveness to (anterior) nasal packing, he most likely has a posterior epistaxis. Posterior bleeds are less common, but they should be suspected when the bleeding is large volume and unresponsive to nasal packing/tamponade. Some sources show a link with hypertension. This patient's elevated blood pressure could be related to the stress of a 2-hour unremitting nosebleed or an underlying contributor. Hypertension can make management of epistaxis more difficult. A specialist should be consulted in this case in order to ensure effective management.

A 25-year-old man presents due to heartburn. It only occurs 1 or 2 times a month, but it is extremely noticeable when these episodes do occur. He states that eating large meals, eating late at night right before going to sleep, and excessive alcohol consumption seems to exacerbate and even initiate episodes. He has noticed that limiting the aforementioned behaviors has decreased the severity of the symptoms in recent months, but it is still occurring despite this modification. He denies any difficulty swallowing, weight loss, night sweats, chest pain, use of tobacco, or coughing up blood. Physical examination is unremarkable for any abnormalities.Since this patient's symptoms would be classified as mild, what is the next best option for this patient? A. Proton-pump inhibitor B. H2-receptor antagonists C. Antiemetics D. Antibiotics E. Prokinetic agents

Proton-pump inhibitor; Mild or intermittent symptoms of gastroesophageal reflux disease (GERD) are not typically seen as adversely affecting patients' quality of life. Initially, action is taken in terms of modification of behaviors, such as eating smaller meals and eliminating acidic foods and foods known to precipitate the reflux (fatty foods, alcohol, chocolate, or peppermint). Weight loss has also been shown to help decrease issues, and so has advising patients to avoid lying down at least 3 hours after eating meals. Elevation of the head of the bed is also suggested to initiate relief. Proton-pump inhibitors are considered the mainstay of pharmacological treatment. PPIs work by blocking the production of acid. Examples of these include omeprazole 20 mg or lansoprazole 30 mg. Proton-pump inhibitors help patients achieve adequate control of their heartburn symptoms, and they can potentially offer resolution of these symptoms; they even aid in the healing of erosive esophagitis if it is present.

A 33-year-old man with no significant past medical history presents with a 2-month history of persistent right knee pain. The knee pain is located in the anterior part of the knee; "behind the kneecap," according to the patient. Pain is worse as he descends stairs, performs squatting maneuvers, and sits for excessive periods of time. He is an avid runner and states that running also increases pain. He denies any trauma, falls, accidents, or prior surgeries. He further denies any fever, chills, insect bites, rashes, effusions, grinding, popping, or clicking sensations in the knee. He denies any hip or ankle pain. The physical exam reveals tenderness to palpation along the medial undersurface of the right patella and a positive patellar apprehension test. The anterior and posterior draw tests, McMurray's test, and Apley's compression and distraction tests are all negative. What is the most appropriate clinical intervention for this patient at this time? A. weight gain B. reduction of running exercises C. prescription for narcotic analgesia D. referral for knee arthroscopy E. cast immobilization

Reduction of running exercises;This patient's most likely diagnosis is patellofemoral pain syndrome. Clinical interventions include relative rest, a reduction of running pace and mileage, and avoidance of squats, lunges, and running uphill and downhill. Other interventions include quadriceps strengthening and NSAID medications. Surgical interventions are indicated if symptoms persist beyond 6 months, if a rehabilitation program fails, and if other causes of knee pain have been excluded. Weight loss is recommended to decrease the stress on the patellofemoral joint. Knee orthotics may be beneficial.

A 52-year-old man presents with a concern of hearing changes. He has noticed a decreased ability to hear sounds for the past few months; he tested it at home by covering each ear, and he now thinks there is a hearing loss in only the left side. Furthermore, he hears a ringing sound all the time. He is a business manager, and he denies occupational exposure to loud noises. He denies head trauma, headaches, and prior ear problems. His wife thinks this is just normal age-related hearing loss. His review of systems is negative for other neurological symptoms. The patient's past medical history is unremarkable; he has no known medical conditions. He takes no medications. He has no allergies, and he has not had any surgeries. He denies alcohol, tobacco, and drug use. On physical exam, his vitals are normal. His HEENT exam is significant only for decreased auditory acuity and Weber test lateralizing to the right. Audiometry confirms a sensorineural hearing loss on the left. An MRI is performed; it shows a well-delineated intracranial mass. Further investigation reveals the origin of cells is from Schwann cells. What choice represents the best intervention for this patient's current condition? A. Referral for chemotherapy B. Referral for electroencephalography C. Referral for surgery D. Referral for unilateral hearing aid E. Referral for ventricular shunt

Referral for surgery; This patient is presenting with a vestibular schwannoma, or acoustic neuroma, that is affecting his vestibulocochlear nerve (cranial nerve VIII). This is one of the more common benign head and neck neoplasms. A common presentation is unilateral hearing loss and tinnitus. Treatment is typically surgical removal; another possibility is radiation therapy. Of the choices listed, referral for surgery is the best option; if he turns out to be a poor surgical candidate, radiotherapy should be discussed.

A 2-day-old infant still in hospital care is found to have erythematous patches with 1-2 mm yellow pustules with a surrounding irregular erythematous base, giving a "flea-bitten" appearance scattered all over the body. The infant was full-term, delivered via spontaneous vaginal delivery without complication. The mother received regular prenatal care. The patient is feeding well and has had several wet diapers and 2 meconium stools. Vital signs have been normal since delivery. On exam, patient is alert and awake. No sign of jaundice, no murmur, and lungs are clear. What should be done at this time? A. Biopsy of a pustule B. Transfer to the NICU for start of acyclovir C. Immediate blood cultures and lumbar puncture D. Topical antibiotic as needed E. Routine monitoring and parental education

Routine monitoring and parental education;The correct response is routine monitoring with parental education. Erythema toxicum neonatorum is a benign transient condition occurring in 48-72% of full-term newborns. Appearance is as described in the patient scenario. Additionally, the appearance may be only splotchy erythema. The differential diagnosis is extensive, but the most common differential diagnoses include: staphylococcus folliculitis acne neonatorum congenital candidiasis Treatment begins with education of the parents of the benign nature, duration of the condition and assurance that the condition will resolve without any sequelae.

7-year-old boy presents because he is fidgety, impulsive, and unable to sit still. The patient is observed running around. There is no evidence of any hallucinations or delusions. The mother notes that the child speaks excessively and loudly, makes simple arithmetic errors, and has short-term memory deficiencies. He finds it difficult to wait in lines or wait his turn in games or group situations. What is correct regarding this patient's condition? A. Serological lab tests are confirmatory for the illness. B. Stimulant medications are considered first-line pharmacologic therapy. C. The onset must be over age 13 to qualify as the suspected diagnosis. D. This disorder is more common in female patients and resolves completely in adulthood. E. Thought content disturbances and a heightened suicide risk are expected.

Stimulant medications are considered first-line pharmacologic therapy; This patient is demonstrating manifestations of attention deficit hyperactivity disorder (ADHD). Stimulants (e.g., methylphenidate, dextroamphetamine) are first-line therapy and are probably the most effective treatment. For related areas of functioning such as social skills and academic performance, medications combined with behavioral treatments may be indicated.

A 4-year-old boy presents with bloody diarrhea, anemia, thrombocytopenia, fever, and lethargy following the exposure to the homemade hamburgers. His urine output is decreasing. What is the acute mechanism of kidney failure in this child? A. Consumptive coagulopathy B. Autoimmune coaguloptahy C. Thrombotic microangiopathy D. Segmental glomerulosclerosis E. Tubulointerstitial nephritis

Thrombotic microangiopathy; Based on the symptoms in the case, the patient is diagnosed with hemolytic uremic syndrome (HUS). E coli serotype O157:H7, which causes more than 80% of infections leading to HUS, produces shiga-like toxin. Toxin enters the circulation and causes the endothelial injury with the formation of arteriolar and capillary thrombi and red cell fragmentation. Thrombi damage glomerular filtration system in the kidneys and cause kidney failure; therefore, the progressive renal failure in HUS is the result of microangiopathic non-immune hemolytic anemia, and thrombocytopenia and the main mechanism is endothelial injury.

A 66-year-old woman presents for a health maintenance visit. She reports no issues and has no history of chronic illness except postmenopausal osteoporosis, with a bone mineral density >3 standard deviations below the mean. She takes supplemental calcium and is being treated with denosumab IM every 6 months. Her only recent fracture was a compression fracture at T-6, diagnosed 5 months ago. Although she had previously enjoyed tennis, dancing, and gardening, she has drastically reduced her activity for fear of suffering further fractures. She asks if she should resume any sort of regular physical activity. Past medical history is otherwise unremarkable except for anemia, which is now resolved. Vital signs are normal, as is the remainder of the examination. What advice would you give? A. Perform only activities of daily living due to history of fracture. B. Exercise is contraindicated with osteoporosis. C. Work toward resuming former exercise program. D. Begin weight training, but avoid weight-bearing activities. E. Wait to resume exercise until denosumab is discontinued.

Work toward resuming former exercise program; Inadequate physical activity contributes to the development of osteoporosis. This patient should work towards resuming her former exercise program. Regular weight-bearing and muscle strengthening exercises are recommended to maintain and improve bone strength; to improve agility, strength, and posture; and to reduce the risk of falls. Such a regimen may also lead to some increase in bone density. Tennis and jogging are weight-bearing activities, to which a muscle strengthening activity such as weight training can be added.

A 63-year-old man with a past medical history of type 2 diabetes mellitus, hypothyroidism, and hyperlipidemia presents to his primary care provider with a 3-month history of intermittent bouts of mild to moderate "squeezing, pressure, and tight" left-sided chest and left shoulder pain, each episode lasting approximately 10-15 minutes. Additionally, he admits to associated shortness of breath and nausea during these episodes, which are provoked upon walking, exposure to the cold weather, during times of emotional stress, and following consumption of a meal, but he is not aware of any specific foods that provoke these symptoms. He denies diaphoresis, fever, chills, palpitations, peripheral edema, hemoptysis, abdominal pain, reflux, regurgitation, diarrhea, cough, and pleurisy. He also denies travel, sick contacts, cigarette, and drug or alcohol use. Upon physical exam, he is found to have a blood pressure of 146/92 mm Hg, and he is considered obese according to his BMI. His chest is free of deformity or tenderness. His heart rate is normal with a regular rhythm and free of murmurs, gallops, or rubs. His pulmonary exam reveals normal fremitus, breath sounds, and percussion. His left shoulder exhibited no palpable tenderness or deformity, and it has normal ranges of motion. What is the most likely diagnosis in this patient? A. myocardial infarction B. peptic ulcer disease C. pneumonia D. shoulder arthritis E. angina pectoris

angina pectoris; This patient's most likely diagnosis is angina pectoris. Angina typically presents as retrosternal chest discomfort, described as a pressure, heaviness, squeezing, burning, or choking sensation. It is localized to epigastrium, back, neck, jaw, or shoulders, with radiation to the arms, shoulders, and neck. Typically, angina is precipitated by exertion, eating, exposure to cold, or emotional stress. It lasts for approximately 1-5 minutes and is relieved by rest or nitroglycerin. The intensity of angina does not change with respiration, cough, or change in position. Pain above the mandible and below the epigastrium is rarely anginal in nature.

An 87-year-old woman presents with progressive shortness of breath. She has been in a wheelchair for 15 years due to paralysis of her lower extremities from unknown causes. At this time, she is unable to transfer from the chair to her wheelchair without having dyspnea. She is extremely tired but denies chest pain, palpitations, cough, hemoptysis, dysphagia, hoarseness, and sick exposures. She has never smoked. Her past medical history is positive for hypertension (treated with enalapril), heart failure, chronic kidney disease, hepatitis C, breast cancer, s/p lumpectomy, and radiation treatment 10 years ago. You order a chest X-ray. What in her medical history would lead you to suspect an exudative pleural effusion? A. breast cancer B. chronic kidney disease C. cirrhosis D. heart failure E. hypertension

breast cancer; The patient presented in this case was treated for left-sided breast cancer with a lumpectomy and radiation therapy 10 years ago. She underwent a thoracoscopy and pleurodesis. During the procedure, 1500 cc of pleural fluid was removed. Cytology was positive for breast cancer.

A 25-year-old man with no significant medical history presents due to sudden onset of shortness of breath associated with right-sided chest pain. The pain is worse with inspiration but is unaffected by position. He states he was grocery shopping when it started. He denies chest trauma. Patient admits to an upper respiratory infection earlier in the month that had resolved without incident. He smokes 1 pack of cigarettes per day. On examination, he is afebrile, BP is 138/80 mm Hg, pulse is 124, respiratory rate is 24, and pulse oximetry is 94% on room air with mild respiratory distress. Trachea is midline. He has increased resonance to percussion with no breath sounds on the right anterior apex; the other lung fields are clear to auscultation. Heart is tachycardic with normal S1 and S2; no murmur, rubs, or gallops are present. What is the imaging of choice to make the diagnosis? A. Chest computed tomography (CT) B. Chest radiograph C. Chest ultrasound D. Electrocardiogram (ECG) E. Spiral chest computed tomography (CT)

chest radiograph; History and physical are key in making a diagnosis of primary spontaneous pneumothorax (PSP), confirmed by chest radiograph. There is a higher incidence in men, and it usually occurs in ages 20-40. PSP is heavily associated with smoking. Patient presentation and physical exam findings will vary depending on the size of the pneumothorax. Patients typically present with unilateral chest pain, dyspnea, and cough, which occur with minimal activity, as well as tachycardia and tachypnea. A large PSP may become a tension pneumothorax, in which case the patient may have a deviated trachea, no breath sounds on the affected side with increased resonance to percussion, as well as respiratory distress and shock. Imaging of choice for a PSP is a chest radiograph, usually an upright inspiratory film. Supine or lateral decubitus views can also be used. A chest CT can be used to visualize a pneumothorax, but it is not indicated unless additional pathology is suspected. Ultrasound is user dependent, and it is not superior to a plain film in the diagnosis of PSP.

A 70-year-old man with hypertension, diabetes, obesity, and coronary artery disease presents with a 3-day history of fever, headache, nausea, vomiting, lethargy, and myalgias. His wife states that the symptoms began the day following a summer's evening walk around a lake. Today, his condition has worsened; he has developed diminished level of consciousness, behavioral changes, and abnormal movements. His physical exam reveals a lethargic man with photophobia, cranial nerve deficiencies, neck stiffness, and abnormal extremity movements. What is the next most appropriate step in the management of this patient? A. Place the patient in a Trendelenburg position B. Intraventricular intracranial pressure monitoring C. Begin parenteral cefazolin D. Perform a CT scan of the brain E. Perform a lumbar puncture

perform a CT scan of the brain;This patient's most likely diagnosis is West-Nile virus encephalitis, which is caused by a flavivirus mosquito-borne infection. Laboratory samples and blood cultures should be collected before the start of IV therapy. Even in uncomplicated cases of encephalitis, most authorities recommend a neuroimaging study (e.g., magnetic resonance imaging [MRI], or if unavailable, a contrast-enhanced head computed tomography [CT] scan) before lumbar puncture, if there are focal complaints or findings, signs to search for evidence of elevated intracranial pressure obstructive hydrocephalus, or mass effect due to focal brain infection. Performance of a head CT scan with and without contrast agent should be performed in virtually all patients with encephalitis. Head CT scanning also helps exclude brain hemorrhage or infarction as a cause of an encephalopathic state. Patients with signs of increased intracranial pressure should have their heads elevated.

A 16-year-old girl with a past medical history of asthma and known to your practice to have "annoying skin" states that around the spring and fall season changes, areas of her skin will become significantly irritated, red, itchy, and dry; sometimes, the areas will even drain clear fluid. She has had these problems with her skin for many years, but she has noticed recently the symptoms increasing in severity. Areas affected are around the inside of her elbows and behind both knees. Her asthma is maintained successfully with a daily inhaled corticosteroid and an as-needed short-acting beta-agonist. Pertinent family history includes her mother having asthma and her father having very similar dermatologic problems. Physical examination shows red erythematous scaly patched skin with occasional vesicles on the antecubital and popliteal fossae. What treatment would help better control the patient's symptoms? A. Over-the-counter topical antihistamines B. Prescription oral antibiotics C. Allergen immunotherapy D. Prescription topical corticosteroids E. Prescription oral corticosteroids

prescription topical corticosteroids; The correct response is prescription topical corticosteroids. The patient in this clinical scenario is most likely suffering from atopic dermatitis, which is otherwise known as eczematous dermatitis. The diagnosis can be deduced from several components: symptoms occur seasonally; the patient has diagnosed components of the atopy triad; there is family history of atopic issues on both her mother and father's side. A major cause of eczematous dermatitis is seasonal and perennial airborne allergies, which may cause significant eczematous issues if severe enough. Other causes that can lead to outbreaks include food allergies, substances that come into contact with the skin, changes in temperature and humidity, and even psychological stress.

A 62-year-old man is hospitalized because of a 1-week history of extreme malaise and painful skin changes. It started as "just a rash" but developed into clusters of clear vesicles; new vesicles appear while old ones dry and crust over. His past medical history is significant for type 2 diabetes mellitus, for which he is on a controlled diet. You find the rash distributed over his body and you make a diagnosis of disseminated herpes zoster. Acyclovir IV is introduced together with the supportive therapy, but after 2 days, the patient starts experiencing nausea and swelling; his urine output dramatically decreased and urinalysis revealed gross hematuria, with other laboratory studies showing elevated BUN and creatinine. What is the most probable mechanism of renal failure in this patient? A. Renal tubular obstruction B. Endothelial injury C. Hypersensitivity reaction D. Interstitial nephritis E. Kidney infection

renal tubular obstruction; Acyclovir precipitates in renal tubules because it is poorly soluble in urine. In that way, it causes the obstruction of renal tubules and acute renal failure.

A 39-year-old previously well Caucasian man presents to the emergency department with a 10-day history of fever >101°F and acute dyspnea with pleuritic chest pain. His past medical history is notable only for childhood asthma (no recurrences since age 12) and appendectomy. He has no known drug allergies. He denies taking prescribed medications on a regular basis. Social history is notable for use of IV drugs. Vital signs show: Temperature - 100.8°F, pulse - 108, respirations - 24, and blood pressure - 98/60. O2 saturation is 90% on room air. Physical examination reveals mild crackles of the mid-lung fields bilaterally and a grade II/VI soft systolic murmur, loudest at the left lower sternal border. A spiral CT reveals evidence of multiple pulmonary emboli. He is admitted to the general medical floor of an acute care hospital. Additional diagnostic tests are ordered; preliminary results of blood cultures showed 4+ growth of Gram-positive cocci. Infectious Diseases is consulted and he is started on an IV antibiotic regimen. What is the most likely source of the multiple pulmonary emboli in this patient? A. Deep venous thrombosis B. Tricuspid valve vegetation C. Left atrial thrombosis from atrial fibrillation D. Disseminated intravascular coagulation E. Metastatic cancer

tricuspid valve vegetation;A known complication of right-sided bacterial endocarditis (most commonly affecting the tricuspid valve) is multiple septic pulmonary emboli originating from vegetation of the infected cardiac valve. Clinical manifestations of septic pulmonary emboli include fever, dyspnea, chest pain, cough, and symptoms of the primary infection. Imaging studies such as chest CT or ventilation:perfusion scan will demonstrate evidence of pulmonary emboli. Bacterial endocarditis is typically associated with positive blood cultures and echocardiographic evidence of cardiac vegetation, myocardial abscess, new valvular regurgitation, or partial dehiscence of a prosthetic cardiac valve. Transesophageal echocardiogram is more sensitive than transthoracic echocardiogram. Treatment is generally with IV antibiotics (rarely with embolectomy); cardiac valve or other cardiac surgery may be required for treatment of the underlying bacterial endocarditis. Controversy exists regarding the use of anticoagulation or antiplatelet therapy for pulmonary septic emboli; therefore, the decision must be carefully individualized.

An elderly man is admitted with an acutely severe myocardial infarction. His status quickly deteriorates. His symptoms include hypotension, altered mental status, cold clammy skin, and metabolic acidosis seen on laboratory tests. What is the most appropriate initial pharmaceutical choice for a patient in this type of shock? A. aspirin B. clopidogrel C. lidocaine D. beta blockers E. vasopressors

vasopressors;Early identification of shock is necessary to help improve any patient's chance of survival and recovery. It is also critical in reversing the cause of the shock and initiating early resuscitation efforts. Early on, patients suffering from shock may have only a few or very subtle symptoms, such as tachypnea, tachycardia, hyper- or hypothermia, weak or bounding peripheral pulses, delayed capillary refill, and/or pale or cool skin. Decreased mental status, weak or absent central pulses, central cyanosis, hypotension, and bradycardia are ominous; they indicate the shock has progressed. Shock is generally classified into four major categories, depending on the etiology causing it: cardiogenic, hypovolemic, distributive, and obstructive. Cardiogenic shock occurs as a consequence of cardiac pump failure. Myopathic, mechanical, or arrhythmic issues lead to cardiogenic shock. Whatever the cause, there is typically an acute loss of 15-20% of circulating blood volume that leads to a lack of blood to pump throughout the circulatory system. The prompt treatment of hypoperfusion and hypotension is essential in the initial management of cardiogenic shock. This is usually initiated by use of vasopressors or inotropic agents. Usually, both pharmacologic and non-pharmacologic methods of circulation support are promptly initiated to reverse hypotension, to maintain vital organ perfusion, and to maintain coronary perfusion pressures until intervention of the etiology of the cardiogenic shock can be treated.